Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting

Nonpharmacological Nursing Interventions in Postoperative Nausea and Vomiting: A Systematic Review

PURPOSE

This study aims to assess the impact of nonpharmacological nursing interventions on postoperative nausea and vomiting (PONV).

DESIGN

This is a systematic review.

METHODS

MEDLINE, Web of Science, ScienceDirect, Tübitak-ULAKBİM, and TRDizin databases were searched for the following search terms, including "Postoperative Nausea and Vomiting," "Nurse," "Nursing," and "Nonpharmacological Interventions" to identify nonpharmacological nursing interventions for PONV. A systematic review of English and Turkish articles published in the period between January 1, 2012 and June 1, 2023 was conducted. The PICOT-SD method was used to determine the compatibility of the pieces with the eligibility criteria.

FINDINGS

Fifty-eight of 3,874 articles obtained from databases fulfilled the eligibility criteria. This study demonstrated that acupuncture, aromatherapy, the oral intake of ginger, listening to music, education, and visits to patients decreased the incidence of nausea and vomiting and increased the quality of life. Additionally, it was found that patients' quality of life tended to improve along with reductions in postoperative complications.

CONCLUSIONS

The results of this study support previous findings in the literature and demonstrate that nonpharmacological nursing interventions help reduce and prevent PONV. Based on our results, we suggest that nonpharmacological nursing interventions can be employed for the management of PONV in patients undergoing surgery.

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, parallel-group and multi-center design. Patients diagnosed with AP were randomly and equally assigned to EA1, EA2 or control groups. All participants received conventional standard-of-care therapy for AP. Local EA alone was administered in EA1, and local plus distal EA was given in EA2. Local EA included two abdominal acupoints, while distal EA included twelve peripheral acupoints. EA groups underwent one session of EA daily for 4 days (days 1-4), or until pain was resolved or discharged.

MAIN OUTCOME MEASURES

The primary outcome measure was the change in the visual analogue scale (VAS; 0-100) pain score between baseline and day 5.

RESULTS

Eighty-nine participants were randomized into EA1, EA2 and control groups, and 88 (EA1, 30; EA2, 29; control, 29) were included in the full-analysis set. VAS score change (median [interquartile range]) on day 5 was (12.3 ± 22.5) in the EA1 group, (10.3 ± 21.5) in the EA2 group, and (8.9 ± 15.2) in the control group. There were not significant differences in the change in VAS score among treatments (P = 0.983). However, time to food intake was significantly shorter in the EA group (EA1 + EA2) than in the control group (median 2.0 days vs 3.0 days), with a hazard ratio of 0.581 (P = 0.022; 95% CI, 0.366-0.924). No significant adverse events occurred.

CONCLUSION

EA treatment did not significantly reduce pain after 4 days of treatment in patients with AP-associated abdominal pain but significantly reduced time to first food intake.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03173222. Please cite this article as: Jang DK, Lee JK, Jung CY, Kim KH, Kang HR, Lee YS, Yoon JH, Joo KR, Chae MK, Baek YH, Seo BK, Lee SH, Lim C. Electroacupuncture for abdominal pain relief in patients with acute pancreatitis: A three-arm randomized controlled trial. J Integr Med. 2023; 21(6): 537-542.

Research trends of acupuncture therapy on postoperative nausea and vomiting from 2011 to 2023: A bibliometric analysis

BACKGROUND

The utilization of acupuncture as a therapeutic intervention for the management of postoperative nausea and vomiting has experienced a notable increase in its popularity, and the purpose of this analysis is to provide a comprehensive understanding of the level of concern within the academic discipline and the main contributors and their partnership, as well as to identify research focal points and trends.

METHODS

A comprehensive search was carried out to identify relevant articles on the topic of acupuncture therapy for PONV in the Web of Science and China National Knowledge Internet. The search spanned from January 1, 2011, to June 6, 2023. The annual publications were count to see the degree of scholarly attention devoted to the discipline and how it has changed over time. A statistical analysis of article distribution across various journals was conducted to serve a rough indicator for assessing the quality of articles. And a bibliometric analysis was conducted using the software CiteSpace to visually analyze various aspects of the literature. Analyze authors, institutions and countries to identify the main contributors and their collaborative relationship; and analyze keywords and references to explore research hotspots and trends.

RESULTS

This study examined a comprehensive collection of 819 articles focused on acupuncture therapy for PONV, demonstrating a varying upward trend in the quantity of publications. Notably, the most productive author and institution were identified as Zheng Man and Guangzhou University of Traditional Chinese Medicine, respectively. While China had the highest number of publications, the United States held a greater prominence in this specific field. Collaboration among contributors was found to be weak. High-frequency keywords in the publications included "transcutaneous electrical acupoint stimulation," "electroacupuncture," "pain," and so forth. The literature with the highest citation count pertained to "Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting," while the article with the highest centrality was "Consensus Guidelines for the Management of Postoperative Nausea and Vomiting." Several large clusters obtained from the references are also included "postoperative pain," "transcutaneous electrical acupoint stimulation". Nothing pertaining to mechanism study was found in the analysis results.

CONCLUSION

The utilization of acupuncture for the treatment of postoperative nausea and vomiting has been gaining increasing recognition, although there remains room for improvement in the quality of research conducted in this area. Chinese authors and institutions have emerged as significant contributors to this field, while the United States has demonstrated greater proficiency in fostering collaborative efforts. It is imperative to enhance collaboration among these contributors. The current focal points of acupuncture for PONV encompass pain management, electroacupuncture, auricular acupuncture, and transcutaneous electrical acupoint stimulation. Additionally, TEA and enhanced recovery after surgery have been identified as the forefronts of research in this particular domain. In addition, there is still much room for research in the aspect of mechanism and insurance coverage. This study provides an in-depth perspective on acupuncture for PONV, which offers reference material for clinicians with rational choice of therapeutic scheme, educators with hot topics, and researchers with valuable research directions.

Effect of Integrated Yoga Program Along With Pilates in Abdominal Hysterectomy Patients: A Case Report

Abdominal hysterectomy is a surgical procedure that involves the removal of the uterus through an incision in the abdominal wall. Hysterectomy is associated with a number of complications; hence, early mobilization and physiotherapy are necessary following surgery. This is a case report of a 45-year-old female who presented with complaints of abdominal pain associated with white discharge. Investigations showed an anterior submucosal fibroid measuring 3.2x2.7 cm and the patient underwent an abdominal hysterectomy. Early mobilization and physiotherapy were started on Day 6, which included breathing exercises, upper limb mobility, lower limb mobility, and positioning and postural advice. Yoga and pilates therapy were integrated into the protocol starting from the second week. The patient attended 30 days of therapy in two phases and was advised to continue even after discharge. We concluded that this unique approach of including pilates and yoga showed a positive impact on the patient's condition in terms of her quality of life, strength, endurance, and power, even decreasing her difficulty in performing activities of daily living.

Acupuncture Analgesia in Patients with Postoperative Neck Pain: A Protocol for Systematic Review and Meta-Analysis

Background. There is a yearly increase in pain after neck surgery, which is accompanied by high consumption of opioids. However, the opioid addiction epidemic is one of the most serious public health problems worldwide. Therefore, it is important to find suitable alternatives for opioids. Acupuncture therapy has been found effective for some types of pain control. This protocol aims to evaluate the efficacy and safety of acupuncture therapy in the treatment of pain after neck surgery. Methods and Analysis. We will search eight electronic databases from their inception to April 2022. Only randomized controlled trials (RCTs) using manual acupuncture, auricular acupuncture, or electroacupuncture as major therapy will be included, regardless of whether the study was published in Chinese or English. The selection of studies and data extraction will be independently completed by at least two experienced reviewers with a master's degree. The methodological quality of the included studies will be assessed by the Cochrane risk-of-bias tool. For the meta-analysis, Review Manager Statistical (RevMan V.5.3) software will be used. The results will be presented as the risk ratio (RR) for the binary data and the mean difference (MD) or standardized mean difference (SMD) for the continuous data. Ethics and Dissemination. This protocol for a systematic review will be submitted to a peer-reviewed journal for publication and presented at a relevant conference, and there is no need to obtain formal ethical approval. Trial Registration Number. PROSPERO registration number CRD42021281722.

