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The potential use of acupuncture for shoulder pain of various etiologies and whether clinicians make recommendations about the use of acupuncture was examined. Shoulder pain is a common clinical problem. What is the level of evidence and how often is acupuncture recommended for shoulder pain? A manual and database (PubMed) search of review articles of related clinical trials and guidelines was performed. The evidence for effectiveness of acupuncture treatment of different types of shoulder pain was weak. However, there are some studies, with a weak to moderate level of evidence, on shoulder pain (across nine subtypes of shoulder pain). Acupuncture is safe and may be a cost-effective treatment for shoulder pain. There were 131 statements recommending the use of acupuncture for shoulder pain across 12 subtypes of shoulder pain. The most common statements were for non-specific ‘shoulder pain.’ There were 11 statements against the use of acupuncture for shoulder pain and three subtypes of shoulder pain. The level of evidence in studies of acupuncture treatment for shoulder pain is low, therefore, further research is needed. Recommendations for the use of acupuncture for shoulder pain are increasing but lag behind those for other pain problems such as low back pain.

Introduction - In a previous study, evidence was found of the variability of signs/symptoms (s/s) of blood stasis syndrome among texts of Chinese and Asian origin and English language texts including evidence of the differences between non-Asian and Asian patients. In the current study the diagnostic patterns of qi deficiency (QD) and qi stagnation (QS) were examined to see if similar results could be found. Methods - The study consisted of two phases – a search of libraries and a search of electronic databases, and searching for texts describing QD and QS s/s ensuring inclusion of Asian origin texts (principally Chinese) and Western origin texts. More commonly mentioned s/s were compared for each type of source and across all sources. Results - Study one: From the 21 included QD texts, six s/s were generally agreed upon with three more commonly mentioned in Western origin texts, three more commonly mentioned in Chinese origin texts. From the 17 included QS texts, three s/s were more generally agreed upon with three more commonly mentioned in Western origin texts. Study two: Comparing s/s in 13 QD studies, five were mentioned by more than half the studies. Comparing six QS studies, six s/s were more generally agreed upon. In a comparison of s/s for QD mentioned by Western and Chinese origin texts and the Asian studies, three were mentioned by >50% sources, one more often by Chinese texts, three more often by Western texts and one more often by Asian studies. In a comparison of s/s for QS mentioned by Western and Chinese origin texts and the Asian studies, two were mentioned by >75%, two more often by Western texts and two more often by Asian studies. Conclusion - English language texts and studies describing QD and QS s/s were examined. Evidence of agreement on a few s/s were identified. English origin texts showed differences in texts originating from Asia, which may support the hypothesis that QD and QS may manifest differently among Western and Asian patients.

Breast cancer (BC) is the most common cancer in women and is a serious threat to women’s health. Cancer-related fatigue (CRF) is a distressing symptom in BC patients during and after chemotherapy or radiation therapy that severely affects quality of life (QoL). AT is widely used for fatigue management. However, the effect of AT on CRF is still uncertain. This study aimed to evaluate the efficacy and safety of AT in the management of CRF in patients with BC. Eleven databases were searched through June 2022. Two researchers independently performed the database search, study selection, data extraction, and risk of bias assessment. Study selection was performed based on predefined Participants, Intervention, Comparators, Outcomes, Study design (PICOS) criteria, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed when reporting the results. A meta-analysis was performed according to the Cochrane systematic review method using RevMan 5.3. A total of 12 studies including a total of 1084 participants were included. The results showed that AT had a beneficial effect compared with sham AT (n = 256, SMD = −0.26, 95% CI [−0.51, −0.01], p = 0.04, I2 = 0%) and a long-term effect on fatigue score (n = 209, MD = −0.32, 95% CI [–0.59, −0.04], p = 0.02, I2 = 0%). Meta-analysis showed that AT had a beneficial effect compared with usual care (UC) on fatigue scores (n = 238, SMD = −0.39, 95% CI [−0.66 to −0.12], p = 0.005, I2 = 0%). Of the 12 articles, 3 articles were judged as having a low risk of bias in all domains and hence were of high quality. No serious adverse effects were identified. AT is an effective and safe treatment for CRF, and AT is more effective than sham AT or UC or wait-list control (WLC). Nevertheless, the methodological quality of most of these studies was low, and the included studies/sample sizes were small, so the ability to derive decisive implications was limited. Further research is needed to confirm these findings.

