A Pilot Study of Acupuncture for Tension Headache, Using a Novel Placebo

Tension headache is common, and treatment with acupuncture is frequently recommended, although the evidence of its effectiveness is contradictory. This small, randomised, controlled trial was designed as a pilot to test procedures in preparation for a multi-centre trial investigating the effect of acupuncture as a treatment for tension headache. Ten volunteers suffering from episodic, tension-type headache were recruited by local newspaper articles. Patients were randomised to receive either brief needling to tender areas or selected traditional points (Group A), or pressure from a cocktail stick supported within a guide tube to defined, non-tender and non-acupuncture areas (Group B). The patients’ view of the treatment sites was obstructed so that no indication could be gained as to which form of treatment was being given.

Throughout the period of the trial, duration, frequency and intensity of headaches were recorded, from which the mean weekly headache index was calculated. There was no difference between the changes in weekly headache index in the two groups, comparing scores before and after treatment. However, Group A experienced a considerably higher number of headache-free weeks than Group B. The credibility of the two procedures was tested using a standard credibility questionnaire and a “final verdict”. One subject in Group B concluded that she had not received genuine acupuncture, but overall there was no statistical difference between the credibility of treatment in the two groups.

Traditional Acupuncture for Reflex Sympathetic Dystrophy: A Randomised, Sham-Controlled, Double-Blind Trial

Acupuncture has been suggested as helpful in reflex sympathetic dystrophy (RSD), but no controlled study has yet been published. The hypothesis of this randomised, double-blind, sham-controlled trial, therefore, was that traditional Chinese acupuncture improves subjective as well as objective signs in this condition. Patients were included when suffering from clinically and scintigraphically confirmed acute RSD of the upper or lower limb, with a history between one and four months. They were randomly assigned to either traditional acupuncture (group A) or sham acupuncture (group S). Treatments were applied five times a week for three weeks, each session lasting for 30 minutes. Both groups received identical standard treatments in addition. The primary outcome variable had been pre-defined to be pain, as measured by visual analogue scale assessed before each treatment. Subjective success was also recorded by the patients on a rating scale. Due to force of circumstances, only 14 patients were entered into the study, therefore no test statistics could be performed and the data was evaluated descriptively. At baseline, pain was almost identical in both groups. During the course of the study, patients in group A demonstrated a more pronounced reduction of pain: 28.6% ± 1.9 vs 17.9% ± 2.4 (Mean ± SEM). Similarly, subjective success was rated to favour traditional acupuncture. It is concluded that acupuncture may be useful in the management of pain in patients with acute RSD, but that the present results are not conclusive. Larger, rigorous studies are required to answer the question.

Comprehensive study on the light shielding potential of thermotropic layers for the development of new materials

In recent years thermotropic overheating protection glazings have been the focus for both solar thermal collector technology and architecture. A thermotropic glazing changes its light transmittance from highly transparent to light diffusing upon reaching a certain threshold temperature autonomously and reversibly. In thermotropic systems with fixed domains (TSFD) the scattering domains are embedded in a polymer matrix, which exhibits a sudden change of the refractive index upon reaching a threshold temperature. The aim of the present study was to comprehensively investigate the light shielding characteristics and potential of TSFD materials by applying simulation of light scattering in particle-filled layers. In random walk simulations a variety of parameters were varied systematically, and the effect on the light transmission behavior of TSFD was studied. The calculation steps of the simulation process are shown in detail. The simulations demonstrate that there is great potential for the production of functional materials with high overheating protection efficiency.

[Chronic prostatitis/chronic pelvic pain syndrome. Influence of osteopathic treatment - a randomized controlled study]

BACKGROUND

Prostatitis is the most common urological disease in males under [corrected] the age of 50 years old. As bacteria are detected in only <5% of cases the disease can mostly be classified as chronic nonbacterial prostatitis. The symptoms of this problem complex, often described as chronic prostatitis and chronic pelvic pain syndrome (CP-CPPS), seem to be multifactorial so that an improvement can only rarely be achieved with conventional forms of therapy.

MATERIALS AND METHODS

The aim of this study was to investigate whether osteopathic treatment can influence the symptoms of CP-CPPS (randomized controlled study, 5 sessions, follow-up after 6 weeks and 1.5 years without treatment). The study was carried out in a practice for osteopathy. Patients were recruited by referral from urologists, newspaper articles and lectures on the topic. A total of 35 males with medically diagnosed CP-CPPS aged 29-70 years old took part in the study. Of the patients 20 were allocated to the treatment group and 15 to the placebo group whereby 2 patients had to retire from the study prematurely. Patients in the treatment group received 5 osteopathic treatment sessions separated by 1 week at the beginning and by up to 3 weeks at the end (total period 8 weeks). The osteopathic dysfunctions of the patients were treated according to the principles of osteopathy. The placebo treatment in the control group consisted of a training program with simple gymnastic and physiotherapeutic exercises. Improvements of the complaints by urination (LUTS), chronic pelvic pain (CPPS) and quality of life (QOL) were measured using the questionnaires for international prostate symptom score (IPSS), the National Institutes of Health chronic prostatitis symptom index (NIH-CPSI) and the quality of life index (QOL).

RESULTS

Comparison of the results from the osteopathy and placebo groups revealed statistically significant differences in favor of the osteopathy group (p<0.0005). During the study period the average IPSS in the osteopathy group improved from 19.7 to 10.3 points (48%, p<0.0005), the NIH from 26.0 to 12.0 (54%; p<0.0005) and the QOL from 4.4 to 1.9 points (58%, p<0.0005). In contrast the corresponding values in the placebo group remained relatively constant. At the follow-up 6 weeks after the last session the improvements in the osteopathy group were found to be stabile and remained so at least up to the second follow-up after 1.5 years.

CONCLUSIONS

The positive results of this study indicate that osteopathic treatment can be considered a genuine alternative to the conventional treatment of CP-CPPS and a closer cooperation between urologists/internists and osteopaths would be desirable. Further studies with larger numbers of patients should be carried out to substantiate these results.

A pragmatic randomized controlled trial on the effectiveness of low concentrated saline spa water baths followed by ultraviolet B (UVB) compared to UVB only in moderate to severe psoriasis

OBJECTIVE

To evaluate whether low concentrated saline spa water baths followed by ultraviolet B (LC-SSW-UVB) are superior to UVB alone in moderate to severe psoriasis.

BACKGROUND

There is a lack of sufficiently large randomized controlled clinical trial evaluating the additional benefit of saltwater baths followed by UVB compared to UVB only in psoriasis.

STUDY DESIGN

Partly evaluator blind, multicentre, pragmatic, randomized controlled trial.

SETTING

Five German spa centres.

SUBJECTS

One hundred and forty-three adults with stable psoriasis during the last month and a Psoriasis Area and Severity Index (PASI) of > 10 and/or an affected body surface area of > 15%.

INTERVENTIONS

LC-SSW-UVB or UVB thrice a week until remission (PASI < 5) or for a maximum of 6 weeks. Sodium chloride concentrations of natural springs varied between 4.5% and 12%. Conventional UVB (broadband UVB or selective UVB phototherapy) was used as irradiation source.

MAIN OUTCOME

Reduction of PASI and/or affected body surface area of 50% at the end of the intervention period (PASI-50). Only participants receiving at least one intervention were included in the primary analysis.

