The Methodology and Practices of Real-world Study of Acupuncture and Moxibustion / 中山大学学报(医学科学版)

Real-world study is based on evidence in real clinical medical environments. The results of real-world study have high clinical applicability and strong extrapolation， and are more in line with the characteristics of acupuncture and moxibustion. Therefore， real-world study is receiving more and more attention from the clinical research community. In this article， we briefly analyze the compatibility between real-world study and clinical research of acupuncture and moxibustion，and discuss the implementation of real-world research methodology of acupuncture and moxibustion. In addition， the shortcomings and countermeasures of real-world study on acupuncture and moxibustion in China are also summarized. At the end， we provide an outlook on the application of real-world study in clinical research of acupuncture and moxibustion.

Improving acupuncture research: progress, guidance, and future directions / 中国针灸

This paper makes an interpretation of the collection Acupuncture: how to improve the evidence base published by BMJ & BMJ Open. Studies show that the quality of randomized controlled trial (RCT) of acupuncture is low, and multivariable Meta-regression analysis fails to confirm most factors commonly believed to influence the effect of acupuncture. The methodological challenges in design and conduct of RCT in acupuncture were analyzed, and a consensus on how to design high-quality acupuncture RCT was developed. The number of acupuncture systematic reviews was huge but the evidence was underused in clinical practice and health policy, and a large number of western clinical practice guidelines recommended acupuncture therapy, but the usefulness of recommendations needed to be improved. In view of the problems in clinical research on acupuncture mentioned in this collection, combined with the analysis of the purpose of clinical research on acupuncture, perspectives, study types, as well as the relationship between evidence and clinical decision-making, a five-stage study paradigm of clinical research on acupuncture is proposed.

Effect of acupotomy intervention on the morphology and ultrastructure of rectus femoris muscle in rabbits with knee osteoarthritis / 中国骨伤

OBJECTIVE@#To observe the effect of acupotomy on the morphology and ultrastructure of rectus femoris muscle in rabbits with knee osteoarthritis and to reveal the possible therapeutic mechanism involved in the effect of acupotomology on the treatment of knee osteoarthritis(KOA).@*METHODS@#Twenty-four male New Zealand rabbits aged 6 months and weighed (2.0±0.5) kg were randomly divided into blank group, model group and acupotomy group, 8 rabbits in each group. KOA model was established by modified Videman method with left hind limb extended plaster immobility for 6 weeks. In acupotomy group, the transfascial focal points of quadriceps femoris muscle were released by acupotomy under the guidance of Jingjin theory for 4 times and once a week, and the treatment points include Hedingci, Binwaixia, Binneixia. Blank group and model group were fed normally without intervention. One week after the end of the intervention, the pennation angle(PA), muscle thickness(MT), cross-sectional area(CSA) and strain ratio(SR) of rectus femoris were measured by ultrasound. HE staining was used to observe the changes of the tissue morphology, the number of muscle fibers and the average area of muscle fibers. The myofibril of rectus femoris, sarcomere and myofilament were observed by transmission electron microscope.@*RESULTS@#The PA of rectus femoris muscle in the blank group was (9.05±0.21)°. The MT was(1.09±0.09) cm and the CSA was(1.30±0.01) cm2. The PA of rectus femoris muscle in the model group was (3.06±0.15)°. The MT was (0.71±0.02) cm and the CSA was(0.77±0.02) cm2. The PA of rectus femoris muscle in the acupotomy group was (6.94±0.28)°. The MT was (0.80±0.05) cm and the CSA was(0.94±0.03) cm2. The muscle PA, MT and CSA of rectus femoris in the model group were significantly smaller than those in the blank group (P<0.05). Those in acupotomy group were significantly increased compared with those in model group (P<0.05). The SR of rectus femoris muscle was 1.19±0.02 in the blank group, 3.50±0.05 in the model group and 1.99±0.07 in the acupotomy group. The elastic SR of the model group was significantly higher than that of the blank group (P<0.05). These in acupotomy group was significantly lower than that in model group(P<0.05). The results of HE staining showed:in blank group, the fascicles of rectus femoris were arranged neatly, the number of beam of muscle fibers within the fixed visual field was 94.38±3.50 and the average CSA was(0.75±0.22) mm2. In model group, the fascicles of rectus femoris with different sizes were disorganized with a small amount of inflammatory cell infiltration, the number of beam of muscle fibers within the fixed visual field was 196.63±2.62 and the average CSA was(0.26±0.03) mm2. Compared to the blank group, a significant increase in the number of muscle fibers in the fixed field in the model group (P<0.05) and the average CSA decreased significantly(P<0.05). In acupotomy group, the rectus femoris fascicles in the acupotomy group tended to be arranged in a more orderly manner, with the inflammatory cells decreased, the number of beam of muscle fibers within the fixed visual field was 132.88±4.61 and the average CSA was(0.70±0.07) mm2. Compared to the model group, a significant decrease in the number of muscle fibers in the fixed field in the model group(P<0.05) and the average CSA increased significantly(P<0.05). The results of transmission electron microscope showed:compared with the blank group, the overall arrangement of the myofibrils of the rectus femoris in the model group was less structured. There was fracture between the muscle fibers and the sarcomere, the myofilaments were disordered, and the fracture of the Z line was discontinuous. Compared with the model group, the myofibrillar texture of rectus femoris in acupotomy group was clearer, and the Z line was more continuous.@*CONCLUSION@#Based on the jingjin theory, the release of quadriceps femoris by acupotomy can effectively improve the morphology and structure of rectus femoris, and promote the repair and reconstruction of chronic skeletal muscle injury in rabbits with KOA, which may be one of the mechanisms of acupotomy in the treatment of KOA.

