First Dark Matter Search Results from the LUX-ZEPLIN (LZ) Experiment

The LUX-ZEPLIN experiment is a dark matter detector centered on a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility in Lead, South Dakota, USA. This Letter reports results from LUX-ZEPLIN's first search for weakly interacting massive particles (WIMPs) with an exposure of 60 live days using a fiducial mass of 5.5 t. A profile-likelihood ratio analysis shows the data to be consistent with a background-only hypothesis, setting new limits on spin-independent WIMP-nucleon, spin-dependent WIMP-neutron, and spin-dependent WIMP-proton cross sections for WIMP masses above 9  GeV/c^{2}. The most stringent limit is set for spin-independent scattering at 36  GeV/c^{2}, rejecting cross sections above 9.2×10^{-48}  cm at the 90% confidence level.

Conductance quantisation in patterned gate In0.75Ga0.25As structures up to 6 × (2e 2/h)

We present electrical measurements from In_0.75Ga_0.25As 1D channel devices with Rashba-type, spin-orbit coupling present in the 2D contact regions. Suppressed backscattering as a result of the time-reversal asymmetry at the 1D channel entrance results in enhanced ballistic transport characteristics with clear quantised conductance plateaus up to 6  ×  (2e ²/h). Applying DC voltages between the source and drain ohmic contacts and an in-plane magnetic field confirms a ballistic transport picture. For asymmetric patterned gate biasing, a lateral spin-orbit coupling effect is weak. However, the Rashba-type spin-orbit coupling leads to a g-factor in the 1D channel that is reduced in magnitude from the 2D value of 9 to ~6.5 in the lowest subband when the effective Rashba field and the applied magnetic field are perpendicular.

Transition from direct to Fowler-Nordheim tunneling in chemically reduced graphene oxide film

We investigate charge transport in a chemically reduced graphene oxide (RGO) film of sub-micron thickness. The I-V curve of RGO film shows current switching of the order of ∼10(5) above the threshold voltage. We found that the observed I-V curve is consistent with quantum tunnelling based charge transport. The quantum tunnelling based Simmons generalized theory was used to interpret the charge transport mechanism which shows that the current switching phenomenon is associated with transition from direct to Fowler-Nordheim (F-N) tunneling. The absence of current switching in the I-V curve after stripping away the oxygen functional groups from chemically RGO film confirms that the presence of these groups and reduced interaction between adjacent layers of RGO play a key role in charge transport. Such metal-based current switching devices may find applications in graphene-based electronic devices such as high voltage resistive switching devices.

The role of mitochondria in the development and progression of lung cancer

The influence of mitochondria in human health and disease is a rapidly expanding topic in the scientific literature due to their integral roles in cellular death and survival. Mitochondrial biology and alterations in function were first linked to cancer in the 1920s with the discovery of the Warburg effect. The utilization of aerobic glycolysis in ATP synthesis was the first of many observations of metabolic reprogramming in cancer.

Mitochondrial dysfunction in cancer has expanded to include defects in mitochondrial genomics and biogenesis, apoptotic signaling and mitochondrial dynamics. This review will focus on the role of mitochondria and their influence on cancer initiation, progression and treatment in the lung.

What can qualitative research do for randomised controlled trials? A systematic mapping review

OBJECTIVE

To develop an empirically based framework of the aspects of randomised controlled trials addressed by qualitative research.

DESIGN

Systematic mapping review of qualitative research undertaken with randomised controlled trials and published in peer-reviewed journals.

DATA SOURCES

MEDLINE, PreMEDLINE, EMBASE, the Cochrane Library, Health Technology Assessment, PsycINFO, CINAHL, British Nursing Index, Social Sciences Citation Index and ASSIA.

ELIGIBILITY CRITERIA

Articles reporting qualitative research undertaken with trials published between 2008 and September 2010; health research, reported in English.

RESULTS

296 articles met the inclusion criteria. Articles focused on 22 aspects of the trial within five broad categories. Some articles focused on more than one aspect of the trial, totalling 356 examples. The qualitative research focused on the intervention being trialled (71%, 254/356); the design, process and conduct of the trial (15%, 54/356); the outcomes of the trial (1%, 5/356); the measures used in the trial (3%, 10/356); and the target condition for the trial (9%, 33/356). A minority of the qualitative research was undertaken at the pretrial stage (28%, 82/296). The value of the qualitative research to the trial itself was not always made explicit within the articles. The potential value included optimising the intervention and trial conduct, facilitating interpretation of the trial findings, helping trialists to be sensitive to the human beings involved in trials, and saving money by steering researchers towards interventions more likely to be effective in future trials.

CONCLUSIONS

A large amount of qualitative research undertaken with specific trials has been published, addressing a wide range of aspects of trials, with the potential to improve the endeavour of generating evidence of effectiveness of health interventions. Researchers can increase the impact of this work on trials by undertaking more of it at the pretrial stage and being explicit within their articles about the learning for trials and evidence-based practice.

Prevalence of complementary and alternative medicine (CAM) use by the general population: a systematic review and update

OBJECTIVES

To update previous systematic reviews of 12-month prevalence of complementary and alternative medicine (CAM) use by general populations; to explore trends in CAM use by national populations; to develop and apply a brief tool for assessing methodological quality of published CAM-use prevalence surveys.

DESIGN

Nine databases were searched for published studies from 1998 onwards. Studies prior to 1998 were identified from two previous systematic reviews. A six-item literature-based tool was devised to assess robustness and interpretability of CAM-use estimates.

RESULTS

Fifty-one reports from 49 surveys conducted in 15 countries met the inclusion criteria. We extracted 32 estimates of 12-month prevalence of use of any CAM (range 9.8-76%) and 33 estimates of 12-month prevalence of visits to CAM practitioners (range 1.8-48.7%). Quality of methodological reporting was variable; 30/51 survey reports (59%) met four or more of six quality criteria. Estimates of 12-month prevalence of any CAM use (excluding prayer) from surveys using consistent measurement methods showed remarkable stability in Australia (49%, 52%, 52%; 1993, 2000, 2004) and USA (36%, 38%; 2002, 2007).

CONCLUSIONS

There was evidence of substantial CAM use in the 15 countries surveyed. Where national trends were discernable because of consistent measurement, there was no evidence to suggest a change in 12-month prevalence of CAM use since the previous systematic reviews were published in 2000. Periodic surveys are important to monitor population-level CAM use. Use of government-sponsored health surveys may enhance robustness of population-based prevalence estimates. Comparisons across countries could be improved by standardising approaches to data collection.

