Acupuncture using pattern-identification for the treatment of insomnia disorder: a systematic review and meta-analysis of randomized controlled trials

Chinese herbal medicine and acupuncture for insomnia in stroke patients: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Insomnia is highly prevalent in stroke patients; however, there is no ideal intervention. This systematic review examined the effect and safety of Chinese herbal medicine (CHM) and acupuncture on sleep in adults with stroke.

METHODS

Six databases were searched from inception to June 2023 to identify randomised controlled trials (RCTs). The primary outcome was Pittsburgh Sleep Quality Index (PSQI) scores. Risk of bias and evidence quality was assessed. A pairwise random-effect meta-analysis was performed.

RESULTS

A total of 54 RCTs published in 55 articles were finally included in the systematic review, including 35 of CHM and 19 of acupuncture therapies. Compared with placebo/sham procedure, CHM and acupuncture were more effective in improving PSQI scores. The evidence of moderate quality suggested that CHM outperformed benzodiazepine drugs (BZDs) while it presented an effect similar to that of non-BZDs in improving sleep quality. CHM and acupuncture also provided additional benefits to the patients treated with pharmacological agents alone. However, the evidence specific to individual CHM prescriptions lay in various factors and methodological quality, and the evidence on the comparative effectiveness between acupuncture and other therapies was conflicting or limited.

CONCLUSIONS

Overall, CHM and acupuncture used alone or in combination with pharmacotherapy can safely improve sleep in stroke patients with insomnia. In the future, RCTs on outstanding CHM prescriptions and the comparative effectiveness research between acupuncture and other therapies are needed.

REGISTRATION

PROSPERO No. CRD42020194029 and No. CRD42020194030.

PRECIS-2 analysis of pragmatic acupuncture trials: a systematic review

BACKGROUND

Pragmatic acupuncture trials (PATs) are a research tool for assessing the effectiveness of acupuncture treatments in a real-world setting. This study aimed to provide a comprehensive methodological analysis of PATs using the PRECIS-2(PRagmatic Explanatory Continuum Indicator Summary-2) tool to determine their pragmatism.

METHODS

The MEDLINE, EMBASE, Cochrane Central Register for Controlled Trials, CINAHL, Allied and Complementary Medicine Database, China National Knowledge Infrastructure, VIP, WANFANG, Taiwan Periodical Literature Database, KoreaMed, KMbase, Research Information Service System, Oriental Medicine Advanced Searching Integrated System, CiNii and ClinicalTrials.gov were searched. The search included randomised controlled trials (RCTs) and protocols of RCTs that investigated all types of acupuncture and used self-declared pragmatic design. Two authors independently collected the basic information and characteristics of the studies and assessed their pragmatism using the nine PRECIS-2 domains and the additional domain of control.

RESULTS

A total of 93 studies were included. The means of eligibility, recruitment, organisation, primary outcome, primary analysis, and control domains were statistically larger than three and were shown to be pragmatic. The means of setting, flexibility:delivery, and follow-up domains were not greater than three and were shown to be non-pragmatic. For flexibility:adherence domain was inappropriate for assessment owing to insufficient information in the studies.

CONCLUSIONS

PATs were pragmatic in the domain of eligibility, recruitment, organisation, primary outcome, primary analysis, and control and were not pragmatic in the domain of setting, flexibility:delivery, and follow-up. Future PATs need to strengthen the pragmatism in the setting, flexibility:delivery, and follow-up domains and to describe the flexibility:adherence domain in more detail.

TRIAL REGISTRATION

CRD42021236975.

Acupuncture for primary insomnia: Effectiveness, safety, mechanisms and recommendations for clinical practice

Primary insomnia (PI) is an increasing concern in modern society. Cognitive-behavioral therapy for insomnia is the first-line recommendation, yet limited availability and cost impede its widespread use. While hypnotics are frequently used, balancing their benefits against the risk of adverse events poses challenges. This review summarizes the clinical and preclinical evidence of acupuncture as a treatment for PI, discussing its potential mechanisms and role in reliving insomnia. Clinical trials show that acupuncture improves subjective sleep quality, fatigue, cognitive impairments, and emotional symptoms with minimal adverse events. It also positively impacts objective sleep processes, including prolonging total sleep time, improving sleep efficiency, reducing sleep onset latency and wake after sleep onset, and enhancing sleep architecture/structure, including increasing N3% and REM%, and decreasing N1%. However, methodological shortcomings in some trials diminish the overall quality of evidence. Animal studies suggest that acupuncture restores circadian rhythms in sleep-deprived rodents and improves their performance in behavioral tests, possibly mediated by various clinical variables and pathways. These may involve neurotransmitters, brain-derived neurotrophic factors, inflammatory cytokines, the hypothalamic-pituitary-adrenal axis, gut microbiota, and other cellular events. While the existing findings support acupuncture as a promising therapeutic strategy for PI, additional high-quality trials are required to validate its benefits.

