Sedative effect of acupuncture during cataract surgery: prospective randomized double-blind study

Nontraditional approaches to sedation for anterior segment surgery: a narrative review

PURPOSE OF REVIEW

Surgical and anesthetic technological advancement have made both cataract and noncataract anterior segment surgery significantly less invasive and time-intensive, facilitating the transition of some of these procedures from the operating room under monitored anesthesia care (MAC) to the office-based setting without MAC. This transition has been aided by the popularization of nonintravenous approaches to achieving patient sedation for these procedures. In this review, we discuss the literature surrounding traditional and nontraditional methods of achieving patient sedation for anterior segment surgery.

RECENT FINDINGS

Our survey of the literature suggests that nonintravenous (IV) approaches to sedation for these procedures may be just as safe, effective, and satisfactory to patients as traditional IV approaches.

SUMMARY

As anterior segment surgery becomes less invasive and less time-intensive, providers considering transitioning their cataract and anterior segment surgery out of the operating room and into the office-based setting without MAC anesthesia should consider the non-IV sedation options outlined in this review to achieve adequate patient sedation and comfort.

Clinical study of acupuncture combined with surface anesthesia using proparacaine in geriatric cataract phacoemulsification

BACKGROUND

During anesthesia administration for cataract surgery, low pH of proparacaine may induce pain or complications such as corneal damage and poor wound healing, with the use of additional drops intraoperatively increasing the risk of complications. Accordingly, there is a clinical need for adjuncts to local anesthesia needs to improve the efficiency of anesthesia and reduce the required amount of intraoperative proparacaine.

AIM

To identify a method of anesthesia for geriatric cataract phacoemulsification that provides more efficient analgesia and improves clinical efficacy.

METHODS

A total of 130 geriatric patients with cataracts who attended Hebei Eye Hospital from December 2020 to December 2022 were included in the present study. Patients were divided into the proparacaine surface anesthesia (SA) group (65 cases) and the compound acupuncture-medicine anesthesia group (CAMA group, 65 cases). Patients in the CAMA group were provided acupuncture analgesia in addition to SA. Preoperative anxiety [Self-Rating Anxiety Scale (SAS) score and state anxiety inventory (SAI) score], intraoperative stress, vital signs, analgesia, and cooperation, as well as postoperative adverse events, were compared between groups.

RESULTS

More marked reductions in anxiety were observed among patients in the CAMA group, with corresponding reductions in SAS and SAI scores. During the operation, no change in the secretion of E, NE, or Cor group compared to the preoperative period was observed in the CAMA, which was markedly lower than that in the SA group. Heart rate, blood pressure, and respiratory rate were more stable intraoperatively in the CAMA group. In addition, the incidence of intraoperative pain and the number of additional doses of anesthesia required in the CAMA group were markedly lower than in the SA group. Accordingly, patients in the CAMA group were able to avoid eye movements and eyelid closing leading to greater cooperation with surgeons during surgery. Furthermore, marked reductions in intraoperative adverse effects were observed in the CAMA group, indicating greater overall safety.

CONCLUSION

Proparacaine SA combined with acupuncture as an analgesic provides improved analgesia with greater safety compared to surface anesthesia with proparacaine during geriatric cataract phacoemulsification.

Effect of electroacupuncture on discomfort during gastroscopy: A randomised controlled trial

BACKGROUND

Gastrointestinal reactions, pain and discomfort are inevitable in patients undergoing common gastroscopy. Acupuncture is an effective therapy that assists in the perioperative period; however, evidence of it relieving discomfort is limited. We conducted this trial to observe the effect of electroacupuncture (EA) on discomfort caused by gastroscopy without sedatives.

