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Halfway through March, we're still waiting — patiently -- for the first major GOP presidential candidate to enter the race. (Hint, hint.)
At this point, though,we have a good sense of how the field will shake out – or at least who might run. Former Massachusetts governor Mitt Romney, former House Speaker Newt Gingrich, former Minnesota governor Tim Pawlenty and former Pennsylvania Sen. Rick Santorum are basically in, while several others –former Alaska governor Sarah Palin, former Arkansas governor Mike Huckabee, Indiana Gov. Mitch Daniels – are giving it serious thought.

subset: commoncrawl


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Conceived and designed the experiments: KBC YH. Performed the experiments: KBC JPZ YH. Analyzed the data: KBC. Contributed reagents/materials/analysis tools: KBC. Wrote the manuscript: CKB. Comments on meta-analysis: ZJZ.
Acupuncture therapy for preventive and treatment of postoperative nausea and vomiting(PONV), a condition which commonly present after anaesthesia and surgery is a subject of growing interest.
This paper included a systematic review and meta-analysis on the effect of different type of acupuncture and acupoint selection in PONV prevention and treatment.
Randomised controlled trials(RCTs) comparing acupuncture with non-acupuncture treatment were identified from databases PubMed, Cochrane, EBSCO, Ovid, CNKI and Wanfangdata. Meta-analysis on eligible studies was performed using fixed-effects model with RevMan 5.2. Results were expressed as RR for dichotomous data, with 95%CI.
Thirty RCTs, 1276 patients (intervention) and 1258 patients (control) were identified. Meta-analysis showed that PC6 acupuncture significantly reduced the number of cases of early vomiting (postoperative 0-6h) (RR=0.36, 95%CI 0.19,0.71; P=0.003) and nausea (postoperative 0-24h) (RR=0.25, 95%CI 0.10,0.61; P=0.002), but not early nausea (postoperative 0-6h) (RR=0.64, 95%CI 0.34,1.19; P=0.150) and vomiting (postoperative 0-24h) (RR=0.82, 95%CI 0.48,1.38; P=0.450). PC6 acupressure significantly reduced the number of cases of nausea (RR=0.71, 95%CI 0.57,0.87; P=0.001) and vomiting (RR=0.62, 95%CI 0.49,0.80; P=0.000) at postoperative 0-24h. PC6 electro-acupoint stimulation significantly reduced the number of cases of nausea (RR=0.49, 95%CI 0.38,0.63; P<0.000) and vomiting (RR=0.50, 95%CI 0.36,0.70; P<0.000) at postoperative 0-24h. Stimulation of PC6 with other acupoint(s) significantly reduced the number of cases of nausea and vomiting (RR=0.29, 95%CI 0.17,0.49; P<0.000) at postoperative 0-24h. Stimulation of other acupoint(s)(non PC6) also significantly reduced the number of cases of nausea and vomiting (RR=0.63, 95%CI 0.49,0.81; P=0.000) at postoperative 0-24h. However, the quality of study was generally low in studies of PC6 combined with other acupoint(s) and other acupoint(s). Details of blinding were not reported in most reports.
Besides PC6, PC6 combined with other acupoint(s) and other alternative acupoint(s) might be beneficial in prevention and treatment of PONV, the evidence justifies future high-quality studies.
Postoperative nausea and vomiting (PONV) is a condition commonly present after anaesthesia and surgery, with overall incidence of 40%-90%[1]. Despite the use of newer drugs, PONV within 24 hours still occurs in 25%-30% of patients[2].
Though self-limitating, PONV can cause significant morbidity including dehydration, electrolyte imbalance, suture tension and dehiscence, venous hypertension and bleeding, esophageal rupture, and life-threatening airway compromise, although the more severe complications are rare[3]. PONV increases medical cost. An episode of vomiting could prolong postanaesthetic care unit (PACU) stay by about 25min[4].
Type of anaesthesia, type of surgery and site of operation contribute to PONV occurrence rate. Breast and gynaecological surgeries presented the most frequent report of PONV in adults[1]. Operations associated with high incidence of vomiting in children include strabismus, adenotonsillectomy, hernia repair, orchidopexy and penile surgery[4]. Research also demonstrated higher PONV occurrence rate in patients under general anaesthesia[5].
Limited efficacy and side effects with antiemetics led to the use of alternative treatment[1]. Researches in various countries believe acupuncture improves the quality of patients' life[2]. An inventory concerning 32,000 acupuncture consultations in UK revealed the most common adverse events of bleeding, needle pain and aggravation of symptoms, but none were serious[1]. Various type of acupuncture has been used in mainland China and abroad[2], but the most suitable method is yet to be confirmed.
According to the theory of traditional Chinese medicine (TCM), surgery breaks the balanced state of the human body and disturbs the movement of both qi and blood[6], causes the stomach qi to reverse its direction and go upward, causing nausea and vomiting[6]. One of the PC6's functions is to avoid the adverse flow of qi, thus is an effective acupoint in preventing nausea and vomiting[6].
Meta-analysis by Shiao SY and Dibble SL (2006)[7] showed additional effective meridian points included Korean hand points(K-K9, K-D2), bladder points(BL10, BL11, BL18-26), spleen points(SP4, SP6), stomach points(ST34, ST36, ST44), and others. Countries abroad found more than 30 meridians and acupoints effective for PONV treatment, though their specific use has not been thoroughly investigated[8].
Chu YC et al. 1998 found that prophylactic bilateral stimulation with noninvasive acuplaster at BL10, BL11 and GB34 in children significantly reduces vomiting after strabismus correction[9]. PC6 may act only on hollow organs while these acupoints are more related to the meridians of the eye[9].
Researchers gradually realised that PC6 may not be the only acupoint in PONV treatment[8]. Patients' diseases and specific symptoms should be considered for method of selection[8].
The timing of acupuncture intervenes has also been an argument. Dundee JW and Ghaly RG (1989)[10] demonstrated a significant reduction in PONV incidence following preoperative PC6 acupuncture. However, Weightman WM et al. (1987)[11], did not find similar effect in their studies. The former[10] gave a possible explanation in terms of the timing of acupuncture intervene. To be effective, it should be administrated before the emetic stimulus. Yang LC et al. (1993)[12], however, found that PC6 electro-acupuncture administered in the recovery room was effective in reducing postoperative emesis.
This study is carried out to evaluate the efficacy of different type of acupuncture, acupoint selection, optimal timing, technique of intervention, side effects and used of rescue therapy in PONV in the recent years.
A research protocol was drafted and approved by the faculty members. A copy was kept by the principal investigator.
Search criteria: We combined the following MeSH and text words with filters:
Database: PubMed, Cochrane Controlled Trials Register (CCTR), EBSCO, OVID, CNKI, Wanfangdata.
Supplementary search: http://www.google.cn and http://www.clinicaltrials.gov; to search for articles which could not be assessed from the database via the university library website and to check for any left out trials.
Unpublished trials were not included.
Any uncertainties were clarified by contacting the respective corresponding authors via e-mails.
Inclusioncriteria: 1. randomised controlled clinical trials (RCTs); 2. patients underwent surgery regardless of age, gender, ethnic, type of anaesthesia or surgery; 3. all forms of acupuncture; 4. publications within 1986 to 30 Jun 2013, full text articles in English or Chinese.
Primary outcomes: efficacy of different type of acupuncture and acupoint selection in prevention and treatment of PONV
Subgroups were divided according to the type of acupuncture (manual acupuncture, acupressure, electro-acupoint stimulation), acupoint (PC6, PC6 combined with other acupoint(s), other acupoint(s)) and time of PONV.
Control group consisted of standard care, sham, medication or counseling.
Complete prevention was defined as absence of nausea and vomiting within 0-6 h (early PONV), 6-24h (late PONV) and 0-24h for the whole operation.
Secondary outcomes: optimal timing, technique of intervention, side effects and used of rescue therapy
Exclusioncriteria: 1. non-randomised trials; 2. non clinical trials; 3. patients with other co-existing acute or chronic illness; 4. patients nausea and vomiting before operation; 5. patients taking anti-emetics medication before operation; 6. articles not in English or Chinese; 7. duplicate articles; 8. articles which data analysis did not fulfill protocol criteria.
Evaluation was performed independently by 2 authors (KBC & JPZ). Relevant, full articles were sorted and cross-examined. Any discrepancies were discussed or further evaluated by a 3rd author (YH). Data was collected using MS Excel 2010 which included the title of journals, author(s), year of publication, type of randomisation, type and duration of anaesthesia and surgery, type of intervention, sample size, details of participants, timing and technique of intervention, needle retention, depth of needle insertion, frequency and duration of intervention, results, conclusion, side effects and use of rescue therapy.
