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Be Sound Hostel
Registration Number 01-2004-0184
Barcelona is a never-ending dream - we invite you to have your best dream with us!!
Be Sound Hostel is a modern and cool hostel in the perfect location. With us you can easily explore Barcelona and enjoy our young and friendly environment. It is only two minutes' walk from Las Ramblas, the port and is located in the partying and shopping area of Barcelona.
Be Sound Hostel has great character and many chill-out areas. From our huge common room, the small but lovely roof terrace, a fully equipped kitchen, international and friendly staff, cultural tours, spicy flamenco shows and daily tapas-tasting, it's the perfect place to hang out and meet new people.
We give you loads of free stuff!
- FREE breakfast!
- FREE locker with personal key
- FREE Wi-Fi and Internet
- FREE local maps
- FREE use of our kitchen
- FREE fully-equipped kitchen
- FREE walking tour
- FREE drink and tapas at check-in
- FREE air conditioning
- FREE pillow, duvet and blanket (sheets available for rent from reception)
- FREE dinner voucher
Be Sound has 6- and 8-bed dorms, with 100 beds in total. There is air conditioning and heating in all rooms - very important for the very, very hot Spanish summers! You can also use our luggage storage after check-out if you're waiting for late planes and trains. We have laundry facilities and reception is open 24 hours. Each room, as well as the front door, is locked with electronic keys, providing a safe environment during your stay.
Be Hostels Sound is the best option for backpackers and everyone who wants to discover our vibrant city. Barcelona is a never-ending dream - we invite you to have your best dream with us.
Availability & RatesTo view availability and prices please select dates and click 'Update Dates'
Hostel Facilities & Policies
- 24 Hour Reception
- Air Conditioning
- Bicycle hire
- Breakfast Not Included
- Card Phones
- Common Room
- Credit Cards Accepted
- Elevator
- Free Internet Access
- Free WiFi
- Games Room
- Internet Access
- Key Card Access
- Self-Catering Facilities
- Late check-out
- Security Lockers
- Luggage Storage
- No Curfew
- Reception (limited hours)
- Taxes not included
- Tours/Travel Desk
- Towels For Hire
- Wheelchair Friendly
Cancellation PolicyThis property has a 1 day cancellation policy. Failure to cancel within this time will result in a cancellation charge equal to the first night of your stay.
Must-Read Hostel InfoThis property has specific Terms & Conditions.
Since November 2012 there is a tourist tax of €0.50 per person per night, which is not included in our rates. It is payable upon arrival and only applies for the first seven nights of accommodation.
We have a 24hr cancellation policy. Cancellations must be made via email by noon the day before your scheduled arrival date. Late cancellations and no-shows shall be charged the equivalent of the first night's accommodation.
The hostel is open 24 hours, including reception.
Check in at any time from 12pm.
If you are going to arrive later than 11pm please send us an email confirming your arrival time.
DirectionsShow MapHide Map
It's best if you purchase a T-10 ten-journey card for only €9.25; you can use it on any line for the metro, train, bus or night bus. The main city centre areas are all in Zone 1, including El Prat airport.
From Plaça Catalunya:
On foot (10-15 minutes): Walk down Las Ramblas towards the sea for about 10 minutes. You will see on your right-hand side the street Nou de la Rambla - you will get to the hostel in a couple of minutes. Number 91 is on the left side.
By metro: Time: 5 min, cost: €2. Take the green line and get off at Paral-lel station. Take the exit for Nou de la Rambla and once you're on Nou de la Rambla street you will find the hostel on the right side at number 91.
From Barcelona El Prat Airport:
By train: From Terminal 2 take the RENFE train and get off at Sants Estació or Barna Sants (if you arrive at Terminal 1 there's a free shuttle bus to Terminal 2). Time: 30 mins. Cost: €3.80. From there change to the metro system. Take the green metro line in the direction of Trinitat Nova and get off at Paral-lel (time: 5 min, cost: €2). Take the exit for Nou de la Rambla and once you are on Nou de la Rambla street you will find number 91 on your right.
By bus: Take the Aerobus from Terminal 1 or Terminal 2 and get off at the last stop, which is Plaça Catalunya. Then follow directions as above.
Time: 30 min, cost: €5.30. The T10 is valid on the RENFE train to the airport but not valid on the Aerobus (the express bus service to the airport).
By the night bus: The night bus (NitBus N17) goes from Terminal 1 and Terminal 2 and stops in Plaça Espanya and carries on to Plaza Catalunya. The first bus from Terminal 1 is at 11pm and the last one is at 5am (which is when the metro opens anyway). The bus passes every 20 minutes and it takes 30 minutes from Terminal 2 and about 40 minutes from Terminal 1. One way: €2 or a journey on your T-10 card.
From Girona Airport:
Take the only bus; it brings you to Estació del Nord at Barcelona city centre. Ryanair prepare and coordinates theses buses with each flight. The ride takes 1h and 15 minutes and it costs €2. Then follow directions from Estació del Nord as below.
From Sants Estació (main train station):
Take the green metro line in the direction of Trinitat Nova and get off at Paral-lel (time: 5 min; cost: €2). When leaving the station, take the exit for Nou de la Rambla. Once at the street you are on Nou de la Rambla - we are at number 91.
From Estació Del Nord (main bus station):
Get out of the station to find the metro system. Take the red metro line and get off at Plaça Catalunya, then follow directions from Plaça Catalunya as above.
By car from any highway entering Barcelona:
You need to find the highway called Ronda del Litoral to get to the city centre. Once you are on the Ronda del Litoral take exit 21. Do the roundabout and take Avenue Paral-lel. Turn down the second street on your right. This is Nou de la Rambla and we are at number 91.
By car from the Port of Barcelona:
The square next to the port is Plaça Colon. From there take the Avenue Drassanes. After that, take the second street to your left-hand side, Nou de la Rambla. You will find the hostel on the left side at number 91.


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Decay is the process of decline or destruction.
Physical decay of people, places and things can be observed every day. Moral, spiritual, and other, less tangible, forms of decay may be more difficult to observe, but are equally present in our lives.
Submit a photograph that captures the decay in your field of view.

subset: commoncrawl


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Press/Education Materials
Learn more about the arts and history of Asia––recommended websites:
- Asia Society Museum
- Freer Gallery of Art and Arthur M. Sackler Gallery, Smithsonian Institution
- The Metropolitan Museum of Art Timeline of Art History
- Online Museum Resources on Asian Art/Weatherhead East Asian Institute at Columbia University
Image: Yong Soon Min, born South Korea, 1953. Movement (detail of "energy source"), 2008 (revised 2012). Installation. Records, CD's, round mirrors of varying sizes. Photograph by Yong Soon Min.


text:
Selected Properties of Carbon Nanostructures: from Exotic Fullerenes to Nanotubes
Additional materials available (2)
Licensed according to this deed.
Published on
The talk presents results from ongoing projects in the field of carbon
nanostructures: (i) Mass selected ion beam soft-landing has been used
to generate exotic fullerene materials comprising covalent linked,
non-IPR cages. Apart from microscopic structure, we have studied
thermal and electronic properties as well as reactivity towards
(atomic) hydrogen. (ii) Confocal fluorescence microscopy was applied
to the near-infrared emission properties of individual semiconducting
single-walled carbon nanotubes subject to external perturbations such
as unaxial strain, torsion as well as interaction with surfaces,
sourrounding dielectrics and other nanotubes.
Full Professor. Physical Chemistry of Microscopic
Systems. Born 1957; B.Sc. 1977, Concordia University,
Montreal, Canada; Ph.D. 1981, Massachusetts Institute
of Technology, Cambridge, USA; Postdoctoral Fellow
1981-87, Universiät Bern, Switzerland; Habilitation
1987, Bern; Assistant and Associate Professor 1987-
1991, Northwestern University, Evanston, USA.
Sponsored by
Cite this work
Researchers should cite this work as follows:
Pancoe ENH - Abbott Auditorium, Northwestern University, Evanston, IL