RESULTS

Patients allocated to LC-SSP-UVB attained a statistically significantly higher rate of PASI-50 at the end of the intervention period than patients allocated to UVB [58/79 (73%) vs. 32/64 (50%); P = 0.01; NNT, 4.3, 95% CI, 2.4-18.1]. Benefit persisted until 3 months only for one of two secondary outcomes considered.

CONCLUSIONS

In routine clinical practice balneophototherapy using conventional UVB is superior to conventional UVB only at the end of a 6-week treatment course.

Exercise for women receiving adjuvant therapy for breast cancer

BACKGROUND

A huge clinical research database on adjuvant cancer treatment has verified improvements in breast cancer outcomes such as recurrence and mortality rates. On the other hand, adjuvant therapy with agents such as hormone therapy, chemotherapy and radiotherapy impacts on quality of life due to substantial short- and long-term side effects.

OBJECTIVES

To assess the effect of aerobic or resistance exercise interventions during adjuvant treatment for breast cancer on treatment-related side effects such as physical deterioration, fatigue, psychosocial distress and physiological, morphological and biological changes.

SEARCH STRATEGY

We searched the Cochrane Breast Cancer Specialised Register (16 July 2004) and the following electronic databases: MEDLINE (1966 to 2006), EMBASE (1988 to 2004), CINAHL (1982 to 2004), SPORTDiscus (1975 to 2004), PsycINFO (1872 to 2003), SIGLE (1880 to 2004), ProQuest Digital Dissertations (1861 to 2004) and Conference Papers Index (1973 to 2004). Furthermore, we screened references in relevant reviews and clinical trials and handsearched relevant journals.

SELECTION CRITERIA

We included randomised and non-randomised controlled trials that examined aerobic or resistance exercise, or both, in women undergoing adjuvant treatment for breast cancer.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed methodological quality and adequacy of the training stimulus following a set of standardised criteria. Meta-analyses were performed for physical fitness, fatigue and weight gain using a random-effects model.

MAIN RESULTS

Nine trials involving 452 women met the inclusion criteria. Meta-analysis for cardiorespiratory fitness (involving 207 participants) suggested that exercise improves cardiorespiratory fitness (SMD 0.66, 95% CI 0.20 to 1.12). Meta-analysis for fatigue (317 participants) found statistically non-significant improvements for participants in the exercise intervention groups compared to control (non-exercising) groups (SMD -0.12, 95% CI -0.37 to 0.13); the same applied for the meta-analysis of weight gain (147 participants) (SMD -1.11, 95% CI -2.44 to 0.22). Evidence for other outcomes remains limited. Adverse effects (lymphedema and shoulder tendonitis) were observed in two trials. The results from non-randomised controlled trials are similar to those of randomised controlled trials and do not appear to produce any bias. This review is based on a small number of trials with a considerable degree of clinical heterogeneity regarding adjuvant cancer treatments and exercise interventions.

AUTHORS' CONCLUSIONS

Exercise during adjuvant treatment for breast cancer can be regarded as a supportive self-care intervention which results in improved physical fitness and thus the capacity for performing activities of daily life, which may otherwise be impaired due to inactivity during treatment. Improvements in fatigue were ambiguous and there was a lack of evidence for improvement with exercise for other treatment-related side effects. Since exercise interventions (for sedentary participants) require behaviour change, strategies for behaviour change should underpin these interventions. Furthermore, long-term evaluation is required due to possible long-term side effects.

Analyzing the content of outcome measures in clinical trials on irritable bowel syndrome using the international classification of functioning, disability and health as a reference

BACKGROUND

Patients with irritable bowel syndrome (IBS) report a significant impact of their symptoms on functional health. In outcome assessment of clinical studies on IBS, however, functional aspects other than gastrointestinal symptoms seem to be disregarded to a great extent.

AIM

To analyze the content of outcome measures used in clinical IBS trials.

METHODS

A systematic review was performed in terms of a quantitative content analysis using the International Classification of Functioning, Disability and Health (ICF) as a coding scheme. Outcome measures were selected from all randomized controlled trials on IBS published in PubMed from the beginning to April 2002. From the outcome measures pre-specified text passages, so-called coding units, were extracted and linked to the ICF. A coding unit had to describe a single health aspect or an internal or external factor with an impact on health. If the outcome measure was a test the goal of the test was semantically implicated. Only second-level ICF categories contained in the outcome assessment of at least 10 % of the studies were considered. All steps of the review were performed by three independent raters.

RESULTS

99 studies were included. Single items were used as outcome measures in 88, clinical and paraclinical tests in 42 and questionnaires in 24 studies. Ninety percent of the coding units (n = 2271) could be linked to the ICF. ICF categories describing gastrointestinal symptoms were considered in the outcome assessment of 37 to 85 studies depending on the type of content compared to extra-gastrointestinal symptoms in 10 to 22 studies. Health information of ICF components other than "body functions" was scarcely included. Clear secular trends for individual ICF categories could not be found. Only a single IBS-specific questionnaire considered health information other than gastrointestinal symptoms.

DISCUSSION AND CONCLUSION

Outcome assessment of clinical IBS studies is mainly based on gastrointestinal symptoms. The assessment of other health aspects like comorbid psychological symptoms or social consequences of the disease seems to be similarly important and should be considered in future trials. This would also facilitate the understanding of IBS as a biopsychosocial health condition, both in matters of aetiology and consequences.

Distributing entanglement and single photons through an intra-city, free-space quantum channel

We have distributed entangled photons directly through the atmosphere to a receiver station 7.8 km away over the city of Vienna, Austria at night. Detection of one photon from our entangled pairs constitutes a triggered single photon source from the sender. With no direct time-stable connection, the two stations found coincidence counts in the detection events by calculating the cross-correlation of locally-recorded time stamps shared over a public internet channel. For this experiment, our quantum channel was maintained for a total of 40 minutes during which time a coincidence lock found approximately 60000 coincident detection events. The polarization correlations in those events yielded a Bell parameter, S=2.27+/-0.019, which violates the CHSH-Bell inequality by 14 standard deviations. This result is promising for entanglement-based freespace quantum communication in high-density urban areas. It is also encouraging for optical quantum communication between ground stations and satellites since the length of our free-space link exceeds the atmospheric equivalent.

IFNgamma induces functional chemokine receptor expression in human mesangial cells

Infiltration of leucocyte populations into sites of inflammation is a common feature in renal diseases. Glomerular mesangial cells are potent producers of a variety of chemokines, leading to specific attraction of distinct types of inflammatory leucocytes into the glomerulus, but so far there is limited knowledge about the responsiveness of mesangial cells to chemokines. We investigated the expression of chemokine receptors and the responsiveness of primary human mesangial cells (HMC) to the chemokines which they produce, namely monocyte chemoattractant protein-1 (MCP-1) and interleukin (IL)-8. We found that mRNAs of the chemokine receptors CCR1, which has been shown before, CCR2 and CXCR2 were induced by T-helper cytokine interferon-gamma (IFNgamma). In IFNgamma-stimulated cells, CCR2 and CXCR2 were detectable by flow cytometry. Following treatment with IFNgamma, HMC responded to MCP-1 and IL-8 with an increase of IL-6 mRNA and protein expression, which was in part blocked by pertussis toxin. Moreover, chemokine stimulation of transfected HMC led to an activation of the immunoregulatory transcription factors NFkappaB and AP-1. Additionally, we found that MCP-1 enhanced the expression of its own mRNA in cells activated to express CCR2, suggesting autocrine feedback mechanisms in MCP-1 regulation. Finally, IFNgamma-activated cells migrated towards an MCP-1 gradient in a chemotaxis assay. These results strengthen the assumption that chemokines are not only involved in the recruitment of immune cells to inflamed tissues, but also seem to play a central role in the autocrine regulation of local tissue cells, leading to proceeding inflammation and possibly contributing to healing by mediating cell growth and migration.

