Are Sham Acupuncture Interventions More Effective than (Other) Placebos? A Re-Analysis of Data from the Cochrane Review on Placebo Effects

Background and Objective: A recent Cochrane review on placebo interventions for all kinds of conditions found that `physical placebos' (which included sham acupuncture) were associated with larger effects over no-treatment control groups than `pharmacological placebos'. We re-analyzed the data from this review to investigate whether effects associated with sham acupuncture differed from those of other `physical placebos'. Methods: All trials included in the Cochrane review as investigating `physical placebos' were classified as investigating either (sham) acupuncture or other physical placebos. The latter group was further subclassified into groups of similar interventions. Data from the Cochrane review were re-entered into the RevMan 5 software for meta-analysis. The primary analysis was a random-effects analysis of trials reporting continuous outcomes of trials that used either sham acupuncture or other physical placebos. Results: Out of a total of 61 trials which reported a continuous outcome measure, 19 compared sham acupuncture and 42 compared other physical placebos with a no-treatment control group. The trials re-analyzed were highly heterogeneous regarding patients, interventions and outcomes measured. The pooled standardized mean difference was -0.41 (95% confidence interval -0.56, -0.24) between sham acupuncture and no treatment and -0.26 (95% CI -0.37, -0.15) between other physical placebos and no treatment (p value for subgroup differences = 0.007). Significant differences were also observed between subgroups of other physical placebos. Conclusion: Due to the heterogeneity of the trials included and the indirect comparison our results must be interpreted with caution. Still, they suggest that sham acupuncture interventions might, on average, be associated with larger effects than pharmacological and other physical placebos

The challenges of assessing evidence of practice learning (from an English perspective)

This paper discusses the complexities of evidencing and assessing work-based learning, within educational, professional programmes at post-qualifying levels. Through an exploration of how learning takes place in practice situations and the most commonly used method of evidence collection and assessment, portfolio-building, the paper debates the principles, rationale and characteristics underpinning assessment of practice in health and social care. The author concludes that there are two aspects of evidence collection and its assessment that must be clarified. One aspect being that the objectives of collecting evidence need to be understood by all stakeholders, particularly in respect of the interface between professional regulation and professional development. The second aspect relates to the format and focus of the assessment strategy. The paper offers a framework for understanding the nature and purpose of evidence collection and its place in the assessment of practice in the context of post-qualifying continuing professional education. The author’s objective is that this paper and the analytical model proposed, should contribute to the professional knowledge-base about ‘practical experiences in professional education’ by raising awareness and debate about how professional post-qualifying education and learning in practice is evidenced and assessed

Position and interpretation of adjuncts: process, event and wieder 'again'

This paper deals with restitutive and repetitive wieder. Proceeding from the assumption that adverbial adjuncts have base positions which reflect their semantic relations to the rest of the sentence, it is shown that repetitive wieder belongs to the class of event adverbs minimally c-commanding the base positions of all arguments whereas restitutive wieder has many properties in common with process adjuncts, minimally c-commanding the final verb

Spatially explicit groundwater vulnerability assessment to support the implementation of the Water Framework Directive – a practical approach with stakeholders

