J Korean Med Sci. 2013 Mar;28(3):485-8. doi: 10.3346/jkms.2013.28.3.485. Epub 2013 Mar 4.
Stanford type A aortic dissection secondary to infectious aortitis: a case report.
Park BS, Min HK, Kang do K, Jun HJ, Hwang YH, Jang EJ, Jin K, Kim HK, Jang HJ, Song JW.
Source
Department of Internal Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea.
Abstract
Nowadays, infectious aortitis has become a rare disease thanks to antibiotics, but remains life-threatening. We present a case of a patient with acupuncture-induced infectious aortitis leading to aortic dissection. Chest computed-tomogram scan revealed Stanford type A dissection with pericardial effusion. Under the impression of an impending rupture, emergent surgery was performed. During surgery, infectious aortitis was identified incidentally, so she underwent resection of the infected aorta including surrounding tissues. Then the ascending aorta and hemi-arch were replaced with a prosthetic graft as an in situ fashion. The resected tissue and blood cultures revealed Staphylococcus aureus, so prolonged antibiotherapy was prescribed.
KEYWORDS:
Acupuncture, Aneurysm, Dissecting, Aortitis



Forsch Komplementmed. 2012;19(4):202-5. doi: 10.1159/000341869. Epub 2012 Aug 20.
[Development of lipoma following a single cupping massage - a case report].
[Article in German]
Schumann S, Lauche R, Hohmann C, Zirbes T, Dobos G, Saha FJ.
Source
Lehrstuhl für Naturheilkunde der Alfried Krupp von Bohlen und Halbach-Stiftung, Universität Duisburg-Essen, Deutschland.
Abstract
BACKGROUND:
The cupping massage is a form of bloodless cupping. This type of cupping is particularly used to treat muscular tension and musculoskeletal pain, such as chronic neck pain; however the data records on mechanisms and potential side effects are not satisfactory.
CASE REPORT:
In a study on the effectiveness of cupping massage in patients with chronic neck pain, one patient showed a formation of a lipoma in the cupping area after the first treatment session.
CONCLUSION:
Because of the short time interval between therapy and development of the lipoma, a primary cause is not realistic. This adverse event has not been described in the literature before, and the present report describes the case in summary.



Myositis ossificans in the paraspinal muscles of the neck after acupuncture: a case report.
Lee DG, Lee SH, Hwang SW, Kim ES, Eoh W.
Department of Neurosurgery, School of Medicine, Eulji University, 77, 771 beon-gil, Gyeryong-ro, Jung-gu, Daejon 301-746, Republic of Korea.
Abstract
BACKGROUND CONTEXT:
Although traumatic myositis ossificans (MO) has been reported occasionally, MO of paraspinal muscles has been rarely seen in the cervical spine after minor injury. This is difficult to distinguish from benign and malignant soft lesions in cases of a lack of definite trauma history.
PURPOSE:
We report a case of MO in the cervical paraspinal muscle after acupuncture and describe methods for diagnosis and proper treatment, including classification, etiology, and radiologic and histologic features.
STUDY DESIGN:
CaBull World Health Organ. 2010 December 1; 88(12): 915–921C.
Published online 2010 August 27. doi:  10.2471/BLT.10.076737

PMCID: PMC2995190

Acupuncture-related adverse events: a systematic review of the Chinese literature

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Événements indésirables liés à l’acupuncture: une évaluation systématique de la documentation chinoise

Junhua Zhang,corrautha Hongcai Shang,a Xiumei Gao,a and Edzard Ernstb
Author information ► Article notes ► Copyright and License information ►
This article has been cited by other articles in PMC.

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Abstract

Objective
To systematically review the Chinese-language literature on acupuncture-related adverse events.
Methods
We searched three Chinese databases (the Chinese Biomedical Literature Database, 1980–2009; the Chinese Journal Full-Text Database, 1980–2009; and the Weipu Journal Database, 1989–2009) to identify Chinese-language articles about the safety of traditional needle acupuncture. Case reports, case series, surveys and other observational studies were included if they reported factual data, but review articles, translations and clinical trials were excluded.
Findings
The inclusion criteria were met by 115 articles (98 case reports and 17 case series) that in total reported on 479 cases of adverse events after acupuncture. Fourteen patients died. Acupuncture-related adverse events were classified into three categories: traumatic, infectious and “other”. The most frequent adverse events were pneumothorax, fainting, subarachnoid haemorrhage and infection, while the most serious ones were cardiovascular injuries, subarachnoid haemorrhage, pneumothorax and recurrent cerebral haemorrhage.
Conclusion
Many acupuncture-related adverse events, most of them owing to improper technique, have been described in the published Chinese literature. Efforts should be made to find effective ways of monitoring and minimizing the risks related to acupuncture.se report.
METHODS:
A 26-year-old woman complained of posterior neck pain that had began 2 months earlier and neck swelling after acupuncture. No abnormal finding existed on the X-ray except soft tissue swelling. Magnetic resonance imaging was evaluated because of constant neck pain. To obtain more accurate assessment, computed tomography-guided biopsy was performed and a diagnosis of MO was made.
RESULTS:
The patient was conservatively treated through rest and analgesics. Posterior neck pain and swelling improved for a several months. The hyperdensity was comparable with the bony density, and the size of the calcified lesion on X-ray diminished until the last follow-up.
CONCLUSIONS:
Myositis ossificans that can occur after acupuncture should be recognized as a possible cause of persistent neck pain and swelling despite no definite trauma after thorough evaluation of the neoplasm and infection.
Copyright © 2013 Elsevier Inc. All rights reserved.


 
 
 
The journal of the American Academy of Medical Acupuncture with acupuncture research articles, reviews, abstracts and case studies.
 
 
 
 
 
 
 
 
 
 
 
 
 

Medical Acupuncture

A Journal For Physicians By Physicians
Fall 1999 / Wiinter 2000- Volume 11 / Number 2 "Aurum Nostrum Non Est Aurum Vulgi"

 

 
 
 
 
 

Table of Contents

       On-line Journal Index

 

 
 
 
 
 
adverse events
OVERVIEW: ADVERSE EVENTS OF ACUPUNCTURE
James K. Rotchford, MD
ABSTRACT      Acupuncture and adverse event are defined herein, followed by a review of problems associated with accurately determining the incidence of acupuncture's adverse events. The adverse events of acupuncture stated in the English-language literature, as well as suggestions on avoiding these adverse events from a clinical perspective, follow.
KEY WORDS      Acupuncture, Adverse Events, Adverse Effects, Side Effects, Overview
INTRODUCTION      The ancient Greeks gave Western medicine an important maxim: primum non nocere, "first do no harm." This maxim needs reassessing. If we are honest, we acknowledge that rare is the intervention that carries no risk of harming the patient. On the other hand, we have a duty to ensure that the possible benefits of any intervention clearly outweigh its risks. Additionally, informed consent is an appropriate and standard expectation in modem medicine; with the scanty data currently available, informed consent related to acupuncture is compromised. Further research into the possible adverse events associated with acupuncture will improve our ability to provide better informed consent. Exploring issues related to reducing and researching the risks are fundamental to serious research regarding clinical applications for acupuncture.
Definition of Acupuncture      Many of the reviews and case studies of adverse events of acupuncture fail to clearly define their use of the term acupuncture. One definition might be derived through the etymology of the word from the Latin roots acus (needle) and punctura (to puncture), implying that acupuncture is simply puncturing with needles. Another definition of acupuncture is "a model of medicine that promotes health through altering Qi flow within the body, and whose theories date from ancient Chinese times " Webster's dictionary defines acupuncture as originally a Chinese practice of puncturing the body (as with needles) to cure disease or relieve pain.      According to a 1997 National Institutes of Health Consensus Conference on acupuncture, "Acupuncture describes a family of procedures involving stimulation of anatomical locations on the skin by a variety of techniques. There are a variety of approaches to diagnosis and treatment in American acupuncture that incorporate medical traditions from China, Japan, Korea, and other countries."1      Definitions of acupuncture vary significantly. For the purpose of this discussion and research prerequisites, a very explicit definition is indicated. Thus, the definition of acupuncture is proposed:
Acupuncture is considered a therapeutic and/or preventive surgical procedure, and defined as the insertion of at least 1 thin, solid, metallic needle into the body. To meet the specific definition of acupuncture, the needles can be manipulated or stimulated only manually. The primary intent of needling is the stimulating of acupuncture point(s) as commonly defined in textbooks of acupuncture.2,3
     To be more explicit regarding the elements generating risk, the term acupuncture is limited to the use of needles. It is best to consider electrical stimulation, moxibustion, laser therapy, plum blossom therapy, cupping, etc, as separate procedures that are associated with their own unique risks. The paucity of data on these procedures, along with their inherent differences from "needling," also warrants their separate consideration. The intent to stimulate acupuncture points as a criteria for acupuncture is included. The common technique of dry needling trigger points should remain a separate procedure vis-a-vis definitions and risk assessment. Until data can be gathered to show otherwise, the risks and prerequisite skills associated with established Western medical procedures are best considered different from those of actually performing acupuncture. Perhaps this is true despite the common acceptance that when dealing with musculoskeletal complaints, a majority of "active" acupuncture points are also trigger points.
Definition of Adverse Event      A simple definition, used in the medical literature on adverse events in the hospital setting, is: "An adverse event is an injury or untoward event due to treatment, including failure to treat." Medical personnel generally know what this means in the hospital setting. For acupuncturists and researchers alike, there has been controversy regarding what constitutes an adverse event. Recent reviews and surveys, along with editorials and letters to the editor, have underscored some of these controversies.4-8      In response to MacPherson, along with White's opinion, to differentiate "healing reactions" from other acupuncture events, 6,7 Yamashita notes that "we should be consistent with those of adverse drug reactions."8 Further discussion followed about events that should be considered practitioner negligence or malpractice, and which simply are patient reactions. In her letter, White wrote of delayed diagnosis/therapy as an adverse event! She recounts the case in which a person died from asthma because of a failure to receive "standard" allopathic care in a timely fashion. This example reflects an indirect adverse event of acupuncture, rather than a direct one. Should it, therefore, be listed as an adverse event of acupuncture? The definition offered above includes delayed treatment as an adverse event, and is consistent with the list of adverse events following. As long as there are differences in intent with regard to acupuncture and differences in the interpretation of acupuncture events, a resolution of this controversy is unlikely. Cultural and intracultural differences with regard to standards of care also further complicate what is considered "adverse" in terms of care. Furthermore, it is problematic to define a priori what events constitute negligence or malpractice. These types of judgments are inevitably contextual/ legal, and rather than facilitating research in this area, might actually impede it and interfere with appropriate "system" preventive measures.9 It is difficult enough to accurately assess and evaluate the incidence of events attributable to acupuncture.
Problems Determining the Incidence of Acupuncture-Related Events
Under-reporting      Acupuncture is a surgical procedure and thus, clearly not entirely safe. It is, nonetheless, commonly considered to be relatively safe compared with Western medications and procedures.10,11 Acupuncture literature supports this notion; malpractice premiums are consistent with relatively low risk.12 The majority of state legislatures have permitted non-physician health care professionals to be licensed as acupuncturists.13 However, some believe that underreporting of adverse events is rampant, even in hospital settings.14 Perhaps under-reporting of pneumothorax following acupuncture is an example.      The medical literature suggests that the incidence of pneumothorax is rare and/or is only associated with incompetency.4,5,15 Yet there have been at least 2 cases in the author's practice of 15 years, and reports of at least 3 other cases in patients or their immediate family members. This reflects higher incidences than reported in the literature, but does not necessarily reflect incompetency. In the aforementioned 2 cases, the patients had chronic serious lung disease, and their tissues were compromised by prolonged cortisone use. In addition, electrical acupuncture was used.      If no attempt is made to define comorbidity or other risk factors that might act as significant confounding variables, the expected incidence of pneumothorax secondary to acupuncture is impossible to assess accurately. Furthermore, pneumothorax can be easily missed diagnostically. Physicians and non-physician health care professionals may be unaware that shoulder pain might be the only symptom. Perhaps non-physician clinicians are not adequately trained to either suspect or to adequately make the diagnosis. Suspicions of under-reporting of pneumothorax associated with acupuncture are perhaps justified.      Another reason to expect under-reporting comes from the work of Lucian Leape, MD, an established authority in hospital adverse events and unwarranted surgical procedures.9,16-23
There is abundant evidence that most adverse events are not reported, as high as 95%. 1 can think of no obvious reason why that should be different for acupuncture complications or errors. So you do have to do some on-hands data collection, and the better you do that, the more you will find alone (i.e., we found more with the nurse visit and daily review than with just retrospective review of hospital charts alone) [personal communication, 1997].
     In addition, if one looks at studies in which the population studied, techniques used, and/or location of points needled are not "typical," the ability to generalize the findings are significantly compromised. The recent report of 65,482 treatments in Japan' for which no pneumothorax was reported is an example. In this report, the fact that adverse events were noted by students, and were reported only through self-report of the practitioners, further compromises the validity of the findings.      Based on current available data, under-reporting is a significant issue and limits our ability to accurately predict the incidence of adverse events related to acupuncture.
Over-reporting      Paradoxically, over-reporting is also a problem. The frequency of infection in Western nations is most likely exaggerated by the literature, and may be based on the degree of Western standard training in sterile technique and use of sterile needles. Perhaps a selection bias in the English medical literature toward reporting adverse effects of alternative forms of therapy, rather than their benefits, is prevalent.      Another cause of possible inflation of acupuncture adverse events has to do with baseline incidence of certain medical events. Again, let us look at pneumothorax as an example. The incidence of pneumothorax has been estimated to be as high as 18.0 cases per 100,000 population per year. The risk can be 7 times greater in smokers.24 If this is true, then the odds of having spontaneous pneumothorax may be as high as what some literature reports as being associated with acupuncture. This would be especially true in a high-risk group such as tall male smokers. One can easily see the possibility of a case of spontaneous pneumothorax being inaccurately attributed to acupuncture.
Overview of the Literature      Several formal reviews of adverse effects of acupuncture have been reported in the literature.4,25-28 Recent editorials and letters are testimony to controversies/difficulties in the area of reporting acupuncture adverse events.6-8,29 A recent report from Japan reported that of a total of 55,291 acupuncture treatments, 64 adverse events were reported, including I I types of events .5      The list of adverse events reported in the literature and/or personally observed includes:
Acute bacterial endocarditis from auricular acupuncture Aggravation of symptom(s) Asthma attack Behcet's cedilla syndrome Bleeding Blue macules of localized argyria Bum injury (caused by thermotherapy, including moxibustion) Cardiac tamponade Cellulitis Compartmental syndrome Contact dermatitis Convulsion Coughing Death Deep venous thrombosis Delayed conventional diagnosis/therapy Discomfort, general, during or after treatment Dizziness Drowsiness Ecchymosis without pain Ecchymosis with pain Fall from treatment table Feeling faint Forgotten needles Glenohumeral pyoarthrosis Granuloma Hemothorax Hematoma Hepatitis B Hepatitis C HIV infection Hypotension, transient Interactions with drugs Itching and/or redness, during treatment and/or afterward Malaise Multiple lymphocytoma cutis of the ears Myelitis Nausea, during treatment and/or afterward Nerve injury-peripheral Pain in the puncture region, during insertion, removal, or afterward Pain at distant location, during insertion, removal, or afterward Perichondritis of the ear Peripheral nerve injury Perspiration Pneumothorax Prurigo pigmentosa Pseudoaneurysm Psoas abscess Reduced bowel movements Renal injury and calculus formation from retained needles Retained needles Return of old complaints Sepsis Spinal injury Spinal cord injury Spinal arachnoiditis Subarachnoid hemorrhage Suppression of a demand cardiac pacemaker (electrical acupuncture) Syncope Vomiting
Serious Adverse Events      In the English-language literature, 5 fatalities (case reports) have been published: 2 with cardiac tamponade,30,31 2 cases of staphylococcal septicemia,32 and 1 asthmatic death.33      This list is most likely incomplete. The question remains: Does the frequency of reports in the literature correspond to the true incidence of the events? The article by Rosted28 is a good review of the frequency of specific adverse events reported in the literature.      Common events associated with acupuncture are drowsiness, pain with insertion and manipulation, minor bruising, and a temporary aggravation of the symptom. Hepatitis and pneurnothorax are the most commonly reported serious adverse events. "Serious" events associated with acupuncture are rare. (In the author's opinion, a serious complication [pneumothorax, hepatitis, delayed diagnosis, cardiac tamponade, etc.] of acupuncture occurs in about 1 in 5,000 cases. This estimate is based on personal experience of approximately 30,000 treatments over a 15-year period, plus the review of the current literature on adverse events in acupuncture.)      Based on current standards of practice in surgery and anesthesiology, these rare events need not be discussed with patients a priori. Nonetheless, it remains the responsibility of practitioners to prevent and recognize these events when they do occur. Prompt and appropriate treatment can then follow.
Clinical Strategies for Reducing Adverse Events      Given the current literature on adverse events related to acupuncture, along with personal experience and observations, clinical recommendations generally self-evident for the medical physician with some background in acupuncture include the following:
Spine J. 2013 Mar 21. pii: S1529-9430(13)00169-1. doi: 10.1016/j.spinee.2013.02.012. [Epub ahead of print]
Use appropriate sterile technique.
  • Over the sternum, angulate the needle to avoid passing through congenital foramens overlying the heart.
  • If the patient has a significant risk factor for infection, i.e., advanced age, diabetes, immunosuppressive therapy, artificial joints, heart murmurs, prosthetic valves, active cancer, etc., avoid using implanted needles. Generally, implanted needles imply greater risk to the patient.
  • Based on personal experience and stories from patients, if cellulitis occurs in the context of acupuncture, take appropriate cultures and consider immediate parenteral antibiotics.
  • If a patient is taking anticoagulants, consider superficial needling and in all cases, apply firm pressure after removing a needle. (The author believes that electrical acupuncture in this context implies greater risk to the patient.)
  • To avoid pneumothorax, consider patients at greater risk to be smokers, tall males, patients with emphysema, patients who are or have been taking corticosteroids, patients with active cancer, and patients who are emaciated for any reason. (Any point overlying pleura can be risky but especially LR 14, GB 21, 23, 25, and SP 21 are vulnerable. Electrical stimulation of these points implies greater risk.)
  • Physicians are legally held to higher standards than lay acupuncturists with regard to missed conventional diagnoses and/or therapeutic options.
    Be cautious and hesitant to assume that acupuncture is the only therapy indicated for your patients.
  • Elderly and new patients are preferably supine during acupuncture treatments.
  • Significant insomnia predating acupuncture generally is associated with significantly more discomfort and pain during and after an acupuncture session.
  • Be alert for metal allergy.
  • Warn patients, especially after the first treatment, to be more cautious in driving. A half-hour recovery period for new patients would be considered prudent.
  • Be vigilant and informed about possible adverse events.
  • 9
    Facilitate a systematic approach toward reducing barriers that interfere with improving patient care and safety.
    • (This author would be interested in hearing the results of a study in which the hypothesis was that practitioners who actively prayed for their patients had patients who experienced fewer adverse events.)
    CONCLUSION      Informing the reader of possible complications of acupuncture and how to prevent them is the intent of this article. Factors that are essential for further progress in the research of acupuncture are emphasized. Clear definition of terms is mandatory.
    REFERENCES 1. NIH Consensus Statement. Acupuncture. Bethesda, Md: National Institutes of Health; 1997. 2. O'Connor J, Bensky D, eds trans. Acupuncture: A Comprehensive Text. Seattle, Wash: Eastland Press; 1981:67-75. 3. Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley, Calif: Medical Acupuncture Publishers; 1995. 4. MacPherson H. Fatal and adverse events from acupuncture: allegation, evidence, and the implications. J AItern Complement Med. 1999;5:47-56. 5. Yamashita H, Tsukayama H, Tanno Y, Nishijo K. Adverse events in acupuncture and moxibustion treatment: a six-year survey at a national clinic in Japan. J Altern Complement Med. 1999;5:229-236. 6. MacPherson H. How safe is acupuncture? developing the evidence on risk. J Altern Complement Med. 1999;5:223-224. 7. White A. Letter to the editor. J Altern Complement Med. 1999;5:1-2. 8. Yamashita H. Letter to the editor. J Altern Complement Med. 1999;5:2. 9. Leape LL. A systems analysis approach to medical error. J Eval Clin Pract. 1997;3:213-222. 10. Safety and Regulation of Acupuncture Needles and Other Devices. Bethesda, Md: National Institutes of Health; 1998. 11. American Medical Association. Proceedings of the House of Delegates. 1981. 12. Studdert DM, Eisenberg DM, Miller FH, et al. Medical malpractice implications of alternative medicine. JAMA. 1998;280:1610-1615. 13. Acupuncture Licensure, Training, and Certification in the United States. Bethesda, Md: National Institutes of Health; 1997. 14. Bates DW, Leape LL, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults. J Gen Intern Med. 1993;8: 289-294. 15. Rampes H. Adverse reactions to acupuncture. In: Filshie J, White A, eds. Medical Acupuncture: A Western Scientific Approach. Edinburgh, Scotland: Churchill Livingstone; 1998:361-374. 16. Leape LL. Preventing adverse drug events. Am J Health Syst Pharm. 1995;52:379-382. 17. Leape LL. Unnecessary surgery. Annu Rev Public Health. 1992;13: 363-383. 18. Leape LL. Out of the darkness: hospitals begin to take mistakes seriously. Health Syst Rev. 1996;29:21-24. 19. Johnson WG, Brennan TA, Newhouse JP, et al. The economic consequences of medical injuries: implications for a no-fault insurance plan. JAMA. 1992;267:2487-2492. 20. Leape LL, Woods DD, Hatlie MJ, Kizer KW, Schroeder SA, Lundberg GD. Promoting patient safety by preventing medical error. JAMA. 1998;280:1444-1447. 21. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35-43. 22. Leape LL, Lawthers AG, Brennan TA, Johnson WG. Preventing medical injury. QRB Qual Rev Bull. 1993; 19:144-149. 23. Brennan TA, Leape LL, Laird NM, Localio AR, Hiatt HH. Incidence of adverse events and negligent care in hospitalized patients. Trans Assoc Am Physicians. 1990; 103:137-144. 24. Fraser R, Pare J. Diagnosis of Diseases of the Chest. 2nd ed. Philadelphia, Pa: WB Saunders; 1977. 25. Ernst E, White A. Life-threatening adverse reactions after acupuncture? a systematic review. Pain. 1997;71:123-126. 26. Ernst E. The risks of acupuncture. Int J Risk Saf Med. 1995;6:179-186. 27. Rampes H, James R. Complications of acupuncture. Acupuncture Med. 1995;8:26-31. 28. Rosted P. Literature survey of reported adverse effects associated with acupuncture treatment. Am J Acupuncture. 1996;24:27-34. 29. Ernst E, White A. Acupuncture: safety first [editorial]. BMJ. 1997;314:1362. 30. Schiff AF. A fatality due to acupuncture. Med Times. 1965;93:630-631. 31. Halvorsen TB, Anda SS, Naess AB, Levang OW. Fatal cardiac tamponade after acupuncture through congenital sternal foramen [letter]. Lancet. 1995;345:1175. 32. Pierik MG. Fatal Staphylococcal septicemia following acupuncture: report of two cases. R I Med J. 1982;65:251-253. 33. Ogata M, Kitamura 0, Kubo S, Nakasono 1. An asthmatic death while under Chinese acupuncture and moxibustion treatment. Am J Forensic Med Pathol. 1992;13:338-341.
    AUTHOR INFORMATION      Dr James K. Rotchford is in private practice in Port Townsend, Washington. Rotchford is a founding member of the American Academy of Medical Acupuncture (AAMA), and is President of the Medical Acupuncture Research Foundation (MARF). He acts as Web Dragon Master for the AAMA home page (www.medicalacupuncture.org).