All trials satisfying the inclusion criteria were included in initial analysis (Figure 1). Trials whose protocols varied significantly from others were excluded.
Meta-analysis was performed using fixed-effects model with RevMan 5.2. Analysis was presented as RR (relative risk) for dichotomous data and 95%CI with P<0.05 as significant level. I2 values of 25%, 50%, and 75% represent low, moderate and high heterogeneity. Funnel plots were performed to check the existence of bias (outcome level). If heterogeneity showed P<0.1 or I2>50, sensitivity analysis were carried out; any outlier would be examined the cause of differences.
Quality of studies was assessed using GRADE profiler version 3.6. Items evaluated included:
According to GRADE Working Group grades of evidence[13], quality of studies was graded as high, moderate, low or very low:
All trials were evaluated using CONSORT[14] and STRICTA[15] for TCM according to the standard guideline. Items evaluated included title and abstract, introduction, methods, discussion and other information for CONSORT; acupuncture rationale, details of needling, treatment regimen, other components of treatment, practitioner background and control or comparator interventions for STRICTA.
Data was summarised in Table S1A-C. Of the 186 studies reviewed, finally 30 studies met the inclusion criteria for meta-analysis: 16(53.33%) on PC6[16-31], 6(20.00%) on PC6 combined with other acupoint(s)[32-37] and 8(26.67%) on other acupoint(s) (including auricular acupoints)[38-45].
All 16 studies on PC6 served as prevention. Of the 6 studies on PC6 combined with other acupoint(s), interventions were served as analgesic and prevention[32,35,36], prevention[33,37], and treatment[34]. Of the 8 studies on other acupoint(s) (3 on auricular acupuncture[42,45]/acupressure[41]), interventions were served as prevention[38,41,43-45], prevention and treatment[39], analgesic and prevention[40,42].
Of the 30 studies, 2(6.67%) were performed under i/v anaesthesia[16,25], 15(50.00%)[17,19,20,22,24,27,29-32,37,38,41,42,44] under general anaesthesia, 3(10.00%) under infusion-inhalation anesthesia (PCA)[18,21,26], 2(6.67%) under spinal anaesthesia[23,28], 4(13.33%) under epidural anaesthesia[35,36,39,45] and 2(6.67%) under local anaesthesia[40,43]. Another 2(6.67%) did not report the type of anaesthesia used[33,34].
One study on PC6[20] and 1 on other acupoint(s)[41] were based on paediatric population while the remaining were on adults.
Postoperative nausea: 4 studies, 281 participants, were divided into subgroups according to the time of PONV.
Postoperative nausea 0-6h (early postoperative nausea): Proportion of nausea in 3 pooled trials (200 participants) was 14%(14/100) for PC6 acupuncture and 22%(22/100) for control (no acupuncture). Pooled RR was 0.64(0.34,1.19); P=0.150 with no significant difference between the 2 groups[16-18] (Figure 2A)
Postoperative nausea 0-24h: Proportion of nausea in 3 pooled trials (231 participants) was 4.35%(5/115) for PC6 acupuncture and 18.96%(22/116) for control (no acupuncture). Pooled RR was 0.25(0.10,0.61); P=0.002. PC6 acupuncture significantly reduced the number of cases of nausea[17-19] (Figure 2B)
Postoperative vomiting: 5 studies, 326 participants were divided into subgroups according to the time of PONV.
Postoperative vomiting 0-6h (early postoperative vomiting): Proportion of vomiting in 3 pooled trials (200 participants) was 7.00%(7/100) for PC6 acupuncture and 21.00%(21/100) for control (no acupuncture). Pooled RR was 0.36(0.19,0.71); P=0.003. PC6 acupuncture significantly reduced the number of cases of vomiting[16-18] (Figure 3A.)
Postoperative vomiting 0-24h: Proportion of vomiting in 4 pooled trials (276 participants) was (13.04%)18/138 for PC6 acupuncture and 15.94%(22/138) for control (no acupuncture). Pooled RR was 0.82(0.48,1.38); P=0.450 with no significant difference between the 2 groups[17-20] (Figure 3B).
Postoperative nausea 0-24h: Proportion of nausea in 6 pooled trials (580 participants) was 30.82%(90/292) for PC6 acupressure and 43.40%(125/288) for sham control. Pooled RR was 0.71(0.57,0.87); P=0.001. PC6 acupressure significantly reduced the number of cases of postoperative nausea compared to sham group[21-26] (Figure 4A).
Postoperative vomiting 0-24h: Proportion of vomiting in 6 pooled trials (582 participants) was 24.23%(71/293) for PC-6 acupressure and 38.75%(112/289) for sham control. Pooled RR was 0.62(0.49,0.80); P=0.000. PC6 acupressure significantly reduced the number of cases of postoperative vomiting compared to sham group[21-26] (Figure 4B).
Postoperative nausea 0-24h: Proportion of nausea in 5 pooled trials (426 participants) was 26.51%(57/215) for PC6 electro-acupoint stimulation and 54.50%(115/211) for sham control. Pooled RR was 0.49(0.38,0.63); P<0.000. PC6 electro-acupoint stimulation significantly reduced the number of cases of postoperative nausea compared to sham group[27-31] (Figure 5A).
Postoperative vomiting 0-24h: Proportion of vomiting in 5 pooled trials (426 participants) was 17.67%(38/215) for PC6 electro-acupoint stimulation and 35.07%(74/211) for sham control. Pooled RR was 0.50(0.36,0.70); P<0.000. PC6 electro-acupoint stimulation significantly reduced the number of cases of postoperative vomiting compared to sham group[27-31] (Figure 5B).
Funnel plots were shown in Figure 6.
Postoperative nausea and vomiting 0-24h: Proportion of PONV in 6 pooled trials (527 participants) was 6.08%(16/263) for intervention group and 21.21%(56/264) for control group. Pooled RR was 0.29(0.17,0.49); P<0.000. Intervention group significantly reduced the number of cases of PONV compared to control group[32-37] (Figure 7).
Funnel plot were shown in Figure 8.
Postoperative nausea 0-24h: Proportion of nausea in 3 trials (234 participants) was 11.76%(14/119) for intervention group and 29.56%(34/115) for control group . Pooled RR was 0.41(0.24,0.69); P=0.001. Intervention group significantly reduced the number of cases of postoperative nausea compared to control group[38-40] (Figure 9A).
Postoperative vomiting 0-24h: Proportion of vomiting in 4 trials (337 participants) was 5.71%(10/175) for intervention group and 18.52%(30/162) for control group. Pooled RR was 0.32(0.17,0.61); P=0.000. Intervention group significantly reduced the number of cases of postoperative vomiting compared to control group[38-41] (Figure 9B).
Postoperative nausea and vomiting 0-24h: Proportion of PONV in 5 trials (396 participants) was 24.87%(49/197) for intervention group and 39.20%(78/199) for control group. Pooled RR was 0.63(0.49,0.81); P=0.000. Intervention group significantly reduced the number of cases of PONV compared to control group[38,42-45] (Figure 9C).
Funnel plot were shown in Figure 10.
Results of meta-analysis for all subgroups showed low to moderate heterogeneity, with P>0.1 and I2<50 (Figure 2-5,,77,,9).9). No bias was demonstrated (Funnel plots, Figure 6,,88,,10).10).
For PC6 acupuncture, manual needling was administered before[18] and after induction of anaesthesia[16,19,20]; and postoperatively[17]. All studies in PC6 acupressure intervened prior to induction of anaesthesia[21-26]. This is similar for PC6 electro-acupoint stimulation[27-31].
For PC6 combined with other acupoint(s), intervention were carried out before[32,36] and during induction of anaesthesia[35]; and during operation[33,34,37].
For other acupoint(s), intervention were performed before[43] and after induction of anaesthesia[39]; preoperatively[40,42,43,45] and postoperatively[38,44].
Time of needle retention for PC6 acupuncture varied from 5min[16,20], 30min[17] to whole duration of surgery[18,19]. PC6 acupressure was maintained for at least 24h[22,24,26]. Electro-acupoint stimulation was performed for 20min[27] or (30min[30,31] to 60min[28,29]) before induction of anaesthesia until 6h[30] to end of surgery[29] or 24 h[27,28,31] postoperatively.
For PC6 combined with other acupoint(s), in a study with manual acupuncture, needle was kept for every 7-8min until end of surgery[37], while for 30min[32] and 5-10 min[33] in transcutaneous electrical acupoint stimulation (TEAS).
