Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis

Abstract Despite wide use in clinical practice, acupuncture remains a controversial treatment for chronic pain. Our objective was to update an individual patient data meta-analysis to determine the effect size of acupuncture for four chronic pain conditions.We searched MEDLINE and the Cochrane Central Registry of Controlled Trials randomized trials published up until December 31, 2015. We included randomized trials of acupuncture needling versus either sham acupuncture or no acupuncture control for non-specific musculoskeletal pain, osteoarthritis, chronic headache, or shoulder pain. Trials were only included if allocation concealment was unambiguously determined to be adequate. Raw data were obtained from study authors and entered into an individual patient data meta-analysis. The main outcome measures were pain and function. An additional 13 trials were identified, with data received for a total of 20,827 patients from 39 trials. Acupuncture was superior to both sham and no acupuncture control for each pain condition (all p<0.001) with differences between groups close to 0.5 standard deviations (SD) for comparison with no acupuncture control and close to 0.2 SDs in comparison with sham. We also found clear evidence that the effects of acupuncture persist over time with only a small decrease, approximately 15%, in treatment effect at one year. In secondary analyses, we found no obvious association between trial outcome and characteristics of acupuncture treatment, but effect sizes of acupuncture were associated with the type of control group, with smaller effects sizes for sham controlled trials that used a penetrating needle for sham, and for trials that had high intensity of intervention in the control arm.We conclude that acupuncture is effective for the treatment of chronic pain, with treatment effects persisting over time. While factors in addition to the specific effects of needling at correct acupuncture point locations are important contributors to the treatment effect, decreases in pain following acupuncture cannot be explained solely in terms of placebo effects. Variations in the effect size of acupuncture in different trials are driven predominately by differences in treatments received by the control group rather than by differences in the characteristics of acupuncture treatment. Perspective Acupuncture is effective for the treatment of chronic musculosketal, headache and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain

Obstructive sleep apnea and Fuhrman grade in patients with clear cell renal cell carcinoma treated surgically

PURPOSE: To assess the association between obstructive sleep apnea (OSA) and Fuhrman grade in patients with clear cell renal cell carcinoma (ccRCC). As secondary endpoints, we studied its association with tumor size, metastasis-free survival (MFS) and cancer-specific survival (CSS). METHODS: We reviewed the databases of two tertiary care centers, identifying 2579 patients who underwent partial or radical nephrectomy for ccRCC between 1991 and 2014. Descriptive statistics were used to compare pathologic variables between patients with and without OSA. Linear and logistic regression models were used to assess the association of OSA with Fuhrman grade and tumor size. A Cox proportional hazards model was used to determine OSA association with MFS and CSS. A pathway analysis was performed on a cohort with available gene expression data. RESULTS: In total, 172 patients (7 %) had self-reported OSA at diagnosis. More patients with OSA had high Fuhrman grade compared to those without OSA [51 vs. 38 %; 13 % risk difference; 95 % confidence interval (CI), 5-20 %; p = 0.003]. On multivariable analysis, the association remained significant (OR 1.41; 95 % CI 1.00-1.99; p = 0.048). OSA was not associated with tumor size (p > 0.5), MFS (p = 0.5) or CSS (p = 0.4). A trend toward vascular endothelial growth factor pathway enrichment was seen in OSA patients (p = 0.08). CONCLUSIONS: OSA is associated with high Fuhrman grade in patients undergoing surgery for ccRCC. Pending validation of this novel finding in further prospective studies, it could help shape future research to better understand etiological mechanisms associated

Empirical estimates of prostate cancer overdiagnosis by age and prostate-specific antigen

Background: Prostate cancer screening depends on a careful balance of benefits, in terms of reduced prostate cancer mortality, and harms, in terms of overdiagnosis and overtreatment. We aimed to estimate the effect on overdiagnosis of restricting prostate specific antigen (PSA) testing by age and baseline PSA.Methods: Estimates of the effects of age on overdiagnosis were based on population based incidence data from the US Surveillance, Epidemiology and End Results database. To investigate the relationship between PSA and overdiagnosis, we used two separate cohorts subject to PSA testing in clinical trials (n = 1,577 and n = 1,197) and a population-based cohort of Swedish men not subject to PSA-screening followed for 25 years (n = 1,162).Results: If PSA testing had been restricted to younger men, the number of excess cases associated with the introduction of PSA in the US would have been reduced by 85%, 68% and 42% for age cut-offs of 60, 65 and 70, respectively. The risk that a man with screen-detected cancer at age 60 would not subsequently lead to prostate cancer morbidity or mortality decreased exponentially as PSA approached conventional biopsy thresholds. For PSAs below 1 ng/ml, the risk of a positive biopsy is 65 (95% CI 18.2, 72.9) times greater than subsequent prostate cancer mortality.Conclusions: Prostate cancer overdiagnosis has a strong relationship to age and PSA level. Restricting screening in men over 60 to those with PSA above median (>1 ng/ml) and screening men over 70 only in selected circumstances would importantly reduce overdiagnosis and change the ratio of benefits to harms of PSA-screening

Public Health and Public Perception in the Franco-African Experience of the 1918 Influenza Pandemic

Senior Project submitted to The Division of Languages and Literature of Bard College

Interpreting Patient Reported Urinary and Sexual Function Outcomes across Multiple Validated Instruments

PurposeComparing patient reported outcomes such as urinary and erectile function across institutions is critical for prostate cancer research and quality assurance. Such comparisons are complicated due to the use of different questionnaires. We aimed to develop a method to convert scores among 4 commonly used instruments.Materials and methodsPatient reported data on urinary and sexual function were collected on 1,284 men with localized prostate cancer using the EPIC-26 (Expanded Prostate Index Composite), PCI (UCLA Prostate Cancer Index), SHIM (Sexual Health Inventory for Men) and I-PSS (International Prostate Symptom Scale) questionnaires. We investigated several methods to convert scores among questionnaires.ResultsConversion between EPIC and PCI urinary and sexual function subscales was best achieved using only the subset of questions asked on both questionnaires. For the conversion between EPIC or PCI erectile function scores and SHIM scores, we defined thresholds of poor, intermediate and good function as EPIC/PCI 0 to 40 and SHIM 1 to 7, EPIC/PCI 41 to 59 and SHIM 8 to 16, and EPIC/PCI 60 to 100 and SHIM 17 to 25, respectively. Urinary continence scores highly correlated for PCI and EPIC (r = 0.94). No comparison was possible for I-PSS with EPIC and PCI due to differences in the domains addressed by these questionnaires.ConclusionsWe have introduced methods to convert scores among the EPIC, PCI and SHIM questionnaires. While these conversion methods may introduce minor imprecision, to our knowledge they represent the best available tools to combine and compare patient reported outcomes that are assessed using different instruments in men undergoing radical prostatectomy or active surveillance