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Liao X, Tian Y, Zhang Y, Bian Z, Wang P, Li P, Fang J, Shao X. Acupuncture for functional dyspepsia: Bayesian meta-analysis. Complement Ther Med 2024; 82:103051. [PMID: 38761869 DOI: 10.1016/j.ctim.2024.103051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/09/2024] [Accepted: 05/13/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Acupuncture stands out as a prominent complementary and alternative medicine therapy employed for functional dyspepsia (FD). We conducted a Bayesian meta-analysis to ascertain both the relative effectiveness and safety of various acupuncture methods in the treatment of functional dyspepsia. METHODS We systematically searched eight electronic databases, spanning from their inception to April 2023. The eligibility criteria included randomized controlled trials investigating acupuncture treatments for FD. Study appraisal was conducted using the Cochrane risk of bias tool. Pairwise and network meta-analyses were conducted using RevMan 5.3 and ADDIS V.1.16.6 software. Bayesian network meta-analysis was performed to compare and rank the efficacy of different acupuncture therapies for FD symptoms. RESULTS This study found that combining different acupuncture methods or using acupuncture in conjunction with Western medicine is more effective in improving symptoms of functional dyspepsia compared to using Western medicine alone. According to the comprehensive analysis results, notably, the combination of Western medicine and acupuncture exhibited superior efficacy in alleviating early satiation and postprandial fullness symptoms. For ameliorating epigastric pain, acupuncture combined with moxibustion proved to be the most effective treatment, while moxibustion emerged as the optimal choice for addressing burning sensations. Warming needle was identified as the preferred method for promoting motilin levels. CONCLUSION The findings of this study demonstrate that acupuncture, both independently and in conjunction with other modalities, emerged as a secure and effective treatment option for patients with functional dyspepsia.
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Affiliation(s)
- Xiaoyun Liao
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Yu Tian
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Yajun Zhang
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Zhiyuan Bian
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Pingzhu Wang
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Peiqi Li
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China
| | - Jianqiao Fang
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China; Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Key Laboratory for Research of Acupuncture Treatment and Transformation of Emotional Diseases, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310009, China.
| | - Xiaomei Shao
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou 310053, China; Key Laboratory of Acupuncture and Neurology of Zhejiang Province, Key Laboratory for Research of Acupuncture Treatment and Transformation of Emotional Diseases, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310009, China.
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Zhang S, Liu Y, Li S, Ye F, Yin J. Autonomic and cytokine mechanisms of acute electroacupuncture in a rodent model of functional dyspepsia. Neurogastroenterol Motil 2024; 36:e14702. [PMID: 37983919 DOI: 10.1111/nmo.14702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 10/11/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Cytokines have been presumed to play an important role in the pathophysiology of functional dyspepsia (FD). Electroacupuncture (EA) has been used for FD treatment; however, its mechanisms remain largely unknown. This study aimed to (1) compare the plasma levels of cytokines, including tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, and IL-10, in "FD" rats with normal control rats; (2) investigate whether EA, using chronically implanted electrodes, could inhibit the release of these cytokines; and (3) explore the correlation of cytokine levels with plasma norepinephrine (NE) levels and gastric emptying (GE). METHODS A rodent model of FD was established via neonatal treatment with intragastric iodoacetamide. After 8 weeks, the rats were implanted with electrodes at acupoint ST36 for EA. The plasma levels of cytokines and NE were measured using enzyme-linked immunosorbent assay. We explored the correlations of cytokine levels with NE levels and GE. KEY RESULTS (i) "FD" rats demonstrated increased levels of TNF-α, IL-1β, and IL-6 (p < 0.05 each) compared with the control rats. (ii) EA significantly decreased the plasma levels of TNF-α, IL-1β, and IL-6 in "FD" rats (p < 0.05 each) compared with sham EA. (iii) The plasma levels of NE were positively correlated with those of IL-6 (r = 0.86, p < 0.05) and IL-1β (r = 0.81, p < 0.05), whereas NE levels and GE were negatively correlated with IL-10 levels (r = -0.870, p < 0.05 and r = -0.791, p < 0.05, respectively). CONCLUSIONS EA inhibits the release of proinflammatory cytokines probably via the suppression of sympathetic activity in "FD" rats.