    Dr James K. Rotchford, MD, MPH 1334 Lawrence St Port Townsend, WA 98368 Phone: 360-385-4843 - Fax: 360-379-1441 E-mail: kimber@olympus.net

     
     
     
     
     
     
     

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    • logo-postmedj
    Postgrad Med J. 2007 July; 83(981): 461–465.
    doi:      10.1136/pgmj.2007.056978

    PMCID: PMC2600088

    Pneumothorax: an update

    Graeme P Currie, Ratna Alluri, Gordon L Christie, and Joe S Legge
    Author information ► Article notes ► Copyright and License information ►
    This article has been corrected. See Postgrad Med J. 2007 November; 83(985): 722.

    This article has been     cited by other articles in PMC.

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    Abstract

    Pneumothorax is a relatively common clinical problem which can occur in individuals of any age. Irrespective of aetiology (primary, or secondary to antecedent lung disorders or injury), immediate management depends on the extent of cardiorespiratory impairment, degree of symptoms and size of pneumothorax. Guidelines have been produced which outline appropriate strategies in the care of patients with a pneumothorax, while the emergence of video‐assisted thoracoscopic surgery has created a more accessible and successful tool by which to prevent recurrence in selected individuals. This evidence based review highlights current practices involved in the management of patients with a pneumothorax.
    Pneumothorax is the presence of air between the parietal and visceral pleura. It is a relatively common respiratory disorder and can occur in a variety of clinical settings and in individuals of any age. The presentation of a pneumothorax varies between minimal pleuritic chest discomfort and breathlessness to a life‐threatening medical emergency with cardiorespiratory collapse requiring immediate intervention and subsequent prevention.    1,2,3 This evidence based review article outlines the causes, diagnosis and current management of a pneumothorax. All authors performed a comprehensive literature search using Medline, Clinical Evidence, Cochrane Library and Embase up to November 2006. The following key words were used in the search: pneumothorax, causes, diagnosis, management, pleurodesis, diving, flying, tension, surgery and video assisted thoracoscopic surgery (VATS); we then selected and extracted articles that we felt to be of relevance to practising clinicians.

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    CLASSIFICATION AND PATHOGENESIS

    Pneumothorax can be categorised as primary, secondary, iatrogenic or traumatic according to aetiology. Occasionally, individuals may develop a concomitant haemothorax due to bleeding caused by shearing of adjacent subpleural vessels when the lung collapses.
    Primary spontaneous pneumothoraces occur most commonly in young, tall, thin males with no predisposing lung disease or history of thoracic trauma, although rupture of an underlying small subpleural bleb or bulla is thought to be responsible in many cases (fig 1
    1
    ).4,5 Moreover, current cigarette smoking greatly increases the risk of developing a pneumothorax by as much as nine times, with evidence of a dose–response relationship.6 The exact incidence of primary spontaneous pneumothorax is uncertain, although the yearly frequency in healthy individuals has been reported to be approximately 18–28/100x2009000 for males and 1.2–6/100x2009000 for females.7,8
    pj56978.f1
    Figure 1x2003A lung bleb.
    Secondary pneumothoraces occur when there is an underlying lung abnormality. Conditions predisposing to the development of a secondary pneumothorax are shown in box 1, although chronic obstructive pulmonary disease is the most common.
    Box 1: Conditions predisposing to the development of a secondary pneumothorax
    Obstructive airway disease

      • - 
        chronic obstructive pulmonary disease

      • - 
        asthma

    • Suppurative lung disease

      • - 
        bronchiectasis

      • - 
        cystic fibrosis

    • Malignant disease

      • - 
        lung cancer

    • Interstitial lung disease

      • - 
        pulmonary fibrosis

      • - 
        extrinsic allergic alveolitis

      • - 
        sarcoidosis

      • - 
        lymphangioleiomyomatosis

      • - 
        histiocytosis X

    • Infections
      • Staphylococcus aureus or Pneumocystis jiroveci)

        - 
        pneumonia (for example, due to

      • - 
        tuberculosis

    • Miscellaneous

      • - 
        adult respiratory distress syndrome

      • - 
        Marfan syndrome

      • - 
        Ehlors Danlos syndrome

      • - 
        catamenial

      • - 
        rheumatoid arthritis and other connective tissue diseases

    An iatrogenic pneumothorax is most commonly caused by central vein cannulation (subclavian more commonly so than internal jugular vein), pleural tap or biopsy, transbronchial biopsy, fine needle aspiration, and has occasionally been caused by acupuncture. Intravenous drug users who try and locate central veins are also at risk of developing a pneumothorax in the community.9 Intubated patients being mechanically ventilated may develop an iatrogenic pneumothorax due to high inspiratory inflation pressures causing pulmonary barotrauma. Before the widespread use of effective chemotherapy, artificial pneumothoraces were created by clinicians treating tuberculosis in an attempt to collapse and “rest” the affected lung and help heal cavitating disease. Traumatic pneumothorax occurs following direct injury to the thorax; common causes include penetrating chest injury or a fractured rib lacerating the visceral pleura.
    Tension pneumothorax can occur due to any aetiology and is defined as any size of pneumothorax causing mediastinal shift and cardiovascular collapse. In individuals with advanced lung disease, even a small pneumothorax can cause significant respiratory failure and cardiovascular instability.

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    DIAGNOSIS
    Clinical features
    It is often possible to diagnose a pneumothorax—or include it in a list of possible diagnoses—on the basis of a consistent history and examination findings. Patients typically report an abrupt onset of pleuritic pain and breathlessness. Examination findings may vary according to the size of the pneumothorax and presence of limited cardiorespiratory reserve. Typical signs include reduced breath sounds, reduced ipsilateral chest expansion and hyperresonant percussion note. Tracheal shift away from the affected side, tachycardia, tachypnoea and hypotension occur in a tension pneumothorax. Contrary to traditional teaching, it has been recently suggested that in tension, lateralising signs are an inconsistent finding, although general features such as acute onset and rapid cardiovascular instability are universal.10
    Imaging
    The postero‐anterior chest radiograph shows absent lung markings extending from the edge of visceral pleura to chest wall, although it is possible to confuse a pneumothorax with a lung bulla, edge of the scapula or artefact such as a piece of clothing. Care should be taken in the evaluation of the chest radiograph, especially portable films taken in accident and emergency. There is generally no need to request an expiratory film, although lateral views can sometimes provide additional information if it is uncertain whether a pneumothorax is present or not.11 Mediastinal shift is usually evident in individuals with a tension pneumothorax (fig 2
    2).
    ). In patients undergoing transbronchial needle biopsy, transthoracic ultrasound has been proposed as being a useful and sensitive bedside test to detect a post‐intervention pneumothorax or hydropneumothorax.12
    pj56978.f2


    Figure 2x2003Chest radiograph showing a tension pneumothorax.
    Computed tomography (CT) imaging of the chest is occasionally performed when diagnostic uncertainty exists—for example, in order to distinguish a pneumothorax from large bulla or when the lung field is obscured by surgical emphysema. It is also often carried out before a contemplated surgical procedure, or when an underlying lung abnormality—such as interstitial lung disease, lymphangioleiomyomatosis or histiocytosis—is considered a possibility.

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    MANAGEMENT

    The management of a pneumothorax depends on the severity of symptoms, its size, and presence of underlying lung disease. Chest radiographs are notoriously poor at assessing the volume of pneumothorax, although recent guidelines published by the British Thoracic Society suggest that the size of a pneumothorax should be categorised according to the amount of air visible between the lung edge and chest wall2:
     cm rim present between the lung edge and chest wall
    Small pneumothorax: <2
  • ges2 cm rim present between the lung edge and chest wall.
    Large pneumothorax:
    • Oxygen
    High flow oxygen (>28%) should usually be given to individuals with a pneumothorax in order to maintain adequate oxygenation (saturation >92%) to vital organs. This also lowers the partial pressure of nitrogen, which may in turn accelerate the rate of absorption of air from the pleural cavity and hasten lung re‐expansion. However, care should be taken in individuals with chronic obstructive pulmonary disease who may retain carbon dioxide.
    Primary spontaneous pneumothorax
    Patients with a small spontaneous pneumothorax with few symptoms do not require active intervention. Most of these individuals do not require admission to hospital, but should be given written instructions to return to hospital if symptoms such as worsening breathlessness or chest pain develop. A follow up appointment within 1–2 weeks for repeat chest radiograph should be arranged before discharge. In some cases, it might be appropriate to admit patients if they live remote from medical access or if concerns exist regarding follow up care or attendance.
    According to British Thoracic Society guidelines, symptomatic individuals with a large primary spontaneous pneumothorax should initially undergo needle aspiration with subsequent chest radiograph and observation.    2 Thereafter, if needle aspiration is unsuccessful, a chest drain is usually required. This is in contrast to US guidelines where simple aspiration is not advocated and chest drain insertion is considered more appropriate.1 In a randomised trial of 137 patients with first episode of primary spontaneous pneumothorax, the effects of simple aspiration versus chest drain insertion were assessed.13 Immediate success was obtained in 62% assigned to undergo aspiration versus 68% having a chest drain inserted, while the 1 week success rates were similar in both group (88% vs 89%, respectively). Recurrence rates at 1 and 2 years were 22% and 31%, respectively, for patients who had simple aspiration, and 24% and 25%, respectively, for patients who had a chest drain insertion. In another study of 91 patients with primary spontaneous pneumothorax who underwent needle aspiration, recurrence occurred in 18% over the subsequent year.14
    Current guidelines do not generally advocate that a surgical procedure to prevent recurrence after the first spontaneous episode is undertaken.    1,2 However, it is important to inform patients that the recurrence rate for primary pneumothorax is more than 20% after the first episode13 and even greater after the second episode and tends to be more likely in women, tall men and smokers.15 It is conceivable that given the relatively high recurrence rate, perhaps in the future, greater numbers of individuals with first episode of spontaneous primary pneumothorax will proceed to have surgical intervention. Further randomised controlled studies, incorporating patient preference, cost and short and long term outcomes, are required to establish whether such an approach is merited.
    Secondary pneumothorax
    Patients with a small secondary pneumothorax with few symptoms require overnight observation. Individuals who are symptomatic from a larger pneumothorax require chest drain insertion, as needle aspiration is less likely to be successful, especially in older patients.16,17 Since many of these patients experience a further pneumothorax, it is advisable that an attempt is made to prevent recurrence with pleurodesis.
    Tension pneumothorax
    Tension pneumothorax is a medical emergency and clinicians should follow the ABC in terms of immediate management. In a life‐threatening situation, treatment may be necessary without a chest radiograph. A plastic cannula (Venflon) should be placed in the mid‐clavicular line in the second intercostal space and once the pleural space has been entered, a release of air should be heard when the internal needle is removed (fig 3
    3).
    ). The cannula should be left in place until a chest drain is inserted and bubbling.
    pj56978.f3


    Figure 3x2003In patients with a tension pneumothorax, a plastic cannula (Venflon) should be inserted into the second intercostal space in the mid‐clavicular line. Informed consent was obtained for publication of this figure.Chest drains
    Since most hospital doctors will be expected to insert a chest drain at some point in their career, it is imperative that the safe technique of doing so and subsequent management is taught by an experienced operator.18 However, unnecessary and avoidable problems such as drain misplacement and inadequate attachment to the skin are frequently encountered. Indeed, in a recent survey of 55 junior doctors, 45% failed to identify correctly a safe position for insertion.19 Other problems encountered include bleeding, infection and empyema, damage to the neurovascular bundle, myocardium, mediastinal contents and lung parenchyma, surgical emphysema, and chest tube kinking and blockage.
    Chest drains are most easily inserted using the Seldinger technique (tube over wire) in the “safe triangle”—such as in the mid‐axillary line in the fifth intercostal space—with the patient sitting at 45° (fig 4
    4).
    ). This minimises risk of injury to adjacent thoracic structures. The drain should be connected to an underwater seal and seen to be bubbling following insertion. In the treatment of a straightforward pneumothorax, a large bore chest drain is not usually required and a 10–14 calibre French gauge is adequate. In individuals who may have cervical spine instability—especially those involved in significant antecedent thoracic trauma—the chest drain should be placed with the patient lying supine. Drains should not be secured using a “purse‐string suture” as this has a poor cosmetic outcome and may be painful; a suture placed in the skin and then wrapped several times around the drain is usually adequate. Suction should not generally be applied to a chest drain within 48 h of insertion in order to avoid the possibility of re‐expansion pulmonary oedema.20 A chest radiograph should be arranged following insertion to check tube placement, although drains positioned either apically or basally can effectively drain a pneumothorax.
    pj56978.f4



    Figure 4x2003The “safe triangle” is the area bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, a line superior to the horizontal level of the nipple, and apex below the axilla. ...Chest drains should be removed (preferably during expiration or when performing a Valsalva manoeuvre) providing the lung has re‐expanded on the chest radiograph and there is no evidence of air leak for around at least 24 h. However, in a study of 69 trauma patients (102 chest drains), a similar (8% vs 6%, pthinsp=thinsp1.0) number of pneumothoraces occurred following removal during end‐inspiration and end‐expiration, respectively.21 Debate continues as to whether drains should be clamped and a subsequent chest radiograph arranged before removal,19 although doing so avoids the unnecessary trouble of re‐inserting a further chest drain if the lung collapses. If clamped, it is preferable to do so in a ward where nursing and medical staff are experienced in chest drain management and are aware that it should be unclamped if the patient becomes symptomatic. However, chest drains should never be clamped in patients where bubbling persists.

