ACUPUNCTURE RELIEVES PAIN IN REFLEX SYMPATHETIC DYSTROPHY:PITFALLS IN THE ANALYSIS OF RESULTS

Objective: Despite thousands of years of utilizing acupuncture for relief of pain, there is considerable controversy whether acupuncture deserves to be considered an efficacious modality along with medications and operations.Many publications claiming to answer this most important question have inspired more controversy regarding experimental design, designation of adequate controls and avoiding the dreaded placebo effect.Methods: We present a retrospective series of patients all of whom have severe chronic pain of the extremities with the unequivocal diagnosis of reflex sympathetic dystrophy.The patients were included if they had 15 treatments with acupuncture.The patients were treated in a single practice of acupuncture by two of the authors.There was no standardization of treatment given to each patient.The treatments were modified at each session.Objective date collected included the pain level on a 0 to 10 visual analogue scale and other functional data such as range of motion and daily activities.Results: At each treatment time, the acupuncture treatment significantly decreased the pain level from the value before the treatment to the pain level after the acupuncture treatment.Firsttreatment pre-treatment pain level: 7.43±2.15, post treatment 3.86±2.76(P0.0019).Over the course of the initial 15 treatments, the pre-treatment pain level did not significantly decline.Treatment number 15 had an average pain level of 6.5±1.51(P0.40).Conclusions: The treatment with acupuncture unequivocally caused a significant reduction in pain level on each treatment day; however, 15 treatments with acupuncture did not significantly produce a lasting effect.However, reviewing each individual charted data and analyzing the individual patient course gives a more accurate picture of the effect of acupuncture on patients with c omplex pain problems.     

Exercise and Manual Auricular Acupuncture： A Pilot Assessor-blind Randomized Controlled Trial

Background： Evidence supports the use of exercise for chronic low back pain （CLBP）; however, adherence is often poor due to ongoing pain. Auricular acupuncture is a form of pain relief involving the stimulation of points on the outer ear corresponding with specific body parts. It may be a useful adjunct to exercise in managing CLBP; however, there is only limited evidence to support its use with this patient group. Methods/Design： This study was designed to test the feasibility of an assessor-blind randomized controlled trial which assess the effects on clinical outcomes and exercise adherence of adding manual auricular acupuncture to a personalized and supervised exercise programme （PEP） for CLBP. No sample size calculation has been carried out as this study aims to identify CLBP referral rates within the catchment area of the study site.     

TOPICAL LONG-TENG-TONG-LUO GEL INHIBITS BONE CANCER PAIN BY SUPPRESSING TRANSIENT SPINAL RECEPTOR POTENTIAL CATION CHANNELS AND CYTOKINES

Objective: Cancer pain severely affects patients' overall quality of life; its management is challenging.Because Chinese herbal medicine has been widely used for cancer pain, its efficacy and mechanisms warrant the study.We explored the effects and spinal mechanisms of a seven-herb compound, Long-Teng-Tong-Luo(LTTL) gel, on bone cancer pain.Methods: Walker 256 cells(3.5×105 in 6 μL of vehicle) were injected into the tibias of female Sprague-Dawley rats to produce a bone cancer pain model.Six sets of experiments were carried out:(1) the effect of LTTL on cancer-induced pain was assessed with mechanical allodynia and thermal hyperalgesia;(2) cancer and LTTL modulation of transient receptor potential cation channel(TRP) subfamily members V1, A1, and V4 in lumbar dorsal root ganglia(DRG) were detected with immunofluorescence staining;(3) cancer and LTTL modulation of spinal interleukin-17A(IL-17A) were measured with real time-polymerase chain reaction and enzyme-linked immunosorbent assay;(4) the effects of intrathecal(i.t.) TRPV1, TRPA1, and TRPV4 antagonists on cancer-induced pain;(5) i.t.antibodies against IL-17A on cancerinduced pain, and(6) TRP channel antagonists on spinal IL-17A were determined.LTTL or inert gel, 0.5 g/(cm2·d), was applied to the skin of the rats' tumor-bearing tibias for 21 d, starting a day after the injection.Results: LTTL significantly(P0.01) increased mechanical threshold and hind paw withdrawal latency compared to the vehicle, demonstrating that the gel inhibited cancer-induced mechanical allodynia and thermal hyperalgesia, and it suppressed cancer-enhanced expression of spinal IL-17A, TRPV1, TRPV4, and TRPA1 in lumbar DRG.TRP antagonists at 10 μg significantly attenuated mechanical allodynia, thermal hyperalgesia, and IL-17A expression, indicating that TRP channels facilitate spinal IL-17 expression and cancer pain; IL-17A antibodies inhibited cancer pain, suggesting that IL-17A promotes the pain.Conclusion: We concluded that the gel inhibits cancer pain by decreasing DRG TRP and spinal IL-17A action.     