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Affiliation(s)
- Sujuan Zhang
- Department of Gastroenterology, No. 983 Hospital of Chinese People's Liberation Army, Tianjin, China
| | - Yi Liu
- Department of Traditional Chinese Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shiying Li
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Feng Ye
- Department of Hepatology, First Affiliated Hospital of Xi'an Jiao tong University, Xi'an, China
| | - Jieyun Yin
- Transtimulation Research Inc., Houston, Texas, USA
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Wang D, Zhang J, Yang D, Wang J, Li J, Han Y, Kang Z, Zhang H. Electroacupuncture restores intestinal mucosal barrier through TLR4/NF-κB p65 pathway in functional dyspepsia-like rats. Anat Rec (Hoboken) 2023; 306:2927-2938. [PMID: 34713984 DOI: 10.1002/ar.24800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 09/06/2021] [Accepted: 09/15/2021] [Indexed: 11/09/2022]
Abstract
Functional dyspepsia (FD) is a common functional gastrointestinal disorder with high morbidity. Electroacupuncture (EA) has been applied to treat FD for a long time. The aim of this study was to investigate the effects of EA and its mechanism about intestinal mucosal barrier in rodent model of FD. Male Sprague-Dawley rats were randomly divided into the control group and the model group. Then, the rats in model group were established to the FD model by multifactor interventions. In Experiment 1, qualified FD-like rats were randomly divided into three groups: FD, EA, and acupuncture (AP) groups. The interventions of EA and AP lasted 14 days, food intake, and body weight were recorded every 5 days. In Experiment 2, qualified FD-like rats were randomly divided into five groups: FD, EA, AP, EA + TAK242, and TAK242 groups. The interventions of EA and AP lasted 14 days, while TAK242 injection continued for 6 days. The rats were sacrificed for the measurement of serum Interleukin- 6 (IL-6) and Tumor necrosis factor-α (TNF-α) assayed by ELISA. Western blotting was used to assess the expression of TLR4, Myd88, NF-κB p65, p-NF-κB p65, TRAF6, ZO-1, and occludin in the duodenum. The transmission electron microscope was used to observe the ultrastructure of intestinal epithelial cells. Compared with the rats in the group FD, the rats in EA group had significantly increase of body weight, food intake, and protein expressions of ZO-1 and occludin, while expressions of TLR4, Myd88, NF-κB p65, p-NF-κB p65, TRAF6 in the duodenum and IL-6, and TNF-α in serum were decreased. The EA + TAK242 treatment had similar effects to the EA treatment but with increased potency; compared with EA, AP showed similar but reduced effects. Our data demonstrated that EA is more effective than AP in improving intestine mucosal barrier. The possible mechanisms of EA may involve the TLR4/NF-κB p65 pathway.
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Affiliation(s)
- Dan Wang
- Chongqing Medical University, College of Traditional Chinese Medicine, Chongqing, China
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
- Hubei University of Chinese Medicine, Wuhan, China
| | - Jinling Zhang
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Daye Yang
- Hubei University of Chinese Medicine, Wuhan, China
| | - Junying Wang
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jia Li
- Hubei University of Chinese Medicine, Wuhan, China
| | - Yongli Han
- Hubei University of Chinese Medicine, Wuhan, China
| | - Zhaoxia Kang
- Guizhou University of Traditional Chinese Medicine, Guiyang, China
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Alam MJ, Chen JDZ. Non-invasive neuromodulation: an emerging intervention for visceral pain in gastrointestinal disorders. Bioelectron Med 2023; 9:27. [PMID: 37990288 PMCID: PMC10664460 DOI: 10.1186/s42234-023-00130-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/24/2023] [Indexed: 11/23/2023] Open
Abstract
Gastrointestinal (GI) disorders, which extend from the esophagus to the anus, are the most common diseases of the GI tract. Among these disorders, pain, encompassing both abdominal and visceral pain, is a predominant feature, affecting the patients' quality of life and imposing a substantial financial burden on society. Pain signals originating from the gut intricately shape brain dynamics. In response, the brain sends appropriate descending signals to respond to pain through neuronal inhibition. However, due to the heterogeneous nature of the disease and its limited pathophysiological understanding, treatment options are minimal and often controversial. Consequently, many patients with GI disorders use complementary and alternative therapies such as neuromodulation to treat visceral pain. Neuromodulation intervenes in the central, peripheral, or autonomic nervous system by alternating or modulating nerve activity using electrical, electromagnetic, chemical, or optogenetic methodologies. Here, we review a few emerging noninvasive neuromodulation approaches with promising potential for alleviating pain associated with functional dyspepsia, gastroparesis, irritable bowel syndrome, inflammatory bowel disease, and non-cardiac chest pain. Moreover, we address critical aspects, including the efficacy, safety, and feasibility of these noninvasive neuromodulation methods, elucidate their mechanisms of action, and outline future research directions. In conclusion, the emerging field of noninvasive neuromodulation appears as a viable alternative therapeutic avenue for effectively managing visceral pain in GI disorders.
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Affiliation(s)
- Md Jahangir Alam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - Jiande D Z Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
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Kim MJ, Lee S, Kim SN. Effects of acupuncture on gastrointestinal diseases and its underlying mechanism: a literature review of animal studies. Front Med (Lausanne) 2023; 10:1167356. [PMID: 37351066 PMCID: PMC10282137 DOI: 10.3389/fmed.2023.1167356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/16/2023] [Indexed: 06/24/2023] Open
Abstract
Acupuncture is a non-pharmacological traditional Chinese medical technique that has been used for various types of gastrointestinal (GI) diseases in Eastern medicine. However, the specific mechanisms underlying acupuncture treatment in the GI tract have not yet been elucidated. In this study, we searched the electronic databases PUBMED, EMBASE, and MEDLINE and identified 30 eligible studies that were summarized in this review. This review demonstrates that treatments, including both manual and electroacupuncture, have therapeutic mechanisms in diverse GI diseases. The underlying mechanisms are broadly divided into the following: changes in gene expression in the gastric mucosa or nuclei of the solitary tract, metabolic change induction, regulation of anti-inflammatory substances, vagal activity increase, change in functional connectivity between brain regions, and control of the number of neurons related to GI diseases. Although this study is limited in that it does not represent all types of GI diseases with different acupuncture methods, this study identified acupuncture as effective for GI diseases through various biological mechanisms. We hope that our study will reveal various mechanisms of acupuncture in GI diseases and play an important role in the therapy and treatment of GI diseases, thus advancing the field of study.