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    REFERRAL TO A THORACIC SURGEON

    The basic principle behind surgical intervention lies in removing pleural bullae or suturing apical perforations, in addition to performing a pleurodesis, pleural abrasion or pleurectomy to prevent recurrence. Video assisted thoracoscopic surgery (VATS) has facilitated a less invasive means by which to access the pleural space, especially in more elderly patients with comorbidities.3 Some patients with poor performance status may not be fit for a surgical procedure (for example, those with advanced chronic obstructive pulmonary disease) and a chemical pleurodesis with talc (magnesium silicate) slurry is preferable. Ward based pleurodesis with talc is usually well tolerated, although it can be associated with pleural pain, mild fever or occasionally empyema; a rare complication is adult respiratory distress syndrome.2 The success rate of ward based talc slurry pleurodesis is between 80–90% and for surgical intervention (VATS stapling, pleurectomy or instillation of talc) is at least 95%.22,23,24,25 In one study of 861 cases of primary spontaneous pneumothorax, VATS talc pleurodesis with or without stapling of bullae was safe and resulted in a recurrence rate of only 1.7% over a 52 month follow up period.26 In the same study, recurrence was significantly associated (pthinsp=thinsp0.037) with smoking. Other data have indicated that thoracoscopic pleural argon beam coagulation may have a role to play in the treatment of primary spontaneous pneumothorax, although further studies are required to investigate this.27
    Referral to a thoracic surgeon should be considered in patients who have a first spontaneous pneumothorax and an “at‐risk” profession (such as aircraft pilot or diver). Other indications for consideration of a definitive surgical procedure to reduce chance of recurrence include second ipsilateral pneumothorax, bilateral pneumothorax, concomitant haemothorax or first contralateral pneumothorax. Individuals who have a persistent air leak (a bubbling chest drain) after 5     days of chest intubation should also be referred for surgical consideration.2

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    PNEUMOTHORAX IN SPECIAL CONDITIONS

    Flying
    As pressure falls during ascent in aircraft, an inversely proportional rise in gas volume occurs (Boyle's law). This causes expansion of air within gas filled bodily chambers such as in an undrained pneumothorax. Airline passengers with a closed pneumothorax may therefore experience difficulties due to gas expansion during ascent, and can develop a tension pneumothorax. As a consequence, individuals with an untreated pneumothorax must not fly in commercial aircraft. Providing 1 week (or 2 weeks in the case of a traumatic pneumothorax or thoracic surgery) has elapsed after resolution of a pneumothorax and the chest radiograph is normal, individuals may be permitted to fly (http://www.brit‐thoracic.org.uk/c2/uploads/FlightPCsummary04.pdf). Some individuals with a longstanding pneumothorax have flown without complication but only with careful pre‐flight assessment, including CT imaging and exposure to a hypoxic hypobaric environment in a decompression chamber.28
    Diving
    The development of a pneumothorax at depth is associated with potentially fatal consequences, since during ascent, the volume of gas within a closed pneumothorax will expand, in turn leading to a tension pneumothorax. Current guidelines suggest that a previous spontaneous pneumothorax is a contraindication to underwater diving unless treated by bilateral surgical pleurectomy in association with normal lung function and CT scan following surgery. A previous traumatic pneumothorax may not be an absolute contraindication providing it has healed and subsequent lung function and CT thorax scan are normal.29
    Cystic fibrosis
    Patients with cystic fibrosis who develop a pneumothorax should generally be managed in a manner similar to those without the disease, although needle aspiration is usually less successful. It may take longer for the lung to expand and concomitant infection—often with Pseudomonas aeruginosa—should be treated aggressively with intravenous antibiotics. Consideration should be given to prevention of subsequent pneumothorax by either surgical intervention or talc pleurodesis in order to prevent recurrence (which tends to be high without intervention).
    HIV infection
    Previous data have shown that infection with tuberculosis or Pneumocystis jiroveci (previously carinii) can predispose to the development of a pneumothorax in patients with HIV infection.30 Indeed, in an HIV infected individual, P jiroveci infection should be considered as the most likely aetiological factor.31

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    CONCLUSION

    Pneumothorax is a relatively common respiratory diagnosis and it is important that it is managed promptly and in an appropriate manner. Immediate management is largely determined by the extent of cardiorespiratory compromise, degree of symptoms and size of pneumothorax and may involve observation alone, needle aspiration or chest drain insertion. Since recurrence rates are relatively high, selected individuals should be considered for definitive surgical treatment (usually by VATS) or instillation of talc slurry in less fit individuals.
    Junior doctors are frequently given responsibility to insert chest drains but should ideally receive a period of training and supervision before this. Indeed, with increased availability of clinical skills laboratories this procedure should form a core element of postgraduate training. This has the ultimate aim of reducing complications at insertion and subsequent aftercare of chest drains, which are not infrequently encountered in accident and emergency, and acute medical receiving and respiratory wards.

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    Footnotes


    Competing interests and acknowledgements: none.


    Informed consent was obtained for publication of figs 3 and 4

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    References

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    6. Bense L, Eklund G, Wiman L G. Smoking and the increased risk of contracting spontaneous pneumothorax. Chest 1987. 921009–1012.1012. [    PubMed]
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    8. Bense L, Wiman L G, Hedenstierna G. Onset of symptoms in spontaneous pneumothorax: correlations to physical activity. Eur J Respir Dis 1987. 71181–186.186. [    PubMed]
    9. Miller D R, Harden J L, Currie G P. A case of self‐inflicted bilateral pneumothorax. Resuscitation 2006. 71122–123.123. [    PubMed]
    10. Leigh‐Smith S, Harris T. Tension pneumothorax—time for a re‐think? Emerg Med J 2005. 228–16.16. [    PMC free article] [PubMed]
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    12. Reissig A, Kroegel C. Accuracy of transthoracic sonography in excluding post‐interventional pneumothorax and hydropneumothorax. Comparison to chest radiography. Eur J Radiol 2005. 53463–470.470. [    PubMed]
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    14. Chan S S, Rainer T H. Primary spontaneous pneumothorax: 1‐year recurrence rate after simple aspiration. Eur J Emerg Med 2006. 1388–91.91. [    PubMed]
    15. Sadikot R T, Greene T, Meadows K.     et al Recurrence of primary spontaneous pneumothorax. Thorax 1997. 52805–809.809. [PMC free article] [PubMed]
    16. Archer G J, Hamilton A A, Upadhyay R.     et al Results of simple aspiration of pneumothoraces. Br J Dis Chest 1985. 79177–182.182. [PubMed]
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    19. Hyde J, Sykes T, Graham T. Reducing morbidity from chest drains. BMJ 1997. 314914–915.915. [    PMC free article] [PubMed]
    20. Tariq S M, Sadaf T. Images in clinical medicine. Reexpansion pulmonary edema after treatment of pneumothorax. N Engl J Med 2006. 3542046. [    PubMed]
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    Intern Med. 2011;50(20):2375-7. Epub 2011 Oct 15.
    Chylothorax caused by acupuncture.
    Inayama M, Shinohara T, Hino H, Yoshida M, Ogushi F.
    Source
    Division of Pulmonary Medicine, National Hospital Organization National Kochi Hospital, Japan.
    Abstract
    Chylothorax, the accumulation of fatty fluid within the chest cavity, is associated with multiple etiologies including surgical injuries. A rare complication of acupuncture in a 37-year-old woman who developed left pneumothorax and pleural fluid collection after acupuncture was performed on the neck and upper back is described. Chest tube drainage resulted in complete lung expansion, and analysis of the milky fluid revealed chyle leakage. Conservative treatment with a diet low in lipids and rich in medium-chain triacylglycerols allowed extubation. Acupuncture-induced thoracic duct injury, although extremely rare, should be considered as a cause of chylothorax.
    PMID: 22001469 [PubMed - indexed for MEDLINE] Free full text



    Zhongguo Zhen Jiu. 2009 Mar;29(3):239-42.
    [Clinical analysis on 38 cases of pneumothorax induced by acupuncture or acupoint injection].
    [Article in Chinese]
    Zhao DY, Zhang GL.
    Source
    Department of Thoracic Surgery, Langfang Municipal People's Hospital, Langfang 065000, China.
    Abstract
    OBJECTIVE:
    To probe into the mechanism of pneumothorax caused by acupuncture or acupoint injection and the preventive methods.
    METHODS:
    Retrospectively analyze the clinical original symptoms of 38 cases with pneumothorax caused by acupuncture and acupoint injection, which were divided into four clinical types: dyspnea type, shock type, thoracalgia type and tardy type. Illustrate the relation of the clinical types with severe degrees of pneumothorax, and the mechanism of pneumothorax inducing death of the patient.
    RESULTS:
    In the series there were 38 cases with pneumothorax induced by acupuncture or acupoint injection, including 4 cases of dyspnea type, 16 cases of shock type, 14 cases of thoracalgia type, 4 cases of tardy type. After proper treatment, 37 cases were cured and one case of dyspnea type died of tension pneumothorax.
    CONCLUSION:
    The mechanism of pneumothorax caused by acupuncture or acupoint injection is that due to the filiform needle tip or the syringe's needle tip inserting into the lung tissue at the patient's respiration in acupuncture or acupoint injection, the filiform needle tip or the syringe's needle tip lacerates the lung tissue. Air in alveolus goes into the thorax pleura cavity to form pneumothorax. In acupuncture or acupoint injection, the needle tip must not insert into the lung tissue, which is a key for prevention of pneumothorax.
    PMID: 19358511 [PubMed - indexed for MEDLINE]



    Pneumothorax Using Bladder 14 Thye K. Leow, MB (MD)

    ABSTRACT This case report describes an adverse event, pneumothorax, resulting from the use of acupuncture point Bladder 14. The pneumothorax resolved without surgical intervention. KEY WORDS Acupuncture, Pneumothorax, Bladder 14, Adverse Event
    INTRODUCTION Acupuncture treatment for musculoskeletal conditions, especially in cases where conventional treatment has failed, is increasingly being utilized. Although relatively innocuous when properly performed,1,2 the insertion of needles in the chest wall or at the base of the neck is not devoid of complications.3 This is my case of pneumothorax following acupuncture of the back in a patient with a whiplash neck and upper thoracic injury. There may not be a previously documented case of pneumothorax following needling of this particular acupuncture point, Bladder 14 (BL 14) in the literature. CASE REPORT The patient was a 21-year-old woman with past history of mild asthma, occasional use of salbutamol through inhalers, and a non-smoker with no history of pneumothorax prior to this event. She has a fair complexion, fine skin, average amount of muscular tissue, and little adipose tissue. Her habitus can be described as ectomorphic. Following a motor vehicle collision resulting in a whiplash injury to her neck and upper back, the patient had 5 sessions of physiotherapy treatment before opting for acupuncture as her condition deteriorated. METHODS Consent was obtained and the patient was treated with acupuncture 18 days following her injury. The needles used were sterile single-use, stainless steel filiform with dimensions of 0.25 mm X 40 mm. The acupoints selected were BL 10 and BL 14 bilaterally, as well as GV 14. Needles were inserted between 1.5 and 2.0 cm deep, and counterclockwise manipulation performed. Needles (Taichi, Morgan and Aickin Co, Auckland, New Zealand) remained in place 30 minutes. RESULTS The patient had a near syncopal attack 10-15 minutes following the insertion. She complained of pain with deep breathing following the prompt removal of the needles. She was not breathless and was discharged to home following a period of observation. She reported back to the clinic about 18 hours later complaining of worsening pleuritic chest pain with deep breathing associated with breathlessness overnight. Chest x-rays revealed that the patient had a moderate-sized left pneumothorax. She was immediately admitted to the hospital for observation and oxygen. No intercostal chest drain was inserted and she was discharged the next day. DISCUSSION The most frequent serious adverse effect following acupuncture is pneumothorax. Rosted4 commented that a clear lack of anatomical knowledge is one of the causes of pneumothorax. However, the number of reported adverse effects are remarkably low throughout the world. A recent study in Japan did not show any case of pneumothorax in 30,338 acupuncture treatments.5 The usual causes of pneumothorax from acupuncture are acupuncture needles placed in the chest wall for conditions such as bronchial asthma,6,7 neck pain, weakness, and herpes zoster.8,9 The reasons why a left-sided pneumothorax occurred in this case could be due to any or a combination of reasons. The needle on the left side was inadvertently placed deeper than expected. Bodily movement during the dizzy phase of presyncopal attack could be another reason, although this would have instead pushed the needle out. Other factors include poorly developed parathoracic musculature, thinning of visceral pleura from previous use of inhaled steroid medication or simply from being asthmatic. Perhaps this incident should serve as a warning to all acupuncturists of the potential for a much more serious incident. Yellow flags should be raised for any ectomorphic patients taking steroids who have never had acupuncture in the past, and needles along the medial line of the thoracic bladder channel need to be placed much more superficially. Needles placed in the region of the lateral line of the thoracic bladder meridian (BL 41 to BL 54) should be placed rather superficially, as the surface of the lung is about 15-20 mm beneath the skin.10 However, depending on the thickness of the needles and the tissue resistance, a variable degree of compression of the soft tissue takes place, and the actual puncturing depth may be considerably greater than the length of the needle. Nevertheless, the patient should be warned of the risk even though discussed (as reported by Rotchford11), adverse events such as pneumothorax are rare and the incidence of pneumothorax secondary to acupuncture is impossible to assess accurately. Further studies are cited depicting the possibility of having a spontaneous pneumothorax as a result of acupuncture11; thus exists the possibility of a case of spontaneous pneumothorax being inaccurately attributed to acupuncture. In my 11-year experience of some 30,000 needlings, this has been the only severe case of an adverse event with acupuncture. CONCLUSION It is a major concern that needling a relatively safe acupoint such as BL 14 has the potential of causing a severe adverse reaction such as pneumothorax. This case highlights the need for acupuncture practitioners to be vigilant, able to recognize these events, and then take the appropriate steps following such events. Needles placed in the region of both the lateral and medial lines of the thoracic bladder mer-idian should be inserted much more superficially, especially in cases of ectomorphic patients.
    REFERENCES

    • Millman BS. Acupuncture: context and critique. Ann Rev Med. 1977;28:223.
    • Lee KP, Anderson WT, Moddell HJ, Saga AS. Treatment of chronic pain with acupuncture. JAMA. 1975;232:1133.
    • Carron H, Epstein BS, Grand B. Complications of acupuncture. JAMA. 1974;228:1552.
    • Rosted P. Literature survey of reported adverse effects associated with acupuncture treatment. Am J Acupunct. 1996;24:27-34.
    • Yamashita H, Tsukayama H, Tanno Y, Nishijo K. Adverse events in acupuncture and moxibustion treatment: a six-year survey at a national clinic in Japan. J Altern Complement Med. 1999;5:229-236.
    • Wright RS, Kupperman JL, Libhaber MI. Bilateral tension pneumothorax after acupuncture. West J Med. 1991;154:102-103.
    • Bodner G, Topiskky M, Greif J. Pneumothorax as a complication of acupuncture in treatment of bronchial asthma. Ann Allergy. 1983;51: 401-402.
    • Gray R, Maharajh GS, Hyland R. Pneumothorax resulting from acupuncture. Can Assoc Radiol J. 1991;42:139-140.
    • Valenta LJ, Henhesh JW. Pneumothorax caused by acupuncture. Lancet. 1980;II:332.
    • Peuker E, Gronemeyer D. Rare but serious complications of acupuncture: traumatic lesions. Acupunct Med. 2001;19(2):103-108.
    • Rotchford JK. Overview: adverse events of acupuncture. Medical Acupuncture. 2000;11(2):1-8.