Treatment of Visceral Pain Associated with Irritable Bowel Syndrome using Acupuncture: Mechanism of Action

Irritable bowel syndrome (IBS) is a relatively common condition characterized by abdominal pain, among other symptoms, that significantly impacts the quality of life of IBS patients. Therapeutic treatment of IBS results in limited success, and the focus is placed on relieving patients of some of the symptoms, visceral pain in particular. Acupuncture is commonly used as a treatment modality of choice. However, the debate on whether acupuncture can be effectively used for this purpose is ongoing. In this work, we critically review the available literature to establish a potential mechanism of action in treating visceral pain in IBS using acupuncture. The sources used are Google Scholar, EBSCO, Cochrane Library and PubMed as well as Chinese database sources. The keywords used in the literature search are “acupuncture,” “IBS,” “Irritable Bowel Syndrome,” and “visceral pain.” We find that the literature strongly indicates that acupuncture, by stimulating points located on the dermatomes proximal to the spinal level of the area where the sympathetic outflow of the particular gut area affected by the pain is, can interfere with the efferent signal that transports information about the noxious stimuli and interrupt the “connectivity” between the gut and brain, and as a final result, reduce or stop IBS pain. Our findings justify that clinical trials are conducted to test the utility of acupuncture in treating abdominal visceral pain in IBS.     

ACUPUNCTURE AND KETAMINE IN TREATING CHRONIC BACKACHE

Purpose: The primary aim of this research was to determin whether the use of oral ketamine is effective, safe, and acceptable fo patients presenting with low-back pain.It was used in conjunctio with acupuncture treatment to reduce the number of the seat(when treating a patient with acupuncture, they receive treatment over a series of days—this may mean every day or every othe day for a period of 10 d, for example, this is called a "seat") o acupuncture.Results: The results showed that(1) 58%(29/50) of the patients became pain-free;(2) 26%(13/50) of the patients experienced a decrease in pain by one half.They continued on acupuncture only, without ketamine;(3) The remaining 16%(8/50) had no response during the 1st course.Among these eight participants, six requested ketamine in combination with acupuncture, and two required surgery.The result of this study is compared with other studies in which acupuncture alone was used in treatment of the 30 patients in the control group.Thirty percent were pain-free after the 1st course of acupuncture, 50% of the patients had pain reduced by one half, and only 20% showed no response during the first course.     

Diagnosis and objective pain assessment of traditional Chinese medicine may be useful to demonstrate specific effects of acupuncture in low back pain: A prospective, randomized, controlled and single blinded pre-study

Objective： To prove specific effects of acupuncture on chronic pain. It was speculated that the potential specific effectiveness of acupuncture could be better shown in more properly designed studies. Therefore, diagnoses of both Western medicine and traditional Chinese medicine （TCM） were used as inclusion criteria to allocate acupoints more precisely to the complaints of the patients. Secondly, objectively measurable parameters of pain relief in addition to usual Visual Analogue Scale （VAS） were chosen to quantify the effects of acupuncture. Methods： The study was prospective, randomized, controlled and single-blinded. Eighteen patients with chronic back pain and TCM diagnosis of a Taiyang/Yangming syndrome received one single session of acupuncture chosen according to TCM diagnosis or acupuncture on points outside the meridian system （controls）. We evaluated pain via VAS and increased mobility via inclinometry of the back. Results： Although the sample size was small, there was a statistically significant improvement in pain and mobility in the intervention group （n=13）, but not in the control group （n=5）. The calculated sample size adequate power was lower for inclinometry than for VAS, indicating that VAS is less probable to discriminate acupuncture effects. Conclusion： Objectively measurable physical parameters such as the angle of flexion before and after acupuncture （inclinometry） may be more suitable to measure pain relief than subjective assessment by VAS in acupuncture studies. TCM diagnosis may be a helpful inclusion criterion in studies on acupuncture, so as to potentially allocate interventions better to the complaints of patients.     