Comparative study analyzing effects of sirolimus-cyclosporin and sirolimus-tacrolimus combinations on bile flow in the rat

The new immunosuppressive agent sirolimus is combined in transplant patients with the cholestatic substances cyclosporin and tacrolimus. Nothing is known about possible cholestatic effects of these combinations. Therefore, we compared their effects on bile flow and on important bile parameters in an acute bile fistula model in rats. Cyclosporin reduced bile flow, biliary excretion of bile salts, cholesterol, and GSH to 20-40% of basal values. Sirolimus decreased bile flow to 50% and excretion of GSH to 30% of the initial conditions but had no effect on cholesterol and bile salt excretion. In contrast, tacrolimus increased bile flow to 120% and GSH excretion to 220% of the basal levels. Sirolimus/cyclosporin decreased bile flow and bile parameters to the same extent as cyclosporin alone. Sirolimus/tacrolimus reversed sirolimus-induced reduction of bile flow and GSH excretion and resulted in a normal bile salt and cholesterol excretion, thus it may be the better alternative in cholestatic patients.

[A hospital suited version of the German SF-36 and its psychometric comparison with the original questionnaire]

OBJECTIVES

The application of the Short-Form 36 Health Survey (SF-36) in hospitals is sometimes problematic, because some formulations like "at work" or "at home" in some items are not adequate in a hospital context. To account for this problem, we deleted 23 words like "at work" and "at home" from the SF-36 and generated thus a slightly modified version, the SF-36 m. The present paper deals primarily with two questions: is the SF-36 m well applicable in hospitals and is it still equivalent with the original version?

METHODS

The SF-36 m was applied in more than 300 patients in two different hospitals. In one hospital a randomised design was used to assess the equivalence of SF-36 and SF-36 m before treatment.

RESULTS

The reported high percentages of missing values in four critical scales were no more observed, when the SF-36 m was applied at the end of hospital stays. Only minor differences between SF-36 and SF-36 m with effect sizes < 0.20 were observed, although the scale "physical role function" and especially item 4d showed unexpectedly significantly higher values in the SF-36 m (p < 0.10). Additionally, higher and significant differences were observed between the applications of the questionnaires at home and in the hospital.

CONCLUSIONS

Opposed to the original SF-36 the SF-36 m is well applicable at the end of hospital stays. SF-36 and SF-36 m show only minor differences in the comparison of their equivalence. The application of SF-36 and SF-36 m in hospitals seems to yield more favourable scores of health related quality of life than the application at home.

Analgesic effectiveness of subcutaneous carbon-dioxide insufflations as an adjunct treatment in patients with non-specific neck or low back pain

OBJECTIVES

To evaluate the analgesic effectiveness of subcutaneous carbon-dioxide insufflations in addition to standard physical treatment in patients with non-specific neck or low back pain.

DESIGN

A pragmatic, randomized controlled trial.

SETTING

Rehabilitation hospital inpatients.

INTERVENTIONS

Patients received either subcutaneous carbon-dioxide insufflations (10 treatments) and standard physical treatment or standard physical treatment only.

OUTCOME MEASURES

Affective pain perception (42-point scale), sensory pain perception (30-point scale), pain intensity (100 mm visual analogue scale).

RESULTS

Between-groups differences were -2.2 [95% CI -5.2; +0.9] (affective pain perception), -1.2 [-3, 0; + 0.7] (sensory pain perception), and -6.5 [-14; +1.0] (pain intensity) respectively in favour of subcutaneous carbon-dioxide insufflations.

CONCLUSIONS

Subcutaneous carbon-dioxide insufflations do not seem to be a worthwhile adjunct in the given setting of inpatient rehabilitation. Trials in a monotherapeutic setting, which aim more at the efficacy of subcutaneous carbon-dioxide insufflations, might help to solve this issue.

Regulation by rho family GTPases of IL-1 receptor induced signaling: C3-like chimeric toxin and Clostridium difficile toxin B inhibit signaling pathways involved in IL-2 gene expression

In this study the participation of Rho family GTPases in the regulation of IL-1-activated protein kinase cascades controlling IL-2 synthesis was investigated in murine EL-4 thymoma cells. The recombinant C3-like chimeric toxin, which consists of the C3 toxin of Clostridium limosum and the N-terminal part of Clostridium botulinum C2 toxin (C2IN-C3) interacting with the C2II binding subunit to facilitate uptake into cells, and selectively inactivates Rho A by ADP-ribosylation, prevented IL-1-stimulated activation of Jun-NH2-terminal-kinases (JNK) and p38 mitogen-activated-protein kinases (MAPK). UDP-monoglucosylation and concomitant inactivation of Rho A and of Rac-2 by Clostridium difficile toxin B also inhibited IL-1-induced activation of JNK and p38 MAPK, but additionally inhibited activation of the extracellular-regulated-kinase pathway and DNA binding of the transcription factor NFkappaB. Accordingly, pre-treatment of cells with C21N-C3 fusion toxin only decreased IL-1-stimulated IL-2 synthesis by 50%, while in C. difficile toxin B-treated cells IL-1-induced IL-2 secretion was reduced by 90%. These results imply that together with Rho A an additional member of the Rho family G proteins, i.e. Rac-2, is critically involved as an upstream regulator in IL-1-induced activation of different MAPK, stress-activated protein kinases, and in NFkappaB activation controlling IL-2 gene expression in response to IL-1, acting in close proximity to the IL-1-receptor complex.

Fasting followed by vegetarian diet in patients with rheumatoid arthritis: a systematic review

Clinical experience suggests that fasting followed by vegetarian diet may help patients with rheumatoid arthritis (RA). We reviewed the available scientific evidence, because patients frequently ask for dietary advice, and exclusive pharmacological treatment of RA is often not satisfying. Fasting studies in RA were searched in MEDLINE and by checking references in relevant reports. The results of the controlled studies which reported follow-up data for at least three months after fasting were quantitatively pooled. Thirty-one reports of fasting studies in patients with RA were found. Only four controlled studies investigated the effects of fasting and subsequent diets for at least three months. The pooling of these studies showed a statistically and clinically significant beneficial long-term effect. Thus, available evidence suggests that fasting followed by vegetarian diets might be useful in the treatment of RA. More randomised long-term studies are needed to confirm this view by methodologically convincing data.

Improvement of thigh muscles by neuromuscular electrical stimulation in patients with refractory heart failure: a single-blind, randomized, controlled trial

OBJECTIVE

To determine the impact of an 8-wk neuromuscular stimulation program of thigh muscles on strength and cross-sectional area in patients with refractory heart failure listed for transplantation.