We are grateful for the relevant comments by Hu et al. [...]

Although acupuncture (AT) is used in the treatment of CRF, the evidence from different systematic reviews (SRs) of AT has not yet been comprehensively evaluated. Moxibustion, which is a treatment method that is well established within Traditional East Asian Medicine, applies the heat of burning herbs towards or onto special points on the skin. Commonly, the herb Artemisia vulgaris, is used. It has been used for palliative cancer care, as well as for CRF. The aim of this overview was to evaluate the efficacy of AT and moxibustion in the management of CRF. Eleven databases were searched through for studies that were published from their dates of inception to February 2022. The study selection, the data extraction, and the assessment were performed independently by two researchers. The methodological and report quality were assessed by using the Assessment of Multiple Systematic Reviews-2 (AMSTAR-2) tool. The evidence quality was evaluated by using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Fifteen SRs on AT (n = 10) and moxibustion (n = 5) treatments for CRF were included, and they include 169 randomized controlled trials and 14,392 participants. All of the SRs that were evaluated by the AMASTAR-2 had more than one deficiency, and so all of the SRs were rated as either low or critically low. For the GRADE, 18 outcomes were rated as very-low-quality evidence, 13 as low-quality evidence, 3 as moderate-quality evidence, and 0 as high-quality evidence. Most of the SRs reached the potential benefits of AT for CRF. No serious adverse effects were identified. In conclusion, the evidence suggests that, despite the advantages of AT in terms of the improvement in and the safety of the treatment of CRF, the methodological quality of most of these studies is low, which limits our ability to draw definitive meanings. Further research of high quality is needed in order to confirm these findings.

A prospective cohort study on changes of health complaints after removal of amalgam restorations was carried out at the request of the Norwegian Directorate of Health. The aim was to provide and evaluate experimental treatment to patients with health complaints attributed to dental amalgam fillings. Patients (n = 32) with medically unexplained physical symptoms (MUPS), which were attributed to dental amalgam restorations had all their amalgam restorations removed and replaced with other dental restorative materials. Samples of blood were collected before and 1 year after removal of the fillings, and concentration of inorganic mercury (I-Hg), methylmercury (MeHg), silver (Ag) and selenium (Se) in serum was determined by inductively coupled plasma–sector field mass spectrometry. The comparison groups (one with MUPS but without attribution to amalgam [n = 28] and one group of healthy individuals [n = 19]) received no treatment. The participants responded to questionnaires at baseline and at follow-up after 1 and 5 years. Concentration of I-Hg and Ag in serum decreased significantly after removal of all amalgam restorations. Concentration of MeHg and Se in serum were not changed. Intensity of health complaints was significantly reduced after amalgam removal, but there were no statistically significant correlations between exposure indicators and health complaints. Removal of all amalgam restorations is followed by a decrease of concentration of I-Hg and Ag in serum. The results support the hypothesis that exposure to amalgam fillings causes an increase of the daily dose of both I-Hg and Ag. Even though intensity of health complaints decreased after removal of all amalgam restorations there was no clear evidence of a direct relationship between exposure and health complaints. Trial registration: The project is registered at Clinicaltrials.gov (NCT01682278).

There are many patients in general practice with health complaints that cannot be medically explained. Some of these patients attribute their health complaints to dental amalgam restorations. This study examined the cost-effectiveness of the removal of amalgam restorations in patients with medically unexplained physical symptoms (MUPS) attributed to amalgam fillings compared to usual care, based on a prospective cohort study in Norway. Costs were determined using a micro-costing approach at the individual level. Health outcomes were documented at baseline and approximately two years later for both the intervention and the usual care using EQ-5D-5L. Quality adjusted life year (QALY) was used as a main outcome measure. A decision analytical model was developed to estimate the incremental cost-effectiveness of the intervention. Both probabilistic and one-way sensitivity analyses were conducted to assess the impact of uncertainty in costs and effectiveness. In patients who attribute health complaints to dental amalgam restorations and fulfil the inclusion and exclusion criteria, amalgam removal is associated with modest increase in costs at societal level as well as improved health outcomes. In the base-case analysis, the mean incremental cost per patient in the amalgam group was NOK 19 416 compared to the MUPS group, while mean incremental QALY was 0.119 with a time horizon of two years. Thus, the incremental costs per QALY of the intervention was NOK 162 680, which is usually considered cost effective in Norway. The estimated incremental cost per QALY decreased with increasing time horizon, and amalgam removal was found to be cost saving over both 5 and 10 years. This study provides insight into the costs and health outcomes associated with the removal of amalgam restorations in patients who attribute health complaints to dental amalgam fillings, which are appropriate instruments to inform health care priorities. publishedVersion

