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BMC Endocrine Disorders
The effects of cognitive behavioral therapy for insomnia in people with type 2 diabetes mellitus, pilot RCT part II: diabetes health outcomes
Mohammed M. Alshehri ORCID: orcid.org/0000-0003-0028-09571,2,
Shaima A. Alothman3,
Aqeel M. Alenazi4,
Jason L. Rucker1,
Milind A. Phadnis5,
John M. Miles6,
Catherine F. Siengsukon1 &
Patricia M. Kluding1
BMC Endocrine Disorders volume 20, Article number: 136 (2020) Cite this article
Previous studies have shown the negative impact of sleep disturbances, specifically insomnia symptoms, on glucose metabolism for people with type 2 diabetes (T2D). People with insomnia symptoms are at risk of poor glycemic control and suboptimal diabetes self-care behavior (DSCB). Investigating the impact of a safe and effective intervention for individuals with T2D and insomnia symptoms on diabetes' health outcomes is needed. Therefore, the aim of this exploratory study is to examine the effects of Cognitive Behavioral Therapy for Insomnia (CBT-I) on glycemic control, DSCB, and fatigue.
Twenty-eight participants with T2D and insomnia symptoms, after passing an eligibility criteria at a medical research center, were randomly assigned to CBT-I (n = 14) or Health Education (HE; n = 14). The CBT-I and HE groups received 6 weekly one-hour sessions. This Randomized Controlled Trial (RCT) used a non-inferiority framework to test the effectiveness of CBT-I. Validated assessments were administered at baseline and post-intervention to assess glycemic control, DSCB, and fatigue. A Wilcoxon signed-rank test was utilized to compare within-group changes from baseline to post-intervention. A Mann-Whitney test was utilized to measure the between-group differences. Linear regression was used to assess the association between the blood glucose level and the number of days in the CBT-I group.
The recruitment duration was from October 2018 to May 2019. A total of 13 participants completed the interventions in each group and are included in the final analysis. No adverse events, because of being a part of this RCT, were reported. CBT-I participants showed significantly greater improvement in glycemic control, DSCB, and fatigue. There was a significant association between the number of days in the CBT-I intervention with the blood glucose level before bedtime (B = -0.56, p = .009) and after awakening in the morning (B = -0.57, p = .007).
This study demonstrated a clinically meaningful effect of CBT-I on glycemic control in people with T2D and insomnia symptoms. Also, CBT-I positively impacted daytime functioning, including DSCB and fatigue. Future research is needed to investigate the long-term effects of CBT-I on laboratory tests of glycemic control and to understand the underlying mechanisms of any improvements.
Clinical Trials Registry (NCT03713996). Retrospectively registered on 22 October 2018,
A systematic review and meta-analysis of epidemiological studies found that people with type 2 diabetes (T2D) and sleep disturbances were more likely at risk of poor glycemic control as measured by glycated hemoglobin (HbA1c) and suboptimal diabetes self-care behavior (DSCB) [1, 2]. A recent study found that people with T2D and insomnia symptoms had worse scores in several health domains related to DSCB compared to people with T2D without insomnia symptoms [3]. Additionally, increases in insomnia severity was associated with suboptimal DSCB among people with T2D [3]. It is possible that sleep disturbances lead to fatigue and physical inactivity, which then contributes to poor diabetes health outcomes [4].
Previous studies have shown that insomnia symptoms are common among people with T2D [5, 6], and insomnia itself may independently increase mortality rates [7, 8]. In addition, the increased mortality risk in people with insomnia might be due to inflammation, which is also associated with cardiovascular diseases [9]. The mechanisms underlying the relationship between T2D and insomnia symptoms are not well understood [10, 11], yet there is a need to identify an effective treatment for insomnia symptoms to improve T2D health outcomes.
Among therapeutic options for insomnia, the American Academy of Sleep Medicine recommends the employment of Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line therapy [12], since CBT-I can be superior when compared to sleep medications [13]. These sleep medications can possibly lead to negative side effects [14] or metabolic alterations [15, 16]. Further, a recent study supported the need to investigate the effects of CBT-I on people with T2D due to the harmful side effects of pharmacological treatments and the limited evidence of effectiveness [17].
CBT-I is a potentially efficacious intervention for people with T2D as it may address an altered metabolism. Generally, the components of CBT-I including sleep restriction therapy, stimulus control therapy, cognitive therapy, and relaxation therapy strengthen the association between bed and sleep connection, readjust the homeostatic mechanisms and the circadian rhythm, and reduce anxiety and rumination about sleep [18]. CBT-I modules may interrupt the physiological mechanisms such as hypothalamic pituitary-adrenal (HPA) axis activation [10, 11], which may be one link between insomnia symptoms and T2D. For example, it has been shown that an association between sleep homeostasis and glucose regulation could be adjusted using sleep restrictions and stimulus control therapies [19]. Improvement of the circadian cycle misalignment has intimate correlations with glucose metabolism for people with T2D [20]; however, this has not been proven yet in CBT-I studies. In addition, ancillary modules in CBT-I, such as relaxation techniques and sleep hygiene, could play a role in reducing stress and nocturia episodes (i.e., the number of bathroom visits per night) [21,22,23].
The objective of this study was to explore the effects of 6 sessions of CBT-I on HbA1c, DSCB, and fatigue. We hypothesized that the participants in the CBT-I group would have greater improvements in HbA1c, DSCB, and fatigue compared to the participants in the health education (HE) group. The effects of CBT-I on sleep outcomes were reported separately (Part I of the intervention trial: Using Cognitive Behavioral Therapy for Insomnia in People with T2D, Pilot RCT Part I: Sleep Outcomes and Concomitant Symptoms) [24]. We anticipated improvements in sleep and concomitant outcomes which will positively impact people with T2D and health outcomes because of the relationship between insomnia symptoms and poor diabetes-related health outcomes. Both intervention studies were designed to serve as pilots for a subsequent larger scale intervention trial.
Participants and materials
The procedures and interventions for this project were described in a published protocol report [25]. This intervention trial was described according to the CONSORT 2010 guidelines [26]. Prior to being enrolled in the study, potential participants were screened according to eligibility criteria, which are presented in Table 1.
Table 1 The inclusion and exclusion criteria
This RCT had an allocation ratio of 1:1 and utilized a superiority framework to test the effectiveness of the CBT-I. Participants were randomly assigned to either the CBT-I group (n = 14) or the HE group (n = 14). We used age to stratify participants into either the older (63–75 years) or the younger (40–62 years) age group. This study was retrospectively registered in the Clinical Trials Registry (NCT03713996) [27]. This study was approved by the Institutional Review Board and the Human Subjects Committee of the University of Kansas Medical Center. All participants signed a written informed consent before the assessment visit. Data collections and provided interventions took place at the University of Kansas Medical Center.
All participants completed outcome measures at the baseline, and all participants completed the same outcome measures 1 week after completing the intervention. The primary outcome, insomnia severity, was included in the RCT Part I in which the power calculation was established and its preliminary data were published elsewhere [24].
Diabetes control measurement
A point-of-care instrument was used to assess HbA1c using a disposable finger stick HbA1c kit (A1CNow + test kit; Bayer Healthcare, Tarrytown, NY). This instrument measures the level of glycosylated hemoglobin via an immunoassay test, and reflects the average glucose blood levels over the period of 6 to 12 weeks [28]. During a previous diabetes management program, the A1CNow + provided accuracy and precision when performing a point-of-care, and a 0.05 reduction in HbA1c is considered clinically meaningful [29]. In addition, random blood glucose (RBG) levels were assessed by a glucose meter (FreeStyle Flash, Contour® Bayer Healthcare, Diagnostic Division, Tarrytown, NY). Participants were tested for the RBG without time specifications or diet instructions. During the intervention, participants in the CBT-I group were asked to record their own blood glucose levels right before bedtime and after first awakening in the morning throughout the study period (i.e., 7 days/nights per week for 7 weeks).
Diabetes self-care behavior (DSCB)
Self-care was assessed using the Diabetes Care Profile (DCP), which is a validated survey that measures 13 psychosocial and educational factors [30, 31]. The 13 domains that are associated with the management of diabetes, are inclusive of the following: understanding the management of practice, support, control problems, social and personal factors, positive attitude, negative attitude, care ability, importance of care, self-care adherence, diet adherence, long-term care benefits, exercise barriers, and glucose monitoring barriers [31]. A standardized total DCP composite score was established to present all 13 domains that were scored according to the Fitzgerald et al. scoring criteria [31]. Next, each participant's domain score was standardized using z-scores, and then averaged to create a standardized total DCP composite score. High scores on the DCP composite score indicate better DSCB.
