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Region — Franklin County State-wide trends The reported reduction rate of COVID-19 positive cases shows a 7-day count of 38 confirmed cases by the US Centers for Disease Control and Prevention (CDC) as of February 11. The count shows a 38.71% reduction in confirmed cases from the previous 7 days.
As of February 7, the town of Farmington reported a cumulative maximum of 323 cases of COVID-19 identified in Franklin County, according to the Main CDC.
Federal CDC data provide county-wide confirmed cases across the country, while Maine CDC provides postal code-specific data that combines both state-wide confirmed and possible cases. To provide.
Recent outbreaks in Farmington Orchard Park Rehabilitation & Living Center There were 29 confirmed cases on February 10.
As of February 13, the University of Maine at Farmington (UMF) has reported a total of 20 positive cases since the start of the second semester test.
“As for our positive case, 10 on-campus and 10 off-campus UMF community members are positive this semester from statistics shared in weekly test notes starting January 8, 2021. You can share what you did with the test, “said Christine Wilson, Vice President, Student Affairs & Enrollment Management, in an email.
UMF is currently in Phase 6 of the testing process, and all students, staff, and faculty members working or living on campus need to be tested weekly.
Farmington will also benefit from the wastewater management program of the main university system, which is affiliated with the town’s sewerage facilities. COVID-19 test sewage Fragment for tracking infection trends.
Although the federal level has not set a specific number of positive COVID-19 cases to constitute an outbreak, the CDC in Maine has determined three positive cases that indicate an outbreak at K-12 schools.
According to the state CDC Standard business procedure manualAn outbreak is declared when “there are 3 or more confirmed cases from different households within 14 days”.
Regional School Unit 9 reported a total of 40 positive COVID-19 cases during the 2020-21 school year. District website..
The main CDC shows that the town of Jay has recorded the second highest cumulative probability in the county. There are 150 cases, and Wilton shows a total of 78 cases.
Rangeley, Kingfield, Strong, Phillips, and New Sharon all report a total of 20-49 cumulative possible confirmed cases.
Eustis, Stratton, Temple, New Vineyard, and Weld each have 6-19 estimated and confirmed cumulative cases as of February 7.
Franklin County reported the first confirmed case of COVID-19 variant B.1.1.7 in Maine on February 10. This variant was first detected in the United Kingdom and currently exists in 34 states.Florida and California are currently reporting the maximum number of variants Over 150..
The Maine Department of Agriculture and Forestry recently hosted a webinar to dispel false information about the COVID-19 vaccine. At the webinar, microbiologist Lisa Morici of the University of Train University School of Medicine in New Orleans shared information about the B.1.1.7 variant.
“We know that this virus is more infectious than the original virus, so that’s an important point that we all still need to wear masks,” Morichi said on February 12. Said in the webinar. “It’s less deadly, but if it’s more contagious, it will infect more people and cause more hospitalizations and deaths, but the mutation itself makes it more deadly. I won’t. “
Morici added that vaccination has already been modified to ensure high efficacy rates for variants B.1.1.7, B.1.351, and P.1. The CDC reports the success of current vaccines against these COVID-19 variants.
“So far, studies have suggested that antibodies produced by vaccination with currently approved vaccines recognize these mutants. This has been scrutinized and more studies have been conducted. Is in progress. ” CDC website says..
As of February 16, Maine had received 255,849 coronavirus vaccines, with 75,384 people receiving the second dose. maine.gov vaccination dashboard.. Fully vaccinated people in Maine make up 5.61% of the state’s population.
In Franklin County, 936 people receive both coronavirus vaccines, which is equivalent to 3.10% of the county’s population.
Morici said 60% of the US population needs to be vaccinated to stop the spread of COVID-19. This percentage includes the consideration that about 20% of the country’s population is naturally immune.
“If you say that 80% of the population needs to achieve herd immunity and 20% already have immunity, then 60% more Americans need to be immunized to get there.” Morici said.
To reach 60% of the population, 198 million people need to be vaccinated in the United States. As of February 16, the CDC reported that 15,471,536 people in the United States had been vaccinated with both doses of coronavirus vaccine.
Coronavirus mortality rates range from 1-2%, with an additional 2-4 million deaths in the United States without herd immunity.


Heidi Duckler Dance Theatre Presents FISHEYES at the Baldwin Hills Scenic Overlook
Heidi Duckler Dance Theatre brings FishEyes to Culver City's Baldwin Hills Scenic Overlook on Friday, November 3, 2017 from 6:00pm - 7:00pm.
Heidi Duckler Dance Theatre partnered with local architect Alex Ward to design and build a 15-foot steel fish. That Fish spent much of the year traveling around the Los Angeles area, stopping for residencies in parks in Los Angeles. With each stop, HDDT's core company dancers performed an adventurous, multidisciplinary production exploring water and drought through site-specific choreography in, on, and around the giant stainless steel fish.
The fish comes to the Scenic Overlook for a public performance funded by the City of Culver City to inspire awareness of the Ballona Wetlands, an urban-adjacent ecosystem, within the Culver City community. Choreography will highlight the interaction of dancers with the teaching sculpture, encouraging play, investigation, improvisation, and responsiveness as key strategies towards greater environmental awareness.
This performance is made possible in part by a Culver City Performing Arts Grant with support from Sony Pictures Entertainment.
RSVP at https://fisheyes.eventbrite.com


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There is a visible shortage of female entrepreneurs to act as role models for future founders. This is one of the key things that holds women back in the workplace. How can we, as women, be inspired to start our own business when most start-ups aspire to the success of Steve Jobs, Richard Branson and Mark Zuckerberg? There’s nothing wrong with them, they are accomplished role models; however, if there is going to be a change in the status quo, there needs to be opportunities for women to follow in the footsteps of other women. That journey starts by knowing that it’s possible.
Lu Li, the creator of Blooming Founders, is filling that gap in the market.
“You can’t be what you can’t see,” Lu evangelizes, as she shares her experience of learning business lessons the hard way. Those fortunate enough to be part of the exclusive London launch of her book, Dear Female Founder, would walk away with 66 pieces of impactful advice in the form of letters from new female mentors; housed in a signed copy. Five of the women featured hold MBE and OBE titles. Truly inspiring. The project took 9 months from conception to publication and was born out of a successful crowdfunding exercise. It enabled Lu to connect with female entrepreneurs and learn from their success stories. It’s a valuable resource to many, including Sarah Wood OBE, co-founder of Unruly: “I wish this book had existed when I started my own entrepreneurial journey – it would have saved me a lot of time and heartache.”
Within the pages, the female entrepreneurs, boasting a combined revenue of $1 billion, share their advice and wisdom. “Act like a global CEO from Day 1,” says Sharmadean Reid, founder of WAH London, she then adds, “surround yourself with as many people as possible who know more than you do.”
Starting a business is all about collaboration; working with others that are skilled in areas that you may not be, will only help to support your business growth. Ultimately, you will benefit if you have like minded people around you, so find a co-founder that complements you and collaborate.
Lu frames her book by discussing the power of collaboration and the ability that it has to create a movement. “I didn’t know 70% of the women featured in the book before the project began,” says Lu. It clearly articulates the “power of women supporting women.” The contributions are global featuring letters from Jordan, NYC, New Zealand, Argentina and London, to name a few. The youngest founder is 24 and the oldest 50, which shows, as Lu says, “it’s never too late to start.”
Positive affirmations such as these are exactly what the book embodies. Telling yourself “I am the shit,” everyday can only support you on your journey, professes Alex Depledge, co-founder of Hassle.com. In her opinion, “female confidence is the biggest inhibitor of progression.” We live in a world where life is not like Instagram, even though everyone is pretending that it is by promoting their curated self image to society. So, ‘lean in’ and pursue the idea that has been in the back of your mind. Often the most difficult thing to do is to start.
As a collection, the book is an impactful resource for future generations. By asking these women to write a letter featuring the advice that they want to pass on, Lu has introduced women to new personal mentors. In turn they have advised her on her own business journey.
Irra Ariella Khi, co-founder of Vchain Technology, is one of these mentors. Acknowledged as a champion of the book itself, Lu and Irra connected after a chance phone call in an airport as Irra was waiting to collect her luggage. Support can be found anywhere – you just have to be open to conversation. “What would you do if you were not afraid?” asks Irra in her letter. Courage is the only thing standing between you and your goals.
Sometimes you have to ask for support in order to progress. When Lu voiced her idea to Irra that day on the phone – something along the lines of “Hi I’m Lu, I have this idea for a book…what do you think?” – it was asked boldly and fearlessly to a stranger. An open conversation. A request for insight.
Looking around at a captive audience of women that are so obviously inspired is inspiring. Lu’s book launch brought them all together. The venue? Huckletree – the business venture of Gabriela Hersham, who provides collaborative co-working offices for ambitious people to make things happen. “Always hang out with people who are smarter than you. Osmosis works,” says Gabriela, backing the concept of her own initiative.
Are you starting to see the trend here? Knowledge sharing, confidence, positive self talk, collaboration and support. These are the core words that exude from the 66 letters of advice. They flow in three parts, categorized by stories that focus on how to “start,” “learn” and “reflect.”
Dear future founder: there is something for everyone at every stage of their business journey in this book. Male or female founder, you need to read it. It is now climbing the entrepreneurial book ranking on Amazon – you can buy it here.