Objective Many patients have medically unexplained physical symptoms (MUPS); some of them attribute their health complaints to dental amalgam fillings. The aim of this study was to assess the validity and responsiveness of General Health Complaints index (GHC-index) for measuring the symptom load in MUPS patients compared to the widely used symptom outcome measure, Giessen Subjective Complaints List (GBB-24). Methods Three outcome measures – GHC-index, GBB-24, and Munich Amalgam Scale (MAS) – were administered at baseline and 12 months after removal of all dental amalgam restorations. The validity and responsiveness of these symptom measures were tested against external anchors: bodily distress syndrome (BDS), SF-36 vitality, and visual analogue scale (VAS). We tested both convergent and known group validities. We also examined the predictive validity and responsiveness to changes for each instrument. Results All the main outcome measures showed evidence of convergent and known group validities. The GHC-index, GBB-24 and MAS were all able to detect the anticipated differences in BDS and Energy. But the GBB-24 was more efficient in discriminating the BDS compared with the GHC-index (relative efficiency: RE = 0.69; 95% CI: 0.41–0.96) and MAS (RE = 0.59; 95% CI: 0.32–0.86). Each main outcome variable revealed good predictive validity for vitality (standardized coefficient: b ≈ 0.71 and R2 ≈ 0.50). Moderate to high sensitivity to change over time was demonstrated, with GHC-index performing better. Conclusion The GHC-index is a valid and responsive instrument for assessing symptom load in MUPS patients attributing their health complaints to amalgam fillings and undergoing amalgam removal.

Background: Randomised controlled trials of acupuncture performed using sham interventions to control for the placebo effect have mostly used two types of sham techniques: techniques with minimal insertion of acupuncture needles with no additional stimulation (shallow needling control) and techniques with sham acupuncture devices that do not penetrate the skin (sham device control). To achieve successful blinding, sham device controlled acupuncture trials also use the acupuncture base unit in the verum acupuncture group, but in the shallow needling control trials this is not necessary for the verum acupuncture treatment. Objective: In this study, we analysed the estimated comparative effectiveness of these two verum acupuncture modalities in studies of acupuncture for menopausal hot flashes that used two types of sham control treatments. Methods: We conducted a network meta-analysis that included randomised controlled trials of acupuncture for hot flashes. Electronic databases, including Medline, Embase, Cochrane Library and AMED, were searched through March 2017. Data were extracted using a predefined data extraction tool by two independent reviewers. The risk of bias was assessed using the Cochrane risk of bias tool for randomised controlled trials. A five-node network meta-analysis was conducted based on the frequentist framework. Results: Eight studies were included in this review. From the network meta-analysis, we found that verum acupuncture in the shallow needling controlled trials was more effective than verum acupuncture in the sham device controlled trials (SMD −7.27, 95% CI−9.11 to −5.43). Significant heterogeneity and inconsistency were not observed among the included studies or the comparisons. Conclusions: From this preliminary analysis, we found that different types of verum acupuncture may have different effect sizes with respect to the severity of menopausal hot flashes.

Background Recently research on acupuncture for cancer related symptoms has significantly increased. To what extent have medical professionals recommended to use acupuncture in light of that evidence? Methods Evidence of effectiveness and safety was found by searching Pubmed for reviews to identify for what conditions and general results. Publications that recommend acupuncture in oncology were searched in the database of an ongoing general search for publications that recommend acupuncture. This database was developed by searching google for publications that recommend the use of acupuncture with the terms ‘name of symptom’ and ‘clinical practice guideline’ or ‘treatment guideline’. Results Acupuncture is moderately or weakly effective for 19 symptoms in patients with cancer and cancer survivors. Acupuncture is a safe therapy in cancer care if administered by trained acupuncturists. Acupuncture is targeted to improve symptoms associated with the cancer and different cancer treatments, not to treat the cancer itself. More than 350 publications by clinical practice guideline groups and expert groups, including public health statements made by national and government agencies recommended the use of acupuncture for 61 cancer related symptoms many with positive evidence of effectiveness. Conclusion The strength of evidence is weak for many indications, however the evidence for many standard therapies is either not very strong or if stronger, the incidence of adverse events is more, which makes acupuncture a treatment option despite the weak evidence. We have found evidence that many oncologists around the world have started to incorporate acupuncture into the treatment of various cancer related symptoms.

