Omega-3 Long-Chain Polyunsaturated Fatty Acids: Are They Beneficial for Physical and Cognitive Functioning in Older Adults?

BACKGROUND: There is equivocal evidence about beneficial properties of omega-3 long-chain polyunsaturated fatty acids (ω-3 LCPUFA) for older adults. OBJECTIVE: This study investigated the relationship between circulating ω-3 LCPUFA, docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) levels and their corresponding dietary intakes with cognition and physical function in a cohort of community-dwelling older adults at risk of dementia. METHODS: A cross-sectional analysis was conducted among 142 community-dwelling older adults (60-85 years) with subjective memory complaints. Erythrocyte fatty acids (ω-3 LCPUFA) and the omega-3 index were measured; dietary DHA and EPA were assessed with a LCPUFA specific questionnaire. Cognition was measured using the Cogstate computerised battery and Trail-making tests. Muscle strength was assessed by grip strength and physical function via the four-square step test, 30-second sit-to-stand, timed up-and-go test, and 4-m walk test. Multiple regression analysis was used to assess the relationship between erythrocyte ω-3 LCPUFA, dietary intake, cognitive and physical function. RESULTS: Higher dietary DHA and EPA were associated with better global cognitive function (DHA: ß=0.164, p=0.042; EPA: ß=0.188, p=0.020). Higher dietary EPA was associated with better attention/psychomotor composite scores (ß=0.196, p=0.024), mobility (four-square step test: ß=-0.202, p=0.015) and gait speed (4m walk test: ß=-0.200, p=0.017). No associations were found between erythrocyte ω-3 LCPUFA and cognitive or functional performance measures. CONCLUSIONS: In community-dwelling older adults with subjective memory complaints, higher dietary ω-3 LCPUFA intake was associated with better cognitive and physical function, supporting the evidence that ω-3 fatty acids play a role in optimising physical and cognitive health during ageing.

Laboratory-Based Gait Variability and Habitual Gait Entropy Do Not Differentiate Community-Dwelling Older Adults from Those with Subjective Memory Complaints.

BACKGROUND: Age-related cognitive decline may be delayed with appropriate interventions if those at high risk can be identified prior to clinical symptoms arising. Gait variability assessment has emerged as a promising candidate prognostic indicator, however, it remains unclear how sensitive gait variability is to early changes in cognitive abilities. RESEARCH QUESTION: Do community-dwelling adults over 65 years of age with subjective memory complaints differ from those with no subjective memory concerns in terms of laboratory-measured or free-living gait variability? METHODS: This cross-sectional study recruited 24 (age = 73.5(SD 6.4) years) community-dwelling people with subjective memory complaints and twenty seven (age = 70.9(4.3) years) individuals with no subjective memory concerns. A sample of 9 individuals with diagnosed mild dementia were also assessed (age = 86.5(7.0) years). Gait variability was assessed in a laboratory during walking at preferred pace (single-task) and while counting backward by seven (dual-task). Sixteen passes over a 4.88 m walkway in each condition were recorded and step length and duration variability was analysed. Free-living gait was assessed with a waist-worn accelerometer by identifying gait bouts of at least one min duration, and the mean multiscale sample entropy in one mins non-overlapping epochs is reported. Statistical inferences were based on analysis of variance using sex and group as the factors. RESULTS: No difference between those with subjective memory complaints and those without were observed in either laboratory- or free-living gait variability estimates. Both laboratory- and free-living gait variability were higher in those with mild dementia compared to the other groups. SIGNIFICANCE: Assuming that subjective memory complaints are on the pathway from cognitively intact to cognitively frail, the findings raise the hypothesis that subjective memory complaints occur earlier in the pathophysiology than measurable changes in laboratory or free living gait. Alternatively the gait variability assessments utilised may have been too insensitive.

Examining the relationship between nutrition and cerebral structural integrity in older adults without dementia.