Fatigue severity
Daily fatigue was measured using the Fatigue Severity Scale (FSS) that consists of 9 items developed to assess disabling fatigue on daily life. The FSS has been shown to be valid and reliable [32]. Each item was measured on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Mean item response for the completed FSS items was used for analysis.
All participants in the CBT-I group and HE group attended 6 sessions that were scheduled consistently one session per week with the CBT-I provider. These sessions were provided for around 45 min for both groups to assure all participants received the same amount of attention. Neither the CBT-I provider nor the participants were blinded in this study. The protocol paper describes session by session of both interventions [25].
Cognitive behavioral therapy for insomnia
This protocol intervention was designed based on a session-by-session guide [33]. Five main therapeutic techniques were provided during the 6-sessions including sleep restriction therapy, stimulus control therapy, sleep hygiene, relaxation techniques, and cognitive therapy. In order to monitor nightly sleep changes and issues, the CBT-I provider reviewed the sleep diary for each session. In addition, calculations in sleep changes were made to prescribe the sleep schedules for the following week. The calculations in the sleep changes were made based on the sleep efficiency (the ratio of total sleep time and total bedtime multiplied by 100) from the weekly sleep diary. At each session, the time spent in bed and out of bed was prescribed based on the calculation of sleep efficiency in percentages. If the sleep efficiency was greater than 90%, the opportunity to go to bed earlier was extended by 15 min. If the sleep efficiency was between 85 and 89.9%, the same sleep schedule was prescribed, and if it was less than 85%, then bedtime moved 15 min later.
Session 1: Sleep restriction therapy, stimulus control therapy and sleep hygiene were provided. Sleep restriction therapy aligns the time in bed with the total sleep time by identifying the wake time and total sleep time needed to increase the sleep efficiency [34, 35]. Stimulus control associates the bed environment to sleep only (or sex) to reinforce the circadian rhythm [34, 35]. In addition, sleep hygiene minimizes the influence of negative behaviors on sleep quality and quantity. The principles of sleep hygiene were provided including the impact of diet, exercise, caffeine, alcohol, and environment on the quality of sleep [34, 35].
Session 2: Calculating sleep efficiency, reviewing the principles of sleep hygiene, and providing the diaphragmatic breathing technique were covered in this session. During this week, we also reviewed the sleep diary to confirm any necessary sleep changes (i.e., adjustments to the time both in and out of bed.) The diaphragmatic breathing technique promotes muscle relaxation, better breathing performance, and memory relaxation [36]. It also was especially emphasized for those who were not able to relax.
Session 3: Calculating both sleep efficiency and mindfulness were conducted during this session. Mindfulness reduces cognitive and somatic arousal for people with insomnia who received CBT-I [37]. The principles of mindfulness including how to be non-judgmental and incorporate patience, trust, acceptance, and letting go were covered in this session.
Session 4: Calculating sleep efficiency and progressive muscle relaxation were reviewed in this session. Muscle relaxation therapy helped in improving insomnia and depression symptoms when used in CBT-I [38]. Muscle relaxation therapy is a physiological intervention aimed to assess and decrease muscle tension [38].
Session 5: Calculating sleep efficiency and cognitive therapy were done in this session. Cognitive therapy changes both detrimental beliefs and attitudes about sleep. During this session, we worked on reducing the participants' sleep efforts, catastrophizing, and their anxiety about sleep, while also working on their willingness to modify their sleep-related behaviors and engage in good sleep strategies.
Session 6: Assessing treatment benefits and insomnia relapse education were provided in this session. We graphically reviewed the sleep efficiency of each session to show the sleep changes during the six sessions of CBT-I. In addition, we discussed the approaches to maintain clinical gains and how to remedy any incidents when insomnia returns.
Five main health education materials were introduced during the six sessions including brief sleep hygiene, foot care, diabetes classifications, healthy diet, and physical activity. During the HE sessions, we provided informal face to face interviews to better engage the participants in the conversations. Participants' comprehension of and experiences about the provided materials were facilitated through open questions. Details of the provided sessions for the HE group were provided in the protocol paper of this study [25].
All data analyses were performed using SPSS 23.0 for Mac (Chicago, IL) and R (https://www.R-project.org/) [39]. Descriptive statistics included means and standard deviations for the assessed variables at the baseline (14 participants) and at the post-assessment (13 participants). We used Shapiro–Wilk tests to assess the normality of residuals during model development. For the main analysis, we used Mann-Whitney U tests to examine the between-group differences of the CBT-I and HE groups in HbA1c, RBG, DSCB, and fatigue mean change scores for those who completed the study. We also used Wilcoxon signed-rank tests to compare the within-group changes for both groups. Effect sizes were calculated using Cohen's d [40]. For graphical purposes, we calculated absolute percentage changes in all outcomes to graph the between-group differences. For secondary purpose, we used linear regression analyses to predict blood glucose levels (before bedtime and after first awakening in the morning) based on 49 days throughout the course of the study, including 6 weeks CBT-I and post-assessment. For all analyses, the alpha level was set at .05.
The consort of this intervention trial shows a total of 28 participants enrolled in the study and 26 participants completed the study (Fig. 1). There were no baseline differences between groups in demographics including age, sex, ethnicity, and education (p > .05) [24]. In addition, there were no significant between-group differences in the baseline assessments of HbA1c, RBG, DCP composite score, or FSS (Table 2).
Consort of the study
Table 2 Comparison of clinical variables within and between groups
There were significant between-group post-intervention differences in HbA1c (d = 0.41, p = .01), DCP composite score (d = 1.01, p = .01), and FSS (d = 1.07, p = .009; Fig. 2; Table 2). There were significant within-group differences for the CBT-I group in HbA1c (p = .02), DCP composite score (p = .03), and FSS (p = .002), which are also shown in Table 2. However, there were no within-group differences in HbA1c, DCP composite score, or FSS for the HE group.
Absolute percentage change of all outcomes for both groups; *p = 0.01, **p = 0.001
We noted declines in the blood glucose levels before bedtime and after first awakening in the morning for the CBT-I group using the R software package (Fig. 3). The linear regression analysis showed significant association between the number of days in the CBT-I intervention with a blood glucose level before bedtime (B = -0.56, p = .009) and after first awakening in the morning (B = -0.57, p = .007) (Fig. 3).
Daily glucose blood levels before bedtime and after awakening in the morning during the CBT-I intervention
To the best of our knowledge, this was the first RCT to examine the effects of CBT-I on diabetes outcomes and daytime functioning in people with T2D and insomnia symptoms. This study suggested CBT-I was effective in improving HbA1c, DSCB, and FSS for people with T2D and insomnia symptoms. Glucose blood levels, both before bedtime and after first awakening in the morning, also decreased over the course of the CBT-I intervention.
Diabetes outcomes improved following CBT-I, with a clinically meaningful difference in HbA1c. Clinical improvement in HbA1c may have been due to reductions in insomnia severity or psychological symptoms, which might foster an improved DSCB. After the CBT-I intervention, as shown in Fig. 2, there was a 0.05% absolute percentage reduction in HbA1c that suggests a clinically significant change based on the American Diabetes Association statistics [41]. It is recommended that people with T2D maintain HbA1c levels below 6% to reduce their risk of developing microvascular complications, although HbA1c between 6.5 and 7.9% is often considered acceptable by physicians [42]. Interestingly, the HE intervention provided to the control group, which included sleep hygiene, diet, and physical activity, was not sufficient to improve HbA1c. However, the baseline data of HbA1c for people in the HE group were at the borderline of optimum glycemic control that has been recommended by the American Diabetes Association. Thus, future research is needed to consider HbA1c in the power calculation and randomization process. As shown in the initial part of this intervention trial, improving insomnia symptoms following CBT-I may produce reductions in depression and anxiety symptoms that are often associated with daily hyperglycemia [24]. Previous studies have shown the negative influence of the combination of insomnia and depression on an individual's glucose metabolism [43], which could be adjusted using CBT-I [44].
Besides the effects of improving insomnia symptoms on HbA1c, improvements in DSCB could also explain the clinical changes in HbA1c. Our study tracked glucose levels for participants in the CBT-I group, and there was a statistically significant decrease over the course of the intervention. This is entirely observational, however, as we did not monitor glucose before bedtime and after first awakening in the morning in the HE group. Regardless, self-monitoring of blood glucose should be done as a part of DSCB when trying to minimize problems related to hyperglycemia. It has been suggested that self-monitoring of blood glucose significantly reduces HbA1c levels for people with poorly controlled T2D [45].
