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Shen H, Yang J, Chen X, Gao Y, He B. Role of hypoxia-inducible factor in postoperative delirium of aged patients: A review. Medicine (Baltimore) 2023; 102:e35441. [PMID: 37773821 PMCID: PMC10545271 DOI: 10.1097/md.0000000000035441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 09/08/2023] [Indexed: 10/01/2023] Open
Abstract
Postoperative delirium is common, especially in older patients. Delirium is associated with prolonged hospitalization, an increased risk of postoperative complications, and significant mortality. The mechanism of postoperative delirium is not yet clear. Cerebral desaturation occurred during the maintenance period of general anesthesia and was one of the independent risk factors for postoperative delirium, especially in the elderly. Hypoxia stimulates the expression of hypoxia-inducible factor-1 (HIF-1), which controls the hypoxic response. HIF-1 may have a protective role in regulating neuron apoptosis in neonatal hypoxia-ischemia brain damage and may promote the repair and rebuilding process in the brain that was damaged by hypoxia and ischemia. HIF-1 has a neuroprotective effect during cerebral hypoxia and controls the hypoxic response by regulating multiple pathways, such as glucose metabolism, angiogenesis, erythropoiesis, and cell survival. On the other hand, anesthetics have been reported to inhibit HIF activity in older patients. So, we speculate that HIF plays an important role in the pathophysiology of postoperative delirium in the elderly. The activity of HIF is reduced by anesthetics, leading to the inhibition of brain protection in a hypoxic state. This review summarizes the possible mechanism of HIF participating in postoperative delirium in elderly patients and provides ideas for finding targets to prevent or treat postoperative delirium in elderly patients.
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Affiliation(s)
- Hu Shen
- Department of Neurology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jianyin Yang
- Department of ICU, Chengdu Xinjin District Hospital of Traditional Chinese Medicine, Chengdu, China
| | - Xu Chen
- Department of Pharmacy, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yu Gao
- Department of Pharmacy, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Baoming He
- Department of Neurology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Min YJ, Yao HH, Wang L, Cheng LH, Hong ES. Comparison and effect of moxibustion and acupuncture on Nogo/NgR signaling pathway in rats with cerebral ischemia/reperfusion injury. J Tradit Complement Med 2023; 13:430-440. [PMID: 37693099 PMCID: PMC10491986 DOI: 10.1016/j.jtcme.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 03/04/2023] [Accepted: 03/10/2023] [Indexed: 04/03/2023] Open
Abstract
Background and aim In China, acupuncture and moxibustion have been used effectively to treat various diseases for thousands of years. However, the evidence for a difference in the efficacies of moxibustion and acupuncture in cerebral infarction treatment is scarce. We aimed to compare the effects of acupuncture and moxibustion treatment on the Nogo/NgR signaling pathway in rats with cerebral ischemia/reperfusion (I/R) injury. Experimental procedure Eighty male SD rats were randomly divided into five groups, based on treatment received: sham surgery (sham group), middle cerebral artery occlusion (MCAO, MCAO group), MCAO and NEP(1-40) inhibitor injection (MCAO + block group), MCAO and moxibustion (MCAO + moxi group), and MCAO and minimal acupuncture (MCAO + MA group). Neurological status was evaluated before treatment, and cerebral infarction volume (IV) and neurological function; Nogo-A, NgR, p75NTR, and LINGO-1 expressions; and NgR and LINGO-1 co-expression were assessed after treatment. Results and conclusion After treatment, barring Nogo-A mRNA and protein expression in the MCAO + block group, the Longa score and IV significantly decreased; Nogo-A, NgR, p75NTR, and LINGO-1 mRNA and protein expressions as well as NgR and LINGO-1 co-expression significantly decreased in cerebral tissues; whereas the BWT score increased (P < 0.01) in the MCAO + moxi group, compared with the MCAO group. Except for NgR and LINGO-1 protein expressions, there were no significant differences in the abovementioned parameters between rats that underwent acupuncture and moxibustion. Acupuncture and moxibustion have similar effects on Nogo/NgR signaling pathway inhibition after cerebral infarction.
