Korean Clinical Practice Guideline for the Diagnosis and Treatment of Insomnia in Adults.

OBJECTIVE: We aim to present a clinical guideline for the diagnosis and treatment of insomnia in adults by reviewing and integrating existing clinical guidelines. The purpose of this guideline is to assist clinicians who perform evidence-based insomnia treatment. METHODS: We selected literature that may be appropriate for use in guideline development from evidence-based practice guidelines that have been issued by an academic or governmental institution within the last five years. The core question of this guideline was made in sentence form including Patient/Problem, Intervention, Comparison, Outcome (PICO) elements. After searching PubMed, EMBASE, and medical guideline issuing agencies, three guidelines were judged to be the most appropriately reviewed, up-to-date, and from trusted sources. RESULTS: The Appraisal of Guidelines for Research and Evaluation (AGREE) II tool was used to evaluate the quality of the three clinical guidelines. The final outcome of the guideline development process is a total of 15 recommendations that report the strength of the recommendation, the quality of evidence, a summary of content, and considerations in applying the recommendation. CONCLUSION: It is vital for clinical guidelines for insomnia to be developed and continually updated in order to provide more accurate evidence-based treatments to patients.

The Prevalence and Incidence of Insomnia in Korea during 2005 to 2013.

OBJECTIVE: The aim of this study was to estimate the progress of insomnia prevalence and incidence over the past several years. Also, this study compared survival rates between individuals with and without insomnia. METHODS: The National Health Insurance Service-National Sample Cohort (NHIS-NSC) from 2002-2013 was used for this study. Prevalent cases of insomnia were defined using ICD-10 codes F51.0 or G47.0, or a prescription of sedatives. Cox's proportional hazard analysis was conducted to compare survival rates between insomnia patients and people without insomnia. RESULTS: In 2013, there were 46,167 (5.78%) insomnia patients over 20 years old in this cohort. Insomnia was more common among women and the elderly. Annual incidence over the past several years remained steady but the prevalence increased. The survival of insomnia patients was lower than that of people without insomnia, and the hazard ratio for overall mortality was 1.702 (p<0.001). CONCLUSION: This large-scale population-based cohort study provided current epidemiologic indicators of insomnia in the Korean general population.

Time to Take Sleeping Pills and Subjective Satisfaction among Cancer Patients.

OBJECTIVE: We investigated the influence of the time to take hypnotics and daytime activity on patient satisfaction with sleeping pills. METHODS: Ninety-six cancer patients who were currently taking benzodiazepine or z-drug as hypnotics were grouped into satisfied and dissatisfied groups. The subjects' symptoms, time to take sleeping pills, bedtime, sleep onset time, wake up time, and time in bed within 24 hours (TIB/d) were obtained. RESULTS: The satisfied group had significantly late sleeping pill ingestion time (p=0.04); significantly early wake up time (p=0.01); and significantly shorter sleep latency, TIB/d, duration from the administration of pills to sleep onset, and duration from the administration of pills to wake up time (PTW). Logistic regression analysis revealed that the significant predictors of patient satisfaction to hypnotics were less severity of insomnia [odds ratio (OR)=0.91] and the time variables, including late sleeping pill administration time (OR=1.53) and early wake up time (OR=0.57). Among the duration variables, short PTW (OR=0.30) and short TIB/d (OR=0.64) were significantly related with the satisfaction to hypnotics. CONCLUSION: Reducing the duration from the administration of hypnotics to wake up time and TIB/d can influence the satisfaction to sleeping pills.

Development of Dysfunctional Beliefs and Attitude about Sleep Scale for Cancer Patients.