There are few physiologic mechanisms that might explain improvements in HbA1c. First, the negative effects of sleep disturbances on metabolism might cause decreased brain glucose utilization, which could lead to hyperglycemia [46]. Reducing sleep disturbances via CBT-I might regulate glucose utilization, which could improve HbA1c. Second, previous studies have suggested a U-shaped relationship between sleep duration with HbA1c levels, where excessively short or long sleep durations have been noted to be associated with higher HbA1c levels. Sleep restriction therapy might lead to improved HbA1c levels by maintaining sleep durations within an optimal range of 7–8 h. Third, sleep disturbances are associated with appetite hormone dysregulations [46], and these dysregulations could be adjusted through sleep hygiene and stimulus control therapy. Sleep hygiene and stimulus control might help the participants in scheduling meals and acquiring a better understanding of their bodily needs regarding food consumption. Fourth, abnormal HPA axis activation might be normalized as a result of improving insomnia symptoms. This normalization could reduce cortisol secretion during sleep, which has been linked to reduced morning glucose levels. Finally, people with poor sleep and T2D at risk of impaired decision-making [47], which might be improved following CBT-I. Effective decision making may assist people with T2D in understanding domains related to diabetes such as food choices, control problems, diabetes distress, and medication adherence.
A population-based RCT of 109 older adults with insomnia showed the risk of 8 biomarkers of various health conditions following mood and daytime functioning promotions as a part of cognitive behavioral therapy [48]. The authors suggested that improving sleep quality was associated with reducing the risk of cardiovascular, metabolic, and inflammatory diseases [48]. As mentioned previously, the possible changes in the physiological systems, might be associated with an increased allostatic load, which was related to diabetes, hypertension, metabolic syndrome, and cardiovascular disease [48]. This suggests sleep promotion programs may help in re-establishing healthy patterns of various biomarkers for various health conditions due to the association between the circadian clock regulation and the rhythms of body organs or hormonal secretory patterns that alter numerous biological processes such as metabolism and blood glucose regulation [46]. The current study adds to the literature in regard to the benefits of CBT-I on an important indicator of diabetes control, HbA1c, in people with T2D. Part I of this intervention trial approved the effects of CBT-I on various sleep parameters and psychological symptoms which might indirectly show a positive impact on diabetes health outcomes. However, future study is needed to investigate the effect of CBT-I on a wide range of metabolism parameters for people with T2D.
Although the HE group received the same amount of face-to-face attention, we did not find any significant improvement in their diabetes and daytime functioning outcomes. This reiterated the importance of considering CBT-I as a treatment in diabetes clinics for people with T2D who suffer from insomnia symptoms. Contrary to the positive results of CBT-I on insomnia symptoms, glycemic control, and fatigue in people with T2D, there were no significant improvements in RBG for either group. Several factors might explain these results such as the specificity of interventions, the short-term intervention, or the methodological factors. CBT-I is designed to change detrimental beliefs about sleep behavior, which could demonstrate a secondary effect on RBG over time. However, the data from this study suggests blood glucose levels could be decreased at night before bedtime and in the mornings after first awakening.
This study has identified the effects of CBT-I on diabetes health outcomes in people with T2D; however, some limitations need to be considered for future research. First, including other highly sensitive glucose metabolism measures on larger sample sizes, such as a homeostatic model assessment and an oral glucose tolerance test, may generalize the other effects of CBT-I on diabetes parameters. Second, diabetes management includes interdisciplinary approaches, such as diet, physical activity, and medication adherence, to ensure optimal HbA1c. Future work needs to track daily changes in these activities to better explain the impact of CBT-I on HbA1c. Third, comprehensive functional assessments, including variables such as cognition, motivation, and activities of daily living, may help to efficiently identify other results following CBT-I. Fourth, we were not able to determine if the improvement in HbA1c was mediated by a reduced severity of insomnia or psychological symptoms. A longitudinal design for a larger sample size with T2D is needed to better understand the factors that promote good glycemic control following CBT-I. Finally, although this study demonstrated clinical improvements in HbA1c and DSCB after participants underwent six sessions of CBT-I, future research is needed to measure the sustainability of these improvements for at least 3 months.
This study focuses on clinical information about the effectiveness of CBT-I on diabetes health outcomes. CBT-I showed a clinically meaningful effect on HbA1c and significant improvements in optimal DSCB and fatigue in people with T2D and insomnia symptoms. There is still a need to understand the underlying mechanism of these enhancements, and future research is needed to investigate the long-term effect of CBT-I on diabetes blood parameters and to understand the underlying mechanisms of these improvements.
The datasets analyzed during the current study are available from the corresponding author upon reasonable request.
RCT:
T2D:
HPA:
Hypothalamic Pituitary-adrenal
CBT-I:
HE:
HbA1c:
Random Blood Glucose
DSCB:
Diabetes Self-care Behavior
DCP:
Diabetes Care Profile
FSS:
Fatigue Severity Scale
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Larcher S, Benhamou P-Y, Pépin J-L, Borel A-L. Sleep habits and diabetes. Diabetes Metab. 2015;41(4):263–71.
Carroll JE, Seeman TE, Olmstead R, Melendez G, Sadakane R, Bootzin R, et al. Improved sleep quality in older adults with insomnia reduces biomarkers of disease risk: Pilot results from a randomized controlled comparative efficacy trial. Psychoneuroendocrinology. 2015;55:184–92.
We thank Cray Diabetes Center at KUMC for providing our flyers to the patients. We also thank Jeff Hoover (University of Kansas, USA) for proofreading the manuscript.
This research was funded by the Deanship of Scientific Research at Princess Nourah bint Abdulrahman University through the Fast-track Research Funding Program.
Physical Therapy and Rehabilitation Science Department, University of Kansas Medical Center, 3901 Rainbow Blvd., Mail Stop 2002, Kansas City, Kansas, 66160, USA
Mohammed M. Alshehri, Jason L. Rucker, Catherine F. Siengsukon & Patricia M. Kluding
Physical Therapy Department, Jazan University, Jazan, Southern Region, Saudi Arabia
Mohammed M. Alshehri
Lifestyle and Health Research Center, Princess Nora bint Abdulrahman University, Riyadh, Saudi Arabia
Shaima A. Alothman
Physical Therapy Department, Prince Sattam Bin Abdulaziz University, Alkharj, Central Region, Saudi Arabia
Aqeel M. Alenazi
Department of Biostatistics, University of Kansas Medical Center, Kansas City, Kansas, USA
Milind A. Phadnis
Endocrinology Department, University of Kansas Medical Center, Kansas City, Kansas, USA
John M. Miles
Jason L. Rucker
Catherine F. Siengsukon
Patricia M. Kluding
All Authors read and approved the manuscript. MMA conceptualized the study, researched and analyzed the data, and wrote the manuscript. AMA, SAA, JLR, MAP, JMM, PMK, and CFS contributed in reviewing and writing the manuscript. MAP helped in planning the data analysis and assuring the power analysis. JMM helped in strengthening the research questions and recruitment. JLR, JMM, PMK, and CFS conceptualized the study.
Correspondence to Mohammed M. Alshehri or Aqeel M. Alenazi.
This study was approved by the Institutional Review Board and the Human Subjects Committee of the University of Kansas Medical Center (IRB # STUDY00142985). All participants signed a written informed consent before the assessment visit.
The authors whose names are listed in this manuscript have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.
Additional file 1.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Alshehri, M.M., Alothman, S.A., Alenazi, A.M. et al. The effects of cognitive behavioral therapy for insomnia in people with type 2 diabetes mellitus, pilot RCT part II: diabetes health outcomes. BMC Endocr Disord 20, 136 (2020). https://doi.org/10.1186/s12902-020-00612-6
Received: 22 April 2020
Submission enquiries: bmcendocrinedisorders@biomedcentral.com


CAIRO (AP) - Sudanese protesters on Monday welcomed the "positive steps" taken by the ruling military council, which held talks with opposition leaders over the weekend and released some political prisoners.
Since his ouster, al-Bashir - president for nearly 30 years - has been under house arrest in Khartoum. The military said he was removed from power in response to the demands of the people.
A military spokesman said Sunday it will name a civilian prime minister and Cabinet - but not a president - to help govern the country. The announcement was unlikely to satisfy the protesters. Lt. Gen. Shamseldin Kibashi said in televised remarks that the military had begun to overhaul the security apparatus and wouldn't break up the demonstrations outside the military headquarters.


text:
Dear Jac: Anybody know where a Lotto retailer can find supplies of plastic wallets?
By Jac Roper2005-09-23T00:00:00+01:00
Camelot used to provide special plastic wallets, but no longer does, and furthermore couldn't tell me who could. David Laidlaw, who runs the Laidlaw's, a CTN in Inverness, says it was a useful tool for keeping the Lotto payslips in pristine condition and also served as a means of advertising the shop's opening hours and other services. So, can anybody come up with a creative, practical alternative?
