Treatment-Seeking Behaviors of Persons With Rheumatoid Arthritis

PURPOSE

Describe perceptions of patients with rheumatoid arthritis (RA) regarding disease-related pain, tendency to tell others about their pain, and treatments used since diagnosis.

DESIGN

Cross sectional, exploratory.

METHOD

A total of 63 participants responded to telephone interview about their treatments and tendency to tell others about their RA pain. They also responded to McGill Pain Questionnaire and Health Assessment Questionnaire (HAQ) items. Participants marked pain location on mailed body outlines.

FINDINGS

RA diagnosis occurred an average of 11 years prior. Mean HAQ Standard Disability Index score was 1.26. Previous week symptoms were joint pain (97%), joint swelling (83%), decreased movement/function (83%), fatigue (70%), muscle weakness (65%). Mean morning stiffness duration was 120 ± 137 minutes. Mean pain intensity was 1.15 ± 0.6 at its least and 3.8 ± 1.1 at its worst. 65% were not satisfied with pain levels. 57% stated a tendency not to tell others about their pain; 43% tended to tell. 78% used medications and alternative therapies, none solely used alternative therapies, and 22% only used medications.

CONCLUSIONS

RA patients reported high rates of alternative therapy use. Dissatisfaction with pain levels indicates need for improved pain management. Not talking about pain lends insights into the importance of teaching patients to communicate their pain to others.

136 IMPACT OF SELECTION SYSTEM BY KINETICS ON THE EARLY EMBRYONIC DEVELOPMENT IN BOVINE OVUM PICKUP-IVF EMBRYOS

Recently, in vitro-produced (IVP) embryos have been increasingly produced using ovum pickup (OPU) and IVF in cows worldwide. However, the conception rate of IVP embryos is lower than that of in vivo-derived embryos. This study was conducted to determine the proportion of embryos that led to a high conception rate when the embryos were selected according to the 4 predicting factors. A total of 30 Holstein and 20 Japanese Black cows were used, and 81 OPU-IVF sessions were performed from October 2014 to May 2016. The collected cumulus-oocyte complexes (COC) were cultured for 22 h. Capacitated sperm (at a final concentration of 5 × 106 spermatozoa/mL) were incubated with COC for 6 h. After insemination, presumptive zygotes were separated from cumulus cells and sperm by pipetting. Then, the presumptive zygotes were cultured for 9 days in CR1aa supplemented with 5% calf serum by using a micro-well culture dish (Dai Nippon Printing, Tokyo, Japan). The kinetics of embryo development was observed at 27, 31, and 55 h post-insemination (hpi). The 4 factors used to select embryos were as follows: (1) time at which first cleavage occurred (less than 27 hpi, or less than 31 hpi, in case any of the zygotes did not cleave at 27 hpi in each culture dish); (2) 2 blastomeres after first cleavage at 31 hpi; (3) absence of fragments after first cleavage at 31 hpi; and (4) 8 or more blastomeres at 55 hpi. The number of blastocysts was analysed at 7, 8, and 9 days post IVF. Additionally, the number of produced embryos that could be used for embryo transfer (ET) was determined. The data were analysed using the chi-square test. The total numbers of blastocysts and produced embryos were 615 and 503, respectively. The numbers of blastocysts and produced embryos selected using the combination of factors 1 to 4 were 200 (32.5%) and 169 (27.5%), respectively. The numbers of blastocysts and produced embryos selected using factor 1 were 397 (64.6%) and 340 (67.6%), using factor 2 were 445 (71.3%) and 378 (75.1%), using factor 3 were 364 (81.8%) and 307 (81.2%), and using factor 4 were 374 (60.8%) and 308 (61.2%), respectively. The numbers of blastocysts and produced embryos that were rejected using a combination of factors 1 to 4 were 123 (27.5%) and 90 (17.9%), respectively. The conception rate of fresh embryo transfer was 46.6% (n = 73). We found that the conception rate of the embryos selected using factors 1 to 4 was significantly (P < 0.05) higher than that of embryos without one factor or more [60.0% (n = 35) v. 29.4% (n = 34)]. These results show the applicability and efficiency of the 4 factors for producing embryos with a high competence for conception.

49 SUCCESSFUL CRYOPRESERVATION USING LOW ETHYLENE GLYCOL CONCENTRATION FOR IN VITRO-PRODUCED BOVINE EMBRYOS

In vitro-produced (IVP) bovine embryos tend to have a lower survival rate after cryopreservation than in vivo embryos do. Therefore, the freezing medium (FM) and concentration of cryoprotectant are very important factors. This study was to investigate the effect of 1.2 M ethylene glycol (EG) with 0.1 M sucrose (SUC) on survival of IVP embryos after freezing. The COC were matured in 25 mM HEPES-buffered TCM199 (TCM199) supplemented with 5% calf serum (CS) and 0.02 AU mL−1 FSH. Oocytes (20 to 25) were cultured in 100-μL droplets of maturation medium for 20 h. After 6 h of gamete co-culture (5 × 106 sperm/mL), the presumptive zygotes were cultured in CR1aa medium supplemented with 5% CS for 9 days (fertilization = Day 0). Only the expanded blastocysts from Days 7 to 9 were used in this experiment and separated into 3 treatment groups. The first and second groups were frozen in Dulbecco’s phosphate-buffered saline (D-PBS) supplemented with 20% CS, 0.1 M SUC, and 1.2 or 1.5 M EG (groups 1.2 or 1.5 M EG), respectively. The third group was D-PBS supplemented with 20% fetal calf serum (FCS), 0.25 M SUC, and 1.4 M glycerol (group GLY). In each group, embryos were equilibrated with their FM for 10 min and loaded into 0.25-mL straws individually. These straws were placed into the cooling chamber of a programmable freezer precooled to −7°C. After 2 min, the straws were seeded and then held for a further 13 min at −7°C. Then, the straws were cooled to −30°C at −0.3°C/min before being plunged into liquid nitrogen. The cryopreserved embryos were thawed by allowing the straws to stand in air for 7 s and then warming them in a 30°C water bath for 20 s. The thawed embryos were washed twice using 38°C D-PBS supplemented with 20% FCS. Subsequently, they were immersed in the same medium, held at 38°C for 10 min, and then each embryo was cultured in 20-μL droplets of TCM199 supplemented with 20% FCS and 0.1 mM β-mercaptoethanol for 72 h. The rates of embryos developing to the re-expanded and hatching blastocyst stages were determined 72 h after thawing. All data were analysed by the chi-squared test with Yates’ correction. The re-expanded and hatching rates of frozen-thawed embryos after 72 h in culture were not significantly different between 1.2 M EG (n = 39: 71.8% and 69.2%), 1.5 M EG (n = 38: 76.3% and 63.2%), and 1.4 M GLY (n = 37: 75.7% and 64.9%) groups (P > 0.05). Survival and hatching rates according to embryo quality were also not significantly different between 1.2 M EG (good n = 18: 88.9% and 88.9%; fair n = 21: 57.1% and 52.4%), 1.5 M EG (good n = 19: 89.5% and 84.2%; fair n = 19: 63.2% and 42.1%), and 1.4 M GLY (good n = 18: 77.8% and 66.7%; fair n = 19: 73.7% and 63.2%) (P > 0.05). In conclusion, cryoprotectant type and concentration did not affect embryo survival or development after cryopreservation in this study. Therefore, the ethylene glycol concentration used for the cryopreservation of IVP embryos can be reduced.

