Effect of Electroacupuncture at The Zusanli Point (Stomach-36) on Dorsal Random Pattern Skin Flap Survival in a Rat Model

The current state of knowledge on how to improve skin flap survival: A review

The incorporation of skin flaps in wound closure management with its cosmetic implications has appeared as a gleam of hope in providing desirable outcomes. Given the influence of extrinsic and intrinsic factors, skin flaps are prone to several complications, including ischemia-reperfusion injury (IRI). Numerous attempts have been undertaken to enhance the survival rate of skin flaps entailing pre/post-conditioning with surgical and pharmacological modalities. Various cellular and molecular mechanisms are employed in these approaches in order to reduce inflammation, promote angiogenesis and blood perfusion, and induce apoptosis and autophagy. With the emerging role of multiple stem cell lineages and their ability to improve skin flap viability, these approaches are increasingly being used to develop even more translationally applicable methods. Therefore, this review aims at providing current evidence around pharmacological interventions for improving skin flap survival and discussing their underlying mechanism of action.

Cannabidiol Improves Random-Pattern Skin Flap Survival in Rats: Involvement of Cannabinoid Type-2 Receptors

BACKGROUND

 One of the major complications associated with random-pattern skin flaps is distal necrosis. Cannabidiol (CBD) has recently gained much attention as a therapeutic anti-inflammatory agent. We aimed to evaluate the efficacy of CBD on the random-pattern skin flap survival (SFS) in rats and to explore the possible involvement of cannabinoid type-2 (CB2) receptors.

METHODS

 In this controlled experimental study, we randomly divided male Wistar rats into seven study groups (six rats each). We performed a random-pattern skin flap model in each rat following pretreatment with vehicle (control) or multiple doses of CBD (0.3, 1, 5, or 10 mg/kg). In a separate group, we injected SR144528 (2 mg/kg), a high affinity and selective CB2 inverse agonist, before the most effective dose of CBD (1 mg/kg). A sham nontreated and nonoperated group was also included. Seven days after surgeries, the percentage of necrotic area (PNA) was calculated. Histopathological microscopy, CB2 expression level, and interleukin (IL)-1β and tumor necrosis factor (TNF)-α concentrations were also investigated in the flap tissue samples.

RESULTS

 A PNA of 72.7 ± 7.5 (95% confidence interval [CI]: 64.8-80.6) was captured in the control group. Following treatment with CBD 0.3, 1, 5, and 10 mg/kg, a dose-dependent effect was observed with PNAs of 51.0 ± 10.0 (95% CI: 40.5-61.5; p <0.05), 15.4 ± 5.8 (95% CI: 9.3-21.5; p <0.001), 37.1 ± 10.2 (95% CI: 26.3-47.8; p <0.001), and 46.4 ± 14.0 (95% CI: 31.7-61.1; p <0.001), respectively. Histopathologically, tissues enhanced significantly. Besides, CB2 expression surged remarkably, IL-1β and TNF-α concentrations decreased considerably after treatment with CBD of 1 mg/kg compared with the control (p <0.05 and <0.001, respectively). Administering SR144528 reversed the favorable effects of CBD of 1 mg/kg, both macroscopically and microscopically.

CONCLUSION

 Pretreatment with CBD of 1 mg/kg improved SFS considerably in rats and exerted desirable anti-inflammatory effects which were possibly mediated by CB2 receptors.

Study on the effect of acupunture treatment on autonomic nerve dysfunction in convalescent period of stroke based on heart rate variability assessment technique

Stroke patients with autonomic dysfunction are more likely to develop cardiac problems, which have been linked to lower functional outcomes and increased mortality. In this study, heart rate variability (HRV) detection paired with the Clinical Feature Scale will be utilized to elucidate the immediate impact of manual acupuncture on autonomic dysfunction of varying severity in the convalescence stroke phase. This is a randomized, single-blind, controlled clinical trial approach. At a ratio of 1:1, 60 appropriate patients will be randomly randomized into either the experimental or control group. On the basis of symptomatic treatment drugs, the experimental group will additionally undertake acupuncture therapy 3 times a week for 4 weeks, for a total of 12 times. Primary outcomes include 24-hour HRV and 60-minute HRV detection at week 4 compared with baseline. The secondary outcome is the score of clinical feature scale at week 4 compared with the baseline. Adverse events and safety indices will be recorded throughout the experiment. The SPSS V.25.0 statistical program was applied for analysis, and measurement data were expressed as mean ± SD.