The proportion of adults aged 60 years and over is expected to increase over the coming decades. This ageing of the population represents an important health issue, given that marked reductions to cerebral macro- and microstructural integrity are apparent with increasing age. Reduced cerebral structural integrity in older adults appears to predict poorer cognitive performance, even in the absence of clinical disorders such as dementia. As such, it is becoming increasingly important to identify those factors predicting cerebral structural integrity, especially factors that are modifiable. One such factor is nutritional intake. While the literature is limited, data from available cross-sectional studies indicate that increased intake of nutrients such as B vitamins (for example, B6, B12 and folate), choline, n-3 fatty acids and vitamin D, or increased adherence to prudent whole diets (for example, the Mediterranean diet) predicts greater cerebral structural integrity in older adults. There is even greater scarcity of randomised clinical trials investigating the effects of nutritional supplementation on cerebral structure, though it appears that supplementation with B vitamins (B6, B12 and folic acid) or n-3 fatty acids (DHA or EPA) may be beneficial. The current review presents an overview of available research examining the relationship between key nutrients or adherence to select diets and cerebral structural integrity in dementia-free older adults.

The persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with chronic pain.

There is uncertainty regarding how long the effects of acupuncture treatment persist after a course of treatment. We aimed to determine the trajectory of pain scores over time after acupuncture, using a large individual patient data set from high-quality randomized trials of acupuncture for chronic pain. The available individual patient data set included 29 trials and 17,922 patients. The chronic pain conditions included musculoskeletal pain (low back, neck, and shoulder), osteoarthritis of the knee, and headache/migraine. We used meta-analytic techniques to determine the trajectory of posttreatment pain scores. Data on longer term follow-up were available for 20 trials, including 6376 patients. In trials comparing acupuncture to no acupuncture control (wait-list, usual care, etc), effect sizes diminished by a nonsignificant 0.011 SD per 3 months (95% confidence interval: -0.014 to 0.037, P = 0.4) after treatment ended. The central estimate suggests that approximately 90% of the benefit of acupuncture relative to controls would be sustained at 12 months. For trials comparing acupuncture to sham, we observed a reduction in effect size of 0.025 SD per 3 months (95% confidence interval: 0.000-0.050, P = 0.050), suggesting approximately a 50% diminution at 12 months. The effects of a course of acupuncture treatment for patients with chronic pain do not seem to decrease importantly over 12 months. Patients can generally be reassured that treatment effects persist. Studies of the cost-effectiveness of acupuncture should take our findings into account when considering the time horizon of acupuncture effects. Further research should measure longer term outcomes of acupuncture.

Teachers of the Alexander Technique in the UK and the people who take their lessons: A national cross-sectional survey.

OBJECTIVES: Given the rising profile of the Alexander Technique in the UK, there is a need for a comprehensive description of its teachers and of those who currently take lessons. In a national survey of Alexander teachers, we set out to address this information gap. DESIGN: A cross-sectional survey of 871 UK members of three main Alexander Technique teachers' professional associations was conducted. A questionnaire requested information about their professional background, teaching practice and methods, and about the people who attend lessons and their reasons for seeking help. RESULTS: With an overall response rate of 61%, 534 teachers responded; 74% were female with median age of 58 years, 60% had a higher education qualification, and 95% were self-employed, many with additional non-Alexander paid employment. The majority (87%) offered lessons on their own premises or in a privately rented room, and 19% provided home visits; both individual and group lessons were provided. People who took lessons were predominantly female (66%) with a median age of 48 years, and 91% paid for their lessons privately. Nearly two-thirds (62%) began lessons for reasons related to musculoskeletal conditions, including back symptoms, posture, neck pain, and shoulder pain. Other reasons were general (18%, including well-being), performance-related (10%, including voice-, music-, and sport-related), psychological (5%) and neurological (3%). We estimate that Alexander teachers in the UK provide approximately 400,000 lessons per year. CONCLUSIONS: This study provides an overview of Alexander Technique teaching in the UK today and data that may be useful when planning future research.

Acute mood but not cognitive improvements following administration of a single multivitamin and mineral supplement in healthy women aged 50 and above: a randomised controlled trial.