domain: literature


text:
Background: The treatment of insomnia with sleep medication causes problems such as long-term use, dependence, and significant economic losses, including medical expenses. Evidence-based lifestyle guidance is required to improve insomnia symptoms not only in person but also in easy-to-use web-based formats.
Objective: This study aims to clarify whether unguided internet-based cognitive behavioral therapy (ICBT) or the Three Good Things (TGT) exercise, both administered as self-help internet interventions without email support, could improve insomnia symptoms compared with a waiting list control (WLC) group.
Methods: A 4-week program was implemented, and participants were randomly allocated to 1 of the 3 groups. The primary outcome measure was the Pittsburgh Sleep Questionnaire (PSQI) score at 4 weeks compared with baseline.
Results: Of the 21,394 individuals invited to participate, 312 (1.46%) met the eligibility criteria and were randomly assigned to 1 of the 3 groups. Of these 312 individuals, 270 (86.5%; ICBT 79/270, 29.3%; TGT 88/270, 32.6%; and WLC 103/270, 38.1%) completed a postintervention survey at 4 and 8 weeks. The adjusted mean changes of the primary outcome measure (PSQI) in the ICBT (−1.56, 95% CI −2.52 to −0.59; P<.001) and TGT (−1.15, 95% CI −2.08 to −0.23; P=.002) groups at 4 weeks from baseline showed a significant improvement compared with the WLC group. The adjusted mean changes in the secondary outcome measures of sleep onset latency, total sleep time, Athens Insomnia Scale score, and Patient Health Questionnaire-9 score at 4 weeks from baseline, as well as in the PSQI at 8 weeks from baseline, showed significant improvement for ICBT. Moreover, total sleep time, Athens Insomnia Scale, and Patient Health Questionnaire-9 scores at 4 weeks from baseline showed a significant improvement in the TGT group compared with the WLC group.
Conclusions: A total of 4 weeks of unguided ICBT and TGT exercises improved insomnia.
Trial Registration: University Hospital Medical Information Network Clinical Trial Registry UMIN000034927; https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000039814
Insomnia describes the inability to sleep, including difficulty falling asleep, difficulty staying asleep, difficulty sleeping, and early waking, despite an attempt to sleep at the right time and in the right environment. This condition reduces an individual’s quality of life by causing various daytime dysfunctions, including sleepiness during the day . Insomnia can be caused by a variety of factors, including changes in social life such as decreased interpersonal interaction and socializing, as well as mental and physical illnesses, decreased physical function, and physiological changes in the brain. Insomnia impairs daytime activity and triggers additional illnesses such as depression, lifestyle-related diseases, and cancer. Insomnia is a common complaint in adults, with 13.5% to 20.6% of the general population experiencing daytime sleepiness >3 times per week [ ]. It has been reported that 14.9% of people in Japan have profound daytime sleepiness [ ]. Another study found that 1 in 5 Japanese adults had sleep problems [ ]. In Japan, the economic losses caused by sleep deprivation and insomnia have been estimated to be 15 trillion yen (US $8.67 billion) [ , ].
From the perspective of optimizing medical costs associated with lifestyle-related diseases, such as diabetes, hypertension, and hyperlipidemia, lifestyle guidance is increasingly being introduced as a complement to the use of medication. However, the evidence base to support the introduction of lifestyle guidance is lacking. The provision of face-to-face advice paired with an insomnia improvement program delivered as easy-to-use internet-based life guidance will likely reduce medical expenses.
Insomnia practice guidelines in the United States and Australia recommend cognitive behavioral therapy (CBT) as the first choice for the treatment of insomnia. In Japan, there are very few medical institutions that can provide CBT, and there are no barriers to prescribing psychotropic drugs outside of psychiatry and psychosomatic medicine. However, pharmacotherapy is associated with side effects such as dependence, tolerance, anterograde amnesia, muscle relaxant effects, carryover effects, and rebound insomnia. Furthermore, it increases the risk of double prescription and overdose and requires long-term treatment. However, the success of pharmacotherapy is limited. According to the Japanese Society of Sleep Studies guidelines, it is preferable to prioritize CBT over pharmacotherapy for insomnia.
CBT for insomnia is a treatment that focuses on anxiety and biased thinking about sleep and improves insomnia by reviewing an individual’s lifestyle, existing anxiety and tension, and any thinking related to the maintenance of insomnia. Sleep hygiene instructions can provide important knowledge about sleep, including how to adjust living conditions so that good-quality sleep can be obtained, and practice measures for maintaining good-quality sleep throughout life. This study used internet-based CBT (ICBT) without email support to provide sleep hygiene guidance as a trial treatment. ICBT was paired with a self-help intervention as a form of noninvasive self-medication.
Positive psychology focuses on positive psychological traits such as happiness, optimism, and satisfaction with life and was developed by Seligman et al  of the University of Pennsylvania based on the reflection that traditional psychology was excessively focused on normalizing negative traits such as mental illness. Positive psychology is based on the idea of nurturing [ ]. A typical method of positive psychology comprises the exercise of writing 3 good things every day before going to bed every night [ ]. It is a simple diary-like exercise that involves listing 3 good things that happened that day and providing a written explanation of why those things happened. In this study, this exercise was called the Three Good Things (TGT) exercise.
ICBT has gained increasing attention as a possible treatment for improving insomnia, and many studies on ICBT have been conducted. ICBT provides web-based CBT and sleep hygiene guidance, simulating an ordinary CBT session (counseling) that is typically conducted by the patient and therapist face-to-face. With the approval of the Chiba University School of Medicine Hospital clinical trials ethics review board (approval number G27040), the combination of guided ICBT for insomnia and routine care (ie, usual care [UC]) has been shown to significantly reduce the Pittsburgh Sleep Quality Index (PSQI) score [, ]. In a randomized controlled trial (RCT) of 23 patients with insomnia whose symptoms persisted even after taking sleep medications such as benzodiazepines, the adjusted mean change in total PSQI score from baseline to 6 weeks was −6.11 in the ICBT+UC group (n=11), which was significantly better than the 0.40 change seen in those who underwent UC alone (n=12; P<.001). In addition, a significant improvement was seen for the adjusted mean changes in PSQI score; sleep onset latency (SOL); sleep efficiency (SE); number of awakenings; and mean change in depression at 3, 6, and 12 weeks from baseline in the ICBT+UC group. No adverse events were reported.
Seligman et al  previously evaluated the effects of the TGT exercise in a RCT. According to that study, the group that performed this exercise daily for 1 week not only increased self-reported levels of happiness but also reported decreased depression compared with the control group, and the effect persisted after 6 months. To the best of our knowledge, no studies have examined whether the TGT exercise can reduce insomnia. However, recent reviews have shown that there is a correlation between positive emotions and sleep [ ]. TGT may improve sleep by improving positive emotions.
This study aims to determine the effectiveness of an unguided, web-based self-help intervention in reducing insomnia. Using an RCT design, a nonclinical population of adults with insomnia was allocated to one of three groups: (1) the ICBT group, (2) the TGT group, and (3) the waitlist group. It is hypothesized that unguided ICBT and TGT would result in higher quality sleep in the treatment groups than in the waitlist group.
We report this RCT trial in accordance with the CONSORT-EHEALTH (Consolidated Standards of Reporting Trials of Electronic and Mobile Health Applications and Online Telehealth) version 1.6 checklist ().
This study comprised an exploratory, parallel-group (3 groups), randomized, open-label, controlled study, incorporating a nonintervention group (waiting list control [WLC]). The registration of the participants was started in February 2019.
Participants and Recruitment
