Few studies have focused on the cost of acupuncture treatments although acupuncture has become popular in the United States (U.S.). The purpose of the current study was to examine the out-of-pocket costs incurred from acupuncture services based on an online website, OkCopay.com. We examined descriptive statistics (range, median and 20% intervals) for the cost of acupuncture "first-time visits" and "follow-up visits" in 41 metropolitan regions in the U.S. The acupuncture prices of 723 clinics throughout 39 metropolitan regions were included, except for Birmingham, Alabama and Detroit, Michigan as there was no online data available at the time of the study for these two regions. The cost range for a first-time acupuncture visit was $15–400; the highest median was $150 in Charleston, South Carolina, while the lowest was $45 in St. Louis, Missouri. The top 10 cities for the highest median were: Baltimore, Washington, D.C., New York, San Francisco, San Jose, Boston, Atlanta, Seattle, Portland and Indianapolis, with the median $120, while the median for all 723 clinics was $112. For the follow-up visits, the cost range was $15–300; the highest median was $108 in Charleston, South Carolina, and the lowest $40 in Miami, Florida. The 10 cities with highest median follow-up acupuncture visit costs were: New York, Baltimore, New Orleans, Washington, D.C., Philadelphia, San Francisco, San Jose, Seattle, Boston and Atlanta, with the median $85, while for all 723 clinics the median price was $80. The estimation of the average gross annual income of each acupuncturist from the regions studied was $95,760, while the total annual cost of patients seeking acupuncture services in the U.S. was about $3.5 billion in 2018.

Spinal manipulation has been an effective intervention for the management of various musculoskeletal disorders. However, the mechanisms underlying the pain modulatory effects of spinal manipulation remain elusive. Although both biomechanical and neurophysiological phenomena have been thought to play a role in the observed clinical effects of spinal manipulation, a growing number of recent studies have indicated peripheral, spinal and supraspinal mechanisms of manipulation and suggested that the improved clinical outcomes are largely of neurophysiological origin. In this article, we reviewed the relevance of various neurophysiological theories with respect to the findings of mechanistic studies that demonstrated neural responses following spinal manipulation. This article also discussed whether these neural responses are associated with the possible neurophysiological mechanisms of spinal manipulation. The body of literature reviewed herein suggested some clear neurophysiological changes following spinal manipulation, which include neural plastic changes, alteration in motor neuron excitability, increase in cortical drive and many more. However, the clinical relevance of these changes in relation to the mechanisms that underlie the effectiveness of spinal manipulation is still unclear. In addition, there were some major methodological flaws in many of the reviewed studies. Future mechanistic studies should have an appropriate study design and methodology and should plan for a long-term follow-up in order to determine the clinical significance of the neural responses evoked following spinal manipulation.

Objective
Assessing adverse drug reactions (ADRs) is a proven method to estimate the safety of medicines. The ADRs to herbal medicines in Australia (and by inference, the safety of herbal medicines in Australia) remain unknown. This study examines spontaneous ADR cases to four of the most popular herbs in Australia from 2000 to 2015: echinacea (Echinacea purpurea), valerian (Valeriana officinalis), black cohosh (Actaea racemosa) and ginkgo (Ginkgo biloba).

Methods
ADRs of echinacea, valerian, black cohosh and ginkgo reported to the Australian Therapeutic Goods Administration (TGA) between 2000 and 2015 were obtained from the TGA database. Data were collated and analysed according to age, sex, severity, type of ADR and body system affected. Statistics were calculated using GraphPad Prism software.

Results
Most ADRs were mild or moderate. However, every herbal medicine was associated with life-threatening ADRs. In each life-threatening case, the herbal medicine was taken concomitantly with prescription medications. Black cohosh was associated with a significant number of severe ADRs (30.3% of the total), with 39.4% of these ADRs being associated with abnormal hepatic function, hepatitis or hepatotoxicity.

Conclusion
This study highlights the lack of public awareness with regard to herb–drug interactions, since most of the severe ADRs involved a herb–drug interaction.

Background
Bloating is a common gastrointestinal complaint which is difficult to treat.

Objective
This study investigated the efficacy and compliance of a formulation called KAASER comprised of Trachyspermum ammi (L.) Sprague seed, Zingiber officinale Roscoe. rhizome and Piper nigrum L. berry in the treatment of functional bloating.

Design, setting, participants and intervention
A total of 106 patients with functional bloating, between 20 and 50?years of age, participated in this double-blind randomized controlled trial. Patients were divided into 3 parallel groups that received 500?mg of placebo, dimethicone or KAASER, three times a day for 2?weeks.

Main outcome measures
The frequency and severity of bloating were primary outcomes, while the frequencies of eructation, defecation, borborygmus and early satiation were secondary outcomes. All parameters were evaluated at the beginning (week 0), and also weeks 2, 4 and 10 of the study, through self-report checklists with a scoring system.