Dear Jac - Equipment
Dear Jac: What a fine business this is to be in
I got some feedback from my last column on the subject of credit card authorisation through terminals and fraud prevention. It was Ukash/Visa last time through PayPoint. This time it is Elavon credit cards through Payzone.
It might be you...maybe...perhaps
A few retailers have been in touch to ask how they could improve their chances with Camelot now that it's been announced that there may be some new terminals on offer come the end of the year. I asked Camelot for some advice and got the usual…
We'd love to hear from you sunshine
Just a quickie. Anybody out there successfully installed solar panels in their store?
More Dear Jac
The error had been admitted but still no refund
Instead it was to and fro, back and forth, for months and months
How can this retailer remove a display stand he hasn't got?
And why are they chasing him for a debt he doesn't owe?
Doing the sums
When we last featured Taranjeet Singh in this column in mid-May, he was waiting for the rep's visit from Hermes to decide whether or not to continue with the parcel service.

redpajama_set_name: RedPajamaCommonCrawl


text:
In a statement on her defamation lawsuit loss, Tasha K says she "wouldn't…
TOPICS:Cardicardi bCelebrity NewsFeaturedKebe StudiosKebe Studios LLCTashaTasha K
In a statement on her defamation lawsuit loss, Tasha K says she "wouldn't change a single thing."
Tasha K has issued a statement following the defamation lawsuit filed by Cardi B against her. Tasha K and her firm, Kebe Studios LLC, were found responsible on all charges by a jury on Monday.
Defamation, invasion of privacy by misleading light portrayal, and deliberate infliction of emotional distress are among the claims. Tasha and Kebe Studios are now liable for over $4 million in damages.
Tasha is well-known for her unWinewithTashaK YouTube channel. She presents and creates segments for her one million-follower YouTube channel.
Tasha makes a public statement in the form of a video.
Tasha added in her video statement, "These last four years battling this conspiracy case have been tremendously tough, but I wouldn't change a single thing about any of it."
Tasha stated that she "learned so much" from the journey, which included "strong and illuminating" moments. According to the blogger, the guilty verdict came as "no surprise" to her, her husband, or her legal team.
Tasha K remarked, "We called bluff against a machine that sought to bully me for not compromising my personal views." "A machine that serves corporate interests by protecting prostitution, drug addiction, promiscuity, and glorifying the violence that wreaks havoc on our society and neighborhoods."
This machine, according to Tasha K, "secured an extraordinarily prejudicial verdict" against her and Kebe Studios. She claimed the decision was made "solely on the basis of sympathy and payola." Tasha also thinks the case "successfully made [her] out to be an angry and spiteful lady." She went on to defend her company and platform.
Tasha stated, "This is a serious business." "I am a 17-year-old wife and mother to a lovely 15-year-old honor student and a two-year-old kid. My platform disseminates information and sheds light on current events in our society."
Tasha Refutes Guilty Conviction
Tasha mentioned her First Amendment rights several times. She rejected all of the claims on which the jury found her guilty later in the 12-minute film.
"We established that there was no defamation, invasion of privacy, or suicidal ideation with adequate, verifiable information," Tasha stated.
The remark is a jab at a portion of Cardi's trial testimony. Due to the false stories Tasha published about her, the rapper told jurors she "wanted to commit suicide." False charges of prostitution, infidelity, sexual penetrative actions with beer bottles, developing herpes, and utilizing strong narcotics were among the stories told.
Tasha intends to file an appeal. Despite the fact that the jury gave Cardi a substantial $3.8 million in damages, medical bills, attorney fees, and punitive damages, the decision was made.
"We will fight no matter how much it costs or how long it takes," Tasha stated.
The YouTuber added that she will defend the case "all the way to the Supreme Court if necessary."
Cardi B Makes a Public Statement
Cardi B released a statement about her success after receiving further cash on Tuesday.
"All of you have learned about the darkest period of my life during this trial. "The ugly, filthy, and entirely untrue narratives that were continuously and aggressively shared online fueled that moment in time," Cardi stated.
"I felt absolutely helpless and vulnerable, believing that I would never be heard or vindicated." I've never taken for granted the platform that my celebrity provides, which is why I spent nearly three years of my life seeking justice."
After previously criticizing Kyrie Irving's vaccination status, Shaq slams vaccine mandates
Jamal Edwards, a music entrepreneur, died at the age of 31
Following Nick Cannon's announcement that he and Bri Tiesi are expecting a child…
In a movie lawsuit, Dame Dash was ordered to pay over $800,000 in damages
Be the first to comment on "In a statement on her defamation lawsuit loss, Tasha K says she "wouldn't…"
According to Mets reports, here's why the Eric Hosmer trade fell through
The New York Mets were on the verge of acquiring San Diego Padres first baseman Eric Hosmer, as well as some starting pitching, on Saturday….
Following a recent COVID-19 diagnosis, Jazmine Sullivan announces her official…
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The Romantic Comedy-Drama 'Harlem' Has Been Renewed For Season Two By Amazon…


This fruity mustard is particularly delicious with ham and adds color and interest to meat and fish entrees.
COMBINE mustard seeds and liquid, water and Worcestershire sauce in a food processor or blender. Process until slightly grainy. Add cranberries and blend until chopped.
BRING cranberry mixture to a boil in a medium saucepan, stirring constantly. Reduce heat and simmer for 5 minutes, stirring frequently. Whisk in sugar, dry mustard and allspice. Continue to simmer, stirring frequently, until volume is reduced by a third, about 15 minutes.
LADLE hot cranberry mustard into hot jars leaving 1/4 inch headspace. Remove air bubbles. Wipe rim. Center hot lid on jar. Apply band and adjust until fit is fingertip tight.
Do you have a photo of Cranberry Mustard Recipe you made?


i used free unity and built a project from a tutorial. it turned out good but i can't cast it to my phone from my oculus go. how do i enable casting?
windows pc, oculus go, udemy cardboard tutorials, forum, virtual freedom.
I'm having the same problem, headset says can't cast outside of headset when I try? And the recordings I make with the recorder on the go won't play on my computer when I import them, only solution I've got for showing of unity in vr is to render out a panoramic image and upload to veer / Facebook etc as a 360 photo, in veer you can view it in vr from the go app.
You might need to enable "developer mode." This is done on the mobile app on your phone under device settings. There should be a little cast icon on the bottom menu once this is done. Hope this helps! The video compression was a little rough, and we were trying to then cast to a TV, which was unviable at this point. Just to phone should work ok though!
Same problem, but i think it is not possible to cast an unpublished build.
I really hope they would do it in a near future because i need it too, but searching around there is not an official way to do it at the moment.


"How inappropriate is to call this planet Earth, when it is obvious that it should be called Ocean". Arthur Clarke.
We validate and optimize technologies and models for Naval Industry.
We consider fundamental research a technology factory.
We are at the forefront of marine renewable energies.
We develop tools to innovate engineering.


text:
Summation of perceptual cues in natural visual scenes
M. To, P. George Lovell, T. Troscianko, D.J. Tolhurst
SAS - PFS - Psychology
Natural visual scenes are rich in information, and any neural system analysing them must piece together the many messages from large arrays of diverse feature detectors. It is known how threshold detection of compound visual stimuli (sinusoidal gratings) is determined by their components' thresholds. We investigate whether similar combination rules apply to the perception of the complex and suprathreshold visual elements in naturalistic visual images. Observers gave magnitude estimations (ratings) of the perceived differences between pairs of images made from photographs of natural scenes. Images in some pairs differed along one stimulus dimension such as object colour, location, size or blur. But, for other image pairs, there were composite differences along two dimensions (e.g. both colour and object-location might change). We examined whether the ratings for such composite pairs could be predicted from the two ratings for the respective pairs in which only one stimulus dimension had changed. We found a pooling relationship similar to that proposed for simple stimuli: Minkowski summation with exponent 2.84 yielded the best predictive power (r=0.96), an exponent similar to that generally reported for compound grating detection. This suggests that theories based on detecting simple stimuli can encompass visual processing of complex, suprathreshold stimuli.
Proceedings of the Royal Society B: Biological Sciences
https://doi.org/10.1098/rspb.2008.0692
Perceptual Cues
Magnitude Estimation
Visual Processing
Visual Image
Visual Stimuli
To, M., Lovell, P. G., Troscianko, T., & Tolhurst, D. J. (2008). Summation of perceptual cues in natural visual scenes. Proceedings of the Royal Society B: Biological Sciences, 275(1649), 2299-2308. https://doi.org/10.1098/rspb.2008.0692
To, M. ; Lovell, P. George ; Troscianko, T. ; Tolhurst, D.J. / Summation of perceptual cues in natural visual scenes. In: Proceedings of the Royal Society B: Biological Sciences. 2008 ; Vol. 275, No. 1649. pp. 2299-2308.