DESIGN

Forty-two patients with a stable disease course were assigned randomly to a stimulation group (SG) or a control group (CG). The stimulation protocol consisted of biphasic symmetric impulses with a frequency of 50 Hz and an on/off regime of 2/6 sec.

RESULTS

Primary outcome measures were isometric and isokinetic thigh muscle strength and muscle cross-sectional area. Our results showed an increase of muscle strength by mean 22.7 for knee extensor and by 35.4 for knee flexor muscles. The CG remained unchanged or decreased by -8.4 in extensor strength. Cross-sectional area increased in the SG by 15.5 and in the CG by 1.7.

CONCLUSIONS

Activities of daily living as well as quality of life increased in the SG but not in the CG. Subscales of the SF-36 increased significantly in the SG, especially concerning physical functioning by +7.5 (1.3-30.0), emotional role by +33.3 (0-66.6), and social functioning by +18.8 (0-46.9), all P < 0.05. Neither a change nor a decrease was observed in the CG. Neuromuscular electrical stimulation of thigh muscles in patients with refractory heart failure is effective in increasing muscle strength and bulk and positively affects the perception of quality of life and activities of daily living.

The NF-kappa b repressing factor is involved in basal repression and interleukin (IL)-1-induced activation of IL-8 transcription by binding to a conserved NF-kappa b-flanking sequence element

Interleukin (IL)-8, a prototypic chemokine, is rapidly induced by the pro-inflammatory cytokine IL-1 but is barely detectable in noninduced cells. Although there is clear evidence that the transcription factor NF-kappaB plays a central role in inducible IL-8 transcription, very little is known about the cis-elements and trans-acting factors involved in silencing of the IL-8 promoter. By sequence comparison with the interferon-beta promoter, we found a negative regulatory element (NRE) in the IL-8 promoter overlapping partially with the NF-kappaB response element. Here we show that an NF-kappaB-repressing factor (NRF) binds to the IL-8 promoter NF-kappaB-NRE. Reduction of cellular NRF by expressing NRF antisense RNA results in spontaneous IL-8 gene expression. In contrast, IL-1-induced IL-8 secretion is strongly impaired by expressing NRF antisense RNA. Mutation of the NRE site results in loss of NRF binding and increased basal IL-8 transcription. On the other hand IL-1-induced IL-8 transcription is decreased by mutating the NRE. These data provide evidence for a dual role of the NRF in IL-8 transcription. Although in the absence of stimulation it is involved in transcriptional silencing, in IL-1-induced cells it is required for full induction of the IL-8 promoter.

The MAPK kinase kinase TAK1 plays a central role in coupling the interleukin-1 receptor to both transcriptional and RNA-targeted mechanisms of gene regulation

Mechanisms of fulminant gene induction during an inflammatory response were investigated using expression of the chemoattractant cytokine interleukin-8 (IL-8) as a model. Recently we found that coordinate activation of NF-kappaB and c-Jun N-terminal protein kinase (JNK) is required for strong IL-8 transcription, whereas the p38 MAP kinase (MAPK) pathway stabilizes the IL-8 mRNA. It is unclear how these pathways are coupled to the receptor for IL-1, an important physiological inducer of IL-8. Expression of the MAP kinase kinase kinase (MAPKKK) TAK1 together with its coactivator TAB1 in HeLa cells activated all three pathways and was sufficient to induce IL-8 formation, NF-kappaB + JNK2-mediated transcription from a minimal IL-8 promoter, and p38 MAPK-mediated stabilization of a reporter mRNA containing IL-8-derived regulatory mRNA sequences. Expression of a kinase-inactive mutant of TAK1 largely blocked IL-1-induced transcription and mRNA stabilization, as well as formation of endogenous IL-8. Truncated TAB1, lacking the TAK1 binding domain, or a TAK1-derived peptide containing a TAK1 autoinhibitory domain were also efficient in inhibition. These data indicate that the previously described three-pathway model of IL-8 induction is operative in response to a physiological stimulus, IL-1, and that the MAPKKK TAK1 couples the IL-1 receptor to both transcriptional and RNA-targeted mechanisms mediated by the three pathways.

[Incidence of stomach ruptures after ingestion of sodium bicarbonate-containing or carbonated beverages]

SUBJECT

Spontaneous rupture of the stomach is an uncommon condition with a usually poor prognosis. The questions of pathophysiologic factors and the possible role of carbonated or bicarbonate-containing beverages were addressed.

METHODS AND RESULTS

A review of the literature based on a search of MEDLINE (1966-1998) was performed. Using the key word 'stomach rupture', we found 675 publications. 279 publications dealt with etiologic factors 15 of which mentioned the ingestion of bicarbonate preparations. No record of carbonated or bicarbonate-containing beverages as a single etiologic factor could be found.

CONCLUSION

These beverages do not seem to play a significant role in the pathogenesis of stomach rupture, whereas in rare cases bicarbonate preparations can cause rupture of the previously overdistended stomach.

Clinical evidence of subcutaneous CO2 insufflations: a systematic review

OBJECTIVE

To evaluate the evidence of clinical effectiveness of subcutaneous CO2 insufflations (SCIs). STUDY LOCATION: The entire databases of MEDLINE, EMBASE Excerpta Medica (Field: Rehabilitation and Physical Medicine) and the Cochrane Library were screened for data up to August 1999. In addition, other potentially relevant journals were handsearched and references were checked.

STUDY SELECTION

Uncontrolled observational trials (UCOTs) with sample sizes of at least n = 100, and controlled clinical trials (CCTs) and randomized controlled trials (RCTs) were included. Outcomes had to be patient-centered. English-, Czechoslovakian-, and German-language papers were considered.

DATA ANALYSIS

For all study types, a criteria-based analysis was performed. For controlled trials only, quality was quantitatively assessed with the Jadad and Maastricht Scales.

RESULTS

Thirteen studies (5 RCTs, 2 CCTs, and 6 UCOTs) were included. Mean scores on the Jadad and Maastricht Scales were 2 (Maximum 5) and 37 (Maximum 100), respectively. SCIs were found to be effective in addition to standard physical therapy in "peripheral arterial occlusive disease" (2 RCTs) and "stable angina pectoris" (1 RCT) and superior to sham needling for migraine headaches (1 RCT). There were no differences among SCIs and CO2 gas baths (1 RCT) or combined interventions, including SCIs (2 CCTs). All 6 UCOTs showed marked longitudinal effects.

CONCLUSIONS

The low number and quality of the available studies precludes firm conclusions on the clinical effectiveness of SCIs.

Preliminary experience with 2-octylcyanoacrylate in a pediatric emergency department

OBJECTIVE

Documentation of use of octylcyanoacrylate adhesives in a pediatric emergency department with reference to patient selection, complications, and parent satisfaction.

DESIGN

Retrospective and concurrent chart review of the first 100 patients on which 2-octylcyanoacrylate (2-OCA, Dermabonda) was used in a pediatric emergency department. Additional telephone follow-up was performed for each patient.

RESULTS

The average patient age was 4.7 years, average laceration size 1.2 cm. Sixteen percent of wounds were repaired with 2-OCA. Three immediate complications involved a minor dehiscence and two eyelid adhesions. Two wound infections and a patient with hematoma and keloid formation were identified as later complications. The vast majority of parents preferred tissue adhesive repair to sutures. Time in department was reduced from 106 minutes to 69 minutes on average (P < 0.0001, CI 26-52).