Ultrasound anatomy and needle-knife insertion approach of common tendon lesions in knee osteoarthritis based on meridian sinew theory / 中国针灸

OBJECTIVE@#To explore the ultrasonic anatomical characteristics and needle-knife insertion approach of common tendon lesions in knee osteoarthritis (KOA), so as to provide the references for accurate release of KOA by needle- knife along tendon lesions based on meridian sinew theory.@*METHODS@#Sixty patients with one-knee KOA were selected. High-frequency musculoskeletal ultrasound was used to collect sonograms at the anatomical positions of "Hedingci" "Binwaixia" "Binneixia" and "Yinlingshang". The anatomic levels were marked on the sonograms. The anatomic levels and sonographic features of lesions were compared and analyzed, and the relevant data of needle-knife simulation approach was measured.@*RESULTS@#The "Hedingci" lesions were mainly located at the attachment of quadriceps tendon to patella and suprapatellar bursa. The "Binwaixia" and "Binneixia" lesions were mainly located at the attachment of retinaculum patellae laterale and retinaculum patellae mediale to patella and infrapatellar fat pad. The "Yinlingshang" lesions were mainly located at the attachment of goose foot tendon to medial tibial condyle and bursa of goose foot. With "Hedingci" as an example, when the needle-knife entry point was 1 cm above the patella, the attachment of quadriceps tendon to patella was released, and the average depth of needle-knife was (3.60±0.10) cm, and the needle body was perpendicular to the skin. The average depth of needle-knife for releasing suprapatellar bursa was (2.35±0.17) cm, and the needle body was 45° towards head.@*CONCLUSION@#The musculoskeletal ultrasound could clearly show the local detailed anatomical level, ultrasonic characteristics and anatomical level of common tendon lesions of KOA, and could improve the accuracy of needle-knife along tendon lesions with non-direct vision, which has important reference value for needle-knife medical standardization and standardized operation.

Application of expertise-based pragmatic randomized controlled trial in acupuncture-moxibustion clinical research / 中国针灸

According to clinical practice, the characteristics and issues of pragmatic randomized controlled trial(PRCT) and expertise-based randomized controlled trial (EBRCT) in acupuncture-moxibustion clinical research were summarized. The characteristics of expertise-based pragmatic randomized controlled trial (EB-PRCT), which is the combination of above two, and its application in acupuncture-moxibustion clinical trial were explored. PRCT emphasizes the clinical practice, the positive control of standard therapy and the the blind performance on data collection and statistics. PRCT has the advantage of flexible grouping, nevertheless, it also has shortcomings such as higher cost and lack of typical subjects. EBRCT emphasizes the participation of professional acupuncturists, so that the therapeutic effect is ensured, the compliance of subjects and the bias of manipulation are improved. Thus, the replacement scheme of acupuncturists is essential in EBRCT. Having the complementary advantages, EB-PRCT provides a superior research method for acupuncture-moxibustion clinical trial, and leads to convincing results.