Anti-Inflammatory Effects of Acupuncture at ST36 Point: A Literature Review in Animal Studies

So far, a number of acupuncture studies have shown anti-inflammatory effects of acupuncture treatment, mostly known at specific point ST36. However, there is no literature that oversaw the inflammation-regulatory effects of acupuncture in each tissue. Therefore, we investigated how acupuncture at specific acupoint ST36 regulates inflammation and its underlying mechanisms. We searched literatures on PubMed until July 2021 using the keywords “animal, acupuncture, ST36, inflammation, immune,” and 292 literatures were searched. We ultimately selected 69 studies to determine the anti-inflammatory actions of acupuncture at ST36 and classified the changes of inflammatory mediators according to target regions. Forty-three studies were included in body fluids, 27 studies in the digestive system, 17 studies in the nervous system, and 30 studies in other tissues or organs. In this review, we found that acupuncture at ST36 has clinical benefits in relieving inflammation through several mechanisms such as vagus nerve activation, toll-like receptor 4 (TLR4)/NF-κB signaling, macrophage polarization, mitogen-activated protein kinase (MAPK) signaling pathway, and cholinergic anti-inflammatory pathway. We expect that these data will inform further studies related to ST36 acupuncture on inflammation.

Effect of Electrical Stimulation on Gastrointestinal Symptoms in Lung Cancer Patients during Chemotherapy: A Randomized Controlled Trial

Objective:

The objective was to evaluate the effects of transcutaneous acupoint electric stimulation (TAES) and gastric electrical stimulation (GES) on cancer patients with chemotherapy-induced gastrointestinal (GI) symptoms.

Methods:

A total of 122 lung cancer patients receiving chemotherapy were assigned randomly to the following two groups: control group (usual care group, n = 61) and intervention group (TAES plus GES, n = 61). TAES involved two acupoints such as Neiguan (PC6) and Zusanli (ST36). GES was performed at gastric pacing sites on the body surface such as the places of projection of gastric antrum and corpus on the body surface. GES was performed on these sites for 14 days continuously (25 min every time, once daily). The effects of TAES and GES on GI symptoms were assessed using the Memorial Symptom Assessment Scale on the day prior to chemotherapy (time point 1) and days 14 (time point 2) and 28 (time point 3) after chemotherapy.

Results:

No significant differences in the demographic and disease-related variables were detected between the two groups. Differences in symptom occurrence and severity at time point 1 were not statistically significant between the two groups (both P > 0.05). At time points 2 and 3, GI symptoms such as loss of appetite, nausea, vomiting, diarrhea, and constipation in the stimulation group had statistically significantly improved compared with the control group (all P < 0.05).

Conclusions:

TAES and GES were efficacious in relieving GI discomfort in lung cancer patients after chemotherapy. TAES combined with GES is a safe and easy-to-use tool to manage GI symptoms in practice.

Apelin/APJ-Manipulated CaMKK/AMPK/GSK3β Signaling Works as an Endogenous Counterinjury Mechanism in Promoting the Vitality of Random-Pattern Skin Flaps

A random-pattern skin flap plays an important role in the field of wound repair; the mechanisms that influence the survival of random-pattern skin flaps have been extensively studied but little attention has been paid to endogenous counterinjury substances and mechanism. Previous reports reveal that the apelin-APJ axis is an endogenous counterinjury mechanism that has considerable function in protecting against infection, inflammation, oxidative stress, necrosis, and apoptosis in various organs. As an in vivo study, our study proved that the apelin/APJ axis protected the skin flap by alleviating vascular oxidative stress and the apelin/APJ axis works as an antioxidant stress factor dependent on CaMKK/AMPK/GSK3β signaling. In addition, the apelin/APJ-manipulated CaMKK/AMPK/GSK3β-dependent mechanism improves HUVECs' resistance to oxygen and glucose deprivation/reperfusion (OGD/R), reduces ROS production and accumulation, maintained the normal mitochondrial membrane potential, and suppresses oxidative stress in vitro. Besides, activation of the apelin/APJ axis promotes vascular migration and angiogenesis under relative hypoxia condition through CaMKK/AMPK/GSK3β signaling. In a word, we provide new evidence that the apelin/APJ axis is an effective antioxidant and can significantly improve the vitality of random flaps, so it has potential be a promising clinical treatment.

Effect of bilateral needling at an acupuncture point, ST-36 (Zusanli) on blood glucose levels in type 2 diabetes mellitus patients: A pilot randomized placebo controlled trial

Background Diabetes mellitus is one of the major current public health problems. Electro-acupuncture at ST-36 showed a significant reduction in plasma glucose levels in diabetic rats. There are lacks of studies reporting its hypoglycemic effect in humans and thus, the present study was conducted to evaluate the effect of needling at ST-36 (Zusanli) on blood glucose levels in patients with type 2 diabetes mellitus (T2DM). Methods Sixty T2DM participants were recruited and randomized into acupuncture group (n=30) and placebo control group (n=30). The participants of the acupuncture group received needling at ST-36 (one finger breadth lateral to the inferior border of the tibial tuberosity), and the participants those in the placebo control group received needling at placebo point (midpoint between the apex of the patella and tibial tuberosity). For both the groups, needles were retained for 30 min. Baseline and post-test assessments were performed prior to and after each intervention. Statistical analysis was performed using SPSS version 16. Results The present study showed a significant reduction in random blood glucose levels in the acupuncture group compared to the placebo control group. Conclusion This study suggests that 30 min of bilateral acupuncture needling at ST-36 with manual stimulation is effective in reducing blood glucose levels in T2DM patients.