CONCLUSIONS

Octylcyanoacrylate adhesives performed well in the daily practice of a pediatric emergency department, and were used for a significant percentage of laceration closures. Convenience, average infection rates, and good parental satisfaction make tissue adhesives a valuable addition to our wound closure techniques. Certain pitfalls occurring during early experience with these adhesives can be recognized and avoided.

Acupuncture for episodic tension-type headache: a multicentre randomized controlled trial

A multicentre, randomized clinical trial was undertaken to test the hypothesis that acupuncture is more efficacious than sham control procedure in the prevention of episodic tension-type headache. Fifty subjects were randomized to receive a course of treatment with either brief acupuncture or a sham procedure. Subjects were followed up for 3 months. Changes in headache were assessed by daily diary, the primary outcome measure being the number of days with headache. No significant differences were found between the changes in the two groups for any measure at any time point. Results also show that patient blinding was successful. In conclusion, this study does not provide evidence that this form of acupuncture is effective in the prevention of episodic tension-type headache.

1) rheuma: komplementare therapien hoch im kurs; 2) ist der Ruckenschmerz magnetisch? 3) morbus alzheimer: unkonventionelle therapeutische Wundertute; 4) homocystein: Im westen nichts neues

Wahrend in akademischen Kreisen noch ausgiebig diskutiert wird, wie Naturheilkunde, Komplementarmedizin und Alternativmedizin begrifflich fassbar gemacht, sprich definiert werden konnen, hat sich langst ein Parallelmarkt entwickelt, auf dem seriose und obskure Anbieter eine breite Palette von vermeintlich hilfreichen diagnostischen Massnahmen und Therapien feilbieten. Ohne kassenarztliche Vereinigung, ohne wissenschaftliche Fachgesellschaften, ohne amtlichen Segen. Der Markt boomt, wie das Beispiel rheumatische Erkrankungen zeigt. Das hat seine Grunde, von denen S. Hill in ihrem Kommentar einige nennt. Abstrahiert konnte man sagen, dass es offensichtlich einen grossen Bedarf in Bereichen gibt, fur die die konventionelle Medizin zu wenig zu bieten hat. Die daraus resultierende Tatsache, dass Patienten immer mehr bereit sind, zusatzlich und erganzend Leistungen einzukaufen, musste nicht weiter schrecken (und ware parteienubergreifend sogar ganz im Sinne unserer Gesundheitspolitiker), wenn man unterstellen konnte, Patienten hatten eine einigermassen verlassliche Moglichkeit, seriose Angebote von denen von Quacksalbern, Scharlatanen und miesen Geschaftemachern zu unterscheiden. Das haben Sie aber nicht. Die Beispiele in diesem Journal Club sollen aufzeigen, wie schwer es manchmal selbst dort ist, Stellung zu beziehen, wo bereits Versuche vorliegen, bestimmte Angebote zu hinterfragen. Das liegt nicht zuletzt an den ziemlich durchgangigen Defiziten, was die Forschungsqualitat in diesem Bereich anbelangt. Es scheint hochste Zeit, dass sich die akademische Medizin ihrer Verantwortung in diesem Bereich bewusst wird und sich seiner annimmt. Wer sonst sollte das tun? Copyright 2000 S. Karger GmbH, Freiburg

Long-term efficacy of radon spa therapy in rheumatoid arthritis--a randomized, sham-controlled study and follow-up

OBJECTIVE

To quantify the efficacy of a series of baths containing natural radon and carbon dioxide (1.3 kBq/l, 1.6 g carbon dioxide/l on average) versus artificial carbon dioxide baths alone in patients with rheumatoid arthritis.

SUBJECTS

Sixty patients participating in an in-patient rehabilitation programme including a series of 15 baths were randomly assigned to two groups.

DESIGN

Pain intensity (100 mm visual analogue scale) and functional restrictions [Keitel functional test, Arthritis Impact Measurement Scales (AIMS questionnaire)] were measured at baseline, after completion of treatment and 3 and 6 months thereafter. To investigate whether the overall value of the outcomes was the same in both groups, the overall mean was analysed by Student's t-test for independent samples.

RESULTS

The two groups showed a similar baseline situation. After completion of treatment, relevant clinical improvements were observed in both groups, with no notable group differences. However, the follow-up revealed sustained effects in the radon arm, and a return to baseline levels in the sham arm. After 6 months, marked between-group differences were found for both end-points (pain intensity: -16.9%, 95% confidence interval -27.6 to -6.2%; AIMS score: 0.57, 95% confidence interval 0.16 to 0.98). The between-group differences were statistically significant for both overall means (pain intensity, P: = 0.04; AIMS, P: = 0.01).

CONCLUSION

Marked short-term improvements in both groups at the end of treatment may have masked potential specific therapeutic effects of radon baths. However, after 6 months of follow-up the effects were lasting only in patients of the radon arm. This suggests that this component of the rehabilitative intervention can induce beneficial long-term effects.

Selective inhibition of monocyte chemoattractant protein-1 gene expression in human embryonal kidney cells by specific triple helix-forming oligonucleotides

Monocyte chemoattractant protein-1 (MCP-1) is a chemokine that is expressed by a variety of tissue cells in response to inflammatory stimuli, such as IL-1beta, TNF-alpha, and IFN-gamma. A major function of MCP-1 is the recruitment and activation of monocytes and T lymphocytes. Overexpression of MCP-1 has been implicated in a number of diseases, including glomerulonephritis and rheumatoid arthritis, indicating that the modulation of MCP-1 activity and/or expression is a desired therapeutic strategy. In the present study, our aim was to test whether the MCP-1 expression could be inhibited at the transcriptional level using triple helix-forming oligonucleotides (TFOs). We designed a TFO targeted to the SP-1 binding site in the human MCP-1 gene promoter. Gel mobility shift assays demonstrated that the phosphodiester TFO formed a sequence-specific triplex with its dsDNA target with an EC50 of approximately 1.9 x 10(-7) M. The corresponding phosphorothioated oligonucleotide was also effective in this assay with an 8-fold higher EC50 value. Binding of the TFO to the target DNA prevented the binding of rSP-1 and of nuclear proteins in vitro. The TFO could also partially inhibit endogenous MCP-1 gene expression in cultured human embryonic kidney cells. Treatment of TNF-alpha-stimulated human embryonic kidney 293 cells with the TFO inhibited the secretion of MCP-1 in a dose-dependent manner (up to 45% at 5 microM oligonucleotide). The inhibition of MCP secretion was caused at the level of gene transcription, because MCP-1 mRNA levels in oligonucleotide-treated cells were also decreased by approximately 40%.

[Mineral water or tap water? A systematic analysis of the literature concerning the question of microbial safety]

BACKGROUND

Based on sporadic reports of microbial contamination of mineral waters, it has been recommended that, for safety reasons, particularly immunocompromised patients should drink tap water rather than bottled mineral water. However, in terms of safety, evidence of the clinical consequences may allow a better estimate than a positive in vitro test for contamination. Therefore, we reviewed the literature on documented disease outbreaks due to contaminated mineral and tap waters.

MATERIAL AND METHODS

We performed a systematic search of the literature using the database MEDLINE. In order to identify evidence relevant for Germany, we restricted our search to the years 1985-1997 (i.e. legal force of the mineral and table waters act in Germany) and the countries of Central and Northwestern Europe as well as the USA and Canada.