Acupuncture and Acupressure in Labor

Acupuncture and acupressure, 2 modalities of Traditional Chinese Medicine, are based on reducing pain and symptoms of disease through balancing yin and yang. Acupuncture and acupressure have been used in China for reduction of labor pain, labor augmentation, and other intrapartum indications for more than 2 millennia. This article presents a review of the current literature that has addressed the effects of acupuncture and acupressure on intrapartum events. Studies of acupuncture have demonstrated that acupuncture may reduce labor pain, the use of pharmacologic agents, the use of forceps and vacuum-assisted births, and the length of labor. Studies that examined the effect of acupuncture on labor that is induced or augmented for premature rupture of membranes have found that acupuncture may increase the degree of cervical ripening but does not reduce the amount of oxytocin or epidural analgesia administration, nor does it shorten length of induced labor. Acupressure may reduce labor pain and labor duration, but acupressure has not been found to increase cervical ripening or induce labor. There are insufficient studies about acupuncture and acupressure and their effects on labor at this time, and there is need for further research. Areas of uncertainty include efficacy, optimal point selection, best techniques, and length of time for point stimulation.

164 EFFECTS OF KINETICS AND MORPHOLOGY ON EARLY EMBRYONIC DEVELOPMENT IN BOVINE OPU-IVF EMBRYOS

In recent years, the use of ovum pick up (OPU) and IVF for embryo production has increased worldwide; however, the conception rate of embryo transfer is lower for OPU-IVF embryos than for in vivo-derived embryos. This study aimed to determine the efficacy of embryo selection by a 3-step observation method by using a micro-well culture dish (Dai Nippon Printing, Tokyo, Japan). In this study, 9 Holstein and 15 Japanese Black cows were used, and the OPU-IVF was conducted from October 2014 to May 2015. The collected cumulus-oocyte complexes (COC) were cultured for 22 h in 25 mM HEPES-buffered TCM-199 supplemented with 5% calf serum (CS) and 0.02 AU mL–1 of FSH. Sperm (at a final concentration of 5 × 106 spermatozoa mL–1) were incubated with COC for 6 h. After insemination, presumptive zygotes were separated from cumulus cells and sperm by pipetting. Then, the presumptive zygotes were cultured for 9 days in CR1aa supplemented with 5% CS by using a micro-well culture dish. Kinetics and morphology were observed at 27, 31, and 55 h post-insemination (hpi). The presumptive zygotes were divided to 3 groups (more than 2 cells, 2 cells, and no cleavage) at 27 and 31 hpi. Then, embryos at the 2-cell stage at 31 hpi were divided into 2 groups: 2-cell with normal cleavage and 2-cell embryos with abnormal cleavage (unequal cleavage, 2-cell with fragments, and 2-cell with protrusion). Subsequently, embryos were classified as 8-cell and more than 8 cell, or less than 8 cell at 55 hpi. The blastocyst rate (BL%) was analysed at 7, 8, and 9 days post IVF. Embryos selected by the 3-step observation method were used for fresh embryo transfer. The data were analysed by chi-squared test. In total, 856 oocytes were collected by OPU and 633 oocytes were cultured, of which 39.7% (263/663) developed to the blastocyst stage. The BL% of 2-cell embryos (72.5%, 116/160) was significantly higher (P < 0.01) than that of no cleavage (47.0%, 117/249) at 27 hpi. The BL% of 2-cell (65.4%, 206/315) and more than 2-cell (53.0%, 35/66) was significantly higher (P < 0.01 and P < 0.05) than that of embryos divided as no cleavage (25.9%, 22/85) at 31 hpi. The BL% was not significantly different between 2-cell with normal cleavage (68.5%, 172/251) and abnormal cleavage (53.1%, 34/64). The BL% of 8-cell and more than 8-cell stage (72.8%, 182/250) was significantly higher (P < 0.01) than that of embryos with less than 8 cells (38.8%, 81/209) at 55 hpi. Overall, 2-cell embryos at 27 hpi, 2-cell embryos with normal cleavage at 31 hpi, and 8-cell and more than 8 cell at 55 hpi showed the highest BL% (82.1%, 78/91). The conception rate was higher for following the selected fresh embryo transfer that was 70.6% (12/17) than average of in vitro fertilization embryos transfer that was 40.0%. These results demonstrate that the 3-step observation method used in this study can be effectively applied for the selection of IVF embryos that have a strong ability to develop into blastocysts and high competence for conception.