Acupuncture for patients with insomnia and predictors of treatment response: a chart review

BACKGROUND

Acupuncture is a potentially effective non-pharmacological treatment for insomnia.

OBJECTIVE

We observed the responses of patients with insomnia to acupuncture in routine clinical practice. In addition, we explored patient characteristics that might affect the treatment response to acupuncture for insomnia.

METHODS

Medical records of patients with insomnia in a Korean medicine clinic with baseline Insomnia Severity Index (ISI) scores ⩾8 and Pittsburgh Sleep Quality Index (PSQI) scores ⩾5 were reviewed. Acupuncture was applied at ST43, GB41, ST41, SI5, HT3, KI10, HT7 and ST3, for 1-2 months. The ISI and PSQI were measured monthly to assess insomnia severity. The effect of acupuncture over time was analyzed using a multilevel linear model for repeated measures. In addition, logistic regression was used to explore predictors of treatment response.

RESULTS

A total of 91 patients with insomnia aged 59.2 ± 12.5 years (mean ± standard deviation (SD)) (90.1% female) were included in the analysis. After the acupuncture treatment, ISI scores were significantly reduced by -3.75 (95% confidence interval (CI) = -4.99, -2.50) and -4.69 (95% CI = -6.22, -3.16) after the first and second month, respectively. The PSQI global scores also improved, and sleep duration showed a tendency to increase by 0.35 h (95% CI = -0.17, 0.86) after acupuncture treatment. Three cases of mild fatigue were reported. In addition, higher baseline pain/discomfort predicted a greater likelihood of response after acupuncture treatment (odds ratio (OR) = 1.66, 95% CI = 1.10, 2.60).

CONCLUSION

In a real-world setting, the insomnia of outpatients in a clinic was slightly alleviated after acupuncture treatment. These findings require validation by randomized controlled trials.

Current Research Status and Implication for Further Study of Real-World Data on East Asian Traditional Medicine for Heart Failure: A Scoping Review

This study used real-world data (RWD) to explore the long-term effects of East Asian traditional medicine (EATM) on heart failure (HF). A comprehensive search was conducted across five databases to identify relevant studies, which were then reviewed using the Arksey and O'Malley scoping review framework. The analysis focused on a descriptive examination of the long-term outcomes associated with EATM intervention. Methodologically, the study explored various aspects, including study subjects, interventions, applied clinical outcomes, and statistical methods. Out of 258 studies, 12 were selected. Eight studies involved patients with HF, while the others used HF as an outcome. Datasets from the National Health Insurance Research Database were used in Taiwan, while electronic medical record data were used in China and Japan. EATM interventions have been found to be associated with lower mortality and readmission rates. One study indicated that an increased dose of Fuzi, a botanical drug, or prompt use of Fuzi after diagnosis led to a decreased mortality hazard ratio. In two studies examining readmission rates, a significant increase was observed in the non-exposed group, with odds ratios of 1.28 and 1.18. Additionally, in patients with breast cancer, the subdistribution hazard ratio for the occurrence of doxorubicin-induced HF was reduced to 0.69. Although cohort studies with survival analysis were common, methodological flaws, such as issues with statistical methods and HF diagnosis, were identified. Despite these challenges, the study observed an association between EATM and improved clinical outcomes in patients with HF, emphasizing the potential of RWD studies to complement randomized controlled trials, especially for longer-term follow-ups. These results provide foundational data for future RWD research.