An email was sent to the registered monitors owned by the internet research company that commissioned the research, and a preliminary survey was conducted on the internet in relation to the inclusion and exclusion criteria given in the following sections, after which informed consent was obtained.
Potential participants were required to meet all the following inclusion criteria at the time of the preliminary survey: (1) aged 20 to 70 years (regardless of sex); (2) patients with mild or severe sleep disorders, who scored ≥6 on the Athens Insomnia Scale (AIS) and ≥6 on the PSQI; (3) sleep disorder occurring at least three nights per week and lasting for at least 3 months; (4) access to internet use with PCs, smartphones, and tablets; and (5) understood the explanations in Japanese and freely provided web-based consent.
Exclusion criteria of the study included (1) those with moderate or severe anxiety symptoms, scoring ≥10 on the Generalized Anxiety Disorder-7 (GAD-7) questionnaire; (2) those with moderate or severe depression symptoms, scoring ≥10 points on the Patient Health Questionnaire-9 (PHQ-9); (3) the confirmed presence of alcohol or drug dependence, diagnosed by a medical institution within the past year, excluding tobacco smokers; (4) suicidal thoughts, with a score of ≥2 in the Q9 part of the PHQ-9; (5) the confirmed diagnosis of cerebral organic diseases such as sleep apnea syndrome, restless leg syndrome, epilepsy, dementia, or cerebrovascular disease; (6) the confirmed diagnosis of a severe progressive physical illness, such as cancer or heart failure; (7) the use of pharmacotherapy for mental disorders, including insomnia symptoms; and (8) night shift work between 8 PM and 2 AM.
Individuals who met the above conditions and provided consent were enrolled as study participants. This study excluded patients commonly treated with pharmacotherapy for insomnia.
Case Registration and Allocation Methods
Case registration was performed via the trial website. Among the registered members (candidate participants) of monitors owned by the internet research company, those who met the conditions were automatically assigned participant identification codes when they accessed the servers. Members voluntarily underwent a preliminary survey after explanation and agreement, following the distribution of the recruitment materials. In the first preliminary survey, AIS, PSQI, GAD-7, and PHQ-9 were administered to select and screen participants for inclusion. Only those who met the inclusion criteria and did not meet any of the exclusion criteria were able to proceed to the next preliminary survey. The second preliminary survey was conducted 2 weeks after the first preliminary survey and contained the same content as the first survey. Only those who met the inclusion criteria and did not meet any of the exclusion criteria proceeded to take part in the study. Responses from the second preliminary survey were used in the analysis as baseline values before the intervention. After the participants were randomly assigned, the method of accessing the intervention program assigned to each participant was provided by email.
Allocation modifiers included baseline PSQI scores (≥12 and ≤11) and gender (male and female).
Intervention Schedule and Methods
Participants were randomly assigned to 1 of the 3 groups. The study period was 4 weeks; thus, the ICBT group underwent an unguided ICBT program for 4 weeks, the TGT group underwent a TGT exercise program for 4 weeks, and the nonintervention group (WLC) waited for 4 weeks without an intervention. They then received access to their assigned unguided ICBT program and the TGT exercise program for 4 weeks, 7 times a week for 15 to 20 minutes each time.
The intervention programs comprised the following two types: unguided ICBT program and TGT program.
Unguided ICBT Program
We encouraged participants to take part in the unguided ICBT program for 4 weeks. Participants accessed the ICBT site and performed the following tasks autonomously:
- Week 1 session: keeping a sleep diary (understanding the significance of the sleep diary and how to write it)
- Week 2 session: changing behavior (improving behavioral habits that maintain insomnia, using stimulus control)
- Week 3 session: capturing thoughts (reconstructing cognition related to sleep using the column method)
- Week 4 session: changing sleep time (adjusting sleep schedule using the sleep restriction method)
Participants were encouraged to participate in the TGT exercise for 4 weeks. The participants who accessed the site received the prompt by email and autonomously filled out the 3 good things on that day. An explanation of the methods of the TGT exercise is provided elsewhere by Seligman et al  and Seligman [ ].
The primary outcome was the change in PSQI scores from baseline to the postintervention survey at 4 weeks. The secondary outcome was the change in PSQI scores from baseline to the postintervention survey at 8 weeks and changes in SOL, total sleep time (TST), SE, AIS, GAD-7, PHQ-9, and Center for Epidemiologic Studies–Depression Scale (CES-D) positive items only from baseline to the first and second postintervention surveys at 4 and 8 weeks. Web-based assessments were also administered.
The PSQI is a self-administered questionnaire for evaluating sleep and sleep quality . Eighteen questions evaluated seven factors: sleep quality, sleep onset time, sleep time, SE, difficulty sleeping, use of sleep medication, and drowsiness during the day that hinders daily life. A total of 7 factors (0-3 points) were summed to calculate the total score (0-21 points). The higher the score, the greater the sleep impairment. A Japanese version has also been developed, with the cutoff set at 6 points [ ].
The AIS is a self-administered questionnaire for assessing the severity of insomnia . It comprises eight items: sleep, midnight awakening, early morning awakening, TST, overall sleep quality, daytime satisfaction, physical and mental daytime activity, and daytime sleepiness. A total of 8 items (0-3 points) were summed to calculate the total score (0-24 points). A Japanese version has also been developed, with the cutoff set at 6 points [ ].
The GAD-7 is a self-administered questionnaire for evaluating generalized anxiety disorders . It comprises 7 items, and covers the 2 weeks immediately before the administration of the test. The scoring system is as follows: No at all: 0 points, Several days: 1 point, More than half: 2 points, and Almost every day: 3 points. The total score is calculated from 0 to 21 points. A Japanese version has also been developed, with 0 to 4 points suggesting no generalized anxiety disorder, 5 to 9 points representing mild generalized anxiety disorder, 10 to 14 representing moderate generalized anxiety disorder, and 15 to 21 indicating severe generalized anxiety disorder [ ].
The PHQ-9 is a self-administered questionnaire for evaluating major depressive disorder . It comprises 9 items and covers 2 weeks immediately before administration of the test. The scoring system is as follows: No at all: 0 points, Several days: 1 point, Half or more: 2 points, and Almost every day: 3 points. The total score is calculated from 0 to 27 points. A Japanese version has also been developed, with 0 to 4 points suggesting that the individual is not depressed, 5 to 9 points suggesting mild depression, 10 to 14 points suggesting moderate depression, 15 to 19 points suggesting moderate to severe depression, and 20 to 27 points suggesting severe depression [ ].
The CES-D is a self-administered questionnaire for assessing depression . It comprises 20 items about mood and physical condition covering the past week using a 4-point scale ranging from 0 (not at all) to 3 (over 5 days). In this study, 16 negative items were not used, and only positive items were used. The positive items comprised four statements: “I think I have the same ability as other people,” “I can think positively about the future,” “I can enjoy my life without complaints,” and “I enjoy every day.” The total score is calculated from 0 to 12 points. A Japanese version has also been developed, with a higher total score indicating a higher degree of positive emotions [ ].
All participants who enrolled in this study, responded to the intervention program at least once after randomization, and had efficacy data were the most significant population for full analysis set (FAS). However, participants for whom baseline data could not be obtained and those who violated the dominant protocol (eg, violating the inclusion criteria or exclusion criteria and incorrect assignment to the intervention program) were excluded.