A number of randomised controlled trials have indicated that multivitamin/mineral supplementation for a period of 4 weeks or greater can enhance mood and cognition. To date, no studies have investigated whether a single multivitamin dose can benefit mental function in older adults. This study investigated the acute effects of a single multivitamin and mineral and herbal (MVMH) supplement versus placebo on self ratings of mood and the performance of an effortful computerised cognitive battery in a sample of 76 healthy women aged 50-75 years. Mood was assessed using the depression anxiety stress scale (DASS), state trait anxiety inventory-state anxiety scale and visual analogue scales (VAS). Mood was rated at 1 h post supplementation and again after the competition of the cognitive assessments at 2 h post supplementation. It was demonstrated that the MVMH supplement improved overall DASS mood ratings; however, the most prominent effects appeared to be a reduction in ratings of perceived mental stress. These findings were confirmed using visual analogue scales, with these measures also demonstrating MVMH-related increased ratings of calmness. There were no benefits of the MVMH to mood ratings of depression and performance was not enhanced on the cognitive battery. Supplementation with a single multivitamin, mineral and herbal supplement reduces stress several hours after intake in healthy older people.

Acupuncture, counselling or usual care for depression and comorbid pain: secondary analysis of a randomised controlled trial.

BACKGROUND: Depression with comorbid pain is associated with a poor response to various treatments. The objective in this secondary analysis was to determine whether patients reporting pain have different depression and pain outcomes over time in response to acupuncture, counselling or usual care. METHODS: Self-reported ratings of depression and pain from 755 patients in a pragmatic randomised controlled trial of acupuncture (302) or counselling (302) compared to usual care alone (151) are described and analysed using a series of regression models and analysis of covariance. Patient-reported outcomes of Patient Health Questionnaire (PHQ)-9 for depression, SF36 bodily pain and EQ-5D, all at baseline, 3, 6, 9 and 12 months. RESULTS: At baseline, 755 patients reported EQ-5D pain categories; 384 (50.9%) reported moderate-to-extreme pain. Controlling for baseline depression, a linear regression model showed that the presence of pain at baseline was associated with poorer depression outcomes at 3 months mean difference=-1.16, (95% CI 0.12 to 2.2). Participants with moderate-to-extreme pain at baseline did better at 3 months if they received acupuncture (mean reduction in Patient Health Questionnaire 9 (PHQ-9) from baseline=6.0, 95% CI 5.0 to 7.1 and a mean reduction in SF-36 bodily pain=11.2, (95% CI 7.1 to 15.2) compared to improvements for those who received counselling (4.3, 95% CI 3.3 to 5.4; 7.6, 95% CI 3.6 to 11.6) or usual care (2.7, 95% CI 1.50 to 4.0: 7.2, 95% CI 2.3 to 12.1). In comparison, no notable differences were seen between treatment arms within the no pain comparator group. CONCLUSIONS: Patients with depression and pain at baseline recovered less well from treatment over 3 months than those with depression and no pain. Reductions in both depression and pain were most marked in the acupuncture group, followed by the counselling group and then the usual care group.

A critical scoping review of external uses of comfrey (Symphytum spp.).

BACKGROUND: External preparations of the herb comfrey (most commonly Symphytum officinale L.) are widely available for over-the-counter, practitioner and healthcare professional usage. Traditional practice suggests comfrey can be used to treat musculoskeletal disorders, wounds and various other conditions; however a full and critical coverage of the evidence base has not yet been undertaken. METHODS: A critical scoping review was undertaken. Six bibliographic databases, 10 grey literature databases and nine trials registers were searched plus reference lists of included studies and a descriptive overview of comfrey. Randomised or non-randomised clinical trials assessing the external use of comfrey for any indication were included and methodological and reporting quality were assessed. Observational studies were included only in the assessment of adverse events. Studies were grouped and summarised according to the type of indication treated. RESULTS: Of 1348 identified records, 64 full texts were screened for inclusion and 26 were included in the review - 13 RCTs, 5 non-randomised controlled trials and 8 observational studies evaluating treatments for ankle distortion, back pain, abrasion wounds, venous leg ulcers and osteoarthritis. The majority of included trials had an overall unclear risk of bias due to poor quality of reporting. Few adverse events were reported. CONCLUSIONS: Individual clinical trials showed evidence of benefit for ankle distortion, back pain, abrasion wounds and osteoarthritis. Topical application appears to be safe but further rigorous assessment is needed. Systematic reviews focussing on particular indications may clarify the treatment effect and safety of external comfrey preparations.

Acupuncture for Depression: Patterns of Diagnosis and Treatment within a Randomised Controlled Trial.