METHODS

This was a single-centre, patient-assessor blind, randomised controlled trial. Sixty patients requiring gastroscopy were randomly assigned to the EA and control groups (sham acupuncture, SA, group) in a 1:1 ratio. Patients in the EA group underwent treatment at acupoints LI4 (Hegu), PC6 (Neiguan), ST36 (Zusanli), and ST34 (Liangqiu) for 30 min before gastroscopy, whereas patients in the SA group underwent superficial acupuncture at non-acupoints. The patients' nausea level, throat discomfort, bucking, and agitation were evaluated using a visual analogue scale (VAS) within 30 min after gastroscopy. The mean VAS score was the primary outcome. Secondary outcomes were the Amsterdam Preoperative Anxiety and Information Inventory Scale, used to evaluate patients' preoperative anxiety levels, and the 6-item State-Trait Anxiety Inventory (STAI-S6), used to assess anxiety before and after gastroscopy. The patients' vital signs, including heart rate, blood pressure, and pulse oxygen saturation, were recorded before, during, and after gastroscopy.

RESULTS

At 30 min after gastroscopy, the mean VAS score in the EA group (4.20 ± 0.63) was lower than that in the control group (5.14 ± 0.70, mean difference (MD): - 0.94, 95% confidence interval (CI): - 1.28, - 0.59, P < 0.001). There were statistically significant between-group differences in the nausea and vomiting, throat discomfort and agitation VAS scores (all P < 0.01), whereas no difference was found in the bucking VAS score (P = 0.692). Compared with the SA group, patients in the EA group had a 6.90-point lower in STAI-S6 (95% CI: -12.98, -0.81, P = 0.027) after gastroscopy. Patients in the EA group had a slower heart rate and lower blood pressure than those in the SA group. Serious adverse events were not observed during the trial.

CONCLUSION

EA can help relieve patients' anxiety, and improve their nausea and vomiting, throat discomfort, and agitation during gastroscopy.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR) ID: ChiCTR2000040726.

Effects of electroacupuncture on perioperative anxiety and stress response in patients undergoing surgery for gastric or colorectal cancer: Study protocol for a randomized controlled trial

BACKGROUND

Perioperative anxiety is one of the main psychological stresses experienced by patients who undergo cancer surgery. The surgery itself inevitably causes a stress response characterized by activation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis. Both the perioperative anxiety and surgical stress response lead to increased levels of catecholamines and prostaglandins, which may be related to perioperative suppression of antimetastatic immunity and tumor-promoting alterations in the microenvironment. Hence, we designed this clinical trial to investigate the effect of electroacupuncture in reducing perioperative anxiety and surgical stress response.

METHODS

This is a randomized, single-center, parallel, and controlled clinical trial. Seventy-eight participants between the ages of 35 and 85 with gastric or colorectal cancer who plan to undergo tumorectomy will be randomly divided into an electroacupuncture group and a control group. The primary outcome will be the six-item short form of the State-Trait Anxiety Inventory score. The secondary outcomes will be the Amsterdam Preoperative Anxiety and Information Scale score; levels of plasma cortisol, adrenocorticotropic hormone, interleukin-6, and tumor necrosis factor-α; first exhaust time after surgery; postoperative quality of the recovery-15 score, numeric rating scale for pain score; and dosage of postoperative analgesics.

DISCUSSION

Cumulative studies revealed the efficacy of various types of acupuncture therapy with regard to reducing the anxiety and stress response caused by surgery. We expect that the results of this trial will provide high-quality clinical evidence for the choice of perioperative acupuncture for patients undergoing cancer surgery.

CLINICAL TRIAL REGISTRATION

https://www.chictr.org.cn, identifier ChiCTR200003 7127.

EEG and ECG Power Spectrum Analysis of Sedative Effects on Propofol-Anesthetized Rats with Electroacupuncture

Background

In previous studies, electroacupuncture (EA) with 2/15 Hz has been shown to enhance the sedative effects in general anesthesia patients. Central lateral thalamic stimulation of 50 Hz showed an arousal effect in macaques. Therefore, it is worth studying the sedative effect of EA at peripheral acupoints with different frequencies, especially the frequency of around 50 Hz.

Methods

Rats were anesthetized under the constant infusion of propofol and EA at Zusanli (ST36) and Neiguan (PC6) locations. Electroencephalography (EEG) and heart rate were continuously recorded before and after the intervention by EA in the C group (control), LEA group (low-frequency group, 2/15 Hz diffuse/dense wave EA stimulation), and HEA group (high-frequency group, 50 Hz stimulation).