Effectiveness of external Sanjierupi Gao on mastalgia caused by mammary gland hyperplasia： a placebo controlled trial

OBJECTIVE： To evaluate the curative effect of external application of the Chinese drug, Sanjierupi Gao,on mastalgia caused by mammary gland hyperplasia.METHODS： This randomized, double-blinded, and placebo controlled study enrolled 260 patients with mammary gland hyperplasia from five hospitals. Patients were randomly and equally divided in-to a Sanjierupi Gao treatment group and a placebo control group. An adhesive plaster was applied to the most painful area on either breast for 7 h a day.Treatment lasted for two menstrual cycles without application during menstruation. Mastalgia was used as the main index of curative effect. The change before and after treatment in days of mastalgia, the time to alleviate pain, pain extent, and severe pain scores were observed.RESULTS： Compared to the control group, the treatment group had significantly fewer days of mastalgia（P0.01）, a significantly lower severe pain score（P0.01）, and significantly less subjective pain and tenderness（P0.05 and P0.01, respectively）. Three days before the follow-up visit, the pain score in the treatment group was significantly lower than that in the control group（P0.05）. A non-parametric test was used to compare the time to alleviate mastalgia between the two groups and found no statistical difference（Z= 0.313, P=0.754）.CONCLUSION： Application of Sanjierupi Gao can decrease mastalgia duration in patients with mammary gland hyperplasia during menstruation and alleviate the extent of mastalgia. The time to alleviate pain is psychologically influenced.     

ACUPUNCTURE IN REHABILITATION:RESULTS IN CHRONIC AND DEGENERATIVE NEUROLOGICAL PATHOLOGIES,VASCULAR SEQUELAE AND REHABILITATION POST ORTHOPEDIC SURGERY IN PITIGLIANO HOSPITAL CENTRE OF INTEGRATED MEDICINE

Objective: The purpose of this research is to evaluate the efficacy and safety of acupuncture in restoring and improving functional recovery in addition to standard rehabilitation.The research has been led on inpatients admitted to the orthopedic and neurological rehabilitation in the Public Hospital of Manciano–Pitigliano(GR) which is part of a pilot project of the Region of Tuscany to study the possibility of intervention of acupuncture in Italian public hospitals.This is the first study made in an Italian public hospital.Participants: We analyzed the data of 78 patients treated with acupuncture during the period of rehabilitation, and divided them into three groups: rehabilitation after cerebral vascular accident, ongoing rehabilitation of chronic neurological disease, and rehabilitation after surgery for hip and knee prosthesis.Methods: We analyzed the scales of reference for the evaluation of the effectiveness of rehabilitation: GARS, NBI, Trunk Control Test, Motricity Index and VAS pain scale.User satisfaction and perception of integrated medicine were measured by multiple choice questionnaires among the patients and the medical staff of the hospital.Results and conclusion: Compared to the control group, a significant increase of rehabilitative performances was obtained in patients treated with acupuncture and homeopathy, suggesting the need to continue with research and with the use of integrated medicine in orthopedic and neurological rehabilitation.The effectiveness of treatment can be detected in the reduction of pain, reduction of disability, traction and mobility.Acupuncture was judged useful or very useful by the vast majority of users, recognizing an important contribution to the improvement of symptoms.Medical staff has gained more confidence in integrated medicine that has allowed a better understanding of the proposed model with an increase of teamwork's enthusiasm.     

Electroacupuncture for abdominal pain relief in patients with acute pancreatitis: A three-arm randomized controlled trial

Background: Electroacupuncture(EA) may reduce the severity of acute pancreatitis(AP) and provide additional pain relief in patients with chronic pancreatitis. However, the ability of EA to relieve pain in patients with AP has not been well documented.Objective: This study was undertaken to compare the pain-relieving effects of EA and conventional treatment in patients with AP.Design, setting, participants and interventions: This study was conducted using a randomized, controlled,three-arm, paral...     