2023 Guidelines on the Diagnosis and Treatment of Insomnia in Adults - Brazilian Sleep Association

Chronic insomnia disorder (simplified in this document as insomnia) is an increasingly common clinical condition in society and a frequent complaint at the offices of different areas of health practice (particularly Medicine and Psychology). This scenario has been accompanied by a significant evolution in treatment, as well as challenges in approaching patients in an appropriately way. This clinical guideline, coordinated by the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine and counting on the active participation of various specialists in the area, encompasses an update on the diagnosis and treatment of insomnia in adults. To this end, it followed a structured methodology. Topics of interest related to diagnosis were written based on theoretical framework, evidence in the literature, and professional experience. As for the topics related to the treatment of insomnia, a series of questions were developed based on the PICO acronym (P - Patient, problem, or population; I - Intervention; C - Comparison, control, or comparator; O - Outcome). The work groups defined the eligible options within each of these parameters. Regarding pharmacological interventions, only the ones currently available in Brazil or possibly becoming available in the upcoming years were considered eligible. Systematic reviews were conducted to help prepare the texts and define the level of evidence for each intervention. The final result is an objective and practical document providing recommendations with the best scientific support available to professionals involved in the management of insomnia.

Development of Provisional Acupuncture Guidelines for Pelvic Pain in Endometriosis Using an e-Delphi Consensus Process

Introduction: Growing evidence suggests that acupuncture can improve pelvic pain in women with endometriosis. The treatments used in research vary considerably. It remains unclear which treatment could be recommended for clinical practice. This research project aimed at clarifying how acupuncture could be used when treating this condition. Methods: This research comprised two phases: a systematized literature review to extract acupuncture treatment details from published research, and an e-Delphi study to gain knowledge about details as used by expert acupuncturists. Review: Four databases were searched using predefined eligibility criteria. Data were extracted based on the STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) criteria. e-Delphi: Purposeful sampling from colleagues and international experts. An open first round gathered qualitative data, analyzed with the Framework method. In rounds 2 and 3, experts rated statements to build group consensus, defined as a rating of ≥5 on a 7-point Likert scale by ≥70% of the experts. The strength of agreement was graded using the median score and interquartile range. Results from the literature review and the e-Delphi were compared using the STRICTA items. Results: The literature review (n = 29 unique studies) found a wide range of treatment details with little agreement. The e-Delphi of international experts (n = 20) resulted in agreement on 94 statements (such as key factors for effectiveness); disagreement on a further 29 (such as acupressure); and absence of consensus on 55 statements (such as the number of needle insertions). A comparison of the review and e-Delphi results found little agreement. Conclusions: Details of acupuncture treatment for endometriosis-related pelvic pain were presented. In the absence of acupuncture guidelines for this condition, the researchers of this e-Delphi recommend using the treatment details on which experts agreed as guidance for good practice. The effectiveness of these guidelines should be evaluated in future research. Study registration: Deutsches Register Klinischer Studien, DRKS00022215, June 30, 2020, retrospectively registered.

Effect of switching from continuous to bilevel positive airway pressure on sleep quality in patients with obstructive sleep apnea: the prospective POP IN VAuto study

Background

Issues with tolerability and side effects can decrease continuous positive airway pressure (CPAP) device usage and the benefits of therapy. Different positive airway pressure (PAP) therapy modes providing expiratory pressure relief or using a different pressure during inspiration vs. expiration (bilevel PAP) may alleviate some of these issues. This multicenter, prospective study evaluated the effects of switching from CPAP to bilevel PAP (VAuto mode) on respiratory parameters, device usage, side effects and patient-reported outcomes in patients with obstructive sleep apnea (OSA).

Methods

Eligible OSA patients had started CPAP ≥3 months previously, had good compliance (mean 6.1±2.0 h/night) and well-controlled OSA [residual apnea-hypopnea index (AHI) 4.9±3.1/h] but had pressure tolerance issues or persistent side effects/discomfort. All were switched from CPAP to bilevel PAP (AirCurve 10 VAuto; ResMed). Effectiveness (residual AHI), sleep quality, daytime sleepiness, fatigue, therapy-related side effects, and patient satisfaction/preference were assessed after 3 months and 1 year.