For other acupoint(s), in 1 study, cupping therapy was applied for 10min at postoperative 6h and 24h[38]; in another study electro-acupuncture was performed for 25min, followed by acupoint injection bd[39]; in a study, auricular acupressure was performed for 1-3min for 2-3 times during surgery, followed by 3-4 times daily post-surgery[41]; in 1 study acupoint massage was performed for 10-15min every 4-6h[44]; and in another study auricular acupuncture was applied every 30min and kept until end of surgery[45].
Technique used in PC6 acupuncture included rotating, reinforcing-reducing[17,18] and rotating[19]. For PC6 acupressure "SeaBand"[21], "SeaBand" with beads[23,24,26] and "Vital-Band"[25] were used. Korean Hand acupressure used 2-mm diameter acupressure seeds[22]. For PC6 electro-acupoint stimulation, needling[27]; "active ReliefBand"[28]; surface[29] and (HANS) electrode[30,31] were used for stimulation. Electrical stimulation varied, with 4Hz[27] to 2-100Hz alternating waveform[29-31]. Reported current included 0.5-4mA, 50ms with conventional peripheral nerve stimulator (PNS) train-of-four (TOF) mode[29] and 2mA with HANS dual-channel unit[31].
For PC6 combined with other acupoint(s), technique used included TEAS at 2Hz/100Hz, 5-10mA[32], TEAS with relaxation therapy[33], acupoint injection[34], continuous electrical stimulation at 50-100Hz[35], electro-acupuncture at 16-50Hz, 10-15mA with HANS electrode[36] and manual acupuncture with rotating, reinforcing-reducing technique using filiform needles[37].
For other acupoint(s), cupping therapy[38], electro-acupuncture(10-50Hz, 1-2mA) with acupoint injection[39], catgut embedment[40], auricular acupressure (plaster therapy with Vaccaria seed)[41], auricular acupuncture[42,45], acupoint injection[43] and acupoint massage[44] had been used.
Three studies in PC6 acupuncture intervened bilaterally[17-19] while one at left PC6[20]. For PC6 acupressure, intervention was performed at dominant wrist[21]; right[23] and bilateral PC6[24,26]. One study applied Korean Hand acupressure at bilateral K-K9[22]. Another study intervened at PC6 ipsilateral to the site of anaesthesia[25]. For PC6 electro-acupoint stimulation, "ReliefBand" and HANS electrode was applied to the dominant hand[28,31], and right PC6[30]. Surface electrode was applied to left PC6 in 1 study[29].
For PC6 combined with other acupoint(s), manual acupuncture was performed at bilateral PC6, LI4, BL10, GB34, ST36, SP4, CV12, with supplementary acupoints LV3, SP6, SP9 and ST40[37], TEAS at bilateral LI4 and PC6[33], electro-acupuncture at bilateral PC6, ST36 and LI4[35,36] and acupoint injection at bilateral PC6 and ST36[34].
For other acupoint(s), electro-acupuncture 10-50Hz was performed at bilateral LI4 with acupoint injection at bilateral ST36[39], catgut embedment at bilateral BL57[40], bilateral auricular acupressure at CO13, C04, AT(brain) and TF4[41], auricular acupuncture at MA-AH4(AH5), MA-TF1(TF4), MA-IC1(CO14) ipsilateral to the surgery site[42], acupoint injection at bilateral ST36[43], bilateral ST36 acupoint massage[44] and right auricular acupuncture at TF4, AT(brain), CO18, with supplementary acupoint at TF5 and TF(Uterus)[45].
For PC6 acupuncture, needles used included 0.18mm and 0.20mm diameter[19,20] and 1-2cm, 30 steel wire gauge stainless steel[16]. For PC6 electro-acupoint stimulation, 1 study reported the use of (0.25 x 30)mm Serin no 5 Japan needles[27].
For PC6 combined with other acupoint(s), 1 study used no 1, 1.5 inch in length filiform needles for manual acupuncture[37].
For other acupoint(s), 1 study used auricular acupuncture needles size 0.22mm in diameter, 1.5mm in length[42], another study used disposable pinhead (0.90 x 38)mm and acupuncture needles of (0.30 x 50)mm for catgut embedment[40].
Of the 30 studies, 10(33.33%) reported no side effects. One study(3.33%) with acupressure wristbands and sham, reported redness, swelling, tenderness and paraesthesia of wrist and hand in approximately 1/3 of patients. The local side effects caused by the acupressure wristband were equally distributed between PC6 stimulation and sham[25]. Another study with acupressure band reported swelling and erythema of the treated hand, where patient finally excluded from the study[26]. A study on electro-acupuncture reported local complication of erythema in 15% of cases[27]. Two studies(6.67%) reported no major side effects[23,37]. The remaining 15(50.00%) studies did not report whether there were any side effects in their findings.
Of the 30 studies, 15(50.00%) reported use of anti-emetics, while 11(36.67%) reported comparison between the intervention and control group. Significant differences were noted in 4(13.33%) studies[23,26,27,29], one with Metoclopramide 10mg i/v[26], another three with Ondansetron 4mg i/v[23,27,29].
Subset analysis by gender in 1 study[24] with Dimenhydrinate 50mg i/v showed that acupressure group female patients required less antiemetic than control. However, no significant difference was noted in male patients.
No significant differences were reported in 5(16.67%) studies[24,25,28,30,31] with Dimenhydrinate 50mg i/v[24], Ondansetron 4mg i/v[28] and Metoclopramide 10mg i/v[30] and i/m[31].
Of the 30 studies (Table S1A-C), 4(13.33%) from PC6 demonstrated high quality of evidence[19,23,28,31] which involved manual acupuncture[19], acupressure[23] and TEAS[28,31] conducted in UK[19], Ireland[23], USA[28] and China[31]. Nine studies in PC6 showed moderate quality of evidence[18,20,22,24-27,29,30] while three showed low quality[16,17,21].
All studies in PC6 combined with other acupoint(s) showed low quality of evidence[32-37]. One study on other acupoint(s) (conducted in German) demonstrated moderate quality[42] while the remaining showed low quality[38-41,43-45].
Moderate quality of evidence was mainly due to precision not reported in the study outcomes while low quality of evidence was due to study not blinded and precision not reported in the study outcomes.
CONSORT: of the 30 studies, 18(60.00%) reported demographic baseline, 11(36.67%) reported sequence generalization randomisation, 5(16.67%) reported allocation concealment, 13(43.33%) reported details of blinding (Figure 11A).
STRICTA: Of the 30 studies, 14(46.67%) reported the style of acupuncture, 25(83.33%) reported acupoint locations, 6(20.00%) reported depth of needle insertion, 11(36.67%) reported response sought, 17(56.67%) reported needle stimulation, 15(50.00%) reported duration of needle retention and 7(23.33%) reported needle type (Figure 11B).
For prevention of nausea (postoperative 0-24h), PC6 acupuncture vs. no acupuncture had the lowest pooled RR, followed by PC6 electro-acupoint stimulation vs. sham and PC6 acupressure vs. sham. PC6 acupuncture vs. no acupuncture seemed to be most effective amongst the three groups, followed by PC6 electro-acupoint stimulation and PC6 acupressure vs. sham.
For prevention of vomiting (postoperative 0-24h), PC6 electro-acupoint stimulation vs. sham had the lowest pooled RR, followed by PC6 acupressure vs. sham and PC6 acupuncture vs. no acupuncture. PC6 electro-acupoint stimulation vs. sham seemed to be most effective amongst the 3 groups, followed by PC6 acupressure vs. sham and PC6 acupuncture vs. no acupuncture.
Overall, all modalities seemed to be effective in PONV prevention. Electrical stimulation with ReliefBand or electrodes might be more costly than manual needling, however it is reusable and more effective in some cases. ReliefBand and electrode were less invasive, require minimal training and cost-effective, though local effects such as swelling, erythema[25,26], tenderness or paraesthesia[25] had been reported in few studies with ReliefBand.
Meta-analysis by Shiao SY, Dibble SL 2006 found that acupressure was more effective in reducing symptoms for adults (pregnant or postoperative) than children, and is as effective and more feasible to use than medications and acupuncture modalities[7]. Study by El-Bandrawy AM et al 2013 showed a significant decrease in nausea and vomiting in patients treated by acupressure in addition to anti-emetic drug; while PC6 TEAS was more effective than acupressure in alleviating PONV after abdominal hysterectomy[46].
For PC6 acupuncture vs. no acupuncture, stimulation of PC6 significantly reduced the number of cases of early vomiting (postoperative 0-6h) and nausea (postoperative 0-24h). However, it seemed not effective for early nausea (postoperative 0-6h) and vomiting (postoperative 0-24h). At postoperative 0-24h, both PC6 acupressure and PC6 electro-acupoint stimulation vs. sham significantly reduced the number of cases of nausea and number of cases of vomiting.