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Alam MJ, Chen JDZ. Electrophysiology as a Tool to Decipher the Network Mechanism of Visceral Pain in Functional Gastrointestinal Disorders. Diagnostics (Basel) 2023; 13:627. [PMID: 36832115 PMCID: PMC9955347 DOI: 10.3390/diagnostics13040627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/27/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023] Open
Abstract
Abdominal pain, including visceral pain, is prevalent in functional gastrointestinal (GI) disorders (FGIDs), affecting the overall quality of a patient's life. Neural circuits in the brain encode, store, and transfer pain information across brain regions. Ascending pain signals actively shape brain dynamics; in turn, the descending system responds to the pain through neuronal inhibition. Pain processing mechanisms in patients are currently mainly studied with neuroimaging techniques; however, these techniques have a relatively poor temporal resolution. A high temporal resolution method is warranted to decode the dynamics of the pain processing mechanisms. Here, we reviewed crucial brain regions that exhibited pain-modulatory effects in an ascending and descending manner. Moreover, we discussed a uniquely well-suited method, namely extracellular electrophysiology, that captures natural language from the brain with high spatiotemporal resolution. This approach allows parallel recording of large populations of neurons in interconnected brain areas and permits the monitoring of neuronal firing patterns and comparative characterization of the brain oscillations. In addition, we discussed the contribution of these oscillations to pain states. In summary, using innovative, state-of-the-art methods, the large-scale recordings of multiple neurons will guide us to better understanding of pain mechanisms in FGIDs.
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Affiliation(s)
- Md Jahangir Alam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Jiande D. Z. Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA
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Auricular Vagus Nerve Stimulation Improves Visceral Hypersensitivity and Gastric Motility and Depression-like Behaviors via Vago-Vagal Pathway in a Rat Model of Functional Dyspepsia. Brain Sci 2023; 13:brainsci13020253. [PMID: 36831796 PMCID: PMC9954117 DOI: 10.3390/brainsci13020253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/19/2023] [Accepted: 01/25/2023] [Indexed: 02/05/2023] Open
Abstract
Transcutaneous auricular vagus nerve stimulation was recently reported to have a therapeutic potential for functional dyspepsia (FD). This study aimed to explore the integrative effects and mechanisms of auricular vagus nerve stimulation (aVNS) in a rodent model of FD. METHODS We evaluated the effects of aVNS on visceral hypersensitivity, gastric motility and open field test (OFT) activity in iodoacetamide (IA)-treated rats. The autonomic function was assessed; blood samples and tissues were collected and analyzed by an enzyme-linked immunosorbent assay and western blot. Vagotomy was performed to investigate the role of vagal efferent nerve. RESULTS aVNS reduced the electromyography response to gastric distension, improved gastric emptying and increased the horizontal and vertical motion scores of the OFT in IA-treated rats. The sympathovagal ratio was increased in IA-treated rats but normalized with aVNS. The serum cytokines TNF-α, IL-6, IL-1β and NF-κBp65 were increased in IA-treated rats and decreased with aVNS. The hypothalamus-pituitary-adrenal axis was hyperactive in IA-treated rats but inhibited by aVNS. The expression of duodenal desmoglein 2 and occludin were all decreased in IA-treated rats and increased with aVNS but not sham-aVNS. Vagotomy abolished the ameliorating effects of aVNS on gastric emptying, horizontal motions, serum TNF-α and duodenal NF-κBp65. CONCLUSION aVNS improves gastric motility and gastric hypersensitivity probably by anti-inflammatory mechanisms via the vago-vagal pathways. A better understanding on the mechanisms of action involved with aVNS would lead to the optimization of the taVNS methodology and promote taVNS as a non-pharmacological alternative therapy for FD.
