Introduction: This guideline establishes clinical practice recommendations for the use of behavioral and psychological treatments for chronic insomnia disorder in adults. Methods: The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep medicine and sleep psychology to develop recommendations and assign strengths based on a systematic review of the literature and an assessment of the evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The task force evaluated a summary of the relevant literature and the quality of evidence, the balance of clinically relevant benefits and harms, patient values and preferences, and resource use considerations that underpin the recommendations. The AASM Board of Directors approved the final recommendations. Recommendations: The following recommendations are intended as a guide for clinicians in choosing a specific behavioral and psychological therapy for the treatment of chronic insomnia disorder in adult patients. Each recommendation statement is assigned a strength ("strong" or "conditional"). A "strong" recommendation (ie, "We recommend…") is one that clinicians should follow under most circumstances. A "conditional" recommendation is one that requires that the clinician use clinical knowledge and experience, and to strongly consider the patient's values and preferences to determine the best course of action.1. We recommend that clinicians use multicomponent cognitive behavioral therapy for insomnia for the treatment of chronic insomnia disorder in adults. (STRONG) 2. We suggest that clinicians use multicomponent brief therapies for insomnia for the treatment of chronic insomnia disorder in adults. (CONDITIONAL) 3. We suggest that clinicians use stimulus control as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL) 4. We suggest that clinicians use sleep restriction therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL) 5. We suggest that clinicians use relaxation therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL) 6. We suggest that clinicians not use sleep hygiene as a single-component therapy for the treatment of chronic insomnia disorder in adults. (CONDITIONAL)

Introduction:The purpose of this systematic review is to provide supporting evidence for a clinical practice guideline on the use of behavioral and psychological treatments for chronic insomnia disorder in adult populations. Methods: The American Academy of Sleep Medicine commissioned a task force of 9 experts in sleep medicine and sleep psychology. A systematic review was conducted to identify randomized controlled trials that addressed behavioral and psychological interventions for the treatment of chronic insomnia disorder in adults. Statistical analyses were performed to determine if the treatments produced clinically significant improvements in a range of critical and important outcomes. Finally, the Grading of Recommendations Assessment, Development, and Evaluation process was used to evaluate the evidence for making specific treatment recommendations. Results: The literature search identified 1,244 studies; 124 studies met the inclusion criteria, and 89 studies provided data suitable for statistical analyses. Evidence for the following interventions is presented in this review: cognitive-behavioral therapy for insomnia, brief therapies for insomnia, stimulus control, sleep restriction therapy, relaxation training, sleep hygiene, biofeedback, paradoxical intention, intensive sleep retraining, and mindfulness. This review provides a detailed summary of the evidence along with the quality of evidence, the balance of benefits vs harms, patient values and preferences, and resource use considerations.

Correspondence e36classic Kawasaki disease. Two of these six patients (patients 7 and 8) had sufficient criteria for typical Kawasaki disease. None of these six children showed evidence of myocardial dysfunction, although pericardial effusion was observed in 3 of 6 children.Coronary artery dilatation was seen in five (62•5%) patients. A z-score of more than 2•5 in the left anterior descending or right coronary artery was reported in three and 2•0-2•5 in two patients (mean 2•94, SD ± 0•97, 95%CI 1•7 -4•16, SE ± 0•44, median 2•6, range +2•06 to +4•27, spread range +2•2). Both children with shocklike pre sentation had coronary artery involve ment, but two patients who fulfilled the Kawasaki disease criteria showed healthy coronary arteries. All children except one (7 of 8, 87•5%) received intra venous immuno globulin (2 g/kg body weight) within the first 2 days of their stay. Three patients received thera peutic anticoagulation (enoxaparin) on the basis of the high risk of thrombo embolism and amount of D-dimers. With the exception of the one death discussed already, the other seven children have been discharged home.Other children with PIMS-TS reported in the literature have presented with acute heart failure and features of acute myocarditis. 3,5,7 This feature has a special notability in our country, because viral myocarditis is a common presentation all year long, and there would be background cases with dilated cardiomyopathy or myocarditis. All children presenting with acute myocarditis in the study period were screened for exposure to SARS-CoV-2 and underwent COVID-19 antibody testing. Only one of six patients admitted with myocarditis during the study period tested positive for COVID-19 antibodies. This child, however, did not show evidence of raised inflammatory markers and is not included in the series.Our data, although restricted by numbers, show some differences For data on COVID-19 cases in Pakistan see www.covid.gov.pk

Risks associated with fatigue that accumulates during work shifts have historically been managed through working time arrangements that specify fixed maximum durations of work shifts and minimum durations of time off. By themselves, such arrangements are not sufficient to curb risks to performance, safety, and health caused by misalignment between work schedules and the biological regulation of waking alertness and sleep. Science-based approaches for determining shift duration and mitigating associated risks, while addressing operational needs, require: 1) a recognition of the factors contributing to fatigue and fatigue-related risks; 2) an understanding of evidence-based countermeasures that may reduce fatigue and/or fatigue-related risks; and 3) an informed approach to selecting workplace-specific strategies for managing work hours. We propose a series of guiding principles to assist stakeholders with designing a shift duration decision-making process that effectively balances the need to meet operational demands with the need to manage fatigue-related risks.

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