Results

In the LEA group, a significant increase in the power of the delta component with a decrease in the alpha component (p < 0.05) was observed after EA stimulation. In the HEA group, significant increases in the powers of alpha and beta components of EEG (p < 0.05) and a decrease in the delta component of EEG were observed (p < 0.05). The phenomenon is also shown in full-frequency waves. In addition, a significant decrease in the low-frequency/high-frequency ratio parameter was observed in the LEA group.

Conclusions

EA at bilateral ST36 and PC6 can enhance the sedative effects of propofol anesthesia in low-frequency stimulation but lighten the sedative effects in high-frequency (50 Hz) stimulation. The sympathetic-vagal balance was affected due to low-frequency EA.

Can acupuncture therapy reduce preoperative anxiety? A systematic review and meta-analysis

BACKGROUND

Acupuncture therapy has shown promise for effectively relieving preoperative anxiety. Nevertheless, previous findings from randomized controlled trials (RCTs) are inconsistent and must be examined in detail.

OBJECTIVE

This study systematically evaluates the efficacy and safety of acupuncture therapy for preoperative anxiety as well as the quality of evidence supporting this application.

SEARCH STRATEGY

The China National Knowledge Infrastructure Database, Wanfang Data Journal Database, Chinese Biomedical Literature Database, Chongqing VIP, Embase, PubMed and Cochrane Library Databases were queried from their inception to 19, February 2020, using keywords such as "acupuncture therapy," "preoperative" and "anxioty." Manual searches expanded the search breadth and included conference abstracts and other reference lists.

INCLUSION CRITERIA

RCTs were included in the current study if they contained a comparison between a group of anxiety patients that received acupuncture therapy and a control group that received sham acupuncture.

DATA EXTRACTION AND ANALYSIS

Literature was reviewed, and various articles were selected using the NoteExpress 3.2.0 software. Two researchers independently screened and extracted data and evaluated the risk of bias in the included studies. The RevMan 5.3 software was used for data aggregation and the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) assessment was used to evaluate the quality of the study outcomes.

RESULTS

Twelve studies were included in the review, containing a total of 916 patients. Meta-analysis showed that, compared with the control group, patients who received acupuncture therapy had reduced State-Trait Anxiety Inventory Scale (STAI-S) score (mean difference [MD] = -9.07, 95% confidence interval [CI] [-13.19 to -4.96], P < 0.0001) and Visual Analogue Scale (VAS) score (MD = -1.37, 95% CI [-2.29 to -0.45], P = 0.003). However, for the Hamilton Anxiety Scale (HAMA) score, there was no difference between the two groups (MD = -3.98, 95% CI [-12.89 to 4.92], P = 0.38). Further, the GRADE assessment demonstrated that the STAI-S was of moderate quality, the VAS of low quality and the HAMA of very low quality.

CONCLUSION

Acupuncture therapy may be able to decrease anxiety in preoperative patients, but the results need to be further verified due to the small sample sizes and the low quality of evidence to date.

The selection of dermatomes for sham (placebo) acupuncture points is relevant for the outcome of acupuncture studies: a systematic review of sham (placebo)-controlled randomized acupuncture trials

BACKGROUND

Many randomized controlled trials (RCTs) of acupuncture reveal no significant differences between acupuncture and so-called placebo acupuncture. There is a strong tendency to replace the term "placebo" by the term "sham," because any needling stimulates a certain physiological response. However, neither concept accounts for the great diversity of results in RCTs comparing verum acupuncture and sham (placebo) acupuncture. Some trials have shown little or no difference, while other studies have found statistically significant differences.

OBJECTIVE

Verum acupuncture and sham (placebo) acupuncture may achieve similar results to the extent that they share active constituents. We identified these common active constituents as dermatomes: the segmental structure of the human body. In our study, we tested the hypothesis that the more verum and sham (placebo) acupuncture share the same dermatomes, the closer the clinical outcomes will be, and vice versa.

