Acupuncture in pain medicine: An integrated approach to the management of refractory pain

As the acupuncture nomenclature permeates medical literature, the artificial barriers to integration of acupuncture and allopathic medicine are disappearing. More patients are looking to their physicians for guidance on how to incorporate acupuncture into their health care, and pain physicians are accepting the challenge. Similar to allopathic medicine, acupuncture is an intricate diagnostic and therapeutic system. However, for practicing physicians, mastery of the skills necessary for safe and effective treatment of many conditions is well within reach. Used in an integrated medical model, acupuncture is well suited to deal with many of the functional problems that allopathic medicine is not equipped to address. The result is patient and physician satisfaction.     

Worldwide risk factors for heart failure: A systematic review and pooled analysis

Background

Heart failure risk factors are diverse and likely to vary among world regions. Systematic review and pooled analysis were used to describe contributions of major underlying risk factors for heart failure in six world regions.

Methods

Electronic databases were systematically searched, and 37 clinic-based studies representing 40 countries published in 1980–2008 and reporting underlying risk factors for heart failure were included. Risk factors were classified as ischemic heart disease (IHD), hypertension, rheumatic/other valvular heart disease, cardiopulmonary disease, cardiomyopathy, and “other”. Crude and age- and sex-adjusted risk factor prevalences were estimated for each region using a regression analysis, under specifications of overlapping as well as additive contributions.

Results

Many heart failure cases were assigned multiple underlying risk factors, leading to a considerable overlap. Crude IHD prevalence among heart failure patients was > 50% in Europe and North America, approximately 30–40% in East Asia and Latin America and the Caribbean, and < 10% in Sub-Saharan Africa. Age and sex adjustment attenuated regional differences in IHD-as-risk factor but IHD remained rare in Sub-Saharan Africa. Hypertension prevalence was high in heart failure patients of all regions but the highest in Eastern and Central Europe and Sub-Saharan Africa (age- and sex-adjusted, 35.0% and 32.6%, respectively). Cardiomyopathy was most common in Latin America, the Caribbean and Sub-Saharan Africa (age- and sex-adjusted, 19.8% and 25.7%).

Conclusions

Heart failure risk factors vary substantially among world regions. More detailed regional heart failure epidemiology studies are needed in order to quantify the global burden of heart failure and identify regional prevention and treatment strategies.     

Metformin‐associated lactic acidosis (MALA): Moving towards a new paradigm

Although metformin has been used for over 60 years, the balance between the drug's beneficial and adverse effects is still subject to debate. Following an analysis of how cases of so‐called “metformin‐associated lactic acidosis” (MALA) are reported in the literature, the present article reviews the pitfalls to be avoided when assessing the purported association between metformin and lactic acidosis. By starting from pathophysiological considerations, we propose a new paradigm for lactic acidosis in metformin‐treated patients. Metformin therapy does not necessarily induce metformin accumulation, just as metformin accumulation does not necessarily induce hyperlactatemia, and hyperlactatemia does not necessarily induce lactic acidosis. In contrast to the conventional view, MALA probably accounts for a smaller proportion of cases than either metformin‐unrelated lactic acidosis or metformin‐induced lactic acidosis. Lastly, this review highlights the need for substantial improvements in the reporting of cases of lactic acidosis in metformin‐treated patients. Accordingly, we propose a check‐list as a guide to clinical practice.     

Cardiovascular Effects of Medical Marijuana: A Systematic Review

Utilization of marijuana as a medicinal agent is becoming increasingly popular, and so far, 25 states have legalized it for medical purposes. However, there is emerging evidence that marijuana use can result in cardiovascular side effects, such as rhythm abnormalities, syncope/dizziness, and myocardial infarction, among others. Further, there are currently no stringent national standards or approval processes, like Food and Drug Administration (FDA) evaluation, in place to assess medical marijuana products. This review includes the largest up-to-date pooled population of patients with exposure to marijuana and reported cardiovascular effects. Although purported as benign by many seeking to advance the use of marijuana as an adjunctive medical therapy across the country, marijuana is associated with its own set of cardiovascular risks and deserves further definitive study and the same level of scrutiny we apply in research of all other types of medications. When used as a medicinal agent, marijuana should be regarded accordingly, and both clinical providers and patients must be aware of potential adverse effects associated with its use for early recognition and management.     

