Meditation for the primary and secondary prevention of cardiovascular disease

BACKGROUND

Interventions incorporating meditation to address stress, anxiety, and depression, and improve self-management, are becoming popular for many health conditions. Stress is a risk factor for cardiovascular disease (CVD) and clusters with other modifiable behavioural risk factors, such as smoking. Meditation may therefore be a useful CVD prevention strategy.

OBJECTIVES

To determine the effectiveness of meditation, primarily mindfulness-based interventions (MBIs) and transcendental meditation (TM), for the primary and secondary prevention of CVD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers on 14 November 2021, together with reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of 12 weeks or more in adults at high risk of CVD and those with established CVD. We explored four comparisons: MBIs versus active comparators (alternative interventions); MBIs versus non-active comparators (no intervention, wait list, usual care); TM versus active comparators; TM versus non-active comparators.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were CVD clinical events (e.g. cardiovascular mortality), blood pressure, measures of psychological distress and well-being, and adverse events. Secondary outcomes included other CVD risk factors (e.g. blood lipid levels), quality of life, and coping abilities. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included 81 RCTs (6971 participants), with most studies at unclear risk of bias. MBIs versus active comparators (29 RCTs, 2883 participants) Systolic (SBP) and diastolic (DBP) blood pressure were reported in six trials (388 participants) where heterogeneity was considerable (SBP: MD -6.08 mmHg, 95% CI -12.79 to 0.63, I2 = 88%; DBP: MD -5.18 mmHg, 95% CI -10.65 to 0.29, I2 = 91%; both outcomes based on low-certainty evidence). There was little or no effect of MBIs on anxiety (SMD -0.06 units, 95% CI -0.25 to 0.13; I2 = 0%; 9 trials, 438 participants; moderate-certainty evidence), or depression (SMD 0.08 units, 95% CI -0.08 to 0.24; I2 = 0%; 11 trials, 595 participants; moderate-certainty evidence). Perceived stress was reduced with MBIs (SMD -0.24 units, 95% CI -0.45 to -0.03; I2 = 0%; P = 0.03; 6 trials, 357 participants; moderate-certainty evidence). There was little to no effect on well-being (SMD -0.18 units, 95% CI -0.67 to 0.32; 1 trial, 63 participants; low-certainty evidence). There was little to no effect on smoking cessation (RR 1.45, 95% CI 0.78 to 2.68; I2 = 79%; 6 trials, 1087 participants; low-certainty evidence). None of the trials reported CVD clinical events or adverse events. MBIs versus non-active comparators (38 RCTs, 2905 participants) Clinical events were reported in one trial (110 participants), providing very low-certainty evidence (RR 0.94, 95% CI 0.37 to 2.42). SBP and DBP were reduced in nine trials (379 participants) but heterogeneity was substantial (SBP: MD -6.62 mmHg, 95% CI -13.15 to -0.1, I2 = 87%; DBP: MD -3.35 mmHg, 95% CI -5.86 to -0.85, I2 = 61%; both outcomes based on low-certainty evidence). There was low-certainty evidence of reductions in anxiety (SMD -0.78 units, 95% CI -1.09 to -0.41; I2 = 61%; 9 trials, 533 participants; low-certainty evidence), depression (SMD -0.66 units, 95% CI -0.91 to -0.41; I2 = 67%; 15 trials, 912 participants; low-certainty evidence) and perceived stress (SMD -0.59 units, 95% CI -0.89 to -0.29; I2 = 70%; 11 trials, 708 participants; low-certainty evidence) but heterogeneity was substantial. Well-being increased (SMD 0.5 units, 95% CI 0.09 to 0.91; I2 = 47%; 2 trials, 198 participants; moderate-certainty evidence). There was little to no effect on smoking cessation (RR 1.36, 95% CI 0.86 to 2.13; I2 = 0%; 2 trials, 453 participants; low-certainty evidence). One small study (18 participants) reported two adverse events in the MBI group, which were not regarded as serious by the study investigators (RR 5.0, 95% CI 0.27 to 91.52; low-certainty evidence). No subgroup effects were seen for SBP, DBP, anxiety, depression, or perceived stress by primary and secondary prevention. TM versus active comparators (8 RCTs, 830 participants) Clinical events were reported in one trial (201 participants) based on low-certainty evidence (RR 0.91, 95% CI 0.56 to 1.49). SBP was reduced (MD -2.33 mmHg, 95% CI -3.99 to -0.68; I2 = 2%; 8 trials, 774 participants; moderate-certainty evidence), with an uncertain effect on DBP (MD -1.15 mmHg, 95% CI -2.85 to 0.55; I2 = 53%; low-certainty evidence). There was little or no effect on anxiety (SMD 0.06 units, 95% CI -0.22 to 0.33; I2 = 0%; 3 trials, 200 participants; low-certainty evidence), depression (SMD -0.12 units, 95% CI -0.31 to 0.07; I2 = 0%; 5 trials, 421 participants; moderate-certainty evidence), or perceived stress (SMD 0.04 units, 95% CI -0.49 to 0.57; I2 = 70%; 3 trials, 194 participants; very low-certainty evidence). None of the trials reported adverse events or smoking rates. No subgroup effects were seen for SBP or DBP by primary and secondary prevention. TM versus non-active comparators (2 RCTs, 186 participants) Two trials (139 participants) reported blood pressure, where reductions were seen in SBP (MD -6.34 mmHg, 95% CI -9.86 to -2.81; I2 = 0%; low-certainty evidence) and DBP (MD -5.13 mmHg, 95% CI -9.07 to -1.19; I2 = 18%; very low-certainty evidence). One trial (112 participants) reported anxiety and depression and found reductions in both (anxiety SMD -0.71 units, 95% CI -1.09 to -0.32; depression SMD -0.48 units, 95% CI -0.86 to -0.11; low-certainty evidence). None of the trials reported CVD clinical events, adverse events, or smoking rates.