Background. In a large randomised controlled trial of acupuncture, counselling, or usual care for depression, we document the acupuncture intervention and explore the relationship between traditional acupuncture diagnosis and outcome. Methods. Patients who were continuing to experience depression were recruited from primary care to the ACUDep trial (n = 755). Practitioners documented for each patient the traditional Chinese medicine diagnosis, the points needled, and additional components of the treatment, such as lifestyle advice, as recommended by the STRICTA guidelines. Results. Over an 18-month period, 23 acupuncturists delivered 2741 treatments to 266 patients, an average of 10 sessions per patient. The primary and secondary zang fu syndromes were identified for 99% of patients. When combining primary and secondary diagnoses, there was a predominant Liver Qi Stagnation cluster (66% of patients) and a Spleen Deficiency cluster (34%). Practitioners sought de qi responses 96% of the time. Lifestyle advice was given to 66% of patients, most commonly dietary. When comparing patient outcomes, no significant differences were found between the two main syndrome clusters. Conclusion. In this large-scale trial, our documentation of diagnosis and treatment provides a useful snapshot of common patterns that patients present with when continuing to experience depression after consulting in primary care.

Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis.

OBJECTIVE: To compare the effectiveness of acupuncture with other relevant physical treatments for alleviating pain due to knee osteoarthritis. DESIGN: Systematic review with network meta-analysis, to allow comparison of treatments within a coherent framework. Comprehensive searches were undertaken up to January 2013 to identify randomised controlled trials in patients with osteoarthritis of the knee, which reported pain. RESULTS: Of 156 eligible studies, 114 trials (covering 22 treatments and 9,709 patients) provided data suitable for analysis. Most trials studied short-term effects and many were classed as being of poor quality with high risk of bias, commonly associated with lack of blinding (which was sometimes impossible to achieve). End of treatment results showed that eight interventions: interferential therapy, acupuncture, TENS, pulsed electrical stimulation, balneotherapy, aerobic exercise, sham acupuncture, and muscle-strengthening exercise produced a statistically significant reduction in pain when compared with standard care. In a sensitivity analysis of satisfactory and good quality studies, most studies were of acupuncture (11 trials) or muscle-strengthening exercise (9 trials); both interventions were statistically significantly better than standard care, with acupuncture being statistically significantly better than muscle-strengthening exercise (standardised mean difference: 0.49, 95% credible interval 0.00-0.98). CONCLUSIONS: As a summary of the current available research, the network meta-analysis results indicate that acupuncture can be considered as one of the more effective physical treatments for alleviating osteoarthritis knee pain in the short-term. However, much of the evidence in this area of research is of poor quality, meaning there is uncertainty about the efficacy of many physical treatments.

Iron pyrite nanocubes: size and shape considerations for photovoltaic application.

Multiple lines of recent research indicate that iron pyrite (FeS(2)) requires a {100}-terminated crystal morphology in order to maintain semiconducting properties. Additionally, the large absorption coefficient of pyrite allows for the near complete absorption of above band gap radiation in <50 nm layers. However, to our knowledge <50 nm pyrite nanocubes have yet to be isolated. Herein, we demonstrate the synthesis of ~37 nm phase pure pyrite nanocubes by manipulating the sulfur chemical potential and ligand environment of the system. Ultraviolet-visible (UV-vis) absorption spectroscopy gives a signal of resonant light scattering indicating strong electronic coupling between nanocubes, which may allow for nanocube films with superior electron mobility. The absorption spectroscopies of cubic and irregular nanocrystals are contrasted and compared with recent theoretical work in order to investigate the effect of shape on electronic properties. Specifically, nanocubes have been found to have absorption characteristics closer to theory as compared to irregular nanocrystals, especially for UV radiation: 250-350 nm. Pyrite nanocubes display an indirect band gap at ~1.1 eV in addition to two direct transitions at ~1.9 and ~3.0 eV, correlating well to theoretical values.

Costs and consequences of acupuncture as a treatment for chronic pain: a systematic review of economic evaluations conducted alongside randomised controlled trials.