Functional Nausea Is Real and Makes You Sick

Functional nausea is a condition that severely impairs the quality of life of affected individuals. Only recently, it has been added to the pediatric list of disorders of gut-brain interaction. In most cases, only minimal testing is needed to diagnose functional nausea. Hypnotherapy has been shown to be a very effective treatment and there are several other medical and non-medical interventions which have the potential to benefit sub-groups of patients with chronic nausea.

Complementary and Alternative Medicines in Oral Health Care: An Integrative Review

Complementary and alternative medicine (CAM) uses a holistic approach that finds natural solutions that help the immune system to fight off infection and diseases. In conventional medicine, the diseases are treated as a series of symptoms developed and not its actual cause or etiology, but CAM commonly targets the exact cause of the disorder thereby stimulating the body's healing process. This is based on an integrative literature review of methods and techniques used as complementary and alternative approaches for oral health care. A comprehensive electronic database search was conducted in PubMed, CINAHL, MEDLINE, EMBASE, Google, Google Scholar, and SCOPUS. Medicinal plants such as Medicago Sativa, Aloe Barbadensis Miller (Aloe Vera), and Trifolium Pratense (Red Clover) have excellent applications in treating gum disorders, prevent tooth decay, and have demonstrated good antifungal activity in the oral cavity. Homeopathic medicines such as Belladonna, Antimonium crudum, and Chamomilla have useful applications in relieving toothache. In Chinese medicine, various acupressure points (Acupuncture) have been used to relieve pain related to tooth, head-and-neck region, sinusitis, etc. Dental professionals can utilize these treatment modalities in their practice along with other conventional procedures as an integrative treatment approach to achieve better outcomes.

Analysis of the Most-Cited Systematic Review or Meta-Analysis in Acupuncture Research

Objectives

The aim of the current study was to analyze the 100 most-cited systematic reviews or meta-analyses in the field of acupuncture research.

Methods

The Web of Science Core Collection was used to retrieve lists of 100 most-cited systematic reviews or meta-analyses in the field of acupuncture research. Two authors screened literature, extracted data, and analyzed the results.

Results

The citation number of the 100 most-cited systematic reviews or meta-analyses varied from 65 to 577; they were published between 1989 and 2018. Fourteen authors published more than 1 study as the corresponding author and 10 authors published more than 1 study as the first author. In terms of the corresponding authors, Edzard Ernst and Linde Klaus published the most systematic reviews/meta-analyses (n = 7). The USA published most of the systematic reviews or meta-analyses (n = 24), followed by England (n = 23) and China (n = 14). Most institutions with more than 1 study were from England (4/13). The institutions with the largest numbers of most-cited systematic reviews or meta-analyses were the Technical University of Munich in Germany, the University of Maryland School of Medicine in the USA (n = 8), the Universities of Exeter and Plymouth in England (n = 6), and the University of Exeter in England (n = 6). The journal with the largest number of most-cited systematic reviews or meta-analyses was the Cochrane Database of Systematic Reviews (n = 20), followed by Pain (n = 6).

Conclusion

Our study reveals that the 100 most-cited systematic reviews or meta-analyses in the acupuncture research field are mostly from high impact factor journals and developed countries. It will help researchers follow research hot spots, broaden their research scope, expand their academic horizons, and explore new research ideas, thereby improving the quality of acupuncture research.

Comparative Effectiveness of Pediatric Integrative Medicine: A Pragmatic Cluster-Controlled Trial

Symptoms of pain, nausea/vomiting, and anxiety (PNVA) are highly prevalent in pediatric inpatients. Poorly managed symptoms can lead to decreased compliance with care, and prolonged recovery times. Pharmacotherapy used to manage PNVA symptoms is of variable effectiveness and carries safety risks. Complementary therapies to manage these symptoms are gaining popularity due to their perceived benefits and low risk of harm. Pediatric integrative medicine (PIM) is the combination of complementary therapies with conventional medicine in pediatric populations. A two-arm, cluster-controlled, pragmatic clinical trial was carried out to compare the effectiveness of a PIM service in conjunction with usual care, versus usual care only to treat PNVA symptoms in hospitalized pediatric patients. The primary outcome was the improvement of PNVA symptom severity using a 10-point numerical rating scale. Participant enrollment occurred between January 2013 and January 2016. A total of 872 participants (usual care n = 497; PIM n = 375) were enrolled. The PIM therapies significantly reduced PNVA symptom severity (p < 0.001). This study found that a hospital-based PIM service is both safe and effective for alleviating PNVA symptoms. Future research should carry out this work in other pediatric inpatient divisions, and in other sites to determine the reproducibility of findings.

Effects of transcutaneous electrical acupoint stimulation on perioperative immune function and postoperative analgesia in patients undergoing radical mastectomy: A randomized controlled trial

Radical mastectomy may lead to suppression of cellular immune function in patients with malignant tumors. Transcutaneous electrical acupoint stimulation (TEAS) is widely used in clinical practice. However, there have been relatively few studies on the effects of TEAS on postoperative analgesia and immune function. The present study aimed to evaluate the effects of TAES on postoperative pain and immune function in patients undergoing radical mastectomy. A total of 65 patients were enrolled and allocated to either receive TEAS or sham TEAS. TEAS was implemented on bilateral Hegu (LI4), Neiguan (PC6) and Zusanli (ST36) acupoints simultaneously for 30 min before induction of anesthesia at 4 and 12 h post-operation. The primary outcomes included visual analogue scale (VAS) scores at 4 h (T₁), 12 h T₂), 24 h (T₃) and 48 h (T₄) post-operation, and serum levels of IL-2, IL-4, IFN-γ and the IL-2/IL-4 ratio at 30 min before TEAS (T₀), T₁, T₂, T₃ and T₄. Secondary outcomes included the cumulative time of rescue analgesia within 48 h post-surgery, as well as the incidence of postoperative nausea and vomiting (PONV) and pruritus. Compared with the sham TEAS group, postoperative VAS scores at T₂ and T₃, the total consumption of opioids in the patient-controlled analgesia (PCA) pump, pressing times of the PCA pump and the incidences of PONV and headache were significantly lower in the TEAS group. The serum levels of IFN-γ at T₃ and T₄, and the serum levels of IL-2 and the IL-2/IL-4 ratio at T₂, T₃ and T₄ were higher in the TEAS group compared with the sham TEAS group. By contrast, the serum levels of IL-4 were lower at T₂, T₃ and T₄ in the TEAS group compared with the sham TEAS group. The results indicated that TEAS could improve postoperative analgesia, reduce postoperative consumption of opioids and alleviate postoperative side effects. Simultaneously, TEAS was able to reverse decreased serum levels of IL-2 and IFN-γ, reduce the level of IL-4 and restore the balance of Th1/Th2, thereby partially attenuating perioperative immune function depression in patients with breast cancer. The current trial was registered prior to participant enrollment at www.chictr.org.cn (Clinical Trial no. ChiCTR1800017768).