Study by Streitberger K et al 2004[47] on PC6 acupuncture in women undergoing gynaecology and breast surgery showed that differences in incidence of PONV and/or use of anti-emetic rescue were more pronounced in patients having gynaecological surgery (48.9% acupuncture, 67.6% placebo, P=0.07) than breast surgery (38.7% acupuncture, 40.3% placebo, P=0.86). Author concluded acupuncture at PC6 might be effective in patients having gynaecological surgery, but not in patients having breast surgery.
In a study by Majholm B and Møller AM, 2011[25] using PC6 acupressure vs. sham, no statistical significance was noted for incidence of nausea or vomiting between the treatment and control group in women undergoing breast surgery.
PC6 intervention is simple, inexpensive, and noninvasive with minimal side effects. However, there were limitations with PC6 alone. For example, stimulation of PC6 in eye and breast surgery might not be effective. PC6 combined with other acupoint(s) and use of alternative acupoint(s), such as auricular acupuncture, cupping therapy, catgut embedment, might provide better prospect for prevention and treatment in PONV.
Meta-analysis showed that stimulation of PC6 combined with other acupoint(s) significantly reduced the number of cases of PONV compared to control group at postoperative 0-24h.
Stimulation of PC6 combined with other acupoint(s) at postoperative 0-24h had lower pooled RR compared to other acupoint(s) and seemed more effective than the latter. However, the efficacy in prevention of nausea or vomiting alone could not be evaluated due to lack of studies in the former group.
Common acupoints used were ST36 (Zusanli), LI10 (Shousanli) and LI4 (Hegu). ST36 is located along the Stomach Meridian of Foot-Yangming, which function in adjusting qi and blood, food transport and gastrointestinal activity. After surgery it helps to stimulate the relaxation of gastrointestinal contractions, and enhance body resistance. PC6 is located along the Pericardium Meridian of Hand-Jueyin. Stimulation of PC6 help to adjust the endocrine function, release of epinephrine and vasopressin, inhibit gastic acid secretion, regulate gastrointestinal motility, relieve stomach cramps, and has better effect on sympathetic vomiting and anaesthesia-induced nausea and vomiting. Stimulation of PC6 and ST36 produced better and strengthened anti-emesis effect.
Early stimulation of LI10 and ST36 is effective in PONV prevention and treatment in abdominal surgery. Stimulation of ST36 strengthens and helps to regulate the function of spleen and stomach digestion, smooth and clear the function of qi and blood. LI10 is an important acupoint of the Large Intestine Meridian of Hand-Yangming, and directly connected with the large intestine. It is beneficial in the regulation of the flow of qi and blood of the organs and postoperative symptoms of abdominal surgery.
LI4 is located along the Large Intestine Meridian of Hand-Yangming. With combination with ST36, it helps to regulate the stomach to function more smoothly. Stimulation of LI4, PC6 and ST36 effectively inhibit the vagus nerve which helps to stabilise the cardiovascular function, improve anaesthetic effect, enhance analgesia, adjust the autonomic functions of the digestive system, promote gastrointestinal peristalsis and facilitates patients' recovery.
Study by Yu JM et al 2010[32] on the effect of TEAS on breast radical carcinoma surgery showed that stimulation of LI4 with PC8 and PC6 with TE5 significantly reduced the need of analgesia and number of cases of PONV compared to control (under general analgesia only). It has been demonstrated that acupuncture produces analgesia via the body endorphin system which could be antagonized by naloxone[48]. The analgesic effect of TEAS may be related to its effect in up-regulating plasma beta-endorphin level[32].
Meta-analysis showed that stimulation of other acupoint(s) significantly reduced the number of cases of nausea and/or vomiting in patients at postoperative 0-24h.
Electro-acupuncture at bilateral LI4 with Vit B6 acupoint injection at bilateral ST36[39], bilateral ST36 acupoint injection with Metoclopramide[43], and alternating acupoint massaging were among the effective method used[44].
Lu ZX et al 2009[38] used cupping therapy for PONV prevention among patients undergoing laparoscopy cholecystectomy. Cupping was applied at the patients' back which consists of Du Mai (GV-, governing vessel) and the Kidney Meridian which helps to regulate the flow of blood and qi to become more smoothly and helps to balance yin and yang.
Yang W et al 2011[40] performed a preoperational catgut implantation at bilateral BL57 on patients undergoing hemorrhoid operation, and found to be significantly more effective than medication in reducing pain, nausea and vomiting.
Stimulation at acupoints such as large Intestine LI4 (on the hand), Spleen SP6 (on the lower limb), and "back-shu" (paravertebral area) have been shown to have analgesic properties[49].
Auricular acupoint application was found to be effective in reducing pain[42], nausea and vomiting[41,42,45], in adult[42,45] and children[41]. Auricular acupuncture reduced the concentration of 5-HT, which is the main cause of vomiting by acting on the peripheral nerve plexus of the small intestine of the receptor that mediate vomiting[45].
Boehler M et al 2002[22] found that Korean Hand acupressure on K-K9 (located at middle phalanx of the 4th finger, corresponds to PC6) was effective for reducing PONV in women after minor gynecological laparoscopic surgery.
Other effective Korean hand points (K-K9; K-D2), bladder points (BL10, BL11, BL18-26), spleen points (SP4, SP6), stomach points (ST34, ST36, ST44), and others (GB4, CV12, and others) were found to be as effective as PC6 and sometimes more so[7]. Study by Kim KS et al 2002[50] on capsicum plaster showed the effectiveness of K-D2 in reducing the incidence of PONV after abdominal hysterectomy was comparable to PC6.
Previous meta-analysis indicated that the antiemetic effect of acupuncture require treatment of awake rather than anesthetized patients[51]. Study by White PF et al 2005[52] to deduce the optimal timing of acustimulation for patients undergoing plastic surgery found that perioperative use of ReliefBand (applied for 30min before and 72h after surgery) significantly increased the complete responses (68%) compared to before surgery only (43%) (applied for 30 min before surgery). Median postoperative nausea scores were significantly reduced and patient satisfaction (with quality of recovery and antiemetic management) was significantly higher in the former group. For patients discharged on the day of surgery, time to home readiness was significantly reduced when acustimulation was administered perioperatively (vs. preoperatively). Acustimulation with ReliefBand was most effective in reducing PONV and improving patients' satisfaction with their antiemetic therapy when it was administered after surgery[52].
Systematic review by Holmér Pettersson P and Wengström Y 2012[1] found that acupuncture prior to surgery reduced the incidence of nausea but not vomiting compared to antiemetic prophylaxis alone.
Yentis SM and Vashisht S 1998[53] performed a study on whether antiemetic effect of PC6 acupuncture in preventing PONV is affected by the timing of administration in 50 patients undergoing major gynaecological surgery. Patients were randomly assigned to receive PC6 acupuncture either 5 min before induction of anaesthesia (Group 1), 5 min after induction of anaesthesia (Group 2) or when awake in recovery room post-operatively (Group 3). Results showed no significant differences in the emetic sequelae amongst the three groups, with incidence of vomiting of 29%, 24% and 25% within the first 6h post-operatively. General anaesthesia does not affect the antiemetic action of PC6 acupuncture.
Lee A and Done ML[54] showed that non-pharmacologic techniques (acupuncture, electro-acupuncture, TEAS, acupoint stimulation and acupressure) were more effective than placebo in preventing nausea and vomiting within 6h of surgery in adults, but not in children. Study by El-Bandrawy AM et al 2013 showed that time was an important variable, with significant effects of acupressure in the first 6 h[46].
Rotating, reinforcing-reducing[17,18,37] and rotating[19] were among the common technique used in manual acupuncture. Stimulation was performed for 2min[17,18], 1-2min[37] and 5s[19]. Response of "deqi' is usually sought to ensure stimulation.
"Seaband" with pressure stud[21], acupressure seed (2-mm diameter)[22], "Seaband" with beads [23,24,26], "Vital-Band" with stud[25], "ReliefBand"[28] and auricular plaster therapy with Vaccaria seed[41] had been used to exert pressure. In some cases, bead was pressed for 1 min[24] and brief presses of wristband for 30s were performed[25] to achieve stimulation.
It has been suggested that low frequency (2-4Hz) stimulation resulted in the release of endorphin and high frequency (50-200Hz) the release of encephalin[55]. Low frequency stimulation produced analgesia of slower onset but longer duration of time. High frequency stimulation resulted in more rapid onset but shorter duration[55]. Current intensity was usually increased to a degree just less than what caused discomfort or at a degree tolerable to patients.