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I pride myself on making the Primal Blueprint [1] an easy lifestyle to follow. If you were just starting out, you could easily read a few articles, do a couple hours of research [2], and start making positive changes to your diet, exercise [3] routine, sleep [4] schedule, or daily life immediately. You could ditch grains [5] or replace some chronic cardio [6] with weights [7] or switch to grass-fed meat [8], and even if you did nothing else, you'd have made a significant improvement to your life and eventually your health. I often receive thank you emails for putting together a program that Internet-illiterate grandmas and grandpas can get into and actually understand. That said, sometimes things get a little confusing.
Like with honey.
See, as a general rule, I am against the consumption of refined sugars, especially sucrose and high fructose corn syrup. To understand why – if you're still wondering – check out my definitive post on the subject [9]. But what about the preeminent unrefined natural sweetener – the rich amber nectar that's been available to humans from the very start [10] (albeit protected by barbed, flying suicide stingers)? How are we to approach honey? Because while refined sugar and particularly fructose are to be avoided, alone those are refined, manmade, processed "foods." White sugar is just sucrose, which is just fructose and glucose. High-fructose corn syrup is just fructose and glucose. Isolated fructose is just fructose. Those aren't even foods, though they can be eaten; they're just disaccharides and monosaccharides, with zero minerals, vitamins, phytonutrients, flavonoids, and other micronutrients.
Honey, on the other hand, contains over a hundred different compounds, not just fructose and glucose. It has a small amount of minerals, amino acids, and vitamins, but the point is that it's not just sugar. Entire colonies of honey bees thrive on the stuff. It's food by any definition. And whole foods are different than refined foods, and especially refined food-like products. They have different effects when you eat them. Eating an almond [11] is not the same as taking a shot of rancid seed oil. Eating a handful of berries isn't the same as sprinkling an equal amount of berry-extracted sugar in your water and drinking it.
The question, then, is whether or not this holds true for honey. Is honey "better" than sugar or HFCS? Are some of the harmful effects of the sugar contained therein mitigated by the presence of bioactive compounds? Let's take a look.
(Speaking of which, I won't get into the individual compounds found in honey, because each batch of honey is unique. Besides the whole vomiting thing, honey bees don't really have strict manufacturing standards, and which bioactive compounds end up in the honey depends on the variety of flowers visited by the bees, as well as the season. I might refer to different honey varietals, like buckwheat or wild flower, but keep in mind that buckwheat from area to area and even harvest to harvest will have different pollen concentrations, giving the honey different qualities.)
Humans have certainly been figuring out ways to get their mitts on the sticky mess for as long as we've realized it tasted good: a 6,000 year-old [12] cave painting [13] from Spain even depicts a honey hunter climbing a ladder, stick in hand and satchel at its side, gathering honey as bees swarm. Modern day people, like the San bushmen and the Ache of Paraguay, are honey hunters, with the Ache getting upwards of 10% of their calories from wild honey (and the larvae found in the honeycombs). For a visceral idea of the great lengths some people go to for honey, check out this incredible video [14] of a tribesman from the Congo scaling a 40 meter tree to get at the hive. That's dedication. After that climb, I imagine his muscle and liver glycogen stores were rather depleted and the honey was a welcome fuel source.
Studies on honey paint a pretty favorable picture, actually, especially when it's compared to table sugar or other more refined sweeteners. Let's dig in to a few, shall we?
In one study (PDF [15]), researchers compared the effects of honey and refined fructose feeding on rats. Using equal amounts of fructose – just different sources – the authors explored the effects on several health markers. Feeding fructose raised triglycerides more than feeding honey. Feeding fructose decreased blood levels of vitamin E, while honey did not, suggesting less oxidative stress. Feeding fructose also promoted more inflammation than honey. All in all, honey did well for itself.
Another set of studies [16] compared the effects of honey, sham-honey (a mix of fructose and glucose), dextrose (which is just glucose), and sucrose on several health markers in various groups of people. There's a lot to wade through, but the gist is that honey performed well. Honey resulted in smaller blood glucose spikes (+14%) than dextrose (+53%). Sham honey increased triglycerides, while real honey lowered them (along with boosting HDL and lowering LDL). After fifteen days of honey feeding, CRP and LDL dropped. Overall, honey improved blood lipids, lowered inflammatory markers, and had minimal effect on blood glucose levels.
In rats, honey produced lower triglycerides, less body fat, and greater satiety (as indicated by the spontaneous reduction in food intake) when compared to sucrose [17].
Looks like wildflower honey might go well in a meat marinade, too: wildflower honey inhibited lipid oxidation [18] in ready to eat beef patties. I'm not sure what a ready to eat beef patty is, and I don't think I want to know, but the honey info is good to have. Wildflower honey, which comes from bees dining on a wide variety of wild plant life, outperformed clover honey in the study.
Although discerning the full effects of individual honey-based compounds is many research years out, it looks like honey with lower levels of bioactive compounds acts more like regular sugar while honey with higher levels of compounds acts more like a whole food. In one study (PDF [19]), buckwheat honey was found to be the richest in phenolics and flavonoids, while rapeseed (yes, canola) honey was found to have the lowest number of compounds. The researchers didn't explore the metabolic effects of the two honeys, but another study did find that people who ate rapeseed honey, but not acacia honey, displayed highly elevated levels of serum fructose [20]. The same thing happens when you eat HFCS [21]. That tells me the bioactive compounds are probably responsible for the "benefits" of honey.
Darker honeys are typically higher in bioactive compounds [22] and show greater antioxidant activity [23]. They also taste better, if you ask me. Buckwheat is a personal favorite of mine and ranks quite highly in antioxidants, even showing some beneficial effects on serum antioxidant status in those who consume it [24]. When in doubt, choose the darker honey.
Now, I don't have much of a sweet tooth, so I don't go out of my way to dip my paws in a jar labeled "Hunny," but I keep some raw buckwheat honey around. The last pound I bought has lasted me well over six months, and there's still plenty left in the bottle. And in the past, it has certainly proven useful [25]. Can you eat it? Sure; you can do just about anything you want. Should you eat it? That depends. Are you active and in need of liver glycogen repletion like the guy who climbed the Congolese tree? Then raw honey might be a nice choice for a treat. It's clearly superior to refined sugar, and the extent of the damage we normally see from sugar intake doesn't seem to occur with honey.
What do you think? Does honey fit into your diet? Is it Primal? Let me know what you think.


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Call to Schedule an Appointment Today!
Or Schedule Online to Save Time and Money!
Free Install For Most Clients!
Simply put, an ignition interlock device is an electronic device connected directly to your vehicle. It is a car breathalyzer that requires a clean breath sample. It will prevent the engine from starting in the event that it detects alcohol over a preset limit. The device will not damage your vehicle and will work and any make and model. Our technicians are certified and have installed thousands of devices. The 20/20 pictured here is the most technologically advanced unit. It has incredibly fast testing and remote unlocking to prevent being towed.
Anyone convicted of a DUI that is required by the court or DMV to install an Ingition Interlock Device for license or court restrictions. Or those who want to protect a family member. You can find a list of Kansas conditions on our Kansas Page. Every DUI in Kansas will require that you have an ignition interlock, or car breathalyzer device installed for a preset amount of time. Time limits depend on the number of DUI or test refusal violations you have had prior.
Smart Start of Kansas makes this process easy. You can call us at 1-866-747-8278, or visit our Schedule an Installation Page by clicking here. We will collect your information that is perinent to the state of Kansas. You will provide some simple information about you and your vehicle and we will handle the rest. We will setup a convenient time for your installation, fill out and complete your paperwork, inform the state once you are installed and answer any questions that you have. We help thousands of Kansans!
The device will require you to take a breath test to start your vehicle. the test takes 6-7 seconds to complete. Our device then analyzes the test in less than ONE SECOND. If alcohol free, you then can start your vehicle. Random tests are required once your vehicle is started. Read more about frequently asked questions on our FAQ page.
Smart Start offers the Fastest, Smallest, most Technologically Advanced Ignition Interlock Breathalyzer devices. We have been the leader for years becuase of our service to our customers. We offer the most reliable devices for the lowest prices. We offer 24 hour support, so you are covered at ALL times.
Smart Start gives it to you straight forward, you won't have to worry about finding hidden fees later. No misleading contracts or tactics. We have no deposits, paying mulitiple months in advance or early termination fees. We don't have long fixed length contracts, missed appointment fees or tow in charges. We include tax in our pricing, don't charge to calibrate the device, offer free 24 hour service and have local technicians to take care of you. Simply the best interlock experience, without the high prices. Best Equipment, Best Service, Best Price!
We are all over the state of Kansas. You can find a map of our statewide service network by clicking here. We have over 30 facilities to serve you. We have physical locations to serve you from day one till you are removed. We are not going to meet you in a parking lot, only to leave you stranded the next day. We will be there if you ever have questions and always there for service. We have Kansas covered.
We are located all over the United States, and have over 1000 locations to serve you. If you are looking for Nebraska or Iowa click the following links.


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Other available options
Tolkowsky 18ct white gold 3/4ct diamond solitaire ring. A brilliant cut diamond combining a clarity and colour of HI S12 encased in four claw setting. Each Tolkowsky diamond comes with a gemological certificate.
Tolkowsky are the creators of the brilliant Ideal Cut diamonds.
Normally available in sizes I to SExclusive to Ernest Jones Certificated diamond
- Birthstone
- April
- Brand
- Tolkowsky
- Diamond
- 3/4 carat
- Diamond clarity
- Diamond colour
- Diamond cut
- 57 Facet
- Material
- 18ct White Gold
- Stone setting
- Claw
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- Round
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- Solitaire
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- Diamond
- Height
- 0.6 cm
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Delivery & Returns
At Ernest Jones we provide the following range of delivery options:
- Free Standard Delivery available on orders over £100.
- Free Next Day Delivery available on selected orders over £499.
- Free Click & Collect to any Ernest Jones store in the UK.
For more Delivery Information click here.
Returns policy: you can return items to us by post or in store within 30 days for a full refund or exchange.*
*We cannot refund or exchange pierced jewellery, e.g. earrings, if they have been removed from the original sealed packaging due to hygiene reasons.
Help Centre
There are a number of different ways to contact us if you need help or advice with your purchase.
How to contact us