Defects in mitochondrial fission protein dynamin-related protein 1 are linked to apoptotic resistance and autophagy in a lung cancer model

Evasion of apoptosis is implicated in almost all aspects of cancer progression, as well as treatment resistance. In this study, resistance to apoptosis was identified in tumorigenic lung epithelial (A549) cells as a consequence of defects in mitochondrial and autophagic function. Mitochondrial function is determined in part by mitochondrial morphology, a process regulated by mitochondrial dynamics whereby the joining of two mitochondria, fusion, inhibits apoptosis while fission, the division of a mitochondrion, initiates apoptosis. Mitochondrial morphology of A549 cells displayed an elongated phenotype–mimicking cells deficient in mitochondrial fission protein, Dynamin-related protein 1 (Drp1). A549 cells had impaired Drp1 mitochondrial recruitment and decreased Drp1-dependent fission. Cytochrome c release and caspase-3 and PARP cleavage were impaired both basally and with apoptotic stimuli in A549 cells. Increased mitochondrial mass was observed in A549 cells, suggesting defects in mitophagy (mitochondrial selective autophagy). A549 cells had decreased LC3-II lipidation and lysosomal inhibition suggesting defects in autophagy occur upstream of lysosomal degradation. Immunostaining indicated mitochondrial localized LC3 punctae in A549 cells increased after mitochondrial uncoupling or with a combination of mitochondrial depolarization and ectopic Drp1 expression. Increased inhibition of apoptosis in A549 cells is correlated with impeded mitochondrial fission and mitophagy. We suggest mitochondrial fission defects contribute to apoptotic resistance in A549 cells.

Compressibility measurements of quasi-one-dimensional quantum wires

We report measurements of the compressibility of a one-dimensional quantum wire, defined in the upper well of a GaAs/AlGaAs double quantum well heterostructure. A wire defined simultaneously in the lower well probes the ability of the upper wire to screen the electric field from a biased surface gate. The technique is sensitive enough to resolve spin splitting of the subbands in the presence of an in-plane magnetic field. We measure a compressibility signal due to the 0.7 structure and study its evolution with increasing temperature and magnetic field. We see no evidence of the formation of the quasibound state predicted by the Kondo model, instead our data are consistent with theories which predict that the 0.7 structure arises as a result of spontaneous spin polarization.

Willingness to Try Acupuncture Again: Reports from Patients on Their Treatment Reactions in a Low Back Pain Trial

Background

Reactions to treatment are common following acupuncture. Understanding how these reactions are interpreted by patients is largely unexplored.

Objective

To examine patients’ ratings of the severity and bothersomeness of a range of common treatment reactions, and to assess their impact on willingness to try acupuncture again.

Methods

Self-reported ratings of the frequency, severity and bothersomeness of treatment reactions from 133 patients in the acupuncture arm of a pragmatic randomised controlled trial of acupuncture for chronic back pain are described and analysed.

Results

A total of 133 acupuncture patients reported at 3 months reactions that they had experienced at any time during a course of up to 10 acupuncture treatment sessions. They received a total of 1150 treatments, an average of 8.6 sessions per patient. All patients reported treatment reactions, most commonly relaxation (84%, n = 112), which was significantly associated with willingness to try acupuncture again, (χ2 = 7.860, df = 1, p = 0.005). Only 16% (n=21) were unwilling to experience a specific treatment reaction again, and 9% (n = 12) were unwilling to try acupuncture again. The most ‘bothersome’ reaction was a temporary worsening of symptoms (29%, n=38), though this was not associated with an unwillingness to try acupuncture again (χ2 = 0.382, df = 1, p>0.536). Those unwilling to try acupuncture again reported significantly less reduction in their pain at 3 months (mean (SE) SF-36 bodily pain score at 3 months 30.453 (3.598) vs 19.30 (1.128); p=0.003).

Conclusion

Among this group of patients seeking help for low back pain, the experience of treatment reactions was universal. There was no evidence that the bothersomeness of treatment reactions was associated with patient's willingness to try acupuncture again. The benefit of pain reduction over the course of treatment appeared to outweigh self-rated bothersome reactions to treatment.

DJ-1 acts in parallel to the PINK1/parkin pathway to control mitochondrial function and autophagy

Mutations in DJ-1, PINK1 (PTEN-induced putative kinase 1) and parkin all cause recessive parkinsonism in humans, but the relationships between these genes are not clearly defined. One event associated with loss of any of these genes is altered mitochondrial function. Recent evidence suggests that turnover of damaged mitochondria by autophagy might be central to the process of recessive parkinsonism. Here, we show that loss of DJ-1 leads to loss of mitochondrial polarization, fragmentation of mitochondria and accumulation of markers of autophagy (LC3 punctae and lipidation) around mitochondria in human dopaminergic cells. These effects are due to endogenous oxidative stress, as antioxidants will reverse all of them. Similar to PINK1 and parkin, DJ-1 also limits mitochondrial fragmentation in response to the mitochondrial toxin rotenone. Furthermore, overexpressed parkin will protect against loss of DJ-1 and, although DJ-1 does not alter PINK1 mitochondrial phenotypes, DJ-1 is still active against rotenone-induced damage in the absence of PINK1. None of the three proteins complex together using size exclusion chromatography. These data suggest that DJ-1 works in parallel to the PINK1/parkin pathway to maintain mitochondrial function in the presence of an oxidative environment.

Parkin deficiency disrupts calcium homeostasis by modulating phospholipase C signalling

Mutations in the E3 ubiquitin ligase parkin cause early-onset, autosomal-recessive juvenile parkinsonism (AJRP), presumably as a result of a lack of function that alters the level, activity, aggregation or localization of its substrates. Recently, we have reported that phospholipase Cgamma1 is a substrate for parkin. In this article, we show that parkin mutants and siRNA parkin knockdown cells possess enhanced levels of phospholipase Cgamma1 phosphorylation, basal phosphoinositide hydrolysis and intracellular Ca2+ concentration. The protein levels of Ca2+-regulated protein kinase Calpha were decreased in AJRP parkin mutant cells. Neomycin and dantrolene both decreased the intracellular Ca2+ levels in parkin mutants in comparison with those seen in wild-type parkin cells, suggesting that the differences were a consequence of altered phospholipase C activity. The protection of wild-type parkin against 6-hydroxydopamine (6OHDA) toxicity was also established in ARJP mutants on pretreatment with dantrolene, implying that a balancing Ca2+ release from ryanodine-sensitive stores decreases the toxic effects of 6OHDA. Our findings suggest that parkin is an important factor for maintaining Ca2+ homeostasis and that parkin deficiency leads to a phospholipase C-dependent increase in intracellular Ca2+ levels, which make cells more vulnerable to neurotoxins, such as 6OHDA.

Mitochondrial alterations in PINK1 deficient cells are influenced by calcineurin-dependent dephosphorylation of dynamin-related protein 1

PTEN-induced novel kinase 1 (PINK1) mutations are associated with autosomal recessive parkinsonism. Previous studies have shown that PINK1 influences both mitochondrial function and morphology although it is not clearly established which of these are primary events and which are secondary. Here, we describe a novel mechanism linking mitochondrial dysfunction and alterations in mitochondrial morphology related to PINK1. Cell lines were generated by stably transducing human dopaminergic M17 cells with lentiviral constructs that increased or knocked down PINK1. As in previous studies, PINK1 deficient cells have lower mitochondrial membrane potential and are more sensitive to the toxic effects of mitochondrial complex I inhibitors. We also show that wild-type PINK1, but not recessive mutant or kinase dead versions, protects against rotenone-induced mitochondrial fragmentation whereas PINK1 deficient cells show lower mitochondrial connectivity. Expression of dynamin-related protein 1 (Drp1) exaggerates PINK1 deficiency phenotypes and Drp1 RNAi rescues them. We also show that Drp1 is dephosphorylated in PINK1 deficient cells due to activation of the calcium-dependent phosphatase calcineurin. Accordingly, the calcineurin inhibitor FK506 blocks both Drp1 dephosphorylation and loss of mitochondrial integrity in PINK1 deficient cells but does not fully rescue mitochondrial membrane potential. We propose that alterations in mitochondrial connectivity in this system are secondary to functional effects on mitochondrial membrane potential.