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title = "Summation of perceptual cues in natural visual scenes",
abstract = "Natural visual scenes are rich in information, and any neural system analysing them must piece together the many messages from large arrays of diverse feature detectors. It is known how threshold detection of compound visual stimuli (sinusoidal gratings) is determined by their components' thresholds. We investigate whether similar combination rules apply to the perception of the complex and suprathreshold visual elements in naturalistic visual images. Observers gave magnitude estimations (ratings) of the perceived differences between pairs of images made from photographs of natural scenes. Images in some pairs differed along one stimulus dimension such as object colour, location, size or blur. But, for other image pairs, there were composite differences along two dimensions (e.g. both colour and object-location might change). We examined whether the ratings for such composite pairs could be predicted from the two ratings for the respective pairs in which only one stimulus dimension had changed. We found a pooling relationship similar to that proposed for simple stimuli: Minkowski summation with exponent 2.84 yielded the best predictive power (r=0.96), an exponent similar to that generally reported for compound grating detection. This suggests that theories based on detecting simple stimuli can encompass visual processing of complex, suprathreshold stimuli.",
author = "M. To and Lovell, {P. George} and T. Troscianko and D.J. Tolhurst",
doi = "10.1098/rspb.2008.0692",
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publisher = "The Royal Society London",
To, M, Lovell, PG, Troscianko, T & Tolhurst, DJ 2008, 'Summation of perceptual cues in natural visual scenes', Proceedings of the Royal Society B: Biological Sciences, vol. 275, no. 1649, pp. 2299-2308. https://doi.org/10.1098/rspb.2008.0692
Summation of perceptual cues in natural visual scenes. / To, M.; Lovell, P. George; Troscianko, T.; Tolhurst, D.J.
In: Proceedings of the Royal Society B: Biological Sciences, Vol. 275, No. 1649, 22.10.2008, p. 2299-2308.
T1 - Summation of perceptual cues in natural visual scenes
AU - To, M.
AU - Lovell, P. George
AU - Troscianko, T.
AU - Tolhurst, D.J.
N2 - Natural visual scenes are rich in information, and any neural system analysing them must piece together the many messages from large arrays of diverse feature detectors. It is known how threshold detection of compound visual stimuli (sinusoidal gratings) is determined by their components' thresholds. We investigate whether similar combination rules apply to the perception of the complex and suprathreshold visual elements in naturalistic visual images. Observers gave magnitude estimations (ratings) of the perceived differences between pairs of images made from photographs of natural scenes. Images in some pairs differed along one stimulus dimension such as object colour, location, size or blur. But, for other image pairs, there were composite differences along two dimensions (e.g. both colour and object-location might change). We examined whether the ratings for such composite pairs could be predicted from the two ratings for the respective pairs in which only one stimulus dimension had changed. We found a pooling relationship similar to that proposed for simple stimuli: Minkowski summation with exponent 2.84 yielded the best predictive power (r=0.96), an exponent similar to that generally reported for compound grating detection. This suggests that theories based on detecting simple stimuli can encompass visual processing of complex, suprathreshold stimuli.
AB - Natural visual scenes are rich in information, and any neural system analysing them must piece together the many messages from large arrays of diverse feature detectors. It is known how threshold detection of compound visual stimuli (sinusoidal gratings) is determined by their components' thresholds. We investigate whether similar combination rules apply to the perception of the complex and suprathreshold visual elements in naturalistic visual images. Observers gave magnitude estimations (ratings) of the perceived differences between pairs of images made from photographs of natural scenes. Images in some pairs differed along one stimulus dimension such as object colour, location, size or blur. But, for other image pairs, there were composite differences along two dimensions (e.g. both colour and object-location might change). We examined whether the ratings for such composite pairs could be predicted from the two ratings for the respective pairs in which only one stimulus dimension had changed. We found a pooling relationship similar to that proposed for simple stimuli: Minkowski summation with exponent 2.84 yielded the best predictive power (r=0.96), an exponent similar to that generally reported for compound grating detection. This suggests that theories based on detecting simple stimuli can encompass visual processing of complex, suprathreshold stimuli.
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DO - 10.1098/rspb.2008.0692
JO - Proceedings of the Royal Society B: Biological Sciences
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To M, Lovell PG, Troscianko T, Tolhurst DJ. Summation of perceptual cues in natural visual scenes. Proceedings of the Royal Society B: Biological Sciences. 2008 Oct 22;275(1649):2299-2308. https://doi.org/10.1098/rspb.2008.0692
10.1098/rspb.2008.0692


text:
Marketing•10 Minutes
Storytelling: How to Leverage in Public Relations?
Brand stories convey feelings and emotional experiences. This makes them both educational and entertaining, and captivating in a broad number of ways. When it comes to acquiring B2B consumers in Thailand, these two features might also be beneficial to any Marketing team, regardless of their level of advancement, language competency or skill. We can use storytelling to pique the interest of those involved in the decision-making process in a product or service. Storytelling is the art of encapsulating information in a narrative.
The primary goal of B2B storytelling in particular is to elicit subliminal interest in a product or brand and, ideally, to result in conversions. It frequently accomplishes this by combining somewhat dry product data and figures with true (or fictional, if used suitably) anecdotes and origin tales. The goal is to generate the same feel as entertaining films, writing, and other things that are easy to consume and capture the attention of professionals and/or customers. This is why it becomes increasingly crucial as the product or service becomes more sophisticated. We need to cut through lethargy.
Give Your Business Its Own Unique Personality
Why is storytelling so important?
Storytelling is most effective when it cleverly combines entertaining and facts. As a result, it's also appropriate for B2B content marketing. In B2C marketing, there is nearly always a storytelling element to consumer comms.
Logical considerations play a more significant influence in B2B transactions. This long-held (and widely held) belief may not always mirror reality. Today, we know that emotions play a big role in business decisions, even if the recipient isn't necessarily aware of it. The reason for this is that they are also "only" people who believe their gut instincts as much as statistics and facts. This can be positively influenced by effective B2B storytelling.
Storytelling is also vital for sticking out from the crowd. The net is a noisy space, and ditto for your social feeds. his is due to the fact that numerous players have comparable basic numbers and pricing, and therefore require some more creative cut-through. Storytelling allows you to set yourself out from the competition and give your business its own unique personality.
What is the secret to good storytelling?
The ingredients – like baking a great cake with a heart-warming origin story with its own lore – are derived from the preferences of the target information consumer. Yet, in the correct form and balance, and when delivered to an exceptional quality, we can be sure that there are several common components that contribute to its success:
• A story must have a central character with whom the reader can identify.
• This means it must be appropriate for the target audience, such as in terms of age.
• Young decision-makers are undoubtedly more receptive to the adventures of a family with young children than a CEO in his or her sixties, for example.
• He or she is most likely more interested in good food or expensive travel experiences.
• There must be some sort of challenge for the hero to overcome. In screenwriting, this is encapsulated in the goal setting of, "My story is about a XX who wants to XX."
Your imagination has no bounds, so go nuts. This is nearly always a better approach than having no backstory at all and just a range of products to sell.
However, the manner in which information is provided must be consistent with the product or service and be authentic. Slapstick storytelling isn't acceptable for a solemn funeral home, and it's more likely to agitate the audience than to persuade them. With all due respect to original content, storytelling cannot be divorced from its subject, too. Each tale should, in some way, connect to the brand's core and the major topic – and therefore ultimately sell your product.
The appropriate moment to publish is also important. As a result, B2B storytelling should always be a component of a larger marketing plan, and should be timely and topical (Public Relations is an enormous help here, especially). With the use of digital storytelling, B2B companies can breathe fresh life into their material.
Given the high level of consumer participation in the industry, as well as the consumer research that many companies have conducted, there are several chances for B2B organisations to use digital storytelling. Companies must, however, get creative with their digital storytelling in order to develop content that stands out and engages people.
Overview of PR storytelling:
Formats empathy x authenticity
1. Empathy – Companies must first modify the way they think about and develop content in order to fully embrace and reap the benefits of digital storytelling. Empathy is the most critical aspect of this shift because when a firm takes the time to understand its customers, it can produce "tales" that are more emotionally memorable. These types of stories make customers feel more connected to a company on a deeper level than just a transactional level. They can even make them part of your story, which is a massive help to any firm looking to build a social media following or community.
It's critical to develop tangible deliverables in a digital storytelling strategy, whether a firm is aiming to explain its brand story or construct a promotional narrative. That implies businesses should have a strategy in place for telling their narrative effectively, taking into consideration thought leadership, market trends, and the target audience.
2. Authenticity – Due to the digital change over the last several years, and more so since the pandemic began, marketing methods that were previously only used by organisations in the B2C industry have begun to become prevalent among companies in the B2B industry as well. We can say that this is very true from the perspective of us at Gemini, as Bangkok's leading PR specialist.