RESULTS

Cases of contamination of tap water were documented in nearly all countries included. In 35 communications we found reports on a total of 423,000 cases of disease outbreaks due to contaminated tap water, in some cases even with lethal outcome. Main diagnosis was gastroenteritis, and main species of microorganism was crytosporidium. In contrast, there was no documented case of disease outbreak due to contaminated bottled mineral water.

CONCLUSION

Tap water as well as bottled water are both supremely safe components of nutrition. The recommendation that tap water is better than mineral water, particularly for high-risk patients, is not supported by the literature.

Calcium supplementation with calcium-rich mineral waters: a systematic review and meta-analysis of its bioavailability

The relevance of calcium (Ca2+), an essential bone mineral, to the prevention and treatment of osteoporosis is well established. However, a good deal of evidence casts doubt on the validity of current RDAs (recommended daily allowance), i.e., 800-1000 mg/day. New guidelines consistently advocate higher daily intakes (up to 1500 mg/day), a goal that may be difficult to achieve for many patients. Environmental as well as individual behavioral factors may limit the consumption of dairy products, whereas calcium supplements require a high level of compliance and cause additional costs. Calcium-rich mineral waters may offer a promising alternative. A systematic literature search was performed (Medline, years 1966-1998) to identify experimental studies on the bioavailability of calcium-rich mineral waters. First, all publications on calcium absorption from mineral waters were identified, and, in a second step, studies comparing calcium absorption from mineral waters with that from dairy products. Four studies fulfilled all inclusion criteria. A meta-analysis based on published p values indicated calcium absorption from mineral waters was significantly higher (p = 0.03) than that from dairy products. Although only few studies with a relatively small number of subjects are available to date, the bioavailability of calcium from calcium-rich mineral waters thus seems to be at least comparable to, and possibly better than, that from dairy products. These results are in keeping with the assumption that calcium-rich mineral water is a useful calcium source to achieve new, higher recommended daily allowances of calcium.

A synthetic peptide derived from the non-structural protein 3 of hepatitis C virus serves as a specific substrate for PKC

A synthetic peptide corresponding to the amino acid sequence Arg1487-Arg-Gly-Arg-Thr-Gly-Arg-Gly-Arg-Arg-Gly-Ile-Tyr-Arg1500 of the hepatitis C virus (HCV) polyprotein was found to be a selective substrate for protein kinase C (PKC). In the presence of Ca2+, TPA and phospholipid, PKC phosphorylates the peptide [termed HCV(1487-1500)] with a Km of 11 microM and Vmax of 24 micromol x min(-1) x mg(-1). HCV(1487-1500) acts as a competitive inhibitor of PKC towards other peptide or protein substrates and inhibits the kinase activity with an IC50 corresponding to the Km values measured for the substrates. N- or C-terminally deleted analogs of HCV(1487-1500) did not show inhibitory effects and were only marginally or not phosphorylatable. We designed an additional peptide in which the tyrosine residue was replaced by phenylalanine ([Phe1499]HCV(1487-1500)). This peptide was neither phosphorylated by other serine/threonine kinases tested nor by whole cell extracts prepared from PKC-depleted cells. [Phe1499]HCV(1487-1500) was used to monitor the TPA-induced translocation of PKC activity to the particulate fraction in JB6 cells. The use of SDS/PAGE to separate the peptide from ATP and Pi allowed to monitor simultaneously PKC autophosphorylation and phosphorylation of the peptide. The data presented here show that[Phe1499]HCV(1487-1500) can serve as a convenient tool for investigations of PKC activity also in the presence of other kinases in tissues or in crude cell extracts.

Overexpression of the bcl-2 oncogene in the mouse pre-B cell line SPGM-1 protects from apoptosis, but does not affect blocked B-lineage differentiation and lineage switch towards macrophage like cells

The CD5(+) mouse pre-B cell line SPGM-1 is able to undergo lineage conversion towards a macrophage like cell type. Although one of the kappa-light chain alleles is rearranged in V-Jkappa4 configuration, no protein is expressed nor could the expression be induced. Infection with and expression of the human bcl-2 gene protected SPGM-1 cells from apoptosis, allowing the rearrangement of their second kappa-allele in V-Jkappa5 configuration. mRNA transcripts of the V-Jkappa regions were detected only in SPGM-1 x bcl-2 cells, but not in SPGM-1, while kappa-light chain protein was not found in any of the cell lines. The myeloid differentiation potential of SPGM-1 cells was not affected by overexpression of the human bcl-2 gene. Upon appropriate stimulation, SPGM-1xbcl-2 cells became enlarged, adhered to the plastic surfaces and lost their immunoglobulin mu heavy chain expression.

A meta-analysis of acupuncture techniques for smoking cessation

OBJECTIVE

To determine the effectiveness of acupuncture for smoking cessation and to examine whether any individual aspect of trials is associated with an effect.

DATA SOURCES

All randomised controlled trials of acupuncture for smoking cessation that were listed in computerised databases or reference lists of relevant articles.

STUDY SELECTION

All randomised single-blind studies that compared acupuncture with sham acupuncture.

DATA EXTRACTION

Methodological data were extracted for quality assessment. Outcome data were extracted for rates of total smoking cessation at three intervals: early after treatment and after six and 12 months follow up.

DATA SYNTHESIS

Results were expressed as odds ratios of success over failure in intervention over control groups. The combined odds ratio for all studies was calculated. Repeated meta-analyses were subsequently performed on subsets of studies combined according to defined characteristics: acupuncture technique, number of attendances, country of origin, status of journal, and control procedure. The overall quality of studies was poor. The combined odds ratio for smoking cessation calculated for the earliest results after the end of treatment was 1.20 (95% confidence intervals (95% CIs) = 0.98 to 1.48). The combined odds ratio for smoking cessation after six months was 1.29 (95% CI = 0.82 to 2.01), and after 12 months was 1.03 (95% CI = 0.73 to 1.46). There were no significant effects of relevance among subsets of studies grouped according to defined characteristics.

CONCLUSIONS

Acupuncture was not superior to sham acupuncture for smoking cessation; no particular aspect of acupuncture technique was associated with a positive effect. The conclusions are limited by methodological inadequacies of studies and by the absence of testable hypotheses; design of future trials should avoid these deficiencies.

Molecular mechanisms of T lymphocyte activation: convergence of T cell antigen receptor and IL-1 receptor-induced signaling at the level of IL-2 gene transcription

Co-stimulation of murine EL-4 thymoma cells-carrying high numbers of TCR and type I IL-1 receptors (IL-1R)-with anti-CD3 antibodies and IL-1 resulted in synergistic enhancement of IL-2 synthesis. While the extracellular signal-regulated kinase (ERK) cascade was activated by both receptors, IL-1 preferentially stimulated Jun-N-terminal kinases (JNK) and p38 mitogen-activated kinase or microtubule-associated protein kinase (MAPK). Interruption of TCR- or IL-1R-stimulated ERK cascade by PD-98059, a specific inhibitor of MAP/ERK kinase (MEK), resulted in partial suppression of nuclear factor of activated T cells activation and in complete inhibition of IL-1-stimulated NFkappaB activation. Suppression of activation of both MEK and p38 MAPK resulted in significant inhibition of IL-2 gene expression. The results show that maximal activation of the IL-2 gene requires activation of at least two different protein kinase cascades, i.e. of the ERK and p38 pathways but presumably also that of JNK which converge at the level of the IL-2 promoter resulting in enhancement of its transcriptional activity.