Results

Forty patients were analyzed (68% male, age 64±11 years, body mass index 30.7±5.8 kg/m²). At 3 months and 1 year after switching to bilevel PAP, median [interquartile range] residual AHI was 4/h [2-5.3] and 3.7/h [1.8-5], respectively, and device usage was 7.0 [4.9-7.5] and 6.4 [4.4-7.3] h/night, respectively. Device switch was associated with significant reductions from baseline in expiratory PAP {from 12 [11-13] to 8 [7-9] cmH₂O at 3 months (P<0.001) and 9 [8-12] cmH₂O at 1 year (P=0.005)}, 95^th percentile pressure {from 14 [12-14] to 10 [9-11] and 10 [8-11] cmH2O; P<0.001 and P=0.001, respectively} and leak {from 1 [0-6] to 0 [0-1] and 0 [0-2] L/min; P=0.049 and P=0.033, respectively}. The Pittsburgh Sleep Quality Index score decreased significantly from baseline to 3 and 6 months [7.2±4.0 to 5.0±3.2 (P=0.005) and 4.5±2.7 (P<0.001), respectively]. CPAP-related mouth dryness, choking sensation and aerophagia were significantly improved one year after switching to bilevel PAP. Bilevel PAP was preferred over CPAP by 90% of patients.

Conclusions

Switching to bilevel PAP had several benefits in patients struggling with CPAP, facilitating therapy acceptance and ongoing device usage.

Efficacy and safety of anti-obesity herbal medicine focused on pattern identification: A systematic review and meta-analysis

BACKGROUND

Herbal medicine based on pattern identification (PI) is used widely in Traditional Chinese Medicine. Proper herbal medicine based on PI has been suggested for effective weight reduction and decreasing the adverse events. This systematic review examined the effectiveness and safety of herbal medicine, focusing on PI in treating obesity.

METHODS

Eight electric databases were used for searching randomized controlled trials (RCT) (to August 31, 2021). RCTs which prescribed herbal medicine to obese patients based on PI were included. Body weight (BW) and body mass index (BMI) were the primary outcomes. The risk of bias was assessed using Cochrane risk of bias tool, and the meta-analysis was conducted. Grading the evidence was conducted by using GRADEpro.

RESULTS

Sixteen RCTs (1052 patients) were included: 2 studies compared herbal medicine to placebo (128 patients); 2 studies compared them to western medication (161 patients); 12 studies compared them with usual care (763 patients). The meta-analysis showed that the herbal formulas reduced the BW and BMI without significant Adverse events compared to the control group (BW: mean difference  = -4.10, 95% confidence interval: -5.14 to -3.06, I2 = 2% and BMI: mean difference = -1.53, 95% confidence interval: -1.88 to -1.19, I2 = 25%). Moderate-quality evidence on the primary outcomes was found.

CONCLUSIONS

Herbal medicine - has good clinical efficacy and safety in treating obesity. This study has limitations that some literatures with high risk of bias in blinding or without using a standardized diagnosis of PI were included. However, the current evidence suggests the possibility of precision medicine using PI.

Effectiveness of Acupuncture, Mind and Body Practices, and Natural Products for Insomnia: an overview of systematic reviews

Objectives

This overview summarizes the evidence for the effectiveness and safety of complementary therapies for insomnia through systematic reviews (SRs) and meta-analyses (MAs).

Methods

A comprehensive literature search on SRs and MAs for complementary therapies for insomnia was conducted using six databases.

Results

This overview included 30 SRs/MAs. The Pittsburgh Sleep Quality Index (PSQI) analysis of insomnia included 383 randomized controlled trials and 31,748 participants. Twenty-four SRs/MAs (80%) out of 30 SRs/MAs reported a positive result, and six SRs/MAs reported a partially positive result. The most frequently used form of acupuncture reported a positive effect in 89.5% (17/19) of SRs/MAs and a superior effect to western medicine, sham/placebo, and no treatment. The lack of protocol registration and the excluded studies list resulted in generally poor methodological and reporting quality in SRs/MAs with AMSTAR 2.

Conclusion

This overview confirmed that complementary therapies positively affected the PSQI scores in patients with insomnia. However, better-designed primary studies are needed to strengthen the relevant evidence in the future. A more stringent assessment of multiple systematic reviews 2 must be followed when performing SR and MA.

Two Case Reports of Tapering Sedative-hypnotic Drugs Through Classical Conditioning Using Herbal Medicine (CARE-compliant)

RATIONALE

Sedative-hypnotic drugs (SHDs) used for insomnia are recommended for short-term use owing to concerns regarding abuse and dependence. Nevertheless, drug discontinuation is challenging owing to rebound insomnia that occurs when the SHD is ceased. Therefore, a strategy is required to reduce or discontinue SHDs, while minimizing rebound insomnia.