AUTHORS' CONCLUSIONS

Despite the large number of studies included in the review, heterogeneity was substantial for many of the outcomes, which reduced the certainty of our findings. We attempted to address this by presenting four main comparisons of MBIs or TM versus active or inactive comparators, and by subgroup analyses according to primary or secondary prevention, where there were sufficient studies. The majority of studies were small and there was unclear risk of bias for most domains. Overall, we found very little information on the effects of meditation on CVD clinical endpoints, and limited information on blood pressure and psychological outcomes, for people at risk of or with established CVD. This is a very active area of research as shown by the large number of ongoing studies, with some having been completed at the time of writing this review. The status of all ongoing studies will be formally assessed and incorporated in further updates.

Hormonal response in patients transplanted with cryopreserved ovarian tissue is independent of whether freezing was performed in childhood or adulthood

PURPOSE

This study evaluated the concentrations of hormones resulting from the transplantation of ovarian tissue (OTT) in relation to whether the tissue was frozen at a time close to puberty or above the age of 19 years.

METHODS

Six girls and adolescents (aged 9-14 years) who underwent ovarian tissue cryopreservation (OTC) were followed after transplantation in adulthood. After OTT, the women were followed via regular blood samples to evaluate the concentrations of FSH, LH, oestradiol and AMH. Twenty-three women undergoing OTT (aged 19-36 years at the time of OTC) were included as a reference group. All of the women had postmenopausal levels of gonadotropins at the time of transplantation.

RESULTS

The return of FSH and LH to normal premenopausal concentrations in adult women transplanted with ovarian tissue that was frozen at a time close to puberty was similar to the profiles in women from the reference group. Serum AMH levels were below the detection limit (via the Roche Elecsys assay) in many samples, but four out of six young girls showed measurable concentrations. Oestradiol similarly increased in the first 12 weeks following transplantation, after which it tended to be higher in women having frozen tissue in adulthood.

