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To evaluate the utilization, financial costs, and benefits of incorporating acupuncture into a university-based family medicine center.Retrospective billing records review.An academic family medicine center located within a university-based medical center.The entire population of consecutive patients seen in an acupuncture clinic from April, 2002 through October, 2006.Patient characteristics, number and types of visits, and charges and collections.Analysis of de-identified, electronic billing records.During the 4(1/2)-year study period, 788 unique patients were seen, accounting for a total of 4953 visits. The most common clinical conditions treated were back pain, headache, and neck pain. Mean charge and collection per visit was $82 and $53, respectively. Mean annual clinic revenues and expenses were $58,653 and $74,223, respectively.The authors' experience with an acupuncture clinic within an academic medical center has been generally positive, but we have not been able to turn a profit within the first 4(1/2) years of operation. Advantages of including physician-acupuncturists include improved patient access to third-party payers for clinical services, and possibly better acceptance by physician colleagues and the larger medical center system. Physician-acupuncturists, however, tend to have higher salary and liability costs associated with their services. Incorporating licensed acupuncturists allows for improved access to patients as well as lower operating expenses. We postulate that patients are generally more willing to pay cash for acupuncture services provided by a licensed acupuncturist compared to a physician, whose services are generally expected to be covered by medical insurance. Our findings suggest that incorporating acupuncture into existing medical practices may benefit patients, providers, the clinic as a whole, and the larger community, but the profit margin associated with providing acupuncture in these settings is likely to be negative or slim.

To evaluate the efficacy of acupuncture for labor stimulation.Nulliparous women at 38 weeks or greater were randomized to traditional Chinese medicine (TCM) acupuncture, sham acupuncture, or usual care only groups. Acupuncture points LI4, SP6, BL32, and BL54 were needled bilaterally. The primary outcome was time from enrollment to delivery. Secondary outcomes included rates of spontaneous labor and cesarean delivery. Medical records were abstracted for maternal demographic, medical, and delivery outcome data. ANOVA, Student's t-test, Chi-square, and Kaplan-Meier statistics were used to compare groups.Eighty-nine women were enrolled and randomized. Maternal age, gestational age, prior acupuncture experience, tobacco, alcohol and drug use, gravida, and history of gynecological surgery were similar among the groups. There were no statistically significant differences among groups for time from enrollment to delivery (p=0.20), rates of spontaneous labor (p=0.66), or rates of cesarean delivery (p=0.37). Rates of maternal and neonatal outcomes were not significantly different.TCM acupuncture was not effective in initiating spontaneous labor or reducing the rate of cesarean delivery compared with sham acupuncture or usual medical care.

To investigate the feasibility of conducting a randomized trial of the effect of acupuncture in decreasing hot flashes in peri- and postmenopausal women.Fifty-six women ages 44 to 55 with no menses in the past 3 months and at least four hot flashes per day were recruited from two clinical centers and randomized to one of three treatment groups: usual care (n = 19), sham acupuncture (n = 18), or Traditional Chinese Medicine acupuncture (n = 19). Acupuncture treatments were scheduled twice weekly for 8 consecutive weeks. The sham acupuncture group received shallow needling in nontherapeutic sites. The Traditional Chinese Medicine acupuncture group received one of four treatments based on a Traditional Chinese Medicine diagnosis. Usual care participants were instructed to not initiate any new treatments for hot flashes during the study. Daily diaries were used to track frequency and severity of hot flashes. The mean daily index score was based on the number of mild, moderate, and severe hot flashes. Follow-up analyses were adjusted for baseline values, clinical center, age, and body mass index.There was a significant decrease in mean frequency of hot flashes between weeks 1 and 8 across all groups (P = 0.01), although the differences between the three study groups were not significant. However, the two acupuncture groups showed a significantly greater decrease than the usual care group (P0.05), but did not differ from each other. Results followed a similar pattern for the hot flash index score. There were no significant effects for changes in hot flash interference, sleep, mood, health-related quality of life, or psychological well-being.These results suggest either that there is a strong placebo effect or that both traditional and sham acupuncture significantly reduce hot flash frequency.