Can acupuncture treatment be double-blinded? An evaluation of double-blind acupuncture treatment of postoperative pain

Blinding protects against bias but the success of blinding is seldom assessed and reported in clinical trials including studies of acupuncture where blinding represents a major challenge. Recently, needles with the potential for double-blinding were developed, so we tested if acupuncture can be double-blinded in a randomized study of sixty-seven patients with acute pain ≥ 3 (0-10 scale following third molar removal) who received active acupuncture with a penetrating needle or placebo acupuncture with a non-penetrating needle. To test if acupuncture was administered double-blind, patients and acupuncturists were asked about perceived treatment allocation at the end of the study. To test if there were clues which led to identification of the treatment, deep dull pain associated with needle application and rotation (termed “de qi” in East Asian medicine), and patients’ pain levels were assessed. Perceived treatment allocation depended on actual group allocation (p < 0.015) for both patients and acupuncturists, indicating that the needles were not successful in double-blinding. Up to 68% of patients and 83% of acupuncturists correctly identified the treatment, but for patients the distribution was not far from 50/50. Also, there was a significant interaction between actual or perceived treatment and the experience of de qi (p = 0.027), suggesting that the experience of de qi and possible non-verbal clues contributed to correct identification of the treatment. Yet, of the patients who perceived the treatment as active or placebo, 50% and 23%, respectively, reported de qi. Patients’ acute pain levels did not influence the perceived treatment. In conclusion, acupuncture treatment was not fully double-blinded which is similar to observations in pharmacological studies. Still, the non-penetrating needle is the only needle that allows some degree of practitioner blinding. The study raises questions about alternatives to double-blind randomized clinical trials in the assessment of acupuncture treatment.

242 PROMISING TWO-STEP EVALUATION SYSTEM FOR SELECTING HIGH DEVELOPMENTAL COMPETENCE IN VITRO FERTILIZED EMBRYOS IN CATTLE USING WELL-OF-THE-WELL DISH

Bovine IVF embryos are evaluated morphologically using light microscopy just before transfer. However, this evaluation method is subjective, and an objective method with more certainty is needed. Sugimura et al. (PLoS ONE 2012 7, e36627) reported a promising system for selecting healthy IVF bovine embryo by using time-lapse cinematography and 5 prognostic factors. This study was to investigate the efficacy of a 2-step evaluation system of IVF embryos using microscopy for selecting high developmental competence IVF embryos. Cumulus-oocyte complexes (COC) were collected by ovarian follicular aspiration (2 to 5 mm diameter) obtained from a local abattoir. The COC (n = 488) were matured in TCM-199 medium supplemented with 5% calf serum (CS) and 0.02 IU mL–1 of FSH at 38.5°C for 20 h in an atmosphere of 5% CO2 (20 COC 100 µL–1 droplets). After 10 h of gametes co-culture (5.0 × 106 sperm cells mL–1), the presumptive zygotes were cultured in 125 µL of CR1 aa medium supplemented with 5% CS in well of-the-well culture dishes (AS ONE, Japan; 25 zygotes well–1) at 38.5°C in an atmosphere of 5% CO2, 5% O2, and 90% N2 for 9 days. Two-step evaluations of embryos were done at 27 and 55 h post-IVF (hpi). In the first step of evaluation, cleavage patterns at 27 hpi were categorized as mono-cell, 2-cell with even blastomeres and without fragments (normal cleavage), 2-cell with uneven blastomeres, and ≥3 blastomeres. During the second step of evaluation, embryos were classified by their number of blastomeres (2 to 5 cells, 6 to 8 cells, and >8 cells) and the absence or presence of multiple fragments (<20 or >20%) at 55 hpi. The data were analysed by chi-square test. The blastocyst rate (BL%) of embryos cleaved before 27 hpi (56.6%, n = 106) was higher (P < 0.01) than those of embryos cleaved after 27 hpi (37.0%, n = 235). A greater percentage (P < 0.05) of 2-cell embryos with normal cleavage (68.0%, n = 50) developed to blastocysts than from with =3 blastomeres at 27 hpi (40.6%, n = 32). Superior BL% (P < 0.01) was obtained from embryos categorized as 6- to 8-cell stage (58.6%, n = 140) and >8 cell stage (70.6%, n = 25) compared with those embryos at the 2- to 5-cell stage at 55 hpi (26.1%, n = 176). Embryos with no fragments (58.0%, n = 467) had higher BL% (P < 0.01) compared with those with <20% fragments (30.7%, n = 127) and having with >20% fragments (17.5%, n = 25) at 55 hpi. The highest of BL% was observed in embryos showing a normal cleavage to 2-cells with at 27 hpi and having >6 cells with no fragments at 55 hpi (95.2%, n = 21, P < 0.01). These results demonstrate that the 2-step evaluation system at 27 and 55 hpi using microscopy is an effective method for selecting IVF embryos with high developmental competence.

The Potential of Double Blinding with Two Placebo Acupuncture Needles: A Randomized Controlled Pilot-Trial

Background: Whether acupuncture treatment employing multiple penetrating, skin-touch placebo, or no-touch placebo needles designed for double blinding actually do blind practitioners and patients has not been investigated. We aimed to investigate this question. Subjects: 120 patients with functional neck/shoulder stiffness but in otherwise healthy condition were randomly assigned to a treatment using four penetrating, four skin-touch placebo, or four no-touch placebo needles. Each of six acupuncturists applied four needles to four acupoints in the neck/shoulder of 20 patients. Acupuncturists and patients were asked to guess the treatment mode and their confidence in their guesses on 100 mm visual analog scales. Results: The kappa coefficients between practitioner guesses and treatment type and between patient guesses and treatment type were 0.15 and 0.44, respectively. The median score of practitioner confidence was 46.8, and no significant difference in confidence between correct and incorrect guesses was revealed for any treatment. The median score of patient confidence for correct guesses was 77.6. The kappa coefficient between practitioner and patient guesses was 0.06. Conclusions: The practitioners were blinded to the nature of treatment using the same multiple needles, but patient blinding was insufficient. Further improvement is necessary to achieve satisfactory patient blinding with these acupuncture needles.