CONCLUSIONS

Ovarian tissue that was excised from girls at a time close to puberty, after which it was frozen and transplanted in adulthood, interacts with pituitary tissue in a similar manner to ovarian tissue that is frozen from adult women. Follicles located in the ovarian tissue from young girls are equally sensitive to gonadotropin stimulation as follicles from adult women when exposed to postmenopausal levels of gonadotropins. This result indicates that it is not the ovaries that require maturation to sustain full reproductive potential but rather proper FSH and LH stimulation. Moreover, these results support the continued use of OTC in young women.

O-081 High variability of molecular isoforms of AMH in follicular fluid and granulosa cells from human small antral follicles

Study question

Is the composition of AMH isoforms different in follicular fluids (FF) and granulosa cells (GCs) from human small antral follicles?

Summary answer

There is a high viability of AMH isoforms in FFs and GCs. Even between same size follicles from the same women, the isoform composition differs.

What is known already

Anti Müllerian Hormone (AMH) is a member of the TGF-β superfamily produced by follicular granulosa cells (GCs) in women from late gestation to the end of reproductive live. AMH is suggested to inhibit aromatase (i.e. CYP19) expression and thereby decreasing the conversion of androgens to oestrogens in humans, especially in small antral follicles before dominance is achieved and thereby act as a gatekeeper of ovarian steroidogenesis. However, the exact function and processing of AMH in human follicles is still not clarified.

Study design, size, duration

This retrospective study measured AMH isoforms in human FF and GCs from small antral follicles using ELISA, Western blot, and immunofluorescence analysis. A total of 41 female adolescents and women aged 15 to 38 years (mean age: 29.7 years), who underwent ovarian tissue cryopreservation (OTC) at the University Hospital of Copenhagen, Rigshospitalet were included between year 2006 and 2020 included.

Participants/materials, setting, methods

Donated human ovarian medulla tissue were FFs and GCs were obtained in connection with OTC. The following isoforms were evaluated in FFs using ELISA analysis: full-length AMH precursor (proAMH), cleaved associated AMH (AMHN,C), N-terminal pro-region (AMHN), and active C-terminal (AMHC) AMH. Antibodies specific for the N-terminal and the C-terminal AMH were used in both Western blot and immunofluorescence analysis of FFs and GCs.

Main results and the role of chance

A negative correlation between follicle diameter and the mentioned AMH forms were detected. Moreover, Western blot analysis detected various AMH forms in both FFs and GCs, which did not match the above-mentioned consensus forms suggesting an unknown proteolytic processing of AMH. The presence of these new molecular weight isoforms of AMH differs between individual follicles of identical size from the same woman.

Limitations, reasons for caution

The study group is limited and the significance of the variable AMH isoforms compositions between follicles cannot not be clarified from this data.

Wider implications of the findings

Collectively, these data suggest that intrafollicular processing of AMH is complex and variable, and thus, it may be difficult to develop an antibody based AMH assay that detect all AMH isoforms. Furthermore, the variability between follicles suggests that designing a proper standard will be difficult.

Trial registration number

not applicable

A simple method to quantify follicle survival in cryopreserved human ovarian tissue

STUDY QUESTION

Can follicle survival in frozen-thawed human ovarian tissue be quantified in situ using the dye Neutral Red (NR) to stain viable follicles specifically?

SUMMARY ANSWER

A follicle survival rate within ovarian tissue can be calculated using NR followed by histological evaluation and evidence for a consistently high follicle survival in a series of ovarian tissue from 25 Danish girls and women undergoing ovarian tissue cryopreservation (OTC) was obtained.

WHAT IS KNOWN ALREADY

Securing follicle survival in cryopreserved ovarian tissue is crucial for proper quality control when centers wish to implement OTC. The only established technique for validation of follicle survival is xenografting of thawed ovarian tissue to immunodeficient mice. However, this functional test is expensive, time consuming, requires animal facilities and only provides a qualitative-not quantitative-measure for follicle survival.