Tang W et al 2013[56] evaluated the impacts of electro-acupuncture at bilateral PC6 at different frequencies in patients undergoing laparoscopic surgery under general anaesthesia. Patients were randomised into 2Hz electro-acupuncture (group A), 2Hz/100Hz electro acupuncture (group B), 100Hz electro acupuncture (group C) and control (group D). The incidence and severity of PONV in group B was apparently lower than other groups (P<0.01).
Study by Lin JG et al 2002[57] showed that the incidence of nausea during the first 24h after surgery was significantly reduced in low (2Hz) and high (100Hz) electro-acupuncture groups compared to control and sham electro-acupuncture. Both high- and low-frequency electrical stimulation also reduced postoperative analgesic requirement, with best results in high-frequency stimulation. Use of electro-acupuncture also resulted in a decrease in the incidence of opioid-related side effects after lower abdominal surgery.
Acupoint injections combine the effect of both acupoint stimulation and drugs, with Chinese and Western application, and had been proved to be effective in PONV prevention and treatment.
Cupping therapy acts on the meridians and acupoints along the pores and skin, mediate the flow of qi and blood, and balances yin and yang. It is effective in PONV prevention[38].
Catgut embedment involves the theory of acupuncture and needle retention. It forms a complex, soft and durable stimulation, reduces pain and remains longer duration than manual acupuncture. It was found to be significantly more effective than medication in reducing pain, nausea and vomiting[40].
A trial indicated neither unilateral nor bilateral application of acupressure significantly affected the incidence of nausea and vomiting[58] while another study showed both had mixed effects, although bilateral application seemed to have more consistent complete response (PONV incidence and antiemetic use)[59].
Shorter needles are usually used near the face and eyes, while longer needles are used in more fleshy areas. Thicker needles are often used on more robust patients.
Needles are usually inserted until "deqi" to achieve stimulation and to a degree which cause least pain and discomfort to patients.
Overall, acupuncture is safe though there were few reports on local erythema with electro-acupuncture; and redness, erythema, swelling, tenderness and paraesthesia with acupressure bands. The effects were local and no major adverse events followed.
The intervention group seemed to be effective in reducing the use of anti-emetics rescue therapy.
Most of the studies on PC6 combined with other acupoint(s) and other acupoint(s) did not emphasis the details of blinding and allocation concealment. Most of these studies were conducted in mainland China.
Although high quality evidence doesn't necessarily imply strong recommendations, and strong recommendations can arise from low quality evidence[13], studies in the future should follow the standard guideline for better quality of evidence.
Future studies should be carried out according to recommendations for better quality of evidence.
For combination of interventions, the order of intervention might need to be considered, as it might affect the efficacy and study outcome. For example, Norheim AJ et al 2010[62] and Liodden I et al 2011[63] performed PC6 acupuncture followed by acupressure in children undergoing tonsillectomy and/or adenoidectomy. Results showed less vomiting in the treatment group compared to control in both studies. On the other hand, Shenkman Z et al 1999[64] performed a study with PC6 acupressure followed by acupuncture, no significant differences in retching and vomiting were demonstrated between the treatment and control group. Hence, type and order of intervention might contribute to the difference in results.
Previous studies on combinations of interventions such as acupuncture with transdermal scopolamine vs. transdermal scopolamine[65], acupoint sticking therapy with massage vs. standard care[66], electro-acupuncture with tropisetron vs. tropisetron[67] at bilateral PC6 and ST36 demonstrated significant better results in intervention compared to control group.
Acupuncture for prevention and treatment of PONV is worth popularising for its efficacy, safe, cost effectiveness and benefits. It also has analgesic effects and could serve as pain relief.
Besides PC6, PC6 combined with other acupoint(s) and other alternative acupoint(s) might be beneficial in prevention and treatment of PONV, the evidence justifies future high-quality studies.
PRISMA Checklist.
Data summary and GRADE of the 16 studies included in meta-analysis for PC6 (A). Data summary and GRADE of the 6 studies included in meta-analysis for PC6 combined with other acupoint(s) (B). Data summary and GRADE of the 8 studies included in meta-analysis for other acupoint(s) (C).
We would like to express our gratitude and thanks to the Committee of Development and Reform, Guangdong Province [2009] 431, for the support and contribution.
This work was supported by Committee of development and reform, Guangdong Province [2009] 431. It was the 3rd-stage "211 project" key subject construction project of Guangdong Province. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's Canada Institute for Scientific and Technical Information in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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The Alde Feanen
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Between Leeuwarden, Heerenveen and Drachten lies a beautiful fenland, a breeding sanctuary for over one hundred species of birds and over four hundred plant species. This type of marsh is considered one of the richest natural areas in North-West Europe. Explore the area that includes swamps, open water, reed beds, grassland and brushwood full of herbs, insects, plants and birds. The area is open to all ages and the environment is well attuned to the thousands of tourists who arrive each year to enjoy a vacation in nature.
Bird hides and water recreation
Every year, National Park De Alde Feanen attracts thousands of people who enjoy scenery and water recreation. The permanent residents of the area are the birds. Venture out into the National Park and you will come across several bird hides. Take some time to study the behavior of the hundreds of birds at the Alde Feanen without being noticed.
One of the best ways to explore The Alde Feanen is by taking to the water. You can take the ferry to the village Earnewâld, where you can rent canoes, rowboats, sail boats and power boats. If you do not want to steer a boat yourself, there are several cruise companies to choose from. The park also has a visitor center with information about all routes, expeditions and activities. They will also tell you how to reach the stork station in Eibertshiem.
Skating and sailing on the Alde Feanen
National Park De Alde Feanen is a beautiful area to relax throughout the year. In summer, thousands sail the lakes and during icy winters the area is a popular venue for ice skating. Both seasons in the Alde Feanen offer special experiences that create a lifetime of memories.
When visiting the Alde Feanen, have a look in the Skûtsje Museum in Earnewâld. The historic shipyard De Stripe can teach you everything from craftsmanship to the history behind these beautiful ships, which are typical for Friesland.
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Schiermonnikoog has such special flora and fauna, that the whole of this Wadden Island is designated as a National Park.Read More
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told by someone it was... pt has a patch and taking oxycodone then they gave a shot of morphine..told it was the same as fentynal
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5 Mar 2013
Fentanyl and morphine are both opioid medications but they are different drugs. In other words, they are in the same family of drug but they are both different drugs within that family. As kaismama says, morphine is morphine and fentanyl is fentanyl. Fentanyl patch is a long acting drug. It is not unusual to use a short acting drug like oxycodone for breakthrough pain. If a person has chronic pain and is on chronic pain medications then has surgery or breaks a bone, you cant expect their normal chronic pain meds to cover acute pain too. They will usually give the normal chronic pain meds plus a little extra to cover the acute pain too.
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While we were walking and exploring the smaller streets, we came across Rancho Bufalo, and just had to give it a try, we were hungry.