METHODS

All major databases were searched for RCTs that tested acupuncture versus sham (placebo) acupuncture. The dermatome charts of Hansen and Schliack were used to verify verum and sham (placebo) needling locations. Reported clinical outcomes were assessed in relation to the percentage of overlap between the dermatomes stimulated by acupuncture and sham (placebo) acupuncture.

RESULTS

Our literature search yielded a total of 1738 references. Thirty-four studies met the inclusion criteria. The effects of sham (placebo) acupuncture varied according to the dermatomes stimulated: high overlap with those stimulated by verum acupuncture resulted in almost identical efficacy, while low overlap resulted in significant differences in efficacy. Clinical outcomes were similar when verum acupuncture and sham (placebo) acupuncture shared the same dermatomes (p < 0.01).

DISCUSSION

The findings of this review confirm our hypothesis. Acupuncture studies that employed verum and sham locations on overlapping dermatomes helped to create a mediocre to negative picture of acupuncture's efficacy. The segmental structure of the body with its interconnected reflex system offers an additional neurophysiological explanation for the effectiveness of acupuncture applied to structures segmentally innervated by the spinal and visceral nervous system. Further comparative acupuncture studies should be based on knowledge of segmental anatomy. In testing verum acupuncture versus sham acupuncture, the chosen sham acupuncture needling locations should be situated on non-overlapping dermatomes.

Feasibility of Acupuncture to Induce Sleep for Brainstem Auditory Evoked Response Testing

Purpose Brainstem auditory evoked response (BAER) testing is often performed under general anesthesia for children unable to complete behavioral audiologic evaluation. Alternatively, acupuncture treatment may be considered appropriate for BAER. Reports of acupuncture treatment in pediatric patients are scarce but are needed to demonstrate effectiveness. This study had 2 main objectives: (a) to examine the feasibility and effectiveness of acupuncture to achieve sleep to perform diagnostic BAER testing in medically complex (Cohort I) and nonmedically complex (Cohort II) children and (b) to assess acceptability to parents and audiologists of acupuncture as an alternative to anesthesia for BAER testing. Method A prospective feasibility study at Seattle Children's Hospital Outpatient Audiology Clinic from August 2015 through December 2018 was performed. A total of 31 pediatric patients were included. The median age for Cohort I was 29 months (interquartile range: 19-37 months), and the median age for Cohort II was 25.5 months (interquartile range: 16-32 months). Variables included number of BAER thresholds obtained, sleep indicators, and acceptability. The cost of BAER with acupuncture and the cost of BAER under anesthesia were compared. Results Acupuncture treatment effectively contributed to an adequate sleep state to obtain BAER results for most patients in both cohorts. Across cohorts, most patients (81%) fell asleep after acupuncture treatment. Complete test results were obtained in 48% of patients. Audiologists and parents reported high satisfaction rates with this procedure (87%). There were no adverse safety effects. Acupuncture treatment was less costly than anesthesia for BAER testing. Conclusions Acupuncture to induce sleep for BAER testing is effective, safe, and cost-efficient in small samples of medically and nonmedically complex pediatric patients. This procedure allowed earlier detection of hearing status and avoided potential adverse effects of anesthesia. Audiologists and parents reported that acupuncture treatment was an acceptable alternative to anesthesia for the BAER procedure.

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.

Perioperative acupuncture medicine: a novel concept instead of acupuncture anesthesia

Objective:

To confirm that acupuncture applied to patients would improve the clinical curative effect and accelerate the patient's recovery by introducing the application of acupuncture in pre-operation, during operation, and post-operation.

Data sources:

Literature cited in this review was retrieved from PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) and was primarily published in English or Chinese from 2010 to 2018, with keywords of “acupuncture,” “electroacupuncture,” “perioperative period,” “sedation,” “analgesia,” and “recovery.” Relevant citations in the retrieved articles were also screened to include more data.

Study selection:

All retrieved literature was scrutinized, most typical articles related on perioperative acupuncture application in clinical study were reviewed.