BACKGROUND: The economic burden that chronic pain conditions impose on individuals and society is significant. Acupuncture appears to be a clinically effective treatment for some chronic pain conditions. Given the need for policy decisions to be informed by economic evaluations, the objective of this systematic review was to synthesise data from economic evaluations to determine whether acupuncture for the treatment of chronic pain conditions is good value for money. METHODS: A literature search was conducted using health and economics databases, with additional hand-searching. Economic evaluations conducted alongside randomised controlled trials were eligible. RESULTS: Eight economic evaluations were included in this review, seven cost-utility analyses and one cost-effectiveness analysis. Conditions treated included low back pain, neck pain, dysmenorrhoea, migraine and headache, and osteoarthritis. From the seven cost-utility analyses, acupuncture was found to be clinically effective but cost more. The cost per quality adjusted life year (QALY) gained ranged from £2527 to £14,976 per QALY, below the commonly quoted threshold used by the UK National Institute for Health and Clinical Excellence of £20,000 to £30,000. The one cost-effectiveness study indicated that there might be both clinical benefits and cost savings associated with acupuncture for migraine. There was heterogeneity across the eight trials in terms of professional who provided the acupuncture, style of acupuncture, and country of origin. CONCLUSION: The cost per QALY gained in all seven cost-utility studies was found to be below typical thresholds of willingness to pay. Acupuncture appears to be a cost-effective intervention for some chronic pain conditions.

An aerolysin-like enterotoxin from Vibrio splendidus may be involved in intestinal tract damage and mortalities in turbot, Scophthalmus maximus (L.), and cod, Gadus morhua L., larvae.

Vibrio splendidus is a pathogen that can cause major losses during the early stages of larval turbot rearing when live feed (rotifers or Artemia) is used. As haemolytic bacteria have often been associated with larval rearing losses, we studied the role of the V. splendidus haemolysin in infection of larvae. From a bank of over 10,000 transposon mutants of V. splendidus, two different types of haemolysin-negative mutants were obtained. Both had lost virulence for larval fish, and immunohistochemistry showed that the transposon mutant studied colonized the turbot larval intestinal tract at a similar level to the wild-type organism but did not cause damage or signs of enteritis found with the wild-type organism. One transposon insertion site was located within a gene with high homology to aerolysin, the cytolytic toxin produced by several Aeromonas spp. The haemolysin, which we have termed vibrioaerolysin, had properties similar to aerolysin and osmotic protection studies showed that it formed pores in the membranes of erythrocytes of similar diameter to those of aerolysin. The Tn10 insertion site of the second transposon mutant was in an adjacent ToxR-like gene, suggesting that this might control expression of the vibrioaerolysin. The gastroenteritis caused by Aeromonas spp. in humans is considered to be due to production of aerolysin causing cyclic AMP-dependent chloride secretion in cells of the gastrointestinal tract. Damage to the intestinal tract of marine fish larvae could occur in a similar way, and it is possible that several Vibrio spp. found in the developing bacterial flora of the larval fish gut can secrete aerolysin-like toxins leading to death of larvae in the early rearing stages. Routine bacteriological screening on blood agar plates of live feed is recommended with measures to reduce the concentrations of haemolytic bacteria in rearing systems.

Acupuncture in practice: mapping the providers, the patients and the settings in a national cross-sectional survey.

Background There is relatively limited knowledge about the practitioners who provide acupuncture treatment within the UK, what conditions patients consult for and the treatment provided. Objectives To characterise the conditions treated and by whom, to examine characteristics of the treatment and to explore trends over time. Method A cross-sectional survey of the UK acupuncture practitioners was conducted; 800 practitioners were selected by computer-generated randomisation sequences from the four major UK-based professional associations. Data collected on the practitioners included demographic details, association membership, statutorily regulated status, practice setting, style of acupuncture, diagnostic methods and needle response sought. Practitioners recorded details of their 10 most recent patients, including demographic details, primary reason for consulting and lifestyle advice provided. Results 330 practitioners responded comprising doctors (29%) physiotherapists (29%), nurses (15%) and independent acupuncturists (27%): 62% were women with median age of 48 years. The majority (68%) practiced in independent settings and 42% practiced within the National Health Service. Patients most commonly consulted for low back, neck, shoulder and knee pain, as well as headaches and migraine. Treatment for infertility by independent acupuncturists was found to have increased fivefold in 10 years. Conclusion Acupuncture provides a substantial contribution to the healthcare of the UK, with an estimated 4 million sessions provided annually. The primary complaints for which patients consult reflect the growing evidence base on acupuncture for these conditions. These data provide a basis for decision-making regarding policy and practice.