Genetic polymorphism of plasminogen and vitamin D binding protein in red deer (Cervus elaphus L.)

Genetic polymorphism was detected in the red deer (Cervus elaphus L.), plasma proteins, plasminogen (PLG) and vitamin D binding protein (GC) using antiserum to human proteins. The affinity of the antisera to deer plasma was less than 10% that of a human standard but they bound specifically to proteins of molecular weight expected for GC and PLG. Three codominant alleles of GC and five of PLG were observed. In a set 124 farmed deer calves and their parents, six calves had genotypes which were not consistent with the expectations of inheritance. Further inconsistencies were found when variation in isocitrate dehydrogenase (IDH) and transferrin (TRF) was examined. Using genetic models which included pedigree error parameters the data were shown to be consistent with genetic inheritance of all loci in a data set containing approximately 4.8% (SE 1.4%) parent-progeny pedigree mismatches. In samples from four deer populations representative of the red deer introduced to New Zealand the GC and PLG polymorphisms provided a probability of paternity exclusion (PE) of between 0.34 and 0.54 and when IDH and TRF were also included the PE was between 0.46 and 0.66. The four populations differed significantly in allele frequency, which supports historical evidence that they originate from separate introductions of small numbers of European red deer.

Pink1 forms a multiprotein complex with Miro and Milton, linking Pink1 function to mitochondrial trafficking

Recessive mutations in Pink1 lead to a selective degeneration of dopaminergic neurons in the substantia nigra that is characteristic of Parkinson disease. Pink1 is a kinase that is targeted in part to mitochondria, and loss of Pink1 function can alter mitochondrial morphology and dynamics, thus supporting a link between mitochondrial dysfunction and Parkinson disease etiology. Here, we report the unbiased identification and confirmation of a mitochondrial multiprotein complex that contains Pink1, the atypical GTPase Miro, and the adaptor protein Milton. Our screen also identified an interaction between Pink1 and Mitofilin. Based on previously established functions for Miro and Milton in the trafficking of mitochondria along microtubules, we postulate here a role for Pink1 in mitochondrial trafficking. Using subcellular fractionation, we show that the overexpression of Miro and Milton, both of which are known to reside at the outer mitochondrial membrane, increases the mitochondrial Pink1 pool, suggesting a function of Pink1 at the outer membrane. Further, we document that Pink1 expressed without a mitochondrial targeting sequence can still be targeted to a mitochondria-enriched subcellular fraction via Miro and Milton. The latter finding is important for the interpretation of a previously reported protective effect of Pink1 expressed without a mitochondrial targeting sequence. Finally, we find that Miro and Milton expression suppresses altered mitochondrial morphology induced by loss of Pink1 function in cell culture. Our findings suggest that Pink1 functions in the trafficking of mitochondria in cells.

The role of PTEN-induced kinase 1 in mitochondrial dysfunction and dynamics

Mutations in parkin, PTEN-induced kinase 1 (PINK1) and DJ-1 can all cause autosomal recessive forms of Parkinson's disease. Recent data suggest that these recessive parkinsonism-associated genes converge within a single pathogenic pathway whose dysfunction leads to the loss of substantia nigra pars compacta neurons. The major common functional effects of all three genes relate to mitochondrial and oxidative damage, with a possible additional involvement of the ubiquitin proteasome system. This review highlights the role of the mitochondrial kinase, PINK1, in protection against mitochondrial dysfunction and how this might relate to loss of substantia nigra neurons in recessive parkinsonism.

Incipient formation of an electron lattice in a weakly confined quantum wire

We study the low-temperature transport properties of 1D quantum wires as the confinement strength V_{conf} and the carrier density n_{1D} are varied using a combination of split gates and a top gate in GaAs/AlGaAs heterostructures. At intermediate V_{conf} and n_{1D}, we observe a jump in conductance to 4e;{2}/h, suggesting a double wire. On further reducing n_{1D}, plateau at 2e;{2}/h returns. Our results show beginnings of the formation of an electron lattice in an interacting quasi-1D quantum wire. In the presence of an in-plane magnetic field, mixing of spin-aligned levels of the two wires gives rise to more complex states.

Shoulder injuries in competitive swimmers in KwaZulu-

Objective. To determine the incidence of shoulder injuries in competitive swimmers in KwaZulu-Natal, a province in South Africa. Design. A cross-sectional survey was conducted. A random sample of 96 swimmers from a pool of 300 swimmers registered with first-division clubs affiliated to the KwaZulu-Natal Aquatics Association participated in the study by informed voluntary consent. Data were gathered using a validated questionnaire. Setting. Data were gathered at time trials, races and club meetings. Main measures. Variables monitored included the incidence of shoulder injuries, shoulder pain and proportion of overuse injury. Results. Seventy-one per cent of the swimmers had shoulder pain and 64% reported injury to the shoulder. Forty-six per cent of the swimmers with pain complained of anterior shoulder pain, while 65% of all injuries were due to overuse. The commonest diagnoses included tendonitis (35%), muscle imbalance (29%), impingement (19%) and other (17%). Sixty-nine per cent of the swimmers swam freestyle which was related to 70% of the injuries. Eighty-one per cent of the injured swimmers sought physiotherapy for the shoulder pain. Conclusion. The incidence of shoulder injuries in competitive swimmers is high. This study shows the need for more research into swimming injuries, and the conditioning and rehabilitation of athletes in South Africa. South African Journal of Sports Medicine Vol. 18 (1) 2006: pp. 10-12

Mitochondrial function and morphology are impaired in parkin-mutant fibroblasts

OBJECTIVE

There are marked mitochondrial abnormalities in parkin-knock-out Drosophila and other model systems. The aim of our study was to determine mitochondrial function and morphology in parkin-mutant patients. We also investigated whether pharmacological rescue of impaired mitochondrial function may be possible in parkin-mutant human tissue.

METHODS

We used three sets of techniques, namely, biochemical measurements of mitochondrial function, quantitative morphology, and live cell imaging of functional connectivity to assess the mitochondrial respiratory chain, the outer shape and connectivity of the mitochondria, and their functional inner connectivity in fibroblasts from patients with homozygous or compound heterozygous parkin mutations.

RESULTS

Parkin-mutant cells had lower mitochondrial complex I activity and complex I-linked adenosine triphosphate production, which correlated with a greater degree of mitochondrial branching, suggesting that the functional and morphological effects of parkin are related. Knockdown of parkin in control fibroblasts confirmed that parkin deficiency is sufficient to explain these mitochondrial effects. In contrast, 50% knockdown of parkin, mimicking haploinsufficiency in human patient tissue, did not result in impaired mitochondrial function or morphology. Fluorescence recovery after photobleaching assays demonstrated a lower level of functional connectivity of the mitochondrial matrix, which further worsened after rotenone exposure. Treatment with experimental neuroprotective compounds resulted in a rescue of the mitochondrial membrane potential.

