Acupuncture and the Treatment of Irritative Bladder Symptoms

The conventional management of irritative bladder symptoms, namely urgency, urge incontinence, frequency and nocturia, with anticholinergic medication is limited by the side effects of treatment. Acupuncture is shown to be as effective in the management of irritative bladder symptoms as conventional anticholinergic therapy, with few side effects and a high degree of patient acceptability and compliance.

A prospective randomised study to evaluate the effectiveness of standard 23 gauge fine needle, compared with a thinner 27 gauge needle for breast cytology

The aim of this study was to determine whether a 27 gauge needle could be used to obtain adequate cytology with less discomfort to the patient. Two types of needles were compared-23 gauge (blue) needle versus 27 gauge very fine needle. The cytology specimen was assessed for quality in terms of adequacy for diagnosis. Ninety samples were randomised into this study. The quality of samples was similar in both groups; there was no statistical difference in the quality of samples obtained. The 27 gauge needle produced two inadequate samples (4.4%), whereas there were no inadequate samples with the 23 gauge needle. There was no statistical difference in the amount of blood on the slide between the two groups. The pain scores were significantly better with the finer needle (P=0.004). This study provides evidence that the 27 gauge FNAC is suitable for obtaining cytology in palpable breast lumps.

Evidence-based complementary medicine for palliative cancer care: does it make sense?

Complementary medicine is fast becoming an integral part of palliative cancer care. There is considerable debate as to whether such treatments require proof of effectiveness through randomized clinical trials or whether it may suffice that patients adopt them with apparent appreciation. We attempt to raise some of the arguments on both sides. The arguments include the logistical problems of conducting research in palliative care, ethical problems of placebo controls, methodological difficulties of standardizing treatments or quantifying subtle effects and the, often considerable, costs of clinical trials. We feel that neither those who argue against nor those who argue in favour of rigorous clinical trials are entirely wrong or entirely right. However, our final verdict is that an absence of rigorous science will critically hinder progress. This, in turn, would be to the detriment of future patients. Through discussing the strengths and weaknesses of both sets of arguments, both sides might learn valuable lessons.

Clinical trials of acupuncture: consensus recommendations for optimal treatment, sham controls and blinding

Evidence of effectiveness is increasingly used to determine which health technologies are incorporated into public health provision. Acupuncture is a popular therapy that has been shown to be superior to placebo in the treatment of nausea and dental pain, and promising for migraine and osteoarthritis of the knee. For many other conditions, such as chronic pain, in which acupuncture is often used, the evidence is either insufficient or negative. Misleading results may occur for a number of reasons. False negative results may arise from inadequate treatment schedules and inappropriate control interventions. This consensus document considers these issues with the aim of improving the design of efficacy trials of acupuncture in order that they are more likely to be conclusive and more meaningfully interpreted. Clinical trials of acupuncture must use an optimal form of treatment; this can be defined by examining standard texts, by surveying and consulting experts. There are a great many variables in treatment (such as point selection, form of stimulation) all of which need to be addressed in designing and reporting clinical trials. The control procedure is determined by the precise research question that is being addressed. For efficacy studies, in which the question is whether acupuncture has specific effects (i.e. is superior to placebo), sham forms of acupuncture appear the most appropriate method of controlling for needle penetration. A recent development of blunted, telescopic needles may represent a major advance. Such procedures may produce a therapeutic response so should preferably be recorded as 'sham' procedures rather than true 'placebo' controls. Blinding in clinical trials is an accepted means of reducing bias. Patient blinding in acupuncture studies can be achieved by sham procedures and its success should be measured. While practitioner blinding is difficult, though not impossible, blinding of the observer and the analyst should be considered as the ideal for all studies. A number of recommendations are made which aim to improve the quality of sham-controlled acupuncture studies.

Safety aspects of acupuncture in palliative care

Acupuncture can mask symptoms of cancer and tumour progression. It is not safe to use such a therapy without full knowledge of the clinical stage of the disease, and the current status of orthodox therapy. Contraindications to acupuncture needling include an unstable spine, severe clotting disorder, neutropenia and lymphoedema. Whilst semi-permanent needles are used increasingly in symptom control and pain management they should not be used in patients with valvular heart disease or in vulnerable neutropenic patients. Acupuncture has an increasing role in support for pain and symptom management, but patients should not be advised to abandon conventional treatments in favour of complementary or alternative therapies alone, and should not have their hopes raised inappropriately, or have any guilt projected on to them for the cause of their cancer.