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Affiliation(s)
- You-jiang Min
- School of Traditional Chinese Medicine, Nanchang Medical College, Nanchang, 330052, Jiangxi, China
- Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang, 330006, Jiangxi, China
| | - Hai-hua Yao
- Shanghai Eighth People's Hospital, Shanghai, 200235, Shanghai, China
| | - Li Wang
- School of Traditional Chinese Medicine, Nanchang Medical College, Nanchang, 330052, Jiangxi, China
| | - Li-hong Cheng
- Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang, 330006, Jiangxi, China
| | - En-si Hong
- Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, Nanchang, 330006, Jiangxi, China
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Perreault T, Ball A, Dommerholt J, Theiss R, Fernández-de-las-Peñas C, Butts R. Intramuscular Electrical Stimulation to Trigger Points: Insights into Mechanisms and Clinical Applications—A Scoping Review. J Clin Med 2022; 11:jcm11206039. [PMID: 36294360 PMCID: PMC9605351 DOI: 10.3390/jcm11206039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 11/21/2022] Open
Abstract
Intramuscular electrical stimulation (IMES) is a modality used by clinicians to treat myofascial pain. Recent studies have shown positive results for the use of IMES on pain outcomes, yet studies investigating the potential mechanisms of IMES directly to trigger points (TrPs) are lacking. We performed a scoping review of the literature to summarize the current evidence from human and animal studies on the mechanisms of IMES to the TrP location, and to identify gaps in the existing literature. Electronic literature searches were conducted across five databases from inception to 15 August 2022, including PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), Scopus and Cochrane Register of Controlled Trials. Four studies met our full criteria for inclusion in this review. Three studies assessed the effects of IMES to TrPs on human subjects with MPS, and only one study used an animal model with experimentally generated TrPs. Based on the results of the included studies, IMES within a TrP region was reported to normalize muscle blood flow, decrease endplate noise of the TrP and elicit antinociceptive effects, at least partially, through engaging supraspinal descending pain inhibitory systems. At present, no clinical implications can be determined on the use of IMES to TrPs due to the limited amount and quality of the available evidence. Further studies investigating the clinical effectiveness and also underlying mechanisms of IMES to TrPs are clearly needed.
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Affiliation(s)
- Thomas Perreault
- Department of Physical Therapy, Wentworth Douglass Hospital, Dover, NH 03820, USA
- Correspondence: ; Tel.: +1-603-740-2101
| | - Andrew Ball
- Atrium Health, Carolinas Rehabilitation, Charlotte, NC 28216, USA
- Myopain Seminars, Bethesda, MD 20814, USA
| | - Jan Dommerholt
- Myopain Seminars, Bethesda, MD 20814, USA
- Department of Physical Therapy and Rehabilitation Science, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
| | - Robert Theiss
- Department of Physical Medicine and Rehabilitation, Atrium Health, Carolinas Rehabilitation, Charlotte, NC 28203, USA
| | - César Fernández-de-las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28922 Madrid, Spain
- Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, 28922 Madrid, Spain
| | - Raymond Butts
- Department of Rehabilitative Sciences, Gannon University, Ruskin, FL 33573, USA
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The following was originally published in ACUPUNCTURE & ELECTRO-THERAPEUTICS RES., INT. J., Vol. 46, pp. 357-369, 2021. ACUPUNCTURE ELECTRO 2021. [DOI: 10.3727/036012921x16237619666067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Hua Y, Li C, Hu J, Wang YY, Liu PL, Gao BY, Chen C, Xu DS, Zhang B, Bai YL. Fluoxetine adjunct to therapeutic exercise promotes motor recovery in rats with cerebral ischemia: Roles of nucleus accumbens. Brain Res Bull 2019; 153:1-7. [PMID: 31369829 DOI: 10.1016/j.brainresbull.2019.07.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 07/03/2019] [Accepted: 07/19/2019] [Indexed: 01/05/2023]
Abstract