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Tables 1-4
Training, certification & licensing of acupuncture In the United States
The Centers for Medicare and Medicaid Services (CMS) has commissioned a Technology Assessment from The Agency for Healthcare Research and Quality (AHRQ) to review the evidence regarding the use of acupuncture for osteoarthritis.
In order to expedite the review, CMS requested that the review be based on systematic reviews that are published by other groups. The AHRQ review therefore contains:
A review of recent (1995 to present) systematic reviews on the use of acupuncture for osteoarthritis, updated with any RCTs published since the date of the last systematic review (2000 to present).
Osteoarthritis is the result of ongoing or chronic deterioration of the joint cartilage. The cartilage degenerates, in part through stress and wear, and in so doing causes a roughening and wearing on the ends of the once-protected bones. Sometime new bone forms, this time as irregular spurs, and contributes to pain and joint dysfunction. The most common sites for osteoarthritis include cervical and lumbar spine, finger, wrist and toe joints, hip and knees. Asymptomatic forms of osteoarthritis can occur between 30 and 40 years of age, but by 70 years old, nearly all persons have some symptoms of osteoarthritis. 1
Description of Acupuncture
In its original form acupuncture was based on the principles of traditional Chinese medicine.2-4 The general theory of acupuncture is based on the premise that there are patterns of energy flow through the body that are essential for health. Traditional acupuncturists understand health in terms of a vital force of energy called Qi which circulates between the organs along channels called meridians. The traditional Chinese medicine acupuncture practitioner seeks to identify the nature of any imbalance in Qi, and then selects the appropriate acupuncture points from among approximately 360 points distributed along the meridians.3, 5, 6
Acupuncture involves the stimulation of the specific acupuncture points (acupoints) on the skin, usually by the insertion of needles ranging in length from 1 cm to 10 cm. Between 5 and 15 needles are used in a typical treatment, with the point combinations varying during a course of sessions. The acupoints can be chosen based on a standardized "formulary" involving a fixed menu of consistent points for each disease or condition or selected for each patient individually based on a patient's specific symptoms and Qi balance. Depth of puncture can be up to 5 cm.
Other forms of acupuncture include electroacupuncture, heat (including moxibustion), pressure, and laser-generated light.4, 5, 7 A glossary of these procedures is found in Appendix A. Generally, studies have addressed either manual needling or electroacupuncture because the stimulation parameters of these procedures are easiest to control.3, 5, 6
FDA's Role
The U.S. Food and Drug Administration (FDA) regulates devices used for acupuncture, such as the needles. Since 1973, the FDA considered acupuncture devices, including needles, as investigational medical devices.8 In December of 1994, petitions were filed with the FDA to approve the needles as treatment for five medical conditions: pain, nausea and vomiting, substance abuse, asthma and other respiratory problems, and stroke and paralysis.9 As a result of these events, FDA undertook an extensive review of the available evidence regarding the effectiveness of acupuncture.5, 9 FDA announced on March 29, 1996 that acupuncture needles had been reclassified from Class III (experimental) medical devices to Class II (non-experimental but regulated) medical devices for "general acupuncture use" by licensed, registered or certified practitioners.10 As part of this reclassification, FDA determined that the "investigational use" labeling requirements no longer applied. However, the FDA determined that acupuncture needles must comply with the following special controls:
Class II devices involve less stringent controls by FDA that include good manufacturing procedures and proper labeling. However, clinical data demonstrating clinical effectiveness is not required. To receive marketing clearance as a class II device, acupuncture devices must go through the FDA's 510 (k) process.11
The FDA requires manufacturers of acupuncture needles to label them for single use only. Acupuncture needles must also bear a prescription labeling statement which restricts their use to qualified practitioners as determined by the states. Manufacturers also have to provide information about device material bio-compatibility and sterility.12
Adverse events associated with acupuncture
Serious adverse events associated with acupuncture include transmission of infectious disease, pneumothorax, other problems associated with organ punctures, spinal lesions, cardiac tamponade, and broken needles with remnants migrating to other locations.6, 7 Minor adverse events include forgotten needles, exacerbation of symptoms, minor bleeding, hematoma, fatigue, sweating, severe nausea, fainting, and headache.3, 6, 7 Adverse events may be associated with practitioner competence and training.3, 13, 14
There have been several studies quantifying the rates of adverse events. A few studies compiled case reports. One Japanese systematic review of case reports found 25 cases of pneumothorax, 18 cases of spinal cord injury, 11 cases of acute hepatitis B and two fatalities from infections.15 This study and other similar studies establish that serious adverse events are possible, but they were not able to measure the frequency of these complications.16
Two large prospective studies in the U.K. provided estimates of the rates of adverse events. White et al. conducted a prospective survey of 32000 treatments and found that the rate of "significant" events were 14 per 10,000 acupuncture visits.17 None of these were deemed to be serious. A total of 671 minor events (such as bleeding or needling pain) per 10,000 acupuncture visits were reported in this study. MacPherson et al. conducted a prospective survey of 34000 treatments and found that there were no reports of serious adverse events that required hospital admission or led to permanent disability or death.18 Minor adverse events such as severe nausea and vomiting occurred in 1.3 out of 1000 visits. Mild transient reactions such as pain or bleeding occurred in 15% of the visits.
We examined two recent Technology Assessments to provide a review of systematic reviews as of 2001 (Table 1).
The search strategy used to identify studies listed in all Tables is summarized in Appendix D.
Literature Search
To evaluate the current evidence for the efficacy of acupuncture we identified two recent methodologically sound Technology Assessments:
"Alberta": Alberta Health Technology Assessment, Acupuncture: Evidence from Systematic Reviews and Meta-analyses (2002).7
"NHS": United Kingdom National Health Service Center for Reviews and Dissemination: Effective Health Care on Acupuncture (2001). 6
These reviews systematically assessed available systematic reviews and meta-analyses on acupuncture.
The Alberta assessment referenced one systematic review by Ernst of acupuncture as a symptomatic treatment of osteoarthritis, but excluded it because it did not use a "tool" to evaluate methodological quality.19 Therefore, no systematic reviews for acupuncture as a treatment for osteoarthritis are included in the Alberta technology assessment.
The NHS assessment included two systematic reviews on osteoarthritis: the systematic review by Ernst that was excluded by the Alberta report and a systematic review by Ezzo et al. on knee osteoarthritis.20
One systematic review, Berman et al., was found that was published since the NHS review.21 Four additional RCTs were found that were published since the last systematic review for osteoarthritis.22-25
Three clinical trials on the use of acupuncture to treat osteorarthritis are currently underway (Table 4).
Issues in Evaluating Acupuncture for Osteoarthritis
In addition to standard design issues such as the number of patients needed for adequate statistical power, the randomization procedures, and the appropriateness of outcome measures, the Alberta report summarized specific issues in designing a study for acupuncture including:
In addition, it is important to consider that osteoarthritis is a chronic disease characterized by recurring pain over a period of many months or longer. Long term follow-up would be critical to determine the effectiveness of the treatment.
Clinical data
A total of 19 controlled studies published as full articles were found in the systematic reviews and our update search; some of the studies were cited by multiple systematic reviews but others were cited by only a single systematic review. There is some disagreement among the systematic reviews about the study design of some of the studies. In table 2, basic information from the controlled studies was extracted from the abstracts of the studies; we were unable to retrieve an abstract for two of the articles (citations 30, 35-see table 3).
Ernst reviewed 13 studies, of which 12 were identified as being controlled clinical trials or RCTs.19 Ernst concluded that most trials suffer from methodological flaws, but that the most rigorous studies suggest that acupuncture is not superior to sham-needling in reducing pain of osteoarthritis; both are equally effective. This would suggest that sham-needling has similar specific effects as acupuncture or both methods are associated with considerable non-specific effects. Other methodological problems in some of the studies included heterogeneous samples, infrequent therapy sessions, no formal test statistics, groups not equal at entry and essential details missing.
Ezzo et al. reviewed 7 studies of osteoarthritis of the knee, all of which were identified as being RCTs.20 These studies suggested that acupuncture is more effective than being on a waiting list for treatment or treatment as usual. The studies did not find a benefit for acupuncture compared to physical therapy. The studies also did not find a benefit for acupuncture compared to sham acupuncture for improving function. Ezzo et al. reviewed three studies with sham acupuncture as a control. Two studies found larger improvements in pain with acupuncture compared to sham; while the third did not.26-28 Ezzo et al. noted that in the two studies that showed a benefit, the sham acupuncture consisted of needles placed at distal non-acupuncture points, which they refer to as "minimal sham". The third study, which did not show a benefit for sham acupuncture, the sham acupuncture was at sites one inch adjacent to the real points, which the authors note may have inadvertently elicited an analgesic response. They also noted that some studies were small and may be underpowered to find a positive effect. Other methodological problems in some of the studies included lack of blinding of patients and outcomes assessors and lack of description of dropouts and withdrawals.
Berman et al. reviewed 8 studies of the use of acupuncture in treating osteoarthritis as part of a larger review of the use of acupuncture for rheumatological conditions.21 Three of the studies were identified as being RCTs. However, he classified studies by Christensen et al. and their own study as "time series", although the abstracts of these studies indicate that they were "randomized".27, 28 Another study by Junnila is cited by both Berman et al. and Ernst; both refer to it in summary tables, calling it "non-randomized".29 However, the text of the Berman systematic review describes the Junnila study as "randomly assigning patients".21 The paper describes "successive patients" enrolled in either arm of the study, months apart. Thus two cohorts were formed uniformly from available patients, but in two distinct time periods; leaving open to interpretation whether or not the choice of time of the year constitutes randomization.
Berman found that for the studies they classified as RCTs there were no significant benefits for acupuncture compared to sham acupuncture. None of the studies had sufficient power to detect a difference between acupuncture and sham acupuncture, and there were significant improvements compared to baseline for both acupuncture and sham acupuncture groups. Berman suggests that this may be because puncturing the skin at any position may elicit an analgesic response or that the sham sites chosen were actually active acupuncture sites.21
We found four additional RCTs published after the date of the last systematic review.22-25 The results of these trials were consistent with the results of studies previously reviewed. Haslam et al. and Singh et al. compared acupuncture to advice and exercises for the hip or waiting for treatment respectively and found benefit for acupuncture compared to the control.23, 24 Fink et al. compared acupuncture to sham acupuncture and found that both groups had significant improvements compared to baseline with no differences between the groups.22 Tillu et al. compared acupuncture in the most affected knee to acupuncture in both knees and found a significant reduction in symptoms in both knees in both groups.25
A key issue in studies of acupuncture is the effect of sham acupuncture. Most studies on acupuncture for osteoarthritis do not find a benefit for acupuncture compared to sham acupuncture. Researchers hypothesize that this may be because placement of a needle anywhere elicits a physiological response or because the sham sites chosen were actually true acupuncture sites. Most studies found a benefit for both acupuncture and sham acupuncture compared to baseline. All the reviewers agree that more research is necessary to understand the effects of sham acupuncture.
The systematic reviews describe other methodological problems with some of the studies. Many studies are small and may be underpowered to measure statistically significant differences between the interventions. Other methodological issues include lack of blinding, lack of description of handling of dropouts and withdrawals, no formal test statistics, heterogeneous samples and groups not equal at entry in some of the studies.
Two studies did find a benefit for acupuncture compared to sham: Petrou et al. and Molsberger et al. Ezzo et al. noted that in these studies the needles were placed superficially, at sites distal to true acupuncture sites.30, 31, 20 Ernst also reviewed the study by Petrou et al. and noted that there was a small sample size (31 patients), that it lacked blinding and that not all the variables showed improvement.19
The systematic reviews had somewhat different conclusions based on their interpretation of the evidence (Table 2). Ernst qualitatively described methodological flaws in most of the studies, and concluded that acupuncture is not superior to sham. Ezzo et al. acknowledged the methodological problems in the studies, but concluded that acupuncture may play a role in the treatment of osteoarthritis; this conclusion was largely based on the two studies showing a positive effect of acupuncture compared to sham.30, 31 Berman et al. also found no benefit for acupuncture compared to sham, but they suggest that sham acupuncture may have pain relieving effects and that this may explain the relative equivalence of acupuncture compared to sham acupuncture.21 They concluded that there is moderately strong evidence supporting adjunctive use of acupuncture.
Overall, the NHS review concluded that the evidence was probably sufficient to justify the use of acupuncture as a second or third line treatment for a patient who is not responding to conventional management or not tolerating medication or experiencing recurrent pain, but also suggest that the evidence is not sufficient to justify acupuncture as first line treatment.
Three clinical trials on the use of acupuncture in osteoarthritis are currently underway (Table 4). These studies have randomized controlled designs and intend to enroll several hundred patients. Two of the studies are specifically designed to further investigate the effect of sham acupuncture. One of these studies (Table 4, #2) uses a validated placebo needle that does not penetrate the skin.32 A study with this placebo needle suggested that patients who have never had acupuncture could not tell that the technique was a placebo. The needle is designed based on the hypothesis that the beneficial effect of sham acupuncture is due to penetration of the skin by the needle. This study is not testing acupuncture alone but acupuncture in combination with physical therapy. Another study is also designed to further understand the effect of sham acupuncture (Table 4, #3). In this study, patients are randomized to groups with different models for practitioner-patient interactions. Patients in each interaction group will be further randomized to receive either acupuncture or sham acupuncture. This study is designed to test the hypothesis that placebo effects of sham acupuncture can be enhanced by the practitioner's communicative style, which can affect the patient's expectations and beliefs.
Most studies show a benefit for acupuncture compared to no treatment. It has been more difficult to determine whether the effect observed is a non-specific placebo effect because of the issues around the design of sham acupuncture procedures in randomized controlled trials. These problems arise from the lack of clear definition of what constitutes "acupuncture" and through what mechanisms it is purported to work. The currently available evidence is insufficient to determine whether acupuncture has a specific beneficial effect in osteoarthritis. New studies are underway which were designed with the aim of answering some questions about the effects associated with sham acupuncture. These studies should help to clarify the potential specific effect, if any, of acupuncture for osteoarthritis.
Table 1: Acupuncture for Osteoarthritis: A Review of Systematic Reviews Through 2001*
No specific conclusions were drawn about Osteoarthritis because no reviews on the use of acupuncture for osteoarthritis were included.
Current levels of evidence from RCTs of acupuncture for chronic pain (including osteoarthritis) are probably sufficient to justify the use of acupuncture as second or third line treatment for a patient who is not responding to conventional management, not tolerating medication or experiencing recurrent pain; however, there is insufficient evidence to warrant first-line treatment of chronic pain.
Ernst 1997
Ezzo et al 2001
* The Alberta Health Technology Assessment,Acupuncture: Evidence from Systematic Reviews and Meta-analyses (2002) 7.and the United Kingdom National Health Service Center for Reviews and Dissemination: Effective HealthCare on Acupuncture (2001) 6 systematically assessed available systematic reviews and meta-analyses on acupuncture. This Table provides those systematic reviews for osteoarthritis.
Table 2: Systematic Reviews on the use of Acupuncture for Osteoarthritis
Ernst E. Acupuncture as a Symptomatic Treatment of Osteoarthritis19
The most rigorous studies suggest that acupuncture is not superior to sham needling
Knee Osteoarthritis
Ezzo J et al. Acupuncture for osteoarthritis of the knee: a systematic review20
Evidence strong that real acupuncture is more effective than sham acupuncture for pain; inconclusive evidence for function. Insufficient evidence to determine whether the efficacy of acupuncture is similar to other treatments. The existing evidence suggests that acupuncture may play a role in the treatment of knee OA. Future research should define an optimal acupuncture treatment
Berman BM, Swyers JP, Ezzo J. The evidence for acupuncture as a treatment for rheumatic conditions. Rheu Dis Clin North Am. 2000;26(1):103-15,ix-x 21
In all the studies that employed sham acupuncture as a placebo control, there were no significant between-group differences. Moderately strong evidence supports the use of acupuncture as an adjunctive therapy for osteoarthritis.
Table 3: Acupuncture Controlled Trials
Gaw et al., 197533
Berman et al., 2000
Not specificied
Treatment at standard acupuncture points
Treatment at placebo points
Significant (p<0.05) improvement in tenderness and subjective report of pain in both groups compared to baseline
No significant differences between groups
Coan et al., 198134
Ernst, 1997
Cervical (neck)
12 weeks
Not specified
12/15 of treatment group felt improved: mean 40% reduction in pain score, 54% reduction in pain pills, 68% reduction of pain hours per day, 32% less limitation of activity
2/15 of the control group reported improvement: mean 2% worsening in pain score, 10% reduction in pain pills, no lessening of pain hours and 12% less limitation of activity
Milligan et al., 198135
Ezzo et al., 2001
Abstract unavailable
Junnila et al.,
large joints
4 months
Acupuncture reported to have a greater pain reducing effect than Piroxicam
Loy et al., 198336
Loy et al., 198336 (continued)
Both methods were effective, electroacupuncture produced an earlier symptomatic improvement with increased neck movement