Electroacupuncture: A New Approach for Improved Postoperative Sleep Quality After General Anesthesia

General anesthesia produces a state of drug-induced unconsciousness that is controlled by the extent and duration of administered agents. Whether inhalation or intravenous in formulation, such agents may interfere with normal sleep-wake cycles, impairing postoperative sleep quality and creating complications. Electroacupuncture is a new approach widely applied in clinical practice during recent years. This particular technology helps regulate neurotransmitter concentrations in the brain, lowering norepinephrine and dopamine levels to improve sleep quality. It also alleviates surgical pain that degrades postoperative sleep quality after general anesthesia by downregulating immune activity (SP, NK-1, and COX-1) and upregulating serotonin receptor (5-HT1AR, 5-HT2AR) and endocannabinoid expression levels. However, large-scale, multicenter studies are still needed to determine the optimal duration, frequency, and timing of electroacupuncture for such use.

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

The Role of Tactile Stimulation for Expectation, Perceived Treatment Assignment and the Placebo Effect in an Experimental Nausea Paradigm

Introduction

Tactile stimulation during a placebo treatment could enhance its credibility and thereby boost positive treatment expectations and the placebo effect. This experimental study aimed to investigate the interplay between tactile stimulation, expectation, and treatment credibility for the placebo effect in nausea.

Methods

Ninety healthy participants were exposed to a 20-min vection stimulus on two separate days and were randomly allocated to one of three groups on the second day after the baseline period: Placebo transcutaneous electrical nerve stimulation (TENS) with tactile stimulation (n = 30), placebo TENS without tactile stimulation (n = 30), or no intervention (n = 30). Placebo TENS was performed for 20 min at a dummy acupuncture point on both forearms. Expected and perceived nausea severity and further symptoms of motion sickness were assessed at baseline and during the evaluation period. At the end of the experiment, participants in the placebo groups guessed whether they had received active or placebo treatment.

Results

Expected nausea decreased significantly more in the placebo groups as compared to the no treatment control group (interaction day × group, F = 6.60, p = 0.003, partial η² = 0.20), with equal reductions in the two placebo groups (p = 1.0). Reduced expectation went along with a significant placebo effect on nausea (interaction day × group, F = 22.2, p < 0.001, partial η² = 0.35) with no difference between the two placebo groups (p = 1.0). Twenty-three out of 29 participants in the tactile placebo group (79%) but only 14 out of 30 participants (47%) in the non-tactile placebo group believed that they had received the active intervention (p = 0.015). Bang’s blinding index (BI) indicated random guessing in the non-tactile placebo group (BI = 0; 95% CI, −0.35 to 0.35) and non-random guessing in the direction of an “opposite guess” in the tactile placebo group (BI = −0.52; 95% CI, −0.81 to −0.22).

Conclusion

Tactile stimulation during placebo TENS did not further enhance positive treatment expectations and the placebo effect in nausea but increased the credibility of the intervention. Further trials should investigate the interaction between perceived treatment assignment, expectation, and the placebo effect during the course of a trial.

Acupuncture for hiccups: A systematic review protocol of high-quality randomized trials

BACKGROUND

A Hiccup is a common disease that often occurs along with other chronic or acute conditions. At present, there is a lack of feasible therapies for hiccups, and acupuncture is a treatment method with enormous clinical practice worldwide.

METHODS

Based on a pre-defined search strategy, we searched seven databases and screened them by two independent investigators, without language and publication status restriction from inception to date. We use the pre-set form to incorporate data and utilize Revman software to synthesize data. We will evaluate the risk of bias in the inclusion of the study based on the Cochrane 'Risk of bias' assessment tool. The quality of the evidence will be evaluated according to the GRADEpro software.

RESULTS

This systematic review will evaluate the efficacy and safety of acupuncture treatment for hiccups. The entire process will be referred to the Cochrane handbook recommended by the Cochrane Collaboration.

CONCLUSION

This review will provide systematic evidence to summarize whether acupuncture is an effective intervention in the treatment of hiccup.

Comparison of Two Acupuncture Protocols (K1, DU25 or K1, DU26) Efficacy on Recovery Time of Patients After General Anesthesia, a Randomized Control Clinical Trial

Background

Acupuncture has been used for more than two thousand years as part of traditional Chinese medicine.

Objectives

This randomized prospective clinical trial aimed to compare the effect of acupuncture on K1 (Yongquan) and DU26 (Renghong) with acupuncture on K1 (Yongquan) and DU25 (Suliao), with sham acupuncture on the recovery time of general anesthesia.

Methods

The patients (51) were randomly assigned to three groups: (A) acupuncture on K1 and DU26, (B) acupuncture on K1 and DU25, and (C) sham acupuncture. In each group, at the end of surgery acupuncture was performed accordingly for twenty minutes and the Bispectral Index (BIS) values at end of surgery, 5th minute, 10th minute, 15th minute and 20th minute as well as time of extubation and time of eye opening after the end of surgery were evaluated.

Results

BIS study at 5th minute, 10th minute and 15th minute after the end of surgery in the groups revealed a significant difference between sham acupuncture group and both A and B acupuncture groups, which was higher in groups A and B in comparison with sham acupuncture group. Time of opening eyes and time of extubation after the end of surgery between group A and sham acupuncture group differed significantly, which was earlier in group A. There was no significant difference between group B and sham acupuncture group in terms of eye opening and extubation time.

Conclusions

Acupuncture on K1 and DU26 accelerates restoring of consciousness and shortens of eye opening and extubation after general anesthesia, but on K1 and DU25 only speeds up retrieving of consciousness without significant effect on time of eye opening or extubation after general anesthesia.

Acupressure to Reduce Treatment-Related Symptoms for Children With Cancer and Recipients of Hematopoietic Stem Cell Transplant: Protocol for a Randomized Controlled Trial

Background

We describe the study design and protocol of a pragmatic randomized controlled trial (RCT) Acupressure for Children in Treatment for a Childhood Cancer (ACT-CC).

Objective

To describe the feasibility and effectiveness of an acupressure intervention to decrease treatment-related symptoms in children in treatment for cancer or recipients of a chemotherapy-based hematopoietic stem cell transplant (HSCT).

Design

Two-armed RCTs with enrollment of 5 to 30 study days.

Setting

Two pediatric teaching hospitals.

Patients

Eighty-five children receiving cancer treatment or a chemotherapy-based HSCT each with 1 parent or caregiver.

Intervention

Patients are randomized 1:1 to receive either usual care plus daily professional acupressure and caregiver delivered acupressure versus usual care alone for symptom management. Participants receive up to 20 professional treatments.

Main Outcome

A composite nausea/vomiting measure for the child.

Secondary Outcomes

Child's nausea, vomiting, pain, fatigue, depression, anxiety, and positive affect.

Parent Outcomes

Depression, anxiety, posttraumatic stress symptoms, caregiver self-efficacy, and positive affect. Feasibility of delivering the semistandardized intervention will be described. Linear mixed models will be used to compare outcomes between arms in children and parents, allowing for variability in diagnosis, treatment, and age.

Discussion

Trial results could help childhood cancer and HSCT treatment centers decide about the regular inclusion of trained acupressure providers to support symptom management.

[Postoperative nausea and vomiting in neurosurgery: the approaches are varied but the problem remains unsolved]

Postoperative nausea and vomiting (PONV) can induce brain displacement and herniation, especially in patients with cerebral edema.

OBJECTIVE

To evaluate the urgency of the problem associated with postoperative nausea and vomiting in current clinical practice (with modern approaches being used for its prevention) and to reveal the risk factors of PONV that are typically encountered in neurosurgical patients.

MATERIAL AND METHODS

A prospective observational study involved 240 patients who had undergone elective surgeries at the N.N. Burdenko National Scientific and Practical Center for Neurosurgery between July and November 2017. The data were collected from the questionnaires filled out by the patients during the first 48 h after the surgery and from patients' medical records.