Tetramethylpyrazine improved the survival of multiterritory perforator flaps by inducing angiogenesis and suppressing apoptosis via the Akt/Nrf2 pathway

Background: Multiterritory perforator flaps were commonly designed to cover the large soft-tissue defects in reconstructive surgery. But the high risk of partial necrosis in the distal portion of the flaps hindered their clinical application. The purpose of this study was to evaluate the effects of tetramethylpyrazine (TMP) on the survival of the multiterritory perforator flaps and to explore the underlying mechanism.

Materials and methods: Seventy-two Sprague–Dawley rats underwent multiterritory perforator flap procedure and were divided into three groups with 24 each. Flap survival and water content were measured, and the area of angiogenesis and apoptosis in the ischemia skin flaps were assessed on the postoperative day 7. The expressions of angiogenesis-related protein VEGF and apoptosis-related protein Bax, Bcl-2 in each group were detected by Western blotting, which also had been used to assess the expressions levels of Akt, p-Akt, and Nrf2.

Results: Following TMP treatment, the survival area and number of microvessels presented in the skin flaps increased and tissue edema reduced on postoperative day 7. The expressions of angiogenesis-related protein VEGF increased in the TMP treatment group than in the control group. In addition, compared with the control group, TMP inhibited apoptosis, and increased the expression levels of p-Akt, Nrf2 in the areas of ischemia. These effects were reversed by an Akt protein inhibitor LY294002. Similarly, treatment with LY294002 inhibited TMP induced by interfering the Akt/Nrf2 signaling pathway.

Conclusion: These results illustrated that TMP could promote the survival of multiterritory perforator flaps by enhancing angiogenesis and attenuating apoptosis. These were involved in Akt/Nrf2 signaling pathway.

Comparison of incisional delay patterns on a rat random flap model

One of the simplest form of surgical delay can be performed by placing an incision around the flap without undermining, prior to flap elevation. In this study, we have compared the efficiency of different patterns of skin incision to improve flap survival. Twenty-eight animals were used in four groups. Incisional delay was performed prior to flap elevation in the three experiment groups. Complete incision of the three flap edges was performed in the all experiment groups with the exception of an intact skin section on the middle 1/3rd of the bilateral edges in group 1 (bilateral skin edge preserved delay: BSEPD), of a unilateral edge in group 2 (unilateral skin edge preserved delay: USEPD) and of the superior edge in group 3 (superior skin edge preserved delay: SSEPD) without any undermining. Two weeks following the delay procedure, dorsal skin flaps were raised and reinserted back to their place. The results were evaluated with the measurement of necrotic flap area, microangiographic imaging and histological evaluation. The mean percentage of necrotic flap area to whole flap area was 16.94%, 7.54%, 23.34% and 50.6% in the BSEPD, USEPD, SSEPD and control groups, respectively. In selected microangiographic images, vessels were more prominent in the delay groups. The results of the study indicate that three sided incision with an intact skin on the superior edge is not effective in providing a sufficient delay and flap survival improvement when compared to incisions with intact skin on the unilateral and bilateral edges.

Flap Preconditioning with the Cyclic Mode (Triangular Waveform) of Pressure-Controlled Cupping in a Rat Model: An Alternative Mode to the Continuous System

BACKGROUND

Improving flap survival is essential for successful soft-tissue reconstruction. Although many methods to increase the survival of the distal flap portion have been attempted, there has been no widely adopted procedure. The authors evaluated the effect of flap preconditioning with two different modes (continuous and cyclic) of external volume expansion (pressure-controlled cupping) in a rat dorsal flap model.

METHODS

Thirty rats were randomly assigned to the control group and two experimental groups (n = 10 per group). The continuous group underwent 30 minutes of preconditioning with -25 mmHg pressure once daily for 5 days. The cyclic group received 0 to -25 mmHg pressure for 30 minutes with the cyclic mode once daily for 5 days. On the day after the final preconditioning, caudally based 2 × 8-cm dorsal random-pattern flaps were raised and replaced in the native position. On postoperative day 9, the surviving flap area was evaluated.

RESULTS

The cyclic group showed the highest flap survival rate (76.02 percent), followed by the continuous and control groups (64.96 percent and 51.53 percent, respectively). All intergroup differences were statistically significant. Tissue perfusion of the entire flap showed similar results (cyclic, 87.13 percent; continuous, 66.64 percent; control, 49.32 percent). Histologic analysis showed the most increased and organized collagen production with hypertrophy of the attached muscle and vascular density in the cyclic group, followed by the continuous and control groups.

CONCLUSION

Flap preconditioning with the cyclic mode of external volume expansion is more effective than the continuous mode in an experimental rat model.