Petrie et al., 198337
4 weeks
Placebo transcutaneous nerve stimulation
Treatment twice weekly
Acupuncture superior to placebo (p<0.01)
Petrie et al., 198638
No significant difference found either post-treatment or at follow-up
Petrou et al., 198830
Ammer and Petschnig, 198839
Ammer and Petschnig, 198839 (continued)
Physical therapy
Patients treated with acupuncture showed 2/10 parameters improved after 4 weeks of therapy.
Patients treated with physical therapy showed 4/10 parameters improved after 2 weeks and 7/10 parameters improved after 4 weeks.
Physical therapy was superior in objective measurements, but no significant difference in subjective judgment by patients.
Dickens and Lewith, 198940
Trapezio-metacarpal (hand)
12 patients
6 sessions over two week period
Acupuncture group: 76.01% pain reduction
Placebo group: 20% pain reduction
Statistically significant within groups but not between groups; study likely underpowered
Thomas et al., 199141
Sham acupuncture
Acupuncture significantly (p<0.05) more effective than placebo-diazepam
Acupuncture not significantly more effective than sham acupuncture or diazepam.
Christensen et al., 199227
Christensen et al., 199227 (continued
49 weeks
No treatment control for 9 weeks, then crossed over into treatment
In second part of study 17 patients continued treatment once a month
Treatment group had significant reduction in pain and analgesic use compared to no treatment group.
Benefit was maintained in the second part of the study
Patients were all initially waiting for arthroplasty; 7 patients no longer wanted surgery after acupuncture treatment
Molsberger et al., 199431
3 months
Sham acupuncture at non-acupuncture points
Treatment 2x per week for 5 weeks
47.5% pain reduction for acupuncture groups vs. 26.1% for control after treatment period
48.2% pain reduction for acupuncture group vs. 26.1% for control at 3 month follow up
Functional parameters had no significant change
Takeda and Wessel, 199426
3 weeks
Real acupuncture
Treatment 3x per week for 3 weeks
Both real and sham acupuncture significantly reduced pain, stiffness and physical disability compared to baseline
No significant difference between groups
Berman et al., 199928
73 elderlypatients
Standard care
Significant improvement for acupuncture patients compared to control at 4 and 8 weeks.
Slight decline in effect at 4 weeks after cessation of treatment
No adverse effects reported
Fink et al., 200122
Update search
2 months
Traditional needleplacement and manipulation
Needles placed away from classic positions and not manipulated
Both groups had significant improvement compared to baseline
Haslam et al., 200123
8 weeks
Acupuncture (six sessions each lasting up to 25 minutes)
Advice and exercises for the hip
Significant improvement in acupuncture group immediately post treatment (p=0.002) which was maintained at the 8 week follow up (p=0.03) compared to baseline.
Significant improvement in acupuncture group compared to control immediately post treatment (p=0.02) and at 8 week follow up (p=0.03)
Singh et al.,
Acupuncturetreatments twice weekly for 8 weeks
Crossover control group
Scores on two functional indexes improved at 4, 8, and 12 weeks.
Some decay in scores at week 12, but measures significantly improved over baseline
Tillu et al., 200125
Tillu et al., 200125 (continued)
6 months
Acupuncture to most affected knee
Acupuncture to both knees
Acupuncture to four local points and one distal point on the ipsilateral hand
Significant reduction of symptoms in both groups.
Improvement sustained for 6 months.
No statistical significance between the groups.
* For osteoarthritis, we updated systematic reviews for osteoarthritis (Table 1& Table 2) by identifying all RCTs published since the last systematic review.
Table 4: Current Clinical Trials Studying Acupuncture for Osteoarthritis*
1. Acupuncture Safety/Efficacy in Knee Osteoarthritis
Principle Investigator: Dr. Brian Berman
Sponsor: NCCAM
Knee osteoarthritis
Traditional Chinese acupuncture
Education and attention comparison group
Sham Traditional Chinese Acupuncture
2. Efficacy of Acupuncture with Physical Therapy for Knee Osteoarthritis
Principle Investigator: Dr. John Farrar
Acupuncture with exercise physical therapy
Validated blinded placebo needle with exercise physical therapy
3. Interaction Between Patient and Health Healthcare Provider: Response to Acupuncture in Knee Osteoarthritis
Principle Investigator: Dr. Maria Suarez-Almazor
Sponsor: NIAMS and NCCAM
6 weeks of biweekly treatment visits
6 month follow-up
Each group will also be randomized to different models for practitioner-patient interactions.
*The information provided in this Table comes from searching the ClinicalTrials.gov web site for acupuncture (search term "acupuncture" and search term "osteoarthritis"). The National Institutes of Health (NIH), through its National Library of Medicine (NLM), has developed the ClinicalTrials.gov web site in collaboration with all NIH Institutes and the Food and Drug Administration (FDA) to provide current information about clinical research studies. The site currently contains approximately 7,100 clinical studies sponsored by the National Institutes of Health, other Federal agencies, and the pharmaceutical industry in over 77,000 locations worldwide. Studies listed in the database are conducted primarily in the United States and Canada.
III Provide a review of any information available in the literature on training of the persons to perform this therapy and the number of physicians certified to perform this therapy.
Training, certification & licensing of acupuncturists in the United States
In 1976, California became the first state to license acupuncture as an independent health care profession. Since then, 40 states and the District of Columbia have adopted similar laws. Most states allow herbal medicine within the scope of acupuncture practice; only a few states require the supervision of a physician for the almost 11,000 practicing non-physician acupuncturists.
The number of acupuncturists is rapidly growing and is projected to double by 2005 and quadruple by 2015. The typical education standard for an acupuncturist is between 2,000 and 3,000 hours of training in independently accredited master's degree 4-year schools. Although some states allow physicians to practice acupuncture without additional education, most states require between 200 and 300 hours of special training. There are approximately 3,000 acupuncturists with medical degrees practicing in the United States.
Physician acupuncturists
State regulations
Most states regard acupuncture as being within the scope of practice for licensed physicians, but many require that physician acupuncturists receive additional training and in some cases pass an examination. A table published by the American Academy of Medical Acupuncture in 1999 outlines various state requirements. This table can be viewed at: http://www.medicalacupuncture.org/acu_info/licensure.html.
Professional societies
The American Academy of Medical Acupuncture (AAMA) is the sole physician-only professional acupuncture society in North America, accepting members from a diversity of training backgrounds. Membership requirements for the Academy have been established in accordance with the training guidelines created by the World Federation of Acupuncture-Moxibustion Societies. The AAMA training guidelines can be viewed at: http://www.medicalacupuncture.org/aama_marf/aama.html.
There are two categories of Practice Members of the AAMA. All AAMA Practice Members receive a formal certificate recognizing their level of training and experience. A detailed listing of AAMA membership requirements can be found at: http://www.medicalacupuncture.org/aama_marf/aama_membership.html.
Full membership
Physicians who desire Full Membership in the AAMA must fulfill all three of the following requirements:
Associate membership
Associate Membership is available to physicians that satisfy either of the following requirements:
The AAMA maintains a Physician Acupuncturist Referral Service that contains listings for 1,031 Practice Members of the AAMA. This listing can be viewed at: http://www.medicalacupuncture.org/findadoc/index.html.
Board certification
The American Board of Medical Acupuncture (ABMA) was formally established on April 26, 2000 as an independent entity within the American Academy of Medical Acupuncture. Its mission is to promote safe, ethical, efficacious medical acupuncture to the public by maintaining high standards for the examination and certification of physician acupuncturists as medical specialists.
A physician who desires certification by the ABMA must complete a formal course of study and training designed for physicians that, as a minimum, meets the guidelines and standards set forth by The World Health Organization and the World Federation of Acupuncture and Moxibustion Societies (WFAS). Programs must be a minimum of 200 hours of acupuncture specific training, post-medical school, of which 100 hours should be clinical. More information about the ABMA can be found at: http://www.medicalacupuncture.org/cme/cme/abma_info.html. A current listing of ABMA-approved training programs can be found at: http://www.medicalacupuncture.org/cme/cme/abma_info.html#trainingprograms.
Currently 200 American Academy of Medical Acupuncture (AAMA) members have qualified for ABMA Board Certification.
Non-physician acupuncturists
State licensing requirements
Legislative and regulatory policies that affect non-physician acupuncture practitioners vary from state to state. In their Final Report of March 2002, the White House Commission on Complementary and Alternative Medicine Policy published a table (in Chapter 6: Access and Delivery) that provides a brief overview of these policies. A table detailing licensing regulations by state and specialty can be viewed at: http://www.whccamp.hhs.gov/fr6.html.
United States Acupuncture Laws by State is a comprehensive survey of state policies affecting both non-physician and physician acupuncturists, with links in many instances to the relevant laws, regulations and agencies of that state. This site can be viewed at: http://acupuncture.com/StateLaws/StateLaws.htm.
In those states that license non-physician acupuncturists, education and testing requirements vary. An outline of formal education and examination requirements for licensure in these states has been posted on the Acupuncture Alliance website at: http://www.acupuncturealliance.org/examrequ.htm. The Acupuncture Alliance is an advocacy group that works to support and develop acupuncture and Oriental medicine through encouraging research, assisting in creating and amending state laws and regulations, and creating practice standards.
Most states require that applicants, trained in the U.S., must have graduated from a program accredited by the Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM). Recognized by the U.S. Department of Education as a "specialized and professional" accrediting agency, ACAOM's primary purposes are to establish comprehensive educational and institutional requirements for acupuncture and Oriental medicine programs, and to accredit programs and institutions that meet these requirements. More information about ACAOM can be found at: http://www.acaom.org/AboutUs.htm. A list of ACAOM accredited institutions can be found at: http://www.acaom.org/SchoolistNov2001.htm.
Typically, a licensing board will also require passage by the applicant of the National Certification Commission of Acupuncture and Oriental Medicine (NCCAOM) certification examination. The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) is a non-profit organization established in 1982. Its mission is to promote nationally recognized standards of competency and safety in acupuncture and Oriental medicine for the purpose of protecting the public.
More information about NCCAOM and the certification process can be found at: http://www.nccaom.org/about.html. The NCCAOM published a table in January 2001 that outlines how various states use its certification examination in their acupuncturist licensing requirements. State licensure requirements can be viewed at: http://www.nccaom.org/states.html. Since its inception in 1982, the NCCAOM has certified close to 10,000 Diplomates in Acupuncture, Chinese Herbology and Asian Bodywork Therapy
Appendix A: GLOSSARY
Acupressure refers to the stimulation of a point manually with pressure. 7
Acupuncture, in the strictest sense, refers to insertion of dry needles, at specially chosen sites for the treatment or prevention of symptoms and conditions. 7
Bloodletting refers to the pricking of the skin for the purpose of releasing blood. This may be aided with the application of a cup over the site. 7
Cupping is a technique by which a vacuum force is applied to acupuncture sites. 7
Electroacupuncture refers to the technique of introducing an electrical current to the inserted needles at various frequencies. 7
Fire needle techniques insert red-hot needles at an acupuncture point. 7
Intramuscular stimulation is a technique of applying needles to areas of tenderness. 7
Laser acupuncture directs and stimulates a laser beam directed at the acupuncture site. 7
Medical acupuncture is a medical discipline that integrates traditional and modern acupuncture techniques into contemporary biomedical practice.42 Physician Acupuncturist is one who has acquired specialized knowledge and experience related to the integration of acupuncture within a biomedicine practice.4
Moxibustion refers to heat stimulation and the use of the herb Artemisia vulgaris (mugwort) which is burned over the acupuncture site for purposes of warming. 7
Staple puncture is the application of a metal staple to an acupuncture point where it remains for a prolonged period of time. 7
Zhejiu is the Chinese term and refers to both acupuncture and moxibustion. 7
Appendix B: NHS Methodology
Systematic reviews on acupuncture were located as part of an attempt by the Cochrane Complementary Medicine Field to locate all reviews on acupuncture, herbal medicine and homeopathy. The field registry is a specialized complementary medicine database compiled from searcher of other databases including Embase, AMED and Medline; approximately 4,700 RCTs of complementary medicine are included on the database. Another 5,700 controlled trials have been identified for which the randomization status is unknown. RCTs have also been identified through hand searching of 31 alternative medicine journals. In addition to searches of the field registry, the following searches were conducted:
A search of Medline and the Cochrane Library (2001:1) was made in March 2001 to find further reviews and RCTs published subsequently to each review. All searches used strategies developed by the Complementary Medicine field of the Cochrane Collaboration and published on the Cochrane Library. Where no review was available, all RCTs on that topic were included.
To be included, systematic reviews had to meet the following criteria:
Included clinical trials of acupuncture; describe review methods explicitly; had to be published; had to focus on treatment effects.
Quality assessment was undertaken by two reviewers working independently for the systematic reviews. Data extraction and assessment of methodological quality of the additional RCTs were undertaken by one reviewer and checked by a second reviewer.
Appendix C: Alberta Methodology
Two searches were performed - in January and July 2001. The following outlines the search strategy and the databases used. Effort was made to find criteria accepted by the acupuncture community as well as the scientific community for use in the critical appraisal of the quality of systematic reviews for acupuncture. No quality assessment tool specific to acupuncture was found.
Two of the co-authors (LB and CH) selected the articles based on the inclusion and exclusion criteria while two co-authors (LB and PLT) extracted data from the reviews and evaluated their methodological quality using criteria by Greenhalgh 21 as outlined in Appendix B. The authors of the reviews were not contacted for missing information.
Search Strategy
MEDLINE (Ovid) 1990-May2001
and PreMEDLINE to July 21, 2001
Acupuncture (exploded) OR acupuncture
acupressure OR Electroacupuncture OR
electro-acupuncture OR staple acupuncture OR
staple-acupuncture OR stapleacupuncture OR staple puncture OR staple-puncture OR staplepuncture OR moxibustion
HealthSTAR (Ovid) 1991- Jan 2000 - database discontinued
Best evidence (Ovid) Jan/Feb 2001
CINAHL (Ovid) 1990-March 2001
EMBASE (Ovid) 1990-April 2001
AMED (Ovid) May 2001
Cochrane Database of Systematic Reviews 1st Quarter 2001
Acupunctur* OR acupressure OR electroacupuncture OR
CMA practice guidelines- CPG infobase June 22, 2001
acupuncture OR moxibustion
National guideline clearinghouse June 22, 2001
DARE, HTA, EED June, 2001
Acup OR moxibustion
WWW: ECRI, Bandolier, and other HTA agencies websites
acupuncture OR acupressure OR electroacupuncture OR
Two other databases, ISTAHC, PsycInfo (February 2001), were searched but there were no relevant studies found. Articles were submitted by various people interested in acupuncture, and access was granted to a private collection of journals of acupuncture. This 'grey literature' was hand searched for articles that complied with the inclusion criteria. Reference lists of retrieved reviews were search for systematic reviews and meta analyses.
Publication type limits (where available): meta-analysis, systematic review
"A systematic review is an overview of primary studies that use explicit and reproducible methods" 21.
"A meta-analysis is a mathematical synthesis of the results of two or more primary studies that addressed the same hypothesis in the same way" 21.
These publication types were searched as textwords and where publication type limiting was not available by using this search string: (Subject headings OR Textwords) AND (systematic review OR meta analysis OR critical appraisal OR metaanaly$ OR meta-analy$ OR metanaly$ OR critical$ apprais$ OR systematic$ review$)
Inclusion criteria: Articles were selected if they were systematic reviews, a category which includes but is not limited to meta-analyses. The study must have human participants, but with no restriction of age group or nationality. Reviews were required to have an intervention of acupuncture as being the primary treatment intervention in the study. Studies addressing any medical indication were included if they were published within the past 11 years (1990 - 2001). Only reviews available in English were evaluated.
Exclusion criteria: Reviews were excluded if the use of a tool to evaluate the methodological quality of the primary studies was not apparent. If reviews used the same methodological criteria and had the majority of primary studies in common, the older publications were excluded.
Appendix D: AHRQ Search Strategy
Search Strategies for Acupuncture
Search Strategy for Acupuncture RCT's
(acupuncture[tw] OR acupressure[tw] OR
electroacupuncture[tw] OR electro-acupuncture[tw] OR (staple[tw] AND acupuncture[tw]) OR staple-acupuncture[tw] OR stapleacupuncture[tw] OR (staple[tw] AND puncture[tw]) OR staple-puncture[tw] OR staplepuncture[tw] OR moxibustion[tw])
Limits: Pub. Dates 1995-2002, English, Human
CINAHL (Ovid)
AMED (Ovid)
Inclusion criteria: Acupuncture, acupressure, electro-acupuncture, staple acupuncture, moxibustion, human, adult, English language, RCT
Search Strategy for Systematic Reviews
APC Journal Club (EBM Reviews)
Acupuncture (Exploded)
(acupuncture OR acupressure OR
electroacupuncture OR electro-acupuncture OR (staple AND acupuncture) OR staple-acupuncture OR stapleacupuncture OR (staple AND puncture) OR staple-puncture OR staplepuncture OR moxibustion)
Limits: Pub. Date 2001-2002
HealthSTAR (Ovid)
Acupuncture (MESH)
Inclusion criteria: Acupuncture, acupressure, moxibustion, systematic review, meta-analysis
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36. Loy TT. Treatment of cervical spondylosis. Electroacupuncture versus physiotherapy. Med J Aust. Jul 9 1983;2(1):32-34.
37. Petrie JP, Langley GB. Acupuncture in the treatment of chronic cervical pain. A pilot study. Clin Exp Rheumatol. Oct-Dec 1983;1(4):333-336.
38. Petrie JP, Hazleman BL. A controlled study of acupuncture in neck pain. Br J Rheumatol. Aug 1986;25(3):271-275.
39. Ammer K, Petschnig R. [Comparison of the effectiveness of acupuncture and physical therapy in ambulatory patients with gonarthrosis]. Wien Med Wochenschr. Nov 30 1988;138(22):566-569.
40. Dickens W, Lewith GT. A single-blind, controlled and randomized clinical trial to evaluate the effect of acupuncture for the treatment of trapezio-metacarpal osteoarthritis. Complementary Medical Research. 1989;3:5.
41. Thomas M, Eriksson SV, Lundeberg T. A comparative study of diazepam and acupuncture in patients with osteoarthritis pain: a placebo controlled study. Am J Chin Med. 1991;19(2):95-100.
42. An Overview Of Medical Acupuncture, American Academy of Medical Acupuncture, June 2, 2003. Available at: http://www.medicalacupuncture.org/acu_info/articles/helmsarticle.html