STUDY DESIGN SIZE, DURATION

Quantification of follicle survival in human ovarian tissue donated from 30 girls and women having tissue cryopreserved for fertility preservation from 2000 to 2015 at the Laboratory of Reproductive Biology in Copenhagen, Denmark.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Cryopreserved ovarian cortex was donated from 25 girls and young women aged 10-36 years (mean age: 25 years) and the average storage time in liquid nitrogen was 9.1 ± 5.6 years, ranging from 1.6 to 17.9 years. In 12 of the cases, the ovarian tissue was collected from the local hospital and in the other 13 cases the ovarian tissue was transported on ice up to 6 h prior to freezing. Donated fresh ovarian surplus tissue was obtained from five women aged 23-34 years (mean age: 27 years). Ovarian tissues were chopped into small fragments and incubated in culture medium containing 50 mg/ml NR for 3-4 h. Fragments of ovarian tissue containing clearly NR-stained follicles were selected for counting, encapsulated in 4% agar and were processed for histology to calculate a follicular survival rate.

MAIN RESULTS AND THE ROLE OF CHANCE

The mean follicle survival rate in the 25 patients after freezing and thawing was 84% ± 11 (mean ±SD), ranging from 50% to 98%. The high follicle survival rate in this clinical series of patients reflects a constant high-quality service performed in our center and confirms the robustness of the slow freezing protocol. No significant association between follicle survival rates and storage time was found using linear regression analysis, suggesting that storage in liquid nitrogen does not affect viability of the tissue. No significant association in follicle survival rates was found between ovarian tissues collected at the local hospital compared to tissues transported on ice prior to freezing, supporting that prolonged cooling does not seem to greatly affect the follicle survival. For the fresh ovarian tissue, the average follicle survival rate was 91% ± 5 (mean ± SD) in five patients, ranging from 81% to 95%.

LIMITATIONS, REASONS FOR CAUTION

Even though the NR staining requires active incorporation of the dye, the test is merely a short in situ test that cannot completely replace the functional value of xenografting studies in which the integrity and developmental potential of the ovarian follicles are assessed.

WIDER IMPLICATIONS OF THE FINDINGS

OTC is now being employed around the world but to date it has been difficult for centers to evaluate the effectiveness of their program and perform proper quality control. NR staining combined with histological evaluation is the first quantitative method to provide a survival rate for follicles in frozen-thawed human ovarian tissue and offer a valuable and easily applicable tool to validate the cryopreservation procedure when implementing OTC or as routine quality control for the overall freezing performance within tissue banking facilities.

STUDY FUNDING/COMPETING INTEREST(S)

The Research Pools of Rigshospitalet, the Danish Cancer Foundation, Dagmar Marshalls Foundation, and the Novo Nordic Foundation are thanked for having funded this study. The authors have no conflicts of interest.

Western, Minimal Acupuncture for Neck Pain: A Cohort Study

Minimal acupuncture is easily incorporated into primary care consultations, but there is no rigorous evidence of its effectiveness. In a cohort study, minimal acupuncture was given to 32 patients with acute neck pain. Neck pain scores, measured by the Northwick Park Neck Pain questionnaire, fell from an average of 12.1 (±5.4) before treatment to 4.8 (±5.6) at 3 months (p<0.00l). Three months after acupuncture treatment 76% of patients reported themselves “much better”. Out of 18 patients who had had pain lasting less than 2 weeks, 16 required only one treatment. These results suggest that minimal acupuncture may be an effective treatment for neck pain and further definitive studies are recommended.

The Effect of Auricular Acupuncture on the Pulse Rate: An Exploratory Randomised Controlled Trial

Advocates of auricular acupuncture believe that the internal organs are represented in the concha of the ear and can be affected by needling the appropriate area. These two areas of the body have a common innervation from the vagus nerve. The aim of this randomised, single-blind study was to determine whether stimulation of the ear produced changes in the pulse rate, an indicator of vagal tone. Doctor volunteers were needled in either the vagus area or a control area of the ear, and pulse rate changes were measured over the following 30 minutes. No significant differences were found in the pulse rate changes of the two groups. This study, which was limited in size and in other respects, found no evidence to support the concept that the body is represented on the ear.

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

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

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

Acupuncture Research: Where Are the Problems?