The study aimed to explore the molecular mechanism of fluoxetine as an adjunct to therapeutic exercise to improve motor recovery using a rat cerebral ischemic model with middle cerebral artery occlusion (MCAO). We hypothesized that the nucleus accumbens (NAc) may be one of the responding areas to fluoxetine where relevant elevations in 5-hydroxytryptamine (5-HT) and ΔFosB were associated with motor behavioral recovery. Male Sprague-Dawley rats were randomly divided into five groups: rats without intervention; rats that underwent MCAO without exercise or fluoxetine; rats that underwent MCAO treated only with fluoxetine; rats that underwent MCAO treated only with exercise; and rats that underwent MCAO treated with both exercise and fluoxetine. Motor function and motivation were assessed by the fault footsteps test and the forced swimming test. 5-HT level in the bilateral NAc and the expression of 5-HT2C receptor (5-HT2CR) and ΔFosB in the ipsilesional (left) NAc were measured. Correlation was explored by Pearson correlation analysis. Our results indicated that either treatment helped improve the grasp dexterity of the affected limb, motor motivation, and resilience to adverse environment in MCAO rats. The dual treatment with fluoxetine and exercise may hasten the recovery process. The dual treatment helped restore the balance of 5-HT level between the bilateral NAc by significantly increasing its level in the ipsilesional side. Either treatment could resume the expression of 5-HT2CR in the ipsilesional side of the NAc close to the normal level, which was correlated with motor recovery. The dual treatment significantly increased the expression of ΔFosB in the ipsilesional side of the NAc, which was correlated with the balance of 5-HT in the bilateral NAc, but not directly with motor recovery. In conclusion, the NAc may play an important role in driving physical motivation, which was possibly related to motor recovery after stroke. Fluoxetine may hasten the effectiveness of therapeutic exercise, possibly via regulating 5-HT and its receptors in the NAc.
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Affiliation(s)
- Yan Hua
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Ce Li
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Jian Hu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yu-Yuan Wang
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Pei-Le Liu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Bei-Yao Gao
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Chan Chen
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Dong-Sheng Xu
- Rehabilitation Section, Spine Surgery Division of Department of Orthopedics, Tongji Hospital Affiliated to Tongji University School of Medicine, Key Laboratory of spine and spinal cord injury repair and regeneration (Tongji University), Ministry of Education of the People's Republic of China, Shanghai 200065, China
| | - Bei Zhang
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China.
| | - Yu-Long Bai
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China.
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Electroacupuncture on ST36 and GB39 Acupoints Inhibits Synovial Angiogenesis via Downregulating HIF-1 α/VEGF Expression in a Rat Model of Adjuvant Arthritis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 2019:5741931. [PMID: 31316573 PMCID: PMC6601504 DOI: 10.1155/2019/5741931] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/25/2019] [Accepted: 05/28/2019] [Indexed: 12/19/2022]
Abstract
Introduction. The hypoxia inducible factor-1α (HIF-1α) and vascular endothelial growth factor (VEGF) play a key role in synovial angiogenesis in rheumatoid arthritis (RA). Therefore, this study aimed to test the hypothesis that electroacupuncture (EA) may inhibit RA synovial angiogenesis via HIF-1α/VEGF expression. Methods. Sprague-Dawley rats were randomly distributed to 4 groups: control, adjuvant arthritis (AA), AA+electroacupuncture (AA+EA), and AA+sham EA groups. AA model was induced by injection of Freund's complete adjuvant in bilateral hind footpad. 3 days after injection, EA was delivered to the acupoints Zusanli (ST 36) and Xuanzhong (GB 39) once every two days for a total of 8 times in the AA+EA group, while sham EA treatment was applied in the AA+sham EA group. The arthritis score, paw volume, and H&E staining for each animal were measured. CD34 expression in synovial tissue of ankle joint was observed by immunohistochemistry. HIF-1α and VEGF mRNA and protein levels in synovial tissue were determined by real-time quantitative PCR and Western blot, respectively. Results. Compared with rats in AA group, EA stimulation significantly decreased arthritis scores, paw volume, and pathological damage of synovial tissues. Moreover, EA markedly suppressed the synovial angiogenesis of AA rats, as evidenced by reduced CD34 positive expression. Furthermore, EA significantly reduced HIF-1α and VEGF mRNA and protein levels in synovial of AA rats. Finally, the CD34 expression in synovial tissue was positively correlated with HIF-1α and VEGF protein levels. Conclusion. EA on ST36 and GB39 acupoints can effectively inhibit synovial angiogenesis in the AA rat model via downregulating HIF-1α/VEGF expression.