To evaluate the utility of outpatient acupuncture for labor stimulation.Nulliparous women at 39 4/7 weeks or greater with a singleton gestation and Bishop score of less than 7 were randomized to usual medical care (control group) versus usual care and three outpatient acupuncture treatments (acupuncture group). Each treatment consisted of eight needles applied to bilateral points LI4, SP6, UB31, and UB32. The primary outcome was time elapsed from the time of randomization to delivery. Secondary outcomes included rates of cesarean section and induction of labor. Medical records were abstracted for maternal demographic, medical, and delivery outcome data. A priori sample size calculation revealed that 56 women were required to detect a 72-hour difference in delivery time with a power of 83% and an alpha of 0.05. Student's t-test, Chi-square, and Kaplan-Meier statistics were used to compare groups.Fifty-six women were randomized and completed the study procedures. Race, age, gestational age, and cervical Bishop score were similar in both groups. Mean time to delivery occurred 21 hours sooner in the acupuncture group, but this difference did not reach statistical significance (p = 0.36). Compared to controls, women in the acupuncture group tended to be more likely to labor spontaneously (70% vs. 50%, p = 0.12) and less likely to deliver by cesarean section (39% vs. 17%, p = 0.07). Of women who were not induced, those in the acupuncture group were more likely to be delivered than the controls at any point after enrollment (p = 0.05).Acupuncture is well tolerated among term nulliparous women and holds promise in reducing interventions that occur in post-term pregnancies.

We studied the effect of L-glutamine (Gln), the principal intestinal fuel, on proliferation of a porcine jejunal cell line, IPEC-J2. In cells synchronized by serum deprivation for 4 h, Gln stimulated ornithine decarboxylase (ODC; EC 4.1.1.17) in a dose- and time-dependent manner, with maximal effects at 10 mM in 3 h (P < 0.01). Similar effects were seen for the structurally related amino acid L-asparagine and serum. The Gln effect on ODC was specific, as isosmolar mannitol, glucose, methyl-beta-D-glucoside, L-phenylalanine, ammonia, and aminoisobutyric acid were ineffective. The alanine aminotransferase inhibitor aminooxyacetate (AO) inhibited the ODC stimulation by Gln in a dose-dependent manner (half-maximal inhibitory concentration = 0.5 mM). AO was not toxic to cells, as determined by propidium iodide uptake into nuclei. In addition, Gln stimulated a twofold increase of cellular 24-h [3H]thymidine incorporation above rates of control cells bathed in standard media (P < 0.01); this effect was also blocked by AO. Gln and phorbol 12-myristate 13-acetate stimulated ODC in a synergistic manner. The Na+/H+ exchange inhibitor methylisobutyl amiloride blocked the enhancement of ODC by Gln. Gln also induced the mRNA of the immediate-early gene c-jun. Gln stimulates proliferation in a porcine jejunal cell line through a mechanism requiring transamination and intact Na+/H+ exchange. This stimulation of enterocyte proliferation by Gln suggests that therapeutic Gln administration could facilitate epithelial recovery in the injured small intestine.

To determine the mechanisms of K+ loss in viral diarrhea, K+ fluxes (estimated by tracer Rb+ flows) across piglet jejunum in Ussing chambers were determined. Normal jejunum was characterized by an indomethacin-sensitive short-circuit current and a small K+ secretory flow. Rotavirus-infected gut secreted K+ at high rates, probably resulting from increased prostaglandin generation because secretion was abolished by indomethacin. Tissues pretreated with indomethacin responded to 8-bromoadenosine 3',5'-cyclic monophosphate acid and 16,16-dimethyl-prostaglandin E2 with K+ secretion. The secretory response in rotavirus-infected jejunum was no greater than that in normal tissue. Serosal addition of Ca2+ ionophore A23187 caused K+ secretion in normal but not rotavirus-infected jejunum. To inhibit the basolateral uptake of K+ and reduce the driving force for secretion, ouabain was added to the bath. Ouabain unmasked a K+ absorptive process in normal intestine, which was not seen in rotavirus-infected tissue. K+ absorption was inhibited by 3-(cyanomethyl)-2-methyl-8-(phenyl-methoxy)imidazo (1,2 alpha)pyridine (Sch-28080) and omeprazole. We speculate that the high fecal K+ losses observed in human rotavirus enteritis might be caused by an imbalance between K+ secretion and an impaired apical K+ absorptive mechanism in the crypt-type epithelium.