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Li YW, Li W, Wang ST, Gong YN, Dou BM, Lyu ZX, Ulloa L, Wang SJ, Xu ZF, Guo Y. The autonomic nervous system: A potential link to the efficacy of acupuncture. Front Neurosci 2022; 16:1038945. [PMID: 36570846 PMCID: PMC9772996 DOI: 10.3389/fnins.2022.1038945] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 11/21/2022] [Indexed: 12/13/2022] Open
Abstract
The autonomic nervous system (ANS) is a diffuse network that regulates physiological systems to maintain body homeostasis by integrating inputs from the internal and external environment, including the sympathetic, parasympathetic, and enteric nervous systems (ENS). Recent evidence suggests that ANS is one of the key neural pathways for acupuncture signal transduction, which has attracted worldwide attention in the acupuncture field. Here, we reviewed the basic and clinical research published in PubMed over the past 20 years on the effects of acupuncture on ANS regulation and homeostasis maintenance. It was found that acupuncture effectively alleviates ANS dysfunction-associated symptoms in its indications, such as migraine, depression, insomnia, functional dyspepsia, functional constipation. Acupuncture stimulation on some specific acupoints activates sensory nerve fibers, the spinal cord, and the brain. Using information integration and efferents from a complex network of autonomic nuclei of the brain, such as the insular cortex (IC), prefrontal cortex, anterior cingulate cortex (ACC), amygdala (AMG), hypothalamus, periaqueductal gray (PAG), nucleus tractus solitarius (NTS), ventrolateral medulla (VLM), nucleus ambiguus (AMB), acupuncture alleviates visceral dysfunction, inflammation via efferent autonomic nerves, and relieves pain and pain affect. The modulating pattern of sympathetic and parasympathetic nerves is associated with acupuncture stimulation on specific acupoints, intervention parameters, and disease models, and the relationships among them require further exploration. In conclusion, ANS is one of the therapeutic targets for acupuncture and mediates acupuncture's actions, which restores homeostasis. A systemic study is needed to determine the rules and mechanisms underlying the effects of acupoint stimulation on corresponding organs mediated by specific central nervous networks and the efferent ANS.
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Affiliation(s)
- Yan-Wei Li
- Research Center of Experimental Acupuncture Science, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Wei Li
- Research Center of Experimental Acupuncture Science, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Song-Tao Wang
- Research Center of Experimental Acupuncture Science, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yi-Nan Gong
- Research Center of Experimental Acupuncture Science, Tianjin University of Traditional Chinese Medicine, Tianjin, China,School of Acupuncture & Moxibustion and Tuina, Tianjin University of Traditional Chinese Medicine, Tianjin, China,National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Bao-Min Dou
- Research Center of Experimental Acupuncture Science, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhong-Xi Lyu
- Research Center of Experimental Acupuncture Science, Tianjin University of Traditional Chinese Medicine, Tianjin, China,School of Acupuncture & Moxibustion and Tuina, Tianjin University of Traditional Chinese Medicine, Tianjin, China,National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Luis Ulloa
- Department of Anesthesiology, Center for Perioperative Organ Protection, Duke University, Durham, NC, United States
| | - Shen-Jun Wang
- Research Center of Experimental Acupuncture Science, Tianjin University of Traditional Chinese Medicine, Tianjin, China,School of Acupuncture & Moxibustion and Tuina, Tianjin University of Traditional Chinese Medicine, Tianjin, China,National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China,Shen-Jun Wang,
| | - Zhi-Fang Xu
- Research Center of Experimental Acupuncture Science, Tianjin University of Traditional Chinese Medicine, Tianjin, China,School of Acupuncture & Moxibustion and Tuina, Tianjin University of Traditional Chinese Medicine, Tianjin, China,National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China,Zhi-Fang Xu,
| | - Yi Guo
- Research Center of Experimental Acupuncture Science, Tianjin University of Traditional Chinese Medicine, Tianjin, China,School of Acupuncture & Moxibustion and Tuina, Tianjin University of Traditional Chinese Medicine, Tianjin, China,National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China,*Correspondence: Yi Guo,
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Xuan JL, Zhu YW, Xu WH, Zhao H, Chen JDZ, Wu GJ, Gong L. Integrative effects of transcutaneous electrical acustimulation on abdominal pain, gastrointestinal motility, and inflammation in patients with early-stage acute pancreatitis. Neurogastroenterol Motil 2022; 34:e14249. [PMID: 34536258 DOI: 10.1111/nmo.14249] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 07/17/2021] [Accepted: 08/10/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND/AIMS Gastrointestinal (GI) dysmotility in acute pancreatitis (AP) aggravates inflammation and results in severe complications. This study aimed to explore effects and possible mechanisms of transcutaneous electrical acustimulation (TEA) on abdominal pain, GI dysmotility, and inflammation in AP patients. METHODS Forty-two AP patients were blindly randomized to receive TEA (n = 21) at acupoints PC6 and ST36 or Sham-TEA (n = 21) at sham points for 2 days. Symptom scores, gastric slow waves, autonomic functions (assessed by spectral analysis of heart rate variability), circulatory levels of motilin, ghrelin, and TNF-α were measured before and after the treatment. Sixteen healthy controls (HCs) were also included without treatment for the assessment of gastric slow waves and biochemistry. KEY RESULTS Compared with Sham-TEA, TEA decreased abdominal pain score (2.57 ± 1.78 vs. 1.33 ± 1.02, p < 0.05), bloating score (5.19 ± 1.21 vs. 0.76 ± 0.99, p < 0.001), the first defecation time (65.79 ± 19.51 h vs. 51.38 ± 17.19 h, p < 0.05); TEA, but not Sham-TEA, improved the percentage of normal gastric slow waves by 41.6% (p < 0.05), reduced AP severity score (5.52 ± 2.04 vs. 3.90 ± 1.90, p < 0.05) and serum TNF-α (7.59 ± 4.80 pg/ml vs. 4.68 ± 1.85 pg/ml, p < 0.05), and upregulated plasma ghrelin (0.85 ± 0.96 ng/ml vs. 2.00 ± 1.71 ng/ml, p = 0.001) but not motilin (33.08 ± 22.65 pg/ml vs. 24.12 ± 13.95 pg/ml, p > 0.05); TEA decreased sympathetic activity by 15.0% and increased vagal activity by 18.3% (both p < 0.05). CONCLUSIONS & INFERENCES TEA at PC6 and ST36 administrated at early stage of AP reduces abdominal pain, improves GI motility, and inhibits inflammatory cytokine, TNF-α, probably mediated via the autonomic and ghrelin mechanisms.