RESULTS

The overall rate of PONV was 39.6%. Thirty-six out of 53 (68%) patients developed PONV after the posterior fossa surgeries. The risk of PONV in this group was significantly higher (p<0.05) compared to the rate of PONV after interventions at a different location. The rate of PONV after treatment of extracranial pathology was ~10.5%; for a different location, it was as high as 32-37%. Intraoperative dexamethasone was used in 156 (65%) patients; in this group, the rate of PONV was 39.9%. Patients received ondansetron at a dose of 8 mg for a preventive purpose at the end of the surgery. A total of 162 patients were given the drug; 59 (36.4%) of them developed POTV during 48 h post-administration. Seventy-eight patients did not receive ondansetron. Thirty-six of them (46.2%) (p>0.05) developed POTV. The rate of POTV assessed during the first 8 h after surgery was 22.8% in patients who had received ondansetron and 37.2% in those who had not received it (p<0.05). Patients who had not intraoperatively received a combination of these drugs developed POTV in 55 (45%) cases (p>0.05).

CONCLUSION

The problem associated in POTV remains topical in neurosurgery. The current approaches are not absolutely effective for prevention of POTV, whose rate ranges between 10.5 and 68% depending on surgery location. Further studies focused on administration of NK-1 receptor antagonists and electrical stimulation of the median nerve are needed to enhance the effectiveness of POTV prevention.

The effect of acupuncture on postoperative pain, nausea and vomiting after pediatric tonsillectomy: a systematic review

INTRODUCTION

Tonsillectomy is one of the most commonly performed surgical procedures among children around the world and management of post tonsillectomy complications are very important.

OBJECTIVES

The aim of this study was to evaluate the effects of acupuncture on the amount of pain, nausea and vomiting after tonsillectomy in children.

METHODS

In this study, two researchers searched individually for qualified articles on the effects of acupuncture on post-tonsillectomy pain, nausea and vomiting using PubMed, Cochrane Library, Embase, Google scholar and Ovid databases by September 2018.

RESULTS

After critically appraising the searched studies, 12 studies were selected and entered into a systematic review. Among the studies, various acupuncture methods were used.

CONCLUSION

This systematic review shows that acupuncture as a complementary method can prevent and reduce the severity of complications surrounding tonsillectomy.

Effectiveness of P6 Stimulation for Reduction of Nausea and Vomiting During Caesarean Section Under Combined Spinal-Epidural Anaesthesia: A Randomised Controlled Trial

Objective

Obstetric patients who receive combined spinal-epidural (CSE) anaesthesia for elective caesarean section (CS) frequently experience intraoperative nausea and vomiting (N&V). Prophylactic therapy with antiemetic agents can have multiple adverse effects to the mother and baby. We designed a randomised clinical trial to evaluate the efficacy of electrical P6 stimulation for prophylactic N&V treatment for scheduled elective CS performed under CSE anaesthesia.

Methods

Following the Institutional Review Board approval and informed consent, a total of 180 patients were randomly allocated into three groups: (1) P6 stimulation (via a peripheral nerve stimulator), (2) intravenous (IV) antiemetics (metoclopramide and ondansetron), and (3) control (no IV antiemetic medications and no P6 stimulation), with 60 parturients in each group.

Results

Significantly fewer patients experienced intraoperative N&V in the P6 group (nausea 36.7% and vomiting 13.3%) and IV antiemetic group (nausea 23.3% and vomiting 16.7%) than those in the control group (nausea 73.3% and vomiting 45%; p<0.001). In addition, significantly fewer patients required rescue antiemetic medications in the P6 group (35%) and the IV antiemetic group (31.7%) than those in the control group (73.3%; p<0.001). There was no significant difference in the overall anaesthetic care satisfaction reported between the three study groups.

Conclusion

Our data suggest that P6 stimulation is as simple and as effective as our routine prophylactic IV antiemetic treatment for prevention of N&V during CS performed under CSE anaesthesia that could be of great interest to patients and obstetric anaesthesiologists who prefer treatments with fewer potential side effects.

Use of Acupuncture in Hospices and Palliative Care Services in the Uk

Purpose

The aim of the present work was to evaluate the availability of acupuncture in UK hospices and specialist palliative care services and to identify any barriers to the use of acupuncture in these settings, to determine the characteristics of available acupuncture services and of practitioners providing acupuncture, and to determine awareness of the evidence base for the use of acupuncture in palliative care.

Methods

An online questionnaire with an invitation to participate was circulated by email to 263 hospices and specialist palliative care services in the UK.

Results

A response rate of 54% was obtained. Acupuncture was provided by 59% of services that responded. In general, small numbers of patients receive acupuncture as part of their palliative care treatment as inpatients, day patients or outpatients. Most practitioners were regulated health professionals who had received a Western-style training in acupuncture and used a Western-style medical acupuncture approach. Where acupuncture was not available the commonest reason given was the lack of a suitable practitioner. Most agreed that if funding and a suitable practitioner were available, acupuncture would be a useful addition to their service. The level of awareness of specific types of evidence supporting the use of acupuncture in palliative care was low, but most respondents were aware that some evidence existed.

Conclusions

There is a need to increase training in acupuncture for healthcare professionals working in palliative care. There is also a need to raise awareness of the potential benefits to patients and the evidence base supporting the use of acupuncture in palliative care.

The Neurophysiology and Treatment of Motion Sickness

BACKGROUND

Seasickness and travel sickness are classic types of motion illness. Modern simulation systems and virtual reality representations can also induce comparable symptoms. Such manifestations can be alleviated or prevented by various measures.

METHODS

This review is based on pertinent publications retrieved by a PubMed search, with special attention to clinical trials and review articles.

RESULTS

Individuals vary in their susceptibility to autonomic symptoms, ranging from fatigue to massive vomiting, induced by passive movement at relatively low frequencies (0.2 to 0.4 Hz) in situations without any visual reference to the horizontal plane. Younger persons and women are considered more susceptible, and twin studies have revealed a genetic component as well. The various types of motion sickness are adequately explained by the intersensory conflict model, incorporating the vestibular, visual, and proprioceptive systems and extended to include consideration of postural instability and asymmetry of the otolith organs. Scopolamine and H1-antihistamines, such as dimenhydrinate and cinnarizine, can be used as pharmacotherapy. The symptoms can also be alleviated by habituation through long exposure or by the diminution of vestibular stimuli.

CONCLUSION

The various types of motion sickness can be treated with general measures to lessen the intersensory conflict, behavioral changes, and drugs.

Traumatic Pneumothorax Secondary to Acupuncture Needling

Acupuncture is a common form of therapy involving insertion of fine needles to alleviate nausea and various forms of pain. We describe a case of pneumothorax secondary to acupuncture.

A 50-year-old woman presented to the emergency department with right-sided pleuritic chest pain. This was following a history of acupuncture and cupping treatment an hour earlier at a traditional practitioner for long-standing neck pain. On physical examination, the respiratory rate was 22 breaths per minute and her oxygen saturation was 100% on room air. Breath sounds were decreased on the right hemithorax with hyper resonance to percussion. Inspection of her back revealed multiple needling and cupping marks. A chest radiograph revealed a right-sided pneumothorax with an apex-cupola distance of 3.6 cm. She was put on high flow oxygen and a chest tube was inserted into the right chest wall. The patient was admitted. She had radiographic resolution of the pneumothorax four days later and was discharged uneventfully. Follow-up one week later in the clinic showed no radiographic recurrence of the pneumothorax.

Caregivers' knowledge and acceptance of complementary and alternative medicine in a tertiary care pediatric hospital

Background

The use of complementary and alternative medicine (CAM) therapies has increased in children, especially in those with chronic health conditions. However, this increase may not translate into acceptance of CAM in the perioperative setting. We surveyed caregivers of patients undergoing surgery to determine their knowledge and acceptance of hypnotherapy, acupuncture, and music therapy as alternatives to standard medication in the perioperative period.

