The short-term effects of acupuncture on patients with diabetic gastroparesis: a randomised crossover study

Non-invasive neuromodulation: an emerging intervention for visceral pain in gastrointestinal disorders

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.

Gastroparesis syndromes: emerging drug targets and potential therapeutic opportunities

INTRODUCTION

Gastroparesis (Gp) and related disorders such as chronic unexplained nausea and vomiting and functional dyspepsia, known as gastropareis syndromes (GpS), have large unmet needs. Mainstays of GpS treatments are diet and drugs.

AREAS COVERED

The purpose of this review is to explore potential new medications and other therapies for gastroparesis. Before discussing possible new drugs, the currently used drugs are discussed. These include dopamine receptor antagonists, 5-hydroxytryptamine receptor agonists and antagonists, neurokinin-1 receptor antagonists and other anti-emetics. The article also considers future drugs that may be used for Gp, based on currently known pathophysiology.

EXPERT OPINION

Gaps in knowledge about the pathophysiology of gastroparesis and related syndromes are critical to developing therapeutic agents that will be successful. Recent major developments in the gastroparesis arena are related to microscopic anatomy, cellular function, and pathophysiology. The major challenges moving forward will be to develop the genetic and biochemical correlates of these major developments in gastroparesis research.

ACG Clinical Guideline: Gastroparesis

Gastroparesis is characterized by symptoms suggesting retention of food in the stomach with objective evidence of delayed gastric emptying in the absence of mechanical obstruction in the gastric outflow. This condition is increasingly encountered in clinical practice. These guidelines summarize perspectives on the risk factors, diagnosis, and management of gastroparesis in adults (including dietary, pharmacological, device, and interventions directed at the pylorus), and they represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation process. When the evidence was not appropriate for Grading of Recommendations, Assessment, Development, and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.

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.

Role of Complementary and Alternative Medicine in the Management of Cancer Cachexia

Cancer cachexia is an important concern in cancer patients in view of advanced stage at presentation. The treatment goal for cachexia is the reversal of the loss of body weight and muscle mass with a variety of pharmacological agents. Various treatment guidelines focus on patients with advanced cancer who are likely to suffer from refractory cachexia. There is a paucity of data on research directed to cancer cachexia on cancer patients. Complementary and alternative medicines (CAMs) are widely use at some or other point of time by the majority of cancer patients in spite of little or no evidence to support that. There are many CAM which have been tried in different set up for cancer cachexia. These medicines are well accepted in view of lesser side effects and easy to use. There is a need for more randomized controlled trials with larger sample size with longer follow-up to generate more evidence in support to the use of CAM in cancer and cancer cachexia.

Electroacupuncture at ST36 Improve the Gastric Motility by Affecting Neurotransmitters in the Enteric Nervous System in Type 2 Diabetic Rats

Electroacupuncture (EA) can effectively relieve hyperglycemia and gastric emptying disorders in diabetic gastroparesis (DGP). However, the effect of EA on type 2 diabetes mellitus (T2DM) gastroparesis and its mechanism in the enteric nervous system (ENS) are rarely studied. We investigated the therapeutic effect of EA at ST36 and its effect on the main inhibitory and excitatory neurotransmitters in the ENS in DGP rats. Male Sprague-Dawley (SD) rats were fed a high-fat diet for 2 weeks and injected with streptozotocin (STZ) at 35 mg/kg to induce T2DM. T2DM rats were divided into the diabetic mellitus (DM) group and the EA group. The control (CON) group comprised normal rats without any intervention. EA treatment was started 6 weeks after the induction of DM and continued for 5 weeks. The body weight and food intake of the rats were recorded every week. Blood glucose, insulin, glucose tolerance, gastric emptying, and antral motility were measured after treatment. The expression of protein gene product 9.5 (PGP9.5), neuronal nitric oxide synthase (nNOS), and choline acetyltransferase (ChAT) in gastric antrum were quantified by western blotting and quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR). The T2DM gastroparesis model was successfully established. EA treatment reduced the body weight, food intake, and blood glucose; improved glucose intolerance and insulin resistance; increased the gastric emptying rate, the mean antral pressure, and the amplitude of antral motility; and decreased the frequency of antral motility compared with those in the DM group. EA treatment increased the expression level of nNOS, ChAT, and PGP9.5 proteins, and nNOS and ChAT mRNA. The results suggested that EA at ST36 could ameliorate DGP, partly restore the damage to general neurons, and increase nNOS and ChAT in the gastric antrum. EA improved DGP partly via reducing the loss of inhibitory and excitatory neurotransmitters in the ENS.

