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

Systematic reviews of complementary therapies – an annotated bibliography. Part 3: Homeopathy

Background Complementary therapies are widespread but controversial. We aim to provide a comprehensive collection and a summary of systematic reviews of clinical trials in three major complementary therapies (acupuncture, herbal medicine, homeopathy). This article is dealing with homeopathy. Potentially relevant reviews were searched through the register of the Cochrane Complementary Medicine Field, the Cochrane Library, Medline, and bibliographies of articles and books. To be included articles had to review prospective clinical trials of homeopathy; had to describe review methods explicitly; had to be published; and had to focus on treatment effects. Information on conditions, interventions, methods, results and conclusions was extracted using a pretested form and summarized descriptively. Results Eighteen out of 22 potentially relevant reviews preselected in the screening process met the inclusion criteria. Six reviews addressed the question whether homeopathy is effective across conditions and interventions. The majority of available trials seem to report positive results but the evidence is not convincing. For isopathic nosodes for allergic conditions, oscillococcinum for influenza-like syndromes and galphimia for pollinosis the evidence is promising while in other areas reviewed the results are equivocal. Interpretation Reviews on homeopathy often address general questions. While the evidence is promising for some topics the findings of the available reviews are unlikely to end the controversy on this therapy

How German general practitioners justify their provision of complementary and alternative medicine

Background: Many German general practitioners (GPs) use complementary and alternative medicine (CAM) in their daily work although most CAM procedures are controversial from an academic point of view. Objective: We aimed to investigate how GPs justify their use of CAM. Methods: We performed semi-structured, individual face-to-face interviews with 20 purposively sampled, experienced GPs providing primary care within the framework of the German statutory health insurance system. A grounded theory approach was used for data analysis. Results: All GPs participating in this study used at least some CAM in their clinical practice. Participants did not have any major conflicts when justifying their use of CAM therapies. Important arguments justifying CAM provision were: using it as a supplementary tool to conventional medicine; the feeling that evidence and science leave many problems in primary care unanswered; a strong focus on helping the individual patient, justifying the use of procedures not based on science for therapeutic and communicative purposes; a strong belief in one’s own clinical experience; and appreciation of placebo effects. In general, participants preferred CAM therapies which seemed at least somewhat plausible to them and which they could provide in an authentic manner. Conclusions: Our results suggest that many German GPs integrate CAM treatments in their routine primary carework without perceiving any major internal conflicts with professional ideals

Etnicitet mellem produktion og skole

På baggrund af et interview- og observationsstudie af produktionsskoleelever på tre forskellige produktionsskoler vil vi i denne artikel pege på, hvorledes praktiske arbejdsfællesskaber giver andre deltagelsesmuligheder for etniske minoritetselever sammenlignet med undervisningssituationer tilrettelagt på mere traditionel skolastisk vis. Vi vil pege på, at den traditionelle undervisning, hvor sproglig interaktion fungerer som det organiserende princip, ikke altid formår at matche etniske minoritetselevers dansksproglige forudsætninger, hvilket kan bidrage til at fremstille etniske minoritetselever som knapt så intellektuelt velfungerende. Dette kommer både til udtryk gennem undervisningsformerne og undervisningsmaterialerne. De mere praktiske arbejdsfællesskaber, som er dominerende på produktionsskolerne, synes i højere grad at positionere etniske minoritetselever som mere velfungerende, idet sprogbrugen her i højere grad nærmer sig dagligdagssprog, og de etniske minoritetselever får langt større muligheder for at bruge deres læringserfaringer fra andre kontekster end skolekontekster