Study objectives: This study aimed to develop a scale utilizing the original Dysfunctional Beliefs and Attitudes about Sleep (DBAS) scale that measured maladaptive cognitions associated with sleep that is especially sensitive to cancer patients. In addition to the original scale, we added two additional items that reflected cancer-specific dysfunctional beliefs about sleep. Methods: Participants consisted of 337 cancer patients (mean age 54.0 ± 11.8 years, 32.0% men). All participants completed the DBAS-16, two cancer specific items, and the Insomnia Severity Index. Item-to-total-score correlations, internal consistency, item selection, and factor structure were examined. Results: The DBAS-16 was found to be reliable, and internal consistency was also adequate when adding two cancer-specific questions (Cronbach's alpha = 0.89). A total of 14 items were selected, and a four-factor model was selected using exploratory factor analysis (Tucker-Lewis index = 0.86, root mean square error of approximation = 0.08). The four factors were (a) sleep expectations, (b) worry about insomnia, (c) perceived consequences of insomnia and medication, and (d) two cancer-related items. The modified 14 items of the Cancer-related DBAS (C-DBAS-14) well differentiated cancer patients with and without insomnia. Conclusions: The C-DBAS-14 is a promising measure that has adequate internal consistency. It is also sensitive to sleep-related cognitions in cancer patients and can discriminate patients with cancer who are experiencing insomnia from those who are good sleepers. The enhanced utility of the shortened 14-item scale tailored specifically to cancer patients may be useful in both clinical practice and research settings.Abbreviations: CBT: cognitive behavioral therapy; C-DBAS-14: Cancer-Related Dysfunctional Beliefs and Attitude about Sleep; C-DBS: Cancer-Related Dysfunctional Beliefs about Sleep; DBAS-16: Dysfunctional Beliefs and Attitudes about Sleep; ISI: Insomnia Severity Index.

The Effect of a Sleep Education and Hypnotics Reduction Program on Hypnotics Prescription Rate for the Hospitalized Patients with Cancer at a General Hospital.

OBJECTIVE: We aimed to investigate whether the sleep education and hypnotics reduction program (the i-sleep program), developed for all hospitalized patients and medical personnel, help reducing the hypnotics prescriptions rate among hospitalized cancer patients in a general hospital. METHODS: Patient data such as hypnotics prescribed at the time of admission and discharge during prior to (year of 2014) and after (year of 2015) initiation of the i-sleep program were collected and compared. Also, hypnotics prescription rate at the first day of each month of 2014 and 2015 were estimated and compared. RESULTS: All of 12,382 patients in 2014 and 12,313 patients in 2015 were admitted to the Department of Oncology of the hospital. In 2014, 782 (6.3%) of 12,382 inpatients were already taking hypnotics at the time of admission, and 594 (76.0%) of the 782 patients were still taking sleeping pills at the time of discharge. Following initiation of the i-sleep program (2015), 792 (6.4%) of 12,313 inpatients were already taking hypnotics at the time of admission, and 553 (69.8%) of the 792 inpatients were still taking them at the time of discharge (relative risk, 0.92; 95% confidence interval, 0.87-0.98). On the first day of each month of 2014, 7.3% to 12.6% (mean, 10.0%) of inpatients had prescriptions for hypnotics. Following initiation of the program, the rate of hypnotic prescription was significantly reduced (3.2-10.8%; mean, 8.0%; p = 0.03). CONCLUSION: Our date showed that the i-sleep program may help to reduce the hypnotic prescription rate in hospitalized cancer patients.

An Assessment of Physical Activity Data Collected via a Smartphone App and a Smart Band in Breast Cancer Survivors: Observational Study.

BACKGROUND: Although distress screening is crucial for cancer survivors, it is not easy for clinicians to recognize distress. Physical activity (PA) data collected by mobile devices such as smart bands and smartphone apps have the potential to be used to screen distress in breast cancer survivors. OBJECTIVE: The aim of this study was to assess data collection rates of smartphone apps and smart bands in terms of PA data, investigate the correlation between PA data from mobile devices and distress-related questionnaires from smartphone apps, and demonstrate factors associated with data collection with smart bands and smartphone apps in breast cancer survivors. METHODS: In this prospective observational study, patients who underwent surgery for breast cancer at Asan Medical Center, Seoul, Republic of Korea, between June 2017 and March 2018 were enrolled and asked to use both a smartphone app and smart band for 6 months. The overall compliance rates of the daily PA data collection via the smartphone walking apps and wearable smart bands were analyzed in a within-subject manner. The longitudinal daily collection rates were calculated to examine the dropout pattern. We also performed multivariate linear regression analysis to examine factors associated with compliance with daily collection. Finally, we tested the correlation between the count of daily average steps and distress level using Pearson correlation analysis. RESULTS: A total of 160 female patients who underwent breast cancer surgeries were enrolled. The overall compliance rates for using a smartphone app and smart bands were 88.0% (24,224/27,513) and 52.5% (14,431/27,513), respectively. The longitudinal compliance rate for smartphone apps was 77.8% at day 180, while the longitudinal compliance rate for smart bands rapidly decreased over time, reaching 17.5% at day 180. Subjects who were young, with other comorbidities, or receiving antihormonal therapy or targeted therapy showed significantly higher compliance rates to the smartphone app. However, no factor was associated with the compliance rate to the smart band. In terms of the correlation between the count of daily steps and distress level, step counts collected via smart band showed a significant correlation with distress level. CONCLUSIONS: Smartphone apps or smart bands are feasible tools to collect data on the physical activity of breast cancer survivors. PA data from mobile devices are correlated with participants' distress data, which suggests the potential role of mobile devices in the management of distress in breast cancer survivors. TRIAL REGISTRATION: ClinicalTrials.gov NCT03072966; https://clinicaltrials.gov/ct2/show/NCT03072966.