Participants selected from the FAS and those meeting the following criteria were selected as the target population per-protocol set (PPS) that complied with the study protocol: (1) completed at least 75% of the intervention program, (2) had available measurements of critical variables, and (3) had no major test plan violation such as selection criteria violation, exclusion criteria violation, or incorrect assignment to an intervention program.
The sample size was based on a previous study by van Straten et al , which indicated that the estimated difference in changes of PSQI scores from baseline was approximately 3.5. Assuming a group difference of 3.5 (SD 10.0) points, 66 participants per group provided 80% power to detect a difference in PSQI scores among the WLC, ICBT, and TGT groups at a 5% significance level.
Analysis of Participant Background
The distribution of participant background data and summary statistics for each analysis population were calculated for each group. For nominal variables, the frequency and proportion of categories have been shown for each group. For continuous variables, summary statistics (number of cases, mean, SD, minimum, median, and maximum) were calculated for each group. Pearson chi-square test was used for nominal variables, except when ≥20% of the cells had an expected frequency <5 (when Fisher exact test was used). 2-tailed Student t test, or Wilcoxon rank-sum test, were also used. The significance level was set at 5% for both sides.
Analysis of Effectiveness
The primary outcome of the efficacy of the interventions was the PSQI score, an index for improving insomnia. The primary purpose of this study was to examine the superiority of the ICBT and TGT groups in improving the insomnia status of nonclinical cases of insomnia compared with the WLC group. We estimated the difference in PSQI score change between the test and control groups and the 95% 2-sided CI. To test the null hypothesis that the changes in PSQI scores in both groups were equal in the primary analysis, covariance analysis was performed using the assignment adjustment factor as a covariate. The allocation adjustment factors were the PSQI score at the time of registration and gender. The significance level of the test was set at 5% (2-sided). Adjustment of multiplicity was performed using the Dunnett method, as a pairwise comparison of the 2 groups was performed for the control group.
The secondary evaluation items of effectiveness were analyzed to supplement the primary analysis results. No adjustment for multiplicity was made in the analysis of the secondary efficacy outcomes. The significance level of the hypothesis test was set at 5% (2-sided), and the two-sided 95% CI was calculated.
Statement of Ethics
This study was approved by the clinical trials ethics review board of the Chiba University Hospital (registration number G30022) and was registered as a clinical trial (UMIN000034927). A document explaining consent was presented to the participants on a webpage, accompanied by a verbal explanation as part of a video animation by the principal investigator. After viewing these materials, individuals who freely agreed to participate were recruited into the study.
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.
shows the research flow based on the CONSORT (Consolidated Standards of Reporting Trials) guidelines. Of the 21,394 individuals contacted through the internet research company, consent to participate in the study was obtained from 312 (1.46%) individuals who met the eligibility criteria and were randomly assigned to the ICBT, TGT, or WLC group. Of the 106 people assigned to ICBT, 23 (21.7%) did not start the ICBT program at least once, and 4 (3.8%) who performed the ICBT program at least once were classified as trial deviations, leaving 79 (74.5%) individuals with a FAS.
For details of the deviation related to PSQI, there was an error in the formula set by the internet survey company that conducted the web questionnaire, and the correct score was ≤5; however, it was judged to be ≥6 by incorrect calculation. Therefore, of the 312 individuals, 4 (1.3%) individuals who had initially been selected as participants and who should not have been selected underwent the ICBT program; these individuals were reported as deviations to the Chiba University Hospital clinical trials ethics review committee and accepted as such.
Separately, there was an error in the formula used by the internet survey company that conducted the web questionnaire. In the error, the correct PSQI total score was ≥6; however, it was judged incorrectly to be ≤5. The correct PHQ-9 total score should have been calculated from the 1st to 9th items (the 10th item should have been excluded); however, the internet survey company that conducted the web questionnaire mistakenly calculated from the 1st to the 10th item. In addition, the correct GAD-7 total score should have been calculated from the first to seventh items (the eighth item was not added); however, the internet survey company that conducted the web questionnaire mistakenly calculated from the first to eighth items. For these reasons, of the 21,394 individuals, 83 (0.39%) were not selected in the first screening, and 25 (0.12%) were not selected in the second screening.
Of the 106 participants assigned to the ICBT group, 74 (69.8%) provided data at 4 weeks, 68 (64.2%) provided data at 8 weeks, and 55 (51.9%) had an attendance of ≥75% during the ICBT program; thus, the PPS was 55. Of the 103 participants assigned to the TGT group, 15 (14.6%) were excluded who did not start the TGT program at least once; thus, the FAS was 88. In the TGT group, of the 103 participants, 84 (79.2%) provided data at 4 weeks, and 81 (78.6%) provided data at 8 weeks. Approximately 76.7% (79/103) of participants had an attendance of ≥75% during the TGT program; thus, the PPS was 79.
Of the 312 participants, 103 (33%) were assigned to the WLC group; thus, the FAS score for this group was 103. Data were obtained successfully for 88.3% (91/103) of these participants at 4 weeks and for 84.5% (87/103) of participants at 8 weeks; thus, the PPS was 103. The registration of participants started in February 2019, and the follow-up ended in May 2019.
There were no adverse events. When adverse events occurred for participants, we asked them to report the adverse events by email. However, there were no reports.
shows the characteristics of the participants at baseline. Female participants comprised 41.5% (112/270; ICBT group 32/79, 41%; TGT group 39/88, 44%; and WLC group 41/103, 39.8%) of the study population, with a mean age of 50.4 (SD 10.8; ICBT group: 49.8, SD 11.1; TGT group: 50.5, SD 11.0; and WLC group: 51.0, SD 10.4) years. There were no significant differences in sex, age, marital status, educational history, or employment status among the 3 groups.
presents the baseline data for the primary and secondary outcome measures. There were no significant differences among the 3 groups for the PSQI, AIS, GAD-7, or PHQ-9 scores.
|Characteristics||ICBTa group (n=79)||TGTb group (n=88)||WLCc group (n=103)||P value|
|Female||32 (40.5)||39 (44.3)||41 (39.8)|
|Male||47 (59.5)||49 (55.7)||62 (60.2)|
|Age (years), mean (SD)||49.8 (11.1)||50.5 (11.0)||51.0 (10.4)||.78|
|Marriage, n (%)||.26|
|Single||19 (24.1)||18 (20.5)||25 (40.3)|
|Married||58 (73.4)||60 (68.2)||72 (37.9)|
|Divorce||2 (2.5)||10 (11.4)||6 (33.3)|
|Education, mean (SD)||15.4 (1.9)||15.0 (2.0)||15.4 (2.1)||.33|
|Working, n (%)||.71|
|Full time||52 (65.8)||51 (57.9)||66 (39.1)|
|Part-time||11 (13.9)||14 (15.9)||18 (41.9)|
|Unemployed||16 (20.3)||23 (26.1)||19 (32.8)|
aICBT: internet-based cognitive behavioral therapy.
bTGT: Three Good Things.
cWLC: waiting list control.
|Outcomes||Value, mean (SD)||P value|
|ICBTa group (n=79)||TGTb group (n=88)||WLCc group (n=103)|
|Primary outcome: insomnia symptoms (PSQId)||9.8 (2.4)||9.8 (2.0)||9.8 (2.3)||.97|
|AISe||10.2 (2.9)||10.0 (2.7)||10.2 (2.9)||.77|
|SOLf (minutes)||41.6 (27.9)||47.8 (40.6)||41.2 (35.0)||.66|
|TSTg (hours)||318.6 (63.7)||323.8 (52.1)||319.9 (61.7)||.17|
|Sleep efficiency (%)||82.1 (15.2)||85.3 (10.9)||84.3 (14.7)||.55|
|GAD-7h||3.0 (2.5)||3.1 (2.3)||3.2 (2.5)||.92|
|PHQ-9i||4.5 (2.2)||4.6 (2.2)||4.4 (2.2)||.74|
aICBT: internet-based cognitive behavioral therapy.
bTGT: Three Good Things.
cWLC: waiting list control.
dPSQI: Pittsburgh Sleep Quality Index.
eAIS: Athens Insomnia Scale.
fSOL: sleep onset latency.
gTST: total sleep time.
hGAD-7: Generalized Anxiety Disorder-7.
iPHQ-9: Patient Health Questionnaire-9.
and show the changes in the primary outcome score (PSQI) in each group, and shows the comparison of the changes in the primary outcome PSQI between the intervention and control groups. At week 4, the adjusted mean change from baseline in the ICBT group compared with the WLC group was −1.56 (95% CI −2.52 to −0.59; P<.001), and the adjusted mean change from baseline in the TGT group compared with the WLC group was −1.15 (95% CI −2.08 to −0.23; P=.002), indicating that both the ICBT and TGT groups had a significant reduction in their PSQI scores compared with the WLC group.