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Here are some of the latest health and medical news developments, compiled by the editors of HealthDay:
Antibiotic-Resistant Bacteria Common in Raw Meat: FDA Report
Latest Nutrition, Food & Recipes News
Antibiotic-resistant bacteria are present in a significant amount of raw meat sold in the United States, according to a Food and Drug Administration report.
Tests conducted by the agency found antibiotic-resistant bacteria in 81 percent of raw ground turkey, 69 percent of pork chops, 55 percent of ground beef and 39 percent of chicken, CNN reported.
In addition, there were significant amounts of salmonella and Campylobacter bacteria, which cause millions of cases of food poisoning a year in the U.S. Of the chicken samples tested, 53 percent had an antibiotic-resistant form of E. coli.
In livestock, antibiotics are used to prevent disease and to boost growth. In 2011, nearly 30 million pounds of antibiotics were sold for use in meat and poultry, compared with nearly 8 million pounds for human use, according to the Pew Charitable Trusts.
"Antibiotic use in animals is out of hand," Dr. Gail Hansen, a veterinarian and senior officer for the Pew Campaign on Human Health and Industrial Farming, told CNN. The campaign's goal is to curb the overuse of antibiotics in food production.
Pet Hedgehogs Linked to Salmonella Outbreak: CDC
Pet hedgehogs have been identified as the cause of a salmonella outbreak that sickened 23 people in 9 states and led to one death, the U.S. Centers for Disease Control and Prevention says.
The illnesses were reported between December 26, 2011 and March 5, 2013 and occurred in: Alabama (1), Idaho (1), Illinois (1), Indiana (1), Michigan (3), Minnesota (3), Ohio (5), Oregon (1), and Washington (7).
Thirty-five percent of people who became ill were hospitalized and one death was reported in Washington. Children age 10 and younger accounted for 39 percent of patients, the CDC said.
Investigators linked the outbreak to contact with pet hedgehogs bought from a number of breeders in different states.
The CDC said people should wash their hands thoroughly with soap and water immediately after touching hedgehogs or anything in the area where the animals live and roam. Adults should supervise young children as they wash their hands.
FDA Should Have Been Tougher With Compounding Pharmacies: Commissioner
The U.S. Food and Drug Administration should have taken stronger action against compounding pharmacies like the one linked to a meningitis outbreak last year, agency commissioner Dr. Margaret Hamburg admitted to Congress Tuesday.
Because it had become overly concerned about avoiding lawsuits, the FDA did not control compounding pharmacies as effectively as it could have, Hamburg said at a hearing before a House Energy and Commerce subcommittee, The New York Times reported.
"I think we allowed ourselves to be far too cautious because of fears of litigation that might further undermine our authority," she explained. "That should not happen. Public health should not be impeded by those kinds of legal regulatory ambiguities."
Hamburg added: "We weren't as aggressive as we could have been, and I regret that," The Times reported.
The commissioner also repeated concerns that the FDA still lacked the authority to force compounding pharmacies to follow tougher safety standards, but some committee members expressed doubts about that claim.
In the outbreak last fall, more than 50 people died and 680 more became ill with fungal meningitis after receiving injections of a contaminated steroid made by the New England Compounding Center.
Copyright © 2013 HealthDay. All rights reserved.