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Much of the Neutral Milk story has been pieced together over the years, but never as comprehensively as in Kim Cooper's Neutral Milk Hotel's In The Aeroplane Over the Sea. (Real Detroit Weekly, December 7, 2005 Real Detroit Weekly)
These books are individual love letters to the albums themselves, shedding light on the deepest, most tucked-away aspects of the creative processes that produced them. While reading about music is never quite the same as hearing it, and no prose could ever emulate the same carnival-like, haunting, shiver-inducing sound that is In the Aeroplane Over the Sea, Cooper's billet doux comes pretty close. (Chord Magazine, Winter 2005/06 Chord Magazine)
In her new book 33 1/3: In the Aeroplane Over the Sea... Kim Cooper... unravels the rumors and demystifies much of the legend that has wound itself around songwriter Jeff Mangum since the Athens band's 1998 breakup... Cooper effectively reminds the reader that Neutral Milk Hotel was a band of real people-dear friends- playing instruments, but reinforces the idea that Aerpolane and its songs are a unique document of a time, place and creative community. After only six weeks, the book has gone back to press for a second printing... (Chris Hassiotis, Flagpole Magazine)
Cooper's 2005 book on NMH and Aeroplane is part of the 33 1/3 series that treats cult-classic albums like dissertation fodder, and hers does a particularly stellar job of demystifying--as much as possible--the destitute and devoted dudes behind Neutral Milk Hotel's underground stardom. Her strengths as a social historian lend this read a certain depth that most Spin writers could never muster. Somehow, she miraculously manages to do an album of this ilk--as resistant to the bitter end as it's been to the spotlight--poetic justice. (Los Angeles Alternative, February 2006 Los Angeles Alternative)
There is a treasure-trove of trivia for the NMH aficionado, and a contextual introduction and passionate advertisement for the newcomer. Also, with [Cooper's] detailed account of the NMH community, Cooper gives us a sort of normative sociology of the kind of scene that can produce great art. (Ukula Magazine, Spring 2006)
Cooper delves into the band's roots, setting up the relationships between all of the musicians that made up the Elephant 6 collective and banks like Apples In Stereo and the Olivia Tremor Control. With her easygoing narrative, Cooper achieves one of the hardest things to do when introducing readers to perfect strangers: she infuses each of the main players with a personality. When finishing In The Aeroplane Over The Sea the reader not only has a sense of who Jess Mangrum and friends are, but also what they were trying to accomplish with their music. Cooper explains why the album's audience and importance grow with each passing year while doing a fine job of also relating the music's immense charm and ...dare I say...magic. (Alt.Culture.Guide)
Cooper has managed to write the best music book that I've read so far... Awe alongside simple, direct speech. It's a delicate balance, that Cooper's excellent writing manages to preserve throughout the whole book...And this book doesn't only give information and wrap this exemplary album with an excellent text, it also gives me, and the rest of the prisoners of Jeff Mangum's scorched and wounded world, the excuse and the opportunity to climb on the rooftops and shout: 'For crying out loud, people, you better get to know this album now, before the aeroplane over the sea crashes exactly on that island with the place for only one record. (Guy Hajaj, Haoneg.com, 2006)
Kim Cooper's book belongs to the 33 1/3 series, a group of books in which writers pay tribute to great albums that they love. Well - I assume they love them; at any rate, Cooper loves this one. She writes of its creation, reception, and unintended consequences with the care due a worthy subject. (John Kissane, Buenogato.com)
Kim Cooper is the editrix of Scram, an occasional journal of unpopular culture dedicated to celebrating unjustly neglected artists in the worlds of music, literature, film/TV, comics and bohemia. With fellow 33 1/3 scribe David Smay, she is co-editor of the anthologies Bubblegum Music is the Naked Truth and Lost in the Grooves: Scram's Capricious Guide to the Music You Missed. A third generation Angeleno, Kim offers offbeat bus tours of the city's crimes, literature and architectural gems through Esotouric, and blogs at the crime-a-day 1947project.
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this book has value as a collection of details surrounding the rise and enigmatic end of the band. for fans, it is a trove of information about not just NMH but the associated E6... Read morePublished 4 months ago by xt
Not only it's the history of the album's recording but the whole history of Neutral Milk Hotel and its members from the earliest days. Read morePublished 6 months ago by Denis Romanov
If you like NMH and specifically ItAOtS, this is a very interesting read behind the songs, the making of and Jeff Mangum's parade of oddness.Published 9 months ago by Poolboy
Came very quickly. My roommate is a die hard fan and he really loved this book.Published 9 months ago by Brandi Melton
The best writing I have encountered on Jeff and NMH. It's really gets the "vibe" of the record down as well as the factual history. Read morePublished 9 months ago by Brent
exceedingly well-researched oral history of the band. great for its analysis of the album, but even better for its look into the recording process of the band and the inner... Read morePublished 18 months ago by Gregory Sater
Great read, was very useful for a school report I did on the album. Would suggest it to any fan of NMH.Published 18 months ago by jewells
Another in the brilliant 33 1/3 series, this one is about Neutral Milk Hotel's now legendary In The Aeroplane Over the Sea. Read morePublished 22 months ago by Eric San Juan


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Middle East and North Africa Multimedia
Taliban Fighters Take Over City of Kunduz
Michael Kugelman provides insight into the Taliban's takeover of the city of Kunduz.
Iran's Nuclear Chess Continued: Reviewing The Deal
Robert Litwak, an internationally recognized expert on nonproliferation, has been following the saga of Iran's nuclear program since the beginning. His insightful book, "Iran's Nuclear Chess," has been updated now that a deal has been struck. In this interview, he spoke about the latest developments, and in reviewing the deal, he covers fears and hopes on both sides of the equation.
Iran's Nuclear Chess: An Analysis and Discussion of the Agreement
Nonproliferation expert Robert Litwak provided an insightful analysis of the nuclear agreement between the P5+1 and Iran during a discussion with David Sanger, The New York Times Chief Washington Correspondent and former Public Policy Scholar the Wilson Center.
U.S. Hostage Policy: Will Recent Changes Help?
On the day that President Obama announced changes to U.S. hostage policy, a former captive of Somali pirates, journalist Michael Scott Moore, provided personal insight into the ordeal and America's approach to dealing with ransom demands.
Iran's President Rouhani: Assessing His First Two Years in Office
Two years into a term that promised to change the tone and substance of Iran's politics and relationships around the world, a panel of experts gathered to assess President Rouhani's performance beyond the nuclear deal. That's the focus of this edition of REWIND.
Turkey blames ISIS for suicide bombing
"If there is one group in the Middle East that has managed to bloody ISIS seriously, it has been the Syrian Kurds. Therefore, ISIS has an incentive in hurting the Kurds wherever they are, whether it is in Turkey or in Syria," says Henri Barkey in this interview on CNN.
From War to Peace: In Search of Transitional Justice
When a country moves from conflict to peace, the transitional period includes a desire for justice that can take many forms. Arnaud Kurze's research project explores the creation of "alternative transitional justice spaces" in post-conflict contexts, particularly concentrating on the role of art and the impact of social movements to address human rights abuses. Drawing on the former Yugoslavia, post-Mubarak Egypt and post-authoritarian Tunisia, he scrutinizes the work of contemporary youth activists and artists to deal with the past and foster sociopolitical change. In this edition of Wilson Center NOW, we speak with Kurze about his findings
Iran Nuclear Deal Achieved: A Preliminary Analysis
Robert Litwak, author of "Iran's Nuclear Chess: Calculating America's Moves," has spent decades working on nonproliferation issues and has been following the Iran negotiations since they began. Now that a deal has been achieved, we asked him to provide a concise preliminary analysis of what it means and where we go from here.
Haleh Esfandiari Interview on Trumped Up Charges Against Jason Rezaian
"I have argued that arresting Jason and keeping him for such a long time and finally bringing him on trial is just an effort by the hardliners to embarrass President Rouhani, the Foreign Minister, and the whole team of negotiators," said Haleh Esfandiari during this interview on CNN.
The Iran Nuclear Deal and the Role of the US Congress
On this edition of Wilson Center NOW, Congress expert Donald Wolfensberger describes the role of Congress in the Iran nuclear negotiations.


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Albert Pujols
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Albert Pujols news continually updated from thousands of sources around the net.
Fans experience discouraging lows, uplifting highs in Rangers' division-clinching series
Sunday Oct 4 | Dallas Morning News | Comment?
Old foe Freese plays key role in Rangers meltdown
Sunday Oct 4 | Dallas Morning News | Comment?
No love for Nolan is three-base error
Saturday Oct 3 | Denver Post | Comment?
Saunders: No love for Rockies Nolan Arenado is a three-base error
Saturday Oct 3 | Denver Post | Comment?
MLB Playoffs: Astros, Angels both realize the value of "just getting in"
Saturday Oct 3 | Call to the Pen | Comment?
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She's gorgeous, the full package!
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I've got an
asp:FileUpload control to upload images to my server, which is local.
It works well, however I decided to test what would happen if users upload an image which has the same file name as an existing image on the server. The result is that the original image is overwritten by the new one.
I thought of writing some code which would append a number at the end of the filename if the respective file already exists, however I believe that this is a bit flawed as a user may still be able to provide a file name with a number appended, thus still overwriting.
What would be the best approach to solve this problem?


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Make sure you check out the Call To Action page on the CASAA website. If there are any bans happening in your area please get involved. Protect your right to vape! Click the CASAA logo above to view the Call To Action page.
CASAA Updates
Consumer Advocates for Smoke-free Alternatives association
The FDA Deeming Authority Clarification Act of 2015 (HR 2058), introduced by Representative Tom Cole of Oklahoma, would save the U.S. vapor industry from being decimated by improper regulations by the FDA. This bill would amend the Food, Drug, and Cosmetics Act to change the grandfather date for "deemed tobacco products." This change would allow for all vapor products currently on the market to
Posted: October 7, 2015, 5:00 pm
California "special session" bills threaten consumer access, choice, and use of smoke-free vapor products.