Results:

Acupuncture could relieve anxiety and stress during the preoperative stage. It reduces the usage of narcotics and stress response, and maintains the respiratory stability and homeostasis during surgery. It also exerts a protective effect on vital organs, and during the postoperative stages, enhances the recovery while effectively alleviating the postoperative pain. This phenomenon prevents common postoperative discomforts such as nausea and vomiting. In addition, it might improve the patients’ long-term prognosis.

Conclusions:

The novel concept “perioperative acupuncture medicine” is to focus on the optimal treatment in the perioperative period of surgical patients. The review reveals the important role of acupuncture in enhancing rapid recovery of patients during the perioperative period.

The effect of nursing intervention on preoperative cataract

This retrospective study investigated the effect of nursing intervention (NIV) in Chinese patients under preoperative cataract (PC). A total of 70 eligible patients with PC were included. Thirty-five patients in an intervention group received regular clinical treatment and NIV before the surgery, while the other 35 patients received regular clinical treatment only. The NIV was applied 4 sessions, 1 week before the surgery. The primary outcome of satisfaction was measured by 11-points visual analog scale. The secondary outcomes were measured by the functional impairment caused by cataract (the VF-14), cooperativeness during the surgery period, and sleep quality. All the outcome measurements were assessed before and after the surgery. After NIV, patients in the intervention group exerted better outcomes in decreasing anxiety (P < .01), increasing current experience with satisfaction (P < .01), and enhancing the cooperativeness during the surgery period (P < .01), compared to those outcomes in the control group. The results of this study showed that NIV may help increase satisfaction in experience and cooperation, and decrease anxiety in Chinese patients with PC.

The Influence of Oral Ginger before Operation on Nausea and Vomiting after Cataract Surgery under General Anesthesia: A double-blind placebo-controlled randomized clinical trial

Background

According to Iranian traditional medicine, using safe ginger may contribute to taking less chemical medicines and result in fewer side effects.

Objective

To determine the influence of using ginger before operation on nausea and vomiting, after cataract surgery under general anesthesia.

Methods

This study was a double-blind placebo-controlled randomized clinical trial conducted at Kurdistan University of Medical Sciences in 2015. 122 candidates of cataract surgery were randomly allocated in three groups. The first group received a ginger capsule in a single 1 g dose, the second received two separate doses of ginger capsule each containing 500 mg and the third group received placebo capsule before operation. The patients were examined and studied for the level of nausea and occurrence of vomiting for 6 hours after the operation. The intensity of nausea was scored from zero to ten, based upon Visual Analog Scale. SPSS version 20 was used to analyze the data. We used Chi square and Kruskal-Wallis test for the analyses of outcomes.

Results

The frequency and intensity of nausea and the frequency of vomiting after operation among those who had taken the ginger capsule in 2 separate 500 mg doses was less than the other 2 groups. This difference was significant (p<0.05).

Conclusion

As the results of the study indicated, using ginger as safe medicine, which could act complementary to chemical medicines was really useful in reducing the frequency and intensity of nausea and vomiting after cataract surgery. As this study found, the maximum efficiency of ginger was when it had been taken regularly and constantly in separate doses.

Trial Registration

The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct ID: IRCT2015062122853N1

Funding

This research was supported by the research cluster grant (93/132) from Kurdistan University of Medical Sciences, Sanandaj, Iran.

Acupuncture accelerates recovery after general anesthesia: a prospective randomized controlled trial

BACKGROUND

Acupuncture anesthesia was created in the 1950's in China and continues to be used there today during most major surgeries. It is widely used in China for such complex operations as brain, heart, and abdominal surgery. It is popular in China because it is economical, practical, and beneficial to the patients. With acupuncture anesthesia there is less bleeding during surgery and there is also quicker post-operative recovery.

OBJECTIVE

This randomized prospective study aims at comparing the effect of two acupoints (Yongquan, KI1 and Renzhong, DU26) with sham acupuncture and no acupuncture on the time to recovery of consciousness after general anesthesia by means of the Bispectral Index monitor (BIS).