Materials and methods

An anonymous, 12-question survey was administered to caregivers of children undergoing procedures under general anesthesia. Caregivers reported their knowledge about hypnotherapy, music therapy, and acupuncture and interest in one of these methods during the perioperative period. CAM acceptance was defined as interest in one or more CAM methods.

Results

Data from 164 caregivers were analyzed. The majority of caregivers were 20-40 years of age (68%) and mothers of the patient (82%). Caregivers were most familiar with acupuncture (70%), followed by music therapy (60%) and hypnotherapy (38%). Overall CAM acceptance was 51%. The acceptance of specific CAM modalities was highest for music therapy (50%), followed by hypnotherapy (17%) and acupuncture (13%). In multivariable logistic regression, familiarity with music therapy was associated with greater odds of CAM acceptance (odds ratio=3.36; 95% CI: 1.46, 7.74; P=0.004).

Conclusion

Overall CAM acceptance among caregivers of children undergoing surgery was 51%, with music therapy being the most accepted CAM method. Familiarity with music therapy was the only factor that was independently associated with accepting CAM in the perioperative period. The low acceptance for acupuncture and hypnosis in the perioperative situation may be related to insufficient parental knowledge and information.

Assessing the Impact of Acupuncture on Pain, Nausea, Anxiety, and Coping in Women Undergoing a Mastectomy

PURPOSE/OBJECTIVES

To compare the effect of acupuncture to a standard-of-care (control) group on pain, nausea, anxiety, and ability to cope. 
.

DESIGN

Pilot randomized, controlled trial. 
.

SETTING

Abbott Northwestern Hospital, a large, urban, tertiary care hospital in Minneapolis, Minnesota.
.

SAMPLE

30 adult women undergoing surgery for breast cancer.
.

METHODS

Women were randomly assigned to two hospital-based acupuncture treatments versus usual care after breast cancer surgery. Pain, nausea, anxiety, and the patient's ability to cope pre- and post-treatment were compared within and between groups at two different time points postoperatively. 
.

MAIN RESEARCH VARIABLES

Mean change in pain, nausea, anxiety, and ability to cope by treatment group.
.

FINDINGS

Compared to women assigned to the control group, women who received acupuncture reported a statistically significant greater reduction in pain, nausea, anxiety, and increase in ability to cope on the first postoperative day and in pain on the second postoperative day following mastectomy surgery.
.

CONCLUSIONS

Acupuncture delivered postoperatively in the hospital after mastectomy can reduce the severity of symptoms experienced, as well as increase the patient's ability to cope with her symptoms. However, before implementation as a standard of care, further research needs to be conducted.
.

IMPLICATIONS FOR NURSING

Acupuncture adds a nonpharmacologic intervention for symptom management in women undergoing mastectomies for breast cancer.

Comparison Between Effects of Acupuncture and Metoclopramide on Postoperative Nausea and Vomiting after Gynaecological Laparoscopy: A Randomized Controlled Trial

Background

Gynaecological laparoscopy one ofthe most common operations thatis accompanied by postoperative nausea and vomiting (PONV). A non-pharmacological method of preventing PONV is acupuncture therapy.

Objectives

This study is conducted to compare the effects of acupuncture and metoclopramide on post-operative nausea and vomiting (PONV) after gynaecological laparoscopy.

Methods

In this double-blind, randomized, clinical trial study,122female, ASA I, aged 19 - 46, who had been referred to the Imam Khomini Hospital (Ahvaz, Iran) and were candidates for gynaecological laparoscopy were enrolled. Eligible patients were randomly allocated into three groups group I (acupuncture; n = 40), group II (metoclopramide 0.2 mg/kg IV; n = 41), and group III (control; n = 41). In group I, acupuncture was done by inserting a special needle at point P6 in front of the elbow immediately after induction of anaesthesia and removing it before extubation and transfer of the patient to the recovery room. The occurrences of nausea and vomiting during the period of stay in the recovery room (one and two hours after surgery) were recorded through questions or clinical observation. Statistical analysis was conducted using SPSS V. 19, descriptive statistics, and the Chi-square test.

Results

The acupuncture group (11.1%) showed a significant decrease in the incidence of nausea one hour after surgery compared to the metoclopramide group (33.3%) (P = 0.02), but there was no significant difference between the acupuncture and metoclopramide groups in terms of postoperative vomiting (POV) incidence one and two hours after surgery. Incidence of PONV in the acupuncture group (2.7%) was statistically significantly lower than that in the control group (28.5%), two hours after surgery (P < 0.01).

Conclusions

Acupuncture is better for controlling nausea after laparoscopic surgery, compared to metoclopramide. Acupuncture is an effective method for reduction of PONV in gynaecological laparoscopy.

Psychoneuroimmunoendocrinology: clinical implications

Psychoneuroimmunoendocrinology, which was first described in 1936, is the study of the interactions between the psyche, neural and endocrine functions and immune responses. The aim of psychoneuroimmunoendocrinology is to apply medical knowledge to the treatment of different allergic, immune, autoimmune, rheumatic, neoplastic, endocrine, cardiovascular and dental pathologies, among other disorders. Epigenetic factors and major stresses from different types of stimuli acting through distinct pathways and neurotransmitters are highly involved in altering the psychoneuroimmunoendocrine axis, resulting in the emergence of disease. The main purpose of this report is to expand the understanding of psychoneuroimmunoendocrinology and to demonstrate the importance of the above-mentioned interactions in the etiology of multiple pathologies. In this review, a search of the medical literature using PubMed (free access search engine for the Medline database of the National Library of Medicine of the United States) over the years 1936 to 2016 was conducted, and descriptive and experimental studies and reviews of the scientific literature were included.

An update on the management of postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. PONV and PDNV can delay discharge and recovery and increase medical costs. The high incidence of PONV has persisted in part because of the tremendous growth in ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major operations. Pharmacological management of PONV should be tailored to the patients' risk level using the PONV and PDNV scoring systems to minimize the potential for these adverse side effects in the postoperative period. A combination of prophylactic antiemetic drugs should be administered to patients with moderate-to-high risk of developing PONV in order to facilitate the recovery process. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving an enhanced recovery after surgery. Strategies that include reductions of the baseline risk (e.g., adequate hydration, use of opioid-sparing analgesic techniques) as well as a multimodal antiemetic regimen will improve the likelihood of preventing both PONV and PDNV.

Needle Sensation and Personality Factors Influence Therapeutic Effect of Acupuncture for Treating Bell's Palsy: A Secondary Analysis of a Multicenter Randomized Controlled Trial

BACKGROUND

It has not been solved what kind of needle sensation might influence outcomes of acupuncture treatment. Effects of personality factors on the therapeutic effect of acupuncture have not been investigated. This study aimed to find the effects of the traits of personality on the objective outcome when different acupuncture techniques were used in treating patients with Bell's palsy.

METHODS

We performed a secondary analysis of a prospective multicenter randomized controlled trial of acupuncture for Bell's palsy. Patients were randomly assigned to the de qi and control groups, respectively. The primary outcome was facial nerve function at month 6. The intensity of each needle sensation was rated by a visual analog scale. Psychosocial factors were assessed by the pretreatment mediator questionnaire; 16 Personality Factor Questionnaire (16PF) was used for assessing personality factors and digit cancellation test for assessing attention.