Assessing Blood Flow in an Intracranial Stent: A Feasibility Study of MR Angiography Using a Silent Scan after Stent-Assisted Coil Embolization for Anterior Circulation Aneurysms

BACKGROUND AND PURPOSE

Blood flow in an intracranial stent cannot be visualized with 3D time-of-flight MR angiography owing to magnetic susceptibility and radiofrequency shielding. As a novel follow-up tool after stent-assisted coil embolization, we applied MRA by using a Silent Scan algorithm that contains an ultrashort TE combined with an arterial spin-labeling technique (Silent MRA). The purpose of this study was to determine whether Silent MRA could visualize flow in an intracranial stent placed in the anterior circulation.

MATERIALS AND METHODS

Nine patients treated with stent-assisted coil embolization for anterior circulation aneurysms underwent MRAs (Silent MRA and TOF MRA) and x-ray digital subtraction angiography. MRAs were performed in the same session on a 3T unit. Two neuroradiologists independently reviewed the MRA images and subjectively scored flow in a stent as 1 (not visible) to 4 (excellent) by referring to the latest x-ray digital subtraction angiography image as a criterion standard.

RESULTS

Both observers gave MRA higher scores than TOF MRA for flow in a stent in all cases. The mean score for Silent MRA was 3.44 ± 0.53, and for TOF MRA, it was 1.44 ± 0.46 (P < .001).

CONCLUSIONS

Silent MRA was able to visualize flow in an intracranial stent more effectively than TOF MRA. Silent MRA might be useful for follow-up imaging after stent-assisted coil embolization, though these study results may be only preliminary due to some limitations.

Denture wearing during sleep doubles the risk of pneumonia in the very elderly

Poor oral health and hygiene are increasingly recognized as major risk factors for pneumonia among the elderly. To identify modifiable oral health-related risk factors, we prospectively investigated associations between a constellation of oral health behaviors and incident pneumonia in the community-living very elderly (i.e., 85 years of age or older). At baseline, 524 randomly selected seniors (228 men and 296 women; mean age, 87.8 years) were examined for oral health status and oral hygiene behaviors as well as medical assessment, including blood chemistry analysis, and followed up annually until first hospitalization for or death from pneumonia. During a 3-year follow-up period, 48 events associated with pneumonia (20 deaths and 28 acute hospitalizations) were identified. Among 453 denture wearers, 186 (40.8%) who wore their dentures during sleep were at higher risk for pneumonia than those who removed their dentures at night (log rank P = 0.021). In a multivariate Cox model, both perceived swallowing difficulties and overnight denture wearing were independently associated with an approximately 2.3-fold higher risk of the incidence of pneumonia (for perceived swallowing difficulties, hazard ratio [HR], 2.31; and 95% confidence interval [CI], 1.11-4.82; and for denture wearing during sleep, HR, 2.38; and 95% CI, 1.25-4.56), which was comparable with the HR attributable to cognitive impairment (HR, 2.15; 95% CI, 1.06-4.34), history of stroke (HR, 2.46; 95% CI, 1.13-5.35), and respiratory disease (HR, 2.25; 95% CI, 1.20-4.23). In addition, those who wore dentures during sleep were more likely to have tongue and denture plaque, gum inflammation, positive culture for Candida albicans, and higher levels of circulating interleukin-6 as compared with their counterparts. This study provided empirical evidence that denture wearing during sleep is associated not only with oral inflammatory and microbial burden but also with incident pneumonia, suggesting potential implications of oral hygiene programs for pneumonia prevention in the community.

Design of a randomised acupuncture trial on functional neck/shoulder stiffness with two placebo controls

Background

Functional neck/shoulder stiffness is one of the most well-known indications for acupuncture treatment in Japan. There is little evidence for the effectiveness of acupuncture treatment for functional neck/shoulder stiffness. Research using two different placebos may allow an efficient method to tease apart the components of real acupuncture from various kinds of ‘non-specific’ effects such as ritual with touch or ritual alone. Herein, we describe a protocol of an ongoing, single-centre, randomised, placebo-controlled trial which aims to assess whether, in functional neck/shoulder stiffness, acupuncture treatment with skin piercing has a specific effect over two types of placebo: skin-touching plus ritual or ritual alone.

Methods

Six acupuncturists and 400 patients with functional neck/shoulder stiffness are randomly assigned to four treatment groups: genuine acupuncture penetrating the skin, skin-touch placebo or no-touch placebo needles in a double-blind manner (practitioner-patient blinding) or no-treatment control group. Each acupuncturist applies a needle to each of four acupoints (Bladder10, Small Intestine14, Gallbladder21 and Bladder42) in the neck/shoulder to 50 patients. Before, immediately after and 24 hours after the treatment, patients are asked about the intensity of their neck/shoulder stiffness. After the treatment, practitioners and patients are asked to guess whether the treatment is “penetrating”, “skin-touch” or “no-touch” or to record “cannot identify the treatment”.

Discussion

In addition to intention-to-treat analysis, we will conduct subgroup analysis based on practitioners’ or patients’ guesses to discuss the efficacy and effectiveness of treatments with skin piercing and various placebo controls. The results of practitioner and patient blinding will be discussed. We believe this study will further distinguish the role of different components of acupuncture.

Trial registration

Current Controlled Trial ISRCTN76896018

Inhibitory Effect of Acupuncture on Vibration-Induced Finger Flexion Reflex in Humans: Comparisons Among Radial, Median, and Ulnar Nerve Stimulation

BACKGROUND

Vibration-induced finger flexion reflex (VFR) is inhibited with acupuncture to TE 5 or LI 4 at the skin innervated by the radial nerve.

OBJECTIVE

The aim of this study was to determine if acupoints in regions innervated by the radial nerve are specific to inhibit VFR.