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Affiliation(s)
- Jia-Lei Xuan
- Department of Gastroenterology, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi, China
| | - Ying-Wei Zhu
- Department of Gastroenterology, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi, China.,Department of Gastroenterology, Wuxi No.2 People's Hospital, Affiliated Wuxi Clinical College of Nantong University, Wuxi, China
| | - Wen-Hui Xu
- Department of Gastroenterology, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi, China
| | - Han Zhao
- Department of Gastroenterology, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi, China
| | - Jiande D Z Chen
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Gao-Jue Wu
- Department of Gastroenterology, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi, China.,Department of Gastroenterology, Wuxi No.2 People's Hospital, Affiliated Wuxi Clinical College of Nantong University, Wuxi, China
| | - Lei Gong
- Department of Gastroenterology, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi, China.,Department of Gastroenterology, Wuxi No.2 People's Hospital, Affiliated Wuxi Clinical College of Nantong University, Wuxi, China
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Lei W, Zhao C, Sun J, Jin Y, Duan Z. Electroacupuncture Ameliorates Intestinal Barrier Destruction in Mice With Bile Duct Ligation-Induced Liver Injury by Activating the Cholinergic Anti-Inflammatory Pathway. Neuromodulation 2022; 25:1122-1133. [PMID: 35300921 DOI: 10.1016/j.neurom.2022.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Electroacupuncture (EA) at Zusanli (ST36) can attenuate inflammation in different rodent models. However, the therapeutic mechanisms underlying its action in inhibiting intestinal barrier destruction and liver injury in cholestasis mice have not been clarified. This study aimed at investigating whether EA at ST36 could activate the cholinergic anti-inflammatory pathway to inhibit intestinal barrier destruction and liver injury in cholestasis mice. MATERIALS AND METHODS Male Hmox1floxp/floxp C57BL/6 mice were randomized and subjected to a sham or bile duct ligation (BDL) surgery. The BDL mice were randomized and treated with, or without (BDL group), sham EA at ST36 (BDL+sham-ST36) or EA at ST36 (BDL+ST36), or received α-bungarotoxin (α-BGT), a specific inhibitor of nicotinic acetylcholine receptor α7 subunit (α7nAChR), before stimulation (BDL+ST36+α-BGT). These mice, together with a group of intestine-specific heme oxygenase-1 (HO-1) knockout (KO) Villin-Cre-HO-1-/- mice, were monitored for their body weights before and 14 days after BDL. The levels of plasma cytokines and liver injury-related alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were measured by enzyme-linked immunoassay, and pathological changes in the intestinal mucosa and liver fibrosis as well as intestinal barrier permeability in individual mice were examined by histology and immunohistochemistry. The levels of α7nAChR, HO-1, ZO-1, Occludin, Claudin-1, and NF-κBp65 expression and NF-κBp65 phosphorylation in intestinal tissues were quantified. RESULTS Compared with the sham group, BDL significantly increased the levels of plasma interleukin (IL)-1β, IL-6, IL-10, tumor necrosis factor α, ALT, and AST and caused intestinal mucosal damages, high permeability, and liver fibrosis in mice, which were remarkably mitigated, except for further increased levels of plasma IL-10 in the BDL+ST36 group of mice. Similarly, EA at ST36 significantly up-regulated α7nAChR and HO-1 expression; mitigated the BDL-decreased ZO-1, Occludin, and Claudin-1 expression; and attenuated the BDL-increased NF-κBp65 phosphorylation in intestinal tissues of mice. The therapeutic effects of EA at ST36 were significantly abrogated by pretreatment with α-BGT or HO-1 KO. CONCLUSION EA at ST36 inhibits the BDL-induced intestinal mucosal damage and liver fibrosis by activating the HO-1 cholinergic anti-inflammatory pathway in intestinal tissues of mice.
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Affiliation(s)
- Wei Lei
- Second Department of Gastroenterology, the First Affiliated Hospital of Dalian Medical University, Dalian, China; Laboratory of Integrated Chinese and Western Medicine, the First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Changcheng Zhao
- Second Department of Gastroenterology, the First Affiliated Hospital of Dalian Medical University, Dalian, China; Laboratory of Integrated Chinese and Western Medicine, the First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jiasen Sun
- Second Department of Gastroenterology, the First Affiliated Hospital of Dalian Medical University, Dalian, China; Laboratory of Integrated Chinese and Western Medicine, the First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yanling Jin
- Pathology Department, the First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Zhijun Duan
- Second Department of Gastroenterology, the First Affiliated Hospital of Dalian Medical University, Dalian, China; Laboratory of Integrated Chinese and Western Medicine, the First Affiliated Hospital of Dalian Medical University, Dalian, China.