The Development of Evidence-Based Guideline for Diagnosis and Management of Headache in Korea.

OBJECTIVE: We aimed to develop the clinical guideline for headache by the systematic review and synthesis of existing evidence-based guidelines. The purpose of developing the guideline was to improve the appropriateness of diagnosis and treatment of headache disorder, and consequently, to improve patients' pain control and quality of life. The guideline broadly covers the differential diagnosis and treatment of tension-type headache, migraine, cluster headache, and medication-overuse headache. METHODS: This is a methodological study based on the ADAPTE methodology, including a systematic review of the literature, quality assessment of the guidelines using the Appraisal of Clinical Guidelines for REsearch & Evaluation II (AGREE II) Instrument, as well as an external review using a Delphi technique. The inclusion criteria for systematic search were as follows: topic-relevant, up-to-date guidelines including evidence from within 5 years, evidence-based guidelines, guidelines written in English or Korean, and guidelines issued by academic institutions or government agencies. RESULTS: We selected five guidelines and conducted their quality assessment using the AGREE II Instrument. As a result, one guideline was found to be eligible for adaptation. For 13 key questions, a total of 39 recommendations were proposed with the grading system and revised using the nominal group technique. CONCLUSION: Recommendations should be applied to actual clinical sites to achieve the ultimate goal of this guideline; therefore, follow-up activities, such as monitoring of guideline usage and assessment of applicability of the recommendations, should be performed in the future. Further assessment of the effectiveness of the guideline in Korea is needed.

Psychological Distress and Drawing Tests among Women with Breast Cancer.

BACKGROUND: The aim of this study was to evaluate the use of the Diagnostic Drawing Series (DDS) as a screening tool for the breast cancer patients with psychological distress. METHODS: All of 64 patients with breast cancer participated in this study. Patients' depressive and anxiety symptoms were assessed using Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) when the DDS was applied to the partipicants. RESULTS: Depressed patients used more enclosure in the Feeling drawings (P = 0.002) and tilt in Free drawings (P = 0.048). Patients with anxiety drew a picture over 67% of the paper (P = 0.015) in Tree drawing and more medium pressure (P = 0.049) in Feeling drawings. Thirty four subjects (77.3%) of unstable emotion group used over 67% of the space (P = 0.002). More Landscapes were observed in the Feeling drawings of unstable patients (P = 0.042). CONCLUSION: These results suggested that DDS could be used as a supplemental screening tool for psychological distress in breast cancer patients.

A Sleep Education and Hypnotics Reduction Program for Hospitalized Patients at a General Hospital.

OBJECTIVE: We applied a program of sleep education and hypnotics reduction for inpatients (the i-sleep program). This study explored whether the i-sleep program is effective for reducing the prescription rate of sleeping pills to inpatients in a general hospital. METHODS: We estimated the proportion of inpatients prescribed hypnotics at admission to and discharge from the hospital, excluding pediatric care units, before (2014) and after (2015) the program. In addition, we estimated the proportion of inpatients prescribed sleeping pills among all inpatients on the first day of each month of 2014 and 2015. RESULTS: The proportion of inpatients prescribed hypnotics as discharge medication among inpatients who had been prescribed them at the time of admission decreased significantly, from 57.0% to 46.8%, after the i-sleep program (RR=0.82, 95% CI: 0.79-0.86). The proportion of inpatients newly prescribed sleeping pills after admission to the hospital did not significantly decrease (1.97% to 2.00%; RR=1.01, 95% CI: 0.96-1.07). The mean prescription rate of sleeping pills per day was 8.18% in 2014 and 7.78% in 2015. CONCLUSION: The i-sleep program reduced the proportion of inpatients who continued to take sleeping pills from admission until discharge, although it did't reduce the prescription rate per day.