MATERIALS AND METHODS

This experiment was performed using a crossover design with 3 acupuncture groups (needle insertion to the right LU 11, PC 9, or SI 1) and a control group (no needle treatment). Each acupoint was randomly needled on separate days. Ten healthy volunteers were recruited for this study. VFR was induced by applying vibration on the volar side of the right middle fingertip. An acupuncture needle was inserted in the acupoint and retained for 5 minutes. For the main outcome measure, maximum finger flexion force (MFFF) was measured during vibration and was compared among four groups.

RESULTS

MFFFs in the acupuncture groups were significantly lower (p<0.05) than that in the control group. However, no significant difference was observed in MFFFs in the three intervention groups after acupuncture to LU 11, PC 9, and SI 1.

CONCLUSIONS

Acupuncture to the right LU 11, PC 9, or SI 1 point inhibited the ipsilateral VFR, which suggests that afferent inputs from the radial nerve with needle insertion were not specific, compared with those from the median and ulnar nerves to suppress neuronal activities in the VFR reflex circuits.

Specifying the nonspecific components of acupuncture analgesia

It is well known that acupuncture has pain-relieving effects, but the contribution of specific and especially nonspecific factors to acupuncture analgesia is less clear. One hundred one patients who developed pain of ≥ 3 on a visual analog scale (VAS, 0 to 10) after third molar surgery were randomized to receive active acupuncture, placebo acupuncture, or no treatment for 30 min with acupuncture needles with potential for double-blinding. Patients' perception of the treatment (active or placebo) and expected pain levels (VAS) were assessed before and halfway through the treatment. Looking at actual treatment allocation, there was no specific effect of active acupuncture (P=.240), but there was a large and significant nonspecific effect of placebo acupuncture (P<.001), which increased over time. Interestingly, however, looking at perceived treatment allocation, there was a significant effect of acupuncture (P<.001), indicating that patients who believed they received active acupuncture had significantly lower pain levels than those who believed they received placebo acupuncture. Expected pain levels accounted for significant and progressively larger amounts of the variance in pain ratings after both active and placebo acupuncture (up to 69.8%). This is the first study to show that under optimized blinding conditions, nonspecific factors such as patients' perception of and expectations toward treatment are central to the efficacy of acupuncture analgesia and that these factors may contribute to self-reinforcing effects in acupuncture treatment. To obtain an effect of acupuncture in clinical practice, it may therefore be important to incorporate and optimize these factors.

Association of marine-origin n-3 polyunsaturated fatty acids consumption and functional mobility in the community-dwelling oldest old

OBJECTIVE

To examine whether habitual dietary intake of marine-origin n-3 polyunsaturated fatty acids (MOPUFA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are associated with functional mobility in the community-dwelling oldest old, 85 years or older, who are at high risk for physical disability.

DESIGN

A cross-sectional study.

SETTING

A community-based survey conducted at university research center or home-based.

PARTICIPANTS

Four hundred seventeen (189 men, 228 women) out of 542 participants in the baseline examination of the Tokyo Oldest Old Survey on Total Health, a community-based ongoing longitudinal study among the oldest old living in the center of Japan.

MEASUREMENTS

Habitual dietary intake of MOPUFA was assessed by the brief-type self-administered diet history questionnaire (BDHQ), and functional mobility was assessed by the timed up and go test. Plasma inflammatory biomarkers (C-reactive protein, interleukin-6 and tumor necrosis factor-α) were measured. We evaluated the cross-sectional association between habitual intake of MOPUFA and functional mobility using multivariate logistic regression analysis. Prior to the analysis, validation of BDHQ in this study was confirmed among 190 participants (96 men, 94 women) based on the EPA and DHA concentrations in the erythrocyte membrane phospholipids as reference.

RESULTS

Moderate correlation between estimated dietary intake of EPA/DHA and concentration of EPA/DHA in the erythrocyte membrane phospholipids was obtained (Spearman's r=0.29-0.58, p<0.01). Multivariate logistic regression analysis revealed that a lower habitual intake of EPA+DHA was significantly associated with poor functional mobility in men but not in women (OR (95% CI) per 1 SD increase of EPA+DHA intake; 0.55 (0.33-0.91), 0.88 (0.59-1.32), men and women respectively).

CONCLUSIONS

Habitual intake of MOPUFA was associated with functional mobility in community-dwelling oldest old men.

Tapping-in method (skin penetration technique) with a placebo needle for double-blind acupuncture trials

OBJECTIVES

This study investigated the effect of acupuncture needles developed for double-blind (practitioner-patient blinding) trials employing a tapping-in method that is commonly used to penetrate the skin in Japanese-style acupuncture. DESIGN, SUBJECTS, AND INTERVENTIONS: An acupuncturist applied a penetrating, a skin-touch placebo, and a no-touch control needle designed to blind both practitioners and patients in the forearm in 80 healthy subjects (patients) by tapping-in method.

SETTING

The setting was a practice room of the Japan School of Acupuncture, Moxibustion and Physiotherapy, Tokyo, Japan.

OUTCOME MEASURES

The outcome measures were the acupuncturist's and subjects' guesses at the type of needles and confidence of their guesses on a 100-mm visual analogue scale (VAS). The subjects were asked about pain with needle application.

RESULTS

The number of correct/incorrect guesses (the latter including unidentified) of the acupuncturist were 73/167 with a confidence of 55.2 ± 16.9 (mean ± standard deviation) on the VAS. The subjects identified 148 needles correctly and 92 needles incorrectly, the mean confidence being 71.0 ± 28.4. There were a few penetrating and skin-touch placebo needles that the subjects guessed as "no-touch." Whereas few of the 80 no-touch control needles were guessed as "penetrating," 16% of them were guessed as "skin-touch" and 11% were reported as "unidentifiable" by the subjects. Forty percent (40%) of the penetrating needles and 50% of the skin-touch placebo needles did not elicit skin penetration pain.

CONCLUSIONS

The effect of practitioner blinding employing the needles for double blinding with the tapping-in method was satisfactory. It was difficult to blind the subjects when no-touch control needles together with penetrating and skin-touch placebo needles were used.

Double Blinding with a New Placebo Needle: A Validation Study on Participant Blinding

Background

A no-touch control needle in which the needle tip cannot reach the skin has been designed, and has been validated for practitioner blinding in a previous study but not for participant blinding.