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

This is a prospective randomized controlled study. We randomly assigned 50 patients to 5 groups during recovery from surgical anesthesia. Four groups had acupuncture on KI1 (group A), DU26 (groups B), both KI1 and DU26 (group C), and sham points (group D), and one had no acupuncture (group E).

MAIN OUTCOME MEASURES

Bispectral Index (BIS), time to spontaneous eye opening, time to tracheal extubation, and time to following commands were measured as the main outcome measures.

RESULTS

Time to spontaneous eye opening differed among groups (P=0.002), as well as time to tracheal extubation (P<0.000 1) and time to following commands (P=0.000 6). BIS values differed significantly among groups both 5 and 10 min after the end of anesthesia (P<0.000 1 and P=0.000 4, respectively). BIS values of groups D and E were lower than those of the other groups and those of group C were higher. The same pattern was observed also 15 and 30 min after the end of anesthesia, although the difference among groups was not significant at these time points (P=0.164 and P=0.104, respectively).

CONCLUSION

Acupuncture on DU26 and KI1 accelerates recovery of consciousness after general anesthesia. Moreover, a possible synergistic effect of DU26 and KI1 is suggested. This issue may play a role in the optimization of operating room management and raise interest about the usefulness of acupuncture on unconsciousness states of different nature.

Efficacy of acupuncture in reducing preoperative anxiety: a meta-analysis

Background. Acupuncture has been shown to reduce preoperative anxiety in several previous randomized controlled trials (RCTs). In order to assess the preoperative anxiolytic efficacy of acupuncture therapy, this study conducted a meta-analysis of an array of appropriate studies. Methods. Four electronic databases (MEDLINE, EMBASE, CENTRAL, and CINAHL) were searched up to February 2014. In the meta-analysis data were included from RCT studies in which groups receiving preoperative acupuncture treatment were compared with control groups receiving a placebo for anxiety. Results. Fourteen publications (N = 1,034) were included. Six publications, using the State-Trait Anxiety Inventory-State (STAI-S), reported that acupuncture interventions led to greater reductions in preoperative anxiety relative to sham acupuncture (mean difference = 5.63, P < .00001, 95% CI [4.14, 7.11]). Further eight publications, employing visual analogue scales (VAS), also indicated significant differences in preoperative anxiety amelioration between acupuncture and sham acupuncture (mean difference = 19.23, P < .00001, 95% CI [16.34, 22.12]). Conclusions. Acupuncture therapy aiming at reducing preoperative anxiety has a statistically significant effect relative to placebo or nontreatment conditions. Well-designed and rigorous studies that employ large sample sizes are necessary to corroborate this finding.

Clinically meaningful nocebo effect occurs in acupuncture treatment: a systematic review

OBJECTIVE

To investigate the nocebo effect using randomized acupuncture trials that include sham and no-treatment groups.

STUDY DESIGN AND SETTING

Electronic databases were searched to retrieve eligible trials from their inception until June 2013. Risk differences were then calculated using the acupuncture and sham groups to determine the treatment effect and the sham and no-treatment groups to determine the nocebo effect.

RESULTS

In total, 58 eligible trials were analyzed. On the basis of the rate of patients with any adverse event in 31 trials reporting available data, the treatment effect was 0.012 (95% confidence interval [CI]: 0.003, 0.021), with a number needed to harm (NNH) of 83 (95% CI: 48, 333). The nocebo effect was 0.049 (95% CI: 0.012, 0.086), with an NNH of 20 (95% CI: 12, 83). By contrast, the rate of dropouts due to adverse events in 39 trials reporting available data showed no differences for both effects. In addition, nearly 70% of the trials reported zero dropouts in the sham and no-treatment groups.

CONCLUSION

Our findings suggest that (1) the nocebo effect of acupuncture is clinically meaningful and (2) the rate of patients with any adverse event may be a more appropriate indicator of the nocebo effect.