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HOU LW, FANG JL, ZHANG JL, WU D, WANG JY, RONG PJ. Effects of transcutaneous auricular vagus nerve stimulation on intestinal ligandins in a rat model of functional dyspepsia. WORLD JOURNAL OF ACUPUNCTURE-MOXIBUSTION 2022. [DOI: 10.1016/j.wjam.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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12
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Zhang S, Liu Y, Li S, Ye F, Foreman RD, Chen JDZ. Effects of electroacupuncture on stress-induced gastric dysrhythmia and mechanisms involving autonomic and central nervous systems in functional dyspepsia. Am J Physiol Regul Integr Comp Physiol 2020; 319:R106-R113. [PMID: 32493036 DOI: 10.1152/ajpregu.00256.2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Electroacupuncture (EA) is widely used as an effective method to treat stress-related disorders. However, its mechanisms remain largely unknown. The aim of this study was to investigate the effects and mechanisms of EA on gastric slow wave (GSW) dysrhythmia and c-Fos expression in the nucleus of the solitary tract (NTS) induced by stress in a rodent model of functional dyspepsia (FD). Rats in the neonatal stage were treated using intragastric iodoacetamide. Eight weeks later, the rats were implanted with electrodes in the stomach for the measurement of GSW and electrodes into accupoints ST36 for EA. Autonomic functions were assessed by spectral analysis of heart rate variability. Rats were placed for 30 min in a cylindrical plastic tube for acute restraint stress. The involvement of a central afferent pathway was assessed by measuring c-Fos-immunoreactive cells in the NTS. 1) EA normalized restraint stress-induced impairment of GSW in FD rats. 2) EA significantly increased vagal activity (P = 0.002) and improved sympathovagal balance (P = 0.004) under stress in FD rats. 3) In FD rats under restraint stress, plasma norepinephrine concentration was increased substantially (P < 0.01), which was suppressed with EA. 4) The EA group showed increased c-Fos-positive cell counts in the NTS compared with the sham EA group (P < 0.05) in FD rats. Acute restraint stress induces gastric dysrhythmia in a rodent model of FD. EA at ST36 improves GSW under stress in FD rats mediated via the central and autonomic pathways, involving the NTS and vagal efferent pathway.
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Affiliation(s)
- Sujuan Zhang
- Veterans Research and Education Foundation, Veterans Affairs Medical Center, Oklahoma City, Oklahoma.,Department of Physiology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma.,Department of Gastroenterology, No. 983 Hospital of Chinese People's Liberation Army, Tianjin, China
| | - Yi Liu
- Veterans Research and Education Foundation, Veterans Affairs Medical Center, Oklahoma City, Oklahoma.,Department of Physiology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma.,Department of Traditional Chinese Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shannxi, China
| | - Shiying Li
- Veterans Research and Education Foundation, Veterans Affairs Medical Center, Oklahoma City, Oklahoma.,Division of Gastroenterology and Hepatology, The Johns Hopkins University, Baltimore, Maryland
| | - Feng Ye
- Veterans Research and Education Foundation, Veterans Affairs Medical Center, Oklahoma City, Oklahoma.,Department of Physiology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma.,Department of Hepatology, 1st Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shannxi, China
| | - Robert D Foreman
- Department of Physiology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Jiande D Z Chen
- Veterans Research and Education Foundation, Veterans Affairs Medical Center, Oklahoma City, Oklahoma.,Division of Gastroenterology and Hepatology, The Johns Hopkins University, Baltimore, Maryland
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Guo Y, Wei W, Chen JDZ. Effects and mechanisms of acupuncture and electroacupuncture for functional dyspepsia: A systematic review. World J Gastroenterol 2020; 26:2440-2457. [PMID: 32476804 PMCID: PMC7243644 DOI: 10.3748/wjg.v26.i19.2440] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/16/2020] [Accepted: 04/21/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Functional dyspepsia (FD) is a common digestive disease with limited therapeutic options. According to evidence-based clinical practice, acupuncture or electroacupuncture (EA) seems to be a promising therapy for patients with FD. However, there is still a lack of systematic reviews that have analyzed current clinical trials for a better understanding of mechanisms involved in the ameliorating effect of acupuncture and EA on FD.
AIM To evaluate the results and qualities of existing clinical evidence for researching the underlying mechanisms of acupuncture/EA in treating FD.
METHODS A systematic search of the literature was performed to identify randomized controlled trials in which research on the mechanism of acupuncture or EA was conducted in FD patients. Databases searched included PubMed, EMBASE, Cochrane Library, and Web of Science. Data extraction and quality assessment were completed by two investigators independently and the results of quality evaluation were exported through Review Manager V5.3.
RESULTS Eight studies were included in this review with a total of 17 items for detecting techniques for mechanistic research. Positive effects of acupuncture and EA were observed in regulating gastric motility, gastric accommodation, mental status, gastrointestinal hormones, and central and autonomic functions while improving dyspeptic symptoms and quality of life.
CONCLUSION The key findings of this systematic review support the potential of acupuncture and EA in altering the heterogeneous pathophysiology in patients with FD. However, high-quality studies with well-planned designs are necessary to provide more credible evidence.