INTERPRETATION

Our study demonstrates marked abnormalities of mitochondrial function and morphology in parkin-mutant patients and provides proof-of-principle data for the potential usefulness of this new model system as a tool to screen for disease-modifying compounds in genetically homogenous parkinsonian disorders.

Spin-incoherent transport in quantum wires

When a quantum wire is weakly confined, a conductance plateau appears at e;{2}/h with decreasing carrier density in zero magnetic field accompanied by a gradual suppression of the 2e;{2}/h plateau. Applying an in-plane magnetic field B_{ parallel} does not alter the value of this quantization; however, the e;{2}/h plateau weakens with increasing B_{ parallel} up to 9 T, and then strengthens on further increasing B_{ parallel}, which also restores the 2e;{2}/h plateau. Our results are consistent with spin-incoherent transport in a one-dimensional wire.

Direct observation of oxygen superstructures in manganites

We report the observation of superstructures associated with the oxygen 2p states in two prototypical manganites using x-ray diffraction at the oxygen K edge. In the stripe order system Bi0.31Ca0.69MnO3, hole-doped O states are orbitally ordered, at the same propagation vector as the Mn orbital ordering, but no oxygen charge stripes are found at this periodicity. In La7/8Sr1/8MnO3, we observe a 2p charge ordering described by alternating hole-poor and hole-rich MnO planes that is consistent with some of the recent predictions.

The endocannabinoid system and rimonabant: a new drug with a novel mechanism of action involving cannabinoid CB1 receptor antagonism--or inverse agonism--as potential obesity treatment and other therapeutic use

There is considerable evidence that the endocannabinoid (endogenous cannabinoid) system plays a significant role in appetitive drive and associated behaviours. It is therefore reasonable to hypothesize that the attenuation of the activity of this system would have therapeutic benefit in treating disorders that might have a component of excess appetitive drive or over-activity of the endocannabinoid system, such as obesity, ethanol and other drug abuse, and a variety of central nervous system and other disorders. Towards this end, antagonists of cannabinoid receptors have been designed through rational drug discovery efforts. Devoid of the abuse concerns that confound and impede the use of cannabinoid receptor agonists for legitimate medical purposes, investigation of the use of cannabinoid receptor antagonists as possible pharmacotherapeutic agents is currently being actively investigated. The compound furthest along this pathway is rimonabant, a selective CB(1) (cannabinoid receptor subtype 1) antagonist, or inverse agonist, approved in the European Union and under regulatory review in the United States for the treatment of obesity. This article summarizes the basic science of the endocannabinoid system and the therapeutic potential of cannabinoid receptor antagonists, with emphasis on the treatment of obesity.

Study of solvent effect in laser emission from Coumarin 540 dye solution

The results of a brief investigation of the amplified spontaneous emission and lasing characteristics of Coumarin 540 dye in as many as ten different solvents are reported. It has been found that C 540 dye solutions contained within a rectangular quartz cuvette give laser emission with well resolved equally spaced modes when pumped with a 476 nm beam. The modes were found to originate from the subcavities formed by the plane-parallel walls of the cuvette containing the high-gain medium. While the quantum yield remains a decisive factor, a clear correlation between the total width of the emission spectra and the refractive indices of the solvents of the respective samples has been demonstrated. The well-resolved mode structure exhibited by the emission spectra gives clear evidence of the lasing action taking place in the gain medium, and the number of modes enables us to compare the gain of the media in different samples. A detailed discussion of the solvent effect in the lasing characteristics of C540 in different solutions is given.

A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis

OBJECTIVE

To evaluate the cost effectiveness of acupuncture in the management of persistent non-specific low back pain.

DESIGN

Cost effectiveness analysis of a randomised controlled trial.

SETTING

Three private acupuncture clinics and 18 general practices in York, England.

PARTICIPANTS

241 adults aged 18-65 with non-specific low back pain of 4-52 weeks' duration.

INTERVENTIONS

Ten individualised acupuncture treatments over three months from acupuncturists trained in traditional Chinese medicine (n = 160) or usual care only (n = 81).

MAIN OUTCOME MEASURE

Incremental cost per quality adjusted life year (QALY) gained over two years.

RESULTS

Total costs to the United Kingdom's health service during the two year study period were higher on average for the acupuncture group (460 pounds sterling; 673 euros; 859 dollars) than for the usual care group (345 pounds sterling) because of the costs associated with initial treatment. The mean incremental health gain from acupuncture at 12 months was 0.012 QALYs (95% confidence interval -0.033 to 0.058) and at 24 months was 0.027 QALYs (-0.056 to 0.110), leading to a base case estimate of 4241 pounds sterling per QALY gained. This result was robust to sensitivity analysis. The probabilistic sensitivity analysis showed acupuncture to have a more than 90% chance of being cost effective at a pound20 000 cost per QALY threshold.

CONCLUSION

A short course of traditional acupuncture for persistent non-specific low back pain in primary care confers a modest health benefit for minor extra cost to the NHS compared with usual care. Acupuncture care for low back pain seems to be cost effective in the longer term.

TRIAL REGISTRATION

ISRCTN80764175 [controlled-trials.com].

Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain

OBJECTIVE

To determine whether a short course of traditional acupuncture improves longer term outcomes for patients with persistent non-specific low back pain in primary care.

DESIGN

Pragmatic, open, randomised controlled trial.

SETTING

Three private acupuncture clinics and 18 general practices in York, England.

PARTICIPANTS

241 adults aged 18-65 with non-specific low back pain of 4-52 weeks' duration.

INTERVENTIONS

10 individualised acupuncture treatments from one of six qualified acupuncturists (160 patients) or usual care only (81 patients).

MAIN OUTCOME MEASURES

The primary outcome was SF-36 bodily pain, measured at 12 and 24 months. Other outcomes included reported use of analgesics, scores on the Oswestry pain disability index, safety, and patient satisfaction.

RESULTS

39 general practitioners referred 289 patients of whom 241 were randomised. At 12 months average SF-36 pain scores increased by 33.2 to 64.0 in the acupuncture group and by 27.9 to 58.3 in the control group. Adjusting for baseline score and for any clustering by acupuncturist, the estimated intervention effect was 5.6 points (95% confidence interval -0.2 to 11.4) at 12 months (n = 213) and 8.0 points (2.8 to 13.2) at 24 months (n = 182). The magnitude of the difference between the groups was about 10%-15% of the final pain score in the control group. Functional disability was not improved. No serious or life threatening events were reported.

CONCLUSIONS

Weak evidence was found of an effect of acupuncture on persistent non-specific low back pain at 12 months, but stronger evidence of a small benefit at 24 months. Referral to a qualified traditional acupuncturist for a short course of treatment seems safe and acceptable to patients with low back pain.

TRIAL REGISTRATION

ISRCTN80764175 [controlled-trials.com].