In spite of its long history and widespread use, acupuncture has failed to demonstrate its clinical effectiveness convincingly. This article is aimed at discussing some of the problems related to acupuncture research that might have contributed to this overt discrepancy. These are the effects of investigator bias, the abundance of derivatives of traditional acupuncture, the lack of standardisation of treatment and selection of acupoints, and the difficulty in blinding the investigator, patient or therapist, as well as the problems related to the choice of an appropriate placebo. Such, mostly methodological difficulties, can and must be overcome if the controversy regarding the clinical effectiveness of acupuncture is to be solved.

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

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

Searching for Acupuncture Trials: Which Database?

Evidence based medicine depends on sensitive, precise and informative searches for references to controlled clinical trials. Five databases: Medline, Centralised Information Service for Complementary Medicine (CISCOM), Science Citation Index (SCI), British Library and Embase, were compared for their effectiveness as literature search tools by conducting test searches for acupuncture trials in a single sample year, 1992. CISCOM showed the greatest sensitivity, followed by Medline and SCI; all three usually provided abstracts, but CISCOM did not provide authors’ addresses. Other databases had features that might make them useful for particular purposes. SCI, British Library and Embase covered a different range of journals from Medline, including acupuncture specialist journals, but of these three only SCI contained an additional relevant reference; it also had the advantages of secondary references and associated correspondence. Indexing of Medline appeared to be more effective for acupuncture than for some other complementary and orthodox medical subjects. It was concluded that the CISCOM search was the most sensitive, and that Medline and SCI had other benefits which were significant.

Development of a New Sham Needle

The problem of providing an acupuncture placebo that is indistinguishable from genuine needling has appeared insurmountable. However, the authors have developed an apparatus, the Park sham needle unit, which is intended to match what an acupuncture-naïve subject expects to see and experience with needling, but is intended not to produce the specific needling sensation (deqi) that is felt with true needling. This can still not be regarded as a true placebo since skin contact must be made for verisimilitude and there may thus be some physiological stimulation. Nonetheless this form of sham acupuncture should be considered an advance on all previously used methods.

The apparatus consists of a blunted needle, the shaft of which telescopes into the handle when tapped, so that, while the needle appears to have been inserted, it does not actually pierce the skin. The needle is held in place by a standard guide tube contained within a fitted sheath with basal ring that is secured to the skin with double sided sticky tape.

The Effectiveness of Acupuncture for Depression – a Systematic Review of Randomised Controlled Trials

Objective

To summarise the existing evidence on acupuncture as a therapy for depression.

Methods

RCTs were included, in which either manual acupuncture or electroacupuncture was compared with any control procedure in subjects with depression. Data were extracted independently by two authors. The methodological quality was assessed. Pre and post means and SDs for depression specific measures were extracted, when available, for meta-analysis.

Results

Seven randomised comparative trials involving 509 patients were included. The evidence is inconsistent on whether manual acupuncture is superior to sham, and suggests that acupuncture was not superior to waiting list. Evidence suggests that the effect of electroacupuncture may not be significantly different from antidepressant medication, weighted mean difference −0.43(95% CI −5.61 to 4.76). There is inconclusive evidence on whether acupuncture has an additive effect when given as an adjunct to antidepressant drugs.

Conclusion

The evidence from controlled trials is insufficient to conclude whether acupuncture is an effective treatment for depression, but justifies further trials of electroacupuncture.

Survey of Adverse Events following Acupuncture

Volunteers are sought who will commit themselves to report the incidence of adverse effects in their acupuncture practice over a period of two years. The Department of Complementary Medicine of Exeter University is co-ordinating a survey of 30,000 acupuncture treatments. From the resulting data a complication rate of serious and minor side effects will be compiled. It is hoped that meticulous recording could demonstrate circumstances leading to adverse effects and identify unrecorded complications of acupuncture.

Previous reports suggest that the major complications of acupuncture have an incidence of between 1:10,000 and 1:100,000, which is classified as very low. This survey aims to give an accurate assessment of the risk of major complication and to determine the range and incidence of any other unintended and non-therapeutic ill-effects following acupuncture, no matter how minor. It constitutes the first such investigation into the safety of acupuncture.