RESULTS

After 6 months, patients in the de qi group had better facial function (adjusted odds ratio [OR]: 4.16, 95% confidence interval [CI]: 2.23-7.78). Path analysis showed that intensity of needle sensation of fullness had direct effect on House-Brackmann (HB) score at month 6. In de qi group, the low HB score on day 1 (OR: 0.13, 95% CI: 0.03-0.45) and the low Social Boldness score (OR: 0.63, 95% CI: 0.41-0.97) in 16PF were associated with better facial function. In control group, low HB score on day 1 (OR: 0.25, 95% CI: 0.13-0.50), low Vigilance score (OR: 0.66, 95% CI: 0.50-0.88), and high Tension score (OR: 1.41, 95% CI: 1.12-1.77) in 16PF were related to better facial function.

CONCLUSIONS

The needle sensation of fullness could predict better facial function and personality traits might influence outcomes of acupuncture treatment. Both of them should be considered seriously in acupuncture treatment and research.

Effectiveness of a placebo intervention on visually induced nausea in women - A randomized controlled pilot study

OBJECTIVE

Improvement of nausea by placebo interventions has recently been demonstrated in clinical trials and experimental settings. However, many questions regarding placebo effects on nausea remain unanswered. For example, nausea reduction in women could only be achieved when the placebo intervention was "enhanced" by conditioning, while men responded primarily to verbally suggested improvement. It is unclear whether these findings are generalizable or were due to situational variables. In this pilot study, we investigated the effects of sham acupuncture point stimulation and verbal suggestions on visually-induced nausea in a female population.

METHODS

In a within-subjects design, 21 healthy female volunteers underwent both a placebo condition and a natural history condition (control condition) in a randomized order on two separate days. On both days, nausea was induced through optokinetic stimulation. On the placebo day, participants received sham acupuncture point stimulation together with positive verbal suggestions of nausea improvement. Expected and perceived nausea severity as well as symptoms of motion sickness were repeatedly assessed.

RESULTS

Twenty participants completed both testing days. Participants developed significantly less nausea on the placebo day compared to the control day (p<0.001), and the effect size of placebo-induced nausea reduction was large (partial η²=0.71). Symptoms of motion sickness were also reduced (p=0.003). Expectation of nausea decreased following the placebo intervention as compared to no treatment (p=0.030), indicating successful expectancy manipulation.

CONCLUSION

Sham acupuncture point stimulation combined with verbal suggestions induced a significant placebo effect on visually-induced nausea in women.

The effectiveness of dry-cupping in preventing post-operative nausea and vomiting by P6 acupoint stimulation: A randomized controlled trial

BACKGROUND

Postoperative nausea and vomiting (PONV) is a common complication after general anesthesia, and the prevalence ranges between 25% and 30%. The aim of this study was to determine the preventive effects of dry cupping on PONV by stimulating point P6 in the wrist.

METHODS

This was a randomized controlled trial conducted at the Imam Reza Hospital in Kermanshah, Iran. The final study sample included 206 patients (107 experimental and 99 controls). Inclusion criteria included the following: female sex; age>18 years; ASA Class I-II; type of surgery: laparoscopic cholecystectomy; type of anesthesia: general anesthesia. Exclusion criteria included: change in the type of surgery, that is, from laparoscopic cholecystectomy to laparotomy, and ASA-classification III or more. Interventions are as follows: pre surgery, before the induction of anesthesia, the experimental group received dry cupping on point P6 of the dominant hand's wrist with activation of intermittent negative pressure. The sham group received cupping without activation of negative pressure at the same point. Main outcome was that the visual analogue scale was used to measure the severity of PONV.

RESULTS

The experimental group who received dry cupping had significantly lower levels of PONV severity after surgery (P < 0.001) than the control group. The differences in measure were maintained after controlling for age and ASA in regression models (P < 0.01).

CONCLUSION

Traditional dry cupping delivered in an operation room setting prevented PONV in laparoscopic cholecystectomy patients.

Adjunctive acupuncture for pain and symptom management in the inpatient setting: protocol for a pilot hybrid effectiveness-implementation study

BACKGROUND

Effective pain management among hospitalized patients is an important aspect of providing quality care and achieving optimal clinical outcomes and patient satisfaction. Common pharmacologic approaches for pain, though effective, have serious side effects and are not appropriate for all inpatients. Findings from randomized controlled trials (RCTs) support the efficacy of acupuncture for many symptoms relevant to inpatients including postoperative pain, cancer-related pain, nausea and vomiting, and withdrawal from narcotic use. However, the extent to which findings from RCTs translate to real-world implementation of acupuncture in typical hospital settings is unknown.

METHODS/DESIGN

In partnership with the launch of a clinical program offering acupuncture services to inpatients at the University of California San Francisco's Mount Zion Hospital, we are conducting a pilot study using a hybrid effectiveness-implementation design to: (1) assess the effectiveness of acupuncture to manage pain and other symptoms and improve patient satisfaction; and (2) evaluate the barriers and facilitators to implementing an on-going acupuncture service for inpatients. During a two-month pre-randomization phase, we evaluated and adapted clinical scheduling and treatment protocols with acupuncturists and hospital providers and pretested study procedures including enrollment, consent, and data collection. During a six-month randomization phase, we used a two-tiered consent process in which inpatients were first consented into a study of symptom management, randomized to be offered acupuncture, and consented for acupuncture if they accepted. We are also conducting in-depth interviews and focus groups to assess evidence, context, and facilitators of key provider and hospital administration stakeholders.

DISCUSSION

Effectiveness research in "real-world" practice settings is needed to inform clinical decision-making and guide implementation of evidence-based acupuncture practices. To successfully provide clinical acupuncture services and maintain a rigorous research design, practice-based trials of acupuncture require careful planning and attention to setting-specific, contextual factors.

TRIAL REGISTRATION

This trial has been registered in ClinicalTrials.gov. The identifier is NCT01988194, registered on November 5, 2013.

Effectiveness of P6 acupoint electrical stimulation in preventing postoperativenausea and vomiting following laparoscopic surgery

BACKGROUND/AIM

The effects of pericardium 6 (P6) electrical stimulation in patients at risk of postoperative nausea and vomiting (PONV) following laparoscopic surgery were evaluated.

MATERIALS AND METHODS

Eighty patients for laparoscopic surgery with at least one of the determined risks (nonsmoker, female, previous PONV/motion sickness, or postoperative opioid use) were randomized into either an active or sham group. At the end of surgery, Reletex electrical acustimulation was placed at the P6 acupoint. The active group had grade 3 strength and the sham group had inactivated electrodes covered by silicone. It was worn for 24 h following surgery. PONV scores were recorded.

RESULTS

The active group had significantly shorter durations of surgery and lower PONV incidence over 24 h (35.1% versus 64.9%, P = 0.024) and this was attributed to the lower incidence of nausea (31.4% versus 68.6%, P = 0.006). The overall incidence of vomiting was not significantly different between the groups, but it was higher in the sham group of patients with PONV risk score 3 (23.9%, P = 0.049).

CONCLUSION

In patients at high risk for PONV, P6 acupoint electrical stimulation lowers the PONV incidence by reducing the nausea component. However, this reduction in nausea is not related to increasing PONV risk scores.

Traditional Chinese medicine valuably augments therapeutic options in the treatment of climacteric syndrome

Climacteric syndrome refers to recurring symptoms such as hot flashes, chills, headache, irritability and depression. This is usually experienced by menopausal women and can be related to a hormonal reorganization in the hypothalamic-pituitary-gonadal axis. In Traditional Chinese Medicine, originating 1000s of years ago, above-mentioned symptoms can be interpreted on the basis of the philosophic diagnostic concepts, such as the imbalance of Yin and Yang, the Zang-Fu and Basic substances (e.g. Qi, Blood and Essence). These concepts postulate balance and harmonization as the principle aim of a treatment. In this context, it is not astounding that one of the most prominent ancient textbooks dating back to 500-200 BC, Huang di Neijing: The Yellow Emperor's Classic of Internal Medicine gives already first instructions for diagnosis and therapy of climacteric symptoms. For therapy, traditional Chinese medicine comprises five treatment principles: Chinese herbal medicine, TuiNa (a Chinese form of manual therapy), nutrition, activity (e.g. QiGong) and acupuncture (being the most widespread form of treatment used in Europe). This review provides an easy access to the concepts of traditional Chinese medicine particularly regarding to climacteric syndrome and also focuses on current scientific evidence.