An Apriori Algorithm-Based Association Rule Analysis to Identify Acupoint Combinations for Treating Diabetic Gastroparesis

We explored the potential association rules within acupoints in treating diabetic gastroparesis (DGP) using Apriori algorithm complemented with another partition-based algorithm, a frequent pattern growth algorithm. Apriori algorithm is a data mining-based analysis that is widely applied in various fields, such as business and medicine, to mine frequent patterns in datasets. To search for effective acupoint combinations in the treatment of DGP, we implemented Apriori algorithm to investigate the association rules of acupoints among 17 randomized controlled trials (RCTs). The acupoints were extracted from the 17 included RCTs. In total, 29 distinct acupoints were observed in the RCTs. The top 10 frequently selected acupoints were CV12, ST36, PC6, ST25, BL21, BL20, BL23, SP6, BL18, and ST21. The frequency pattern of acupoints achieved by using a frequent pattern growth algorithm also confirms the result. The results showed that the most associated rules were {BL23, BL18} ≥ {SP6}, {BL20, BL18} ≥ {PC6}, {PC6, BL18} ≥ {BL20}, and {SP6, BL18} ≥ {BL23} in the database. Acupoints, including BL23, BL18, SP6, BL20, and PC6, can be deemed as core elements of acupoint combinations for treating DGP.

Gentle Manual Acupuncture Could Better Regulate Gastric Motility and Vagal Afferent Nerve Discharge of Rats with Gastric Hypomotility

The variation of stimulus intensity of manual acupuncture (MA) may produce diverse acupuncture effects. However, the intensity-effect relationship and the underlying mechanism of MA are still elusive. In this study, the effects of MA regulation of gastric motility were investigated after lifting-thrusting MA treatment with four different frequencies (1 Hz, 2 Hz, 3 Hz, and 4 Hz) at ST36. The experiments were conducted on rats with gastric hypomotility caused by atropine. The results showed that the gastric motility amplitude decreased after atropine injection, while the treatment of four types of MA affected the gastric motility amplitude in varying degrees. Specifically, 2 Hz MA exhibited the most effective results, while 4 Hz MA had the least effect; the effects of 1 Hz MA and 3 Hz MA were between the effects induced with 2 Hz and 4 Hz. Furthermore, the response of gastric vagal afferent nerve discharge and gastric motility was examined after MA treatment with frequencies of 2 Hz and 4 Hz, respectively, on ST36 in order to elucidate the mechanism of MA regulation of gastric motility. The results showed that 2 Hz MA was able to increase the amplitude of gastric motility and discharge frequency of gastric vagal afferent nerves, while 4 Hz MA exhibited seldom effects. These findings suggest that gentle MA (2 Hz) has more stimulating effects than strong stimulation with MA (4 Hz) on gastric hypomotility. In addition, gastric motility regulated by MA was associated with vagal afferent nerve activation.

Zusanli (ST36) acupoint injection for acute diarrhea in children under 5 years old: A protocol of systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Acute diarrhea is the 2nd highest prevalence disease among children under 5 years of age. It can cause malnutrition and even death in children, especially in developing country. Traditional Chinese medicine therapy has been applied and already in the guidelines for clinical practice of acute infectious diarrhea in children in China, but there is no specific methods or recommendations due to lacking of evidence. Zusanli acupoint injection as a form of acupuncture therapy, which is proved to be effective in randomised controlled trials (RCTs) and very suitable for children, has been used in acute diarrhea in children for a long time; therefore, a systematic review is necessary to provide available evidence for further study.

METHODS

Different studies from various databases will be involved in this study. Only RCTs of children under 5 years of age diagnosed with acute diarrhea using any recognized diagnostic criteria will be included. We will search manually the literature in the databases from China Conference Paper Database. Electronic database includes PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Internet, WanFang, Chongqing VIP, and China Biomedical Literature CDROM Database. Primary outcomes: clinical cure rate (clinical cure is defined as the frequency, timing and character of stool back to normal status, as well as disappearance of diarrhea symptoms), diarrhea duration (from admission to the cessation of diarrhea).

SECONDARY OUTCOMES

stool frequency within 24 hours, rate of adverse effect. Data will be extracted by 2 researchers independently; risk of bias of the meta-analysis will be evaluated based on the Cochrane Handbook for Systematic Reviews of Interventions. All data analysis will be conducted by data statistics software Review Manager V.5.3. and Stata V.12.0.

RESULTS

This study will synthesize and provide evidence based on the data of the currently published zusanli (ST36) acupoint injection for acute diarrhea in children under 5 years old, especially in terms of clinical efficacy and safety.

CONCLUSION

This systematic review aims to evaluate the benefits and harms of zusanli acupoint injection for acute diarrhea in children under 5 years old reported in RCTs, and provide evidence reference in TCM field for Chinese guidelines on the treatment of acute diarrhea in children.