Inhibitory Effects of Bio-Energy Therapies on Cancer Growth——An overview of recent laboratory studies in the U.S. And its implications in cancer treatment

Background： Bioenergy therapies （such as Qigong, Reiki, Yoga, Pranic healing, and Therapeutic touch） have reported benefits for cancer patients, but few randomized control trials were done to verify their efficacy. It is believed that laboratory study of inhibitory effects of bio-energy therapies on cancer growth may lead to an understanding of the true efficacy of bio-energy and create a foundation for future clinical trials. Methods： Typical in-vitro study involved randomly dividing lab-prepared cancer cells into different groups with one being treated by bio-energy therapy and one or more as control groups. Sometimes, controls were treated by a sham healer. Typical in vivo study involved injecting or implanting cancerous cells into mice, then randomly dividing them into various groups. The control could be either non-treatment or sham treatment; the outcomes include tumor size or survival time. Results： Most studies demonstrated some inhibitory effects of bioenergy therapies on the growth of cancer cells in comparison with control. The in vivo studies reported that the bio-energy treated group had significantly slower tumor growth or longer survival lives than those in the control. One study reported survival with a normal life cycle instead of dying in 3 weeks, and cancer-infected mice developed immune response to the same breast cancer. However, researchers are confronted with methodological challenges in choosing appropriate controls, minimizing contamination, and replicating study outcomes. Conclusion： Encouraging evidence suggests bioenergy may have inhibitory effects on cancer growth, or prolong the life of cancer-infected animals, although improvement is needed in research design and replication of the findings. Bioenergy for cancer treatment is an area that is often neglected by mainstream medicine and research, and it should be seriously examined and considered as an important supplement to conventional cancer treatment.     

Effect of Meridian Massage for Cancer Related Fatigue

The purpose of this study is to investigate the effectiveness of meridian massage in lessening the fatigue and improving both physical and mental quality of life of cancer patients. Settings and design: This study was conducted at the East-West Cancer Center at Daejeon University; Using a single-arm, waiting list and non-treatment control research design, we compared the results of control group and to that of the experimental group. Materials and methods: From July 2, 2007 to July 28, 2007, eighteen eligible cancer patients were recruited to participate in the experiment. Modified Chalder Fatigue Scale (CFS), Visual Analogue Scale (VAS) and active oxygen level were measured before and after treatment for both control and experimental groups. Lying on their back or stomach inside a room with a temperature of 18-2℃2, the patients received 30 minutes of meridian massages mainly around the trapezius muscles 5 times a week.Statistical analysis used: Data analysis was carried out using independent t-test, paired t-test and One-way ANOVA.Results: Data analysis of modified CFS showed statistically significant results for all groups between before and after treatment. Within CFS, results of physical and psychological analysis showed significant results for all groups except before and after no treatment and secondary treatment. In the analysis of VAS, the experimental group showed a greater decrease in score compared to that of the control group and the average difference was statistically significant (P＜0.05). Although the results were not statistically significant (P＞0.05), active oxygen levels for the control group showed little difference before and after no treatment (331.11 and 330.78, respectively) while the experimental group observed a decrease in active oxygen level before and after treatment (327.28 and 314.11, respectively). Conclusion: In conclusion, patients who received meridian massage showed decreased cancer related fatigue scores compared to the control. These results suggest that meridian massage may alleviate cancer-related fatigue and contribute to the improvement in quality of life among cancer patients.     

Treatment duration of wrist-ankle acupuncture for relieving post-thyroidectomy pain: A randomized controlled trial

Background: Treatment duration of wrist-ankle acupuncture(WAA) is uncertain for post-thyroidectomy pain relief.Objective: This study evaluated the effect of different WAA treatment duration on post-operative pain relief and other discomforts associated with thyroidectomy.Design, setting, participants and intervention: This randomized controlled trial was conducted at a single research site in Guangzhou, China. A total of 132 patients receiving thyroidectomy were randomly divided into the control...     

Efficacy of acupuncture on cardiovascular complications in patients with diabetes mellitus in Korea: A nationwide retrospective cohort

Objective: The main aim of this study is to investigate whether acupuncture could be an effective complementary treatment for reducing the risk of macrovascular complications in diabetic patients currently taking antidiabetic medications using a nationwide population-based database.Methods: We conducted a retrospective cohort study to assess the efficacy of acupuncture on cardiovascular complications in diabetic patients using data from patients between 40 and 79 years of age, newly diagnosed wi...     