The Prevalence of Depression among Patients with the Top Ten Most Common Cancers in South Korea.

OBJECTIVE: Among the various psychiatric disorders, depression is a common comorbid condition in cancer patients. Due to the distinct and diverse nature of cancer, the prevalence of depression may be assumed to be affected by differences in primary cancer sites. In this study, we explored the prevalence rates of depression among the ten most prevalent cancers in South Korea using a national patient sample. METHODS: This was a 1-year cross-sectional study using a national patient sample provided by the South Korean National Health Insurance in 2011. We selected all patients who had received ICD-10 codes of the 10 most prevalent cancers and major depressive disorder. Afterwards, the cancer and depression groups were merged and analyzed. RESULTS: The MDD prevalence rate was highest in lung cancer (11.0%), followed by non-Hodgkin's lymphoma (9.2%), prostate (9.1%), bladder (8.8%), breast (7.8%), cervix (7.8%), colorectal (7.7%), stomach (6.9%), liver (6.5%), and thyroid cancer (5.6%). Within all cancer groups, patients with a MDD diagnosis were significantly older (p<0.05) than non-MDD patients. Colorectal, stomach, and thyroid cancer displayed a higher female proportion in the MDD group than the non-MDD group. In the subgroup analysis, the prevalence rate differed by age and sex. CONCLUSION: The prevalence of depression varied according to cancer types. Patients with lung cancer were the most prone to experience depression. Because clinical and psychological factors may influence MDD prevalence, these factors will need to be studied more closely in the future.

Alterations of awake EEG in idiopathic REM sleep behavior disorder without cognitive impairment.

The aim of this study was to find electroencephalographic (EEG) changes in subjects with drug-naïve idiopathic rapid eye movement sleep behavior disorder (iRBD) who had no cognitive impairment. A total of 57 iRBD patients confirmed by polysomnography (PSG) and 33 sex and age-matched healthy controls were included and their waking EEG was recorded from five cortical regions for 15min. Power spectral analyses by fast Fourier transforms were performed on EEG data. In PSG data, the iRBD patients showed sleep disturbances of short total sleep time, decreased sleep efficiency, increased sleep latency and frequent awakening compared to controls. After adjusting for sleep parameters, the absolute alpha power in frontal region in iRBD patients was higher than that in controls (1.2±0.3 vs. 0.9±0.3, p=0.037). Dominant occipital frequency (DOF) was lower in iRBD patients than in controls after adjusting for the sleep covariates (9.2±0.3Hz vs. 9.5±0.4Hz, F=8, p=0.006). iRBD patients without cognitive impairment also showed EEG alteration in frontal and occipital cortex at wakefulness, which could be an early marker of cerebral dysfunction in iRBD patients.

Sleeping Pill Administration Time and Patient Subjective Satisfaction.

STUDY OBJECTIVES: Taking hypnotic agents 30 min before bedtime is the usual suggested administration time, but some patients report dissatisfaction with their sleeping pills. We investigated whether the timing of sleeping pill administration influences patient subjective satisfaction with these drugs. METHODS: One hundred twelve patients with primary insomnia currently taking benzodiazepine or nonbenzodiazepine gamma-aminobutyric acid (GABA) agonists as sleeping pills were selected. The time of administration for their sleeping pills, bedtime, sleep onset time, and wake up time were obtained from their medical records. Subjects were also categorized into satisfied or dissatisfied groups. RESULTS: Hypnotic agents administration time (p < 0.001) and bedtime (p < 0.001), but not sleep onset or wake up time, occurred later in the night in the satisfied group. The durations from administration of pills to sleep onset (33.6 ± 20.7 min) and to wake up time (7.2 ± 1.2 h) were significantly shorter in the satisfied group when compared to the dissatisfied group (135.9 ± 73.4 min and 9.3 ± 1.5 h for time to sleep onset and wake up, respectively). Logistic regression analysis revealed that patient subjective satisfaction with hypnotic agents could be predicted by a short duration from administration of pills to sleep onset (odds ratio = 0.01; 95% confidence interval [0.001-0.09]) and a short duration from administration of pills to wake up time (0.53; [0.31-0.89], F = 49.9, p < 0.001). CONCLUSIONS: Taking sleeping pills at a later time and a shorter interval between pill administration and wake up time may increase patient subjective satisfaction with hypnotic agents. We propose that physicians advise patients to take sleeping pills approximately 7 h before their usual getting-out-of-bed time instead of the current standard of 30 min before bedtime.