Kinase activity is required for the toxic effects of mutant LRRK2/dardarin

Mutations in the LRRK2 gene, coding for dardarin, cause dominantly inherited Parkinson's disease (PD). Dardarin is a large protein, and mutations are found throughout the gene including the kinase domain. However, it is not clear if kinase activity is important for the damaging effects of pathogenic mutations. In this study, we noted two cellular phenotypes associated with mutant dardarin. First, pathogenic mutations increase the tendency of dardarin to form inclusion bodies. Secondly, neurons and neuronal cell lines undergo cell death after expression of mutant protein. Manipulating activity by replacing the kinase domain with a 'kinase-dead' version blocks inclusion body formation and strongly delays cell death. This predicts that kinase inhibitors will be useful therapeutic agents in patients with LRRK2 mutations and, perhaps, in sporadic PD. We also show that dardarin protein is expressed within human midbrain neurons and that C-terminal epitopes are also found in some Lewy bodies.

Conductance Quantization at a Half-Integer Plateau in a Symmetric GaAs Quantum Wire

We present data from an induced gallium arsenide (GaAs) quantum wire that exhibits an additional conductance plateau at 0.5(2e2/h), where e is the charge of an electron and h is Planck's constant, in zero magnetic field. The plateau was most pronounced when the potential landscape was tuned to be symmetric by using low-temperature scanning-probe techniques. Source-drain energy spectroscopy and temperature response support the hypothesis that the origin of the plateau is the spontaneous spin-polarization of the transport electrons: a ferromagnetic phase. Such devices may have applications in the field of spintronics to either generate or detect a spin-polarized current without the complications associated with external magnetic fields or magnetic materials.

Shoulder injuries in competitive swimmers in KwaZulu-

Objective. To determine the incidence of shoulder injuries in competitive swimmers in KwaZulu-Natal, a province in South Africa. Design. A cross-sectional survey was conducted. A random sample of 96 swimmers from a pool of 300 swimmers registered with first-division clubs affiliated to the KwaZulu-Natal Aquatics Association participated in the study by informed voluntary consent. Data were gathered using a validated questionnaire. Setting. Data were gathered at time trials, races and club meetings. Main measures. Variables monitored included the incidence of shoulder injuries, shoulder pain and proportion of overuse injury. Results. Seventy-one per cent of the swimmers had shoulder pain and 64% reported injury to the shoulder. Forty-six per cent of the swimmers with pain complained of anterior shoulder pain, while 65% of all injuries were due to overuse. The commonest diagnoses included tendonitis (35%), muscle imbalance (29%), impingement (19%) and other (17%). Sixty-nine per cent of the swimmers swam freestyle which was related to 70% of the injuries. Eighty-one per cent of the injured swimmers sought physiotherapy for the shoulder pain. Conclusion. The incidence of shoulder injuries in competitive swimmers is high. This study shows the need for more research into swimming injuries, and the conditioning and rehabilitation of athletes in South Africa. South African Journal of Sports Medicine Vol. 18 (1) 2006: pp. 10-12

Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain

OBJECTIVES

To test whether patients with persistent non-specific low back pain, when offered access to traditional acupuncture care alongside conventional primary care, gained more long-term relief from pain than those offered conventional care only, for equal or less cost. Safety and acceptability of acupuncture care to patients, and the heterogeneity of outcomes were also tested.

DESIGN

A pragmatic, two parallel group, randomised controlled trial. Patients in the experimental arm were offered the option of referral to the acupuncture service comprising six acupuncturists. The control group received usual care from their general practitioner (GP). Eligible patients were randomised in a ratio of 2:1 to the offer of acupuncture to allow between-acupuncturist effects to be tested.

SETTING

Three non-NHS acupuncture clinics, with referrals from 39 GPs working in 16 practices in York, UK.

PARTICIPANTS

Patients aged 18-65 years with non-specific low back pain of 4-52 weeks' duration, assessed as suitable for primary care management by their general practitioner.

INTERVENTIONS

The trial protocol allowed up to ten individualised acupuncture treatments per patient. The acupuncturist determined the content and the number of treatments according to patient need.

MAIN OUTCOME MEASURES

The Short Form 36 (SF-36) Bodily Pain dimension (range 0-100 points), assessed at baseline, and 3, 12 and 24 months. The study was powered to detect a 10-point difference between groups at 12 months post-randomisation. Cost--utility analysis was conducted at 24 months using the EuroQoL 5 Dimensions (EQ-5D) and a preference-based single index measure derived from the SF-36 (SF-6D). Secondary outcomes included the McGill Present Pain Index (PPI), Oswestry Pain Disability Index (ODI), all other SF-36 dimensions, medication use, pain-free months in the past year, worry about back pain, satisfaction with care received, and safety and acceptability of acupuncture care.

RESULTS

A total of 159 patients were in the 'acupuncture offer' arm and 80 in the 'usual care' arm. All 159 patients randomised to the offer of acupuncture care chose to receive acupuncture treatment, and received an average of eight acupuncture treatments within the trial. Analysis of covariance, adjusting for baseline score, found an intervention effect of 5.6 points on the SF-36 Pain dimension [95% confidence interval (CI) -1.3 to 12.5] in favour of the acupuncture group at 12 months, and 8 points (95% CI 0.7 to 15.3) at 24 months. No evidence of heterogeneity of effect was found for the different acupuncturists. Patients receiving acupuncture care did not report any serious or life-threatening events. No significant treatment effect was found for any of the SF-36 dimensions other than Pain, or for the PPI or the ODI. Patients receiving acupuncture care reported a significantly greater reduction in worry about their back pain at 12 and 24 months compared with the usual care group. At 24 months, the acupuncture care group was significantly more likely to report 12 months pain free and less likely to report the use of medication for pain relief. The acupuncture service was found to be cost-effective at 24 months; the estimated cost per quality-adjusted (QALY) was 4241 pounds sterling (95% CI 191 pounds sterling to 28,026 pounds sterling) using the SF-6D scoring algorithm based on responses to the SF-36, and 3598 pounds sterling (95% CI 189 pounds sterling to 22,035 pounds sterling) using the EQ-5D health status instrument. The NHS costs were greater in the acupuncture care group than in the usual care group. However, the additional resource use was less than the costs of the acupuncture treatment itself, suggesting that some usual care resource use was offset.

CONCLUSIONS

Traditional acupuncture care delivered in a primary care setting was safe and acceptable to patients with non-specific low back pain. Acupuncture care and usual care were both associated with clinically significant improvement at 12- and 24-month follow-up. Acupuncture care was significantly more effective in reducing bodily pain than usual care at 24-month follow-up. No benefits relating to function or disability were identified. GP referral to a service providing traditional acupuncture care offers a cost-effective intervention for reducing low back pain over a 2-year period. Further research is needed to examine many aspects of this treatment including its impact compared with other possible short-term packages of care (such as massage, chiropractic or physiotherapy), various aspects of cost-effectiveness, value to patients and implementation protocols.

d-d excitations in manganites probed by resonant inelastic x-ray scattering

We report a study of electronic excitations in manganites exhibiting a range of ground states, using resonant inelastic x-ray scattering (RIXS) at the Mn K edge. Excitations with temperature dependent changes correlated with the magnetism were observed as high as 10 eV. By calculating Wannier functions, and finite-q response functions, we associate this dependence with intersite d-d excitations. The calculated dynamical structure factor is found to be similar to the RIXS spectra.