Dose-Response Studies on the Effect of n-3 Polyunsaturated Fatty Acids on Lipids and Haemostasis

We have studied the dose-response effects of dietary supplementation with n-3 polyunsaturated fatty acids (n-3 PUFA’s) on lipids and haemostasis. Ten healthy males were each given 1.3 g,4 g or 9 g of n-3 PUFA’s daily for 6-week periods. Bleeding time, HDL-cholesterol and plasminogen activator inhibitor increased with the dose of n-3 PUFA. Plasma fibrinogen and triglyceride levels were reduced in a dose-dependent fashion.

After ingestion of 1.3 g of n-3 PUFA’s plasma fibrinogen decreased from 9 to 7 μmol/l and HDL-cholesterol increased from 1.2 to 1.3 mmol/l. The bleeding time was prolonged from 5 to 6.5 min while triglyceride levels decreased from 1.2 to 0.9 mmol/l after ingestion of 4 g of n-3 PUFA’s. Dietary supplementation with the highest daily dose (9 g) reduced plasma levels of triglycerides, fibrinogen and von Willebrand factor, while bleeding time, plasminogen activator antigen, plasminogen activator inhibitor and the ratio of HDL-cholesterol to total cholesterol increased.

The Effect of n-3 Fatty Acids on Lipids and Haemostasis in Patients with Type lla and Type IV Hyperlipidaemia

Plasma lipids and haemostasis were investigated in 17 patients with hyperlipidaemia before and after 6 weeks supplementation with 6 g n-3 fatty acids. Nine of the patients had type IIa and 8 had type IV hyperlipidaemia. No effect on plasma cholesterol, LDL- or HDL-cholesterol were seen, but plasma triglycerides decreased after n-3 supplementation. Apolipoprotein B increased and apolipoprotein A1 decreased after the oil supplement. The bleeding time was prolonged, but platelet aggregation was unaltered by n-3 fatty acids. Protein C activity increased in type II a and decreased in type IV after the supplement. Fibrinolysis was markedly depressed while von Willebrand factor antigen was reduced after intake of n-3 fatty acids.

Is use of homeopathy associated with poor prescribing in English primary care? A cross-sectional study

Objectives Prescribing of homeopathy still occurs in a small minority of English general practices. We hypothesised that practices that prescribe any homeopathic preparations might differ in their prescribing of other drugs. Design Cross-sectional analysis. Setting English primary care. Participants English general practices. Main outcome measures We identified practices that made any homeopathy prescriptions over six months of data. We measured associations with four prescribing and two practice quality indicators using multivariable logistic regression. Results Only 8.5% of practices (644) prescribed homeopathy between December 2016 and May 2017. Practices in the worst-scoring quartile for a composite measure of prescribing quality (>51.4 mean percentile) were 2.1 times more likely to prescribe homeopathy than those in the best category (<40.3) (95% confidence interval: 1.6-2.8). Aggregate savings from the subset of these measures where a cost saving could be calculated were also strongly associated (highest vs. lowest quartile multivariable odds ratio: 2.9, confidence interval: 2.1-4.1). Of practices spending the most on medicines identified as 'low value' by NHS England, 12.8% prescribed homeopathy, compared to 3.9% for lowest spenders (multivariable odds ratio: 2.6, confidence interval: 1.9-3.6). Of practices in the worst category for aggregated price-per-unit cost savings, 12.7% prescribed homeopathy, compared to 3.5% in the best category (multivariable odds ratio: 2.7, confidence interval: 1.9-3.9). Practice quality outcomes framework scores and patient recommendation rates were not associated with prescribing homeopathy (odds ratio range: 0.9-1.2). Conclusions Even infrequent homeopathy prescribing is strongly associated with poor performance on a range of prescribing quality measures, but not with overall patient recommendation or quality outcomes framework score. The association is unlikely to be a direct causal relationship, but may reflect underlying practice features, such as the extent of respect for evidence-based practice, or poorer stewardship of the prescribing budget.