A preoperative stress inquiry and a vulnerable US military population

The preoperative setting is fraught with many stressors, often increasing in magnitude as patients progress through the perioperative environment. Individuals exposed to traumatic or threatening environments, such as US military personnel involved in combat operations, may be at increased risk of developing altered mental and physical health conditions. Collectively, this may result in a hyperarousal state significantly amplifying psychological symptoms and magnifying physiological alterations. The purposes of this article are to (1) describe stress-related concepts and preoperative stress, (2) discuss potential risk factors for preoperative stress in the adult surgical population, (3) present various psychological and physiological measures of preoperative stress, (4) explore preoperative stress interventions, and (5) discuss potential implications for future preoperative stress research in high-stressed populations.

Three-armed trials including placebo and no-treatment groups may be subject to publication bias: systematic review

Background

It has been argued that placebos may not have important clinical impacts in general. However, there is increasing evidence of a publication bias among trials published in journals. Therefore, we explored the potential for publication bias in randomized trials with active treatment, placebo, and no-treatment groups.

Methods

Three-armed randomized trials of acupuncture, acupoint stimulation, and transcutaneous electrical stimulation were obtained from electronic databases. Effect sizes between treatment and placebo groups were calculated for treatment effect, and effect sizes between placebo and no-treatment groups were calculated for placebo effect. All data were then analyzed for publication bias.

Results

For the treatment effect, small trials with fewer than 100 patients per arm showed more benefits than large trials with at least 100 patients per arm in acupuncture and acupoint stimulation. For the placebo effect, no differences were found between large and small trials. Further analyses showed that the treatment effect in acupuncture and acupoint stimulation may be subject to publication bias because study design and any known factors of heterogeneity were not associated with the small study effects. In the simulation, the magnitude of the placebo effect was smaller than that calculated after considering publication bias.

Conclusions

Randomized three-armed trials, which are necessary for estimating the placebo effect, may be subject to publication bias. If the magnitude of the placebo effect is assessed in an intervention, the potential for publication bias should be investigated using data related to the treatment effect.

Issues of design and statistical analysis in controlled clinical acupuncture trials: an analysis of English-language reports from Western journals

OBJECTIVE

To investigate major methods of design and statistical analysis in controlled clinical acupuncture trials published in the West during the past six years (2003-2009) and, based on this analysis, to provide recommendations that address methodological issues and challenges in clinical acupuncture research.

METHOD

PubMed was searched for acupuncture RCTs published in Western journals in English between 2003 and 2009. The keyword used was acupuncture.

RESULTS

One hundred and eight qualified reports of acupuncture trials that included more than 30 symptoms/conditions were identified, analyzed, and grouped into efficacy (explanatory), effectiveness (pragmatically beneficial), and other (unspecified) studies. All were randomized controlled clinical trials (RCTs). In spite of significant improvement in the quality of acupuncture RCTs in the last 30 years, these reports show that some methodological issues and shortcomings in design and analysis remain. Moreover, the quality of the efficacy studies was not superior to that of the other types of studies. Research design and reporting problems include unclear patient criteria and inadequate practitioner eligibility, inadequate randomization, and blinding, deficiencies in the selection of controls, and improper outcome measurements. The problems in statistical analysis included insufficient sample sizes and power calculations, inadequate handling of missing data and multiple comparisons, and inefficient methods for dealing with repeated measure and cluster data, baseline value adjustment, and confounding issues.

CONCLUSION

Despite recent advancements in acupuncture research, acupuncture RCTs can be improved, and more rigorous research methods should be carefully considered.

How large are the nonspecific effects of acupuncture? A meta-analysis of randomized controlled trials

BACKGROUND

While several recent large randomized trials found clinically relevant effects of acupuncture over no treatment or routine care, blinded trials comparing acupuncture to sham interventions often reported only minor or no differences. This raises the question whether (sham) acupuncture is associated with particularly potent nonspecific effects. We aimed to investigate the size of nonspecific effects associated with acupuncture interventions.

METHODS

MEDLINE, Embase, Cochrane Central Register of Controlled Clinical Trials and reference lists were searched up to April 2010 to identify randomized trials of acupuncture for any condition, including both sham and no acupuncture control groups. Data were extracted by one reviewer and verified by a second. Pooled standardized mean differences were calculated using a random effects model with the inverse variance method.