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Architecture of MoDisco
MoDisco aims at providing a platform supporting various legacy modernization use-cases for various kinds of existing technologies. To facilitate reuse of components between several use-cases, MoDisco is organized in three layers:
- the Use-Cases layer containing components providing a solution for a specific modernization use-case.
- the Technologies layer containing components dedicated to one legacy technology but independent from the modernization use case.
- the Infrastructure layer containing generic components independent from any legacy technology.
This layer contains components supporting legacy modernization use-cases. The kind of use-cases MoDisco could support is quite infinite. Nevertheless, the main ones are well identified:
- Comparison : comparing two versions of the same application at a structural level
- Quality Analysis: detection of anti-patterns in existing code and computation of metrics.
- Cartography: detection of the main components of a system and their dependencies.
- Understanding: extraction of features presented independently from the implementation (structure, behaviour, persistence, data-flow …).
- Reverse-Modeling: creation of models out of existing systems to populate modeling tools (supporting UML or Domain-Specific Languages).
- Refactoring: improvement of the source code to integrate better coding norms or design patterns.
- Migration: transformation of the source code to change the framework, the language, or the architecture of existing applications.
Other more specific use-cases may be supported as, for example, extraction of business rules from programs to populate a business-rules engine, modification of an existing system to better integrate with another system, etc…
The technology layer contains components dedicated to one legacy technology.
These components can be reused between several use-cases components involving the same legacy technology. For example, a use-case computing metrics on Java source code and another providing refactoring for Java applications could reuse the same component.
Use-cases generally involve only one legacy technology (the one used to implement the existing system).
Some use-cases can involve several legacy technologies. It is the case when the existing system is heterogeneous, built with several languages. For example, when a system, implemented with Java, stores data into a relational database using JDBC, the use-case may need MoDisco components able to analyse Java and SQL source code.
Each technology component is composed of, at least, a metamodel of the dedicated technology. This metamodel describes the elements required to support modernization use-cases for the corresponding technology. Depending on the kind of use-case the metamodel can be complete (for refactoring or migration) or partial (for cartography or some quality analysis scenarii).
Ideally, the metamodel is completed by a discoverer, a component which aims at building models conforming to the metamodel from artefacts of an existing system.
Artifacts analysed by discoverers are not necessarily source code files. There exist multiple other ways a discoverer can find the information needed to create a model of an existing system :
- analysing parameter files
- analysing execution logs
- unzipping an archive to access to its contents
- querying a database
- using APIs to access a tool with which the system has been designed
- translating data provided by a reverse-engineering tool into model
- transforming models provided by another discoverer
A MoDisco Technology component can come with utilities dedicated to its metamodel:
- Browsers to navigate the models more easily
- Viewers to represent the models graphically
- Computation of standard metrics
- Transformation to standard metamodels (ASTM, KDM, UML …)
- Generator to regenerate the initial artefact from its model
<to be completed>