The aim of this study was to compare Traditional Chinese Medicine (TCM) pattern diagnosis and acupuncture point selection for persons with frequent headache, as ascribed by three highly trained, licensed acupuncturists.Thirty-seven (37) study participants with frequent headaches were independently evaluated by three licensed acupuncturists trained in TCM. The acupuncturists identified the meridians and type of dysfunction they believed were contributing to study participants' symptoms. Study acupuncturists also ascribed one or more TCM diagnoses to each participant and selected eight acupuncture points for needling.Some variation in TCM pattern diagnosis and point selection was observed for all subjects. Liver Yang and Qi dysfunction were diagnosed in more than two thirds of subjects. Acupuncture points Liver 3, Large Intestine 4, and Governing Vessel (DU) 20 were the most commonly selected points for treatment.Headache is a heterogeneous condition represented by a wide variety of TCM diagnoses. There is variability among acupuncturists in the diagnosis of TCM patterns and the selection of acupuncture points for needling. These data suggest, however, that most persons with frequent headache appear to have liver Yang and Qi disharmonies for which needling of Liver 3, Large Intestine 4, and/or Governing Vessel 20 may be appropriate. Further research is needed to determine the extent to which variability in the diagnosis or acupuncture point selection among acupuncturists affects clinical outcomes.

Background: l-Arginine is a nutritional supplement that may be useful for promoting intestinal repair. Arginine is metabolised by the oxidative deiminase pathway to form nitric oxide (NO) and by the arginase pathway to yield ornithine and polyamines. Aims: To determine if arginine stimulates restitution via activation of NO synthesis and/or polyamine synthesis. Methods: We determined the effects of arginine on cultured intestinal cell migration, NO production, polyamine levels, and activation of focal adhesion kinase, a key mediator of cell migration. Results: Arginine increased the rate of cell migration in a dose dependent biphasic manner, and was additive with bovine serum concentrate (BSC). Arginine and an NO donor activated focal adhesion kinase (a tyrosine kinase which localises to cell matrix contacts and mediates β1 integrin signalling) after wounding. Arginine stimulated cell migration was dependent on focal adhesion kinase (FAK) signalling, as demonstrated using adenovirus mediated transfection with a kinase negative mutant of FAK. Arginine stimulated migration was dependent on NO production and was blocked by NO synthase inhibitors. Arginine dependent migration required synthesis of polyamines but elevating extracellular arginine concentration above 0.4 mM did not enhance cellular polyamine levels. Conclusions: These results showed that l-arginine stimulates cell migration through NO and FAK dependent pathways and that combination therapy with arginine and BSC may enhance intestinal restitution via separate and convergent pathways.

Cryptosporidium parvum produces a prolonged watery diarrhea unresponsive to conventional antimicrobials. Because of reported efficacy of antibody-based immunotherapy, we studied the effect of inexpensive, commercially available oral bovine serum concentrate (BSC) in experimental cryptosporidiosis. Twenty-four calves were treated with 57 g/d BSC (n = 12) or soy protein (n = 12) added to their standard whey protein-based milk replacer (227 g/2 L twice daily). Of the 24, 9 were also treated with L-glutamine (GLN), 8 g/L (50 mM) in the milk (5 calves in the BSC group and 4 in the soy group). Animals were inoculated with 10(8) cryptosporidium oocysts per os on d 8 of life and received oral rehydration on d 12-14. Eight uninfected controls were treated with BSC or soy protein. Fecal and urine volume and urinary Cr-EDTA excretion were measured. Animals were killed on d 18 of life. Cryptosporidiosis induced severe watery diarrhea lasting9 d and produced a 25% increase in intestinal permeability, a 33% decrease in villous surface area, and a 40% reduction in mucosal lactase specific activity. Glutamine treatment had no effect on the diarrhea or any of the intestinal tests; and therefore pooled data were used to compare the 12 calves treated with BSC with the 12 treated with soy. In animals receiving BSC, peak diarrheal volume and intestinal permeability were reduced 33%, fewer oocysts were shed, intestinal crypts were significantly deeper, and villous surface area returned to normal by 9 d after infection (all por= 0.05). BSC should be studied as a treatment for human cryptosporidiosis.