Are acupuncture points tender? A blinded study of Spleen 6

OBJECTIVES

To explore the methodology for investigating the tenderness of acupuncture points, with particular reference to the hypothesis that the point Spleen 6 (SP6) is more tender in women than in men.

DESIGN

Single-blind, observational study with volunteers.

SETTING

University of Exeter, U.K.

SUBJECTS

Student volunteers, 13 male and 13 female.

OUTCOME MEASURES

Pressure thresholds at SP6, a control acupuncture point Stomach 36, and two nonacupuncture control sites in each leg were measured weekly for 4 weeks.

RESULTS

No statistically significant differences were found between the pressure thresholds of SP6 in women and those in men.

CONCLUSION

The present study provides no strong evidence to support the hypothesis that the acupuncture point SP6 is more tender in women and in men. Recommendations for further investigations are discussed.

Right phrenic nerve palsy as a complication of indwelling central venous catheters

Five cases are reported of patients who developed a raised right hemidiaphragm while an indwelling central venous catheter was in situ. The patients were being treated with protracted venous infusions of chemotherapy for colorectal carcinoma. All five patients had a chest radiograph following insertion of the Hickman line which showed normal diaphragmatic positions. A mean of 93 days later (range 55-134 days) elevation of the right hemidiaphragm was noted in these patients on repeat chest radiographs. Two of the patients had a right phrenic nerve palsy demonstrated by magnetic stimulation of the nerve. The remaining three patients had paradoxical motion of the right hemidiaphragm on sonography, but were unable to undergo studies of phrenic nerve function before death from metastatic disease. It is suggested that right phrenic nerve palsy is a late complication of an indwelling central venous catheter.

A prospective analysis of 949 long-term central venous access catheters for ambulatory chemotherapy in patients with gastrointestinal malignancy

We present a prospective analysis of the insertion complications and longevity of 949 cuffed, tunnelled central venous catheters used for ambulatory chemotherapy. Mean catheter life span was 121.8 days, 13.4% had complications at insertion, 17.7% had complications not necessitating removal and 18.6% had complications requiring removal. The more experienced operators had fewer complications inserting catheters (P < 0.0001). Late-onset shoulder pain occurred in 4.8% and was associated with an increased incidence of venous thrombosis (P < 0.0001) and infection (P = 0.06). Complications necessitating removal were not predicted by patient' age, site of insertion or malignancy, chemotherapy regimen, insertion platelet and fibrinogen counts, insertion complications, leucocyte count or cuff distance from the exist site. Catheters inserted with their tip in the superior vena cava were more at risk of removal (2.57 times) than those in the right atrium (P = 0.003).

A review of 560 Hickman catheter insertions

Indwelling, cuffed, tunnelled, central venous (Hickman) catheters are increasingly being used for venous access and the administration of chemotherapy for oncological patients. This paper reviews the technical problems associated with the percutaneous insertion of these catheters and the complications arising from their use. Five hundred and sixty catheters were inserted; 31.3% had complications at insertion, most commonly precipitation of an arrhythmia (13.9%). Arterial puncture occurred in 3.8% and pneumothorax in 1.6%. Catheters remained in place for a median period of 91 days. Forty percent of catheters were removed electively on completion of treatment; 30.2% required removal because of complications, which included sepsis, migration, thrombosis and blockage. Twenty percent of patients died with their catheter in place, 8.5% were still in situ and 1.6% were removed because of patient non compliance. Sepsis remains the commonest, long term complication, with staphylococcus epidermidis being the organism isolated most frequently. There were no catheter-related deaths.

Acupuncture for the relief of cancer-related breathlessness

The palliation of cancer-related breathlessness is challenging and complex. An open pilot study was conducted, exploring the safety and efficacy of acupuncture in 20 patients who were breathless at rest and whose breathlessness was directly related to primary or secondary malignancy. Sternal and LI4 acupuncture points were used. Outcome measures included pulse, respiratory rate, oxygen saturation and patient-rated visual analogue scales of breathlessness, pain, anxiety and relaxation. At each time point the mean values of the variables were calculated and compared to their pretreatment levels (Student's t-test). Seventy per cent (14/20) of patients reported marked symptomatic benefit from treatment; there were significant changes in VAS scores of breathlessness, relaxation and anxiety at least up to 6 hours post acupuncture which were measured to be maximal at 90 minutes (p < 0.005, p < 0.001, respectively). There was a significant reduction in respiratory rate, which was sustained for 90 minutes post acupuncture (p < 0.02). The therapeutic value of acupuncture in the management of breathlessness requires further evaluation.