Results
Among the 84 patients who completed the study, the frequency and severity of bloating (P?<?0.001), the frequencies of eructation, defecation and borborygmus (P?=?0.03) were significantly improved in the group receiving KAASER (36 patients) compared with the dimethicone (35 patients) and placebo (35 patients) groups, during the 3 phases of follow-up. These significant differences persisted through the 2 and 8?weeks of follow-ups after cessation of medication (week 4 and 10). In early satiation, no significant differences were observed among the 3 groups.

Conclusion
The results showed that KAASER can be effectively used to treat patients suffering from bloating. Bloating, eructation, defecation and borborygmus in the KAASER group remained significantly improved after 2 and 8?weeks of cessation of medication, making this mechanism an interesting area for further investigation.

Trial registration
Registration trial IRCT2015100324327N on Iranian Registry of Clinical Trials.

Objective
The objective of the work was to optimize the brazilin content and antibacterial activity of Caesalpinia sappan L. heartwood extract using computer software.

Methods
Two independent factors were studied: extraction temperature (45–95 °C) and extraction time (30–60 min). In addition, five dependent factors were monitored, including extraction yield, brazilin content, and clear zones against Staphylococcus aureus TISTR 1466, Staphylococcus epidermidis TISTR 518 and Propionibacterium acnes DMST 14961. The brazilin content was quantified by high-performance liquid chromatography and antibacterial activity was determined by disc diffusion assay.

Results
The high temperature provided high total extract yield as well as brazilin content, while extraction time had little effect on yield or brazilin content. Extraction time had a positive effect, while extraction temperature had little effect on clear zone against S. aureus. The largest clear zone against S. epidermidis was achieved at low extraction temperature and high extraction time. Conversely, low extraction time and high extraction temperature provided the largest clear zone against P. acnes. The optimal conditions providing the highest brazilin content was an extraction temperature and extraction time of 95 °C and 30 min, respectively. The same optimal conditions also provided the simultaneous greatest antibacterial activity against the three bacteria. Modeled optimal conditions were validated be conducting extraction using these values. Yield and antibacterial activity of the resulting extract demonstrated that the model had a low percentage error.

Conclusion
The optimal condition will be used as a standard condition for extraction of C. sappan heartwood to maximize brazilin content and antibacterial activity.

Objective
Hypothyroidism has been claimed to generate sexual dysfunctions such as ejaculatory disorders. Aframomum melegueta is an aphrodisiac plant with pro-ejaculatory properties. We investigated the protective effects of aqueous extract (AE) and methanolic extract (ME) of A. melegueta on the ejaculatory function of hypothyroid male rats.

Methods
Forty sexually experienced male rats were partitioned into 8 groups (5 rats per group) and treated for 28 d as follows: Group 1, Control; Group 2, propylthiouracil (PTU, 10 mg/kg) + distilled water (DW, 10 mL/kg); Group 3, PTU + 5% Tween 80 (10 mL/kg); Group 4, PTU + bromocriptine (6 mg/kg); Group 5, PTU + AE (20 mg/kg); Group 6, PTU + AE (100 mg/kg); Group 7, PTU + ME (20 mg/kg), and Group 8, PTU + ME (100 mg/kg). On days 0, 7, 14 and 28 of treatment, each male rat was paired with primed receptive female for measurement of ejaculatory latency time (ELT) and post-ejaculatory interval (PEI) for 1.5 h. On day 29, each male rat was urethane-anesthetized and the spinal cord was transected. Thereafter, following urethral/penile stimulations and intravenous injection of dopamine, contractions of the bulbospongiosus muscles and the intraseminal pressure were registered. After these recordings, blood was collected through the catheterization of abdominal artery and plasma was used for thyroid-stimulating hormone (TSH), prolactin and testosterone assays.

Results
PTU-induced hypothyroidism was characterized by a significant elevation (P < 0.001) of plasmatic TSH and prolactin levels, but a decline (P < 0.001) in plasmatic testosterone, compared to untreated group. ELT, PEI, contractions of the bulbospongiosus muscles and the intraseminal pressure were also altered by PTU treatment. On the contrary, A. melegueta extracts elevated testosterone (AE, 100 mg/kg, P < 0.01; ME, 100 mg/kg, P < 0.05) and decreased prolactin (AE, 100 mg/kg, P < 0.05; ME, 20 mg/kg, P < 0.05) levels, compared to corresponding controls. With regard to DW + PTU group, prolactin concentration was lowered (P < 0.05) in rats administered with bromocriptine. Treatment with A. melegueta extracts significantly prevented the lengthening of ELT (P < 0.05) and PEI (P < 0.001). Hypothyroid state also altered the fictive ejaculation by increasing the latency and decreasing the number and frequency of bulbospongiosus muscle contractions. There was also a decrease in the intraseminal pressure. These alterations were significantly (P < 0.05) alleviated in plant extract-treated groups.