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Yang JW, Wang XR, Ma SM, Yang NN, Li QQ, Liu CZ. Acupuncture attenuates cognitive impairment, oxidative stress and NF-κB activation in cerebral multi-infarct rats. Acupunct Med 2019; 37:283-291. [PMID: 31166115 DOI: 10.1136/acupmed-2017-011491] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUD Patients with multiple infarct dementia (MID) have subtle deficits that commonly go unnoticed, and are at risk of developing Alzheimer's disease. Oxidative stress induced by ischaemic injury results in intracellular calcium accumulation and neuronal apoptosis, leading to cognitive impairment by triggering various cellular signal transduction pathways. Several studies have suggested that NF-κB in the presence of p53 has a pro-apoptotic function in various models, but the mechanism is unclear. AIMS The aim of this study was to investigate whether acupuncture could protect cognitive function against cerebral multi-infarction (CMi) induced oxidative stress by inhibiting the activation of NF-κB and its target gene p53. METHODS An animal model of CMi was established by injecting homologous blood emboli into the right internal carotid artery of male Wistar rats. After 2 weeks of acupuncture treatment, cognitive function was detected by novel object recognition. Electron spin resonance and Fluo-3 fuorescence imaging were used to test the generation of ROS and intracellular calcium accumulation, respectively. Expression of NF-κB and p53 was examined by Western blot analysis and immunofluorescence. RESULTS CMi induced spatial learning and memory impairment, overproduction of intracellular hydroxyl radicals, and elevations of Ca2+, which were ameliorated by verum acupuncture treatment. Acupuncture inhibited activation of NF-κB and its downstream target gene p53. CONCLUSION These findings suggest that acupuncture could protect cognitive function against oxidative stress induced by CMi, which is partially associated with suppression of NF-κB-p53 activation.
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Affiliation(s)
- Jing-Wen Yang
- Acupuncture and Moxibustion Department, Beijing Hospital of Traditional Chinese Medicine affiliated to Capital Medical University, Beijing, China
| | - Xue-Rui Wang
- Acupuncture and Moxibustion Department, Beijing Hospital of Traditional Chinese Medicine affiliated to Capital Medical University, Beijing, China
| | - Si-Ming Ma
- Acupuncture and Moxibustion Department, Beijing Hospital of Traditional Chinese Medicine affiliated to Capital Medical University, Beijing, China
| | - Na-Na Yang
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Qian-Qian Li
- Acupuncture and Moxibustion Department, Beijing Hospital of Traditional Chinese Medicine affiliated to Capital Medical University, Beijing, China
| | - Cun-Zhi Liu
- School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
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Xing Y, Zhang M, Li WB, Dong F, Zhang F. Mechanisms Involved in the Neuroprotection of Electroacupuncture Therapy for Ischemic Stroke. Front Neurosci 2018; 12:929. [PMID: 30618558 PMCID: PMC6297779 DOI: 10.3389/fnins.2018.00929] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 11/27/2018] [Indexed: 12/13/2022] Open
Abstract
Stroke is one of the main causes of death all over the world. As the combination of acupuncture and electric stimulation, electroacupuncutre is a safe and effective therapy, which is commonly applied in ischemic stroke therapy in both experimental studies and clinical settings. The review was performed via searching for related articles in the databases of OVID, PUBMED, and ISI Web of Science from their respective inceptions to May 2018. In this review, we summarized the mechanism of EA for ischemic stroke via a series of factors, consisting of apoptosis related-factors, inflammatory factors, autophagy-related factors, growth factors, transcriptional factors, cannabinoid CB1 receptors, and other factors. In summary, EA stimulation may effectively alleviate ischemic brain injury via a series of signal pathways and various other factors.