Update - 09.15.15 The California legislature concluded its Second Extraordinary Session on Public Health without passing any anti-vaping bills. This Call to Action is successfully concluded. Update - 09.09.15 With just a couple of days left in California's "Second Extraordinary Session on Public Health," the pressure is on both advocates and lawmakers to make their voices heard. If
Posted: September 9, 2015, 2:00 pm
Pennsylvania Call to Action: Oppose the Governor's unjustifiable 40% wholesale tax on Vapor Products and Smokeless Tobacco.
Update - 08.13.15 After the first round of Pennsylvania budget talks, it was clear that many in the state assembly are listening to the concerns of vaping advocates which is why we provided an opportunity to send a "thank you" message to your PA lawmakers in our last update. However, despite the voices of consumers, Governor Wolf is still pushing for a punitive and unjustifiable 40% tax on
Posted: August 13, 2015, 1:00 pm
FDA Call to Action: Submit Comments on FDA's Proposed Regulation of Safety Packaging and Labeling for E-Cigarettes and Dissolvable Smokeless Tobacco
Update August 21, 2015: The comment deadline has been extended to September 30, 2015. Update September 29, 2015: Updated to include a link to the comment CASAA filed. ______________________ DEADLINE for Comment is August 31, 2015 September 30, 2015. I. Background The FDA recently published an Advance Notice of Proposed Rulemaking (ANPRM) requesting comments on rules about "Nicotine
Posted: August 13, 2015, 11:19 am
Update 09.30.15 - Call to Action successfully concluded. ___________________________________________ On Monday, July 13th, 2015, Alabama Governor Robert Bentley announced that the state legislature would be heading back into special session to hash out the details of the state's budget. One of the proposals to be discussed will be a revived version of an earlier e-cigarette tax bill. Please
Posted: July 21, 2015, 2:10 pm
Several bills are scheduled to be heard in the Joint Committee on Public Health on Tuesday, July 14th at 1:00 PM. We have provided a summary of the bills below. You will see that the proposed regulations range from obvious (prohibiting sales to minors), to predictable (public vaping ban), to dangerous (requiring burdensome testing by manufacturers that would result in all or most e-liquids being
Posted: July 10, 2015, 4:09 am
SB 140 will be heard in the Committee on Governmental Organization on Wednesday, July 8th at 1:30 PM. Oppose SB 140 - Send an Email Please take action now by sending a fully-editable, pre-written email to members of the committee. Please note: if you are not a resident of a district represented by a member of the committee you will be sending a message to your assembly member only. If
Posted: July 6, 2015, 2:19 pm
Vapor taxes in Connecticut may be back on the table as the legislature scrambles to finish the state's budget. It is vital that Connecticut vapers take action now by reaching out to lawmakers and urging them to oppose any bill that would enact taxes on vapor products. Oppose Vapor Taxes in Connecticut - Send an Email In addition to contacting lawmakers from your district, please take a
Posted: June 25, 2015, 10:03 pm
(URGENT) The New York Legislature has gone to extra innings and two bills that would severely limit where electronic cigarettes can be used are still in play. Even if you have previously taken action on this issue, it is critical that you join your fellow New Yorkers and take action again. Please take action NOW to urge NY lawmakers to oppose both Assembly Bill 5955 and Senate Bill 2202.
Posted: June 18, 2015, 4:09 pm
FDA Call to Action: Submit comments on FDA's Third Workshop Regarding E-Cigarettes. The first of three FDA Workshop was held in December 2014, the second in March 2015, and the third in June 2015. You have until July 2nd, 2015 to submit comments on all three workshops. (Please see: CASAA Call to Action for First FDA Workshop and CASAA Call to Action for Second FDA Workshop for details and
Posted: June 17, 2015, 1:24 am
The Utah Legislature will once again be entertaining the prospects of enacting taxes on vapor products as the Revenue and Taxation Interim Committee meets on Wednesday, June 17th, 2015 2:30 PM Rm 445, State Capitol Agenda: http://le.utah.gov/Interim/2015/html/00002676.htm Please take action NOW by sending committee members a message urging them to oppose ANY additional taxes on vapor
Posted: June 15, 2015, 5:20 pm
(Update 06.12.15) Final consideration of The District's Budget is set for Tuesday, June 16th. The excessive and unjustifiable tax on vapor products is STILL in the budget. There are a couple of points to know about this tax: Vapor products will misleadingly be taxed at the same rate as combustible cigarettes -- 70% wholesale. The language makes no distinction between the Cigarette
Posted: June 12, 2015, 4:30 pm
HB 682 would deceptively redefine "smoking" to include the use of e-cigarettes for the purpose of banning vaping in the same places where smoking is currently prohibited. This bill is scheduled for a hearing in the House Health Committee on Monday, June 15th, at 11:00 AM. Testimony at this hearing will be by invitation only. In light of the fact that the committee will not be considering
Posted: June 11, 2015, 1:52 pm
(Update - 06.10.15) URGENT! The Louisiana Legislature is about to take its final steps on, HB 119, a bill that would impose an unnecessary and counterproductive tax on vapor products. There is still time to stop it! In the next 24 hours, a conference committee made up of a total of six members from the House and Senate will meet to decide, among other things, whether to keep or remove (
Posted: June 10, 2015, 3:00 am
(Update - 06.09.15) HB 5 has been placed on the Senate Agenda for Thursday, June 11th, 2015. Even if you've already participated, please take a moment now to remind your State Senator to oppose this bill. Although it is encouraging to hear that an amendment would allow some businesses to continue to allow vaping in their establishments, we are still recommending that Delaware
Posted: June 10, 2015, 2:00 am
(Update - 06.12.15) Overnight, the Kansas legislature passed the tax bill containing a 20 cents per milliliter tax on e-liquid. However, this is not an end to this Call to Action. The tax and distribution regulations will not take effect until July 1, 2016, which is a full legislative session away. Now more than ever, Kansas advocates should take the time to reach out and educate their
Posted: June 8, 2015, 11:00 am
Oregon Call to Action (URGENT): Take Action NOW to oppose 2 bills that would SEVERELY limit access to and use of vapor products!
(Update - 06.05.15) Oregon vapers! Your help is needed immediately to oppose new taxes on vapor products & to protect your local vape shops from a senseless sampling ban. A vapor tax in Oregon is very much on the table as the Legislature is finishing off its budget proposals. Several sources have indicated that a large tobacco company is presently lobbying your elected officials to impose
Posted: June 5, 2015, 2:00 pm
Washington State (Urgent) Call to Action! Take Action now to Oppose HB 2211 an unjustifiable 60% tax on vapor products
(Update - 06.04.15) It's do or die time, Washington vapers! HB 2211 has been scheduled for a vote in the House Committee on Finance Monday, June 8th 11:00 AM House Hearing Room - A (HHR-A) Your elected officials need to hear from you! HB 2211 would enact an unjustifiable extra tax of 60% of sales price on vapor products -- liquids and devices. (Imagine paying $32.00 for your
Posted: June 5, 2015, 4:30 am
(Update - 06.03.15) Ohio vapers, your voices are needed once again! The Ohio Senate is now completing its work on the state's budget and some members are pushing for taxes on vapor products to be included in the final bill. As you may know, Gov. John Kasich has previously proposed a massive tax on vapor products that would equate to nearly $34 on a 30ml bottle. Even if you've already
Posted: June 4, 2015, 12:00 am
Texas Call to Action: SB 97 should be amended to remove unnecessary hurdles to adult access to vapor products online
(Update - 05.31.15) On Thursday, May 28th, Governor Abbott signed SB 97 into law. Although CASAA supports prohibiting sales to minors, the bill also contained onerous requirements for delivery (online) sales, particularly those involving sales from out-of-state. Under this new law, out-of-state retailers will be required to use a method of shipping that requires an adult signature upon
Posted: May 22, 2015, 4:00 pm
It is likely that tax language regarding electronic cigarettes will be added to a revenue or tobacco tax bill in Ohio. As soon as more details emerge, we will update this alert. In the meantime, we are asking Ohio advocates to take action by sending a message to lawmakers urging them to oppose ANY taxes on vapor products. Please take action NOW and send a message to Ohio lawmakers urging them
Posted: May 21, 2015, 4:39 am
(Update - 05.12.15) SB 139 has moved to conference committee and is on the agenda for tomorrow, Wednesday, May 13th at 8:00AM. Please take a moment now to send a message to the members of the committee urging them to reject this bill. Oppose SB 139 - Send an Email To be clear, this is not a public hearing. It is vitally important that you reach out to the members of the conference
Posted: May 12, 2015, 10:00 pm
HP 670 would deceptively redefine "cigarette" to include "e-cigarettes" for the purpose of taxing e-liquid at the same rate as traditional cigarettes. If adopted, this bill would enact a tax of 10 cents per 18mg of nicotine contained in any amount of e-liquid. Please take action now by sending a message to the committee as well as lawmakers from your district urging them to oppose this bill.