Many of those marketing innovations will remain in place in the B2B industry even after the epidemic is over and the world returns to normal, with the usage of digital storytelling being the most significant change.
When using digital storytelling tactics, businesses have a lot of flexibility. Companies can use digital storytelling to overcome a multitude of barriers between brands and customers, resulting in more meaningful and impactful relationships with the target audience. Companies can humanise themselves in the perspective of customers by telling true tales that they believe in.
Digital storytelling, when done right, may help B2B organisations build trust, add a new perspective to a brand's story, and include other industry thought leaders in their marketing efforts.
There's no need for storytelling to be limited to a single digital format, as businesses now have numerous options for presenting and sharing their tales across multiple platforms. One of the most appealing aspects of digital storytelling is that a company's story may take several shapes while still connecting with the target audience. A well-crafted tale can be used in a variety of promotional channels and platforms, such as blogs, social media platforms, video content, podcasts, email, and more.


text:
Coming Soon: Crush Your Divorce
How to Crush Your Divorce and Keep Your Faith
Are you facing a divorce? Trying to help a divorcing friend?
In my new book, you'll:
Learn why it's not unladylike or unChristian to stand up for yourself.
Be reminded of God's great love for you and His wonderful plan for your life.
Gain valuable, practical insight into the nuts and bolts of a divorce case—as well as strategies on how to help your lawyer prepare your case to win.
Reconnect with the promises of God's Word to give you hope and comfort in the storm.
Get help on how to cope with post-separation abuse in all its ugly forms.
Grow in your faith as you put on your armor for the biggest fight of your life.
Come to understand and believe God's plan for your life.
Sign up here to be the first to know when the book hits shelves and we'll send you my "Devotional for the Divorcing" FREE!
Thanks for signing up for my devotional. Please check your inbox. If you don't see an email within a few minutes, check your spam!
Coming Soon to Booksellers
About Bree
Attorney Bree Sullivan-Howell was born and raised in South Georgia. After graduating with honors from Deerfield-Windsor School in Albany, Ms. Sullivan-Howell matriculated to the University of Georgia, where she graduated from the UGA Honors Program with a perfect 4.0 grade point average in Journalism/Public Relations, First Honor Graduate, Summa Cum Laude, with honors, in 1999. Ms. Sullivan-Howell's academic success brought with it memberships in such honor societies as Phi Beta Kappa, Golden Key National Honor Society, Omicron Delta Kappa, Phi Kappa Phi, and Order of Omega Greek Honor Society.
While a student at the University of Georgia, Ms. Sullivan-Howell was named one of ten Outstanding Senior Leaders and was awarded a 1997 National Leadership Award from Delta Epsilon Iota Honor Society. She also represented UGA's athletic department in UGA football recruitment efforts, was a member and philanthrophy chairperson of Kappa Delta Sorority, and was a member of Mortar Board. Perhaps her best preparation for law school and, ultimately, a career as a litigator came when she was selected to serve as Defender/Advocate on UGA's University Judiciary. Ms. Sullivan-Howell served as an intern in the Washington, D.C., offices of the late U.S. Senator Paul Coverdell and U.S. Representative Nathan Deal, who went on to become Georgia Governor. While working on Capitol Hill, Ms. Sullivan-Howell attended and completed a course of study with the Institute on Political Journalism at Georgetown University. Ms. Sullivan-Howell worked two years during college as a file clerk in the Athens law firm of Fortson, Bentley & Griffin, P.A. before matriculating to law school in 1999.
Ms. Sullivan-Howell academic success and leadership while an undergraduate earned her a full scholarship to attend law school at Mercer University's Walter F. George School of Law. While there, Ms. Sullivan-Howell distinguished herself as a top student, graduating Cum Laude in 2002 and receiving CALI Awards For Excellence in First Amendment Law, Environmental Law, Taxation of Tax-Exempt Organizations, Appellate Practice and Procedure, Advanced Legal Research, Legal Writing I and Legal Writing II. Ms. Sullivan-Howell also received Faculty Awards for Excellence in Legal Writing I and Legal Writing II and was named to the school's Dean's List. Outside the classroom, Ms. Sullivan-Howell participated in the Volunteer Income Tax Assistance Program helping needy people complete income tax returns and was active in the Federalist Society. She also served as Vice President of Mercer's chapter of Christian Legal Society and gained invaluable experience as an intern to the late Honorable Duross Fitzpatrick, Judge, U.S. District Court for the Middle District of Georgia in 2001.
After her admission to the Georgia Bar in 2002, Ms. Sullivan-Howell accepted a position as an associate with the Macon firm of James, Bates, Pope & Spivey, LLP, (now known as James Bates) where she worked as a commercial and business tort litigator. Ms. Howell relocated from Macon to Thomasville in 2005.
Ms. Sullivan-Howell formerly served as a Board member for Family Enrichment Group, Inc., the Thomas County affiliate of CASA Georgia, Inc., an organization which provides child advocacy services in Georgia's Juvenile Courts. She is also an active member of the Women's Forum, a subsection of the Thomas County Chamber of Commerce, and has presented legal information programs for Boy Scouts and women's small groups in Thomasville. Ms. Sullivan-Howell has served as a competition judge and advisor to the Scholars Academy team in Georgia High School Mock Trial proceedings. Ms. Sullivan-Howell is a member of the Georgia Bar's Section on Family Law and the Thomas County Bar Association. Ms. Sullivan-Howell has served for many years as Chairperson for the Advisory Board to Southwest Georgia Technical College's program in Paralegal Studies.
The American Institute of Family Law Attorneys named Ms. Sullivan-Howell one of the Ten Best Family Law Attorneys in Georgia. Positive feedback from clients has earned Ms. Sullivan-Howell an Avvo Client's Choice badge on www.avvo.com.
Ms. Sullivan-Howell is admitted to practice in all Superior Courts of the State of Georgia, the U.S. District Court for the Middle District of Georgia and the U.S. Court of Appeals for the District of Columbia Circuit, Washington, D.C. She is an active member of Thomasville First United Methodist Church, where she sings with the Worship Team.
Ms. Sullivan-Howell is working on her first book which is set to be published next year.
In How to Crush Your Divorce and Keep Your Faith, attorney Bree Sullivan-Howell shares experiences and lessons learned from nearly two decades as a leading divorce attorney along with insights from her own divorce journey.
© 2022 by Bree Sullivan-Howell | Website by AdeleCreative.com


text:
Q&A: Courtagen's Kevin McKernan on Skirting Sequencing Gene Patents With Novel PCR Methods
May 15, 2014 | Madeleine Johnson
As CSO of Woburn, Mass.-based genetic testing firm Courtagen, Kevin McKernan recently co-authored a pair of papers with other Courtagen scientists describing novel PCR methods that he hopes will help others to avoid violating gene patents during clinical next-generation sequencing.
McKernan believes that by hypermethylating DNA and using two methylation-specific restriction enzymes, researchers may be able to safely navigate the four main types of gene patents. The technique could also be used to prevent DNA from feeding back and contaminating early processing steps, as well to destroy patient DNA before it leaves a lab.
McKernan spoke with PCR Insider this week about this work. Following is an edited version of the conversation.
Your recent Nature Biotechnology paper reviews the impact of methylation on patents and property rights in genetics. You describe a PCR-based clinical sequencing strategy called DREAM that may challenge the interpretation of many patent claims. Could explain what DREAM stands for, and how it works?
DREAM is an acronym that stands for decontamination-ready encoded amplification.
The decontamination side of it is interesting. In clinical laboratories everyone is increasingly using these universal primers … [which] means that it's very easy to falsely amplify [DNA from] a previous patient while you're trying to amplify the next. What's very interesting about the clinical sequencing space is that there is heavy regulation on how you handle patient data ... under the HIPAA guidelines and the omnibus rulings, but there's not as much scrutiny on the laboratory procedures in terms of … possibly let[ting] DNA leave your lab.
People are not decontaminating their trash of DNA before it leaves, and so connecting any two bits of information — like simply amplifying something with Illumina primers, sequencing it, and seeing who was in that day — could be an identity hazard.
We got interested in decontamination techniques, not necessarily due to concerns over people dumpster-diving our trash, but because we sequence samples that look for heteroplasmy, where we have to pick up sub-percentages of alleles.
When you start getting down to those levels of genotyping, contamination begins to be a concern. You really need to make sure there's no background DNA around. As we were developing this we began to see there are other issues that can persist here. We could have contamination on floors, on carpets, on pipettes, that could easily [allow] somebody … to universally amplify these PCR products and potentially sequence them and break patient confidentiality.
That's much harder to do on the data side right now than it is in the laboratory, and that made us think that we should get the laboratory procedures to be as encrypted and as safe as we have in the data front.