Background Clinical reasoning is generally defined as a way of thinking about diagnostic or therapeutic decision making in clinical practice. Different cognitive models have been proposed for the clinical reasoning process which takes place during the clinical encounter with a patient. This may have similarities with similar approaches used in Traditional Korean Medicine (TKM). Jinchal, the clinical encounter, has specific features in TKM and different Jinchal processes are closely related to several underlying cognitive models in clinical reasoning. It is a necessary process to see the patient, but in TKM, the method has characteristic aspects which should be evaluated based on the principle of clinical reasoning. Methods To obtain a narrative description and explanation of the concept of the Jinchal process, literature from with four authentic KM schools was explored first and expert panel discussion was conducted. Results This article analyses the Jinchal process using theoretical concepts from four authentic KM schools of clinical reasoning which are currently used in contemporary practice. Conclusion Future research should focus on the similarities and differences in understanding clinical reasoning in KM as well as the broader field of traditional East Asian Medicine.

Background Dietary supplements with ginseng, or ginseng alone, are widely used for a broad range of conditions, including erectile dysfunction. Ginseng is particularly popular in Asian countries. Individual studies assessing its effects are mostly small, of uneven methodological quality and have unclear results. Objectives To assess the effects of ginseng on erectile dysfunction. Search methods We conducted systematic searches on multiple electronic databases, including CENTRAL, MEDLINE, Embase, CINAHL, AMED, and loco‐regional databases of east Asia, from their inceptions to 30 January 2021 without restrictions on language and publication status. Handsearches included conference proceedings. Selection criteria We included randomized or quasi‐randomized controlled trials that evaluated the use of any type of ginseng as a treatment for erectile dysfunction compared to placebo or conventional treatment. Data collection and analysis Two authors independently classified studies and three authors independently extracted data and assessed risk of bias in the included studies. We rated the certainty of evidence according to the GRADE approach. Main results We included nine studies with 587 men with mild to moderate erectile dysfunction, aged from 20 to 70 years old. The studies all compared ginseng to placebo. We found only short‐term follow‐up data (up to 12 weeks). Primary outcomes Ginseng appears to have a trivial effect on erectile dysfunction when compared to placebo based on the Erectile Function Domain of the International Index of Erectile Function (IIEF)‐15 instrument (scale: 1 to 30, higher scores imply better function; mean difference [MD] 3.52, 95% confidence interval [CI] 1.79 to 5.25; I² = 0%; 3 studies; low certainty evidence) assuming a minimal clinically important difference (MCID) of 4. Ginseng probably also has a trivial effect on erectile function when compared to placebo based on the IIEF‐5 instrument (scale: 1 to 25, higher scores imply better function; MD 2.39, 95% CI 0.89 to 3.88; I² = 0%; 3 studies; moderate certainty evidence) assuming a MCID of 5. Ginseng may have little to no effect on adverse events compared to placebo (risk ratio [RR] 1.45, 95% CI 0.69 to 3.03; I² = 0%; 7 studies; low certainty evidence). Based on 86 adverse events per 1000 men in the placebo group, this would correspond to 39 more adverse events per 1000 (95% CI 27 fewer to 174 more). Secondary outcomes Ginseng may improve men's self‐reported ability to have intercourse (RR 2.55, 95% CI 1.76 to 3.69; I² = 23%; 6 studies; low certainty evidence). Based on 207 per 1000 men self‐reporting the ability to have intercourse in the placebo group, this would correspond to 321 more men (95% CI 158 more to 558 more) per 1000 self‐reporting the ability to have intercourse. Ginseng may have a trivial effect on men's satisfaction with intercourse based on the Intercourse Satisfaction Domain of the IIEF‐15 (scale: 0 to 15, higher scores imply greater satisfaction; MD 1.19, 95% CI 0.41 to 1.97; I²=0%; 3 studies; low certainty evidence) based on a MCID of 25% improvement from baseline. It may also have a trivial effect on men's satisfaction with intercourse based on item 5 of the IIEF‐5 (scale: 0 to 5, higher scores imply more satisfaction; MD 0.60, 95% CI 0.02 to 1.18; 1 study; low certainty evidence) based on a MCID of 25% improvement from baseline. No study reported quality of life as an outcome. We found no trial evidence to inform comparisons to other treatments for erectile dysfunction, such as phosphodiesterase‐5 inhibitors. We were unable to conduct any predefined subgroup analyses. Authors' conclusions Based on mostly low certainty evidence, ginseng may only have trivial effects on erectile function or satisfaction with intercourse compared to placebo when assessed using validated instruments. Ginseng may improve men's self‐reported ability to have intercourse. It may have little to no effect on adverse events. We found no trial evidence comparing ginseng to other agents with a more established role in treating erectile dysfunction, such as phosphodiesterase‐5 inhibitors., Plain language summary Ginseng for improving erectile function Review question Does ginseng help men’s ability to have erections? Background Many men have problems with gaining an erection. This can result in low self‐esteem, relationship issues and reduced quality of life. Medication and surgery can help with this problem, but studies also suggest that herbal supplements may help. We reviewed the literature to find out whether certain forms of ginseng, a popular root used in many countries, can help with erection problems. Study characteristics We included nine studies that compared the effects of ginseng against a placebo (dummy drug). These studies included 587 participants with mild to moderate difficulty in erection, aged 20 to 70 years old. All information we found was limited to a short follow‐up period of 12 weeks or fewer. Key results Compared to a dummy drug, ginseng may have a trivial effect on erectile function, as assessed by two questionnaires specially developed for this purpose. It may also have little to no effect on unwanted side effects. It may also have a trivial effect on men's satisfaction with intercourse based on responses to two specialized questionnaires. When men were simply asked whether their erections improved (without using a specialized questionnaire), the results of this systematic review show that ginseng may improve the ability to have intercourse. Certainty of evidence The certainty of evidence for most outcomes was low. This means that the true effect may be substantially different from what this review shows.