Short Time Dialysis with Continuous Blood Volume Control

Continuous measurement of haemoglobin concentration is used to control changes of blood volume during haemodialysis. Ultrafiltration is either kept constant throughout the session or after starting with a rate (1.5 to 2 l/h), is manually controlled in order to limit blood volume reduction to a preset percentage. Ultrafiltration is step-wise decreased (a) or switched on and off (b) accordingly. Blood volume decrease with constant ultrafiltration is compared with method (a) and (b) in 4 stable haemodialysis patients. Constant ultrafiltration rate and the same total amount of ultrafiltrate causes a nearly 3% (mean) greater volume reduction as compared with method (a) and (b). No difference was observed in blood pressure and heart rate. We conclude that ultrafiltration in stable haemodialysis patients can be completed in short time without consequences for cardiovascular stability.

The polymorphic insertion of the luteinizing hormone receptor "insLQ" show a negative association to LHR gene expression and to the follicular fluid hormonal profile in human small antral follicles

The luteinizing hormone receptor (LHCGR) has a little studied polymorphic 6 bp insertion (rs4539842/insLQ). This study has evaluated the insLQ polymorphism in relation to potential associations with hormonal characteristics of human small antral follicles (hSAFs). In total, 310 hSAFs were collected from 86 women undergoing fertility preservation. Analysis included hormonal profile of 297 follicular fluid (FF) samples and 148 corresponding granulosa cells samples were evaluated by qPCR for selected genes. Significantly reduced and non-detectable mRNA levels of anti-Müllerian hormone receptor II (AMHR2) and LHCGR, respectively, were observed for insLQ/insLQ compared to -/insLQ and the -/- genotypes. Moreover, LHCGR and CYP19a1 together with oestradiol and inhibin-B were significantly increased in -/insLQ compared to the -/- genotype. The homozygous insLQ genotype showed strong significant associations to GC specific genes LHCGR and CYP19a1, which may translate into significant changes in FF hormone profiles and an altered LH signaling.

Herbal remedies for depression and anxiety

Herbal remedies are used by many people suffering from anxiety or depression. It is therefore important to know whether they generate more good than harm. A systematic review of the published literature revealed trial data for Ginkgo biloba, Lavandula angustifolia, Hypericum perforatum, Valeriana officinalis, Crataegus oxyacantha, Eschscholzia californica, Matricaria recutita, Melissa officinalis, Passiflora incarnate and Piper methysticum. Only two of these herbal remedies are supported by sound evidence: Hypericum perforatum (St John's wort) for mild to moderate depression and Piper methysticum (kava) for anxiety. Neither is free of risks. Our knowledge of herbal remedies is incomplete and the subject merits rigorous study.

A Systematic Review of Systematic Reviews of Spinal Manipulation

Objectives

To systematically collate and evaluate the evidence from recent systematic reviews of clinical trials of spinal manipulation.

Design

Literature searches were carried out in four electronic databases for all systematic reviews of the effectiveness of spinal manipulation in any indication, published between 2000 and May 2005. Reviews were defined as systematic if they included an explicit and repeatable inclusion and exclusion criteria for studies.

Results

Sixteen papers were included relating to the following conditions: back pain (n=3), neck pain (n=2), lower back pain and neck pain (n=1), headache (n=3), non-spinal pain (n=1), primary and secondary dysmenorrhoea (n=1), infantile colic (n=1), asthma (n=1), allergy (n=1), cervicogenic dizziness (n=1), and any medical problem (n=1). The conclusions of these reviews were largely negative, except for back pain where spinal manipulation was considered superior to sham manipulation but not better than conventional treatments.

Conclusions

Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.