What exactly is DNA decontamination?
It's very analogous to what clinical labs have published in the past with the use of uracil, [which] you can target with a specific enzyme so you can eliminate the DNA after you're done sequencing it.
That's the intent here. We switched that uracil base out with a methylated base. Uracil poses problems for a lot of polymerases. This is seen in bisulfite sequencing. It's very difficult to get a polymerase to traverse the uracil. The polymerases are all much happier with the methylated bases and have much better incorporation kinetics. There have recently become available these methyl-specific enzymes that will only digest if the DNA is methylated.
So that was really the swap that we did. It just so happens that in the course of amplifying DNA and reincorporating methylated bases, we believe we've traversed a lot of the gene patents that are out there. That was kind of a side effect we weren't expecting out of the gate.
How does that work?
To be honest it didn't work maybe a year ago, as of the SCOTUS ruling [in Association of Molecular Pathology et al. v. Myriad Genetics]. The Supreme Court ruled that any man-modification of DNA is patent eligible. To the extent that any man-modified DNA is indistinguishable from nature, then it's not patentable. That has left people in a bit of a quandary as to what it really means.
When you do next-generation sequencing, it's very difficult to not man-modify the DNA. You're going to put primers on the DNA, you're going to target it, like doing exome sequencing.
The example that was discussed in the Myriad case was the example of the cDNA. If you look at how cDNA libraries are made in that patent, it's not very different from making an exome library. You are using probes to capture a subselection of the molecules, like you are with an exome capture. Then you're somehow putting primers on them and amplifying them.
Many people, I think, misread that ruling and jumped into Myriad's space, and have since been brought to court … because the SCOTUS ruling really reinforced I'd say three out of four of the typical types of gene patents that are out there.
What are those four types?
People will typically bucket gene patents into four categories. These are loose categorizations, but it's the only way you can really begin to get your head around 4,000 gene patents, or 161,000 claims.
Sliding oligo claim language is one of the four buckets. Arguably, the SCOTUS ruling annihilated those. That's the one thing it probably did do, is that [it said] those aren't specific enough.
Composition of matter claims are often used for drugs. They are atomically interrogated, down to the actual atom. I had some experience with those when I was at Applied Biosystems, after they purchased Agencourt. The whole SOLiD versus Illumina patent estate fell down to whether sulfur was identical to nitrogen. And it turns out it was not, according to the court.
In terms of DNA and composition of matter claims, if you put a methyl group on DNA it's not the same thing. We can see that with PacBio sequencing, and we can see it in the fact that [Integrated DNA Technologies] demands that you specify whether you're oligo is going to be methylated or not. We've also seen it in our papers. If we methylate the DNA, does it behave the same? We can sequence it on an Illumina sequencer, [but] we have to radically change the PCR conditions to make this work. So we feel really strongly that we're not infringing on any composition of matter claim.
The next set of claims is really a tricky set. A lot of lawyers have taken some creativity here, and say, "We claim any DNA sequence which encodes a polypeptide." The reason they can do that is there is a wobble base, which means you get much more coverage on your claim language.
For any given polypeptide sequence there is more than one DNA sequence which can encode it ... So if you claim any DNA sequence which can encode a polypeptide sequence you are making claims to many more DNA sequences that are arguably off target to the gene.
Now, it just so happens that Myriad used that exact language. Many others use that exact language. But in order for a DNA sequence to encode a polypeptide, it has to pass through translation and transcription. DNA which is heavily methylated is silenced in transcription. We've got a good argument that when we methylate DNA, you can't encode anything because it stalls transcription. So, we think we've knocked out that section.
The last category is another clever set of claims. They claim any DNA sequence which is complementary to another DNA sequence. What we've shown in the most recent paper is that, if you were to make an oligo of a given sequence like CATG over and over again, and you were to make the 3' base of that change by a single base, you would see at most a 0.6 to a 0.7 degree change in Tm. If you were to add a methyl group to the C, you'll see a 1.1 degree change. The reason that is important is that complementarity always comes back to Chargaff's rules, A to T, C to G, and it has to do with Tm. Once you start methylating this, the Tm starts changing much more radically than it would if you had any other base composition change. We think we've got a strong argument that by hypermethylating [DNA] we're radically changing the complementarity and therefore the claim language doesn't stick.
This [idea] has been reviewed by many lawyers. We decided to publish it because we wanted to have even more people argue whether it was right or wrong. Frankly, we don't know the answer. We know that it's a very complex space and with there being 161,000 claims, we're not about to pay our attorneys to read them all. We'd rather have the public debate about it and see where things fall.
So that was the motivation for the Nature Biotechnology paper?
Yeah, it was. We put it in the patent section … but we didn't have enough space to go into the methods. We [also] wanted the methods to be open source, so we … put them in PLoS One, where we'd have enough page space to go through one by one, what you do in order to enable this.
For example, with the different enzymes —MspJI for 5mc, and AbaSI for 5hmc?
That's right, there are two different enzymes that are described in there. There's also a lot of DMSO in order to get this to work. We mention it raises the Tm when you put that many methyl groups on a molecule. You can't raise it to 110 [°C] to deal with it because you'll just end up getting hydrolytic damage in the DNA. What you have to do is change the solvation through non-thermal methods. DMSO is great for that. We tested out all the way up to eight percent DMSO and showed what that curve looks like. Somewhere between three and four percent DMSO seems to be right for this library.
The other new thing in the paper is the use of these two different enzymes.
Many exome capture techniques that are out in the marketplace today require you to perform two amplifications. You amplify before you enrich, then you amplify after you enrich. You really need to have different bases at each of those steps if you want to ensure that one amplification isn't going to contaminate the other.
The first application we showed in Nature Biotechnology, we're using [Agilent Technologies'] Haloplex, which is a different assay and only requires one amplification. So we can get away with just doing 5-methylcytosine. The moment we got into steps which were going from genomic DNA, which does have a little bit of methylation in it, then amplifying that, and then amplifying it again, we needed to start working with 5-hydroxymethylcytosine [as well].
There happens to be enzymes that discriminate the two that can create what we've termed a DNA diode, where DNA can only go unidirectionally through a lab. If it ever feeds its way back into other laboratory equipment, it is going to get digested by these enzymes that are very specific for digesting post-amplification products.
Both of those enzymes are heat labile, so they're in all of our reagents, and only when you heat them up, like in PCR, do you kill them. We have MspJI in our PCR cocktail, which means it's constantly digesting any hypermethylated double-stranded DNA that's around. The moment we kickstart PCR, it kills that enzyme and then that PCR reaction creates hypermethylated double-stranded products. If any of those find their way back into the previous step, they're chewed by the enzyme.
The same thing is true with the second amplification. We have hydroxymethylated bases in there, which are slightly different than methylated C, and AbaSI will specifically digest hydroxymethlyated C without digesting methylated C. That's important because the input DNA at that point is going to be hypermethylated from the first PCR. So we needed to have an enzyme that could differentiate those two.
We think there's a lot of applications for this outside of just these assays, and I think if you ever want to make something portable, or [develop] field amplification techniques, where you don't want to worry about clean rooms and all the hyper-cleanliness, or disposable tips and robots, there's all types of areas where this will simplify the PCR process because of the built in error correction.
Are there any potential pitfalls?
Genomic DNA is going to be lightly methylated. So, if you apply MspJI there, you're arguably going to deplete your first exons, and your CpG islands will get digested. Some people have asked if that's a problem for your capture. If you're running around cutting all the regions that are methylated they're not going to be in your exome to capture. It turns out that doesn't appear to be the case with the Haloplex protocol [we use] because it turns everything into a single-stranded circle at the point at which we're using this enzyme. That's not to say it wouldn't create problems for other assays, people just need to be aware of that. On the flip side, about 0.1 percent of the DNA is hydroxymethylated, so you can always switch to that enzyme and rearrange what we've done if people are concerned about losing the first exons or the CpG islands in their assay.
Déjà vu PCR is the method using both enzymes. You published this as a method and it sounds like you want people to try it, and hopefully publish on it also.
Yes. There are also a couple companies that have asked us to license it to put it into kits. So, it will probably come out in the form of a kit, and what they call it is up to them. Déjà vu is really meant to emphasize we're doing it again. It's methylated one time and then remethylated with a slightly different methyl group the second time.
[This would likely be] a kit for keeping PCR clean. I don't think anyone is going to turn this into a spray for the lab trash. I have a feeling it would be in everyone's PCR tools. This is important for capturing clean sequences out of mitochondrial DNA, mosaicism, or heterogeneity in cancer. You have to call five percent allele frequencies, and you're questioning, "Is that a contamination event, or is that actually a rare population of tumor cells that I need to worry about?" You can waste a ton of time looking at contamination questions. It's better just to build tools that safeguard against it.