The objectives of this study were to assess the effects of ginseng on erectile dysfunction. We searched multiple electronic databases from their inceptions to 30 January 2021 without restrictions by language. We included randomized or quasirandomized controlled trials that evaluated the use of any type of ginseng as a treatment for erectile dysfunction compared to placebo or conventional treatment. The authors independently screened the literature, extracted data, assessed risk of bias, and rated the certainty of evidence (CoE) according to the GRADE approach. We included nine studies, and all compared ginseng to placebo. Ginseng appears to have a trivial effect on erectile dysfunction when compared to placebo based on the Erectile Function Domain of the International Index of Erectile Function (IIEF)-15 instrument (mean difference [MD] 3.52, 95% confidence interval [CI] 1.79 to 5.25; I2=0%; 3 studies; low CoE). Ginseng may have little to no effect on adverse events compared to placebo (risk ratio [RR] 1.45, 95% CI 0.69 to 3.03; I2=0%; 7 studies; low CoE). While ginseng may improve men's self-reported ability to have intercourse (RR 2.55, 95% CI 1.76 to 3.69; I2=23%; 6 studies; low CoE), it may have a trivial effect on men's satisfaction with intercourse based on the Intercourse Satisfaction Domain of the IIEF-15 (MD 1.19, 95% CI 0.41 to 1.97; I2=0%; 3 studies; low CoE). No study reported quality of life as an outcome.

Background - Trials of acupuncture in the West began before textbooks about acupuncture were generally available. This placed trials at risk of possible faulty assumptions about the practice of acupuncture and adoption of problematic research assumptions and methods. Further, this lack of information has had an influence on the theories of developing a valid and reliable sham control treatment in clinical trials of acupuncture. This commentary explores these issues. Methods - Literature review focussing on the time line of developments in the field, developments of sham interventions and use thereof and knowledge of physiological effects of needling. Results - Early trials demonstrated a lack of knowledge about acupuncture. As the methodology of trials improved, new sham treatment methods were developed and adopted; however, the sham treatment methods were implemented without physiological studies exploring their potential physiological effects and without examining the broader practice of acupuncture internationally. Conclusions - Mistaken assumptions about the practice of acupuncture reinforced by paucity of physiological investigations are factors that led to use of inappropriate sham interventions for acupuncture trials. These not only lead to confusing or misleading trial results, they, as far as we can see underestimate the effects of acupuncture leading to bias against acupuncture. There are significant problems with sham interventions and how they are applied in trials of acupuncture. Further research is needed to explore the effects of this both for future trials and for interpreting existing evidence.