Growth characteristics of ChimeriVax-Den vaccine viruses in Aedes aegypti and Aedes albopictus from Thailand

Four chimeric yellow fever (YF) 17D-dengue (DEN) candidate vaccine viruses (ChimeriVax-DEN; Acambis, Cambridge, MA) were characterized in Aedes aegypti and Ae. albopictus mosquitoes collected from Thailand. The four vaccine viruses contained the relevant prM and E genes of wild-type dengue viruses (DENV; serotypes 1-4) substituted for the equivalent genes in the YF vaccine virus (17D) backbone. Each chimera conferred protection against the homologous DENV serotype; a tetravalent mix of all four chimeras stimulates an immune response against all serotypes. Field-collected mosquitoes from Thailand were fed on blood containing each of the viruses under study and held 21 days after infection. Infection and dissemination rates were based on antigen detection in the body or head tissues, respectively. All four wild-type DENV serotypes infected and disseminated, but the candidate vaccine viruses were highly attenuated in mosquitoes with respect to infection and especially with respect to dissemination. Considering the low level viremias anticipated in humans vaccinated with these viruses, it is predicted that the risks of infection and transmission by mosquitoes in nature is minimal.     

The Detectability and Localization Accuracy of Implanted Fiducial Markers Determined on In-Room Computerized Tomography (CT) and Electronic Portal Images (EPI)

Many different methods of image guidance are available for radiotherapy treatment (IGRT). The aims of the study were (1) to determine the optimal diameter of gold markers for IGRT to the prostate; (2) to compare, using the Siemens Primatom, the relative merits of in-room computerized tomography (CT) and electronic portal image (EPI) for locating the marker seeds. Gold markers of differing widths were embedded in 2 phantoms (perspex slabs and anthropomorphic). Images were acquired with an amorphous silicon flat panel detector (Siemens Optivue 500) and with the in-room CT scanner (Siemens Somatom Balance). The EPIs were reviewed independently by 6 operators to determine which diameter marker could be best visualized. The optimal marker technique was determined by comparing the investigators' observed marker co-ordinates with the known locations within the phantom. The visibility of all markers on anterior-posterior EPIs was 100%. On the lateral EPI, of a possible 180 visualizations of 1.2-, 1.0-, and 0.8-mm diameter markers, 176 (97.8%), 151 (83.9%), and 132 (73.3%), respectively, were successful. On EPI, the average deviation of fiducial markers from the known position was less than 0.5 mm in any direction. On CT, the largest deviation (2.17 mm) of markers from the known coordinate position was in the superior-inferior direction, reflecting the 3.0-mm slice thickness used. EPI accurately located internal markers in all dimensions. The availability of “gold standard” CT imagery at the treatment unit does not improve how accurately the position of markers in a phantom can be defined compared with EPI. However, CT imagery does provide important soft tissue information, the benefits of which are being investigated further.     

National,regional, and global trends in adult overweight and obesity prevalences

Background

Overweight and obesity prevalence are commonly used for public and policy communication of the extent of the obesity epidemic, yet comparable estimates of trends in overweight and obesity prevalence by country are not available.

Methods

We estimated trends between 1980 and 2008 in overweight and obesity prevalence and their uncertainty for adults 20 years of age and older in 199 countries and territories. Data were from a previous study, which used a Bayesian hierarchical model to estimate mean body mass index (BMI) based on published and unpublished health examination surveys and epidemiologic studies. Here, we used the estimated mean BMIs in a regression model to predict overweight and obesity prevalence by age, country, year, and sex. The uncertainty of the estimates included both those of the Bayesian hierarchical model and the uncertainty due to cross-walking from mean BMI to overweight and obesity prevalence.

Results

The global age-standardized prevalence of obesity nearly doubled from 6.4% (95% uncertainty interval 5.7-7.2%) in 1980 to 12.0% (11.5-12.5%) in 2008. Half of this rise occurred in the 20 years between 1980 and 2000, and half occurred in the 8 years between 2000 and 2008. The age-standardized prevalence of overweight increased from 24.6% (22.7-26.7%) to 34.4% (33.2-35.5%) during the same 28-year period. In 2008, female obesity prevalence ranged from 1.4% (0.7-2.2%) in Bangladesh and 1.5% (0.9-2.4%) in Madagascar to 70.4% (61.9-78.9%) in Tonga and 74.8% (66.7-82.1%) in Nauru. Male obesity was below 1% in Bangladesh, Democratic Republic of the Congo, and Ethiopia, and was highest in Cook Islands (60.1%, 52.6-67.6%) and Nauru (67.9%, 60.5-75.0%).

Conclusions

Globally, the prevalence of overweight and obesity has increased since 1980, and the increase has accelerated. Although obesity increased in most countries, levels and trends varied substantially. These data on trends in overweight and obesity may be used to set targets for obesity prevalence as requested at the United Nations high-level meeting on Prevention and Control of NCDs.