ETHICS AND DISSEMINATION

This study is a systematic review; the outcomes are based on the published evidence, and hence examination and agreement by the ethics committee are not required in this study. We intend to publish the study results in a journal or conference presentations.

PROSPERO REGISTRATION NUMBER

PROSPERO 2019 CRD42019135275.

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.

Treatment of persistent hiccups after arthroplasty: effects of acupuncture at PC6, CV12 and ST36

OBJECTIVE

There are multiple treatment options for hiccups, including non-pharmacological therapies, but little evidence of superiority of one treatment over another. The aim of this study was to investigate the effects of acupuncture on persistent hiccups after arthroplasty.

METHODS

From April 2010 to December 2015, 15 patients with primary unilateral total hip/knee arthroplasty were diagnosed with persistent hiccups and given acupuncture at PC6, CV12 and ST36. Each acupuncture session lasted 30 min. The total number of treatment sessions was determined by the persistence of symptoms, but acupuncture was administered no more than three times over the course of a week. The hiccups assessment instrument (HAI) was used to assess the severity of hiccups pre-treatment and post-treatment. Adverse events were also recorded.

RESULTS

Absolute resolution was observed in all 15 patients after less than three acupuncture sessions. Of these, 10 patients required only one acupuncture session, 3 patients required two sessions and 2 patients required three sessions. The HAI score improved after each round of acupuncture treatment (P<0.05). The average HAI score improved significantly post-acupuncture compared to baseline values pre-treatment (P<0.05). Symptoms accompanying the hiccups included pain in the diaphragmatic area (five patients), mild dyspnoea (three patients), dysphagia (two patients) and nausea/vomiting (one patient). All these accompanying symptoms disappeared at the point of resolution of the hiccups. There were no adverse effects related to acupuncture during the study period.

CONCLUSION

Based on our results, acupuncture may represent a potential treatment option for hiccups after arthroplasty. Caution must be exercised, however, given the lack of a control group. Accordingly, randomised controlled trials will be required to verify the efficacy and effectiveness of acupuncture for the treatment of hiccups.

Gastroparesis and Functional Dyspepsia: A Blurring Distinction of Pathophysiology and Treatment

Gastroparesis and functional dyspepsia are 2 of the most common gastric neuromuscular disorders. These disorders are usually confused, having both similarities and differences. The pathophysiology of these disorders involves abnormal gastric motility, visceral hypersensitivity, mucosal inflammation, and various cellular changes. Both disorders have similar symptoms such as epigastric pain or discomfort, early satiety, and bloating. If patients suspected of having either gastroparesis or functional dyspepsia present with upper gastrointestinal symptoms, they should undergo upper endoscopy to exclude an alternative organic cause. Although the gastric emptying rate is frequently assessed during the clinical workup of patients with gastroparesis or functional dyspepsia, the correlation between gastric emptying and the symptoms is generally poor. Once the diagnosis of gastroparesis or functional dyspepsia is made, treatment should focus on the predominant symptom. Recently, various treatment modalities have been developed and validated. Prokinetic agents are generally used as treatment for both gastroparesis and functional dyspepsia. Acid-suppressive therapy, Helicobacter pylori eradication, and use of drugs that enhance gastric accommodation are employed for functional dyspepsia. Psychoactive drugs are also effective in symptom control. For gastroparesis, antiemetic agents, ghrelin receptor agonists, and serotonergic agents are used aside from prokinetic agents. Acupuncture and gastric electrical stimulation can be attempted. In severe cases, endoscopic and surgical interventions are considered for symptom control.

Acupuncture and related techniques for type 2 diabetes mellitus: A systematic review protocol

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a major global health problem. As a complementary treatment, acupuncture and related techniques are widely used to treat metabolic and endocrine diseases, but their efficacy and safety for T2DM are yet to be established. This systematic review will qualitatively and quantitatively summarize the current randomized controlled trial (RCT) evidence regarding the efficacy and safety of acupuncture and related techniques in patients with T2DM.

METHODS

Comprehensive literature searches will be performed on PubMed, Embase, Cochrane Central Register of Controlled Trials, and a trial registry "ClinicalTrials.gov" from inception to December 3, 2018. We will include RCTs for patients with T2DM that compared acupuncture with placebo, antidiabetic drugs, lifestyle interventions, or the combination. Primary outcomes are fasting blood glucose and hemoglobin A1c. Secondary outcomes include 2-hour blood glucose, fasting insulin, homeostatic model assessment for insulin resistance, incidence of diabetic complications, and acupuncture-related adverse events. The risk of bias of the RCTs included in the review will be examined using a revised Cochrane handbook tool. Heterogeneity will be detected using Cochran Q test and I statistics. With the use of random effects model, we will perform meta-analyses to pool results of RCTs. The effect measures will be weighted or standardized mean difference with 95% confidence intervals (CIs) for the continuous outcomes and risk ratio with 95% CIs for the dichotomous outcomes. Subgroup analyses and meta-regression with predefined effect modifiers will be performed to explore the sources of heterogeneity. Where appropriate, we will assess the possibility of reporting bias based on funnel plots and quantitative detection. We will appraise the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation system for each outcome.