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Affiliation(s)
- Yu Guo
- Department of Gastroenterology, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing 100102, China
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD 21224, United States
| | - Wei Wei
- Department of Gastroenterology, Wangjing Hospital of China Academy of Chinese Medical Sciences, Beijing 100102, China
| | - Jiande DZ Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, MD 21224, United States
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine, Ann Arbor, MI 48109, United States
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Efficacy Comparison of Different Acupuncture Treatments for Functional Dyspepsia: A Systematic Review with Network Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2020; 2020:3872919. [PMID: 32256643 PMCID: PMC7106911 DOI: 10.1155/2020/3872919] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/23/2020] [Accepted: 02/07/2020] [Indexed: 12/13/2022]
Abstract
Background Acupuncture has been found to be an effective treatment for functional dyspepsia (FD). Currently, several types of acupuncture have been developed but it is not clear which type is suitable for FD. Currently, doctors often rely on experience to decide which form of acupuncture to apply. Herein, we employed network meta-analysis (NMA) to compare the effectiveness of various methods of acupuncture in the treatment of functional dyspepsia. Methods We searched for randomized controlled trials (RCTs) of acupuncture treatments for functional dyspepsia in seven databases; PubMed, the Cochrane Library, Embase, Wanfang database, China National Knowledge Infrastructure (CNKI) database, Chinese Science and Technique Journals (CQVIP), and Chinese Biomedical Database (CBM) from the date of database inception to October 10, 2019. Cochrane risk of bias tool was used to analyze the risk of bias of the included RCTs. Pairwise meta-analyses were performed with RevMan 5.3 and the network meta-analysis of the included RCTs was performed using the frequentist framework. Results A total of 35 studies involving 3301 patients and 10 interventions were eligible for this study. NMA results showed that five types of acupuncture (manual acupuncture, acupoint application, moxibustion, acupoint catgut embedding, and warm acupuncture alone) all were superior to prokinetics (itopride, mosapride, and domperidone) and sham acupuncture in terms of improving the symptoms of functional dyspepsia. Specifically, manual acupuncture and electroacupuncture were more effective in improving the MOS 36 Item Short-Form Health Survey (SF-36) compared to itopride and sham acupuncture, and electroacupuncture was the best among the three acupuncture therapies (acupuncture, electroacupuncture, and acupoint catgut embedding). Moxibustion and manual acupuncture were more effective in improving Nepean Dyspepsia Life Quality Index (NDLQI) compared to itopride, domperidone, and sham acupuncture; moxibustion ranks first among the three acupuncture therapies (acupuncture, electroacupuncture, moxibustion). Conclusions These results showed that manual acupuncture alone was the most effective therapy for FD. It should, therefore, be considered as an alternative treatment for FD patients who are unresponsive to prokinetics or intolerant to the adverse effects of prokinetics. We recommend further multiple centers and high-quality RCT studies to confirm the present findings.
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Lu MJ, Yu Z, He Y, Yin Y, Xu B. Electroacupuncture at ST36 modulates gastric motility via vagovagal and sympathetic reflexes in rats. World J Gastroenterol 2019; 25:2315-2326. [PMID: 31148903 PMCID: PMC6529886 DOI: 10.3748/wjg.v25.i19.2315] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/22/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Electroacupuncture (EA) at ST36 can significantly improve gastrointestinal symptoms, especially in promoting gastrointestinal motility. The automatic nervous system plays a main role in EA, but few studies exist on how vagovagal and sympathetic reflexes affect EA to regulate gastrointestinal motility.
AIM To study the role of vagovagal and sympathetic reflexes in EA at ST36, as well as the associated receptor subtypes that are involved.
METHODS Gastric motility was measured with a manometric balloon placed in the gastric antrum area in anesthetized animals. The peripheral nervous discharge was measured using a platinum electrode hooking the vagus or greater splanchnic nerve, and the central nervous discharge was measured with a glass microelectrode in the dorsal motor nucleus of the vagus (DMV). The effects and mechanisms of EA at ST36 were explored in male Sprague-Dawley rats which were divided in to a control group, vagotomy group, sympathectomy group, and microinjection group [including an artificial cerebrospinal fluid group, glutamate (L-Glu) group, and γ-aminobutyric acid (GABA) group] and in genetically modified male mice [β1β2 receptor-knockout (β1β2-/-) mice, M2M3 receptor-knockout (M2M3-/-) mice, and wild-type control mice].
RESULTS EA at ST36 promoted gastric motility during 30-120 s. During EA, both vagus and sympathetic nerve discharges increased, with a much higher frequency of vagus nerve discharge than sympathetic discharge. The gastric motility mediated by EA at ST36 was interdicted by vagotomy. However, gastric motility mediated by EA at ST36 was increased during 0-120 s by sympathectomy, which eliminated the delay effect of EA during 0-30 s, but it was lower than the control group during 30-120 s. Using gene knockout mice and their wild-type controls to explore the receptor mechanisms, we found that EA at ST36 decreased gastric motility in M2/3-/- mice, and promoted gastric motility in β1/2-/- mice. Extracellular recordings showed that EA at ST36 increased spikes of the DMV. Microinjection of L-Glu into the DMV increased gastric motility, while EA at ST36 decreased gastric motility during 0-60 s, and promoted gastric motility during 60-120 s. Injection of GABA reduced or increased gastric motility, and reduced the promoting gastric motility effect of EA at ST36.