Construction of the integrative evidence chain in clinical trial of acupuncture and moxibustion / 中国针灸

The research aims to propose the approaches to the clinical trial of acupuncture and moxibustion and provide the methodological guide for the research in this field in terms of the inadequate systematic collection, lack of the specific characteristics of acupuncture-moxibustion treatment and insufficient persuasion in clinical evidences of acupuncture-moxibustion research. Through a systematic review of the registration of acupuncture-moxibustion clinical trials at home and abroad, the distribution of diseases with the recommendation of acupuncture and moxibustion in Cochrane Library database, combined with the evidence grade of the evidence-based medicine and the individual characteristics of clinical practice with acupuncture and moxibustion, some research ideas and framework are proposed for the clinical trial of acupuncture and moxibustion. To take the curative effect as the forerumer, the dominant disease and therapeutic methods of acupuncture and moxibustion should be initially generalized by the case experiences and clinical observation at the first. In view of the potential function of acupuncture and moxibustion in treatment, the rigorous and standardized clinical trial should be carried out to verify their therapeutic effect. Finally, the experimental research is adopted to explore the mechanism of acupuncture and moxibustion. Through the combination of quantitative and qualitative methods, all of the evidences are integrated to form an integrative evidence chain. It is anticipated that the construction of the integrative evidence chain in clinical trial of acupuncture and moxibustion may enhance the promotion of clinical practice with acupuncture and moxibustion and increase the influence of acupuncture-moxibusiton discipline.

Impact evaluation of CONSORT and STRICTA guidelines on reporting quality for randomized controlled trials of acupuncture conducted in China / 中国结合医学杂志

<p><b>OBJECTIVE</b>To evaluate and compare the reports' qualities of acupuncture randomized controlled trials (RCTs) conducted in China before and after the implementation of two guidelines, i.e., the Consolidated Standards of Reporting Trials (CONSORT) statement and the Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA).</p><p><b>METHODS</b>Proportions of studies that reported CONSORT and STRICTA items were compared for the years before and after implementation of these two guidelines. In addition, the total score of each item's reporting were calculated and reported differences during different date ranges were compared.</p><p><b>RESULTS</b>For CONSORT items (maximum score 8), there was evidence of a slight improvement in reporting between 1994-1995 and 1999-2000 combined (2.5±0.6) and 2004-2005 and 2009-2010 combined (3.0±0.9; difference 0.4, 95% confidence interval, 0.3 to 0.6, P<0.01). For STRICTA items (maximum score 17), there was evidence that a slight improvement in reporting between 1994-1995 and 1999-2000 combined (8.6±2.1) and 2004-2005 and 2009-2010 combined (10.1±1.8; difference 1.5, 95% confidence interval, 1.1 to 1.9, P<0.01).</p><p><b>CONCLUSION</b>Quality of reporting for RCTs of acupuncture treatment conducted in China have generally improved since the introduction of the STRICTA and CONSORT guidelines.</p>

Association of IL-10 promoter polymorphism and plasma levels with susceptibility to vocal cords leukoplakia / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To investigated the association between interleukin-10(IL-10)-1082/-819/-592 promoter polymorphism, plasma IL-10 levels and risk of vocal leukoplakia.</p><p><b>METHODS</b>A case-control study of 61 patients with vocal cords leukoplakia and 119 healthy subjects were performed. Genotypes for the IL-10 gene (IL-10 -1082 G/A, -819 C/T and -592 C/A) were determined using pyrosequencing and plasma IL-10 levels were analyzed by ELISA.</p><p><b>RESULTS</b>Smoking and alcohol consumption increased the risk of vocal leukoplakia (OR = 4.73, 95%CI:2.4-9.1;OR = 5.70, 95%CI:2.9-11.2, P < 0.01) . Patients with vocal cord leukoplakia had significantly higher frequencies of AC at -592 and -819 (OR = 1.93, 95%CI:0.97-3.81, P = 0.05) and AG at -1082(OR = 2.14, 95%CI:0.87-5.27, P = 0.092) than control. Vocal leukoplakia patients had higher concentration of plasma IL-10 (21.6 ± 0.5) pg/ml (X(-) ± s) than controls (19.0 ± 1.1)pg/ml(t = 2.08, P = 0.043) and the haplotype containing the G allele was associated with higher plasma IL-10 concentrations (24.3 ± 5.7) pg/ml compared with the ATA haplotype(19.9 ± 4.7) pg/ml (t = -2.64, P = 0.008).</p><p><b>CONCLUSIONS</b>IL-10-1082/-819/-592 promoter polymorphism and high concentration of plasma IL-10 are associated with vocal cord leukoplakia, and the concentration of plasma IL-10 is associated with the genotypes of IL-10 promoter polymorphism.</p>