Posted: May 10, 2015, 1:28 am
(Update - 05.21.15) With a special thanks to Minnesota Vapers Advocacy, CASAA is pleased to conclude this call to action favorably. The Minnesota Legislature has concluded its regular session without successfully passing any legislation that would negatively impact vapor consumers. MNVA has issued a thoughtful End of Session Call to Action on this issue that we're encouraging Minnesota
Posted: May 8, 2015, 4:00 am
SB 463 would deceptively redefine "Tobacco" to include "electronic nicotine delivery systems" (or ENDS). By altering this definition in Chapter 44 of the states general laws, SB 463 would be subjecting vapor products to the states 80% wholesale tax on tobacco products. SB 463 is scheduled for a hearing on Tuesday, April 5th. Please take action NOW by sending a message to your senator
Posted: May 2, 2015, 3:44 pm
CASAA works tirelessly to educate the pubic about smoke-free alternatives and to keep these products available. They need your support. Use the DONATE button to make a one-time gift. Better yet, use the SUBSCRIBE button to help provide CASAA with a predictable and dependable source of income.
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Publisher:Mariner Books
These poems are about revolutionaries and lovers-about how, both in revolution and in love, loss of trust and compassion robs us of hope. They are also about (and for) those few embattled souls who remain painfully committed to beauty and to love even while facing the firing squad. Quick, direct, witty, pungent (DeWitt Beall, Chicago Daily News).
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2006 LEXUS RX 400H Contact for Price
- Contact for Price
- Mileage 183,000 Miles
- Mileage 183,000 Miles
- Color Black
- Engine Hybrid
- Mpg Avg: 26
- Location Beaverton, OR
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Alentejo Magic Pocket Diary 2013
by Anna Guerrier
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Alentejo Magic
Published September 20, 2015
Dowsing for Healing Remedies
Published March 20, 2013
Alentejo Magic Diary 2013
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Alentejo Inspiration
Published November 11, 2012
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11 years of experience
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Accepting new patients
925 Chestnut St
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Spent about 45 minutes with me. Answered all of my questions
Dr Ahmad is a great doctor he fixed my left foot about 3 years ago i told alot of friends of mine that need a good foot dr to see Ahmad he has been great with me and sure knows what hes doing very happy to hve him as my dr
My experience was the same as Theresa Blair's below.
He clearly is respected in the field, but I can't see why. His resident/intern who I met with first, ended up nailing my issue. Dr. Ahmad had dismissed what his intern suggested. He was generally dismissive of his patient too. He treated me like I was a drug addict, instead of taking my concerns seriously. I can't recommend Dr. Ahmad, but the staff was great, and his intern gave me enough information that I was able to find the right care for myself.
Dr. Ahmad and his staff were great to work with (we mostly used the Bensalem office), and literally got me back on my feet. My only regret is that I didn't go to them first after I broke my foot. We will definitely use Rothman for any future orthopedic needs.
I am so impressed with Dr. Ahmad and his assistants! He is a caring and compassionate surgeon, he spends a good amount of time with his patients. I think he is one of my favorite doctors, a wonderful surgeon.
I think that Dr. Ahmad is one of the nicest doctors I have ever been to. He performed surgery on my foot 3 weeks ago and I am VERY satisfied with him as a doctor and as a wonderful person. He allows his patients to e-mail him and he gets back to you so promptly, it's unbelievable! He is always there to answer the million questions that I have had and to reassure me about everything; he's just plain GREAT! I will recommend him to anyone I know with a foot problem.Thanks for the oppurtunity to post this!Marylou - Age 65 - Jamison, PA
I had torn my peroneal tendon and Dr. Ahmad repaired it for me through a surgical procedure. He made sure that if I had any questions they were answered or if I had any concerns that they were adressed. I felt comfortable asking him about anything related to my foot and ankle issues, as I have many of them because of having flat feet and he answered everything I wondered. Dr. Ahmad is my inspiration for wanting to specialize in foot and ankle surgery. I would highly recommend him to anyone, he is a great doctor!


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9.36 out of 10 (what is this?)
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Willie Anderson Anderson, 39 years old, lives in Cincinnati, Ohio, but has also spent time in Marietta, Georgia; Atlanta, Georgia; Auburn, Alabama and Memphis, Tennessee. He has worked for Lowes, Nfl, Cincinnati Bengals, National Football League, Professional Football Player, Baltimore Ravens, Conference Pro Bowl, Auburn Tigers Football and Offensv Tackle. He's a big fan of Rap, Gospel and R&b. Mtv, Espn, Bet, Sportscenter, Forensic Files and The Wire are his favorite TV shows. Among his favorite movies are Rocky, Scarface, Menace Ii Society and Training Day. Cecile L Anderson, Theresa Darlene Egbuchulam, Mary T Steele, Eddie L Anderson, Maurice A Anderson, Myron Fulton, Billie A Fulton and Chiquita D Steele are in Willie's family. On the web, Willie goes by the alias wwllchll.


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Lou Gossett Jr. leads a unique band of international war aces in this spectacular conclusion to the high-flying Iron Eagle series which delivers spectacular air and ground battles outstanding special effects and the most unique combination of air weaponry ever filmed. Gossett and his Aces team up with the beautiful and courageous Anna to battle to save Anna's Peruvian village held hostage by a Latin American drug cartel led by a German madman.Running Time: 98 min.Format: DVD MOVIE Genre: ACTION/ADVENTURE UPC: 794043748622
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According to a reporter with the TimesDaily.com, Alabama Democratic Rep. Alvin Holmes allegedly said on the state House floor that he doesn't like Supreme Court Justice Clarence Thomas because…he's married to a white woman. Holmes, for the record, is African-American.
Rep. Alvin Holmes, D-Montgomery, just said on House floor that he doesn't like Clarence Thomas because "he's married to a white woman."
— Mary Sell (@DD_MarySell) February 11, 2014
What a sad commentary on the state of race relations in this country.
Leah Barkoukis is the online features editor and web editor at Townhall.com.
Author Photo credit: Jensen Sutta Photography


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This app was removed from the App Store.
iSafe Pro
iOS iPhone Utilities
- Limited time on SALES only
- Get it before the price raise up!!!
*** App of the Day ***
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If you want to protect your documents from spying eyes, then iSafe is for you. This app is like a real safe for your iPhone, locked away with. special code. And you even hide Top Secret stuff from extra curious, like girlfriends, by giving them a fake code that only allows them to see certain content-sneaky ;) An app that could just save your life!
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You can grab the sound tracks from MTV files (mp4, m4v & 3gp). So as to save the disk space and listen the songs in the background.
8. Facebook Connect
- download the albums and videos from your friends
- create album and multi-upload photos
- Multi-upload videos
9. Youtube API
Multi-upload videos to youtube.
10. Live TV
Watch the popular TV channels in the world.
Connect to your webcam. (mms, rtsp)
12. Ringtone Maker
Trim any audio file into 40 seconds ringtone.
13. Files Sharing
Share your files via Email, MMS, Bluetooth, WiFi…
14. Spy Tools:
- Turn on the camera in the login page for immediately needed.
- Turn on the light in the login page immediately for the spy tasks in dark.
- Take a picture of the intruder with the front camera when entered wrong passcode every two times.
- Hidden camera in the left side menu. No one will see when the camera is recording.
15. Minors
- subfolders
- text editor
- file browser
- download files by using URL Scheme
- extract zip and rar files
- compress files
- connect to external screen
- continue playing songs and videos in background
- audio control in lock screen
- assign image into contact book
Supports Various File Formats
- Images: png, jpg, jpeg, bmp, tif, gif
- Videos: mp4, mov, m4v, 3gp, flv, f4v, mpg, mpeg, wmv, rmvb, mkv, asf, webm
- Audios: mp3, m4a, m4r, aac, caf, wma
- Plain Text: txt, php, cgi, asp, h, m, c (editable)
- Rich Text: rtf, pdf
- iWorks: pages, numbers, key
- MS Office: doc, xls, ppt, docx, xlsx, pptx
- Web: htm, html, webarchive
- Archive: zip, rar
- Others: …… (unreadable, save only)
Multi-language: more then 20 languages, including Hindi, Persian.
More and more features are coming. Get it now!
iSafe in Apple Watch Tutorial:
1. Open the iSafe in iPhone
2. Pull the navigation bar to right to show the menu
3. Press the gear in the top of menu and go to Settings page
4. Press the information button in the top right corner of the Settings page, you can see the tutorial page.
What's New
Fixed the crash after entered password in iOS 6