PATIENT CONCERNS

The present report discusses the cases of a 72-year-old man and 27-year-old man with insomnia. Both patients had been taking SHDs for more than 2 months.

DIAGNOSES

Both patients were diagnosed with primary insomnia.

INTERVENTIONS AND OUTCOMES

After 2 weeks of classical conditioning (CC) using Hwangryunhaedok-tang (HHT), both patients succeeded in tapering SHD; the Korean version of the insomnia severity index of patient 1 dropped from 14 to 5, and that of patient 2 dropped from 28 to 11. In the final follow-up, the index dropped to 2 and 3, respectively.

LESSONS

The CC, a concept emerging in psychology, could be a new strategy for tapering drugs. In this case, SHDs, which had been taken for a long time, were successfully reduced or discontinued through CC using HHT. Herbal medicine such as HHT is selected as a neutral stimulus for CC because the risk of rebound phenomenon is low as the compounds of herbal medicine have high structural similarities with human metabolites. Both patients in this study reported no particular challenges when HHT was discontinued. However, further studies are needed that will assist in tapering anticonvulsants or steroids as well as SHDs.

Deep autoencoder-powered pattern identification of sleep disturbance using multi-site cross-sectional survey data

Pattern identification (PI) is a diagnostic method used in Traditional East Asian medicine (TEAM) to select appropriate and personalized acupuncture points and herbal medicines for individual patients. Developing a reproducible PI model using clinical information is important as it would reflect the actual clinical setting and improve the effectiveness of TEAM treatment. In this paper, we suggest a novel deep learning-based PI model with feature extraction using a deep autoencoder and k-means clustering through a cross-sectional study of sleep disturbance patient data. The data were obtained from an anonymous electronic survey in the Republic of Korea Army (ROKA) members from August 16, 2021, to September 20, 2021. The survey instrument consisted of six sections: demographics, medical history, military duty, sleep-related assessments (Pittsburgh sleep quality index (PSQI), Berlin questionnaire, and sleeping environment), diet/nutrition-related assessments [dietary habit survey questionnaire and nutrition quotient (NQ)], and gastrointestinal-related assessments [gastrointestinal symptom rating scale (GSRS) and Bristol stool scale]. Principal component analysis (PCA) and a deep autoencoder were used to extract features, which were then clustered using the k-means clustering method. The Calinski-Harabasz index, silhouette coefficient, and within-cluster sum of squares were used for internal cluster validation and the final PSQI, Berlin questionnaire, GSRS, and NQ scores were used for external cluster validation. One-way analysis of variance followed by the Tukey test and chi-squared test were used for between-cluster comparisons. Among 4,869 survey responders, 2,579 patients with sleep disturbances were obtained after filtering using a PSQI score of &gt;5. When comparing clustering performance using raw data and extracted features by PCA and the deep autoencoder, the best feature extraction method for clustering was the deep autoencoder (16 nodes for the first and third hidden layers, and two nodes for the second hidden layer). Our model could cluster three different PI types because the optimal number of clusters was determined to be three via the elbow method. After external cluster validation, three PI types were differentiated by changes in sleep quality, dietary habits, and concomitant gastrointestinal symptoms. This model may be applied to the development of artificial intelligence-based clinical decision support systems through electronic medical records and clinical trial protocols for evaluating the effectiveness of TEAM treatment.

Traditional East Asian Herbal Medicine Treatment for Alzheimer's Disease: A Systematic Review and Meta-Analysis