Background Evidence of health utility changes in patients who suffer from longstanding health complaints attributed to dental amalgam fillings are limited. The change in health utility outcomes enables calculating quality-adjusted life-year (QALY) and facilitates the comparison with other health conditions. The purpose of this study was to estimate the validity and responsiveness of the EQ-5D-5L and SF-6D utilities following removal of dental amalgam fillings in patients with health complaints attributed to their amalgam fillings, and examine the ability of these instruments to detect minimally important changes over time. Methods Patients with medically unexplained physical symptoms, which they attributed to dental amalgam restorations, were recruited to a prospective cohort study in Norway. Two health state utility instruments, EQ-5D-5L and SF-6D, as well as self-reported general health complaints (GHC-index) and visual analogue scale (EQ-VAS) were administered to all patients (n = 32) at baseline and at follow-up. The last two were used as criteria measures. Concurrent and predictive validities were examined using correlation coefficients. Responsiveness was assessed by the effect size (ES), standardized response mean (SRM), and relative efficiency. Minimally important change (MIC) was examined by distribution and anchor-based approaches. Results Concurrent validity of the EQ-5D-5L was similar to that of SF-6D utility. EQ-5D-5L was more responsive than SF-6D: the ES were 0.73 and 0.58 for EQ-5D-5L and SF-6D, respectively; SRM were 0.76 and 0.67, respectively. EQ-5D-5L was more efficient than SF-6D in detecting changes, but both were less efficient compared to criteria-based measures. The estimated MIC of EQ-5D-5L value set was 0.108 and 0.118 based on distribution and anchor-based approaches, respectively. The corresponding values for SF-6D were 0.048 and 0.064, respectively. Conclusions In patients with health complaints attributed to dental amalgam undergoing amalgam removal, both EQ-5D-5L and SF-6D showed reasonable concurrent and predictive validity and acceptable responsiveness. The EQ-5D-5L utility appears to be more responsive compared to SF-6D. Trial registration The research was registered at ClinicalTrials.gov., NCT01682278. Registered 10 September 2012, https://clinicaltrials.gov/ct2/show/NCT01682278.

Final publication is available from Mary Ann Liebert, Inc., publishers https://doi.org/10.1089/acm.2020.0032. Background: Acupuncture is one of the fastest developing evidence bases in Complementary Medicine and is one of the leading therapies included within integrative health care. This narrative review includes two separate parts: the first is about evaluation of the current evidence status in reviews on acupuncture and the second examines and gives examples of available recommendations on acupuncture in treatment guidelines from health care experts and public health organizations recommending acupuncture as a viable treatment in patients in palliative care. Methods: Electronic searches were performed in PubMed using the terms “acupuncture” + “palliative” and adding the term “safety” to find review articles documenting safety and evidence of effectiveness of acupuncture for treatment of symptoms in palliative care patients. Treatment guidelines that recommend use of acupuncture for symptom control in palliative care were found by searching through a database currently under construction by the lead author. Results: Acupuncture shows emerging evidence for 17 indications in palliative care. Examples were found and presented of publications recommending acupuncture for treatment of symptoms for patients in palliative care from Government, public health, oncology, and medical expert sources. The most publications are in oncology, but other conditions were found and a number were found in pediatric care. Conclusions: While the evidence for use of acupuncture to treat symptoms in palliative care patients is relatively weak, the evidence base is growing. Experts worldwide are also increasingly recommending acupuncture as a treatment for symptoms in palliative care. Since acupuncture is a safe, nonpharmacological treatment but with small, clinically significant effects, these recommended uses appear as pragmatic efforts to bridge the gap of treatment options available to this patient group.