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People are the life force of our business, so we prefer to rely on human beings rather than just computers when it comes to decision-making. We make your hopes and aspirations our business, so that you can make them a reality.
That's why getting to know you and your world is our top priority.
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text:
he Motion's simplicity, versatility and near universal fit makes it one of our most popular designs.
Available in regular, small face with single lens and + with 3 lens kits.
Its soft and infinitely adjustable nosepieces and its friction rubber temples allow for lightweight comfort. Motion weighs only 27 grams. Adjust the Motion close to your face for wind deflection in high speed sports like cycling or slightly farther off the face for ventilation needed in medium speeds sports like running or cross country skiing. Each Motion kit comes with one lens set and a soft microfiber case.


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|Biosequences .. Software .. Molbio soft .. Network News .. FTP
Ficus in general loose their leaves as a way of showing stress-change in temp., breeze from an outside door that is opened and closed regularly, under watered, breeze from air/heat vent are all typical reasons they drop leaves. e.t. and dct <emt1 at bellsouth.net> wrote in message news:Qrv55.1088$vl5.6775 at news2.atl... If you mean the "ficus benjamina", you're doing just fine. LOL...that's one of it's traits. The ficus tree is notorious for going bald on you! Just keep it in the same place...ficus trees hate to be moved. I finally wound up trimming back all the bald sticks so that the new growth could develop on mine. I moved her outside onto my porch, and I'll bet I have a show stopper in a couple of years. Errr...until I have to take her back inside this winter, and I imagine the whole process will repeat itself. e.t. <zischeck_michael at bluewin.ch> wrote in message news:8j4l40$c6g$1 at hs1b01h02-0.dplanet.ch... Hi.. I have a benjamin... and it looses leaves. Can you give me some instructions how to really well take care of the benjamin. What to look for and how to cure what symptoms?... like rippled leaves, falling leaves, yellow leaves Thank you Michael Please reply by email as well... zischeck_michael at bluewin.ch -------------- next part -------------- An HTML attachment was scrubbed... URL: http://iubio.bio.indiana.edu/bionet/mm/plantbio/attachments/20000726/9a326b23/attachment.html


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Cheap web hosts can actually do quite a lot for those of us who know how to use their services to the fullest. Now when I say "cheap", I don't mean anything poorly set up. I'm talking about inexpensive, yet valuable – know what I mean? The fact is that many cheap web hosts online provide excellent service, and their account packages each allow for our creativity in web designing according to each of our individual needs.
For a good example of what I'm talking about here, let's assume you need to create a presence on the web for a business you might have in the real world, in order to spread the word and increase your client base, or just to offer information about your whereabouts, what you do, etc. – using the services of any of the cheap web hosts out there, you could do this with a simple, single-paged website, a domain name and maybe an e-mail account as well. For this, you could easily find an account costing around $5 per month. That's pretty darned cheap, right?
Or it could be that your needs are not so uncomplicated, but cheap web hosts can still supply you with an account to have your needs met. Let's say that you run a web log (or "blog") which showcases the business you run, offers tips or tutorials on the subject of your hobbies you might like to share, or even to create a world-wide discussion on some areas that you are expert in. performing this activity would eventually accumulate a large group of readers, loyal fans, fellow bloggers and others. You could still use the cheap accounts that web hosts can provide.
Imagine that you did all of this as a means of generating income. You could monetize your blog through the use of relevant, contextual ad placement within your posts. This would create the need for more storage
space for posts, bandwidth to accommodate increasing numbers of visitors and perhaps sub-domains for branching off of your main domain name for each post. You could easily find the right account to use for this that cheap web hosts offer, for around ten to fifteen bucks per month to do all of this – perhaps less.
As a further example, let's say that you need to do your web hosting on a much larger scale – cheap web hosts can still provide you with service. Maybe you're someone who generates your income solely online. You'd certainly require more bandwidth and storage space, as well as other things. Maybe you're a publisher of a newsletter that you distribute through e-mail to a vast subscriber base. Maybe you offer products for online sale which people could buy and download from your web pages. Maybe you operate an array of monetized blogs which review other people's products for affiliate commissions.
Okay, so maybe you do all of the above. Can the use of cheap web hosts really still be a feasible option here? With the use of a reseller account, cheap web hosts can still handle this, and surprisingly, even much, much more – seriously. You see, the concept of reseller accounts was originally put together so that anyone who wished to join in on web hosting business, offering services to others, could do so and enjoy a stable monthly income… but now, reseller accounts aren't used for just this type of reason anymore. You can actually use a reseller account, which many cheap web hosts offer, to host an unheard of amount of websites, affiliate promotion sites, monetized blogs, forums, discussion boards on various topics, and stake your claim on a huge chunk of the internet all for your own use.
Paying for a reseller account would only cost around twenty to thirty dollars per month, and it would permit you to create and host more websites, domains, and download pages than you can shake a stick at. If you think about it for a bit, at the price of the account, all of your websites that you can host on a reseller account could effectually be less than one cent each month in cost, per website – could cheap web hosts be any more inexpensive?