Percutaneous insertion of Hickman-type catheters

Hickman lines may be used for long-term venous access in patients having chemotherapy, bone marrow transplantation, parenteral nutrition, or in others needing prolonged venous access. This article describes the technique of percutaneous insertion, some of the problems that may be encountered at insertion, and ways of minimizing these problems.

The bioavailability and pharmacokinetics of morphine after intravenous, oral and buccal administration in healthy volunteers

1. The absolute bioavailability of morphine from oral aqueous solution, a controlled release oral tablet (MST-Continus) and a controlled release buccal tablet has been investigated in six healthy volunteers. 2. Analysis of plasma samples for morphine and its active metabolite morphine-6-glucuronide (M6G) was by means of a differential radioimmunoassay technique. Absolute bioavailability for morphine was estimated to be 23.9% after oral solution, 22.4% after MST-Continus and 18.7% after the buccal tablet. Maximum plasma morphine concentrations were seen at 45 min (oral solution), 2.5 h (MST) and 6 h (buccal). 3. There was no difference in the amount of M6G appearing in plasma after intravenous, oral or buccal administration but the mean ratio of AUCs for M6G: morphine in plasma after intravenous morphine was 2 : 1 compared with 11 : 1 after oral and buccal morphine.

The use of Hickman-Broviac catheters for paediatric radiotherapy

We describe the first use of Hickman-Broviac catheters in 20 children under the age of 4 years for repeated daily general anaesthesia for radiotherapy. These children received a total of four hundred and eighty two general anaesthetics. The advantages and disadvantages of using Hickman-Broviac lines are discussed.

The anaesthetic management of bone marrow harvest for transplantation

The anaesthetic management of 217 donors undergoing 236 operative procedures to donate bone marrow for allogeneic transplantation or for autologous grafting is described. The procedures were those performed between November 1979 and the end of October 1982.

Treatment of advanced malignant melanoma with high-dose melphalan and autologous bone marrow transplantation

Twenty-eight patients with advanced life-threatening metastatic malignant melanoma were treated with high dose (140-260 mgm-2) intravenous melphalan and autologous bone marrow. Cyclophosphamide "priming" 300 mgm-2 i.v. was given to 19 patients one week previously and this resulted in clinical but not histological evidence of amelioration of gastrointestinal toxicity. In 11 patients (43%) there was evidence of tumour response to treatment and in 2 patients complete remissions were observed. However in most patients, responses were short-lived and no patient lived longer than 17 months from start of treatment or 24 months from first recorded evidence of distant metastatic disease.

Unilateral computerised tomography guided coeliac plexus block: a technique for pain relief

Twelve patients have undergone unilateral coeliac plexus block using needle localisation by computed tomography and the technique is described. Computed tomography has the advantage that the needle route to the coeliac axis can be accurately planned, avoiding damage to other organs. In this study nine out of twelve patients had significant pain relief. Most success was achieved in patients with carcinoma of the pancreas.

Mismatched family donors for bone-marrow transplantation as treatment for acute leukaemia

35 patients were treated for acute myeloid leukaemia or acute lymphoblastic leukaemia with allogeneic bone-marrow grafts from a parent, child, or sibling who was mismatched at the major histocompatibility complex (MHC). 11 of these patients are alive at least 6 months after grafting, 5 of them after more than 2 years. Of the 15 patients aged under 20 at the time of the graft, 8 are alive and well 6 months to 3 years later. Cyclosporin A was given to all patients after grafting. 1 patient died of acute graft-versus-host disease and in 2 other cases this was a major factor in their death. Graft failure caused the death of 2 patients. 4 patients died of recurrent leukaemia. A fatal complication in 12 patients was pulmonary oedema, often associated with convulsions, intravascular haemolysis, and renal failure. Some of these patients had viral or bacterial infections, but in the majority the syndrome was not associated with demonstrable infection. This syndrome, in which the essential lesion appears to be vascular, was much more common in recipients of mismatched than matched grafts. 3 others died from lung disease in which infection was a factor.

Cyclosporin A following matched and mismatched family allogeneic bone marrow transplants

One hundred and nineteen patients with leukaemia have received CSA as prophylaxis against acute GVHD following sibling MHC matched (84) or family member mismatched bone marrow transplants (35). four recipients of matched transplants (3%) died of acute GVHD, a marked improvement on our previous results using methotrexate (26 patients; 27% died of GVHD). Thirty-five patients received mismatched transplants, 15 were under the age of 20 years and eight are alive and in remission, the longest survivor being one at 2 1/2 years after transplant.