Homeopathic Arnica for Prevention of Pain and Bruising: Randomized Placebo-Controlled Trial in Hand Surgery

Homeopathic arnica is widely believed to control bruising, reduce swelling and promote recovery after local trauma; many patients therefore take it perioperatively. To determine whether this treatment has any effect, we conducted a double-blind, placebo-controlled, randomized trial with three parallel arms. 64 adults undergoing elective surgery for carpal tunnel syndrome were randomized to take three tablets daily of homeopathic arnica 30C or 6C or placebo for seven days before surgery and fourteen days after surgery. Primary outcome measures were pain (short form McGill Pain Questionnaire) and bruising (colour separation analysis) at four days after surgery. Secondary outcome measures were swelling (wrist circumference) and use of analgesic medication (patient diary).

62 patients could be included in the intention-to-treat analysis. There were no group differences on the primary outcome measures of pain ( P=0.79) and bruising ( P=0.45) at day four. Swelling and use of analgesic medication also did not differ between arnica and placebo groups. Adverse events were reported by 2 patients in the arnica 6C group, 3 in the placebo group and 4 in the arnica 30C group.

The results of this trial do not suggest that homeopathic arnica has an advantage over placebo in reducing postoperative pain, bruising and swelling in patients undergoing elective hand surgery.

WITHDRAWN: Transcendental meditation for the primary prevention of cardiovascular disease

BACKGROUND

A major determinant in cardiovascular disease (CVD) is stress. As transcendental meditation (TM) is thought to help in lowering negative stress indicators, it may be a beneficial strategy for the primary prevention of CVD.

OBJECTIVES

To determine the effectiveness of TM for the primary prevention of CVD.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 10); MEDLINE (Ovid) (1946 to week three November 2013); EMBASE Classic and EMBASE (Ovid) (1947 to week 48 2013); ISI Web of Science (1970 to 28 November 2013); and Database of Abstracts of Reviews of Effects (DARE) and Health Technology Assessment Database and Health Economics Evaluations Database (November 2013). We also searched the Allied and complementary Medicine Database (AMED) (inception to January 2014) and IndMed (inception to January 2014). We handsearched trial registers and reference lists of reviews and articles and contacted experts in the field. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of at least three months' duration involving healthy adults or adults at high risk of CVD. Trials examined TM only and the comparison group was no intervention or minimal intervention. We excluded trials that involved multi-factorial interventions. Outcomes of interest were clinical CVD events (cardiovascular mortality, all-cause mortality and non-fatal events) and major CVD risk factors (e.g. blood pressure and blood lipids, occurrence of type 2 diabetes, quality of life, adverse events and costs).

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials for inclusion, extracted data and assessed the risk of bias.

MAIN RESULTS

We identified four trials (four papers) (430 participants) for inclusion in this review. We identified no ongoing studies. The included trials were small, short term (three months) and at risk of bias. In all studies, TM was practised for 15 to 20 minutes twice a day.None of the included studies reported all-cause mortality, cardiovascular mortality or non-fatal endpoints as trials were short term, but one study reported survival rate three years after the trial was completed. In view of the considerable statistical heterogeneity between the results of the studies for the only outcomes reported, systolic blood pressure (I2 = 72%) and diastolic blood pressure (I2 = 66%), we decided not to undertake a meta-analysis. None of the four trials reported blood lipids, occurrence of type 2 diabetes, adverse events, costs or quality of life.

AUTHORS' CONCLUSIONS

Currently, there are few trials with limited outcomes examining the effectiveness of TM for the primary prevention of CVD. Due to the limited evidence to date, we could draw no conclusions as to the effectiveness of TM for the primary prevention of CVD. There was considerable heterogeneity between trials and the included studies were small, short term and at overall serious risk of bias. More and larger long-term, high-quality trials are needed.

UK Chiropractic: Regulated but Unruly

Since 1994 chiropractic has been regulated by statute in the UK. Despite this air of respectability, a range of important problems continue to bedevil this profession. Professional organizations of chiropractic and their members make numerous claims which are not supported by sound evidence. Many chiropractors adhere to concepts which fly in the face of science and most seem to regularly violate important principles of ethical behaviour. The advice chiropractors give to their clients is often dangerously misleading. If chiropractic in the UK is to grow into an established health care profession, the General Chiropractic Council and its members should comply with the accepted standards of today's health care.