Physical exercise suppresses hepatocellular carcinoma progression by alleviating hypoxia and attenuating cancer stemness through the Akt/GSK-3β/β-catenin pathway

Objective: Physical exercise, a common non-drug intervention, is an important strategy in cancer treatment, including hepatocellular carcinoma (HCC). However, the mechanism remains largely unknown.Due to the importance of hypoxia and cancer stemness in the development of HCC, the present study investigated whether the anti-HCC effect of physical exercise is related to its suppression on hypoxia and cancer stemness.Methods:A physical exercise intervention of swimming (30 min/d, 5 d/week, for 4 we...     

Part Ⅱ Clinical Acupuncture Lecture Five Trigeminal Neuralgia, Peripheral Facial Paralysis and Stiff Neck

ⅠTrigeminal NeuralgiaTrigeminal neuralgia refers to the repeat-ed attacks of severe paroxysmal pain on theface where the trigeminal nerve is distributed.It is mostly seen in middle-aged or aged peo-ple, and in female more than male patients. Atthe beginning, attack lasts for a short timeand the interval between the attacks is pro-tracted, however the pain gradualy become     

Knowledge about,attitude and acceptance towards,and predictors of intention to receive the COVID-19 vaccine among cancer patients in Eastern China: A cross-sectional survey

Objective: The coronavirus disease 2019(COVID-19) pandemic has had a serious impact on health all over the world. Cancer patient, whose immunity is often compromised, faces a huge challenge.Currently, some COVID-19 vaccines are being developed and applied on general population;however,whether cancer patients should take COVID-19 vaccine remains unknown. Our study aimed to explore the knowledge, attitude, acceptance, and predictors of intention to receive the COVID-19 vaccine among cancer patients in Eastern China.Methods: A cross-sectional study was conducted in Eastern China from June 17 th to September 3 rd, 2021.Patients were selected using a convenience sampling method. A self-report questionnaire was developed to assess knowledge about the COVID-19 vaccine, attitude towards the vaccine and acceptance of the vaccine;following a review of similar studies previously published in the scientific literature, multivariate logistic regression analysis was used to determine the predictors associated with COVID-19 vaccine acceptance.Results: A total of 2158 cancer patients were enrolled in this study. The rate of vaccine hesitancy was 24.05%(519/2158);further, among the participants of vaccine acceptance, 767 had taken COVID-19 vaccine(35.54%), and 872 were willing to get vaccinated(40.01%). A total of 24 variables including demographic characteristics, clinical status of cancer, impact of COVID-19 pandemic on study participants,patients’ knowledge about the COVID-19 vaccine, and attitude towards the vaccine, had significant differences between the ‘‘vaccine hesitancy" population and ‘‘vaccine acceptance" population.Multivariate logistic regression analysis indicated that parameters including alcohol consumption(odds ratio [OR] = 1.849;95% confidence interval [CI]: 1.375–2.488;P-reference [P-Ref] < 0.001 vs nondrinkers), income impacted by COVID-19 pandemic(OR = 1.930, 2.037 and 2.688 for mild, moderate,and severe impact, respectively;all P-Ref < 0.01 vs no impact), knowledge of how the vaccine was developed(OR = 1.616;95% CI: 1.126–2.318;P-Ref = 0.009 vs unknown), believing in the safety of the vaccine(OR = 1.502;95% CI: 1.024–2.203;P-Ref = 0.038 vs denying the safety of vaccine), willingness to pay for the vaccine(OR = 3.042;95% CI: 2.376–3.894;P-Ref < 0.001 vs unwilling), and willingness to recommend families and friends to get vaccinated(OR = 2.744;95% CI: 1.759–4.280;P-Ref < 0.001 vs do not recommend) were contributors to vaccine acceptance. While such as being retired(OR = 0.586;95% CI: 0.438–0.784;P-Ref < 0.001 vs unemployed), undergoing multiple therapies of cancer(OR = 0.408;95% CI: 0.221–0.753;P-Ref = 0.004 vs no ongoing treatment), and worrying that the vaccine might deteriorate the prognosis of cancer(OR = 0.393;95% CI: 0.307–0.504;P-Ref < 0.001 vs might not) were contributors to vaccine hesitancy.Conclusion: This study provided preliminary estimates of the rates of vaccine acceptance and vaccine hesitancy among cancer patients in Eastern China. The intention to receive the COVID-19 vaccine was impacted by factors such as patient occupation, alcohol consumption, and some parts of knowledge about and attitude towards COVID-19 vaccine. It is recommended to develop individualized vaccination plans that meet the healthcare needs of cancer patients.     