|Assigned group (week 4)||Estimation (SE; 95% CI)||P value|
|ICBTa||−2.19 (0.29; −2.76 to −1.63)||<.001|
|TGTb||−1.79 (0.26; −2.31 to –1.27)||<.001|
|WLCc||−0.64 (0.25; −1.14 to −0.14)||.01|
aICBT: internet-based cognitive behavioral therapy.
bTGT: Three Good Things.
cWLC: waiting list control.
|Secondary outcomes and assigned group||Estimation (SE)||P value||95% CI|
|ICBTb||−2.09 (0.29)||<.001||−2.66 to −1.51|
|TGTc||−1.34 (0.26)||<.001||−1.86 to −0.82|
|WLCd||−0.99 (0.25)||<.001||−1.49 to −0.50|
|ICBT||−19.11 (2.55)||<.001||−24.13 to −14.08|
|TGT||−13.26 (2.38)||<.001||−17.95 to −8.56|
|WLC||−7.38 (2.29)||.001||−11.88 to −2.87|
|ICBT||−15.13 (2.64)||<.001||−20.33 to −9.94|
|TGT||−12.39 (2.40)||<.001||−17.11 to −7.67|
|WLC||−7.40 (2.26)||.001||−11.86 to −2.94|
|ICBT||37.40 (5.27)||<.001||27.01 to 47.78|
|TGT||25.02 (4.89)||<.001||15.39 to 34.66|
|WLC||4.32 (4.72)||.36||−4.98 to 13.63|
|ICBT||31.73 (5.43)||<.001||21.03 to 42.43|
|TGT||14.25 (4.91)||.004||4.57 to 23.93|
|WLC||14.23 (4.68)||.003||5.00 to 23.45|
|ICBT||5.85 (1.37)||<.001||3.15 to 8.55|
|TGT||6.37 (1.28)||<.001||3.86 to 8.89|
|WLC||2.90 (1.22)||.02||0.50 to 5.31|
|ICBT||6.73 (1.42)||<.001||3.93 to 9.52|
|TGT||3.77 (1.30)||.004||1.19 to 6.34|
|WLC||2.19 (1.21)||.07||−0.19 to 4.57|
|ICBT||−2.11 (0.37)||<.001||−2.83 to −1.39|
|TGT||−2.75 (0.34)||<.001||−3.43 to −2.08|
|WLC||−0.49 (0.32)||<.001||−1.12 to 0.15|
|ICBT||−1.82 (0.38)||<.001||−2.57 to −1.08|
|TGT||−1.62 (0.34)||<.001||−2.29 to −0.95|
|WLC||−1.21 (0.32)||<.001||−1.84 to −0.57|
|ICBT||0.17 (0.30)||.58||−0.43 to 0.77|
|TGT||−0.44 (0.28)||.12||−1.00 to 0.12|
|WLC||0.39 (0.27)||.15||−0.14 to 0.91|
|ICBT||0.07 (0.31)||.83||−0.55 to 0.69|
|TGT||0.11 (0.28)||.70||−0.45 to 0.67|
|WLC||0.07 (0.27)||.79||−0.45 to 0.60|
|ICBT||−0.32 (0.35)||.37||−1.02 to 0.38|
|TGT||−0.40 (0.33)||.23||−1.05 to 0.25|
|WLC||1.38 (0.31)||<.001||0.77 to 2.00|
|ICBT||−0.27 (0.37)||.46||−0.99 to 0.45|
|TGT||−0.03 (0.33)||.93||−0.69 to 0.63|
|WLC||0.38 (0.31)||.22||−0.24 to 1.00|
|ICBT||0.40 (0.36)||.27||−0.30 to 1.10|
|TGT||0.54 (0.33)||.10||−0.11 to 1.20|
|WLC||0.53 (0.31)||.09||−0.09 to 1.14|
|ICBT||0.47 (0.37)||.20||−0.25 to 1.19|
|TGT||0.52 (0.33)||.12||−0.13 to 1.18|
|WLC||−0.51 (0.31)||.11||−1.12 to 0.11|
aPSQI: Pittsburgh Sleep Quality Index.
bICBT: internet-based cognitive behavioral therapy.
cTGT: Three Good Things.
dWLC: waiting list control.
eSOL: sleep onset latency.
fTST: total sleep time.
gAIS: Athens Insomnia Scale.
hGAD-7: Generalized Anxiety Disorder-7.
iPHQ-9: Patient Health Questionnaire-9.
jCES-D: Center for Epidemiologic Studies–Depression Scale.
shows the changes in the secondary evaluation items for each group. shows a comparison of the changes in secondary outcomes between the intervention and control groups.
|Secondary outcomes and assigned group||Control group||Estimation (SE)||Adjusted P valuea||95% CI (adjusted)|
|ICBTc||WLCd||−1.09 (0.38)||.02||−2.07 to −0.12|
|TGTe||WLC||−0.35 (0.36)||.81||−1.27 to 0.57|
|ICBT||WLC||−11.73 (3.40)||.003||−20.36 to −3.10|
|TGT||WLC||−5.88 (3.30)||.27||−14.24 to 2.48|
|ICBT||WLC||−7.74(3.45)||.10||−16.48 to 1.01|
|TGT||WLC||−5.00 (3.29)||.42||−13.34 to 3.34|
|ICBT||WLC||33.07 (7.07)||<.001||15.17 to 50.98|
|TGT||WLC||20.70 (6.79)||.01||3.51 to 37.89|
|ICBT||WLC||17.50 (7.15)||.06||−0.63 to 35.63|
|TGT||WLC||0.02 (6.77)||.99||−17.13 to 17.17|
|ICBT||WLC||2.94 (1.83)||.36||−1.70 to 7.59|
|TGT||WLC||3.47 (1.76)||.18||−1.00 to 7.94|
|ICBT||WLC||4.53 (1.85)||.06||−0.18 to 9.25|
|TGT||WLC||1.57 (1.77)||.85||−2.92 to 6.07|
|ICBT||WLC||−1.62 (0.48)||.004||−2.85 to −0.39|
|TGT||WLC||−2.27 (0.47)||<.001||−3.46 to −1.08|
|ICBT||WLC||−0.62 (0.49)||.61||−1.87 to 0.63|
|TGT||WLC||−0.41 (0.47)||.85||−1.60 to 0.78|
|ICBT||WLC||−0.22 (0.40)||.98||−1.24 to 0.80|
|TGT||WLC||−0.82 (0.39)||.14||−1.81 to 0.16|
|ICBT||WLC||−0.01 (0.41)||.99||−1.05 to 1.03|
|TGT||WLC||0.04 (0.39)||.99||−0.95 to 1.03|
|ICBT||WLC||−1.70 (0.47)||.001||−2.90 to −0.51|
|TGT||WLC||−1.78 (0.45)||<.001||−2.94 to −0.63|
|ICBT||WLC||−0.65 (0.48)||.53||−1.86 to 0.56|
|TGT||WLC||−0.41 (0.46)||.84||−1.57 to 0.74|
|ICBT||WLC||−0.13 (0.47)||.99||−1.32 to 1.06|
|TGT||WLC||0.02 (0.45)||.99||−1.13 to 1.17|
|ICBT||WLC||0.98 (0.48)||.16||−0.23 to 2.19|
|TGT||WLC||1.03 (0.45)||.10||−0.12 to 2.18|
bPSQI: Pittsburgh Sleep Quality Index.
cICBT: internet-based cognitive behavioral therapy.
dWLC: waiting list control.
eTGT: Three Good Things.
fSOL: sleep onset latency.
gTST: total sleep time.
hAIS: Athens Insomnia Scale.
iGAD-7: Generalized Anxiety Disorder-7.
jPHQ-9: Patient Health Questionnaire-9.
kCES-D: Center for Epidemiologic Studies–Depression Scale.
At 4 weeks, the adjusted mean change from baseline in the ICBT group compared with the WLC group was −11.73 for SOL (95% CI −20.36 to −3.10; P=.003), 17.50 for TST (95% CI 15.17-50.98; P<.001), −1.62 for AIS (95% CI −2.85 to −0.39; P=.004), and −1.70 for PHQ-9 (95% CI −2.90 to −0.51; P=.002). There was a significant improvement in the ICBT group compared with the WLC group in SOL, TST, AIS, and PHQ-9 scores at 4 weeks.
At 4 weeks, the adjusted mean change from baseline in the TGT group compared with the WLC group was 20.70 for TST (95% CI 3.51-37.89; P=.01), −2.27 for AIS (95% CI −3.46 to −1.08; P<.001), and −1.78 for PHQ-9 (95% CI −2.94 to −0.63; P=.001). A significant improvement in the TGT group compared with the WLC group in TST, AIS, and PHQ-9 scores was observed at 4 weeks.
At 8 weeks, the adjusted mean change from baseline in the ICBT group compared with the WLC group was −1.09 for PSQI (95% CI −2.07 to −0.12; P=.02). There was a significant improvement in the ICBT group compared with the WLC group in PSQI at 8 weeks.
At 8 weeks, the adjusted mean change from baseline in the TGT group compared with the WLC group did not show a significant difference.
Effectiveness of the Intervention
shows the standardized change from baseline to the postintervention survey (at 4 and 8 weeks). Immediately after the intervention, at 4 weeks, the primary outcome effect size (Hedge g) for the PSQI was 0.81 in the ICBT group (95% CI 6.90-8.20) and 0.76 in the TGT group (95% CI 7.06-8.20).
|Outcomes||Values, mean (SD)||Effect size (95% CI)a,b|
|Baseline||9.63 (2.32)||9.41 (2.05)||9.45 (2.20)||9.10-10.15||8.97-9.84||9.02-9.88|
|Week 4||7.55 (2.79)||7.63 (2.62)||8.90 (2.89)||0.81 (6.90-8.20)||0.76 (7.06-8.20)||0.22 (8.30-9.50)|
|Week 8||7.72 (3.13)||8.17 (2.66)||8.57 (2.93)||0.70 (6.96-8.48)||0.52 (7.59-8.75)||0.34 (7.97-9.18)|
|Baseline||41.75 (27.88)||47.78 (40.64)||41.23 (34.96)||35.50-47.99||39.17-56.39||34.40-48.07|
|Week 4||23.41 (22.55)||32.61 (27.20)||34.87 (37.29)||0.72 (18.18-28.63)||0.44 (26.70-38.51)||0.18 (27.10-42.63)|
|Week 8||27.90 (26.44)||33.72 (29.90)||34.43 (32.74)||0.51 (21.50-34.30)||0.39 (27.19-40.25)||0.20 (27.72-41.13)|
|Baseline||318.56 (63.66)||323.81 (52.11)||319.93 (61.73)||304.30-332.82||312.77-334.85||307.87-332.00|
|Week 4||360.84 (60.28)||350.18 (61.20)||323.57 (65.53)||0.68 (346.87-374.80)||0.46 (336.90-363.46)||0.06 (309.92-337.22)|
|Week 8||355.90 (62.76)||338.67 (58.26)||333.27 (64.46)||0.59 (340.71-371.09)||0.27 (325.95-351.40)||0.21 (320.06-346.47)|
|Baseline||82.12 (15.24)||85.36 (10.93)||84.25 (14.68)||78.64-85.61||83.02-87.70||81.34-87.17|
|Week 4||89.07 (11.77)||90.68 (8.96)||86.76 (13.41)||0.51 (86.26-91.87)||0.53 (88.73-92.64)||0.18 (83.92-89.60)|
|Week 8||89.79 (9.04)||87.62 (10.86)||86.67 (14.75)||0.60 (87.52-92.07)||0.21 (85.15-90.08)||0.16 (83.61-89.72)|
|Baseline||10.19 (2.95)||9.95 (2.66)||10.24 (2.90)||9.53-10.85||9.39-10.52||9.68-10.81|
|Week 4||8.14 (3.18)||7.29 (3.67)||9.72 (3.67)||0.67 (7.40-8.87)||0.84 (6.49-8.08)||0.16 (8.97-10.47)|
|Week 8||8.47 (3.89)||8.47 (3.59)||9.09 (3.28)||0.50 (7.53-9.41)||0.47 (7.69-9.25)||0.37 (8.43-9.76)|
|Baseline||2.67 (2.37)||2.91 (2.41)||2.66 (2.37)||2.14-3.20||2.40-3.42||2.20-3.12|
|Week 4||2.92 (3.29)||2.45 (2.49)||3.02 (3.18)||0.09 (2.16-3.68)||0.19 (1.91-2.99)||0.13 (2.37-3.67)|
|Week 8||2.84 (3.20)||3.00 (3.03)||2.80 (2.93)||0.06 (2.06-3.61)||0.03 (2.34-3.66)||0.05 (2.20-3.40)|
|Baseline||3.99 (2.23)||4.18 (2.38)||4.08 (2.26)||3.49-4.49||3.68-4.69||3.64-4.52|
|Week 4||3.68 (2.88)||3.83 (2.94)||5.33 (4.46)||0.12 (3.01 to 4.34)||0.13 (3.20-4.47)||0.36 (4.42-6.24)|
|Week 8||3.69 (3.29)||4.28 (3.18)||4.29 (3.34)||0.11 (2.90 to 4.49)||0.03 (3.58-4.97)||0.08 (3.59-5.00)|
|Baseline||7.01 (3.46)||7.10 (3.38)||7.02 (3.74)||6.24-7.79||6.39-7.82||6.29-7.75|
|Week 4||7.32 (3.81)||7.60 (3.64)||7.55 (3.65)||0.09 (6.44-8.21)||0.14 (6.81-8.38)||0.14 (6.80-8.30)|
|Week 8||7.41 (3.33)||7.54 (3.67)||6.51 (4.09)||0.12 (6.60-8.22)||0.12 (6.74-8.34)||0.13 (5.67-7.34)|
aHedges g (effect size; 95% CI lower limit to upper limit of each outcome).