The placebo-controlled trial as a test of complementary and alternative medicine: observations from research experience of individualised homeopathic treatment

The authors' experience of conducting clinical trials in homeopathy and analysing data from these has drawn attention to a fundamental problem with the interpretation of results from placebo controlled trials in homeopathy: It is not reasonable to assume that the specific effects of homeopathic medicine and the non-specific effects of consultations are independent of each other-specific effects of the medicine (as manifested by patients' reactions) may influence the nature of subsequent consultations and the non-specific effects of the consultation may enhance or diminish the effects of the medicine. For clinical trials of homeopathy to be accurate representations of practice, we need modified designs that take into account the complexity of the homeopathic intervention. Only with such trials will the results be generalisable to homeopathic practice in the real world. The authors propose that comparative trials are a meaningful way of evaluating the effectiveness of homeopathic treatment.

Patient reports of adverse events associated with acupuncture treatment: a prospective national survey

OBJECTIVE

The primary aim was to establish from acupuncture patients the type and frequency of adverse events they experienced and attributed to their treatment. Secondary aims included the measurement of patient reported adverse consequences arising from advice received about conventional/prescribed medication or from delayed conventional diagnosis and treatment.

METHODS

Postal survey of prospectively identified acupuncture patients. One in three members of the British Acupuncture Council (n = 638) invited consecutive patients to participate in the survey. Participating patients gave baseline data and consented to direct follow up by the researchers at 3 months. A structured questionnaire was used to collect data on perceived adverse events.

RESULTS

9408 patients gave baseline information and consent and 6348 (67%) completed 3 month questionnaires. Responders were not dissimilar to non-responders for all known characteristics. 682 patients reported at least one adverse event over 3 months, a rate of 107 per 1000 patients (95% CI 100 to 115). Three patients reported a serious adverse event. The most common events reported were severe tiredness and exhaustion, pain at the site of needling, and headache. Patients receiving acupuncture treatment that was not funded by the NHS and patients not in contact with a GP or hospital specialist were less likely to report adverse events (odds ratios 0.59 and 0.66, respectively). 199 (3%) of responding patients reported receiving advice about conventional/prescribed medication, six of whom reported adverse consequences after taking the advice. Two patients reported delayed conventional treatment.

CONCLUSION

Patients report a range of adverse events but these do not prevent most patients seeking further acupuncture. This large scale survey supports existing evidence that acupuncture is a relatively safe intervention when practised by regulated practitioners.

Patient reports of adverse events associated with acupuncture treatment: a prospective national survey

OBJECTIVE

The primary aim was to establish from acupuncture patients the type and frequency of adverse events they experienced and attributed to their treatment. Secondary aims included the measurement of patient reported adverse consequences arising from advice received about conventional/prescribed medication or from delayed conventional diagnosis and treatment.

METHODS

Postal survey of prospectively identified acupuncture patients. One in three members of the British Acupuncture Council (n = 638) invited consecutive patients to participate in the survey. Participating patients gave baseline data and consented to direct follow up by the researchers at 3 months. A structured questionnaire was used to collect data on perceived adverse events.

RESULTS

9408 patients gave baseline information and consent and 6348 (67%) completed 3 month questionnaires. Responders were not dissimilar to non-responders for all known characteristics. 682 patients reported at least one adverse event over 3 months, a rate of 107 per 1000 patients (95% CI 100 to 115). Three patients reported a serious adverse event. The most common events reported were severe tiredness and exhaustion, pain at the site of needling, and headache. Patients receiving acupuncture treatment that was not funded by the NHS and patients not in contact with a GP or hospital specialist were less likely to report adverse events (odds ratios 0.59 and 0.66, respectively). 199 (3%) of responding patients reported receiving advice about conventional/prescribed medication, six of whom reported adverse consequences after taking the advice. Two patients reported delayed conventional treatment.

CONCLUSION

Patients report a range of adverse events but these do not prevent most patients seeking further acupuncture. This large scale survey supports existing evidence that acupuncture is a relatively safe intervention when practised by regulated practitioners.

Fano factor reduction on the 0.7 conductance structure of a ballistic one-dimensional wire

We have measured the nonequilibrium current noise in a ballistic one-dimensional wire which exhibits an additional conductance plateau at 0.7x2e(2)/h. The Fano factor shows a clear reduction on the 0.7 structure, and eventually vanishes upon applying a strong parallel magnetic field. These results provide experimental evidence that the 0.7 structure is associated with two conduction channels that have different transmission probabilities.

Soft x-ray resonant diffraction study of magnetic and orbital correlations in a manganite near half doping

We have utilized resonant x-ray diffraction at the Mn L(II,III) edges in order to directly compare magnetic and orbital correlations in Pr0.6Ca0.4MnO3. Comparing the widths of the magnetic and orbital diffraction peaks, we find that the magnetic correlation length exceeds that of the orbital order by nearly a factor of 2. Furthermore, we observe a large (approximately 3 eV) spectral weight shift between the magnetic and orbital resonant line shapes, which cannot be explained within the classic Goodenough picture of a charge-ordered ground state. To explain the shift, we calculate the orbital and magnetic resonant diffraction line shapes based on a relaxed charge-ordered model.

Developing integrated CAM services in Primary Care Organisations

OBJECTIVES

To explore policy development and the provision of integrated NHS CAM therapy services following the reorganisation of UK primary care services in 1999.

DESIGN

Structured survey interviews with Chairpersons in a stratified random sample of 72 Primary Care Organisations (PCOs) in England in 1999 and 2000; semi-structured telephone interviews with purposive samples of (i) providers of primary care CAM services (mostly General Practitioners), and (ii) Commissioners of primary care services in two purposive sub-samples of PCOs involved in positive policy formation in relation to CAM.

RESULTS

By the end of 2000, it is estimated that 85% of PCOs in England (95% CI 78-91%) had discussed CAM at board level, and 37% (95% CI 26-48%) had at least one CAM policy in place. The dominant strategy that emerged was a policy of "provide and review", particularly in practices that had managed their own budgets under the previous fundholding system. We found that a small number of PCOs were developing area-wide services. Positive influences or "drivers" for CAM policy formation were identified as: existing services, local enthusiasm and expertise, patient demand, a willingness to consider the wider evidence-base for CAM, and a perception that complementary therapies could help the PCOs to meet national NHS targets. Negative influences included: the cost of ensuring equitable access to services, a perception that CAM lacks the credibility required for public funding, the need to prioritize services and the need to direct funding towards meeting national and local health objectives.

CONCLUSIONS

Opportunities for development of integrated NHS services are most likely to occur where CAM provision is seen as a potential solution to an NHS problem. Locality-based, integrated CAM services that are responsive to NHS priorities may offer a model for the future development of CAMs in primary care.