Thrichosanthin enhances cisplatin-induced laryngocarcinoma apoptosis through inhibiting transcription factor nuclear factor κB / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To investigate the combined effect of thrichosanthin (TCS) and cisplatin on Hep-2 and AMC-HN-8 cell proliferation.</p><p><b>METHODS</b>Hep-2 and AMC-HN-8 cells were treated with low (3 µg/ml) or high (10 µg/ml) concentration of cisplatin (10 µg/ml), TCS(5 µg/ml), or the combination TCS (5 µg/ml) and cisplatin (3 µg/ml), the cells no exposure to the drugs as control. Cell proliferation was detected by CCK-8. Toxicity of drugs to cells was evaluated by LDH assay. Flow cytometry was used to detect apoptosis. Western blot was performed to detect the expressions of JNK, phosphor-JNK, p38, phosphor-p38, NF-κB, inhibitor of κB (I-κB), and phospho-I-κB.</p><p><b>RESULTS</b>Compared with TCS (5 µg/ml) or cisplatin (3 µg/ml) alone, the combination of them had more significant inhibitory effect on the proliferation of Hep-2 and AMC-HN-8 cells (P < 0.01), but with no significant increase in cytotoxicity (P > 0.05). Western blot showed the expression of p-JNK/SAPK significantly increased in the cells treated with 5 µg/ml TCS for 48 hours, while the expression of NF-κB and phospho-I-κB increased in the cells treated with 3 µg/ml cisplatin. However in the cells treated with 5 µg/ml TCS combined with 3 µg/ml cisplatin, the expression of p-JNK stayed at a high level and the expressions of NF-κB and phospho-I-κB decreased dramatically compared to the cells treated with 3 µg/ml cisplatin alone.</p><p><b>CONCLUSIONS</b>TCS could enhance cisplatin-induced apoptosis in Hep-2 and AMC-HN-8, at least in part, by inhibiting the NF-κB signaling pathway and activating JNK/SAPK signaling pathway and thus strengthening the antitumor effects of cisplatin, which highlights the possibility of combined application of TCS and cisplatin in the treatment of laryngeal carcinoma.</p>

Expression and clinical significance of CCR6, CCR7 and CD4(+)CD25(+) Foxp3(+) regulatory T cells in laryngeal squamous cell carcinoma and neck lymphatic metastasis / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To evaluate the expressions and clinical significance of chemokine receptor 6 (CCR6), chemokine receptor 7(CCR7) and CD4(+)CD25(+)Foxp3(+) regulatory T cells (Treg) in laryngeal squamous cell carcinoma (LSCC) and metastatic lymph nodes.</p><p><b>METHODS</b>Blood samples and fresh specimens of LSCC were obtained from 50 LSCC patients treated. Blood samples from normal subjects were donated by 20 volunteers. The mRNA expressions of CCR6, CCR7 and their ligands CCL20, CCL19/CCL21 were detected by real-time quantitative RT-PCR. Expressions of CCR6 and CCR7 proteins were examined with immunohistochemistry. Flow cytometry was used to investigate Treg in peripheral blood mononuclear cells.</p><p><b>RESULTS</b>The relative expression levels of CCR6, CCR7 and CCL19 mRNA in tumor tissues with lymphatic metastases were significantly lower than those without lymph node metastases (P < 0.05), while the relative expression level of CCL20 mRNA in tumor tissues with lymphatic metastases was significantly higher than that of those without metastatic lymph nodes (t = 2.39, P < 0.05). Immunohistochemistry showed that the expression levels of CCR6 and CCR7 in tumor tissues in patients with lymph node metastases than those without lymph node metastases. CCR6 and CCR7 expressions were also detected in metastatic lymph nodes. Flow cytometry showed that the percentage of Treg in blood in LSCC patients was significantly higher than that in normal subjects (t = 2.19, P < 0.05), and those with lymph node metastasis had a much higher percentage of Treg (t = 2.14, P < 0.05).</p><p><b>CONCLUSIONS</b>CCR6, CCR7 and Treg could take part in the process of lymph node metastasis in LSCC patients.</p>