The effect of temperature on the bacterial load and microbial composition in Norway lobster (Nephrops norvegicus) tail meat during storage.

AIMS: The aim of this study was to update and extend our knowledge of the bacterial load and microbial composition in Norway lobster (Nephrops norvegicus) under commercially relevant storage conditions to optimize handling procedures. METHODS AND RESULTS: Total viable counts were performed at different storage temperatures (0, 4, 8, 10, 12 or 16°C) and after different storage times (1-7 days). Storage at 16°C was found to be most detrimental, and storage at 0°C was found to be optimal. 16S-rRNA sequencing was utilized to determine the composition of the bacteria within the microflora. In this way, Photobacterium isolates, especially Photobacterium phosphoreum, were identified as the main specific spoilage organisms. The abilities to reduce trimethylamineoxide (TMAO) and to produce H(2)S were analysed in a selection of bacterial isolates. The higher the incubation temperature during storage, the more isolates were found to reduce TMAO and produce H(2)S. CONCLUSIONS: Nephrops norvegicus possesses an unusually high initial microbial load when fresh. Storage temperature is the most crucial factor affecting microbial growth, microbial activity and spoilage potential in N. norvegicus produce. Spoilage can be attributed mainly to P. phosphoreum. SIGNIFICANCE AND IMPACT OF THE STUDY: This study presents significant new findings with regard to the progression and causative agents of spoilage in N. norvegicus. Based on the results, we can recommend that N. norvegicus tails should be stored in a 0°C environment immediately after catch. Stored this way, the growth and spoilage activity of the microflora may be reduced significantly and an extension of shelf life might be attained.

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 at3 months reactions that they had experienced at anytime 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.

Non-cardiac chest pain: a retrospective cohort study of patients who attended a Rapid Access Chest Pain Clinic.

BACKGROUND: Rapid Access Chest Pain Clinics have recently been introduced to assist in the management of primary care patients experiencing suspected cardiac chest pain. OBJECTIVE: To study the longer term outcome for patients referred to a Rapid Access Chest Pain Clinic and then given a non-cardiac diagnosis. METHODS: The study collected retrospective data from a cohort of all patients attending the Rapid Access Chest Pain Clinic based in the cardiorespiratory Department at the York District Hospital, England. Questionnaires were sent to all patients who attended the Rapid Access Chest Pain Clinic during the previous 14 months and were diagnosed with non-cardiac chest pain. Participants reported on their chest pain, subsequent episodes of primary and secondary care and their beliefs about causation of pain. RESULTS: Of the patients referred to the Rapid Access Chest Pain Clinic, 235 (52%) did not have cardiac chest pain. Of these patients, 161 (69%) returned the questionnaire, nearly half of whom reported ongoing chest pain. The mean time since Clinic attendance was approximately 8 months and the median duration of ongoing chest pain was 5.4 months. Women were twice as likely as men to continue to be experiencing pain but did not report more frequent or severe pain on average. More than 50% of the non-cardiac group were not convinced by their negative cardiac diagnosis. CONCLUSION: There is an ongoing challenge to support patients with non-cardiac chest pain, including the provision of reassurance that their pain is very unlikely to be caused by their heart.

Vaccine-associated systemic Rhodococcus erythropolis infection in farmed atlantic salmon Salmo salar.

In 7 instances between 2000 and 2003, clinical investigation of populations of fresh- and seawater-reared, vaccinated, Atlantic salmon Salmo salar suffering total losses of between 0.1 and 35 % revealed infection with a Gram-positive rod-shaped bacterium. The isolations were geographically widespread, occurring in both Norway and Scotland. In all cases, a Gram-positive bacterium, subsequently identified as Rhodococcus erythropolis, was isolated in pure culture. Infections, although systemic, were focused within the peritoneal cavity. While initial attempts to reproduce the disease by intraperitoneal injection of unvaccinated Atlantic salmon failed, Koch's postulates were subsequently fulfilled in fish vaccinated with a commercially available oil-adjuvanted vaccine.

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].