Objective

To test whether the no-touch control needle can effectively blind subjects.

Methods

An acupuncturist applied, in turn, a no-touch control, skin-touch placebo and penetrating needle in one forearm of 80 healthy subjects. After removing each needle, the subjects were asked to judge the type of needle and rate the sensation of skin penetration/penetration-like or skin pressure/pressure-like pain on a 100 mm visual analogue scale.

Results

The subjects correctly identified 67% of needles overall. 17 of the 80 no-touch control needles were judged as skin-touch, and one as penetrating. In addition, six skin-touch placebo needles, and no penetrating needles, were judged as no-touch. Half of the 80 skin-touch placebo needles and 65 of the 80 penetrating needles and two no-touch control needles elicited pain. Of 240 needles, the practitioner identified 120 correctly that did not fit the probability of 1/3 (χ2=30.00, p<0.01).

Conclusions

The no-touch control needles may be used as a blind control for the acupuncture procedure, or to test the physiological effect of the skin-touch needles, but are not suitable for double-blind testing of the needle effect.

Immunohistochemical localization of Notch signaling molecules in ameloblastomas

We examined Notch signaling molecules, Notch1 and Jagged1, in serial large cases of typical solid/multicystic ameloblastoma. In general, Notch positive staining products were frequently detected in the cytoplasms of the cells. In the same cells, Jagged positive staining were also frequently observed, while only occasionally positive in peripheral cells, especially in cuboidal cells. The results showed that these morphogenesis regulation factors are closely related to cytological differentiation in neoplastic cells of ameloblastoma. The Notch and Jagged positive-cell ratios were frequently positive, and the ratios were nearly the same between the varied histopathological, cytological patterns. However, the less-differentiated cells were fewer in number than that of well-differentiated cells.

Changes in blood circulation of the contralateral Achilles tendon during and after acupuncture and heating

The purpose of this study was to investigate the effects of acupuncture and heating (application of hot pack) treatments on blood circulation in the contralateral Achilles tendon. During the treatments (10 min for acupuncture, 20 min for heating) and recovery period (40 min), the blood volume (THb) and oxygen saturation (StO2) of the treated and the non-treated tendons were measured using red laser lights. During both treatments, THb and StO2 of the treated tendon increased significantly from the resting level. The increased THb and StO2 of the treated tendon were maintained until the end of the recovery period after removal of the acupuncture needle, although these values decreased after removal of the hot pack. Although THb of the non-treated sides did not change during both acupuncture and heating treatments, it increased gradually after removal of the acupuncture needle or the hot pack. For both treatments, the amount of increase in THb of the non-treated tendon was significantly correlated to that of the treated tendon during the last phase of recovery period. These results obtained from the healthy subjects imply that blood circulation in the injured tendon in a plaster cast may be improved by applying acupuncture or heating treatments to the contralateral healthy limb.

Dose measurement for medical staff with glass dosemeters and thermoluminescence dosemeters during 125I brachytherapy for prostate cancer

Photoluminescence glass dosemeters (PLDs) and thermoluminescence dosemeters (TLDs) are commonly used as a personal monitoring dosemeter. PLDs and TLDs were used for surface dose monitoring of medical staff involved in (125)I brachytherapy for prostate cancer because these dosemeters have a wide dose-response linearity and high sensitivity for low photon energy. Surface doses measured with PLDs agreed with those with TLDs within ∼20 % except for a few cases. Surface doses at a surgeon's left hand and arm were higher than those at the other measuring points. A surgeon received a maximum dose of 650 μGy at the back of left hand. Surface doses to an assistant were <100 μGy. Surface doses to a nurse, a radiologist, an anaesthesiologist and a radiological technologist were <10 μGy. The occupational exposure to a surgeon could be reduced by the adjustment of fluoroscopic parameters and the use of lead gloves.

Anatomical study of the thorax for the safe performance of the Nuss procedure for pectus excavatum

BACKGROUND

To perform a minimally invasive repair for pectus excavatum safely, accurate knowledge of the anatomy of the retrosternal region is crucial. This study was carried out to provide more information on this region.

METHODS

1. Using 32 human cadavers, the vascular structure in the retrosternal region was studied. 2. The pleura, transverse thoracic ligament, pericardium, and diaphragm were taken from 10 fresh cadavers, and their thicknesses and breaking strengths were measured.

RESULTS

Thick vessels connecting the internal mammary vessels and anterosuperior phrenic vessels were present in a certain number of cadavers. This presence of a vascular communication was observed in 44 % of left thoracic cavities and 12.5 % of right thoracic cavities. The breaking strengths of the pericardium and diaphragm were found to be nearly ten times greater than that of the pleura.

CONCLUSIONS

Care should be taken not to injure vessels connecting the internal mammary vessels and anterosuperior phrenic vessels when performing retrosternal undermining of the xiphoid region. Since the pericardium is much thicker than the pleura, injury of the pericardium can be avoided by careful undermining.

Double blinding with a new placebo needle: a further validation study

BACKGROUND

The masking properties of a new, non-penetrating, double-blind placebo acupuncture needle were demonstrated. Practitioners correctly identified some of the needles; if they were confident in this opinion, they would be unblinded.

OBJECTIVE

To investigate the clues that led to correct identification, and the confidence in this decision.

METHODS

Ten acupuncture practitioners, blindly and randomly, applied 10 each of three types of needle to the shoulder: blunt, non-penetrating needles that pressed the skin ('skin-touch placebo needle'); new non-penetrating needles that penetrated soft material (stuffing) but did not reach the skin ('non-touch control needle'); matching penetrating needles. Afterwards, practitioners were asked to judge the type of needle, their confidence in their decision and what clues led them to their judgements.