bEffect size values for baseline were not applicable; hence, only 95% CI values have been reported.
cICBT: internet-based cognitive behavioral therapy.
dTGT: Three Good Things.
eWLC: waiting list control.
fPSQI: Pittsburgh Sleep Quality Index.
gSOL: sleep onset latency.
hTST: total sleep time.
iAIS: Athens Insomnia Scale.
jGAD-7: Generalized Anxiety Disorder-7.
kPHQ-9: Patient Health Questionnaire-9.
lCES-D: Center for Epidemiologic Studies–Depression Scale.
The secondary outcome effect sizes (Hedge g) were as follows: 0.72 for SOL in the ICBT group (95% CI 18.18-28.63), 0.68 for TST in the ICBT group (95% CI of 346.87-374.80), 0.51 for SE in the ICBT group (95% CI 86.26-91.87) and 0.53 in the TGT group (95% CI 88.73-92.64), and 0.67 for AIS in the ICBT group (95% CI 7.40-8.87) and 0.84 in the TGT group (95% CI 6.49-8.08).
After the follow-up period, at 8 weeks, the secondary outcome effect sizes (Hedges g) were as follows: 0.70 for PSQI in the ICBT group (95% CI 6.96-8.48) and 0.52 in the TGT group (95% CI 7.59-8.75), 0.51 for SOL in the ICBT group (95% CI 21.50-34.30), 0.59 for TST in the ICBT group (95% CI 340.71-371.09), 0.60 for SE in the ICBT group (95% CI 87.52-92.07), and 0.50 for AIS in the ICBT group (95% CI 7.53-9.41).
The results of this study suggest that a self-help internet intervention without email support is effective as a noninvasive self-medication for adults with insomnia. The ICBT group showed a significant change of −6.11 in the PSQI score. The participant characteristics of this study differed significantly from those of similar previous studies. A previous study by van Straten et al  showed the efficacy of guided ICBT using an RCT design, in which 1500 patients with insomnia were invited by email, and 118 patients were assigned to the ICBT group (n=59) and a WLC group (n=59). However, the reported baseline mean PSQI score in the ICBT group in that study was relatively severe (12.4, SD 2.1). The mean change in PSQI scores in the ICBT group was −3.5, and in the WLC group it was −0.1. Our previous study of ICBT guided by email support reported a severe baseline PSQI mean score of 13.5 (SD 2.7); furthermore, participants had persistent symptoms despite taking sleep medications such as benzodiazepines [ ].
In this study, the unguided ICBT group showed a change of −2.19, the TGT group showed a change of −1.79, and the WLC group showed a change of −0.64; the mean change in PSQI scores was smaller than those reported by van Straten et al  and Sato et al [ ]. This could be because of the baseline average score of PSQI being 9.8, which indicates relatively mild insomnia. In addition, given that the ICBT was unguided, participant motivation to continue in this study may not have been well-supported.
The TGT group showed a significant decrease in PSQI scores compared with the WLC group only at the end of the program, that is, at the 4-week time point. To the best of our knowledge, no previous studies have examined the effects of TGT on insomnia through an RCT. However, as no significant improvement in positive emotions (indicated by the actual items on the CES-D) was observed in the TGT group, this casts doubt on the existence of a mechanism for the improvement of insomnia through the improvement of positive emotions. Contrary to previous studies, the TGT exercise did not lead to the improvement of positive emotions, and thus, it is unclear whether TGT really contributes to the improvement of happiness.
In this study, comparing the ICBT group and the TGT group was not the original purpose; however, the number of participants who received >75% of the intervention in the ICBT group was 70% (55/79) of participants compared with 90% (79/88) of participants who received >75% of the intervention in the TGT group. This could have been because of difficulties with regular participation in the ICBT program.
At the 4- and 8-week follow-ups, the ICBT group showed a significant improvement in PSQI scores over the WLC group, whereas the TGT group did not show a significant improvement over the WLC group. Therefore, ICBT could have longer-term effectiveness. If further research shows that ICBT results in sustained effects on insomnia, and TGT is easier to participate in more regularly, it may be necessary to consider an unguided intervention that combines both ICBT and TGT to achieve optimal outcomes.
In this study, there were errors in the calculation set by the internet research company that conducted the web questionnaire for PSQI, PHQ-9, and GAD-7 scores, which may have affected the eligible participants. In future studies, the distribution of inclusion and exclusion criteria should be carefully monitored to avoid similar mistakes.
Some participants in the ICBT and TGT groups did not participate more than once. However, in the WLC group, all participants were included in the final analysis. To ensure consistency with the ICBT and TGT groups in future research, it will be necessary to select those who have participated at least once in the WLC group for inclusion in the final analysis, or alternatively a placebo sham program could be implemented.
In conclusion, this RCT provided evidence that 4 weeks of unguided ICBT and TGT exercise for adults with insomnia, both administered as self-help internet interventions without email support, may improve insomnia symptoms compared with the WLC group. The findings also suggest that the effects of ICBT may last longer than TGT, whereas TGT may be easier to participate in more regularly. However, this study experienced errors during the selection process. Further research is warranted to examine the effectiveness of a combined intervention of ICBT and TGT for insomnia.
The authors thank all the participants for their valuable contributions to this study. This study was funded by the Research Institute of Economy, Trade, and Industry (RIETI), Japan, and supported, in part, by the Grant-in-Aid for Scientific Research (B) from the Japan Society for the Promotion of Science (grant KAKENHI 17H04091 to ES), the Grant-in-Aid for Scientific Research (C) from Japan Society for the Promotion of Science (grant KAKENHI 18K10716 to DS), and grants from the Chiba Foundation for Health Promotion and Disease Prevention. The RIETI was involved in the conduct of the study through its contact with the market research company. The RIETI had no role in the study design, data analysis, decision to publish, or preparation of the manuscript.
DS, YS, CS, YH, SO, MH, and ES contributed to the design of the study. RT performed statistical analysis. DS, YS, and ES interpreted the data and drafted the manuscript. All authors have approved the manuscript.
Conflicts of Interest
SD and ES have developed the web-based treatment but have no commercial interests.
CONSORT-eHEALTH checklist (V 1.6.1).PDF File (Adobe PDF File), 935 KB
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- Muramatsu K, Miyaoka H, Kamijima K, Muramatsu Y, Yoshida M, Otsubo T, et al. The patient health questionnaire, Japanese version: validity according to the mini-international neuropsychiatric interview-plus. Psychol Rep 2007 Dec;101(3 Pt 1):952-960. [CrossRef] [Medline]
- Radloff LS. The CES-D Scale: a self-report depression scale for research in the general population. Applied Psychol Measurement 1977;1(3):385-401.
- Shima S, Shikano T, Kitamura T, Asai M. New self-rating scale for depression. Clin Psychiatry 1985;27(6):717-723 [FREE Full text]
- van Straten A, Emmelkamp J, de Wit J, Lancee J, Andersson G, van Someren EJ, et al. Guided internet-delivered cognitive behavioural treatment for insomnia: a randomized trial. Psychol Med 2014 May;44(7):1521-1532. [CrossRef] [Medline]
|AIS: Athens Insomnia Scale|
|CBT: cognitive behavioral therapy|
|CES-D: Center for Epidemiologic Studies–Depression Scale|
|CONSORT: Consolidated Standards of Reporting Trials|
|CONSORT-EHEALTH: Consolidated Standards of Reporting Trials of Electronic and Mobile Health Applications and Online Telehealth|
|FAS: full analysis set|
|GAD-7: Generalized Anxiety Disorder-7|
|ICBT: internet-based cognitive behavioral therapy|
|PHQ-9: Patient Health Questionnaire-9|
|PPS: per-protocol set|
|PSQI: Pittsburgh Sleep Quality Index|
|RCT: randomized controlled trial|
|RIETI: Research Institute of Economy, Trade, and Industry|
|SE: sleep efficiency|
|SOL: sleep onset latency|
|TGT: Three Good Things|
|TST: total sleep time|
|UC: usual care|
|WLC: waiting list control|
Edited by A Mavragani; submitted 17.03.21; peer-reviewed by Y Xu, E Kawamoto; comments to author 27.04.21; revised version received 11.05.21; accepted 12.12.21; published 09.02.22Copyright
©Daisuke Sato, Yoichi Sekizawa, Chihiro Sutoh, Yoshiyuki Hirano, Sho Okawa, Motohisa Hirose, Ryo Takemura, Eiji Shimizu. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 09.02.2022.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