Dear EditorI read with interest the paper by Xindong Qin et al. “Acupuncture for Recurrent Urinary Tract Infection in Women: A Systematic Review and Meta-Analysis.1 In this paper, under the heading “Interpretation” – they discuss possible mechanisms behind a potential effect of acupuncture. They are referring to one of my studies,2 but they are not discussing one of our study’s main finding. We found a correlation between fewer urinary tract infections and less measured volume of residual urine in the women treated with acupuncture. This change in residual urine did not occurred in the non-treated group. Residual urine or post voided volume measured by a Bladder Scan, and by a nurse, in a hospital setting, and she was blinded with regard to the participants group allocation. What is an empty Bladder? A paper by Haylen discuss this and a post-voided volume above 30 ml, in otherwise healthy women, has been regarded as one of many potential risk factors3. Interestingly all women in our study had at baseline more than 30 ml of residual urine.2 After 6 months control this was reduced to 18.2 mL in the acupuncture group while no change in the non-treated group (35.5 vs 38.8mL). Further, residual urine is recognized, and discussed as one of several potential risk factors for recurrent urinary tract infections in children 4 and healthy postmenopausal women. 5 Hence, with regard to post-voided volumes, I hope this can be included in future studies on acupuncture as a prophylactic treatment for recurrent urinary tract infections. Finally, a question to the authors,1 on page 6, you write: “None of the studies reported the secondary outcomes of urinary bacteria culture, WBCs of urine dipstick, kidney function, markers of kidney damage, health-related quality of life or healthcare costs.” However, our study 2 used a dipstick (Uricult) and we presented the number of infections with or without bacteriuria. Do I misunderstand, or do you mean the actual name of the bacteria found?Terje AlraekSchool of Health Sciences / NAFKAM, Department of Community Medicine,Kristiania University College / Faculty of Health Science, UiT The Arctic University of NorwayReferencesQin X, Coyle ME, Yang L, Liang J, Wang K, Guo X, Zhang AL, Mao W, Lu C, Xue CC, Liu X. Acupuncture for recurrent urinary tract infection in women: a systematic review and meta-analysis. BJOG 2020; https://doi-org.pva.uib.no/10.1111/1471-0528.16315Alraek T, Soedal LI, Fagerheim SU, Digranes A, Baerheim A. Acupuncture treatment in the prevention of uncomplicated recurrent lower urinary tract infections in adult women. Am J Public Health 2002;92:1609–11Haylen BT. The empty Bladder. Int Urogynecol J Pelvic Floor Dysfunct. 2007 Mar;18(3):237-9. doi: 10.1007/s00192-006-0111-0Hoebeke P, Van Laecke E, Van Camp C, Raes A, Van De Walle J. One thousand video-urodynamic studies in children with non-neurogenic bladder sphincter dysfunction. BJU International (2001), 87, 575–580Stamm WE, Raz R. Factors contributing to susceptibility of postmenopausal women to recurrent urinary tract infections. Clin Infect Dis. 1999 Apr;28(4):723-5. doi: 10.1086/515209.

Background - The Norwegian Ministry of Health and Care Services initiated a project including experimental treatment for patients with health complaints attributed to amalgam restorations. Objective - The aim was to evaluate changes of general health complaints in patients who participated in the project and had all amalgam restorations removed. Methods - The project was designed as a prospective cohort study and organised by the Dental Biomaterials Adverse Reaction Unit in Bergen, Norway. The dental treatment was provided by the patient's local dentist. The main target group consisted of patients with medically unexplained physical symptoms, attributed to dental amalgam restorations (Amalgam cohort). The primary comparison group consisted of patients with medically unexplained physical symptoms without attribution to dental amalgam restorations (MUPS cohort). Primary outcome was self‐reported general health complaints (GHC index) at follow‐up 12‐months after completed amalgam removal. Results - In the Amalgam cohort, a significant reduction of GHC index from 43.3 (SD 17.8) at baseline to 30.5 (SD 14.4) at follow‐up (mean reduction 12.8, SD 15.9; n = 32; P < .001) was observed. The change scores for GHC index indicated that the reduction of complaints was significantly higher (P = .004) in the Amalgam cohort compared with the MUPS cohort (mean reduction 1.2, SD 12.3, n = 28). After adjustment for age, gender, education and baseline GHC index, the mean adjusted difference was −8.0 (95% confidence interval from −15.4 to −0.5; P = .036). Conclusion - In a group of patients with medically unexplained physical symptoms, which they attributed to dental amalgam restorations, removal of amalgam restorations was followed by a significant reduction of health complaints.