RESULTS

Of the 30 judgements made by each practitioner, the mean number of correct, incorrect and unidentifiable answers were 10.4 (SD 3.7), 15.2 (SD 4.9) and 4.4 (SD 6.1), respectively. There was no significant difference in the confidence scores for 104 correct (mean, 54.0 (SD 20.2)%) and 152 incorrect (mean, 50.3 (SD 24.3)%) judgements. Twelve needles were identified with 100% confidence-three correct, and nine incorrect. For needles correctly identified, the proportions of non-touch (p = 0.14) and skin-touch (p = 0.17), needles were no greater than chance, but the proportion of penetrating needles correctly identified exceeded chance (p < 0.01). 53% of judgements were made from the "feeling of needle insertion", but 57% of these were wrong.

CONCLUSION

Practitioners had a slight tendency to guess the penetrating needles correctly, but were uncertain about most of their judgments, posing only a very small risk to double blinding.

Inhibitory effect of needle penetration on vibration-induced finger flexion reflex in humans

Background

Vibration-induced finger flexion reflex (VFR) in the upper extremity is inhibited by needle insertion acupuncture to the large intestine 4 (LI4) at the hand. This claim has a limitation because the inhibitory effect is deduced only from reduction in the maximum finger flexion (FF) force during the tonic flexion reflex by vibratory stimulation after acupuncture.

Methods

The study was a crossover design with two conditions—acupuncture and control—to which 16 healthy volunteers were subjected. VFR in the upper extremity was induced by applying vibratory stimulation on the volar side of the middle fingertip of the right hand, before and after acupuncture at the right LI4 in 16 healthy volunteers. We measured the area under the curve (AUC) of finger flexion force and surface electromyogram (EMG) in the flexor muscles, in addition to the maximum FF force during vibratory stimulation. We compared AUC, surface EMG and maximum FF force in the acupuncture condition with those in the control condition. We also estimated the correlation between AUC, surface EMG and maximum FF force.

Results

AUC, surface EMG and maximum FF force were significantly reduced (p <0.01) after acupuncture compared with those of the control group. A strong correlation was observed in maximum FF force versus AUC (r=0.98, p <0.01) and surface EMG (r=0.77, p <0.01).

Conclusions

Acupuncture at ipsilateral LI4 inhibited tonic activities in the finger flexor muscles during VFR, which suggests that afferent input with needle penetration has inhibitory effect on the motor neuronal activities in the reflex circuits of VFR.

Typical dipole locations can be estimated using averaged somatosensory-evoked potentials and a standard brain model

It is reasonable to hypothesize that dipoles estimated from grand averaged event-related potentials based on summed-up data obtained from multiple subjects and standard head models could correspond to typical brain regions associated to a particular event. Six healthy subjects were enrolled in a study to test this hypothesis. We estimated dipoles from somatosensory-evoked potentials (SEP) elicited by electrical stimulation to the left median nerve. We also created individual three-layered (scalp, skull, and brain) head models from each subject's magnetic resonance imaging scan, and dipoles were estimated from the individual averaged SEP with each individual head model. We then estimated dipoles using grand averaged SEP across all subjects on the standard head model created from the Montreal Neurological Institute (MNI) standard coordinate system brain template to compare the estimated dipoles located on our own head model and those on the MNI. The dipoles in the post-central gyrus were estimated from negative potentials at 20 ms from the grand averaged data incorporated with the MNI head model, corresponding to a typical location related to SEP stimulation. The results suggest the validity of estimating the dipole location from the grand averaged potential of all subjects with the MNI model if we focus on typical regions related to the task.

Sonolytic hydrolysis of peptides in aqueous solution upon addition of catechol

The sonolytic hydrolysis of peptides with addition of phenolic reagents to aqueous solutions is described. Sonolysis of an aqueous solution of peptides to which catechol (o-dihydroxybenzene) had been added resulted in hydrolytic products reflecting the amino acid sequence without any side reactions, while sonolysis without any additives resulted in oxidation analytes and degradation products caused by side reactions. Although the use of additives such as resorcinol (m-dihydroxybenzene), hydroquinone (p-dihydroxybenzene) and phenol was also effective in producing sequence related products, several degradation products were produced by side reactions. A characteristic of the sonolysis of peptides is that the N-terminal side of proline, Xxx-Pro, is more susceptible than other amino acid residues to the process. This characteristic of sonolysis is superior to that of acid hydrolysis in which cleavage at the C-terminal side of proline, Pro-Xxx is difficult, and where dehydration products result due to side reactions.

A multi-institutional study of radiation therapy for isolated para-aortic lymph node recurrence in uterine cervical carcinoma: 84 subjects out of over 5,000 population

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Background: Most patient who had any recurrent sites of cancer, have been considered to be last-stage of life. However, recent advances of clinical research reveal some patients achieve long-term survival even in recurrence cases. Furthermore, patients who had only one recurrent region, even radiation therapy could play an important role. As for uterine cervical carcinoma, the most common recurrent site other than pelvis is para-aortic lymph node. Furthermore, improvement of diagnostic imaging enables us to detect more frequently isolated para-aortic lymph node recurrence. Thus, we conducted the current study. Methods: Between 1994 and 2003, over 5000 uterine cervical carcinoma patients treated with curative intended treatments at sixteen Japanese major hospitals. Out of them, 84 patients developed para-arotic lymph node recurrence as the only site of initial tumor progression. Seventy-four patitents had squamous cell carcinoma and 5 had adenosquamous cell carcinoma and 5 had adenocarcinoma. These patients were treated with external beam radiation therapy prescribing 1.7–2.0 Gy per fraction, 5 fractions per week and median total dose was 50 Gy (25–60 Gy). Thirty-two patients received adjuvant systemic chemotherapy. Results: Median follow-up time of all patients was 20 months (2–92 months). Three- and 5-year overall survival rates of all patients were 49.5% and 31.3%, respectively. Stratified by patients with or without chemotherapy, 3-year overall survival rate of patients with chemotherapy group was 37.7% and those without group was 56.7% (p = 0.69). Moreover, stratified by symptom sign, 3-year overall survival rate of symptom positive group was 27.6% and those of negative group was 56.1% (p = 0.018). Three-year overall survival rates of the total dose ≥ 51Gy and that of ≤ 50 Gy were 58.0% and 42.8%, respectively (p = 0.07). AS for morbidity, no patients received G3 or greater late toxicity (CTCAE ver. 3.0). Conclusions: The current study suggested that radiation therapy for isolated para-aortic lymph node recurrence in uterine cervical carcinoma could have significant impact on overall survival. Furthermore, no symptom group and over 51Gy irradiation group could achieve better prognosis.