Trends in access to complementary or alternative medicines via primary care in England: 1995-2001 results from a follow-up national survey

A prior national survey of one in eight randomly selected general practices in England estimated that 39% of general practices [95% confidence interval (CI) 35-43%] provided some access to complementary or alternative medicine (CAM) therapies in 1995. A repeat survey, conducted in 2001, estimated that one in two practices in England now offer their patients some access to CAMs (95% CI 46-52%). The change was due to increased provision in-house; the proportion of practices making NHS referrals remained unchanged. The proportion of services supported by patient payments rose from 26 to 42%.

Interaction effects at crossings of spin-polarized one-dimensional subbands

We report conductance measurements of ballistic one-dimensional (1D) wires defined in GaAs/AlGaAs heterostructures in an in-plane magnetic field, B. When the Zeeman energy is equal to the 1D subband energy spacing, the spin-split subband N upward arrow intersects (N+1) downward arrow, where N is the index of the spin-degenerate 1D subband. At the crossing of N=1 upward arrow and N=2 downward arrow subbands, there is a spontaneous splitting giving rise to an additional conductance structure evolving from the 1.5(2e(2)/h) plateau. With further increase in B, the structure develops into a plateau and lowers to 2e(2)/h. With increasing temperature and magnetic field the structure shows characteristics of the 0.7 structure. Our results suggest that at low densities a spontaneous spin splitting occurs whenever two 1D subbands of opposite spins cross.

Progression to wet gangrene in penile necrosis and calciphylaxis

We report a patient who presented with gangrene of the penis due to renal failure and calciphylaxis. In view of his advanced underlying conditions we pursued an expectant approach. Superinfection set in necessitating extensive debridement, demasculinisation and a perineal urethrostomy. Of the 34 reported cases in the literature, 12 (35%) were treated conservatively, 18 (53%) had been treated expectantly with delayed surgery following the development of complications and 4 (12%) underwent early surgery (penectomy). 20 (59%) of the patients subsequently died--8/12 (58%) treated conservatively, 11/18 (61%) treated with expectant surgery and 1/4 (25%) treated with early surgery. Progression to wet gangrene developed in the majority of patients--23/34 patients (68%). Penile gangrene is a symptom of severe systemic disease, where two thirds of affected patients decease within six months of onset of symptoms. Expectant treatment results in superinfection and wet gangrene in the majority of cases who ultimately require extensive surgery and debridement.

Prostatic involvement of a testicular lymphoma in a patient with myasthenia gravis on long-term azathioprine

Side effects of long-term use of azathioprine in myasthenia gravis are infrequently reported. We present a patient who developed non-Hodgkin's lymphoma after eight years of azathioprine treatment for myasthenia gravis. He presented unusually with testicular lymphoma spreading to the prostate and the illness followed a particularly aggressive course.

Use of evidence based leaflets to promote informed choice in maternity care: randomised controlled trial in everyday practice

OBJECTIVE

To assess the effect of leaflets on promoting informed choice in women using maternity services.

DESIGN

Cluster trial, with maternity units randomised to use leaflets (intervention units) or offer usual care (control units). Data collected through postal questionnaires.

SETTING

13 maternity units in Wales.

PARTICIPANTS

Four separate samples of women using maternity services. Antenatal samples: women reaching 28 weeks' gestation before (n=1386) and after (n=1778) the intervention. Postnatal samples: women at eight weeks after delivery before (n=1741) and after (n=1547) the intervention.

INTERVENTION

Provision of 10 pairs of Informed Choice leaflets for service users and midwives and a training session for staff in their use.

MAIN OUTCOME MEASURES

Change in the proportion of women who reported exercising informed choice.

SECONDARY OUTCOMES

changes in women's knowledge; satisfaction with information, choice, and discussion; and possible consequences of informed choice.

RESULTS

There was no change in the proportion of women who reported that they exercised informed choice in the intervention units compared with the control units for either antenatal or postnatal women. There was a small increase in satisfaction with information in the antenatal samples in the intervention units compared with the control units (odds ratio 1.40, 95% confidence interval 1.05 to 1.88). Only three quarters of women in the intervention units reported being given at least one of the leaflets, indicating problems with the implementation of the intervention.

CONCLUSION

In everyday practice, evidence based leaflets were not effective in promoting informed choice in women using maternity services.

Use and expenditure on complementary medicine in England: a population based survey

OBJECTIVES

Many claims are made that complementary medicine use is a substantial and growing part of health-care behaviour. Estimates of practitioner visits in the USA and Australia indicate high levels of use and expenditure. No reliable population-based estimates of practitioner use are available for the UK.

METHODS

In 1998, a previously piloted postal questionnaire was sent to a geographically stratified, random sample of 5010 adults in England. The questionnaire focuses on practitioner contacts, but also asked about the purchase of over-the-counter remedies. Additional information was requested on socio-demographic characteristics, perceived health, and recent NHS resource use. Information on use included reason for encounter, expenditure, insurance, and location of visit.

MAIN OUTCOMES MEASURES

Population estimates (by age group and sex) of lifetime use and use in the past 12 months for acupuncture, chiropractic, homoeopathy, hypnotherapy, medical herbalism, osteopathy. Estimates for two additional therapies (reflexology and aromatherapy), and homoeopathic or herbal remedies purchased over-the-counter. Estimates of annual out-of-pocket expenditure on practitioner visits in 1998.

RESULTS

A crude response rate of 60% was achieved (adjusted response rate 59%). Responders were older and more likely to be female than non-responders. Usable responses (n = 2669) were weighted using the age/sex profile of the sample frame. From these adjusted data we estimate that 10.6% (95% CI 9.4 to 11.7) of the adult population of England had visited at least one therapist providing any one of the six more established therapies in the past 12 months (13.6% for use of any of the eight named therapies, 95% CI 12.3 to 14.9). If all eight therapies, and self-care using remedies purchased over the counter are included, the estimated proportion rises to 28.3% (95% CI 26.6 to 30.0) for use in the past 12 months, and 46.6% (95% CI 44.6 to 48.5) for lifetime use. All types of use declined in older age groups, and were more commonly reported by women than men (P < 0.01 for all comparisons). An estimated 22 million visits were made to practitioners of one of the six established therapies in 1998. The NHS provided an estimated 10% of these contacts. The majority of non-NHS visits were financed through direct out-of-pocket expenditure. Annual out-of-pocket expenditure on any of the six more established therapies was estimated at pound 450 million (95% CI 357 to 543).

CONCLUSION

This survey has demonstrated substantial use of practitioner-provided complementary therapies in England in 1998. The findings suggest that CAM is making a measurable contribution to first-contact primary care. However, we have shown that 90% of this provision is purchased privately. Further research into the cost-effectiveness of different CAM therapies for particular patient groups is now urgently needed to facilitate equal and appropriate access via the NHS.

Access to complementary medicine via general practice

BACKGROUND

The popularity of complementary medicine continues to be asserted by the professional associations and umbrella organisations of these therapies. Within conventional medicine there are also signs that attitudes towards some of the complementary therapies are changing.

AIM

To describe the scale and scope of access to complementary therapies (acupuncture, chiropractic, homoeopathy, hypnotherapy, medical herbalism, and osteopathy) via general practice in England.