Alzheimer's disease (AD) is a leading progressive neurodegenerative disease worldwide, and its treatment is a challenging clinical problem. This review was conducted to evaluate the efficacy and safety of herbal medicine for AD treatment. The PubMed, CENTRAL, EMBASE, CNKI, OASIS, KTKP, and CiNii databases were searched until June 2020 for randomized controlled trials (RCTs) on herbal medicine for AD, and a meta-analysis of 57 RCTs was conducted. For cognitive function, herbal medicine significantly improved the Mini-Mental State Examination (MMSE) and AD Assessment Scale-Cognitive Subscale (ADAS-cog) scores compared with conventional medicine. The MMSE scores showed no significant difference between the groups treated with herbal medicine and donepezil; however, herbal medicine significantly lowered the ADAS-cog score. Acori Graminei Rhizoma-containing and Cnidii Rhizoma-containing herbal medicine significantly improved the MMSE and ADAS-cog scores compared with conventional medicine. Ginseng Radix-containing herbal medicine showed a positive, but not statistically significant, tendency toward improving the MMSE score compared with conventional medicine. Herbal medicine with conventional medicine significantly improved the MMSE, ADAS-cog, and Montreal Cognitive Assessment (MoCA) scores compared with conventional medicine, and herbal medicine with donepezil also significantly improved these scores compared with donepezil. Acori Graminei Rhizoma or Cnidii Rhizoma-containing herbal medicine with conventional medicine significantly improved the MMSE and ADAS-cog scores compared with conventional medicine. Ginseng Radix-containing herbal medicine + conventional medicine significantly improved the MMSE score, but not the ADAS-cog score, compared with conventional medicine. For behavioral and psychological symptoms of dementia, the Neuropsychiatry Inventory (NPI) score was not significantly different between herbal and conventional medicines. Herbal medicine with conventional medicine significantly improved the NPI and Behavioral Pathology in Alzheimer's Disease Rating Scale scores compared with conventional medicine. The NPI score showed no significant difference between the groups treated with herbal medicine and placebo. Furthermore, herbal medicine with conventional medicine significantly lowered plasma amyloid beta levels compared with conventional medicine alone. Herbal medicine, whether used alone or as an adjuvant, may have beneficial effects on AD treatment. However, owing to the methodological limitations and high heterogeneity of the included studies, concrete conclusions cannot be made.

Minimal Clinically Important Difference and Patient Acceptable Symptom State for the Pittsburgh Sleep Quality Index in Patients Who Underwent Rotator Cuff Tear Repair

The Pittsburgh Sleep Quality Index (PSQI) is a valid patient-reported outcome measure developed to assess sleep quality and disturbances in clinical populations. This study aimed to calculate the minimum clinically important difference (MCID) and the patient acceptable symptom state (PASS) for the PSQI in patients who underwent rotator cuff repair (RCR). Preoperative and six-month postoperative follow-up questionnaires were completed by 50 patients (25 males and 25 females, mean age 58.7 ± 11.1 years). The MCID of the PSQI was calculated using distribution-based and anchor methods. To calculate the PSQI’s PASS, the 75th percentile approach and the receiver operating characteristic (ROC) curve were used. The MCID from preoperative to 6 months postoperative follow-up is 4.4. Patients who improved their PSQI score of 4.4 from baseline to 6 months follow-up had a clinically significant increase in their health status. The PASS is 5.5 for PSQI; therefore, a value of PSQI at least 5.5 at six months follow-up indicates that the symptom state can be considered acceptable by most patients.

Acupuncture combined with moxibustion for insomnia after stroke: A protocol for systematic review and meta analysis

BACKGROUND

Stroke is the main cause of death and disability in the world and insomnia is a common complication of stroke patients. Insomnia will not only seriously affect the prognosis and quality of life of patients with stroke, but even cause the recurrence of stroke. Many studies have proved that acupuncture and moxibustion can effectively improve insomnia symptoms. This study will systematically evaluate the effectiveness and safety of acupuncture combined with moxibustion in treating insomnia after stroke.

METHODS

The following 8 databases will be searched from the inception to October 31, 2020, including China National Knowledge Infrastructure Database (CNKI), Chinese Scientific Journal Database (VIP database), China Biomedical Literature Database (CBM), Wanfang Data Chinese Database, PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Allied and Alternative Medicine Database (AMED), Excerpt Medica Database (Embase). We will also search for ongoing trials from the World Health Organization International Clinical Trial Registration Platform search portal, Chinese Clinical Trial Register, Clinical trials.gov. In addition, the reference lists of studies meeting the inclusion criteria will also be searched for achieving the comprehensive retrieval to the maximum. All randomized controlled trials of acupuncture and moxibustion in treating insomnia after stroke will be included. Two reviewers will conduct literature screening, data extraction, and quality evaluation respectively. The main outcome is the Pittsburgh sleep quality index (PSQI), and the secondary outcomes include clinical efficacy, quality of life, and safety. RevMan V.5.4.1 will be used for meta-analysis. We will express the results as risk ratio (RR) with 95% confidence intervals (CIs) for dichotomous data and mean difference (MD) or standard mean difference (SMD) 95% CIs for continuous data.