No significant financial relationships to disclose.

Evaluation of adverse effects in intracarotid propofol injection for Wada test

The authors evaluated adverse effects of intracarotid propofol injection during a Wada test and their risk factors in 58 patients. Nineteen patients had an adverse effect, mostly in patients receiving more than 10 mg. For patients older than age 55 years or those requiring an injection dose greater than 20 mg to produce hemiplegia, propofol should be injected slowly and patients monitored for excitatory movements.

Surgical treatment of seizures from the peri-Sylvian area by perinatal insult: a case report of ictal hypersalivation

OBJECTIVES AND IMPORTANCE: It is important to evaluate the seizure manifestation of epilepsy before surgical planning. A patient with partial epilepsy manifesting hypersalivation who underwent resection of the epileptogenic foci with satisfactory postoperative seizure control is reported.

CLINICAL PRESENTATION AND INTERVENTION

A 26-year-old man, with a history of perinatal asphyxia, started having medically intractable partial epilepsy at the age of 10 years. His seizure was characterized by throat discomfort followed by hypersalivation. Brain MRI showed an atrophic lesion around the peri-Sylvian area. Scalp recorded EEG did not demonstrate robust epileptiform activity localized enough to define the epileptogenic zone. The patient underwent invasive recording by multiple subdural electrode grids, which showed that the seizure arose from the left anterior frontal operculum. After resection of epileptogenic opercular cortex, the seizures disappeared with no additional neurological deficits.

CONCLUSION

Although the responsible sites for ictal drooling are distributed in multiple areas including insula, medial temporal area and operculum, the seizure can be successfully controlled by focus resection of the frontal opercular area in a selected patient with careful presurgical evaluation.

Intracarotid propofol test for speech and memory dominance in man

OBJECTIVE

To evaluate the usefulness of propofol as an alternative drug to amobarbital for the Wada test.

METHODS

The authors analyzed 67 right-handed patients out of 123 patients who were candidates for neurosurgical therapy and thus underwent the Wada test as a preoperative evaluation. Twelve were tested with propofol and 55 were tested with amobarbital. Test conditions of the Wada test, recovery time of muscle power to manual muscle testing (MMT) Grade 3 (T3/5) and Grade 5 (T5/5), onset time of the first verbal response (Tverb) after injection and that of the first nonverbal response (Tnon-verb), were compared between the two groups. Power spectrum analysis of EEG background activity during the Wada test was performed and the time and spatial distribution of polymorphic slow activities were also compared in three cases.

RESULTS

With propofol injection, lateralities of language and memory function were identified in 12 and 9 of 12 patients in comparison to amobarbital (52 and 41 of 55 patients detection in language and memory function). No complications with direct intracarotid injection of propofol were observed. T3/5 and T5/5 with propofol injection were shorter while Tverb and Tnon-verb were longer compared to amobarbital. Absolute power of polymorphic slow EEG waves gradually increased and then rapidly decreased with propofol, which was in contrast to amobarbital injection.

CONCLUSIONS

With direct intracarotid propofol injection, the Wada test was satisfactorily performed in all 12 patients and 2 more patients with left-handedness or with different injection dose for each side without any complications. Clinical usefulness of propofol as an alternative drug to amobarbital for the Wada test was indicated.

Seizures arising from the inferior parietal lobule can show ictal semiology of the second sensory seizure (SII seizure)

A 52-year-old right handed man presented with medically intractable partial seizures consisting of numbness on the left upper back spreading to the left upper as well as lower limbs. Head computed tomography and magnetic resonance imaging showed a round calcified lesion in the depth of the superior ramus of the right sylvian fissure. Ictal electrocorticographic recording with chronically implanted subdural electrodes showed low voltage fast activities starting exclusively from an electrode located on the right inferior parietal lobule. No apparent ictal activities were observed from the depth electrodes inserted in the parietal operculum. Somatosensory evoked potentials of 75 ms to 145 ms latency were recorded from the ictal onset zone, which was 2 cm caudal to the perisylvian area corresponding to the second somatosensory area. Seizures arising from the inferior parietal lobule including the angular and supuramarginal gyri can produce partial seizures whose ictal semiology and scalp electroencephalography are indistinguishable from the ones originating from the second somatosensory area.

Expression and activity of matrix metalloproteinase 2 and 9 in human trophoblasts

Indiscriminate invasion upon the endometrium by normal trophoblasts is strictly regulated unlike that by choriocarcinoma cells. In this study, we focused on the activity of matrix metalloproteinase (MMP)-2 and MMP-9 as parameters of invasion in normal human placenta. In situ hybridization (ISH), immunohistochemical staining (IH) and film in situ zymography (FIZ) were performed to identify cells having MMP-2 or MMP-9 expression and activity. Purified cytotrophoblasts (CTs) were used to examine the expression and activity of MMP-2 and MMP-9, and their invasive ability. In first trimester placental tissue, the MMP-2 expression was observed in extravillous trophoblasts (EVTs), and MMP-9 mainly in villous cytotrophoblasts (VCTs). FIZ revealed marked gelatinase activity in the EVTs which MMP-2 expression was observed in. In full-term placental tissue, the MMP-2 expressions was observed in the EVTs similar to that in first trimester, whereas the gelatinase activity in these cells was decreased or completely lost. Using purified CTs, the gelatinase activity was marked in early CTs, but not term CTs. Invasive ability of early CTs was inhibited by tissue inhibitor of metalloproteinase (TIMP)-2 and MMP-2 antibody in a dose dependent manner. These suggests that the invasive ability of trophoblasts may be regulated by the enzyme activity of gelatinases, especially MMP-2.