Progression of cognitive impairments in idiopathic REM sleep behaviour disorder.

BACKGROUND: Idiopathic REM (rapid eye movement) sleep behaviour disorder (iRBD) has been implicated in cognitive impairments, but there is little evidence about progression of cognitive dysfunction in iRBD. METHODS: A retrospective follow-up study with patients with iRBD was performed. Conversion to neurodegenerative disorders was analysed by Kaplan-Meier survival analysis. Neuropsychological test results at baseline were compared between patients with iRBD and healthy controls. 57 patients with iRBD were successfully followed up for changes of cognitive performance over time (follow-up duration 50.84±25.38 months; range 12-108 months). Factors affecting cognitive decline were evaluated with multiple regression analysis and the subgroup analysis for groups with and without conversion was carried out. RESULTS: Among 84 patients with iRBD, conversion occurred in 18 patients and conversion rates were estimated to be 9%, 18% and 35% at 3, 5 and 6 years from diagnosis of iRBD. Individuals with iRBD showed lower z-scores at baseline than controls in Mini-Mental Status Examination, Trail Making Test A, constructional praxis and Executive Clock Drawing Task (CLOX2). Patients with non-converting iRBD showed significant performance decline in memory (p=0.003, Digit span forward) and a worsening tendency of executive functions (p=0.007, frontal assessment battery; p=0.012, Stroop test) at follow-up tests. Cognitive decline was associated with disease duration or follow-up duration, and lower executive function at baseline increased conversion risk (p=0.031). CONCLUSIONS: Patients with iRBD have cognitive impairments at baseline and progressive cognitive decline over time. Even in idiopathic cases without development of any neurodegenerative disease, degenerative changes in cognition seem to be under way.

Osteoporosis management among chronic glucocorticoid users: a systematic review.

BACKGROUND: Clinical practice guidelines recommend that all patients starting chronic oral glucocorticoid (GC) therapy receive bone mineral density (BMD) testing and osteoporosis pharmacotherapy. OBJECTIVE: We completed a systematic review of observational studies to examine the proportion of patients on chronic oral GC therapy who receive osteoporosis management. METHODS: Two independent reviewers completed a systematic search of Ovid MEDLINE® and EMBASE® to identify all English language articles that examined the prevalence of osteoporosis management among chronic oral GC users. Clinical trials, abstracts, reviews, commentaries, and letters to the editor were excluded. Study methods and results (use of BMD testing and osteoporosis pharmacotherapy) were abstracted and summarized by year and region. RESULTS: We identified 29 eligible studies published between 1999 and October 2013: 17 were conducted in North America, 5 in Europe, and 7 in other regions. Heterogeneity between patient populations and methods used to define chronic GC use precluded the direct comparison of results between regions, or over time. Over 80% of studies identified that < 40% of chronic oral GC users received BMD testing or osteoporosis pharmacotherapy. When results of these studies were plotted by year, there was little evidence of improvement in osteoporosis management over time. CONCLUSIONS: Despite consistent recommendations to target osteoporosis prevention at the onset of chronic oral GC therapy, osteoporosis is undermanaged among chronic oral GC users. Targeted interventions are needed to help reduce the burden of fracture-related morbidity associated with GC-induced osteoporosis.

Gamma oscillation in schizophrenia.

Dysfunctional neural circuitry has been found to be involved in abnormalities of perception and cognition in patients with schizophrenia. Gamma oscillations are essential for integrating information within neural circuits and have therefore been associated with many perceptual and cognitive processes in healthy human subjects and animals. This review presents an overview of the neural basis of gamma oscillations and the abnormalities in the GABAergic interneuronal system thought to be responsible for gamma-range deficits in schizophrenia. We also review studies of gamma activity in sensory and cognitive processes, including auditory steady state response, attention, object representation, and working memory, in animals, healthy humans and patients with schizophrenia.