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size - 18" x 24"
colors - yellow, metallic purple, dark purple
Screen printed on 100 lb pop-tone whip cream French Paper. Limited edition of 100 created for a screening at the Franklin Theatre in TN.
Inspired by The Neverending Story.
designed by Ryan Brinkerhoff
*SHIPPING DETAILS* Tubes will be mailed out the Saturday after purchase was made. US purchases: please allow 3-5 days for tube to arrive. International purchase: may take up to 2 weeks to arrive. If shipping address is not the address you wish the package to be sent, you must specify another address via email. We will not be responsible for reading minds. All sales are final unless order is damaged or incorrect. Refunds or replacements are only made at the discretion of Bandito Design Co.


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Current Rating: 3.66
based on 112 votes and 36 reviewsRate this Movie
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Running Time: 88 min.
Release Date: April 27, 2012
DVD: August 28, 2012
Current rating:
based on 112 votes and 36 reviews
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Cast: Hugh Grant, Martin Freeman, Imelda Staunton, David Tennant, Jeremy Piven, Salma Hayek, Lenny Henry, Brian Blessed, Anton Yelchin, Brendan Gleeson, Ashley Jensen, Al Roker, Mike Cooper, David Schneider
If you'd like to enjoy a movie with the kids for only $2.50 each (including taxes),...
Cineplex Entertainment has announced it will host its third annual National Community...
It turns out five superheroes are always better than just one. Not surprisingly, The...
Think Like a Man, based on comedian Steve Harvey's bestselling book Act Like a...


text: Wednesday, February 15, 2012 Conference Committee Reaches Deal on SGR Update Late last night, the Congressional Conference Committee reached a deal on a 10-month measure that would prevent a 27.4% cut, due to the flawed Sustainable Growth Rate (SGR) portion of the fee schedule, to Medicare providers scheduled for March 1. Sources on Capitol Hill have indicated to APTA that the deal also would extend the therapy cap exceptions process for the remainder of 2012. National Journal is reporting that the 10-month extension, which costs nearly $20 billion, could be paid for by pulling money from a fund earmarked for preventive medicine in the Affordable Care Act (ACA) and cutting Medicare "bad debt" payments to hospitals when beneficiaries fail to pay their copays. Significant pressure from the prevention community to defeat this legislation is expected, due to the defunding of prevention dollars included in ACA. The House and Senate still must pass the measure by February 29 to avoid the return of the therapy cap without exceptions and the 27.4% payment cut for Part B outpatient physical therapy services. Upon its release, APTA will analyze the legislative text to see if it contains language that the association advocated for in the fall to set a path toward payment reform in therapy services. Advocating on behalf of hundreds of thousands of Medicare beneficiaries who receive outpatient rehabilitation services every year, APTA, as part of the Therapy Cap Coalition, yesterday urged members of the Congressional Conference Committee to provide the longest possible exceptions extension for Medicare Part B therapy services in the committee's final agreement.


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Posts TaggedHaiti
As most of you may have heard, Haiti was recently devastated by one of the largest earthquakes in its history. This isn't particularly web app news but what generally follows disasters such as this, is help from around the world. As we all know, help requires money which generally leads to donations.
Thanks to today's web app technology, donations have become so incredibly simple and easy that not donating is virtually inexcusable. There's no need for mailing a check or visiting an office to make a donation. From a simple text message to a short online checkout, donating is literally at our fingertips — no matter where you are.
In recognition of the recent Haiti disaster, we've rounded up ten sites for quick and painless donating. These have been made possible by the power of web applications, no matter how simple (contact forms, payment gateways, etc).


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Crist: America's luckiest pol
After a years-long slump, Charlie Crist is starting to look again like one of the luckiest men in professional politics.
The party-switching ex-Republican governor's name had largely become a punch line in Florida political circles, but he's now not only seriously pursuing a new gubernatorial campaign, each day new obstacles seem to almost miraculously fall out of his path.
Story Continued Below
His most formidable potential Democratic primary opponents – former state CFO Alex Sink and former Miami Mayor Manny Diaz – have quietly signaled they are leaning against running. In Sink's case, that reluctance heightened after her husband, the well-liked Tampa attorney and former gubernatorial candidate Bill McBride, succumbed to a heart attack in December.
Crist has the admiration – and appreciation – of a White House that considered his 2012 endorsement key. And if party-jumping often leads to political oblivion, Crist is proving that timing is everything; not only does he seem to be cruising to the nomination, he would face an increasingly beleaguered incumbent, Gov. Rick Scott, who suddenly seems eminently beatable.
"It's hard at the moment to imagine any scenario where Charlie Crist is not the Democratic nominee for governor in 2014," said Democratic strategist Steve Schale, who was President Barack Obama's senior adviser in Florida in 2012.
( Also on POLITICO: Fla. poll: Crist crushes Gov. Scott)
There are still state and national Democrats who remain skeptical of Crist's strength, worrying about how he might stand up to a withering character assault from Scott. Some have approached Sen. Bill Nelson, who won a third term last November, about the prospect of entering the governor's race.
But several sources familiar with the 70-year-old Nelson's thinking say that while he hasn't totally ruled out a gubernatorial bid, he's loath to hit the campaign trail again so soon after winning reelection.
On the general election front, things look perhaps even brighter for Crist. Two surveys this week – from Quinnipiac University and the Democratic firm Public Policy Polling – showed Scott trailing Crist by double digits in a general-election matchup.
On top of Scott's persistent vegetative state in the polls, several recent stumbles have worked particularly to Crist's benefit.
( Also on POLITICO: Scott plans $100M campaign vs. Crist)
Strategists in both parties agree that Crist's two biggest general-election vulnerabilities would be his reputation as a political flip-flopper and his connections to a state GOP corruption scandal. Former state Republican Party Chairman Jim Greer, a Crist appointee, pleaded guilty last month to money laundering.
"His strength is untested, and there are a lot of Democrats whispering about who in the party would be stronger statewide with the base," said one source close the White House, who added that Team Obama "continues to have good feelings about Crist as a thoughtful guy."


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Apple pie is an enduring symbol of America. Why? Well, there are more reasons than we can go into right now--but if you're curious, we highly recommend Apple Pie: An American Story by John T. Edge.
But what happens when apples are scarce or prohibitively expensive, as during the rations of World War II?
You do another all-American thing: find a quick fix! During those war years, that fix was making a mock "apple" pie filled with a slurry of (inexpensive) Ritz crackers, sugar syrup and lemon rind. Ready to throw up in your mouth a little? Well, hold it in, because while not as good as "real" apple pie, it's strangely passable if you close your eyes and think really hard about apples while chewing.
And when we made this pie recently, we decided to go a little further on the mock concept. In celebration of what seems to be a New England-centered (or does it perhaps root from the Midwest?) preference for eating pie with a wedge of sharp cheddar, we made our mock pie using cheese-sandwich Ritz crackers. Here's a shot of it in progress (before adding the sugar syrup and top crust):
Ritz Mock Apple Pie (from backofthebox.com)
The classic pie, featuring Ritz crackers baked in a golden crust,
is perfect for the holidays.
Pastry for two-crust 9-inch pie
36 RITZ Crackers, coarsely broken (about 1 3/4 cups crumbs) --we used the mini cheese-filled sandwich crackers
1 3/4 cups water
2 cups sugar
2 teaspoons cream of tartar
2 tablespoons lemon juice
Grated peel of one lemon
2 tablespoons margarine or butter
1/2 teaspoon ground cinnamon
1. Roll out half the pastry and line a 9-inch pie plate. Place
cracker crumbs in prepared crust; set aside.
2. Heat water, sugar and cream of tartar to a boil in saucepan
over high heat; simmer for 15 minutes. Add lemon juice and peel;
3. Pour syrup over cracker crumbs. Dot with margarine or butter;
sprinkle with cinnamon. Roll out remaining pastry; place over pie.
Trim, seal and flute edges. Slit top crust to allow steam to escape.
4. Bake at 425 F for 30 to 35 minutes or until crust is crisp
and golden. Cool completely.
Makes 10 servings
Preparation Time: 45 mins.
Cook Time: 30 mins.
Cooling Time: 3 hrs.
Total Time: 4 hrs. 15 mins.