RESULTS

This study will provide a comprehensive review of the available evidence of acupuncture combined with moxibustion in treating insomnia after stroke.

CONCLUSION

The conclusion of our study will provide the updated evidence to judge the effectiveness and safety of acupuncture combined with moxibustion for the treatment of insomnia after stroke.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42020216720.

Semi-Individualized Acupuncture for Insomnia Disorder and Oxidative Stress: A Randomized, Double-Blind, Sham-Controlled Trial

BACKGROUND

Acupuncture is an alternative treatment for improving sleep, and it may attenuate oxidative stress, which is a possible pathophysiological factor in insomnia. The aim of this study was to examine the efficacy and safety of a semi-individualized acupuncture in improving sleep and explore its effect on oxidative stress parameters in adults with insomnia disorder.

METHODS

In this randomized sham-controlled trial, 140 participants were randomly assigned to either a 4-week semi-individualized traditional acupuncture (TA) or noninvasive sham acupuncture (SA). The primary outcome measure was the sleep-diary-derived sleep efficiency. Other outcomes included sleep diary and actigraphy, Insomnia Severity Index, anxiety and depressive symptoms, and quality of life. Blood samples were taken to measure oxidative stress parameters (malondialdehyde, glutathione peroxidase, paraoxonase, and arylesterase).

RESULTS

Although no significant difference was found in the primary outcome measure, both sleep-diary-derived and actigraphy-derived total sleep time (TST) were significantly increased in the TA group at 1-week posttreatment (mean difference in sleep diary = 22.0 min, p = 0.01, actigraphy = 18.8 min, p = 0.02). At 5-week posttreatment follow-up, a significantly higher proportion of participants in the TA group showed sleep-diary-derived sleep efficiency (SE) ≥ 85% than in the SA group (55.6% versus 36.4%, p = 0.03).

CONCLUSION

TA and SA did not significantly differ in improving subjective sleep efficiency in individuals with insomnia disorder. However, the TA group showed a short-term effect on improving TST as measured by both sleep diary and actigraphy at 1-week posttreatment, but there were no differences in the oxidative stress parameters.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: Acupuncture in the Modulation of Peripheral Oxidative Stress Insomnia; Identifier NCT03447587; URL: https://clinicaltrials.gov/ct2/show/NCT03447587.

PRISMA extension for moxibustion 2020: recommendations, explanation, and elaboration

BACKGROUND

Moxibustion is a common intervention of Chinese medicine (CM). Systematic reviews (SRs) on moxibustion are increasing. Although the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement provides guidelines for SRs, the quality of moxibustion-related SRs is still not satisfactory. In particular, descriptions of the interventions and the rationale for using moxibustion are insufficient. To address these inadequacies, the working group developed this PRISMA extension for reporting SRs of moxibustion (PRISMA-M 2020).

METHODS

A group of CM clinical professionals, methodologists of SRs, reporting guideline developers, and journal editors developed this PRISMA-M 2020 through a comprehensive process that includes registration, literature review, consensus meetings, Delphi exercises for soliciting comments, and revision, resulting in this final draft.

RESULTS

Seven of the 27 PRISMA checklist items, namely title (1), rationale (3), eligibility criteria (6), data item (11), additional analyses (16), study characteristics (18), and additional analysis (23), were extended, with specific reference to the application of moxibustion. Illustrative examples and explanations for each item are provided.

CONCLUSION

The PRISMA-M 2020 will help improve the reporting quality of SRs with moxibustion.

SYSTEMATIC REVIEW REGISTRATION

We have registered it on the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network, particularly under the item of PRISMA-TCM: http://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-systematic-reviews/#65 .

Analysis of diagnostic decision in acupuncture from the actual functional dyspepsia patient's clinical information

Background

Clinical research in acupuncture has been criticized for not reflecting real-world practice in terms of diagnosis and intervention. This study aimed to collect data on the principles of diagnosis and selection of acupoints from Korean medicine doctors (KMDs) and analyze the patterns and priorities in decision-making.

Methods

The study design was based on the data of an actual patient with functional dyspepsia (FD) (according to Rome III criteria) to create simulated patients, and a KMD specialized in gastrointestinal disorders was allocated to collect the clinical information as objectively as possible. Sixty-nine KMDs were recruited to diagnose a simulated patient based on the actual patient's clinical information, in a manner similar to that performed in their clinics.