    Embedded Needles In Acupuncture: Case Report And Review Of The Literature Kazutoshi Yokogushi, MD

    ABSTRACT Background   Recent studies provide evidence that the incidence of serious adverse events with acupuncture therapy is rare in standard practice; serious complications usually arise only from illicit use or from gross abuse by incompetent practitioners. Objective   To explain and warn that serious and life-threatening complications may arise through the use of illicit techniques. Design, Setting, and Patient   Case report of a 50-year-old man with a history of receiving embedded acupuncture needles for back pain. In addition, review of the literature on complications due to use of embedded needles. Main Outcome Measures Location of embedded needles on spine radiographs and computed tomography; reports of embedded acupuncture needles and complications. Results   Imaging studies revealed the needles had migrated into the patient's retroperitoneal space and abdominal aorta. He received an L5 nerve root block resulting in successful pain relief. The patient quit working and limited his activities to prevent further migration of the needles. In the English-language literature, complications due to embedded acupuncture needles and their penetration into vital organs are rarely reported, but there are some cases in the Japanese literature. Conclusion   Serious or fatal complications may occur with incompetent and careless implantation of needles. KEY WORDS Acupuncture, Acupuncture Complications, Embedded Needles, Adverse Events
    INTRODUCTION Acupuncture is a conservative, complementary treatment for pain disorders1-4 and other conditions. However, incompetent and careless practice may cause serious complications such as pneumothorax, cardiac tamponade, neurological damage, local and systemic infections, puncture of body cavities and vital organs, burns, and even death.5-11 Embedding needles, a traditional acupuncture method in Eastern countries, was discarded long ago because it is a potentially harmful procedure. This article demonstrates that serious and life-threatening effects may occur through using illicit needling techniques. CASE REPORT A 50-year-old man presented with a 1-month history of increasing low back pain and left leg pain. He had a diskectomy for L4-5 lumbar disk herniation 5 years earlier. However, he experienced low back pain several times after surgery and sought treatment at a chiropractic clinic, receiving physiotherapy that included acupuncture 3 years prior. The patient had embedded needle therapy in the lumbosacral area in 3 sessions within a month. He reported no abdominal pain or discomfort following treatment.
    YOK_fig1a.JPG
    YOK_fig1b.JPG

    Figure 1. Spine radiograph showing embedded needles around the lumbar spine. A: Anteroposterior view; B: lateral view.
     Spine radiographs on his 1st visit showed many embedded needles around the lumbar spine (Figure 1). Computed tomography revealed that some of the needles were migrating into the retroperitoneal space, 1 of them into the abdominal aorta (Figure 2). He was referred to a cardiovascular surgeon who determined that the patient would not benefit from an operation to remove the needles. The patient received an L5 nerve root block, which produced pain relief. The patient ceased employment and limited his activities to prevent further migration of the needles. He remains under careful observation. DISCUSSION Acupuncture is regarded as a safe therapy if it is performed by competent practitioners who use it properly. In chronic disorders, a variety of subcutaneous implants are recommended to effect long-term stimulation of the reflex points. An absorbable, sterile material is usually used because of the potential risk of needle migration. When metal needles are completely implanted into the subcutaneous tissue, they must be taped or anchored by a bead or loop at their outer end to prevent migration; otherwise, they easily move deep through the tissues and penetrate internal organs within several months or years. Broken or forgotten needles are also a potential risk if they not recognized. In this case, metal needles were intentionally embedded and then neglected by an incompetent practitioner. The period between the needles being embedded and the needle penetration into the abdominal cavity was 3 years. It is not certain how and when the needles began to penetrate the aorta. Meanwhile, the patient had neither abdominal discomfort nor disturbance of circulation in the lower extremities. The decision of whether the needles should be removed is not an easy one; the patient would be at other risk even if eligible for surgery to remove the needles.
    YOK_fig2a.JPG
    YOK_fig2b.JPG
    YOK_fig2c.JPG
    Figure 2. Computed tomography scan showing needles migrating into the retroperitoneal space (A, B), and a needle penetrating the abdominal aorta (C).
     Reports of complications due to embedded needles and their penetration into vital organs are rarely found in the English-language literature,6-10 but some cases are found in the Japanese literature.11-15 Norhaim6 reported complications and adverse effects of acupuncture collected from 14 years (1981-1994) of articles on MEDLINE. He classified 193 cases in 78 reports into 3 categories: mechanical visceral injury, infection, and others. Three cases in 5 reports of embedded needles were included. Many Japanese cases of adverse events after acupuncture may not be listed in medical databases such as MEDLINE, CISCOM, and others. Yamashita et al11 reported 124 cases in 89 articles, which were retrieved from Japanese medical databases from 1987-1999. Forty-eight events were caused by needle breakage, including 26 cases of intentionally embedded needles, and 16 cases of accidental breakage. The incidence of complications due to embedded needles appears to be high in Japan. The migration of a needle into the abdominal aorta, such as in the case described above, has been reported only once in the Japanese literature.15 A 77-year-old woman received many embedded needles for back pain and the penetration of a needle into the abdomen was found more than 7 years after the therapy. The patient had an operation to remove the migrated needle with no complications. Although the Japanese Acupuncture and Moxibustion Association officially recommended in 1976 that members not use embedded needles, the high incidence implies that some practitioners do not abide by the recommendation and are ignorant of the results of malpractice. CONCLUSION Recent prospective and retrospective studies indicate that the incidence of minor adverse events associated with acupuncture may be considerable, while serious adverse events are rare in standard practice.16-19 Serious complications have been alleged to result primarily from illicit acupuncture application or from gross abuse by incompetent practitioners. All acupuncture practitioners should be reminded that embedding needles, now regarded as malpractice, may burden the patient with further complications and unnecessary surgery. REFERENCES
    Ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: a criteria based meta-analysis. J Clin Epidemiol. 1990;43:1191-1199.
  • Frymoyer JW, ed. The Adult Spine: Principles and Practice. New York, NY: Raven Press; 1991:1567-1580.
  • Ernst E, White A. Acupuncture for back pain: a meta-analysis of randomized controlled trials. Arch Intern Med. 1998;158:2235-2241.
  • Carlson CP, Sjolund BH. Acupuncture for chronic low back pain: a randomized placebo-controlled study with long-tem follow-up. Clin J Pain. 2001; 17:296-305.
  • Roger P. Serious complications of acupuncture or acupuncture abuses? Am J Acupuncture. 1981;9:347-351.
  • Norhaim AJ. Adverse effects of acupuncture: a study of the literature for the years 1981-1994. J Altern Complement Med. 1996;2:291-297.
  • Ernst E, White A. Life-threatening adverse reactions after acupuncture? a systemic review. Pain. 1997;71:123-126.
  • Peuker ET, White A, Ernst E, Pera F, Filler TJ. Traumatic complications of acupuncture: therapists need to know human anatomy. Arch Fam Med. 1999;8:553-558.
  • MacPherson H. Fatal and adverse events from acupuncture: allegation, evidence, and the implications. J Altern Complement Med. 1999;5:47-56.
  • Puker ET, Gronemeyer D. Rare but serious complications of acupuncture: traumatic lesions. Acupuncture. 2001;19:103-108.
  • Yamashita H, Tsukayama H, White AR, Tanno Y, Sugishita C, Ernst E. Systematic review of adverse events following acupuncture: the Japanese literature. Complement Ther Med. 2001;9:98-104.
  • Shiraishi S, Goto I, Kuroiwa Y, Nishio S, Kinoshita K. Spinal cord injury as a complication of acupuncture. Neurology. 1979;29:1188-1190.
  • Yuzawa M, Hara Y, Kobayashi Y, et al. Foreign body stone of the urethra as a complication of acupuncture: report of a case [in Japanese]. Hinyokika Kiyo. 1991;37:1323-1327.
  • Matsui S, Matsuoka K, Nakagawa K, Kohno K, Sakaki S. Cervical spinal cord injury caused by a broken acupuncture needle: a case report [in Japanese]. No Shinkei Geka. 1992;20:499-503.
  • Kotaki M, Tateoka K. A case of migration of a buried lumbar acupuncture needle into abdominal aneurysm [in Japanese].  Pain Clinic. 2002;23:1411-1415.
  • Yamashita H, Tsukayama H, Tanno Y, Nishijo K. Adverse events in acupuncture and moxibustion treatment: a six-year survey at a national clinic in Japan. J Altern Complement Med. 1999;5:229-236.
  • Ernst E, White AR. Prospective studies of the safety of acupuncture: a systematic review. Am J Med. 2001;110:481-485.
  • MacPherson H, Thomas K, Walters S, Fitter M. A prospective survey of adverse events and treatment reactions following 34,000 consultations with professional acupuncturists. Acupuncture Med. 2001;19: 93-102.
  • White A, Hayhoe S, Hart A, Ernst E. Survey of adverse events following acupuncture (SAFA): a prospective study of 32,000 consultations. Acupuncture Med. 2001;19:84-92.
    • AUTHOR INFORMATION Dr Kazutoshi Yokogushi is Vice-Director and Associate Professor in the Division of Rehabilitation, Sapporo Medical University Hospital, in Sapporo, Japan. Kazutoshi Yokogushi, MD* Sapporo Medical University Hospital Minami-1 Nishi-16, Chuo-ku Sapporo 060-8543, Japan Phone: 81-01-611-2111  • Fax: 81-01-618-5220 E-mail: yokogushi@sapmed.ac.jp *Correspondence and reprint requests

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    Large superficial basal cell carcinoma arising from moxa cautery


    European Journal of Dermatology. Volume 19, Number 4, 387-8, July-August 2009, Correspondence

    DOI : 10.1684/ejd.2009.0679



    Author(s) : Seok-Kweon Yun, Seong-Min Kim, Jin Park, Jong-Sun Lee, Ji-Hyun Yi, Han-Uk Kim, Chull-Wan Ihm , Department of Dermatology, Chonbuk National University Medical School, Chonbuk National University Hospital, Jeonju, 561-712, South Korea, Department of Dermatology, The Armed Forces Daegu Hospital, Daegu, Korea.

    puce_rougePictures


    ARTICLE

    Auteur(s) : Seok-Kweon Yun1, Seong-Min Kim1, Jin Park1, Jong-Sun Lee1, Ji-Hyun Yi2, Han-Uk Kim1, Chull-Wan Ihm1
    1Department of Dermatology, Chonbuk National University Medical School, Chonbuk National University Hospital, Jeonju, 561-712, South Korea 2Department of Dermatology, The Armed Forces Daegu Hospital, Daegu, Korea
    The development of basal cell carcinoma (BCC) on a burn scar is rather rare. Moxa cautery is a technique used in the East whereby heat generated from the burning of a small bundle of moxa is applied to an acupuncture point on the skin. We report an interesting case of BCC on the lower part of the abdomen (hypogastric area) which developed on a burn scar secondary to repeated moxa cautery.
    A 58-year-old Korean man presented with a 3-year-history of a dark reddish plaque on the lower part of the abdomen. The patient had applied moxa cautery to the same abdominal site repeatedly for relief of abdominal pain over the past 10 years. He reported occasional accidental burns from the cautery, that were not serious. Approximately 3 years previously, he had noticed the development of an asymptomatic dark reddish papule at the site of the moxa cautery on his abdomen. The lesion slowly enlarged in size; however, he denied receiving treatment for the lesion. Physical examination revealed a well-demarcated, 7.2 × 5.7 cm, dark-reddish, round plaque with some brown and black crusts and pigmentation on the lower part of the abdomen     (figure 1A). The patient had no remarkable past or family history of skin cancer, excluding his moxa cautery history. Histopathological examination showed nests of basaloid cells arising from basal layers of the epidermis and extending into the dermis. There was peripheral palisading of the nuclei of the tumor cell nests and peritumoral lacunae between the tumor cells and stroma (figure 1B). Based on the histopathological findings, this case was diagnosed as superficial BCC. Because of the patient’s strong refusal of surgery, the tumor was treated with radiation therapy. A time-dose schedule of 3 Gy was given at 2-day intervals for a total accumulated dose of 51 Gy. The lesion responded to radiation therapy well and there was no evidence of recurrence 5 years later.
    The most important risk factor regarding the development of BCC is chronic ultraviolet light exposure. Additional risk factors include genetic predisposition, ionizing radiation, exposure to arsenic, and trauma [1-3].
    The exact mechanism of trauma in the development of BCC is not clear; however, many theories have been proposed regarding the pathogenesis of malignant degeneration. In 1960, Connolly [4] postulated that poor vascularity and elasticity in scar tissue may make the lesion more sensitive to ultraviolet light. Bostwick [5] suggested that scar tissue prevents a host antigen-antibody response against the tumor. Moxa cautery is a traditional eastern therapeutic technique that involves applying the heat generated from burning moxa to an acupuncture point on the skin. It has been used throughout living memory in Asia because it is believed to relieve pain, strengthen blood, stimulate the flow of energy, and maintain general health.
    In our case, it is possible that the burn scar secondary to repeated moxa cautery resulted in the development of BCC in an area protected from sun exposure. The patient delayed visiting our clinic for 3 years because he regarded the skin malignancy as a burn scar from repeated moxa cautery. The size of the BCC had been gradually increasing and the tumor was treated with radiation therapy.
    Although it is unusual for skin cancers to develop in burn scar tissue, it is widely known that malignant degeneration may occur in long-standing burn scars. Treves and Pack [6] estimated that almost 2% of burn scars undergo malignant degeneration. The most common histological type of skin cancer that develops in chronic wounds is squamous cell carcinoma, followed by basal cell carcinoma. Chronic non-healing burn scars should be biopsied to exclude cutaneous malignancy.
    Acknowledgements
    Financial support: none. Conflict of interest: none.
    References
    1 Noodleman FR, Pollack SV. Trauma as a possible etiologic factor in basal cell carcinoma. J Dermatol Surg Oncol 1986; 12: 841-6.
    2 Ozyazgan I, Kontas O. Previous injuries or scars as risk factors for the development of basal cell carcinoma. Scand J Plast Reconstr Surg Hand Surg 2004; 38: 11-5.
    3 Sterry W. Nonmelanoma skin cancer. Eur J Dermatol 2007; 17: 562-3.
    4 Connolly JG. Basal cell carcinoma occurring in burn scars. Can Med Assoc J 1960; 83: 1433-4.
    5 Bostwick J, Pendergrast WJ, Vasconez LO. Marjolin’s ulcer: An immunologically privileged tumor? Plast Reconstr Surg 1976; 57: 66-9.
    6 Treves N, Pack GT. The development of cancer in burn scars. Surg Gynecol Obstet 1930; 51: 749-82.




    Dermatology. 2002;204(2):142-4.
    Basal cell carcinoma of the earlobe after auricular acupuncture.
    Brouard M, Kaya G, Vecchietti G, Chavaz P, Harms M.
    Source
    Department of Dermatology, DHURDV, University Hospital of Geneva, Switzerland. mcvpb@hotmail.com
    Abstract
    The genesis of familial and sporadic basal cell carcinomas involves activation of the Sonic hedgehog signal transduction pathway. Other known factors for the development of basal cell carcinoma are ultraviolet exposure, X-rays, race, age, gender and decreased DNA repair capacity. We here report the case of a right earlobe sporadic basal cell carcinoma in a 65-year-old woman. This case is unusual because of its earlobe localization and its association with multiple auricular acupuncture treatments. This observation suggests a connection between local traumas, which occur in the course of acupuncture treatment and ear piercing, and the genesis of basal cell carcinoma. The incidence of minor adverse events associated with acupuncture is high, but serious events are uncommon. Acupuncture is not known to date for promoting the development of tumors. This connection remains to be elucidated.
    Copyright 2002 S. Karger AG, Basel


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    Selected Reports

    | May 2000

    Cardiac Tamponade Following Acupuncture* FREE TO VIEW
    Andreas Kirchgatterer, MD; Christian D. Schwarz, MD; Eva Höller, MD; Christian Punzengruber, MD; Peter Hartl, MD; Bernd Eber, MD
    Author and Funding Information
    Chest. 2000; 117(5):1510-1511. doi:10.1378/chest.117.5.1510
    Text Size: A A A


    Article



    References




    Acknowledgment
    Acknowledgment | Abstract | Case Report | Discussion | References




    Abstract
    Acknowledgment | Abstract | Case Report | Discussion | References




    We present a rare complication of acupuncture in a 83-year-old woman who developed syncope and cardiogenic shock shortly after an acupuncture procedure into the sternum. Echocardiography revealed cardiac tamponade, and pericardiocentesis disclosed hemopericardium. Due to hemodynamic instability, thoracotomy was indicated. A small but actively bleeding perforation of the right ventricle was found and successfully closed. Although acupuncture represents a relatively safe therapeutic intervention, this case report should remind all acupuncturists of possible and sometimes life-threatening adverse effects.

    Acupuncture is regarded as a safe method of treatment for many conditions. Serious injuries resulting from acupuncture therapy are seldom reported. In times of increasing request for evidence-based medicine and quality control, however, a prospective investigation of the incidence and variety of acupuncture-related adverse effects is not available up to now. Recently, a literature survey of acupuncture-related adverse effects was published, concluding that substantial evidence for the high degree of safety of this technique exists.1 However, a study from Norway that analyzed data of 135 randomly selected physicians and 197 acupuncturists revealed various adverse effects, among them pneumothorax as a major adverse event.2 Even fatal acupuncture-induced pneumothorax has previously been reported.3

    Cardiac tamponade resulting from penetrating trauma represents a life-threatening emergency, for elevated intrapericardial pressure compromises diastolic filling and systolic stroke volume, leading to profound circulatory collapse and shock.4

    Acupuncture-associated cardiac tamponade represents an extremely rare but serious event. Only three case reports of cardiac tamponade due to acupuncture were found in the literature.567
    Case Report
    Acknowledgment | Abstract | Case Report | Discussion | References




    An 83-year-old emaciated female patient without any history of heart disease developed bradycardia and syncope about 20 min after acupuncture, as a needle (stainless steel, 30 mm in length) was inserted into the middle third of the sternum by an experienced acupuncturist. Resuscitation was immediately successful, and the patient was transferred to the emergency department with sinus tachycardia, low BP, jugular venous distention, and unconsciousness. Echocardiography performed in a subcostal four-chamber plane showed cardiac tamponade with collapse of the right atrium and ventricle. Acutely performed pericardiocentesis using a subxiphoid approach disclosed hemopericardium. After drainage of 300 mL of bloody effusion, the patient stabilized hemodynamically and the catheter was left in place.
    In the following 3 h, the drainage of sanguineous effusion persisted up to the total amount of 1,200 mL, systolic BP declined again, and transfusion of two units of blood was necessary. Echocardiography showed hemodynamically relevant, progressive pericardial effusion. As a consequence, immediate surgery was indicated. After median sternotomy, a remarkable distention of the pericardial cavity was seen and about 1,000 mL of blood and clots were evacuated. A small perforating lesion (2 to 3 mm in diameter) with ongoing oozing of blood was identified in the anterior wall of the right ventricle as the cause of hemopericardium. This lesion was oversewn with a felt-buttoned 4–0 Prolene suture, leading to complete termination of bleeding. The surgical procedure was successfully performed without any need of extracorporeal circulation.
    Thereafter, the patient was hemodynamically stable, and weaning and extubation were uneventful. The mental status of the patient was compromised for several days, but after full recovery, discharge was possible 2 weeks later.
    Discussion
    Acknowledgment | Abstract | Case Report | Discussion | References




    A survey based on a MEDLINE search discovered only three reports of similar cases of acupuncture-associated cardiac tamponade in the scientific literature. The present case is remarkable in several regards. To our knowledge, this is the first case of an acupuncture-associated cardiac tamponade, which occurred immediately after the procedure and in which successful surgical intervention was possible due to rapid hemodynamic stabilization and adequate diagnostic evaluation using echocardiography.
    Two case reports have been published showing delayed and nonfatal cardiac tamponade after acupuncture. In Japan, the permanent embedment of acupuncture needles in the musculature represents a common acupunctural technique to relieve pain. As a complication, traumatic cardiac tamponade was caused in a 69-year-old woman after migration of needles from a distant part of the body via the venous route and penetration of the right ventricle.    7 A similar pathogenetic mechanism of slow migration over years and, ultimately, penetration of the pulmonary artery was suspected in a 52-year-old man who presented with cardiac tamponade a few years after a broken acupuncture needle had not been removed.5
    A case of a fatal cardiac tamponade in a 40-year-old woman that occurred immediately after acupuncture was reported by Halvorsen et al.    6 Their precise workup revealed mechanical injury of the right ventricular wall and a congenital foramen in the lower third of the sternum as a crucial factor.
    Our case report documents a nearly fatal complication of acupuncture after insertion of a needle into the sternum at the level of the fourth and fifth intercostal space, which represents an acupuncture point called Ren 17. In the critical analysis of the cause of this dramatic adverse event, one has to consider either a lack of anatomic knowledge or an incorrect application of the procedure. The acupuncture needle may have been inserted in a perpendicular direction in an emaciated patient.    18 Although the involved acupuncturist had gained extensive experience for > 12 years, we are not certain that the placement of the needle was proper. A sternal foramen, as in the case published by Halvorsen et al,6 was not discovered during thoracotomy in the reported patient.
    There exists no evidence to argue against this traditional and daily used medical technique; nevertheless, we conclude that every acupuncturist should also keep in mind possible and sometimes life-threatening adverse effects associated with acupuncture. In addition, this case report documents that only immediate evaluation of cardiogenic shock by means of echocardiography allows emergency decision making, thus leading to successful management of cardiac tamponade.