Widespread use of pure and impure placebo interventions by GPs in Germany

Aim. To collect data on the use of placebo interventions by GPs in Germany. Methods. A questionnaire was mailed to 400 randomly selected GPs in Bavaria. Non-responders were reminded by telephone after 4 weeks and were given a second copy of the questionnaire after a further 3 weeks. Results. In all, 208 completed questionnaires were returned. The majority of GPs (88%) have used a placebo at least once in their practice; 45% have used pure placebos, such as saline injections and sugar pills, at least once last year; the median frequency of use was 5 [interquartile range (IQR), 2-10]. The use of impure placebos during the past year was more common: 76% of GPs have used impure placebos, i.e. medical interventions that have pharmacological or physical activity but have no intrinsic effect (e.g. pharmacological or physical action) on the patient's disease or its symptoms, with a median frequency of 20 times per year (IQR, 10-50). The main reason for the use of placebo was a possible psychological effect, followed by the expectation of patients to receive a treatment. For the majority of GPs placebo interventions were ethically justified if they were used for a possible psychological effect. Conclusions. Placebo interventions are a widely accepted part of medical treatment in German general practices and are used primarily for their psychological effects. Impure placebos are used much more frequently than pure placebo

Global Vertex Algebras on Riemann Surfaces

Conformal field theory is intimately connected to the theory of vertex algebras and the geometry of Riemann surfaces. In this thesis a new algebro-geometric structure called global vertex algebra is defined on Riemann surfaces which is supposed to be a natural generalization of vertex algebras. In order to define this structure a formal calculus of fields on Riemann surfaces is constructed. The basic objects in vertex algebra theory are fields. They are defined as formal Laurent series with possibly infinite principal part. The coefficients are endomorphisms. As an example for such a structure the global vertex algebra of bosons of Krichever-Novikov type will be constructed. At the beginning of this thesis the formal calculus of classical vertex algebras is introduced from the viewpoint of distributions in complex analysis. Furthermore a graphical calculus for the computation of correlation functions of primary fields associated to affine Kac-Moody algebras is introduced.Konforme Feldtheorie is eng mit der Theorie der Vertex-Algebren und der Geometrie Riemannscher Flaechen verknuepft. In der vorliegenden Arbeit wird eine neue algebro-geometrische Struktur, genannt Globale Vertex-Algebra, auf Riemannschen Flaechen definiert, die als natuerliche Verallgemeinerung von Vertex-Algebren verstanden wird. Dazu wird ein Formaler Kalkuel von Feldern auf Riemannschen Flaechen entwickelt. Als Beispiel fuer eine solche Struktur wird die Globale Vertex-Algebra fuer Bosonen vom Krichever-Novikov-Typ konstruiert. Zu Beginn der Arbeit wird der Formale Kalkuel fuer die klassischen Vertex-Algebren unter dem Gesichtspunkt von Distributionen in der komplexen Analysis dargestellt. Darueber hinaus wird ein graphischer Kalkuel zur Berechnung von Korrelationsfunktionen von Primaerfeldern assoziiert zu affinen Kac-Moody-Algebren vorgestellt

Effects of a Web-Based Intervention for Stress Reduction in Primary Care: A Cluster Randomized Controlled Trial

Background: Preliminary findings suggest that Web-based interventions may be effective in achieving significant stress reduction. To date, there are no findings available for primary care patients. This is the first study that investigates a Web-based intervention for stress reduction in primary care. Objective: The aim was to examine the short-term effectiveness of a fully automated Web-based coaching program regarding stress reduction in a primary care setting. Methods: The study was an unblinded cluster randomized trial with an observation period of 12 weeks. Individuals recruited by general practitioners randomized to the intervention group participated in a Web-based coaching program based on education, motivation, exercise guidance, daily text message reminders, and weekly feedback through the Internet. All components of the program were fully automated. Participants in the control group received usual care and advice from their practitioner without the Web-based coaching program. The main outcome was change in the Perceived Stress Questionnaire (PSQ) over 12 weeks. Results: A total of 93 participants (40 in intervention group, 53 in control group) were recruited into the study. For 25 participants from the intervention group and 49 participants from the control group, PSQ scores at baseline and 12 weeks were available. In the intention-to-treat analysis, the PSQ score decreased by mean 8.2 (SD 12.7) in the intervention group and by mean 12.6 (SD 14.7) in the control group. There was no significant difference identified between the groups (mean difference -4.5, 95% CI -10.2 to 1.3, P=. 13). Conclusions: This trial could not show that the tested Web-based intervention was effective for reducing stress compared to usual care. The limited statistical power and the high dropout rate may have reduced the study's ability to detect significant differences between the groups. Further randomized controlled trials are needed with larger populations to investigate the long-term outcome as well as the contents of usual primary care