The main objective of the study presented in this paper was to develop an evaluation scheme which is suitable for spatially explicit groundwater vulnerability assessment according to the Water Framework Directive (WFD). Study area was the Hase river catchment, an area of about 3 000 km2 in north-west Germany which is dominated by livestock farming, in particular pig and poultry production. For the Hase river catchment, the first inventory of the WFD led to the conclusion that 98% of the catchment area is "unclear/unlikely" to reach a good groundwater status due to diffuse nitrogen emissions from agriculture. The groundwater vulnerability assessment was embedded in the PartizipA project ("Participative modelling, Actor and Ecosystem Analysis in Regions with Intensive Agriculture", www.partizipa.net), within which a so-called actors´ platform was established in the study area. The objective of the participatory process was to investigate the effects of the WFD on agriculture as well as to discuss groundwater protection measures which are suitable for an integration in the programme of measures. The study was conducted according to the vulnerability assessment concept of the Intergovernmental Panel on Climate Change, considering sensitivity, exposure and adaptive capacity. Sensitivity was computed using the DRASTIC index of natural groundwater pollution potential. Exposure (for a reference scenario) was computed using the STOFFBILANZ nutrient model. Several regional studies were analysed to evaluate the adaptive capacity. From these studies it was concluded that the adaptive capacity in the Hase river catchment is very low due to the economic importance of the agricultural sector which will be significantly affected by groundwater protection measures. As a consequence, the adaptive capacity was not considered any more in the vulnerability assessment. A groundwater vulnerability evaluation scheme is presented which enjoys the advantage that both exposure and sensitivity can be operationalized in a spatially resolved manner (500×500 m grid) by the two models mentioned above. The evaluation scheme was applied in the Hase river catchment. 21% of the catchment was classified as highly vulnerable, another 73% as medium vulnerable. Only 6% of the Hase river catchment has low vulnerability. Grid cells of the high vulnerability class are considered as priority areas for groundwater protection measures in the programme of measures of the WFD. Measures will be particularly effective in the north-eastern part of the catchment where groundwater vulnerability is mainly due to high nitrogen emissions

Phosphorus in pig diets

Pig feed is mainly based on cereals where phosphorus (P) is mostly present in inositol hexaphosphate (IP6), which is not readily available to monogastric animals. More available P sources are often added to ensure that pigs’ requirements are fulfilled; this results in high excretion levels of P. The digestibility of P depends on phytase activity and amount of IP6 in feedstuffs. The overall aim was to study effects of liquid feeding, P levels and phytase supplementation on digestibility and performance. Effects of soaking and P levels on digestibility were studied by total collection in metabolic cages, and effects on performance were studied in 192 growing pigs. Effects of soaking fermentation and phytase supplementation on ileal and total tract digestibility were studied with indicator technique on pigs surgically fitted with PVTC cannulas. P levels and phytase supplementation were studied in 104 pregnant sows for two reproduction cycles. All diets were cereal based and included wheat. Basic properties of a cereal mix fermented with whey, wet wheat distillers’ grain and water in different temperatures were also studied. Soaking reduced the level of IP6, whereas apparent digestibility of P was not significantly improved. Soaking increased average daily weight gain, carcass weights and improved the energy conversion ratio in pigs fed a low P diet to the same level as pigs fed high P diets. Low P diets resulted in lower femur density than high P diets. However, soaking of a low P diet resulted in increased femur density. Fermentation degraded IP6 efficiently and improved ileal apparent digestibility of P, organic matter, nitrogen, amino acids and total tract apparent digestibility of organic matter. Microbiological and biochemical properties of fermented liquid diets are strongly affected by feed components and temperature used. Phytase supplementation slightly affected apparent digestibility of P. Supplementing a low P gestation diet with phytase did not significantly affect sow performance. The slight effects of phytase supplementations found may depend on high levels of intrinsic phytase in the diets, and possibly suggest that the provided P level in the sows may have been sufficient. Under typical Swedish conditions of sow management, reduced total P level in gestation diets seems not to negatively affect performance

British art show 7: in the days of the comet

Exhibit: Karin Ruggaber’s wall-based Relief #90 presents an arrangement of tile-like forms resembling finds from an archaeological dig. Made from an amalgam of natural and man-made materials – shredded tree bark, concrete and plaster – each component part is cast using a process that produces unpredictable outcomes. Assembled on the wall, the individual parts engage with and activate empty space, while sometimes repeating, copying or mirroring each other. As Ruggaber comments, the work is ‘a kind of tableau, and in this sense it contains and plays with the elements of scenery, such as a focal point, background and foreground.’ Karin Ruggaber's Relief No 90 is an array of small painted sculptures, or sculpted paintings, each with its imprecise suggestion of a form – palettes, clogs, violins, crescent moons – hints from the real world and with the real world carried in their surfaces, from tree bark to pebble and moss. Dancing across the wall, they invoke small objects in rhythm and yet at the same time the turning world itself, the ground beneath one's feet; as beautifully ordered as the words in a sonnet