    Cardiac Tamponade Following Acupuncture* FREE TO VIEW
    Andreas Kirchgatterer, MD; Christian D. Schwarz, MD; Eva Höller, MD; Christian Punzengruber, MD; Peter Hartl, MD; Bernd Eber, MD
    Author and Funding Information
    Chest. 2000; 117(5):1510-1511. doi:10.1378/chest.117.5.1510
    Text Size: A A A


    Article



    References




    Acknowledgment
    Acknowledgment | Abstract | Case Report | Discussion | References




    Abstract
    Acknowledgment | Abstract | Case Report | Discussion | References




    We present a rare complication of acupuncture in a 83-year-old woman who developed syncope and cardiogenic shock shortly after an acupuncture procedure into the sternum. Echocardiography revealed cardiac tamponade, and pericardiocentesis disclosed hemopericardium. Due to hemodynamic instability, thoracotomy was indicated. A small but actively bleeding perforation of the right ventricle was found and successfully closed. Although acupuncture represents a relatively safe therapeutic intervention, this case report should remind all acupuncturists of possible and sometimes life-threatening adverse effects.

    Acupuncture is regarded as a safe method of treatment for many conditions. Serious injuries resulting from acupuncture therapy are seldom reported. In times of increasing request for evidence-based medicine and quality control, however, a prospective investigation of the incidence and variety of acupuncture-related adverse effects is not available up to now. Recently, a literature survey of acupuncture-related adverse effects was published, concluding that substantial evidence for the high degree of safety of this technique exists.1 However, a study from Norway that analyzed data of 135 randomly selected physicians and 197 acupuncturists revealed various adverse effects, among them pneumothorax as a major adverse event.2 Even fatal acupuncture-induced pneumothorax has previously been reported.3

    Cardiac tamponade resulting from penetrating trauma represents a life-threatening emergency, for elevated intrapericardial pressure compromises diastolic filling and systolic stroke volume, leading to profound circulatory collapse and shock.4

    Acupuncture-associated cardiac tamponade represents an extremely rare but serious event. Only three case reports of cardiac tamponade due to acupuncture were found in the literature.567
    Case Report
    Acknowledgment | Abstract | Case Report | Discussion | References




    An 83-year-old emaciated female patient without any history of heart disease developed bradycardia and syncope about 20 min after acupuncture, as a needle (stainless steel, 30 mm in length) was inserted into the middle third of the sternum by an experienced acupuncturist. Resuscitation was immediately successful, and the patient was transferred to the emergency department with sinus tachycardia, low BP, jugular venous distention, and unconsciousness. Echocardiography performed in a subcostal four-chamber plane showed cardiac tamponade with collapse of the right atrium and ventricle. Acutely performed pericardiocentesis using a subxiphoid approach disclosed hemopericardium. After drainage of 300 mL of bloody effusion, the patient stabilized hemodynamically and the catheter was left in place.
    In the following 3 h, the drainage of sanguineous effusion persisted up to the total amount of 1,200 mL, systolic BP declined again, and transfusion of two units of blood was necessary. Echocardiography showed hemodynamically relevant, progressive pericardial effusion. As a consequence, immediate surgery was indicated. After median sternotomy, a remarkable distention of the pericardial cavity was seen and about 1,000 mL of blood and clots were evacuated. A small perforating lesion (2 to 3 mm in diameter) with ongoing oozing of blood was identified in the anterior wall of the right ventricle as the cause of hemopericardium. This lesion was oversewn with a felt-buttoned 4–0 Prolene suture, leading to complete termination of bleeding. The surgical procedure was successfully performed without any need of extracorporeal circulation.
    Thereafter, the patient was hemodynamically stable, and weaning and extubation were uneventful. The mental status of the patient was compromised for several days, but after full recovery, discharge was possible 2 weeks later.
    Discussion
    Acknowledgment | Abstract | Case Report | Discussion | References




    A survey based on a MEDLINE search discovered only three reports of similar cases of acupuncture-associated cardiac tamponade in the scientific literature. The present case is remarkable in several regards. To our knowledge, this is the first case of an acupuncture-associated cardiac tamponade, which occurred immediately after the procedure and in which successful surgical intervention was possible due to rapid hemodynamic stabilization and adequate diagnostic evaluation using echocardiography.
    Two case reports have been published showing delayed and nonfatal cardiac tamponade after acupuncture. In Japan, the permanent embedment of acupuncture needles in the musculature represents a common acupunctural technique to relieve pain. As a complication, traumatic cardiac tamponade was caused in a 69-year-old woman after migration of needles from a distant part of the body via the venous route and penetration of the right ventricle.    7 A similar pathogenetic mechanism of slow migration over years and, ultimately, penetration of the pulmonary artery was suspected in a 52-year-old man who presented with cardiac tamponade a few years after a broken acupuncture needle had not been removed.5
    A case of a fatal cardiac tamponade in a 40-year-old woman that occurred immediately after acupuncture was reported by Halvorsen et al.    6 Their precise workup revealed mechanical injury of the right ventricular wall and a congenital foramen in the lower third of the sternum as a crucial factor.
    Our case report documents a nearly fatal complication of acupuncture after insertion of a needle into the sternum at the level of the fourth and fifth intercostal space, which represents an acupuncture point called Ren 17. In the critical analysis of the cause of this dramatic adverse event, one has to consider either a lack of anatomic knowledge or an incorrect application of the procedure. The acupuncture needle may have been inserted in a perpendicular direction in an emaciated patient.    18 Although the involved acupuncturist had gained extensive experience for > 12 years, we are not certain that the placement of the needle was proper. A sternal foramen, as in the case published by Halvorsen et al,6 was not discovered during thoracotomy in the reported patient.
    There exists no evidence to argue against this traditional and daily used medical technique; nevertheless, we conclude that every acupuncturist should also keep in mind possible and sometimes life-threatening adverse effects associated with acupuncture. In addition, this case report documents that only immediate evaluation of cardiogenic shock by means of echocardiography allows emergency decision making, thus leading to successful management of cardiac tamponade.


    Case Report SingaporeMedJ2004Vol45(4):180
    Necrotising fasciitis: a life-threatening
    complication of acupuncture in a patient
    with diabetes mellitus A Saw, M K Kwan, S Sengupta
    page1image2784
    ABSTRACT
    Acupuncture is used for some conditions as an alternative to medication or surgical intervention. Several complications had been reported, and they are generally due to physical injury by the needle or transmission of diseases. We report a case of life-threatening necrotising fasciitis that developed after acupuncture treatment for osteoarthritis of the knee in a 55-year-old diabetic woman. She presented with multiple discharging sinuses over the right knee. As the patient did not respond to intravenous antibiotics, extensive debridement was performed. She made a good recovery. Since many old diabetic patients with degenerative joint diseases may consider this mode of treatment, guidelines on cleanliness and sterility of this procedure should be developed and practiced.
    Keywords: acupuncture, acupuncture compli- cations, diabetes mellitus, necrotising fasciitis, wound infection
    Singapore Med J 2004 Vol 45(4):180-182
    INTRODUCTION
    Acupuncture is an important component of traditional Chinese medicine. The procedure has been used selectively in the Western countries for management of pain-related conditions, or behavioral problems such as smoking and overeating. Although most acupuncturists considered the procedure to be non- invasive, it is not free from complications. These included physical injuries due to the acupuncture needles, and problems related to wound or systemic infection. Necrotising fasciitis is a life-threatening infection involving the fascia and subcutaneous tissue. We report a case where this condition developed in a patient who had acupuncture treatment for osteoarthritis of the knee.
    CASE REPORT
    A 55-year-old woman who was a known diabetic presented to the emergency department with multiple
    Fig. 1 Photograph shows multiple sinuses over the right knee.
    Fig. 2 Photograph of the left knee shows multiple puncture scars from acupuncture.
    discharging sinuses over the right knee for a few days. She was being treated for bilateral osteoarthritis of the knees with acupuncture for the past three months. She had her last therapy one week earlier. The procedure was carried out over the anterior aspects of both the knees at multiple sites using a single needle. The needle was heated over a candle before each penetration but the skin was cleaned only with a wet cloth without any disinfectant. Two days later, the right knee became painful and purulent discharge was noticed from the puncture marks.
    On physical examination, she had low-grade fever with normal blood pressure but was tachycardic. There were four sinuses over the swollen right knee and right lower thigh (Fig. 1). No crepitation was noted on palpation and distal pulses were present. There were multiple puncture scars over the left knee with no signs of inflammation (Fig. 2). On admission,
    Department of Orthopaedic Surgery
    University of Malaya Medical Centre
    59100 Kuala Lumpur Malaysia
    A Saw, MMed Lecturer and
    Clinical Specialist
    M K Kwan, M Orth Clinical Specialist
    S Sengupta, FRCS Professor
    Correspondence to:
    Dr Saw Aik Tel: (60) 3 7950 2446 Fax: (60) 3 7953 5642 Email: sawaik@ hotmail.com
    page1image33064
    Singapore Med J 2004 Vol 45(4) : 181
    page2image1224
    Fig. 3 Photograph shows the wound over lateral aspect of the right thigh after second debridement.
    the random blood sugar level was 32.8 mmol/L. She was anaemic with Hb of 105g/L, and total white cell count of 16.6 x 109/L. The serum sodium level was 132mmol/L, and blood urea level was 22mg/dL. Intravenous sulbactam-ampicillin was started and blood sugar level was controlled by insulin infusion. After admission, drainage from the wounds persisted. The swelling over the thigh extended to mid-thigh level, with slight discoloration of the overlying skin. Diagnosis of necrotising fasciitis was made clinically and urgent exploration of the wound was arranged.
    Under general anaesthesia, the whole lower limb was prepared and draped up to the groin. The infection was noted to extend along the plane of deep fascia over the whole anterior aspect of the thigh, with no evidence of subcutaneous gas collection. Two large wounds were created over the medial and lateral surfaces of the thigh after extensive debridement of slough and discoloured skin flaps (Fig. 3). The exposed muscle was covered with moist dressing soaked with diluted povidone iodine and changed twice daily. After a few days, further slough developed and a second debridement was carried out. Pseudomonas was cultured from the wound and aminoglycoside was added to the antibiotic regime. Subsequently, her general condition improved and a split skin grafting was performed to cover both the wounds. Patient was discharged five weeks after admission. On follow-up, the grafted skin was dry and patient was able to walk without aid.
    DISCUSSION
    Physical injuries caused by acupuncture needles include median nerve compression(1), spinal cord irritation(2) and pneumothorax(3). Infective complications such as spinal infection(4) and bacterial endocarditis(5) have also been reported. Wound or systemic infections in acupuncture are mostly related to lack of sterility during the administration of therapy. Many acupuncturists who are delivering the service are not medically trained
    and may not be aware of issues related to sterility. For example, heating the needle before skin puncture may sterilise the instrument but without proper cleaning of the skin, this method alone is not adequate.
    Necrotising fasciitis is a dangerous condition with a high mortality rate, and more likely to affect people with diabetes mellitus(6). It may be difficult to make a definitive diagnosis of this condition based only on physical findings, and crepitance is not always present. Wall et al(7) recommended that white blood cell count of more than 14 x 109/L, serum sodium level of less than 135mmol/L and blood urea nitrogen of more than 15mg/dL on admission helps to differentiate this condition from other types of soft tissue infections that are less aggressive. Frozen section of tissue biopsy under local anaesthesia can also help establish the diagnosis(8). In our patient, the initial diagnosis was based on physical findings, and results of blood investigations on admission were also supportive of this condition. Early diagnosis, nutritional support and early extensive debridement(6,9) remain the standard treatment, while the role of hyperbaric oxygen therapy has not been definitively established(10).
    Osteoarthritis is a common condition in the elderly. Concern over complications related to prolonged use of non-steroidal anti-inflammatory drugs and unwillingness to undergo surgery were some of the reasons why patients resort to acupuncture for pain relief. Without proper preparation of skin and needle, transmission of systemic infection or local wound sepsis is possible. Considering the increasing segment of the aged population in many countries, we can expect more elderly diabetics with degenerative joint diseases to go for acupuncture treatment. Measures should be taken to ensure that practicing acupuncturists have adequate knowledge about normal anatomy and common anatomical variations of sites where acupuncture is to be administered(11). They should also adhere to a specific standard of hygiene and are able to identify high risks cases, including diabetics and those with internal implants, where additional precaution may be necessary.
    REFERENCES
    1. Southworth SR, Harting RH. Foreign body in the median nerve: a complication of acupuncture. J Hand Surg 1990; 15B:111-2.
    2. Kondo A, Koyama T, Ishikawa J, Yamasaki T. Injury to the spinal cord produced by acupuncture needle. Surg Neurol 1979; 11:155-6.
    3. Mazal DA, King T, Harvey J, Cohen J. Bilateral pneumothorax after acupuncture. N Eng J Med 1980; 302:1365-6.
    4. Hadden WA, Swanson AJG. Spinal infection caused by acupuncture mimicking a prolapsed intervertebral disc. J Bone Joint Surg 1982; 64A:624-5.
    5. Jeffreys DB, Smith S, Brennand-Roper DA, Curry PVL. Acupuncture needles as a case of bacterial endocarditis. Br Med J 1983; 287:326-7.
    6. Majeski JA, Alexander JW. Early diagnosis, nutritional support, and immediate extensive debridement improve survival in necrotizing fasciitis. Am J Surg 1983; 145:784-7.



     
     
     
     
     
     
     
     

    Medical Acupuncture

    A Journal For Physicians By Physicians
    Volume 13 / Number 2 "Aurum Nostrum Non Est Aurum Vulgi"

     

     
     
     
     
     

    Table of Contents

           On-line Journal Index

     

     
     
     
     
     

     

    Wound Infection After Total Knee Arthroplasty And Acupuncture: Case Report And Survey Of Medical Acupuncturists Steven E. Braverman, MD Rafael L. Prieto, MD

    ABSTRACT Background While acupuncture is a safe treatment modality, complications can occur. The incidence of sequelae in patients with total joint replacement who undergo acupuncture therapy is not well known. Objectives To describe a patient receiving acupuncture with sequelae after arthroplasty, and to establish the incidence of such complications in medical acupuncture practice. Design Case report, and survey of medical acupuncturists (n=300). Main Outcome Measure Incidence of complications following acupuncture in patients receiving total joint replacement. Results The patient developed Staphylococcus aureus infection in the knee 7 weeks postoperatively. Acupuncture was discontinued and the infection resolved with intravenous antibiotics, debridement, and revision arthroplasty. Response rate to the survey was 42% (n=126). Of the respondents, 103 (81.7%) performed acupuncture for patients who had undergone arthroplasty. Regardless of the number of patients treated per year, no acupuncturists reported infectious sequelae in this population. Conclusion From our survey results, it appears that the risk of infectious complications from acupuncture is extremely low. It is possible in our case that the infection was coincidental because it occurred during the period of highest postoperative risk. KEY WORDS Acupuncture, Arthroplasty, Complications, Total Joint Replacement