CONCLUSION These data suggest that EA at ST36 modulates gastric motility via vagovagal and sympathetic reflexes mediated through M2/3 and β1/2 receptors, respectively. Sympathetic nerve activity mediated through β1/2 receptors is associated with an early delay in modulation of gastric motility by EA at ST36.
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Affiliation(s)
- Meng-Jiang Lu
- Key Laboratory of Acupuncture and Medicine Research of Ministry of Education, Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Zhi Yu
- Key Laboratory of Acupuncture and Medicine Research of Ministry of Education, Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Yan He
- Key Laboratory of Acupuncture and Medicine Research of Ministry of Education, Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Yin Yin
- Key Laboratory of Acupuncture and Medicine Research of Ministry of Education, Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Bin Xu
- Key Laboratory of Acupuncture and Medicine Research of Ministry of Education, Nanjing University of Chinese Medicine, Nanjing 210023, Jiangsu Province, China
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Liu Y, Zhang S, Ye F, Yin J, Li S, Chen JDZ. Ameliorating effects and mechanisms of chronic electroacupuncture at ST36 in a rodent model of dyspepsia induced by cisplatin. Neurogastroenterol Motil 2019; 31:e13474. [PMID: 30246392 DOI: 10.1111/nmo.13474] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/08/2018] [Accepted: 08/28/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Chemotherapy-associated dyspepsia syndrome (CADS) is among the most intensive side effects and critical concerns for patients with cancer. To investigate the effects and mechanisms of chronic electroacupuncture (EA) at ST36 on chemotherapy-associated dyspeptic symptoms (CADS) in rats. METHODS Cisplatin (8 mg/kg, ip) was given once to establish CADS model. EA or sham-EA treatment was then performed one hour daily for 21 days. KEY RESULTS (a) EA treatment decreased kaolin intake within 24 hours (1.67 ± 0.23 g vs 2.36 ± 0.37 g in sham-EA, P < 0.05); EA increased food intake (9.43 ± 2.28 vs 4.32 ± 1.26 in sham-EA, P < 0.05) and cisplatin-induced reduction of body weight (426.38 ± 13.25 vs 407.92 ± 13.26 in sham-EA, P = 0.05). (b) The incidence of normal behavioral satiety sequence (53%) in EA group was greater than that in sham-EA (32%) group (X2 = 17.68, P < 0.01). (c) EA increased the percentage of normal gastric slow waves (82.6 ± 5.98 vs 22.8 ± 1.90 in sham-EA, P < 0.05). (d) EA normalized cisplatin delayed gastric emptying (71.3% ± 6.8% vs 44.6% ± 11.2% in control, P < 0.05). (e) EA decreased ratio of heart rate variability (0.30 ± 0.03 vs 0.56 ± 0.05 in sham-EA, P < 0.05). (f) EA decreased fasting ghrelin, glucagon-like peptide-1 and peptide YY (P < 0.01 vs sham-EA for all). CONCLUSIONS AND INFERENCES Chronic EA ameliorates dyspepsia symptom and improves gastric dysmotility induced by Cisplatin, mediated via the vagal and gastrointestinal hormonal mechanisms.
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Affiliation(s)
- Yi Liu
- Veterans Research and Education Foundation, VA Medical Center, Oklahoma City, Oklahoma.,The 1st Affiliated Hospital of Xi'an Jiaotong University, Shannxi, China.,Division of Gastroenterology and Hepatology, Johns Hopkins Center for Neurogastroenterology, Baltimore, Maryland
| | - Sunjuan Zhang
- Veterans Research and Education Foundation, VA Medical Center, Oklahoma City, Oklahoma.,Division of Gastroenterology and Hepatology, Johns Hopkins Center for Neurogastroenterology, Baltimore, Maryland.,Department of Gastroenterology, Tianjin No. 254 Hospital, Tianjin, China
| | - Feng Ye
- Veterans Research and Education Foundation, VA Medical Center, Oklahoma City, Oklahoma.,The 1st Affiliated Hospital of Xi'an Jiaotong University, Shannxi, China.,Division of Gastroenterology and Hepatology, Johns Hopkins Center for Neurogastroenterology, Baltimore, Maryland
| | - Jieyun Yin
- Division of Gastroenterology and Hepatology, Johns Hopkins Center for Neurogastroenterology, Baltimore, Maryland
| | - Shiying Li
- Veterans Research and Education Foundation, VA Medical Center, Oklahoma City, Oklahoma.,Division of Gastroenterology and Hepatology, Johns Hopkins Center for Neurogastroenterology, Baltimore, Maryland
| | - Jiande D Z Chen
- Veterans Research and Education Foundation, VA Medical Center, Oklahoma City, Oklahoma.,Division of Gastroenterology and Hepatology, Johns Hopkins Center for Neurogastroenterology, Baltimore, Maryland
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