Unanticipated Insights into Biomedicine from the Study of Acupuncture

Research into acupuncture has had ripple effects beyond the field of acupuncture. This paper identifies five exemplars to illustrate that there is tangible evidence of the way insights gleaned from acupuncture research have informed biomedical research, practice, or policy. The first exemplar documents how early research into acupuncture analgesia has expanded into neuroimaging research, broadening physiologic understanding and treatment of chronic pain. The second describes how the acupuncture needle has become a tool to enhance biomedical knowledge of connective tissue. The third exemplar, which illustrates use of a modified acupuncture needle as a sham device, focuses on emergent understanding of placebo effects and, in turn, on insights into therapeutic encounters in treatments unrelated to acupuncture. The fourth exemplar documents that two medical devices now in widespread use were inspired by acupuncture: transcutaneous electrical nerve stimulators for pain control and antinausea wrist bands. The final exemplar describes how pragmatic clinical trial designs applied in acupuncture research have informed current general interest in comparative effectiveness research. In conclusion, these exemplars of unanticipated outcomes of acupuncture research comprise an additional rationale for continued support of basic and clinical research evaluating acupuncture and other under-researched therapies.

Nausea: a review of pathophysiology and therapeutics

The sensation of nausea is a common occurrence with diverse causes and a significant disease burden. Nausea is considered to function as a protective mechanism, warning the organism to avoid potential toxic ingestion. Less adaptive circumstances are also associated with nausea, including post-operative nausea, chemotherapy-induced nausea, and motion sickness. A common definition of nausea identifies the symptom as a precursor to the act of vomiting. The interaction, though present, does not appear to be a simple relationship. Nausea is unfortunately the 'neglected symptom', with current accepted therapy generally directed at improving gastrointestinal motility or acting to relieve emesis. Improved understanding of the pathophysiological basis of nausea has important implications for exploiting novel mechanisms or developing novel therapies for nausea relief.

Negative mechanistic reasoning in medical intervention assessment

Traditionally, mechanistic reasoning has been assigned a negligible role in standard EBM (evidence-based medicine) literature, although some recent authors have argued for an upgrade. Even so, the mechanistic reasoning that has received attention has almost exclusively been positive--both in an epistemic sense of claiming that there is a mechanistic chain and in a health-related sense of there being claimed benefits for the patient. Negative mechanistic reasoning has been neglected, both in the epistemic and in the health-related sense. I distinguish three main types of negative mechanistic reasoning and subsume them under a new definition of mechanistic reasoning in the context of assessing medical interventions. This definition is wider than a previous suggestion in the literature. Each negative type corresponds to a range of evidential strengths, and it is argued that there are differences with respect to typical evidential strengths. The variety of negative mechanistic reasoning should be acknowledged in EBM, and it presents a serious challenge to proponents of so-called medical hierarchies of evidence.

Stimulation of the wrist acupuncture point PC6 for preventing postoperative nausea and vomiting

BACKGROUND

Postoperative nausea and vomiting (PONV) are common complications following surgery and anaesthesia. Antiemetic drugs are only partially effective in preventing PONV. An alternative approach is to stimulate the PC6 acupoint on the wrist. This is an update of a Cochrane review first published in 2004, updated in 2009 and now in 2015.

OBJECTIVES

To determine the effectiveness and safety of PC6 acupoint stimulation with or without antiemetic drug versus sham or antiemetic drug for the prevention of PONV in people undergoing surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 12, 2014), MEDLINE (January 2008 to December 2014), EMBASE (January 2008 to December 2014), ISI Web of Science (January 2008 to December 2014), World Health Organization Clinical Trials Registry, ClinicalTrials.gov, and reference lists of articles to identify additional studies. We applied no language restrictions.

SELECTION CRITERIA

All randomized trials of techniques that stimulated the PC6 acupoint compared with sham treatment or drug therapy, or combined PC6 acupoint and drug therapy compared to drug therapy, for the prevention of PONV. Interventions used in these trials included acupuncture, electro-acupuncture, transcutaneous electrical acupoint stimulation, transcutaneous nerve stimulation, laser stimulation, capsicum plaster, acu-stimulation device, and acupressure in people undergoing surgery. Primary outcomes were the incidences of nausea and vomiting after surgery. Secondary outcomes were the need for rescue antiemetic therapy and adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed the risk of bias domains for each trial. We used a random-effects model and reported risk ratio (RR) with associated 95% confidence interval (95% CI). We used trial sequential analyses to help provide information on when we had reached firm evidence in cumulative meta-analyses of the primary outcomes, based on a 30% risk ratio reduction in PONV.

MAIN RESULTS

We included 59 trials involving 7667 participants. We rated two trials at low risk of bias in all domains (selection, attrition, reporting, blinding and other). We rated 25 trials at high risk in one or more risk-of-bias domains. Compared with sham treatment, PC6 acupoint stimulation significantly reduced the incidence of nausea (RR 0.68, 95% CI 0.60 to 0.77; 40 trials, 4742 participants), vomiting (RR 0.60, 95% CI 0.51 to 0.71; 45 trials, 5147 participants) and the need for rescue antiemetics (RR 0.64, 95% CI 0.55 to 0.73; 39 trials, 4622 participants). As heterogeneity among trials was substantial and there were study limitations, we rated the quality of evidence as low. Using trial sequential analysis, the required information size and boundary for benefit were reached for both primary outcomes.PC6 acupoint stimulation was compared with six different types of antiemetic drugs (metoclopramide, cyclizine, prochlorperazine, droperidol. ondansetron and dexamethasone). There was no difference between PC6 acupoint stimulation and antiemetic drugs in the incidence of nausea (RR 0.91, 95% CI 0.75 to 1.10; 14 trials, 1332 participants), vomiting (RR 0.93, 95% CI 0.74 to 1.17; 19 trials, 1708 participants), or the need for rescue antiemetics (RR 0.87, 95% CI 0.65 to 1.16; 9 trials, 895 participants). We rated the quality of evidence as moderate, due to the study limitations. Using trial sequential analyses, the futility boundary was crossed before the required information size was surpassed for both primary outcomes.Compared to antiemetic drugs, the combination of PC6 acupoint stimulation and antiemetic therapy reduced the incidence of vomiting (RR 0.56, 95% CI 0.35 to 0.91; 9 trials, 687 participants) but not nausea (RR 0.79, 95% CI 0.55 to 1.13; 8 trials, 642 participants). We rated the quality of evidence as very low, due to substantial heterogeneity among trials, study limitations and imprecision. Using trial sequential analysis, none of the boundaries for benefit, harm or futility were crossed for PONV. The need for rescue antiemetic was lower in the combination PC6 acupoint stimulation and antiemetic group than the antiemetic group (RR 0.61, 95% CI 0.44 to 0.86; 5 trials, 419 participants).The side effects associated with PC6 acupoint stimulation were minor, transient and self-limiting (e.g. skin irritation, blistering, redness and pain) in 14 trials. Publication bias was not apparent in the contour-enhanced funnel plots.