domain: psychology


text:
Absolutely. Perfect. Day. It rained SO much, but I knew God had a pretty sweet plan in place for these two. I've known both of these beautiful humans for years, going back further than a decade. I was best friends with Darrean and some of the groomsmen, so it was surreal to catch up after high school at his WEDDING. And Juhlya - this beautiful lady I met forever ago at Parkview Church and then she reached out to me about 1.5 years ago to capture their wedding. She has completely poured out her heart and soul into this wedding - planning every little detail, making the centerpieces, and all of the other little details she curated. She also told me that she has sworn since she was a little girl, she would never wear shoes on her wedding day. Talk about GOALS. So about that sweet plan? Well, it started pouring down rain about an hour prior to the ceremony. The planner - Alyssa- came in and talked to Juhlya when we finally started to see a bit of sun in the distance. They decided to simply push the ceremony back by 15 minutes, and the sun made its way to us finally, just in the knick of time.
Juhlya and Darrean, Words absolutely cannot describe how thankful I am for the both of you! Thank you thank you thank you for trusting me with such perfect moments. I love you both and wish you absolutely nothing but joy and endless love.

domain: artistic


text:
Select () or exclude () categories to narrow your recipe search.
As you select categories, the number of matching recipes will update.
Find exactly what you're looking for with the web's most powerful recipe filtering tool.
My grandmother Idella, was known for her good cooking, and these wings were a family favorite. They are pretty spicy and require a fire extinguisher;0)
Units: US | Metric
Serving Size: 1 (49 g)
Servings Per Recipe: 5
The following items or measurements are not included:
salt and pepper
Italian salad dressing mix

domain: food


text:
This product uses mucin extract derived from snail slime to maximize skin cell regeneration and restore elasticity to the skin. Chondroitin sulfate and collagen, the key components of mucin, are key components of cell matter and are highly effective in maintaining skin elasticity. Along with the patented compounds (Patent No. 10-0966835) made from 10 types of oriental medicine extracts, this product effectively renews and nourishes the skin.
The person in chargeWonseok Choi
Address110 Achasan-ro 78-gil, Gwangjin-gu, Seoul (04969)
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domain: biology


text:
This is one of the earliest photos of the Cannon Beach area. It is estimated to have been taken in the mid to late 1800’s, and was brought to us by longtime guests the Horeis family from Nebraska. They found it in a shop in Iowa.
Phone or Fax : 503-436-2457
Office Hours : 8am til 8pm
Ecola Inn P.O. Box 515, Cannon Beach,
1164 Ecola Court, Cannon Beach,

domain: geography


text:
LEICESTERSHIRE’S WILDLIFE PARK IS AT THE FOREFRONT OF PRESERVING SOME OF THE WORLD’S RAREST ANIMALS.
Welcoming over half a million visitors every year, the world famous Twycross Zoo is the vibrant and colourful home to a variety of animals including Asian elephants, Western grey kangaroos and zebras from all over the world.
Set in the open Leicestershire countryside and spread over 80 acres of land, the specialist primate centre is renowned for its wide variety of primates including all four types of the great ape; chimpanzees, gorillas, orang-utans and bonobos. The zoo is also a prime preserver of some of the world’s rarest animals, including the Amur leopards and Asian elephants.
Believe it or not, you can find some of the world’s most exquisite animals as your local residents!
Twycross Zoo first opened its doors to the public in May 1963, after animal enthusiasts Molly Badham and Nathalie Evans decided to expand their zoological collection, which later became a charitable trust in 1972. Since then the zoo has been recognised for the first UK births of thirteen different species including the bonobo, siamang, agile gibbon and woolly monkey.
At the heart of the wildlife sanctuary is its conservation project. Most of the species are part of an endangered species breeding programme and some are almost extinct.
The wildlife park is guaranteed to cater for all types of animal enthusiasts, offering a great family day out and providing an informative and fun day out for school trips, raising the awareness of conservational issues and highlighting the incredible and diverse animals in the world that are in need of protection.
BUT HOW CAN YOU GET INVOLVED?
Visit the zoo of course! All profits made are reinvested into the zoo’s conservation.
There are also other ways to help out – Do you fancy adopting some of the amazing and unique creatures or maybe you would like the chance of training to work with the animals yourself?!
Home to over 600 animals, including birds, reptiles, invertebrates and many endangered species, the zoo offers visitors an unforgettable experience. After a fun day seeing all the animals, you can relax and enjoy a delicious meal in Café Tibet, one of the onsite cafés at the zoo, whilst watching the majestic snow leopards.
Whatever you’re favourite animal, you’ll be sure to have a fun and memorable day out, as there is something for everyone at Leicestershire’s favourite animal wildlife conservation Twycross Zoo.

domain: travel


text:
by Elan Hold
She’s still here. Now that it’s over, it’s not as bad as I thought because she’s still physically present; they can’t bury her and they can’t ignore her, they have to deal with it.
They watch me with new eyes, tho. They’re waiting to see what will happen.
While she was dying I panicked and got really dizzy; now, I feel strangely calm, but I’m winded. She didn’t have much of a brain but she did do most of the breathing. Without her, I can’t take a good, deep breath. She made these funny little hiccuppy gulps that comforted me, and I’m having trouble sleeping without them.
She died three days ago.
Her head hangs far forward without her holding it up. It was stiff for a bit, but today it’s gone floppy and keeps bumping against my chin. I don’t want to think about the stench; it’s so thick I can almost feel it, but it doesn’t matter because I can barely smell. I got a sinus infection years ago and they didn’t treat it; I burned the poison out using a piece of wire I broke off the cage, and a lighter I stole from Godfrey. They watched that, too. They think I can’t see them thru the one-way glass, but I can always tell, even when they’re quiet. I can sense it, the vibrations. The hairs on my spine stand on end, tickling, tickling. When they’re watching, I like to sleep, or pick thru her hair for lice. But all the lice left her head when she went cold and now I’ve got twice the load on mine.
She would have laughed at that.
About the Author
ELAN HOLD is a 44-year-old visual artist who turned to writing because she couldn’t afford paint. She writes poetry, plays, screenplays, short stories, songs and is presently working on her first novel. She has 21 short stories, with plans to release these in a horror/fantasy/SF collection titled Underbelly Love. This piece is the first short story she ever wrote, and it’s the only one that makes her cry.
About the Narrator
Caith Donovan is an aspiring science-fiction and horror author and a voice actor who has appeared in a number of audio projects in recent years. Caith is currently appearing as Zacharias Cobb in CP Studio’s production of Dr. Who, several episodes which can be found at HERE. Some of his (much) older work can be heard in Feedback: A Hero’s Calling.


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The hotel offers a restaurant and a coffee shop/café. Wireless Internet access is complimentary. This business-friendly hotel also offers a sauna, spa services, and a terrace. Onsite self parking is complimentary.
Hotel Ristorante Herbstein is a smoke-free property.
Hotel Ristorante Herbstein offers 25 accommodations with safes and complimentary bottled water. Rooms open to balconies. Beds feature premium bedding. Flat-screen televisions come with cable channels. Bathrooms include bathtubs or showers and complimentary toiletries. Guests can surf the web using the complimentary wireless Internet access. Housekeeping is provided daily.
Free self parking
Available in all rooms: Free WiFi
Available in some public areas: Free WiFi
Buffet breakfasts are available for a surcharge and are served each morning between 8 AM and 10 AM.
Ristorante Herbstein - This restaurant specializes in Italian cuisine.
Room service is available.
Guests can pamper themselves by indulging in the onsite spa services. Services include massages.
If you have requests for specific accessibility needs, please contact the property using the information on the reservation confirmation received after booking.
Recreational amenities at the hotel include a sauna.
You'll be asked to pay the following charges at the property:
We have included all charges provided to us by the property.
The following fees and deposits are charged by the property at time of service, check-in, or check-out.
The above list may not be comprehensive. Fees and deposits may not include tax and are subject to change.
Check-in time starts at 2 PM
Check-in time ends at 10 PM
Minimum check-in age is: 18
Check-out time is 11 AM
Extra-person charges may apply and vary depending on property policy
Government-issued photo identification and a credit card, debit card, or cash deposit may be required at check-in for incidental charges
Special requests are subject to availability upon check-in and may incur additional charges; special requests cannot be guaranteed
This property accepts Mastercard; cash is not accepted
Charges for extra guests may apply and vary according to property policy.
A cash deposit, credit card, or debit card for incidental charges and government-issued photo identification may be required upon check-in.
Special requests are subject to availability at the time of check-in. Special requests can't be guaranteed and may incur additional charges.
This property accepts Mastercard. Cash is not accepted.
Debit cards not accepted
Staffed front desk
No rollaway/extra beds available


text:
Welcome to Librarium Online!
Join our community of 80,000+ members and take part in the number one resource for Warhammer and Warhammer 40K discussion!
Registering gives you full access to take part in discussions, upload pictures, contact other members and search everything!
Originally Posted by Lost Nemesis
i gotcha. I have a CoD game coming up and I want to add a bit of punch for fighting in the city. I know I won't have a problem moving around, but I know other armies will have indirect weapons and plenty of flame templates.
I'm looking for something that will boost my nids.
The biovore rules are pretty confusing, and I dont have my cedox with me to quote but I interpret the rules to mean that you can only shoot as many spores per turn as you have biovores, meaning each one shoots once a turn. BUT, the price you pay for a biovore to have a particular spore, is paying for him to be able to shoot that type of spore for the rest of the game. So, you don't need to buy him multiple spores, just pay the price once and he will never run out.Originally Posted by [Black] Katalyst
Someone please shut me up if I am interpreting this all wrong
Tyranids: 2500 pts
Imperial Guard: 1000 pts
Witch Hunters: 1000 pts
please corect me if im rong but as ive read it "eatch biovore may fire as many spore mines as theare are in that brood" but eatch biovore must have the same type of spoore mine in the first place
basically from what I can tell, the Biovores fire as one. The sporemines all fall within base contact of the first. I see it as kind of like a barrage. And yes, they all fire the same type of mine.
Build a man a fire, and you will keep him warm for a night.
Set a man on fire, and you will keep him warm the rest of his life.
This is how it works:
*All biovores have to have the same type of spore mines. They never run out of them, no matter how many types you buy.
*Each biovore fires 1 mine.
*The mines fire as a normal barrage weapon, but they fire mines instead of templates.
Originally Posted by The Paint Monkey
They also follow the rules for multiple barrages if there are multiple biovores. Kinda like the old school Thudd Gun.

domain: game


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domain: medical


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INSTOCK Thimbleberries Christmas Patterns
There's plenty of time to finish any one of these great projects for Christmas...Quilts, Wallhangings, Pillow Pals, Stockings, and even a Tree Skirt!
(A little bigger PIC when you CLICK on the picture!)
THIMBLEBERRIES' aren't just for Thimbleberries!
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Of Course, we also love the warm and cozy look of Thimbleberries' patterns made with Thimbleberries' fabrics!
We have a nice selection of Thimbleberries blues and autumn colors, too!