Results

After the diagnostic procedures were completed, the pattern identification, selected acupoints, reasons for choosing them, and importance of symptoms for deciding their diagnoses were documented. The information needed was clearly distinguishable from those routinely asked in western medicine, and information regarding fecal status, abdominal examination, appetite status, pulse diagnosis, and tongue diagnosis were listed as vital. The doctors identified the patient's pattern as "spleen-stomach weakness", "liver qi depression", or "food accumulation or phlegm-fluid retention". The most frequently selected acupoints were CV12, LI4, LR3, ST36, and PC6.

Conclusion

There are common acupoints across different patterns, but pattern-specific acupoints were also recommended. These results can provide useful information to design clinical research and education for better clinical performance in acupuncture that reflects real-world practice.

Sedative and Hypnotic Effects and Transcriptome Analysis of Polygala tenuifolia in Aged Insomnia Rats

OBJECTIVE

To study the sedative and hypnotic effects and underlying mechanisms of Polygala tenuifolia (PT) on treating aged insomnia rats.

METHODS

Sixty Sprague-Dawley male rats were divided into 6 groups by a random number table, including control group, model group, diazepam group (0.92 mg/kg), as well as PT low-, medium- and high-dose groups (0.0875, 0.175, 0.35 g/kg, respectively), 10 rats in each group. Aged insomnia rat model was established with subcutaneous injection of D-galactose for 42 days and then intraperitoneal injection of para-chlorophenylalanine for 3 days. PT and diazepam were respectively given to aged insomnia rats by intragastric administration for 7 days after model establishment. Then the rats were investigated by body weight, Morris water maze test, pentobarbital test, enzyme-linked immunosorbent assay, and transcriptome sequencing.

RESULTS

Compared with the model group, PT increased the body weight, improved memory ability, and prolonged pentobarbital-induced sleep time of aged insomnia rats (P<0.01 or P<0.05). The medium dose of PT also increased the neurotransmitter levels of 5-hydroxytryptamine (5-HT) and gamma-aminobutyric acid (GABA), and decreased the level of Glu in the hippocampus of aged insomnia rats (P<0.05 or P<0.01). Twenty-four differentially expressed genes (DEGs) were overlapped among model group, medium-dose PT group, and diazepam group in transcriptome analysis. Fuom and Pcp2 were down-regulated by the treatment of medium-dose PT (P<0.01 or P<0.05). The metabolic pathways of PT were relatively less than diazepam (91 vs. 104).

CONCLUSIONS

The sedative and hypnotic effects of PT in aged insomnia rats might be related to neuro, metabolism pathways, especially through GABAergic signaling pathway. It provided more effective herb choice for the treatment of senile insomnia.

EFFECTIVENESS OF AURICULOACUPUNCTURE ON THE SLEEP QUALITY OF WORKING NURSING PROFESSIONALS DURING THE COVID-19 PANDEMIC

ABSTRACT Objective: to evaluate the effectiveness of auriculoacupuncture in improving the sleep quality of nursing professionals in the fight against the COVID-19 pandemic. Method: quasi-experimental before and after study, without a control or matching group performed from May to July 2020, in a referral hospital for infectious diseases in Ceará. The sample consisted of 26 nursing professionals, including nurses and technicians, who performed three sessions of auriculoacupuncture, once a week, for four weeks. Sleep quality was measured by the Pittsburg Sleep Quality Index. The effects of the intervention were analyzed by the student's “t” test to compare means between the first and last application, one-way ANOVA with repeated measures and post-hoc Sidak´s test. Results: regarding the components of the Pittsburg Sleep Quality Index, significant differences were observed between the individuals in the components: subjective sleep quality (p=0.001); sleep latency (p<0.001), sleep duration (p<0.001), habitual sleep efficiency (p=0.011), sleep disorders (p<0.001), sleeping medications (p=0.005) and excessive daytime sleep sleepiness (p<0.001). The overall sleep index also changed significantly (p<0.001). The intervention reduced the sleep quality index score by 52.35%. Conclusion: the changes that occurred were able to change the category in sleep classification through a detailed decrease in the Pittsburg Sleep Quality Index scores. Significant differences were observed between the first and final moments in the global index and in all components.