RESULTS

This study will provide accurate results and balanced inferences on the efficacy and safety of acupuncture and related techniques on T2DM.

CONCLUSION

This well-designed systematic review will establish high-quality evidence of the efficacy and safety of acupuncture and related techniques for T2DM to facilitate the clinical practice and guideline development.

PROSPERO REGISTRATION NUMBER

CRD42018115639.

Augmentation of Cancer Cachexia Components With Targeted Acupuncture in Patients With Gastrointestinal Cancers: A Randomized Controlled Pilot Study

INTRODUCTION

Patients with gastrointestinal (GI) cancer-associated cachexia are at risk of high morbidity and mortality. This randomized single-blind pilot study compared the complementary use of targeted acupuncture (TA) with nontargeted acupuncture (NTA) for halting cachexia symptoms.

METHODS

GI cancer patients with cachexia undergoing chemotherapy were assigned to receive 8 weekly sessions of either TA (n = 15) or NTA (n = 15) following a specific acupuncture protocol. Bioelectrical impedance analysis and weight were measured weekly. Biological markers, including C-reactive protein, prealbumin, tumor necrosis factor-α, lactate dehydrogenase (LDH), leptin, and ghrelin blood levels were determined at specific intervals.

RESULTS

Prealbumin levels and fat-free mass were significantly higher in the NTA group at the end of the study, but remained stable in TA group. TA group had significantly lower (230 IU/L vs 288 IU/L, P = .04) LDH at the end of the study, but elevated tumor necrosis factor-α levels (13.15 pg/mL vs 9.24 pg/mL, P = .04). The absolute blood leptin and ghrelin levels decreased in the TA but remained stable in the NTA group. Both groups maintained weight, but the TA group trended toward weight gain during the last 2 weeks of the study. No adverse events related to acupuncture were reported.

CONCLUSIONS

TA using predetermined, reproducible points may provide benefits to some patients with GI cancer cachexia by normalizing metabolic dysregulation. Elevated ghrelin levels are indicative of insulin resistance, which can lead to increased muscle loss represented by increased LDH activity in the NTA group. The pilot study provided completion rate and effect size for the primary outcome measures for a larger study. A longer treatment duration may be required to further refine these findings.

The Effects of Auricular Electro-Acupuncture on Ameliorating the Dysfunction of Interstitial Cells of Cajal Networks and nNOSmRNA Expression in Antrum of STZ-Induced Diabetic Rats

BACKGROUD

Interstitial cells of Cajal (ICCs) and nNOS play a crucial role in diabetic gastrointestinal dysmotility(DGD). Our previous study found that electro-acupuncture(EA) on ear point 'stomach' could repair the gastric dysrhythmias in rats induced by rectal distention(RD) after meal. However, little were known about the possible effect of auricular electro-acupuncture (AEA) on diabetic rats. Thus, we designed this study to investigate the effect of AEA on streptozotocin(STZ)-induced diabetic rats.

METHOD

Forty male Sprague_Dawley (SD) rats were injected with STZ, at the end of 8th week after injection, animals were randomly divided into four groups and received 2 weeks-treatment(10 times) respectively: control group(CON,n = 10, no stimulation), sham auricular electro-acupuncture group(SEA,n = 10, low frequency EA on earlobes), auricular eletro-acupuncture group(AEA,n = 10, low frequency EA on ear point 'stomach'), and ST-36 group(ST-36,n = 10, low frequency EA on ST-36). Gastrointestinal (GI) motility was measured by GI transit rate. ICCs(c-kit+ expression) in antrum were analyzed by Immunohistochemistry and western blotting. NO level in blood serum were detected by Griess Reagent, and nNOSmRNA expression in antrum were determined by Real-time PCR.

RESULTS

GI transit rate and ICCs(c-kit+ expression) in antrum of AEA group have the tendency to increase compared with CON group, but had no statistics difference (P>0.05). nNOSmRNA expression in antrum of AEA group was dramatically increased compared with CON group (P = 0.037).

CONCLUSIONS

Low frequency EA on ear 'stomach' point could significantly up-regulate nNOS mRNA expression and ameliorate the ICCs networks partly in gastric antrum of STZ -induced diabetic rats, which may has benefits on regulating the GI motility.