RESULTS

Thirty-seven trials with a total of 5754 patients met the inclusion criteria. The included studies varied strongly regarding patients, interventions, outcome measures, methodological quality and effect sizes reported. Among the 32 trials reporting a continuous outcome measure, the random effects standardized mean difference between sham acupuncture and no acupuncture groups was -0.45 (95% confidence interval, -0.57, -0.34; I2 = 54%; Egger's test for funnel plot asymmetry, P = 0.25). Trials with larger effects of sham over no acupuncture reported smaller effects of acupuncture over sham intervention than trials with smaller nonspecific effects (β = -0.39, P = 0.029).

CONCLUSIONS

Sham acupuncture interventions are often associated with moderately large nonspecific effects which could make it difficult to detect small additional specific effects. Compared to inert placebo interventions, effects associated with sham acupuncture might be larger, which would have considerable implications for the design and interpretation of clinical trials.

Sham acupuncture may be as efficacious as true acupuncture: a systematic review of clinical trials

OBJECTIVE

This study sought to determine whether sham acupuncture is as efficacious as true acupuncture, as defined by traditional acupuncture theories.

METHODS

A systematic review was conducted of clinical trials that used sham acupuncture controls with needle insertion at wrong points (points not indicated for the condition) or non-points (locations that are not known acupuncture points). This study used a convenience sample of 229 articles resulting from a PubMed search using the keyword "acupuncture" and limited to "clinical trials" published in English in 2005 or 2006. Studies were categorized by use of wrong points versus non-points and the use of normal insertion and stimulation versus superficial insertion or minimal stimulation.

RESULTS

Thirty-eight acupuncture trials were identified. Most studies (22/38 = 58%) found no statistically significant difference in outcomes, and most of these (13/22 = 59%) found that sham acupuncture may be as efficacious as true acupuncture, especially when superficial needling was applied to non-points.

CONCLUSIONS

The findings cast doubt on the validity of traditional acupuncture theories about point locations and indications. Scientific rationales for acupuncture trials are needed to define valid controls, and the theoretical basis for traditional acupuncture practice needs to be re-evaluated.

Reported effects of non-traditional treatments and complementary and alternative medicine by retinitis pigmentosa patients

BACKGROUND

Benefits of complementary and alternative medicine (CAM)-related interventions have been demonstrated for patients with chronic, systemic diseases in which stress, anxiety and disability are prevalent. Subjects with retinitis pigmentosa (RP) commonly indicate that they have 'good' and 'bad' vision days, stating that stress causes a decrease in vision and that vision improves when the stress is alleviated. We assessed CAM use by RP patients and its perceived effectiveness.

METHODS

We enquired about nine CAM areas: meditation, mind-body therapies, yoga, movement therapies, energy therapies, acupuncture, massage therapy, spirituality/religion and herbal therapies/aromatherapy. Ninety-six RP patients with any level of vision completed an anonymous internet survey.

RESULTS

Ninety-five per cent of respondents tried at least one of the nine CAM areas. Seventy-five per cent have used nutritional supplements, including lutein (47 per cent), bilberry (32), vitamin A palmitate (36) and docosahexaenoic acid (23 per cent). Some tried meditation (47) and yoga (31 per cent). Stress and anxiety levels were reported as improved in 93, 92 and 87 per cent of those who used yoga, meditation and mind-body therapies, respectively. Many of those who tried mind-body therapies (40) or acupuncture (50 per cent), used it with a desire to fight RP. Vision was subjectively affected in 65 per cent of acupuncture users and from 20 to 35 per cent of the users of the other CAM areas. Those who indicated that their vision was affected by at least one type of CAM (35 per cent) were statistically significantly more likely to require magnification to read (that is, they had lost more vision and RP had progressed), than those who did not believe vision was impacted (59 versus 84 per cent).

CONCLUSIONS

RP patients are using CAM and are experiencing some impact on vision and physical/emotional well-being. Clinicians and researchers should be aware of its use. Clinical trials with CAM interventions are necessary to attempt to validate these findings.