AUTHORS' CONCLUSIONS

There is low-quality evidence supporting the use of PC6 acupoint stimulation over sham. Compared to the last update in 2009, no further sham comparison trials are needed. We found that there is moderate-quality evidence showing no difference between PC6 acupoint stimulation and antiemetic drugs to prevent PONV. Further PC6 acupoint stimulation versus antiemetic trials are futile in showing a significant difference, which is a new finding in this update. There is inconclusive evidence supporting the use of a combined strategy of PC6 acupoint stimulation and antiemetic drug over drug prophylaxis, and further high-quality trials are needed.

Dexamethasone alone vs in combination with transcutaneous electrical acupoint stimulation or tropisetron for prevention of postoperative nausea and vomiting in gynaecological patients undergoing laparoscopic surgery

BACKGROUND

Postoperative nausea and vomiting (PONV) is commonly reported after surgery and anaesthesia. We compared the effects of combinations of electrical acupoint stimulation or tropisetron with dexamethasone with the effects of dexamethasone alone, for inhibition of PONV in gynaecological patients undergoing laparoscopic surgery.

METHODS

We randomized 157 patients undergoing elective gynaecological laparoscopic surgery under general anaesthesia into the following three groups: acupoint stimulation+dexamethasone (Group Acu, n=53), tropisetron+dexamethasone (Group Trp, n=53), and dexamethasone alone (Group Dxm, n=51). The incidence of nausea, vomiting, and need for rescue antiemetics was recorded 2, 6, 24, and 48 h after surgery.

RESULTS

We found significant differences in the incidence of PONV during 24 h after surgery between the combination therapy groups and the dexamethasone-alone group (P=0.021). In the first 24 h, 28% of patients in Group Acu, 26% of patients in Group Trp, and 50% of patients in Group Dxm experienced nausea, vomiting, or both. The incidence of 24 h PONV in Group Acu was significantly lower than that in Group Dxm (P=0.048; odds ratio 0.389; 95% CI 0.170-0.891). The incidence of 24 h PONV in Group Trp was also significantly lower than that in Group Dxm (P=0.042; odds ratio 0.359; 95% CI 0.157-0.819). There was no significant difference between Group Acu and Group Trp (P=0.857). The need for antiemetic rescue medication was similar in the three groups. All groups expressed similar patient satisfaction.

CONCLUSIONS

Combined with dexamethasone, electrical acupoint stimulation or tropisetron is more effective in PONV prophylaxis than dexamethasone alone in gynaecological patients undergoing laparoscopic surgery.

CLINICAL TRIAL REGISTRATION

NCT 02096835.

The Depths from Skin to the Major Organs at Chest Acupoints of Pediatric Patients

Background. Acupuncture is applied to treat numerous diseases in pediatric patients. Few reports have been published on the depth to which it is safe to insert needle acupoints in pediatric patients. We evaluated the depths to which acupuncture needles can be inserted safely in chest acupoints in pediatric patients and the variations in safe depth according to sex, age, body weight, and body mass index (BMI). Methods. We retrospectively studied computed tomography (CT) images of pediatric patients aged 4 to 18 years who had undergone chest CT at China Medical University Hospital from December 2004 to May 2013. The safe depth of chest acupoints was directly measured from the CT images. The relationships between the safe depth of these acupoints and sex, age, body weight, and BMI were analyzed. Results. The results demonstrated significant differences in depth among boys and girls at KI25 (kidney meridian), ST16 (stomach meridian), ST18, SP17 (spleen meridian), SP19, SP20, PC1 (pericardium meridian), LU2 (lung meridian), and GB22 (gallbladder meridian). Safe depth significantly differed among the age groups (P < 0.001), weight groups (P < 0.05), and BMI groups (P < 0.05). Conclusion. Physicians should focus on large variations in needle depth during acupuncture for achieving optimal therapeutic effect and preventing complications.

Drugs for the treatment of nausea and vomiting in adults in the emergency department setting

BACKGROUND

Nausea and vomiting is a common and distressing presenting complaint in emergency departments (ED). The aetiology of nausea and vomiting in EDs is diverse and drugs are commonly prescribed. There is currently no consensus as to the optimum drug treatment of nausea and vomiting in the adult ED setting.

OBJECTIVES

To provide evidence of the efficacy and safety of antiemetic medications in the management of nausea and vomiting in the adult ED setting.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 8), MEDLINE (OvidSP) (January 1966 to August 2014), EMBASE (OvidSP) (January 1980 to August 2014) and ISI Web of Science (January 1955 to August 2014). We also searched relevant clinical trial registries and conference proceedings.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of any drug in the treatment of nausea and vomiting in the treatment of adults in the ED. Study eligibility was not restricted by language or publication status.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, data extraction and assessment of risk of bias in included studies. We contacted authors of studies to obtain missing information if required.

MAIN RESULTS

We included eight trials, involving 952 participants, of which 64% were women. Included trials were generally of adequate quality, with six trials at low risk of bias, and two trials at high risk of bias. Three trials with 518 participants compared five different drugs with placebo; all reported the primary outcome as mean change in visual analogue scale (VAS) (0 to 100) for nausea severity from baseline to 30 minutes. Trials did not routinely report other primary outcomes of the change in nausea VAS at 60 minutes or number of vomiting episodes. Differences in mean VAS change from baseline to 30 minutes between placebo and the drugs evaluated were: metoclopramide (three trials, 301 participants; mean difference (MD) -5.27, 95% confidence interval (CI) -11.33 to 0.80), ondansetron (two trials, 250 participants; MD -4.32, 95% CI -11.20 to 2.56), prochlorperazine (one trial, 50 participants; MD -1.80, 95% CI -14.40 to 10.80), promethazine (one trial, 82 participants; MD -8.47, 95% CI -19.79 to 2.85) and droperidol (one trial, 48 participants; MD -15.8, 95% CI -26.98 to -4.62). The only statistically significant change in baseline VAS to 30 minutes was for droperidol, in a single trial of 48 participants. No other drug was statistically significantly superior to placebo. Other included trials evaluated a drug compared to "active controls" (alternative antiemetic). There was no convincing evidence of superiority of any particular drug compared to active control. All trials included in this review reported adverse events, but they were variably reported precluding meaningful pooling of results. Adverse events were generally mild, there were no reported serious adverse events. Overall, the quality of the evidence was low, mainly because there were not enough data.

AUTHORS' CONCLUSIONS

In an ED population, there is no definite evidence to support the superiority of any one drug over any other drug, or the superiority of any drug over placebo. Participants receiving placebo often reported clinically significant improvement in nausea, implying general supportive treatment such as intravenous fluids may be sufficient for the majority of people. If a drug is considered necessary, choice of drug may be dictated by other considerations such as a person's preference, adverse-effect profile and cost. The review was limited by the paucity of clinical trials in this setting. Future research should include the use of placebo and consider focusing on specific diagnostic groups and controlling for factors such as intravenous fluid administered.

Management of Mild Traumatic Brain Injury Symptoms in a 31-Year-Old Woman Using Cervical Manipulation and Acupuncture: A Case Report

OBJECTIVE

The objective was to describe chiropractic and acupuncture care of a patient with acute mild traumatic brain injury (mTBI) symptoms.

CLINICAL FEATURES

A 31-year-old woman had acute neck pain, headache, dizziness, nausea, tinnitus, difficulty concentrating, and fatigue following a fall. She was diagnosed at an urgent care facility with mTBI immediately following the fall. Pharmaceutical intervention had been ineffective for her symptoms.

INTERVENTION AND OUTCOME

The patient was treated with chiropractic adjustments characterized as high velocity, low amplitude thrusts directed to the cervical spine and local acupuncture points in the cervical and cranial regions. The patient received care for a total of 8 visits over 2.5 weeks with resolution of concussive symptoms.

CONCLUSION

This patient with mTBI responded favorably to a conservative treatment protocol with the combination of chiropractic and acupuncture care.