Conclusion
This study highlighted the ejaculatory disturbance of hypothyroidism in male rats and its prevention with A. melegueta extracts.

Objective
Cyclophosphamide (CP) is commonly used to treat some cancers, but its clinical efficacy is also linked with testicular toxicity. We investigated the effects of aqueous extract (AE) and methanolic extract (ME) of Helichrysum odoratissimum for reducing CP-induced reproductive toxicity in male rats.

Methods
In addition to a normal control (group 1), drugs or vehicles were administered orally to seven groups (n?=?5) of rats that had already received 4-weeks of pre-treatment with CP (5?mg/[kg·d], per oral administration); group 2 received CP?+?distilled water (10?mL/[kg·d]); group 3 received CP?+?5% tween 80 (10?mL/[kg·d]); group 4 received CP?+?clomiphene citrate (0.25?mg/[kg·d]); groups 5 and 6 received CP?+?AE (50 and 100?mg/[kg·d]) and groups 7 and 8 received CP?+?ME (50 and 100?mg/[kg·d]). Animals were sacrificed on day 15, and body and sexual organ weights, sperm characteristics, testosterone level and testicular histology were evaluated.

Results
The CP-treated group showed a significant reduction (P?<?0.001) in the body and seminal vesicle weights, testosterone level, sperm count, sperm motility and sperm viability, but elevated (P?<?0.001) sperm morphological abnormalities and testicular structure alterations, compared to the control group. Interestingly, these detrimental effects of CP were reversed by treatment with H. odoratissimum extracts. For instance, both extracts and all doses of H. odoratissimum significantly increased the sperm count (P?<?0.001), sperm motility (AE, 50?mg/kg, P?<?0.05; ME, 50 and 100?mg/kg, P?<?0.05) and sperm viability (AE, 50?mg/kg, P?<?0.001; ME, 50 and 100?mg/kg, P?<?0.001) compared to the CP group. H. odoratissimum also improved plasmatic and intratesticular testosterone levels and prevented histological alterations of the testes.

Conclusion
H. odoratissimum might be considered as an alternative drug to alleviate/prevent reproductive damage in cancer patients receiving CP chemotherapy.

Objective: The present study investigated the anticataract activity of a novel isoflavonoid, isolated from stem bark of Alstonia scholaris, against fructose-induced experimental cataract.

Methods: The bioactivity of fractions extracted from A. scholaris, an isolated isoflavonoid (ASII) was screened using in vitro (goat lens) and in vivo (albino rats) experimental cataract models. For the in vivo evaluation, albino rats (12–15 weeks old) were divided into five groups (n = 6). Group I (normal) received 0.3% carboxymethyl cellulose solution (10 mL/[kg·d], p.o.). Group II (control) received 10% (w/v) fructose solution in their drinking water. Groups III–V received ASII at three different doses, 0.1, 1.0 and 10 mg/(kg·d), concurrently with 10% (w/v) fructose solution. Treatment was given daily for 8 consecutive weeks. During the protocol, systolic blood pressure, diastolic blood pressure, blood glucose level and lenticular opacity were monitored at 2-week intervals. Pathophysiological markers (catalase, superoxide dismutase, glutathione peroxidase, reduced glutathione and malondialdehyde) in eye lenses were examined at the end of the 8-week treatment period.

Results: The results of in vitro study showed that A. scholaris extract and the active fraction (A3) reduced the lenticular opacity as compared to toxic control group. The in vivo study showed that 8-week administration of ASII (0.1, 1.0 and 10 mg/[kg·d], p.o.) led to significant reduction in blood pressure and blood glucose level and retarded the initiation and evolution of cataractogenesis, compared to the fructose-induced cataract model control. Additionally, ASII treatment led to significant improvement in lens antioxidants (catalase, superoxide dismutase, glutathione peroxidase and reduced glutathione) and decreased lens malondialdehyde, compared to the control group (group II).

Conclusion: Results revealed that administration of ASII played a crucial role in the reduction of cataract formation in diabetic and hypertensive models.

We report about hirudotherapy in a patient with chronic complex regional pain syndrome (CRPS) in the right hand. CRPS is a multifactorial disease associated with disabling pain as well as sensory and motor deficits. The optimal therapeutic management is based on personalized multimodal treatment approaches; however, hirudotherapy has not been described in the available literature. To date, we have completed five medicinal leech treatments. Altogether, hirudotherapy led to rapid and substantial relief of symptoms, especially with respect to pain intensity ratings and skin temperature asymmetries. In addition, the patient’s active and passive agility of the affected limb improved obviously.