     INTRODUCTION To our knowledge, there are no prospective studies that specifically address acupuncture risk and complications. Recent review articles demonstrate that while acupuncture is generally safe, complications can and do happen.1,2 Herein, we describe a patient who developed a deep infection following total knee arthroplasty several weeks into acupuncture treatment for a comorbid condition. Subsequently, a survey was sent to medical acupuncture practitioners in an attempt to determine practice patterns and the risk of infection in patients with total joint prostheses who are treated with acupuncture.
    case2figure1
     CASE REPORT A 59-year-old man was referred to our clinic 3 weeks after bilateral total knee arthroplasty. The patient's chief complaint and reason for referral involved a postoperative exacerbation of his chronic low back pain. Physical examination and magnetic resonance imaging (MRI) findings suggested lumbar spinal stenosis as the likely cause of his back pain. The patient expressed an interest in non-pharmacological management of pain; thus, acupuncture was presented as an option. Patient consent was obtained; acupuncture treatment was initiated and consisted of a series of 3 weekly treatments. Disposable sterile needles were placed in all selected points superficial to the muscle fascia and then coupled in standard fashion to a low-voltage electrical stimulation device. The bilateral acupuncture points selected for analgesia included 2 posterior and superficial to the knee joint, KI 10 and BL 40 (Figure 1). The patient developed left knee pain 7 weeks following the operation. On physical examination, a purulent exudate drained from the anterior surgical wound. Subsequent cultures were positive for Staphylococcus aureus. Acupuncture was discontinued prior to the 4th scheduled treatment. Orthopedic treatment included intravenous antibiotics, surgical debridement of the left knee, and removal of the prosthesis. A revision of the left total knee arthroplasty was completed with good results. Initial anesthesia was delivered by spinal block. Left knee anterior wound erythema and a serosanguinous discharge was noted at 2 to 3 weeks postoperatively. The patient's low back pain resolved during the course of intravenous antibiotics. Survey Methods A survey of 4 questions was prepared and sent to 300 practice members of the American Academy of Medical Acupuncture (AAMA). Nominal and ordinal data were analyzed using standard methods. RESULTS The study included 126 respondents (42%) to the survey. A list of the survey questions and responses is included in Table 1. The majority (n=103 [81.7%]) of these physicians performed acupuncture on patients who had received either a total knee or hip arthroplasty, and 87 (84.5%) of these clinicians placed needles in the vicinity of the surgical site as part of their treatment. Fifty-two physicians (50.5%) performed 10 or fewer treatments in the vicinity of the replaced joint, while 44 (42.7%) reported performing between 11 and 100 of these treatments a year. Seven physicians (6.8%) performed acupuncture in the vicinity of a replaced joint in more than 100 patients a year. There were no joint infections reported during acupuncture treatment. The survey did not request information regarding the timing of acupuncture in relation to the patients' surgeries. DISCUSSION The efficacy of acupuncture in the treatment of many diagnoses, and its safety when properly performed, were discussed in a recent statement released by the National Institutes of Health (NIH).3 Similar to conventional medical therapies, acupuncture involves some degree of risk. Literature reviews of acupuncture-associated adverse effects have grouped the majority of these events into 3 main categories: mechanical organ injuries (pneumothorax, spinal cord injury), infections (hepatitis, endocarditis, HIV), and others (asthma exacerbation, dermatitis).1,2 Many of the mechanical injuries are sustained from the technique of Japanese or implantation acupuncture. In this process, needles are inserted into the body and then cut. Injury of the spinal cord, upper urinary tract, and other organs have occurred when the needles migrate to these structures.1,4 The transmission of infectious disease is a potential complication whenever acupuncture needles are reused. The use of sterilized needles by appropriately-trained staff is the crucial first step in preventing infectious complications. Such complications of acupuncture have been reported only in cases in which sterilization was inadequate, in-dwelling needles were used, or the patient had a pre-existing medical condition commonly associated with immune system compromise.1,5,6 None of the 3 types of sequelae applied to this case where sterile, disposable needles were coupled to a low-voltage stimulation device that may impart some mild bactericidal activity.
    Table 1. Survey of Medical Acupuncturists (N=126)*
    1. Do you treat patients with acupuncture who have had total knee or hip replacement?
    Yes
    103 (81.7)
    No
    23 (18.3)
    2. If yes, do you use points in the vicinity of the replaced joint (including scar area)?
    Yes
    87 (84.5)
    No
    14 (13.6)
    Did not answer
    2 (1.9)
    3. Approximately how many such treatments have you performed per year?
    0-10
    52 (50.5)
    11-100
    44 (42.7)
    101-500
    7 (6.8)
    4. How many of these joints becameinfected during your treatment period?
    None
    103 (100)
    1-2
    0
    1% of the time
    0
    1%-10% of the time
    0
    >10% of the time
    0
    * All data are presented as No. (%) of respondents. The denominator for questions 2-4 is 103 acupuncturists, since 23 respondents reported "no" to question 1.
     The incidence of deep infection following total knee arthroplasty is approximately 1%.7,8 Variation in the rate of infection occurs among medical centers, with 1 center in 1990 reporting an incidence of infection during a 3-year period as high as 8.2%.9 Perioperative antibiotic prophylaxis following total knee arthroplasty is currently standard practice to prevent early postoperative infection.10 One source defines early postoperative infection as infections occurring in the first 2-3 weeks, and late infection as those occurring thereafter.10 As many as 62% of infections occur in the late postoperative period.11 There are no MEDLINE reports of acupuncture as a possible etiology of wound infection following total knee or hip arthroplasty. The physicians who responded to our survey frequently performed acupuncture in the vicinity of a total joint replacement. Although the number of such patients who are treated without infectious sequelae could not be precisely determined from this study, we estimate that between 901 and 8,570 patients were safely treated with acupuncture following total joint replacement. If acupuncture contributed to the reported infection, then the overall patient survey data indicate that the risk of infection when performing acupuncture in these patients may be greater than zero, but much less than 0.1%. The large number of patients with total joint replacement who received acupuncture treatment without developing postoperative infection, coupled with the recognized total knee arthroplasty infection rate of 1%-8%, raises the possibility that this infection was coincidental and unrelated to the acupuncture. CONCLUSION The postoperative timing of acupuncture intervention in the surveyed treatments is unknown. In our case, the acupuncture intervention occurred during the highest risk period for infection. That timing increases the likelihood that a coincidental infection could be attributed to the acupuncture. One can neither definitively conclude nor refute that acupuncture was the source for this S aureus infection. Acupuncturists should avoid needling the extremity containing the prosthetic joint during the immediate postoperative period (3-6 weeks) to decrease any potential infection risk, and decrease the likelihood that a postoperative coincidental infection would be attributed to acupuncture. Prospective, randomized, controlled investigations are needed to more accurately quantify the risks of acupuncture. REFERENCES
    Norheim AJ. Adverse effects of acupuncture: a study of the literature for the years 1981-1994. J Altern Complement Med. 1996;2:291-297.
  • Ernst E, White A. Life-threatening adverse reactions after acupuncture? a systematic review. Pain. 1997;71:123-126.
    • NIH Consensus Conference. Acupuncture. JAMA. 1998;280:1518-1524.
    • Murata K, Nishio A, Nishikawa M, Ohinata Y, Sakaguchi M, Nishimura S. Subarachnoid hemorrhage and spinal root
    • Pierik MG. Fatal Staphylococcal septicemia following acupuncture: report of two cases. R I Med J. 1982;65:251-253.
    • Yazawa S, Ohi T, Sugimoto S, Satoh S, Matsukura S. Cervical spinal epidural abscess following acupuncture: successful treatment with antibiotics. Intern Med. 1998;37:161-165.
    • Garvin KL, Hanssen AD. Infection after total hip arthroplasty: past, present, and future. J Bone Joint Surg Am. 1995;77:1576-1588.
    • Wilson MG, Kelley K, Thornhill TS. Infection as a complication of total knee-replacement arthroplasty. J Bone Joint Surg Am. 1990;72:878-883.
    • Gordon SM, Culver DH, Simmons BP, Jarvis WR. Risk factors for wound infections after total knee arthroplasty. Am J Epidemiol. 1990;131:905-916.
    • Scott WN. The Knee. St Louis, Mo: Mosby-Year Book; 1994:1262.
    • Rasul AT Jr, Tsukayama D, Gustilo RB. Effect of time of onset and depth of infection on the outcome of total knee arthroplasty infections. Clin Orthop. 1991;273:98-104.,

    AUTHORS' INFORMATION Lieutenant Colonel Steven E. Braverman, MD, is on active duty in the United States Army, and Deputy Commander for Clinical Services, Moncrief Army Community Hospital, Ft Jackson, South Carolina. The research for this study was done at Walter Reed Army Medical Center, Washington, DC, where Dr Braverman was the Physical Medicine and Rehabilitation Residency Program Director and Chief of the Physical Medicine and Rehabilitation Service.


    Needle Shock: Adverse Effect Or Transformational Signal Michael T. Greenwood, MB (MD)

    ABSTRACT "Needle shock" is a syndrome that occurs in about 5% of acupuncture patients. It presents as general malaise, cold perspiration, nausea, and, in extreme situations, loss of consciousness. Traditional teaching suggests that when needle shock occurs, all needles should be removed, the session terminated, and the patient informed that he/she may not be a good candidate for acupuncture. The author suggests that needle shock may simply be a signal for a large energy shift and not necessarily a negative effect. KEY WORDS Acupuncture, Needle Shock, Transformation, Original Energy
    INTRODUCTION As most physician-acupuncturists know, acupuncture is a safe intervention. This has been confirmed by 2 major studies that recorded no serious adverse events from acupuncture in tens of thousands of patients. The few minor events that were recorded mostly consisted of nausea, fainting, and heavy sweating. Of those, the majority were immediate reactions, making them likely to be varieties of the "needle shock" phenomenon.1,2 But is needle shock really an adverse effect because the textbooks say so? Or is it, in fact, a marker for something quite the opposite, i.e., something positive, a large energy shift that might be transformational if allowed to evolve in a safe manner? Indeed, does anyone really know? Helms describes needle shock as a vasovagal reflex that manifests as lightheadedness, general malaise, cold perspiration, nausea, and, in extreme situations, loss of consciousness.3 It occurs most often in young, fit, healthy males at the 1st or 2nd visit, especially in those who have a strong psychological investment in their bodies and especially if the needles are placed in the upper back with the patient sitting. However, it can occur in any position. Helms' suggested treatment includes removing the needles, lying the patient down, maintaining verbal communication to allay patient anxiety, and tonification of various acupuncture points such as GV 26 (RenYing), ST 36 (Tsu San Li), and LI 4 (Hegu)3 (Table 1). Differential Diagnosis Needle shock has been attributed to a vasovagal reaction, which is a complex neurovascular reflex mediated by efferent autonomic fibers to the heart and blood vessels. In vasovagal syncope, usually there is a well-defined clinical trigger followed by preliminary warning symptoms related to overactivated sympathetic tone.4 The trigger usually involves an increase in the stress burden coming about as a result of pain, sight of blood, fright, or distressful thought. The result is a syndrome consisting of bradycardia, hypotension, cool and pale skin, nausea, and sweating. In extreme situations, there may be loss of consciousness, accompanied with or followed by myoclonic shaking, nausea, or vomiting.
    Table 1. Needle Shock Treatment

    Symptom
    Treatment
    Chinese Name
    English Name
    Loss of consciousness
    Tonify GV 26
    Renzhong
    Philtrum
    Precipitating needles in upper body
    Tonify ST 36
    Zusanli
    Three Measures on the leg
    Precipitating needles in the lower body
    Tonify LI 4
    Hegu
    Adjoining Valleys

    Usually, it is clear what is transpiring; however, there is always the potential for the unusual or catastrophic. For example, one patient developed a severe headache, nausea, and vomiting following the needling of GV 16 for chronic neck pain. A computed tomographic scan showed a hemorrhage in the 4th ventricle. The headache lasted 28 days.5 In another case, an emaciated 83-year-old woman developed bradycardia and syncope 20 minutes after acupuncture needles were inserted perpendicularly at CV 17 (Shanzhong). At thoracotomy, a 2-3 mm perforation was found in the anterior wall of the right ventricle.6 That patient survived, but others have died from a needle passing through sternal foramina under CV 17, which apparently occurs in 9% of men and 4% of women.2,7,8 Pneumothorax is a well-known adverse effect and can present with chest pain, sweating, and shortness of breath.9 Other conditions in the differential diagnosis might include cardiac arrhythmias, myocardial ischemia, pulmonary embolism, seizure disorders, and various somatiform disorders such as factitious anaphylaxis and pseudoseizures. Anaphylaxis can produce cardiovascular collapse and loss of consciousness, but it is hardly a complication of acupuncture; unlike the vasovagal reaction, it presents with tachycardia, hypotension, and warm, flushed skin.10 History and situation generally rule out these other possibilities. Terminate or Proceed It can be disconcerting to see a patient sweating, choking, vomiting, or having myoclonic activity on the treatment table. But in the absence of a serious pathology, the question is whether it is always a reason for terminating the session. Termination is going to abort whatever is happening, leaving no way of knowing whether a positive outcome would have occurred had the situation been allowed to evolve without interference. The difficulty lies in that in order to find out, the practitioner would have to allow the situation to continue to its own resolution. In my experience, such an unusual course of action can catapult people into significant energetic experiences associated with expanded states of consciousness.11 Should the treatment be terminated or not? It is the discretion of each practitioner to decide depending on the situation and context. Stopping is the safer course, but continuing might be an option if practitioner and patient were appropriately prepared for any chaotic energies that might emerge. Moving the Qi Oriental medicine's concept of stagnant Qi can produce a mental picture of the needle shock phenomenon by comparing the blockage in energy flow to the blockage of water flow in a river. When the Qi has been stagnant for a long time, there is a buildup of Qi, rather like the buildup of water behind a dam. If the dam gates are opened in the presence of a large reservoir of water, the resulting water movement can be massive. Similarly, if an acupuncture needle opens the doors of stagnation in the presence of a large reservoir of Qi, the energy shift can be dramatic, even overwhelming. Since the primary purpose of acupuncture is to move energy, the needle shock phenomenon, rather than indicating that something is wrong, may actually indicate that something is right, albeit large and dramatic. It is not necessarily a sign that the patient is unsuitable for acupuncture, but rather that he/she is particularly sensitive to it. Why it happens in young men with muscular bodies may well speak to their general Qi abundance, together with the degree to which they feel the need to control its spontaneous flow. The Loss of Original Nature While muscular young men have more Qi than most, the tendency to block the spontaneous flow of energy is common to everyone. Moreover, Oriental philosophy posits that this habitual interference with the spontaneous flow of Qi is at the very root of disease. Blocking original energy, as the experience of unrestricted flow might be termed, leads to loss of "original nature" and separation from the Tao.12 Therefore, healing should involve – among other things – an attempt to reconnect with and integrate original energy so that it can be channeled in ways more creative than simply sustaining an illness. This means that one of the primary tasks of the acupuncturist is to help patients learn how to let go into the experience of unrestricted energy flow.
    Figure 1. Yin/Yang Dynamics of Needle Shock
    GRNWD_fig1