To determine whether premature infants who have necrotizing enterocolitis (NEC) have deficiencies in glutamine (GLN) and arginine (ARG), which are essential to intestinal integrity.A 4-month prospective cohort study of serum amino acid and urea levels in premature infants was done. Serum amino acid and urea levels were measured by high-pressure liquid chromatography and enzymatic methods, respectively, on samples obtained on days of life 3, 7, 14, and 21.Infants in the control (n = 32) and NEC groups (n = 13) were comparable for birth weight, gestational age, and Apgar scores. NEC began on mean day of life 14.5 (95% CI, day of life 11 to 18). Median values of GLN were 37% to 57% lower in the NEC group on days 7, 14, and 21 compared with those in the control group (P.05). On days 7 and 14, median values of ARG, GLN, alanine, lysine, ornithine, and threonine were decreased 36% to 67% (P.05) in the NEC group. Total nonessential amino and total essential amino acids were 35% to 50% lower in the NEC group on days 7 and 14 (P.05). Infants in the NEC group had significant reductions in GLN and ARG 7 days before the onset of NEC.Infants who have NEC have selective amino acid deficiencies including reduced levels of GLN and ARG that may predispose to the illness.

Background & Aims: Infectious diarrhea caused by viruses plus enterotoxigenic bacteria is often more severe than diarrhea induced by either pathogen alone. We postulated that the increased cell adenosine 3',5'-cyclic monophosphate (cAMP) concentration observed during infection by enterotoxigenic organisms retards the intestinal repair process by blocking activation of mitogen-activated protein kinases (MAPKs) in proliferating intestinal cells. Methods: We evaluated the effects of glutamine on MAPK activity, thymidine incorporation, and cell number in glutamine-starved and -sufficient rat intestinal crypt cells (IEC-6). Results: In glutamine-starved cells, 10 mmol/L glutamine in the absence of serum stimulated [ 3 H]thymidine incorporation 8-fold. This effect was inhibited by 60% with 8-(4-chlorophenylthio) (8-CPT)-cAMP (100 μmol/L) + isobutyl methylxanthine (100 μmol/L). In cells not starved of glutamine, glutamine stimulated thymidine incorporation by 3-fold, and 8-CPT-cAMP completely blocked the mitogenic effect. Inhibition of proliferation by cAMP persisted for at least 68 hours after cAMP removal. In vitro kinase assays showed that glutamine signaling requires an intact ERK (extracellular signal–related kinase) pathway in unstarved cells. In starved cells, at least one other pathway (JNK) was activated by glutamine, and the mitogenic inhibition by 8-CPT-cAMP was incomplete. Other intestinal fuels (glucose and acetate) were not mitogenic. Conclusions: Increased levels of intracellular cAMP inhibit ERKs but only partially reduce glutamine-stimulated proliferation in enterocytes adapted to low glutamine. GASTROENTEROLOGY 2000;118:90-100

A randomized, investigator-masked trial determined the effects of oral recombinant human transforming growth factor-alpha (TGF alpha) on jejunal mucosal recovery in 75 piglets with rotavirus diarrhea. Rotavirus inoculation of artificially reared piglets induced subtotal (approximately 50%) villus atrophy and watery diarrhea. Dietary TGF alpha was associated with significant restoration of villus surface area by 4 d postinoculation (p.i.) and complete restoration by 8 d p.i., whereas saline-treated animals required 12 d for recovery. Jejunal segments from clinically recovered TGF alpha-treated piglets showed an increase in electrical resistance across the epithelial barrier in vitro which was proportional to villus height. TGF alpha treatment for 12 d also produced a 30-50% increase in jejunal mucosal mass (protein content and wet weight), compared with the corresponding values in saline-treated piglets and in uninfected controls. However, oral TGF alpha did not hasten the resolution of diarrhea, enhance the specific activities of jejunal mucosal digestive enzymes, or increase jejunal glucose-stimulated Na+ absorption in vitro. We conclude that dietary TGF alpha stimulates jejunal mucosal hypertrophy, improves barrier function, and enhances regrowth of villi in rotavirus enteritis; however, it does not facilitate the restoration of functional activity or mucosal digestive enzymes. Oral TGF alpha can facilitate intestinal epithelial recovery in diseases associated with mucosal damage.

sential nutrients, they do not contain glutamine, the most abundant amino acid in the body, considered by some to be an essential amino acid for preterm infants.1 Not only does GLN function as a major precursor for the endogenous synthesis of arginine by way of citrulline, it also plays a role in nucleotide synthesis and in providing “fuel” to intestinal and muscle cells.2 GLN increases protein synthesis and inhibits protein degradation in skeletal muscle, thereby promoting positive nitrogen balance under catabolic conditions. GLN is also essential for intestinal crypt cell proliferation and enhances the cellular response to growth factors.3

Glutamine Protects Intestinal Cells Via Heat Shock Protein (hsp)-Dependent and Metabolic Effects