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|How do you feel about Matthew Ashford's return to DAYS?
Poll Posted: February 2nd, 2007
During an interview with the Bradenton Herald, in which he was promoting his role in the independent film, "The Unlikely's," Ashford revealed that he will be returning to DAYS later this winter.
The return will be the latest twist and turn for the actor who has been a member of the Days of our Lives cast on an off-and-on basis since 1987.
In June 2006, Soap Central reported that Ashford had signed a new contract with the NBC soap. Though the terms of the deal were not revealed, it was widely believed that the contract would extend Ashford's stay in Salem for at least another year.
Then, just about a month later, Ashford broke the news that he was leaving the show - in spite of that contract. The exit was scripted to coincide with the exit of Ashford's on-screen love, Melissa Reeves (Jennifer Deveraux).
Both Ashford and Reeves exited DAYS in August.
Since his departure, Ashford has been working on the film "The Unlikely's." In the film, Ashford appears as the son of a recently-deceased screenwriter whose will stipulates that his son must make a movie from his final movie script in order to inherit his millions.
As reported last year, the door was left open for Ashford and Reeves to return at a later date. Reeves will reportedly not be returning to Salem this time around and it is unclear at this time how the show will address her absence.
A Days of our Lives spokesperson tells Soap Central that ths show "cannot provide any details regarding casting at this moment."


text:
Get Important Stuff Done – Your Coworking Event Invitation – Plant Your Seeds of Transformation Podcast
Episode 2 Topic: How to Understand and Let Go of Toxic Perfectionism
On the Plant Your Seeds Show, we share vulnerably about hard topics to support and bless women leaders who are healing and transforming after trauma or crisis has occurred in their families, marriages, careers, and/or businesses.~ Donna Marie Johnson, @leadlikeaqueen
In the future, I plan to interview some leaders who have been in your shoes and who are sharing vulnerably, too. So, stay tuned for updates later this year.
For now, you’ll be hearing me share on topics relevant to your journey as a leader.
I am glad to be back for season 3. My time away gave me time to deal with some of my own issues so that I can be a better help to you. One of those is perfectionism… I divorced it. I’ll talk about how to begin understanding toxic perfectionism and how to manage it on this episode. (For background, have a look at the blog article I wrote about it at the link above.)
- Contentment v. Complacency
- Continuous Improvement
- Staying Present
- Love for Self and Others
- Trusting God
- Understanding Grace
- Living from Your Core
This podcast seeks to dig deeper on this topic of perfectionism than what was shared on that original blog post. What part of what I shared helped you the most? Send me your comment (click here).
Key Scripture – re: Living from Your Core
“I in them and you in me—so that they may be brought to complete unity. Then the world will know that you sent me and have loved them even as you have loved me.”~ John 17:23 (NIV)
- What support do you need with understanding how toxic perfectionism is impacting your life and relationships?
- Which tools can you use (or use better) to support you in your journey with ridding your life of perfectionism?
- Notes app (ios/apple)
- Reminders app (ios/apple)
- Evernote app (any device)
- OneNote app (any device)
- Other apps that you like best
Get support from a coach with learning how to use these tools to help you manage your tasks and reminders as you begin to release toxic perfectionism.
I am a coach. Join my private group by becoming a patron and get support around this topic of toxic perfectionism.
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text:
A complete guide to Svalbard’s Arctic wilderness
Spitsbergen offers a unique experience at the top of the world
Life in Norway
The largest island in the Svalbard archipelago, Norway’s Spitsbergen, is a truly fascinating place. Here’s everything you need to know.
Welcome to Spitsbergen, Norway. I’m fortunate enough to have visited Norway’s largest island not once but three times, and I’m now planning to go back. Here is why this special Arctic island keeps calling me back.
Spitsbergen is often confused or used interchangeably with Svalbard, but they are different. Svalbard is the name of the whole archipelago of which Spitsbergen—the biggest island—is part.
Where is Spitsbergen?
The Norwegian archipelago Svalbard lies between the north of mainland Norway and the North Pole, experiencing endless days in summer and total darkness in winter. It’s home to the world’s northernmost permanently inhabited communities.
Spitsbergen is by far the largest island within the Svalbard archipelago. At 14,546 square miles, the island is easy to see on the west of the archipelago.
Its southernmost point, “Sørkapp,” lies at a latitude of 76.5° north. Its northernmost point is Vergelegenhuken is at 80.1° north. The island borders the Arctic Ocean, the Norwegian Sea, and the Greenland Sea.
Introducing Spitsbergen, Norway
Spitsbergen is the only permanently inhabited part of Svalbard. Longyearbyen is the best-known settlement and administrative center, home to the majority of Svalbard’s population.
That being said, more than 50% of the land is covered in ice year-round. With the glaciers, it is mountains and fjords that define the landscape.
Under the terms of its sovereignty (more on that later), Norway appoints a governor to administer and police the Svalbard archipelago. The governor’s office is based in Longyearbyen on Spitsbergen.
In addition to roughly 2,500 humans, Spitsbergen is home to a surprisingly diverse animal and bird life, including polar bears, arctic foxes, reindeer, and marine mammals.
Spitsbergen officially has an Arctic climate, albeit with higher temperatures compared with other places at the same latitude. Much of the island’s delicate environment is protected by six Norwegian national parks.
Settlements on Spitsbergen
There are a handful of human settlements on Spitsbergen, all on the coastline or fjords of the west coast. All were originally focused on coal mining, but tourism and international science and research play important roles today.
None of the settlements are connected by road. Airplanes and helicopters are used year-round, while snowmobiles and boats are used when conditions allow.
The administrative center of Spitsbergen is Longyearbyen. Although it’s only home to about 2,250 people, the town has an international airport, hospital, school, indoor swimming pool, shopping mall, several hotels, bars, and restaurants, and even a craft brewery.
The other main settlements on the island include the Russian mining community Barentsburg and the international research community Ny-Ålesund.
Former important settlements include the Russian town Pyramiden and the Norwegian coal mining town Svea. Pyramiden is now largely abandoned and is an occasional tourist destination. There are remains of several other whaling and mining settlements dotted around the island.
Nordvest-Spitsbergen National Park
If you’ve ever been on a cruise to Svalbard, chances are your ship will have sailed into the waters around Nordvest-Spitsbergen National Park.
One of six Norwegian national parks on Spitsbergen, the park contains glaciers, fjords, warm springs, remains of volcanoes in Bockfjorden and an important birding area. At 80° north latitude, the hot springs are the northernmost known hot springs on the planet.
Nordvest-Spitsbergen National Park is also home to important cultural heritage. This includes former whaling stations, graves dating from the 17th century and remains of several Arctic expeditions.
Wildlife on Spitsbergen
Polar bears are perhaps the most famous icons of Spitsbergen and Svalbard. It’s hard to pinpoint an exact number, as they move around over large areas throughout the year. They occasionally visit human settlements in search of food.
Other marine mammals in Spitsbergen include whales, seals, walruses, and dolphins, while Arctic char can be found in freshwater lakes.
Just three terrestrial species inhabit Spitsbergen: the Arctic fox, Svalbard reindeer, and the accidentally introduced southern vole. There have been failed attempts to introduce the Arctic hare and musk ox.
Huskies are important companions for humans on Spitsbergen. They are also somewhat of a tourist attraction, with husky-pulled sled rides a popular activity.
History of Spitsbergen
The history of Svalbard is a long and fascinating one. In 1596, Willem Barentsz made the first documented discovery of Spitsbergen island while in search of the Northern Sea Route. It’s possible Russian hunters found the island even earlier.
Whaling activity began in the early 17th century. The Danish-Norwegian crown, the Dutch and the English were all early visitors and all laid claim to the territory.
Nominally ruled by the Scandinavian countries, Spitsbergen became a rich source of fishing and whaling waters for vessels from many nations during the 18th and 19th centuries. Many Arctic explorers used the island as a base, including the Norwegian explorer Roald Amundsen.
Whalers knew coal was available on Spitsbergen, but commercial operations didn’t begin until 1899. Several newly established companies quickly moved in to take advantage of the new opportunities.
In 1920, the Svalbard Treaty finally settled the issue of sovereignty. Originally signed by nine parties and since expanded to 40, the treaty recognized the sovereignty of Norway while giving the right of residence and economic activity to citizens of any signatory.
How to visit Spitsbergen
With incredible untouched Arctic landscape and fascinating wildlife, Spitsbergen is a popular tourist attraction among outdoor enthusiasts. There are only two realistic ways for foreign tourists to visit the island.
The first is flying via Norway. Regular flights serve Longyearbyen from Oslo and Tromsø. This means that although citizens of many countries can visit Svalbard, you may still require the right to visit Norway to reach Spitsbergen.
From Longyearbyen, you can participate in various tours and experiences—including visiting other settlements—depending on the season.
The second method is via cruise or expedition ship. Several options exist, although the activities of large cruise ships in the waters of Spitsbergen are limited.
Specially equipped expedition ships are the better choice. Most offer daily excursions via small inflatable vessels, allowing passengers to get a much greater appreciation of the landscapes and wildlife of Spitsbergen.
Many cruises start in Longyearbyen (requiring a flight anyway) although some leave from Norway or even the British Isles.
Have you been to Spitsbergen island? What is your favorite thing to do in the Svalbard archipelago? Email Life in Norway at lifeinnorway.net/contact-me.
This article first appeared at lifeinnorway.net and was reprinted with permission.
This article appeared in the February 2023 issue of The Norwegian American.


* Extracted from Drug Label
The quarterly trend chart illustrates changing levels of adverse events over time. Results from both the FDA Adverse Event Database (FAERS) and adverse events extracted from social media by Druginformer are plotted side-by-side for easy comparison.
The proportion of people completing user reviews who complained about a side effect.
The proportion of social media adverse event complaints for each adverse event type.
The proportion of FAERS (FDA) adverse event complaints for each adverse event type.
(Reports Submitted to FDA)
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