    Figure 2. The Gate of Birth and Door of Death (Golden Gate)
    GRNWD_fig2
     Unfortunately, this is not easy and may consume many sessions before a breakthrough occurs. Thus, when something happens that breaks down the ego's barriers in a trice, the astute practitioner should avoid immediate negative conclusions. Indeed, the sudden breaking-down of the barriers to spontaneity through needle shock may be exactly the stimulus necessary to get past entrenched blocks, and the energy shift that occurs while the patient is out of control can be transformational if the practitioner frames the experience in a broad-enough philosophical context. Misinterpretation of Energetic Phenomena The touch of the numinous – which, in Oriental medicine parlance, might be called a glimpse of original energy – is a common theme in mythological literature. For example, at the beginning of the Grail myth, the young Fisher King burns his fingers when he innocently eats some salmon roasting on a spit in a forest clearing. At least one author has interpreted this story to indicate touch of the numinous can be too hot to handle if approached without appropriate caution (the fish is a symbol of the numinous and survives today in the bishop's hat).13 Applied to the acupuncture ritual, a strong energetic reaction may have the potential to injure or to heal, depending on the patient's maturity and ability to integrate unusual experiences. Strong energetic reactions can be immensely healing if they are consciously embraced, which means it is probably a mistake to pathologize the unusual. But medicine has a history of doing exactly that - pathologizing strong energetic reactions instead of considering the possibility of emerging transpersonal phenomena. Stanislov Grof, who pioneered rebirthing and holotropic breathing, has written extensively on this confusion, noting that psychiatry generally does not recognize the difference between mystical and psychotic experiences. He points out that modern medicine considers all unusual states of consciousness as pathological and routinely treats them with suppressive therapies, which often leads to chronicity, long-term dependence on pharmaceuticals with all their associated side effects and impoverishment of the personality.14 Yin-Yang Dynamics Yin-Yang cycles and reversals form the physiological basis of all the various biological rhythms such as the waking/sleeping cycle, menstrual cycle, etc.15 Usually, the changes are gradual and pass largely unnoticed. In contrast, the needle shock captures attention because the phenomenon presents a sudden reversal of Yin and Yang. The physiologist would say that prior to the onset of this phenomenon, there is an increase in sympathetic tone which, in Oriental medicine terms, would be termed a buildup of Yang. This is experienced as increasing tension, especially in the middle and upper Jiaos, nausea, sweating, and a feeling of impending doom. When the subsequent parasympathetic outflow occurs, Yang collapses and Yin comes to dominate the physiology. The sudden change of sympathetic to parasympathetic predominance leads to a precipitous decrease in blood pressure and bradycardia. Upper body tension collapses. The Qi in the upper Jiao falls down the Yang Meridians, Tai Yang, Shao Yang, and Yang Ming, leading to hypotension and even loss of consciousness. During this period of collapse, muscular resistance dissipates and as a result, the Qi begins to flow chaotically (Figure 1). Without the Yang muscular tension to control the flow of Qi, a general discharge of blocked energy can involve every body system, with a variety of phenomena ranging from myoclonic shaking to emotional releases, regressive experiences, coughing, vomiting, and even loss of bladder and bowel control. Because these chaotic phenomena represent unrestricted energy flow, they can be understood as an experience of original energy and an immersion in the Water element, which has been deemed the "void."16 Five Elements and the Golden (Metal) Gate In terms of the Five Elements, needle shock might be understood as a doorway to the transformational vortex of the Water element, a rapid transit through the biggest barrier to original energy. In a previous article, I discussed the concept of a narrow passage that must be negotiated by the patient to achieve transformation.17 To summarize, most patients with chronic symptoms usually present in the region of the Metal element and must move forward through a psychic constriction known as the Golden Gate (Jin Men) into the apparent chaos of Water to find transformation. This process is universally frightening and is usually vigorously resisted by an ego bent on maintaining its own illusory existence. As the ego moves closer and closer to the Gate, symptoms of fear loom larger and manifest as pain, sweating, terror, dizziness, etc. – phenomena that reflect the increasing sympathetic tone. The entrance to the gate is marked by a radical reversal of polarity, with a collapse of Yang into the formlessness of Yin. The reversal marks the end of a complete cycle of the Five Elements, after which the chaotic energies reorder themselves into a new dynamic stability. The Younger Patient: Wood Collapses Back Into Water In the younger patient, the situation is often more effervescent. Younger patients are generally in the process of building an ego (rather than letting go of an outmoded one) and tend to have symptoms that are primarily energetic in nature. They are more likely to present in the Wood sector, with stagnation of Qi rather than the deeper disharmony of Blood stagnation one might expect in someone with chronic multifactorial illness presenting in the Metal sector. As a result, younger patients tend to be more sensitive to acupuncture needles and will have more movement of Qi with fewer needles.18 No sooner is the young man/woman out of the starting gates of ego-building that an acupuncture needle inadvertently engenders a collapse of Yang that reverses him/her back to the beginning. It could be said that they get a glimpse of their original energy before they know its significance. In this way, they touch the transformational vortex unconsciously and in the process, they might get burned. But, by assuming the experience is bad, they miss the point that they have actually touched their original energy. The Golden Gate is also known as the gate of birth and the door of death (Figure 2), which could be interpreted to mean that it represents both the entry and exit points to the experience of original energy.19 The doorway into and the doorway out of the void is, in fact, the same door. Both entry and exit involve a Yin/Yang polarity reversal. The only thing that changes is our direction, whether going in or coming out. Interpretation Later in the Grail myth, the young Parsifal arrives at the Grail castle for dinner, but forgets to ask 2 key questions of his host (as he had been admonished to do) and instead, engages his dinner companions in idle chatter (the first of these 2 questions was, "What is the meaning of the Grail?"). Through this oversight, Parsifal loses the opportunity to avail himself of the healing properties of the Grail – which is precisely what may happen if the physician dismisses the needle shock experience and forgets to help the patient inquire into the real meaning of the experience. It is here that the astute physician has a remarkable opportunity to reframe the experience in a positive way and encourage the patient to understand the deeper significance of the experience. The physician can frame it in terms of the Grail myth or whatever analogy might be appropriate, and then suggest ways the patient can make a more conscious foray into the experience of original Energy – to approach it in such a way that he/she does not have a negative experience. If the physician is successful, the patient's intent will shift from "moving away" to "moving toward;" then, it is just a question of providing an appropriate context in which to express that intent. Since the energies can be chaotic, a location away from the normal office routine may be appropriate. In my experience, when this is done, it is not difficult for many patients to experience the flow of original energy in a positive way. CASE REPORTS Head Injury and Insomnia The patient was a 36-year-old man who came to a 10-day residential chronic pain program with right-hand chronic regional pain syndrome (RSD, now called CRPS type 1) stemming from an industrial injury 3 years previously, several surgeries to repair his thumb, including 2 tendon transfers, and a fusion of the metacarpophalangeal joint. He had a remote head injury 10 years previously, chronic insomnia, and would not permit even light touch on his thumb. During the 1st acupuncture treatment, which included 3 of the 4 gates (LV 3 bilaterally and contralateral LI 4) plus local needles in trigger points in the head and neck area, the patient abruptly lost consciousness. We removed the needles, checked his vital signs, laid him on his side, and pondered what to do next. With some trepidation, we decided to take a wait-and-see approach and he woke up an hour later feeling good. For the next 10 days, the patient spent much of his time sleeping, waking only to eat or smoke a cigarette. After 10 days, he looked more rested and remarked that he had not slept properly in 10 years. This patient returned for a 2nd program; he then permitted needles in the injured arm. He was treated with N-N+1 circuits and local needles. At each treatment session, he exhibited some myoclonic shaking in the right arm and went into an altered state and into a void for several minutes. He later described re-experiencing aspects of his various traumas during these periods of dissociation. However, we were less concerned with this phenomena and made certain he was  lying safely on his side when it occurred. At the end of the program, the patient was pain-free and 2 years later, was running a successful business. Post Motor Vehicle Accident Pain The patient was a 45-year-old man who was involved in a motor-vehicle accident a year previously. During the crash, he put his right hand out to protect his son (who was in the right front seat), and braced his left hand on the steering wheel while slamming his right foot on the brake. He had a severe trigger point in the thoracic spine at T5-6, and his left arm felt as if it was pinned to his chest; he held it awkwardly and did not like to move it away from his chest. During the first session, needles were placed in the 4 gates (LV 3, LI 4) and local points in the upper back at T5-6 (BL 15) and trapezius area (GB 21). He began to sweat, complained of feeling nauseous, and his head and arms began to shake. We removed the needles and laid him down, but encouraged him to continue shaking so long as the impulse was present. We framed the myoclonic activity in a positive manner, suggesting it represented a release of the energetic imprint from the trauma. With this understanding, the patient agreed to engage the process more deeply. In subsequent sessions, his right hand went out as if to protect his son, the left hand braced against an imaginary steering wheel, and his right leg started to move as if pumping the brakes. Each time, he sweated, shook, and felt nauseous. After these kinds of experiences, his pain levels dropped dramatically. In time, he learned the significance of what was happening and was able to develop a home dynamic meditation which included some myoclonic shaking. Furthermore, the patient settled his insurance claim, and after 6 months of acupuncture and home routine, he was pain-free. DISCUSSION Although needle shock is generally regarded as a negative effect of acupuncture, there are good experiential and philosophical reasons for questioning that assumption, especially when one considers that acupuncture is not simply a symptomatic approach to disease. Indeed, if needling can be a doorway to an experience of original energy, then what is generally regarded as an adverse effect may well be a transformational experience in process. To miss this point may be a grave error. Needle shock is simply a large energy shift and if framed that way, can lead to a good outcome with considerable changes in symptoms. To engage this idea in a session can be challenging, but the rewards can make it well worth the effort. Another question is, are there really adverse effects? One practitioner used this example: if a pneumothorax occurs during an acupuncture treatment for chronic bronchitis, but the patient's ensuing hospital experience prompts him to stop smoking, then is it an adverse effect?20 In the immediate sense of things, yes; but in the larger sense of things, no. Because the outcome was ultimately good. Therefore, from a transformational perspective, one cannot make the judgment that something is good or bad – since, what appears to be bad today may turn out to be good later. CONCLUSION In an era of evidence-based medicine and outcome studies, these philosophical musings may seem irrelevant to clinical practice. But when it comes to energy medicine, everything is in transformation and nothing exists in isolation. If we miss that point, perhaps we miss the whole essence of the art of acupuncture. ACKNOWLEDGEMENT Richard Greenwood, Dr Greenwood's son, is responsible for all the graphics herein.

    Medscape Medical News
    Medicinal Herb Linked to Endemic Nephropathy and Cancer
    Rod Franklin
    Nov 12, 2011
     

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    November 12, 2011 — An endemic nephropathy (EN) found in Eastern European farming communities appears to be caused by environmental exposure to the human carcinogen aristolochic acid (AA), a major component of an herb used in Chinese medicine, according to a study published online November 9 in Kidney International.
    Environmental exposure to AA in the Balkans can be traced to the plant     Aristolochia, which invades the wheat crops harvested in the Balkans for grain and bakery production and is also used in Chinese herbal remedies. Some people have been sickened to the point of end-stage renal disease after ingesting Aristolochia fangchi directly as part of a weight-loss regimen.
    Led by Bojan Jelaković, from the School of Medicine, University of Zagreb, and Department for Nephrology, Arterial Hypertension and Dialysis, University Hospital Center Zagreb, Croatia, and coordinated through the Health Sciences Center of Stony Brook University in New York, the study focused on 77 patients living in Bosnia, Croatia, Serbia, and other Balkan regions along the Danube River, where exposure to AA is elevated.
    Seeking to confirm the association between AA exposure and EN, the investigators documented the presence of 2 key biomarkers in patients from areas where nephropathy is endemic, but not in patients living in nonendemic regions.
    Aristolactam–DNA adducts, formed in the renal cortex via the commingling of AA with DNA, are regarded as effective indicators of an individual's environmental exposure to AA. The adducts generate uniquely mutated signatures of the tumor suppressor gene     TP53 in urothelium. These are biomarkers for AA carcinogenicity and the upper urinary tract cancers that are closely associated with EN.
    When DNA was extracted from the renal cortex and urothelial tumor tissue of 67 patients (40 women, 27 men) living in regions known to harbor nephropathy in its endemic form, researchers found aristolactam–DNA adducts in 70% of the cohort (80% of the women, 56% of the men;     P < 0.055). Moreover, specific A:T to T:A mutations of the TP53 gene were found in 40% of the participants from endemic regions, including 33% of the men and 44% of the women. Aristolactam–DNA adducts were found in 94% of the cases that presented with this mutation.
    Neither the aristolactam–DNA adduct nor the     TP53 mutation, however, was present in the tissues of 10 control patients residing in areas of non-EN.

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    Most of the endemic patients had lived in endemic regions for at least 20 years. Average age at the time of nephroureterectomy for removal of urinary tract carcinomas was 73.4 years. Location of the majority of tumors (70%) was either in the renal pelvis or ureter. Severe (stage 4 or 5) chronic kidney disease was evident in 38.8% of the endemic cohort. In comparison, only 20% of the nonendemic cases were classified as chronic kidney disease stage 4 or 5.
    Previous investigations on the etiology of EN and upper urinary tract cancers have focused on environmental agents such as heavy metals, mycotoxins, and trace elements. The authors conclude that the current study supports the hypothesis that environmental exposure to AA is a causal factor for both EN and upper urinary tract cancers in genetically predisposed individuals.
    The authors have disclosed no relevant financial relationships.


    Multifocal Infection of Mycobacterium Other Than Tuberculosis Mimicking a Soft Tissue Tumor of the Extremity
    Han-Soo Kim, MD; Il Hyung Park, MD; Sung Hwa Seo, MS; Ilkyu Han, MD; Hwan Seong Cho, MD

    • Orthopedics
    • December 2011 - Volume 34 · Issue 12: e952-e955
    • DOI: 10.3928/01477447-20111021-31
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    Abstract
    Mycobacterium other than tuberculosis infections rarely develop in healthy individuals, but direct inoculation such as contaminated acupuncture can cause mycobacteriosis even in an immunocompetent host. A 56-year-old woman gradually developed pain on the anterior aspect of the left knee and the distal thigh after hiking without trauma. She received acupuncture for 3 consecutive days on the bilateral knees at the suprapatellar and infrapopliteal areas. After acupuncture, mild localized heat and painful swelling developed around the knees bilaterally. Magnetic resonance imaging (MRI) demonstrated soft tissue masses with a lobulated contour at the prefemoral fat between the suprapatellar pouch and the distal femur and at the proximal tibia behind the knee joint capsule. Fibromatosis, pigmented villonodular synovitis, and soft tissue sarcoma were considered. On pathologic examination, multiple granulomas with lymphoplasmatic infiltration were evident, and acid-fast bacteria staining revealed acid-fast bacilli. A mycobacterial culture confirmed Mycobacterium other than tuberculosis infection, and a polymerase chain reaction-fragment length polymorphism assay identified the isolates as Mycobacterium abscessus. After treatment with appropriate antibiotics, the patient had no evidence of disease and reported no pain during activities of daily living.
    Acupuncture is growing in prominence in Europe and the United States, and the number of reports on complications increases with its widespread use. Although the risk to an individual patient is difficult to determine, acupuncture may cause serious complications in patients with coagulopathy, heart valve disease, and immune deficiency. In addition, direct inoculation such as contaminated acupuncture can cause mycobacteriosis even in an immunocompetent host.
    MULTIFOCAL INFECTION OF MYCOBACTERIUM OTHER THAN TUBERCULOSIS MIMICKING A SOFT TISSUE TUMOR OF THE EXTREMITY
    Drs Kim, Han, and Cho are from the Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Dr Park is from the Department of Orthopedic Surgery, Kyungpook National University School of Medicine, Daegu, and Ms Seo is from the Department of Biomedical Science, Kyungpook National University, Daegu, South Korea.
    Drs Kim, Park, Han, and Cho and Ms Seo have no relevant financial relationships to disclose.
    See Also
    Predictors of Local Recurrence in High-grade Soft Tissue ...
  • Ewing's Sarcoma/Primitive Neuroectodermal Tumor of the ...
  • Malignant Soft Tissue Tumors of the Biceps Muscle Mistaken ...
    • Correspondence should be addressed to: Hwan Seong Cho, MD, Department of Orthopedic Surgery, Seoul National University Bundang Hospital, 166 Gumi-Ro Bundang-Gu, Seongnam-Si, Gyeonggi-Do 463-707, South Korea (mdchs111@snu.ac.kr).
    Posted Online: December 06, 2011
    Mycobacterium other than tuberculosis infections rarely develop in healthy individuals but are substantially more common in immunocompromised hosts.1 They may present with various clinical manifestations dependent on host immune status, such as disseminated disease, primary cutaneous infection, postoperative infection, pulmonary infection, keratitis, and cervical lymphadenitis.2 Proposed mechanisms of musculoskeletal involvement include hematogenous spread, contamination during surgical procedures, or injury in an immunocompromised host.3
    This article describes a case of     Mycobacterium other than tuberculosis infection of the extremities that developed after acupuncture around the bilateral knee joints of an immunocompetent host that was confused with soft tissue tumor. The patient was informed that data concerning the case would be submitted for publication.
    Case Report
    A 56-year-old woman developed pain gradually on the anterior aspect of the left knee and the distal thigh after hiking without trauma. She was treated with oral nonsteroidal anti-inflammatory drugs and physical therapy at a local clinic for 1 month, but her symptoms persisted. She opted for alternative medicine and received acupuncture for 3 consecutive days on the bilateral knees at the suprapatellar and infrapopliteal areas. She did not report the history of acupuncture before we performed a biopsy. After those treatments, mild localized heat and painful swelling developed around the knees bilaterally, and she was admitted to another hospital for 15 days but reported no significant improvement. She was transferred to our institution for further evaluation and treatment.
    She had no general illness that made her susceptible to infectious disease. Physical examination revealed mild heat around the knees bilaterally and small amounts of effusion in both knee joints. A conventional smear/culture and cytologic examination of knee joint aspirates did not suggest infection. Laboratory findings showed slightly elevated erythrocyte sedimentation rate and C-reactive protein. Magnetic resonance imaging (MRI) demonstrated soft tissue masses with a lobulated contour at the prefemoral fat between the suprapatellar pouch and the distal femur and at the proximal tibia behind the knee joint capsule. They also showed low-signal masses on T1-weighted images (Figures     1A, B), heterogenous intermediate signal on T2-weighted image (Figure 1C), and a well-enhanced mass on enhancing image (Figure 1D). Based on MRI findings, fibromatosis, pigmented villonodular synovitis, and soft tissue sarcoma were considered.
    fig1.ashx
    Figure 1: MRIs showing a soft tissue masses in the anterior aspect of the distal femur with a low-signal intensity on T1-weighted images (A, B), a heterogenous intermediate-signal intensity on T2-weighted image (C), and a well-enhanced mass on enhancing image (D).
    On incisional biopsy, a grossly turbid fluid was found, so the entire mass was excised under the impression that it was a kind of infection. On pathologic examination, multiple granulomas with lymphoplasmatic infiltration were evident (Figures 2A, B) and acid-fast bacteria staining revealed acid-fast bacilli (Figure 2C). A mycobacterial culture confirmed Mycobacterium other than tuberculosis infection, and a polymerase chain reaction-fragment length polymorphism assay identified the isolates as Mycobacterium abscessus. After confirmation of M abscessus, intravenous amikacin and high-dose cefoxitin (8 g/day) were given for 4 weeks. Following intravenous injection therapy, antibiotics were switched to oral agents such as clarithromycin, ciprofloxacin, and doxycycline for 6 months. Twelve months postoperatively, the patient showed no evidence of disease and reported no pain during activities of daily living.
    fig2.ashx
    Figure 2: Photomicrographs of the pathologic specimen. Histologic features of the mass show a focus of acute inflammation. (hematoxylin and eosin stain; original magnification ×200) (A). An ill-defined granulomatous reaction shows collections of histiocytes and lymphoplasmacytes (B). A few intracytoplasmic acid-fast bacillary organisms were observed (C).
    Discussion
    Mycobacterium other than tuberculosis is a ubiquitous organism found in both water and soil.4 Although first observed soon after Koch’s5 discovery of the tubercle bacillus, Mycobacterium other than tuberculosis was not widely recognized as a human pathogen until the 1950s. The organisms are frequently isolated from soil, the sputum and saliva of healthy persons, and even from scrub sinks in operating rooms.4,6 Although their existence does not mean infection or disease, the majority of isolates from sources other than sputum are clinically significant and disease producing.2 Rapid-growing mycobacteria such as M fortuitum, M chelonae, and M abscessus are the most common mycobacteria other than tuberculosis associated with nosocomial disease.1,7,8 Several authors have reported rapidly growing mycobacteria associated nosocomial infections after augmentation mammoplasty, median sternotomy, laparotomy, percutaneous catheterization, and hip replacement arthroplasty.8–10 Maloney et al11 reported an M abscessus outbreak associated with endoscopy.
    Musculoskeletal infection by     Mycobacterium other than tuberculosis can lead to osteomyelitis, septic arthritis, tenosynovitis, and bursitis.10,12,13 The mechanisms of musculoskeletal alterations include hematogenous spread and contamination following injury or surgery. However, because of its scarcity, reports of musculoskeletal involvement of Mycobacterium other than tuberculosis are rare, and the treatment protocol of Mycobacterium other than tuberculosis infection of the musculoskeletal system is not established by subspecies. According to the American Thoracic Society, drug therapy or combined surgical and medical therapy is recommended for nonpulmonary Mycobacterium other than tuberculosis infection.14 For serious disease caused by M abscessus, intravenous amikacin is given at a dose of 10 to 15 mg/kg in 2 divided doses to adult patients with normal renal function. The amikacin combined with high-dose cefoxitin (12 g/day given intravenously) is recommended for initial therapy (minimum 2 weeks) until clinical improvement is evident. If organisms are susceptible to oral agents, therapy can be switched to ≥1 of these agents. The oral agents available for M abscessus are clofazimine and clarithromycin. For serious disease, a minimum of 4 months of therapy is necessary to provide a high likelihood of cure. For bone infection, 6 months of therapy is recommended. Surgery is generally indicated with extensive disease or abscess formation or where drug therapy is difficult.
    In our case, initial knee joint aspirates did not suggest an infectious condition, and soft tissue masses were palpable. We considered the possibility of unusual multiple pigmented villonodular synovitis or soft tissue tumor rather than infection. Furthermore, it seemed that multifocal infections without direct inoculation were unlikely in an immunocompetent host. However, postoperative pathologic examination and a mycobacterial culture proved the presence of     Mycobacterium other than tuberculosis infection. After the diagnosis was confirmed, a careful history taking revealed that the patient had undergone acupunctural procedures in the regions.
    Acupuncture is growing in prominence in Europe and the United States.    15 In a recent review, 1.1% of the population sought acupuncture care during the past 12 months. Four percent of the US population used acupuncture at some time in their lives.16 The National Institutes of Health consensus statement concluded that acupuncture is efficacious in the management of postoperative and chemotherapy-induced nausea and vomiting and dental pain.17 Meanwhile, the number of reports on complications increases with the widespread usage of acupuncture.18 Minor disturbances include pain during insertion or withdrawal of the needle, skin irritation, minor bleeding or hematoma, and orthostatic dysregulation. Serious adverse events include local and systemic bacterial infections, the transmission of viral disease, and stab injuries of the central nervous system and internal organs, especially the lungs, resulting in a pneumothorax. Although the risk to an individual patient is difficult to determine, acupuncture may cause serious complications in patients with coagulopathy, heart valve disease, and immune deficiency.
    Mycobacterial infection as a complication of acupuncture has been recently described in a few case reports. Kim et al    19 reported primary cutaneous tuberculosis after acupuncture. All 3 patients had no evidence of immunodeficiency. In a report by Woo et al,20 all but 1 patient with systemic lupus erythematosis showed no underlying disease associated with immunodeficiency. Although mycobacteriosis including Mycobacterium other than tuberculosis is probably related to infection of an immunocompromised host, direct inoculation such as contaminated acupuncture can cause mycobacteriosis even in an immunocompetent host.