You wrote in your Nature Biotechnology paper that you believe gene patents are immoral. Would you like to expound on that?
I spent four of five years of my life burning myself an ulcer at the Human Genome Project to make sure that the genome was public and that there were Bermuda principles involved. The group that we vilified in that process was Celera Genomics because they were going to patent some genes. When all was said and done, the National Institutes of Health has more gene patents than Celera. That has not followed the Bermuda accords by my standards. That has gotten somehow into a hypocritical morass of: What was the genome project for? To me, putting all that effort in, I expected when we went to sequence sick kids in 2014, we wouldn't be threatened with lawsuits for doing it.
Now we're in a scenario where all these start-up companies are coming to play, to bring next-generation sequencing to the market and potentially help a tremendous number of sick people, and 20 percent of genes are thought to be patented. That's not fostering innovation. If that's what the patent system is designed to do, it is failing horribly.
So in terms of your PCR-based method, it may allow other people to get around this problem?
We hope so. We can't say that with 100 percent certainty because we haven't gone and read 161,000 gene patent claims. I wouldn't recommend anyone go do that. That's just a tremendous amount of money wasted that should be put toward building better assays and sequencing more patients. [Our method] is hopefully something that can get sold and spread around to the world. It's been published and there are companies that are talking about commercializing it. We're not in the best position to commercialize it because we are in fact a clinical sequencing lab. For us to build kits to do this we would need a partner, and … the intent of some of these agreements is to get leverage through a supply chain and sales channel that is much more powerful than ours. That should enable other labs to potentially adopt this and not have to spend their time with these sorts of [legal] questions.
Your company launched two next-generation sequencing-based tests last week for neurodevelopmental disorders, developmental delay, intellectual disability, and autism spectrum disorder. Do these use your new methods as well?
All of our methods use the Haloplex plus the DREAM PCR for the panels. We even have that working in whole exomes as well. It's been applied to everything we do.
Are there any other interesting current projects?
The other assay that we are working on, and hope to have launched at the end of the year, is to move the whole chromosomal microarray problem into a next-gen sequencing assay. That's typically the front line of defense. People start with a chromosomal microarray to look for a megabase-sized copy number variation. There's no reason that should be done in a chip anymore. There are assays that would move that on to a next-gen platform that have already been published and are fairly easy to implement. [For example], Zheng et al. published the replacement of an Affymetrix 1.8M SNP array with RAD-Seq on a SOLiD.
Courtagen
Mutational Signatures Profiled in Pediatric Cancers


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NSU athletic trainer Ashley Leggett spotlighted
March 28, 2019 March 28, 2019 / NPJ
By Samantha Clark, NSU Sports Information student intern
While athletic training has been traditionally a male-dominated field, more women are making their mark. Northwestern State employs six women out of the nine-member athletic training staff.
March is National Athletic Training Month and International Women's Month. NSU Athletics salutes its women in athletic training. Featured today in a question and answer interview: Ashley Leggett, associate director of sports medicine, who works primarily with Demon football.
Q: How long have you worked at Northwestern? How long have you been an athletic trainer?
A: I'm in my third year here at NSU. I've been certified for six years.
Q: Since you're from Alabama, what made you decide to come to Northwestern?
A: Esi Atinkah came here as a graduate assistant. Esi and I went to undergrad together (at Alabama). I was an intern at Samford University in Birmingham looking for a full-time job, and there was one available here. Esi called me and was like, "How do you feel about moving to Louisiana?" I said, "I wouldn't mind it one bit." The rest is history. Esi got me here.
Q: How did you get involved with athletic training? What was your moment when you realized this is was your calling?
A: I don't know if I really had an "a-ha" moment. Growing up as a kid I wanted to be a firefighter. Then I wanted to be a doctor. I still have inklings of sometimes I want to be a doctor, but my whole life I loved sports. I grew up watching Braves baseball with my dad. I remember watching the Braves since I was two or three years old. I saw the guy who ran on the field when people got hurt, and I really thought that was cool. I didn't think too much of it. I got to college and went into chemical engineering because I wanted to be a doctor, and they look for random degrees. After a year in chemical engineering, I got this itch that athletic training is where I was supposed to be. It merged the two loves I had of being around sports all day while also getting to work in a medical field, and I don't regret the decision one bit. I love what I do every day.
Q: Since it's Women's History Month, who are some of your women inspirations and role models? Are any of them in the athletic training profession?
A: My biggest mentor in the profession would have to be Erin Weaver (Cohn). Erin was the softball athletic trainer at Alabama while I was there and took me under her wing. She's taught me a lot, mentored me a lot. We're still really good friends. We're still close. She's not the softball athletic trainer at Alabama anymore. She's actually more of the director of rehab. She moved into a different position but still in the profession. I've always looked up to Erin. Other female role models… This is a tough question because my biggest role model in my life is my dad. Sue Falsone was the athletic trainer for the Los Angeles Dodgers. As somebody to look up to and aspire to be, I think Sue is that because she made it to the pinnacle of a man's world in Major League Baseball as a female in athletic training. She made strides for women to break into professional sports, and I think that's really awesome.
Q: How has this profession changed for women since you entered?
A: To be honest, it's gone a lot from a guy's world to a woman's world. I feel like the profession now is almost more female-dominated than men. There are more female athletic trainers now than men, and we're getting more opportunities to work with male sports and bigger-time male sports. We continue to make strides in the right direction by doing things the right way, professionally. I think the sky's the limit now for women in athletic training. I mean I'm a 29-year-old female working collegiate football, and 10 to 15 years ago that was unheard of.
Q: In 1996, the NATA membership was 44 percent female. The most recent stats have come out, and it's now 44 percent male. Why do you think that is?
A: I really don't know. It's hard to say, but I feel like a lot of the medical professions are going that way. I think if you look at physician's assistants and PA school it's more female-dominated than guys. I don't know that med school is there yet, but I feel like more women are going after these historically male-dominated fields because the opportunities are there now. There's been people who have paved the way for us to have these opportunities, and we need to go out there and grasp them and make way for the next generation.
Q: Do you have any advice for females just starting in the profession or are considering becoming an athletic trainer?
A: Chase your dreams and never give up. There are plenty of opportunities out there now. Find a mentor and latch on to them. Learn and grow as much as you can. The sky's the limit. There are really no limitations to what women can do in this field any more, and it's pretty awesome.
Q: Northwestern's athletic training department is 2:1 in gender. Even though it's a noticeable ratio, do you think there's any barriers you've had to break through or work with on this campus as a woman?
A: I don't feel like I have. I work a male-dominated sport. I work with all male coaches, and I've had nothing but respect from them. They all listen to me and take what I say to heart. They trust me. Since I got here three years ago, I haven't had any issues being a female in a male-dominated world.
Q: Do you have any additional comments you'd like to make?
A: I love what I do. I love coming to work every day. I take care of 115 guys, and they're all a joy and a pleasure to work with. They're all nice, respectful, yes ma'am and no ma'am. Sometimes football guys get a bad rap, but I've never been anything but respected around here. I think that says a lot about our coaching staff, and that starts at the top. I think Coach (Brad) Laird is doing a great job with the guys and the program. I think we're going in the right direction. I really appreciate the opportunity to work here.
← LSMSA senior awarded President's Alumni Scholarship to LSU
Dream Run is set for this weekend →


The previous week, a women in the audience when answering the question on whether they feel a bit sorry for the PM, was allowed uninterrupted about 2 minutes to give her reasons why she firmly thinks the answer is no. This clip was shared and celebrated many times on Twitter.
The same people who shared that clip are the same people complaining about Fiona Bruce and the BBC's treatment of Dianne Abbott.
It's basically just an example of how politics is at the moment and how it all pans out on Twitter. Presumably if and when she gets into power nobody will be able to have a go at her when she makes a tough decision in her department, as it will be racist or sexist?
I am so sick of people playing the 'Race' card! Just accept criticism for what it is, and work on your failings like most people!
Probably absolutely nothing since the whole thing is a storm in a teacup! As you were folks!
Andrew, surely you can tell the difference between fair comment from the audience member and Fiona Bruce literally egging the audience on beforehand?
Nope, you're absolutely right, I wasn't. But then, that wasn't relevant to the question I asked. Especially given the Independent's article tonight.
Edit: if not bias (a dodgy thing to claim) then surely it counts as unprofessional?
Nope, you're absolutely right, I wasn't. But then, that wasn't relevant to the question I asked.
What it's relevant to is the claim that "Fiona bruce [was] literally egging the audience on."
I note a few comments on Twitter suggesting that last night's QT was one of the worst ever editions in its entire history.
Having not seen it for myself, I can't comment.


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