Traditional herbal medicine as adjunctive therapy for colorectal cancer:a scoping review

Background:A variety of therapy options are available for colorectal cancer,ranging from traditional medicine to complementary and alternative medicine.There is a growing body of evidence supporting the efficacy of complementary and alternative medicine.Therefore,the main aim of this study is to conduct a scoping evaluation of traditional and herbal medicine’s effectiveness as an additional therapy for colorectal cancer patients in clinical settings.Methods:A systematic search was conducted for all articles pertaining to clinical trials related to traditional herbal medicine(THM)with or without other treatments,such as chemotherapy,placebos,or other types of treatment,published from 2010 to November 13,2020,using four search engines,namely Medline,Web of Science,Cochrane Library,and Scopus.Results:The number of colorectal cancer patients in five trials ranged from 89 to 565 people.The THMs stated in these studies were catalpol(Rehmannia glutinosa extract),the traditional Japanese medicine Daikenchuto(mixture of herbal extracts)and Goshajinkigan,Chinese patent herbal medicine Aidi injection,and the traditional Chinese medicine Simo decoction.Positive results were reported in term of reduction of colorectal cancer tumour marker(by catalpol),improvement of gastrointestinal function following gastrointestinal surgery(by Daikenchuto and Simo decoction),better disease control rate and quality of life score(by combination of Aidi injection and chemotherapy),and a decrease in the incidence of oxaliplatin-induced peripheral neurotoxicity(Goshajinkigan).Conclusion:All studies demonstrated fewer adverse effects found in THM intervention groups,however,evidence pointing to THMs’favourable effects on colorectal cancer patients is still required.Therefore,researchers and clinicians are encouraged to perform more research in this area so that more evidence of THM’s efficacy and safety in clinical settings can be obtained.     

Laser acupuncture combined with auricular acupressure improves low-back pain and quality of life in nurses: A randomized controlled trial

Background:Low-back pain (LBP) in nurses is a major health concern that affects their quality of life and ability to work, with consequences for their economic status.Objective:This study evaluates the effect of low-level laser acupuncture combined with auricular acupressure (LAA) on pain intensity, pain interference and quality of life in nurses with LBP.Design, setting, participants and interventions:This randomized controlled trial recruited a convenience sample of hospital-based nurses from ...     

Research progress of acupuncture analgesia for labor

Labor pain is a kind of severe pain the lying-in women of natural childbirth must undergo. The labor quality is decided by the tolerance to pain. Acupuncture analgesia for labor pain has been increasingly concerned and applied by more and more clinical workers because of its safety and efficacy. By summarizing and analyzing the choice and applications of various factors of acupuncture analgesia for labor pain such as acupoint selection, instrument analgesic coefficient, and the needling techniques in acupuncture analgesia for labor pain in the recent 12 years, this study aims to provide a theoretical foundation for the clinical application of acupuncture analgesia for labor pain.     

Post-marketing safety surveillance and reevaluation of Motherwort injection:A clinical study of 10094 cases

OBJECTIVE:To investigate the safety profiles of Motherwort injection(MI).METHODS:A multi-center,prospective and drugderived hospital intensive monitoring method was conducted to assess the safety of MI in real world applications.This study was based on a very large population after the injection was approved and marketed in China.All patients using the injection in participating hospitals were monitored to determine the incidence,pattern,severity and outcome of associated adverse events.RESULTS:The post-marketing surveillance was performed in 10 094 female patients from April to December,2015.The incidence of adverse drug reactions(ADRs) was 0.79‰(8/10 094).Among the 8 patients,the reported adverse events mainly included systemic abnormalities,such as fever,chills and eyelid edema;skin and appendages disorders,such as pruritus and rash;gastrointestinal disorders,such as nausea,abdominal distension and pain;heart rate and rhythm disorders,such as palpitation and increased heart rate.All of these ADRs were mild in severity.CONCLUSION:In this study the ADRs incidence rate of MI is very low,which supports that it is generally safe for use in obstetric and gynecological diseases.However,the total number of 8 ADRs recorded over a relatively short time span seems limited,and the low number of reports could not represent an absolute guarantee of safety.