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Affiliation(s)
- Ying Xing
- Department of Rehabilitation Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Min Zhang
- Department of Pathophysiology, Hebei Medical University, Shijiazhuang, China
| | - Wen-Bin Li
- Department of Pathophysiology, Hebei Medical University, Shijiazhuang, China
| | - Fang Dong
- Department of Clinical Laboratory Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Feng Zhang
- Department of Rehabilitation Medicine, The Third Hospital of Hebei Medical University, Shijiazhuang, China.,Hebei Provincial Orthopedic Biomechanics Key Laboratory, The Third Hospital of Hebei Medical University, Shijiazhuang, China
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Zhang J, Lin X, Zhou H, Chen Y, Xiao S, Jiao J, Zhao Y, Di Z. Electroacupuncture: a new approach to open the blood-brain barrier in rats recovering from middle cerebral artery occlusion. Acupunct Med 2018; 36:377-385. [PMID: 29903719 PMCID: PMC6287560 DOI: 10.1136/acupmed-2017-011496] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2018] [Indexed: 12/25/2022]
Abstract
Objective To examine for an opening effect on the blood–brain barrier (BBB) in intact rats and rats with experimental ischaemia-reperfusion (I/R) during the recovery period after various electroacupuncture (EA) treatments with different time courses, and to determine whether there is a time-dependent effect. An additional objective was to determine whether this method could induce the penetration of nerve growth factor (NGF) through the BBB. Methods A middle cerebral artery occlusion (MCAO) model was first established. We chose different stimulation time courses and observed the effects of EA treatment (100 Hz frequency; 2 mA intensity) at GV20 and GV26 on the BBB in rats recovering from MCAO 3 weeks after modelling. The rats were injected with 2% Evans blue (EB) saline. The brain water content was measured using a wet/dry weighing method. The degree of penetration of EB was detected using spectrophotometry and laser confocal microscopy. The rats were then injected with NGF, and the concentration of NGF in the brain tissues was measured using ELISA. Results The increase in the BBB permeability was most notable following the 8 min EA stimulation (P<0.05), which may be advantageous for the targeted delivery of drugs (such as NGF) into the brain. Additionally, this effect did not appear to cause brain oedema (P>0.05) in healthy or MCAO rats. Conclusions EA treatment for a certain stimulation time at GV20 and GV26 in MCAO rats can increase BBB permeability.
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Affiliation(s)
- Jiangsong Zhang
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Department of Neurobiology and Acupuncture Research, Hangzhou, China
| | - Xianming Lin
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Department of Neurobiology and Acupuncture Research, Hangzhou, China
| | - Hui Zhou
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Department of Neurobiology and Acupuncture Research, Hangzhou, China
| | - Yuanyuan Chen
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Department of Neurobiology and Acupuncture Research, Hangzhou, China
| | - Shuangkai Xiao
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Department of Neurobiology and Acupuncture Research, Hangzhou, China
| | - Junyue Jiao
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Department of Neurobiology and Acupuncture Research, Hangzhou, China
| | - Yibin Zhao
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Department of Neurobiology and Acupuncture Research, Hangzhou, China
| | - Zhong Di
- The Third Clinical Medical College, Zhejiang Chinese Medical University, Department of Neurobiology and Acupuncture Research, Hangzhou, China
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Abstract
Acupuncture is potentially beneficial for post-stroke rehabilitation and is considered a promising preventive strategy for stroke. Electroacupuncture pretreatment or treatment after ischemic stroke by using appropriate electroacupuncture parameters generates neuroprotective and neuroregenerative effects that increase cerebral blood flow, regulate oxidative stress, attenuate glutamate excitotoxicity, maintain blood-brain barrier integrity, inhibit apoptosis, increase growth factor production, and induce cerebral ischemic tolerance.
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Affiliation(s)
- Qwang-Yuen Chang
- Department of Family Medicine, Lin Shin Hospital, Taichung, Taiwan, China
| | - Yi-Wen Lin
- Research Center for Chinese Medicine and Acupuncture; Graduate Institute of Acupuncture Science, College of Chinese Medicine, China Medical University, Taichung, Taiwan, China
| | - Ching-Liang Hsieh
- Research Center for Chinese Medicine and Acupuncture; Graduate Institute of Acupuncture Science, College of Chinese Medicine; Graduate Institute of Integrated Medicine, College of Chinese Medicine, China Medical University; Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan, China
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