Effects of a Web-Based Intervention for Stress Reduction in Primary Care: A Cluster Randomized Controlled Trial

Background: Preliminary findings suggest that Web-based interventions may be effective in achieving significant stress reduction. To date, there are no findings available for primary care patients. This is the first study that investigates a Web-based intervention for stress reduction in primary care. Objective: The aim was to examine the short-term effectiveness of a fully automated Web-based coaching program regarding stress reduction in a primary care setting. Methods: The study was an unblinded cluster randomized trial with an observation period of 12 weeks. Individuals recruited by general practitioners randomized to the intervention group participated in a Web-based coaching program based on education, motivation, exercise guidance, daily text message reminders, and weekly feedback through the Internet. All components of the program were fully automated. Participants in the control group received usual care and advice from their practitioner without the Web-based coaching program. The main outcome was change in the Perceived Stress Questionnaire (PSQ) over 12 weeks. Results: A total of 93 participants (40 in intervention group, 53 in control group) were recruited into the study. For 25 participants from the intervention group and 49 participants from the control group, PSQ scores at baseline and 12 weeks were available. In the intention-to-treat analysis, the PSQ score decreased by mean 8.2 (SD 12.7) in the intervention group and by mean 12.6 (SD 14.7) in the control group. There was no significant difference identified between the groups (mean difference -4.5, 95% CI -10.2 to 1.3, P=. 13). Conclusions: This trial could not show that the tested Web-based intervention was effective for reducing stress compared to usual care. The limited statistical power and the high dropout rate may have reduced the study's ability to detect significant differences between the groups. Further randomized controlled trials are needed with larger populations to investigate the long-term outcome as well as the contents of usual primary care

Acupuncture in Seasonal Allergic Rhinitis (ACUSAR) - Design and Protocol of a Randomised Controlled Multi-Centre Trial

Background: We report on the study design and protocol of a randomised controlled trial (Acupuncture in Seasonal Allergic Rhinitis, ACUSAR) that investigates the efficacy of acupuncture in the treatment of seasonal allergic rhinitis (SAR). Objective: To investigate whether acupuncture is non-inferior or superior to (a) penetrating sham acupuncture and (b) rescue medication in the treatment of SAR. Design: 3-armed, randomised controlled multi-centre trial with a total follow-up time of 16 weeks in the 1st year and 8 weeks in the 2nd year. Setting: 41 physicians in 37 out-patient units in Germany specialised in acupuncture treatment. Patients: 400 seasonal allergic rhinitis patients with clinical symptoms and test-positive (skin-prick test and/or specific IgE) to both birch and grass pollen. Interventions: Patients will be randomised in a 2:1:1 ratio to one of three groups: (a) semi-standardised acupuncture plus rescue medication (cetirizine); (b) penetrating sham acupuncture at non-acupuncture points plus rescue medication; or (c) rescue medication alone for 8 weeks (standard treatment group). Acupuncture and sham acupuncture will consist of 12 treatments per patient over 8 weeks. Main Outcome Measures: Average means of the Rhinitis Quality of Life Questionnaire (RQLQ) overall score and the Rescue Medication Score (RMS) between weeks 6 and 8 in the first year, adjusted for baseline values. Outlook: The results of this trial available in 2011 will have a major impact on the decision of whether acupuncture should be considered as a therapeutic option in the treatment of SAR