Protein kinase C recognizes the protein kinase A-binding motif of nonstructural protein 3 of hepatitis C virus

The nonstructural protein 3 (NS3) of hepatitis C virus (HCV) inhibits the nuclear transport and the enzymatic activity of the catalytic subunit of protein kinase A. This inhibition is mediated by an arginine-rich domain localized between amino acids 1487-1500 of the HCV polyprotein. The data presented here indicate that the arginine-rich domain, when embedded in recombinant fragments of NS3, interacts with the catalytic site of protein kinase C (PKC) and inhibits the phosphorylation mediated by this enzyme in vitro and in vivo. Furthermore, a direct binding of PKC to the NS3 fragments leads to an inhibition of the free shuttling of the kinase between the cytoplasm and the particulate fraction. In contrast, a peptide corresponding to the arginine-rich domain (HCV (1487-1500)), despite also being a PKC inhibitor, did not influence the PKC shuttling process and was transported to the particulate fraction by the translocating kinase upon activation with tetradecanoylphorbol-13-acetate. Using the tetradecanoylphorbol-13-acetate -stimulated respiratory burst of NS3-introduced neutrophils as a model system, we could demonstrate that NS3 is able to block PKC-mediated functions within intact cells. Our data support the possibility that NS3 disrupts the PKC-mediated signal transduction.

Induction of interleukin-8 synthesis integrates effects on transcription and mRNA degradation from at least three different cytokine- or stress-activated signal transduction pathways

A hallmark of inflammation is the burst-like formation of certain proteins, initiated by cellular stress and proinflammatory cytokines like interleukin 1 (IL-1) and tumor necrosis factor, stimuli which simultaneously activate different mitogen-activated protein (MAP) kinases and NF-kappaB. Cooperation of these signaling pathways to induce formation of IL-8, a prototype chemokine which causes leukocyte migration and activation, was investigated by expressing active and inactive forms of protein kinases. Constitutively active MAP kinase kinase 7 (MKK7), an activator of the stress-activated protein kinase/c-Jun N-terminal kinase (SAPK/JNK) pathway, induced IL-8 synthesis and transcription from a minimal IL-8 promoter. Furthermore, MKK7 synergized in both effects with NF-kappaB-inducing kinase (NIK). Activation of the IL-8 promoter by either of the kinases required functional NF-kappaB and AP-1 sites. While NIK and MKK7 did not affect degradation of IL-8 mRNA, an active form of MKK6, which selectively activates p38 MAP kinase, induced marked stabilization of the transcript and further increased IL-8 protein formation induced by NIK plus MKK7. Consistently, the MAP kinase kinase kinase MEKK1, which can activate NF-kappaB, SAPK/JNK, and p38 MAP kinases, most potently induced IL-8 formation. These results provide evidence that maximal IL-8 gene expression requires the coordinate action of at least three different signal transduction pathways which cooperate to induce mRNA synthesis and suppress mRNA degradation.

The p38 MAP kinase pathway signals for cytokine-induced mRNA stabilization via MAP kinase-activated protein kinase 2 and an AU-rich region-targeted mechanism

Stabilization of mRNAs contributes to the strong and rapid induction of genes in the inflammatory response. The signaling mechanisms involved were investigated using a tetracycline-controlled expression system to determine the half-lives of interleukin (IL)-6 and IL-8 mRNAs. Transcript stability was low in untreated HeLa cells, but increased in cells expressing a constitutively active form of the MAP kinase kinase kinase MEKK1. Destabilization and signal-induced stabilization was transferred to the stable beta-globin mRNA by a 161-nucleotide fragment of IL-8 mRNA which contains an AU-rich region, as well as by defined AU-rich elements (AREs) of the c-fos and GM-CSF mRNAs. Of the different MEKK1-activated signaling pathways, no significant effects on mRNA degradation were observed for the SAPK/JNK, extracellular regulated kinase and NF-kappaB pathways. Selective activation of the p38 MAP kinase (=SAPK2) pathway by MAP kinase kinase 6 induced mRNA stabilization. A dominant-negative mutant of p38 MAP kinase interfered with MEKK1 and also IL-1-induced stabilization. Furthermore, an active form of the p38 MAP kinase-activated protein kinase (MAPKAP K2 or MK2) induced mRNA stabilization, whereas a negative interfering MK2 mutant interfered with MAP kinase kinase 6-induced stabilization. These findings indicate that the p38 MAP kinase pathway contributes to cytokine/stress-induced gene expression by stabilizing mRNAs through an MK2-dependent, ARE-targeted mechanism.

[Effects of Kneippism, a standardized complex therapy, on pain, quality of life and use of medicines: cohort study with a one-year follow-up]

BACKGROUND

Inpatient as well as outpatient cure in a spa environment with commonly 3- to 4-week duration features a combination of different treatments customized according to the needs of the individual patient. The physiological rationale and the mode of action are widely accepted. However, firm quantitative evidence of the clinical effectiveness is incomplete.

OBJECTIVE

To document the effects of a well standardized complex therapeutic regimen (Kneippism) on pain, quality of life, and drug consumption during therapy and with 1-year follow up.

STUDY DESIGN

Prospective cohort study with assessments at the beginning, during, and at the end of treatment and with follow-up investigations 3, 6, and 12 months thereafter.

SETTING

Four spa clinics in Bad Wörishofen, Southern Bavaria.

PATIENTS

363 patients (248 outpatients, mean duration of therapy 23.3 days, and 115 inpatients, mean duration of therapy 27.4 days), one half between 40 and 60 years old above 60 years of age, predominantly suffering from musculoskeletal and/or cardiovascular diseases.

INTERVENTION

Custom-tailored combination of therapies comprising of hydro-, kinesi-, and phytotherapy, dietetics, 'ordnungstherapie', and continued disease-specific standard treatment, if necessary.

MAIN OUTCOME MEASURE

Pain, patients' self-rating, (IRES questionnaire), medication.

RESULTS

The monitored dimensions of pain improved significantly during treatment and remained at that level essentially for the complete follow up interval. The same was true for various dimensions of reported subjective complaints as well as for drug consumption.

CONCLUSION

When estimating the clinical relevance of a complex therapeutic regimen such as a cure of 3- to 4-week duration, the question of the impact of the specific effect of single components is secondary to the question of the overall relevance of that therapeutic concept. The findings of this study point at potential long-term effects of at least 1-year duration.

Ultrasound therapy for calcific tendinitis of the shoulder

BACKGROUND AND METHODS

Although ultrasound therapy is used to treat calcific tendinitis of the shoulder, its efficacy has not been rigorously evaluated. We conducted a randomized, double-blind comparison of ultrasonography and sham insonation in patients with symptomatic calcific tendinitis verified by radiography. Patients were assigned to receive 24 15-minute sessions of either pulsed ultrasound (frequency, 0.89 MHz; intensity, 2.5 W per square centimeter; pulsed mode, 1:4) or an indistinguishable sham treatment to the area over the calcification. The first 15 treatments were given daily (five times per week), and the remainder were given three times a week for three weeks. Randomization was conducted according to shoulders rather than patients, so a patient with bilateral tendinitis might receive either or both therapies.