DESIGN OF STUDY

A postal questionnaire sent to 1226 individual general practitioners (GPs) in a random cluster sample of GP partnerships in England. GPs received up to three reminders.

SETTING

One in eight (1226) GP partnerships in England in 1995.

METHOD

Postal questionnaire to assess estimates of the number of practices offering 'in-house' access to a range of complementary therapies or making National Health Service (NHS) referrals outside the practice; sources of funding for provision and variations by practice characteristics.

RESULTS

A total of 964 GPs replied (78.6%). Of these, 760 provided detailed information. An estimated 39.5% (95% CI = 35%-43%) of GP partnerships in England provided access to some form of complementary therapy for their NHS patients. If all non-responding partnerships are assumed to be non-providers, the lowest possible estimate is 30.3%. An estimated 21.4% (95% CI = 19%-24%) were offering access via the provision of treatment by a member of the primary health care team, 6.1% (95% CI = 2%-10%) employed an 'independent' complementary therapist, and an estimated 24.6% of partnerships (95% CI = 21%-28%) had made NHS referrals for complementary therapies. The reported volume of provision within any individual service tended to be low. Acupuncture and homoeopathy were the most commonly available therapies. Patients made some payment for 25% of practice-based provision. Former fundholding practices were significantly more likely to offer complementary therapies than non-fundholding practices, (45% versus 36%, P = 0.02). Fundholding did not affect the range of therapies offered, and patients from former fundholding practices were no more likely to pay for treatment.

CONCLUSION

Access to complementary health care for NHS patients was widespread in English general practices in 1995. This data suggests that a limited range of complementary therapies were acceptable to a large proportion of GPs. Fundholding clearly provided a mechanism for the provision of complementary therapies in primary care. Patterns of provision are likely to alter with the demise of fundholding and existing provision may significantly reduce unless the Primary Care Groups or Primary Care Trusts are prepared to support the 'levelling up' of some services.

'Getting somewhere', feeling cared for: patients' perspectives on complementary therapies in the NHS

OBJECTIVE

To examine satisfaction with complementary therapy among patients receiving treatment funded within the National Health Service (NHS).

DESIGN

Semi-structured interviews using a critical incident approach (n =49).

SETTING

8 sites across England providing complementary therapy services within primary care.

RESULTS

Complementary therapies are experienced as ameliorating and curing conditions, including chronic problems. Patients also perceive complementary practitioners as being caring and value the development of a therapeutic relationship within which they are encouraged to take an active part in looking after their health. Positive experiences of complementary therapy use were contrasted with either a failure of orthodox medicine or a dislike of the orthodox treatments available to them. Very few negative aspects were reported.

CONCLUSIONS

Patient satisfaction was consistent across settings and type of therapy received. The findings reinforce messages from studies of users in the private sector, but also suggest that for NHS users commitment to treatment develops largely as a result of positive experience rather than prior beliefs. Implications of the findings for research and policy are considered.

Sustaining complementary therapy provision in primary care: lessons from existing services

OBJECTIVE

To examine factors which sustain complementary therapy services in primary care in order to inform policy making in a context of rapid change.

DESIGN

In-depth qualitative case studies, including semi-structured interviews with key informants.

SETTING

10 existing schemes of complementary therapy provision in primary care across England.

RESULTS

GPs and complementary practitioners reported wide-ranging benefits from complementary therapy provision in primary care. However, they felt that their ability to sustain complementary therapy provision was mediated by a) funding, b) the need for research, and c) appropriate service delivery mechanisms. a) Many schemes were the result of and sustained by personal vision. As such they had negotiated a variety of funding sources over a considerable period, against a background perception that continued funding was uncertain. b) Most informants believed that more research was needed to provide a solid evidence base for service continuation and development, in particular clinical and cost-effectiveness work. c) The manner of service delivery, notably whether a service was located within a general practice or in a referral centre, was seen as having implications for the integration of practitioners and for patient access to services.

CONCLUSIONS

Current complementary therapy provision in primary care has developed on an 'ad hoc' basis. In particular, the existence of GP fundholding in the 1990s, in which primary care physicians were able to purchase health services on a practice basis, facilitated the development of services in this way. Within the current Primary Care Group context, where purchasing decisions are made collectively by a group of general practices within a region, consideration needs to be given to both the continuity of schemes already in existence and to whether a more standardized approach to service development will be required to facilitate sustainable provision.

Longer-term clinical and economic benefits of offering acupuncture to patients with chronic low back pain assessed as suitable for primary care management

This paper presents the research protocol for a pragmatic study of the benefits of providing an acupuncture service to patients in primary care with chronic low back pain. The proposal was written in response to a call for bids from the NHS Executive's centrally funded research programme for Health Technology Assessment (HTA). The research question posed was 'Does acupuncture have long-term effectiveness in the management of pain in primary care?' The present study was designed as a collaboration between an interdisciplinary team drawn from health services researchers at the University of Sheffield, acupuncture researchers from the Foundation for Traditional Chinese Medicine in York, and practitioners from general practice and acupuncture in York. The proposal presented here was submitted in response to an invitation from the Commissioning Board following a successful outline bid. It is reproduced here, largely as submitted in January 1998, using the headings under which information was requested. We also present an appendix describing methodological alterations made to the design in response the Commissioning Board's comments on the proposal. We present it in this format to give an idea of the evolution of the design and the process by which the research proposal was shaped. The final working protocol comprises a combination of these two elements.

Transurethral vaporization of the prostate: a promising new technique

OBJECTIVE

To evaluate the efficacy and safety of transurethral electrovaporization of the prostate (TUVP), using a grooved roller electrode, for the surgical treatment of symptomatic benign prostatic hypertrophy (BPH).

PATIENTS AND METHODS

TUVP was carried out using a grooved roller electrode, pure-cutting diathermy and a standard irrigating resectoscope to rapidly heat prostatic tissue to > 100 degrees C, resulting in vaporization and cavitation of the prostatic adenoma. Over a 10 month period, 116 patients (mean age 69.8 years, range 51-93) with symptomatic BPH (confirmed by a symptom score, urinary flow rate and an ultrasonographic estimate of residual volume) were treated by TUVP. Patients with carcinoma of the prostate, an elevated level of prostate-specific antigen or those in chronic urinary retention were excluded from the study. Each patient was followed up every 4 months during the first post-operative year, assessing their flow rate, residual volume and symptom score.

RESULTS

Symptom scores improved by 67% and residual volumes by 72%; the mean maximal flow rate increased from 8.5 mL/s (range 3.5-14) before treatment to 20.5 mL/s (range 4.5-39.0) at the same 4 month review. The procedure was simple and safe, with a mean operative duration of 35 min (range 20-65), and no patients required a blood transfusion. Most patients had their catheters removed within 24 h and were discharged on the second day after treatment.

CONCLUSION

The effectiveness of TUVP in improving symptoms and flow rates in patients with BPH was established. With minimal capital expenditure and a reduced in-patient stay. TUVP appears to have several advantages over other surgical treatments for BPH, although continued follow-up is needed to establish the long-term results.