RESULTS

We enrolled 63 consecutive patients (70 shoulders). Fifty-four patients (61 shoulders) completed the study. There were 32 shoulders in the ultrasound-treatment group and 29 in the sham-treatment group. After six weeks of treatment, calcium deposits had resolved in six shoulders (19 percent) in the ultrasound-treatment group and decreased by at least 50 percent in nine shoulders (28 percent), as compared with respective values of zero and three (10 percent) in the sham-treatment group (P=0.003). At the nine-month follow-up visit, calcium deposits had resolved in 13 shoulders (42 percent) in the ultrasound-treatment group and improved in 7 shoulders (23 percent), as compared with respective values of 2 (8 percent) and 3 (12 percent) in the sham-treatment group (P=0.002). At the end of treatment, patients who had received ultrasound treatment had greater decreases in pain and greater improvements in the quality of life than those who had received sham treatment; at nine months, the differences between the groups were no longer significant.

CONCLUSIONS

In patients with symptomatic calcific tendinitis of the shoulder, ultrasound treatment helps resolve calcifications and is associated with short-term clinical improvement.

Reviewer bias against the unconventional? A randomized double-blind study of peer review

OBJECTIVE

To test the hypothesis that there is a reviewer bias against publication of a test of an unconventional drug.

DESIGN

Randomized, controlled, double-blind study of peer review.

PARTICIPANTS

Convenience sample of 291 medical doctors from a wide variety of specialties drawn from a list of conference participants.

METHODS

Reviewers were randomly assigned to receive one of two versions of a manuscript. Version M related to an in-vitro experiment on a mainstream drug (Metoprolol). The otherwise identical version V used a highly unconventional drug (beef spleen cell extract) for the same experiment. Reviewers were asked to complete a standardised evaluation sheet including visual analogue scales (VASs) on a set of predefined quality criteria. All participants were debriefed after completion of the study.

RESULTS

The response rate was 61%. There were no significant differences in VAS ratings between the two versions of the manuscript. Ratings covered the entire range of the VASs.

CONCLUSION

In the present setting, there was no evidence for a reviewer-bias against testing an unconventional drug. The low inter-rater reliability, however, suggested inadequate validity of peer review.

Synergistic effects of the alkaloid sinomenine in combination with the immunosuppressive drugs tacrolimus and mycophenolic acid

The alkaloid sinomenine extracted from the medicinal plant Sinomenium acutum is used in China for the treatment of various rheumatic diseases. It has immunomodulatory properties in a cardiac allograft transplantation model. Its antiproliferative effect on human mononuclear cells in combination with different immunosuppressive drugs was further analysed in vitro. Sinomenine dose-dependently attenuated thymidine incorporation, interleukin-2 synthesis, and cell cycle progression of activated T-lymphocytes. Cell proliferation was synergistically decreased by addition of sinomenine together with suboptimal concentrations of the established immunosuppressive drugs tacrolimus or mycophenolic acid, respectively.

[Migraine and prevention of migraine: the value of magnesium]

Migraine (with and without aura) is characterised by a marked heterogeneity of clinical symptoms. A variety of pathophysiological models has been proposed and a multitude of prophylactic strategies recommended. It appears that prophylaxis is still problematic, despite considerable progress in acute treatment. Most substances used for the former purpose either have substantial side effects or a wide range of contraindications. Magnesium (Mg) seems to play a significant role in the pathogenesis of migraine. A few clinical trials have produced preliminary evidence of therapeutic efficacy. There is a reasonable amount of empirical evidence, and further research is warranted considering its low cost and favourable side effects profile. An attempt at prophylaxis in mild to mid-severe migraine with a daily dose of 600 mg (about 50 mEq) Mg seems to be justified.

Pragmatic Randomised Controlled Trials for Complex Therapies

In order to be able to 'predict' the extent or likelihood of success of an intervention, it is essential to know that exposure and effect are causally related. The randomised controlled clinical trial (RCT) is commonly referred to as the golden standard to establish causality. Apart from ethical constraints or rare diseases it is rarely impossible to do an RCT. Sometimes, however, RCTs may not be feasible (at least at first glance) due to e. g. patients' or therapists' reluctance to participate, lack of funding, organisational limitations, or because technical skills to deliver a therapy are not available. A variety of design alternatives have been proposed to overcome these problems, e. g. clinician-preferred treatment, single consent design, double consent randomised design, prerandomisation, cluster randomisation, and response-adaptive designs ('play the winner'). For complex ('combined modality') therapies it seems reasonable to study the effect of the whole treatment package on the patient rather than the value of individual components. Change to open label or optional cross-over allow 'individualized treatment' as well as 'individualized outcome' within the framework of the RCT. For clinicians and researchers it seems wise to put more emphasis on the search for a suitable and appropriate de-sign for their current problem rather than to artificially tailor their study to an awkward standard design (or even abandon the idea to seek an answer to an open question): Much more alternatives exist than one would imagine.

[Is homeopathy more than a placebo?]

Homeopathy can be characterized by three axioms "treating like with like" (law of similars), "increasing effects with increasing potency" (potentization) and "effects on the basis of ultra-high dilutions" (beyond-molecular effects), where it is unlikely that the dilutions contain a single molecule of the original substance. On the basis of these tenets and the clinical evidence further research priorities are developed. Current reviews indicate small homeopathic verum effects, even after adjustment for internal validity and publication-bias. However, the results remain disputable, because reproducibility isn't assured by independent examiners. For further validation, independent replication of studies with high quality, including specially treatment with high-potencies according to law of similars, seem to be important. The prerequisites for a homeopathy-specific study methodology (inclusion of populations according to their homeopathic diagnosis) still are not fulfilled today. There is neither convincing evidence for specific drug pictures by placebo-controlled drug provings, nor is the reliability of homeopathic diagnosis proven. By reason of extensive, individual interviews, preceeding every classical homeopathic remedy finding, placebo-effects could play an important therapeutical role. The relevance of homeopathic placebo-effects should be explored against other sham treatments and an untreated group.

Topical anesthesia for pediatric lacerations: a randomized trial of lidocaine-epinephrine-tetracaine solution versus gel

STUDY OBJECTIVE

To compare the adequacy and efficacy of anesthesia experienced with lidocaine-epinephrine-tetracaine (LET) solution versus LET gel during suturing of uncomplicated lacerations on the face or scalp in children.

METHODS

Two hundred children with lacerations of the face and scalp requiring suturing were enrolled in this blinded, randomized controlled trial, in the emergency department of a university-affiliated children's hospital. After the application of anesthetic solution or gel, adequacy of anesthesia was determined before suturing. Efficacy of anesthesia during laceration repair was determined by the length of time after removal of the topical anesthetic to the first sign of discomfort that required additional anesthesia or until suture completion.

RESULTS

Adequacy of initial anesthesia was equivalent between LET solution and LET gel. There was a significant difference in efficacy of anesthesia between the LET formulations. There were more patients with complete anesthesia (85% versus 76%), fewer persons with partial anesthesia (5% versus 21%), and more persons with incomplete anesthesia (9% versus 3%) in the gel group.

CONCLUSION

LET gel is at least as effective as LET solution and possesses theoretical advantages for topical anesthesia during suturing of uncomplicated lacerations on the face and scalp in children.