    World Neurosurg. 2010 Jun;73(6):735-41. doi: 10.1016/j.wneu.2010.03.020. Risks and causes of cervical cord and medulla oblongata injuries due to acupuncture. Miyamoto S, Ide T, Takemura N.


    Acupunct Med. 2012 Sep;30(3):227-8. doi: 10.1136/acupmed-2012-010185. Epub 2012 Jun 27.
    Anaemia and skin pigmentation after excessive cupping therapy by an unqualified therapist in Korea: a case report.
    Kim KH, Kim TH, Hwangbo M, Yang GY.
    Source
    Department of Acupuncture & Moxibustion, Korean Medicine Hospital, Pusan National University, Yangsan, South Korea.
    Abstract
    A case is reported of skin pigmentation and associated anemia resulting from persistently repeated cupping therapies performed by an unqualified practitioner in South Korea. Almost 30 sessions of excessive cupping therapies with blood loss over two months yielded little benefit but led the patient to admit a hospital and receive blood transfusion for acquired iron deficiency anemia. Skin pigmentation on the cupping-attached region remained without any subjective discomfort. We suggest the importance of qualified health professionals when receiving cupping treatments.

    Acupunct Med. 2013 May 9. [Epub ahead of print]
    Transient paralysis during acupuncture therapy: a case report of an adverse event.
    Beable A.
    Abstract
    A patient with apparently well-controlled epilepsy with a painful musculoskeletal condition was treated successfully with two sessions of acupuncture. However, 4 h after the first treatment and during the second, an adverse event involving impairment of consciousness occurred. The patient subsequently experienced an increased frequency of complex partial seizures resulting in the loss of his driving licence. A detailed retrospective review of the past medical history indicated that the patient probably had comorbidities in the form of rapid eye movement sleep behaviour disorder and dysfunctional somatosensory/vestibular processing. Acupuncture may have triggered the adverse event via shared neurosubstrates. This adverse event raises possible implications regarding safe clinical acupuncture practice.


    J Can Chiropr Assoc. 2004 June; 48(2): 132–136.

    PMCID: PMC1840044

    Discitis in an adult following acupuncture treatment: a case report
    Peter SY Kim, BSc, DC, FCCS(C), Associate Professor* and William Hsu, BSc, DC, DACBR, FCCR(C), Associate Professor**
    Author information ► Copyright and License information ►

    This article has been cited by other articles in PMC.

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    Abstract
    Recent papers, including a review conducted by van Tulder et al., have suggested that there is paucity of information as to the efficacy of acupuncture treatment. However, there has been a significant increase in the use of acupuncture therapy for treatment of various ailments, including lower back pain. Chiropractors, along with other health care professionals, are using acupuncture as an adjunct to their main therapeutic intervention as demonstrated by a recent survey by the Canadian Chiropractic Protective Association (CCPA). However, like many other interventions, including NSAIDs and spinal manipulations, signs of side effects should be monitored when acupuncture treatments are considered. Recent papers have noted such complications as pneumothorax and hepatitis following acupuncture treatments. A case is presented in which a patient, who received previous acupuncture treatments, presented to a chiropractic clinic complaining of low back and leg pain. Early recognition of potential complications after acupuncture treatment may minimize significant impairments and disability.
    Keywords: chiropractic, low back pain, discitis, infection, acupuncture




    J Clin Ultrasound. 2013 May 9. doi: 10.1002/jcu.22046. [Epub ahead of print]
    Sonographic diagnosis of bilateral pneumothorax following an acupuncture session.




    An uncommon cause of Staphylococcus aureus sepsis.
    Maas ML, Wever PC, Plat AW, Hoogeveen EK.
    From the Department of Internal Medicine.
    Abstract
    We describe a case of Staphylococcus aureus sepsis after acupuncture for chronic fatigue syndrome (CFS). Sepsis is a rare, but potentially fatal complication of acupuncture. The most common cause of bacterial infection after acupuncture is S. aureus. The effectiveness of acupuncture for the treatment of CFS is not proven, therefore the potential benefits should be weighed against the risks.



    Am J Med. 2013 May;126(5):451-4. doi: 10.1016/j.amjmed.2013.01.001.
    Lead, mercury, and arsenic poisoning due to topical use of traditional Chinese medicines.
    Wu ML, Deng JF, Lin KP, Tsai WJ.
    Source
    Division of Clinical Toxicology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
    Abstract
    BACKGROUND:
    Metal poisonings through a mucocutaneous route are reported rarely in the literature.
    METHODS:
    We report 2 cases of heavy metal intoxication from inappropriate use of Chinese mineral medicines confirmed by toxicologic investigations.
    RESULTS:
    A 51-year-old man developed perianal gangrene and a high fever after a 2-week anal use of hong-dan herbal mixtures for anal fistula. He presented gastrointestinal and constitutional symptoms, followed by skin rash, anemia, hair loss, peripheral neuropathy, and muscle atrophy. Elevated urine arsenic and mercury confirmed the heavy metal poisonings. The hong-dan mixture contained lead tetraoxide, arsenic, and mercury. He was treated with 2,3-dimercapto-1-propanesulfonic acid, with partial improvement, but peripheral neuropathy persists 4 years later. A 75-year-old man developed anorexia, weight loss, headache, dizziness, nausea, vomiting, constipation, weakness, and anemia after a 3-month use of an herbal patch for chronic leg ulcer. His blood lead concentration was 226 μg/dL, and the lead content of the herbal patch was 517 mg/g. Chelation with ethylene diamine tetraacetic acid and dimercaptosuccinic acid was followed by clinical recovery.
    CONCLUSION:
    These cases documented serious systemic poisoning after the short-term use of traditional Chinese medicines containing heavy metals in damaged or infected tissue.




    Ear Nose Throat J. 2010 Jan;89(1):E20-2.
    Ear stapling: a risky and unproven procedure for appetite suppression and weight loss.
    Winter LK, Spiegel JH.
    Source
    Department of Otolaryngology-Head and Neck Surgery, Boston University School of Medicine, 88 E. Newton St., Suite D-616, Boston, MA 02118, USA.
    Abstract
    In an effort to achieve weight loss, many people are pursuing alternative medical interventions. Widely available as a variant of acupuncture, ear stapling (in which a surgical staple is placed in the conchal bowl of the ear) is reported by practitioners to decrease the appetite and induce weight loss. This practice lacks proven efficacy and has a significant risk of infection and deformity. We report a series of 3 patients who developed complications from ear stapling and present this article to describe the practice so that physicians will be prepared when encountering a staple in the ear.




    Am J Forensic Med Pathol. 2012 Mar;33(1):102-4. doi: 10.1097/PAF.0b013e3181f474b0.
    Sudden death due to cerebral leukemic hemorrhage occurring after acupuncture treatment for gingival bleeding.
    Li S, Liu D, He G, Duan Y, Zhou H, Zhou Y.
    Source
    Faculty of Forensic Medicine, Tongji Medical College of Huazhong University of Science and Technology, No.13 Hangkong Rd, Wuhan, People’s Republic of China.
    Abstract
    A 45-year-old woman who experienced stomalgia and gingival bleeding for several days died unexpectedly after acupuncture treatment. At autopsy, trivial injuries on the liver and the stomach and mild hemoperitoneum due to improper acupuncture were found. Also,acute lymphoblastic leukemia and hyperleukocytosis were diagnosed by postmortem examinations. Intracranial hemorrhage due to undiagnosed acute lymphoblastic leukemia was identified as the cause of death.Moreover, the relationship between therapeutic misadventure and death was also determined. We suggest that undiagnosed leukemia should be considered as a differential diagnosis when sudden death occurs owing to intracranial hemorrhage. If therapeutic misadventure was involved,it is also of great importance to assess the relationship between that and death in forensic expertise.
    Scand J Infect Dis. 2013 Jun 9. [Epub ahead of print]




    Acupuncture patient left pinned, locked in Texas clinic
    Published August 25, 2013
    FoxNews.com
    Texas authorities didn’t have any trouble “pinpointing” who was to blame.
    A Texas acupuncture  patient was forced to phone 911 earlier this month when the doctor left for the day – while the patient was still in a treatment room, with needles in her, WFAA Channel 8 reported.
    “Yes, I'm locked in someone's business establishment,” the unidentified woman told the 911 operator. “I don’t hear anybody. The music went off. The door is locked and his car is gone.”
    "Are you a patient?" the flabbergasted operator reportedly asked.
     "Yes,” the woman replied, according to WFAA.  “I was in the middle of a treatment… I had to pull the needles out of me in order to, you know, find out what's going on. I'm yelling for help for about five minutes or so."
    The station reports the incident occurred about 6 p.m., Aug. 5 at the Hwa Tow Acupuncture and Chinese Herbs Clinic in Arlington.
    The doctor -- Jeff Tsing, who is licensed with the Texas Medical Board and has a spotless record -- later told WFAA he was ashamed of what had occurred and “baffled” how he had inexplicably forgotten a patient was still in his care when he left.
    Police arrived after about 10 minutes, and the entrapped patient was reportedly freed by a worker at another business, which shares the same building as the acupuncture clinic.


    Read more:     http://www.foxnews.com/us/2013/08/25/acupuncture-patient-left-pinned-locked-in-texas-clinic/#ixzz2d56qbMgq







    [Clinical application of the penetrating needling technique from neiguan (PC 6) to waiguan (TE 5) by Professor LIU Kong-teng].
    [Article in Chinese]
    Meng XJ, Yang L, Zhou RM.
    Department of TCM in Medical College, Xiamen University, Xiamen 361005, Fujian Province, China. 550412871@qq.com
    Abstract
    The clinical experience of Professor LIU Kong-teng's needling techniques and methods of the penetrating needling from Neiguan (PC 6) to Waiguan (TE 5) in the treatment of various diseases is introduced in this paper. The acupoints characteristics, penetrating needling techniques and methods and the clinical indications are summarized. Examples of Elbow flaccid paralysis, headache, insomnia, neck contracture, vomiting, hiccups, heart disease, the acute abdominal pain, acute lumbar sprain, acute ankle joint sprain and periarthritis of shoulder are given to explain techniques and methods of the penetrating acupuncture.




    Spine J. 2013 Oct 2. pii: S1529-9430(13)00699-2. doi: 10.1016/j.spinee.2013.06.024. [Epub ahead of print]
    Acute spinal subdural hematoma with hemiplegia after acupuncture: a case report and review of the literature.
    Park J, Ahn R, Son D, Kang B, Yang D.
    Source
    Department of Neurosurgery, University of Ulsan College of Medicine, Ulsan University Hospital, 290-3 Jeonha-dong, Dong-gu, Ulsan 682-714, Ulsan, Republic of Korea.
    Abstract
    BACKGROUND CONTEXT:
    Subdural spinal hematoma (SDH) is a very rare entity; however, it can lead to serious complications resulting from injuries to the spinal cord and roots. Although acupuncture has been a popular method for the management of pain control, we encountered the first case of SDH after acupuncture.
    PURPOSE:
    The purpose of this case report was to present the first case of subdural hematoma after acupuncture and the reasons for the risks of blind cervical acupuncture.
    STUDY DESIGN:
    A case report and review of the previous literature are presented.
    METHODS:
    A 69-year-old man complained of progressive weakness in the right upper and lower extremities 2 hours after acupuncture on the cervical spine and back. The diagnosis was delayed because of unilateral weakness, and the symptom was initially misinterpreted as a transient ischemic attack because of no sensory change and pain and normal findings of two brain magnetic resonance imaging (MRI).
    RESULTS:
    Cervical MRI 36 hours after onset revealed acute hematoma from the C3-C5 level; hematoma showed an isointensity on T1-weighted image (WI) with the preservation of epidural fat and a hypointensity on T2WI. A decompressive surgery was scheduled to perform within 2 days after the cervical MRI scan because of a previous anticoagulation therapy, but the patient refused it. Finally, 9 days after the onset, surgical decompression and removal of hematoma were performed. Three months postoperatively, the patient had fully recovered demonstrating fine hand movement and good ability to walk up and down the stairs.
    CONCLUSIONS:
    Our study indicates that it is essential to perform cervical MRI when a patient does not show an improvement in the neurologic deficit and has a negative brain MRI after acupuncture. In addition, blind acupuncture if not correctly practiced may be harmful to the cervical structures.
    Copyright © 2013 Elsevier Inc. All rights reserved.




    Korean J Fam Med. 2013 Sep;34(5):364-368. Epub 2013 Sep 26.
    Pyogenic Liver Abscess Following Acupuncture and Moxibustion Treatment.
    Choi EJ, Lee S, Jeong DW, Cho YH, Lee SJ, Lee JG, Kim YJ, Yi YH, Lim JY.
    Source
    Family Medicine Clinic and Research Institute of Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.
    Abstract
    Acupuncture treatment is generally regarded as a relatively safe procedure. However, most procedures have some complications and acupuncture treatment is no exception. Reported complications of acupuncture treatment were mostly mild or temporary symptoms, but certain severe adverse effects were also observed. We report here for the first time a case of liver abscess following acupuncture and moxibustion treatment.
    KEYWORDS:
    Acupuncture, Liver Abscess, Moxibustion, Streptococcus intermedius




    Chest. 2013 Oct 1;144(4_MeetingAbstracts):498A.
    Hemopneumothorax After Acupuncture.
    Lee O, Sihoe A.
    Abstract
    SESSION TITLE:
    Pleural Global Case ReportsSESSION TYPE: Global Case ReportPRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PMINTRODUCTION: The first written documentation of acupuncture dates back to the 100BC in the Chinese literature Huangdi Neijing, this form of alternative therapy has become increasingly popular globally in the last 20 to 30 years. While viewed by many as an effective means for pain relief, one should also be aware of the possible complications associated with this procedure.CASE PRESENTATION: We present a case of a 45 year old man, with unremarkable past health, who had been a smoker for 20 years. On the day before admission, he went to an acupuncturist for neck pain, who subsequently inserted acupuncture needles over his left supraclavicular region and back. At the time the supraclavicular acupuncture needle was removed, he experienced sudden onset left chest pain and dyspnoea. He then presented to the emergency department where a chest x-ray showed left pneumothorax and left pleural effusion. A chest drain was inserted, and he was admitted to our surgical ward. Over the next 24 hours, the chest drain bottle had accumulated 1 litre of heavily blood stained fluid. The haemoglobin drop over these 24 hours was from 12.8 to 11.4 g/dL. On repeated chest x-ray, there was partial re-expansion of the left lung, with residual rim of apical pneumothorax and apical collection of fluid. At this point, we decided to go into theatre. On left video assisted thoracoscopy (VAT) exploration, there was approximately 400ml of blood clots in left pleural space. A fibrovascular adhesion band over the left upper lobe apex was torn with slow active bleeding from the parietal pleura end of the band. Haemostasis was achieved with diathermy. Mechanical pleurodesis was performed using Prolene mesh abrasion to the parietal pleura. The patient was discharged home on post-operative day 3 with the lung fully expanded on chest x-ray.DISCUSSION: Previous systemic reviews of the adverse events associated with acupuncture concluded that minor adverse events may be considerable but serious events were rare. Pneumothorax was rare, occurring only twice in nearly a quarter of a million treatments. A review in 2004 found reported a total of 715 cases with acupuncture associated adverse events. Within the 715 reports, there were 191 cases of pneumothorax and one case of haemothorax. A systemic review in 2012 of Chinese literature from 1956-2010 found 167 articles with 1038 cases. The most frequent adverse events were syncope (468 cases) and pneumothorax (307 cases). There is one reported case of mortality from acupuncture-induced pneumothorax, the patient died because of bilateral tension pneumothorax. Most of the reported cases of acupuncture-induced pneumothorax do not require surgery, but because of the associated substantial haemothorax in our case, surgery was warranted.CONCLUSIONS: Due to the increasing popularity of alternative therapy, medical practitioners should also be aware of other forms of therapy and their associated complications.Reference #1: Ernest E, White AR. Prospective studies of the safety of acupuncture: a systemic review. Am J Med 2001 Apr 15; 110(6): 481-5Reference #2: White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Accupunct Med. 2004 Sep; 22(3):122-33Reference #3: He W, Zhao X. Adverse events following acuptuncture: a systemic review of the Chinese literature for the years 1956-2010. J Altern Complement Med. 2012 Oct 18 (10); 892-901DISCLOSURE: The following authors have nothing to disclose: Oswald Lee, Alan SihoeNo Product/Research Disclosure Information.




    BMC Complement Altern Med. 2013 Oct 29;13(1):290. [Epub ahead of print]
    Activation of amygdala opioid receptors by electroacupuncture of Feng-Chi (GB20) acupoints exacerbates focal epilepsy.
    Yi PL, Lu CY, Cheng CH, Tsai YF, Lin CT, Chang FC.
    Abstract
    BACKGROUND:
    The effect of seizure suppression by acupuncture of Feng-Chi (GB20) acupoints has been documented in the ancient Chinese literature, Lingshu Jing (Classic of the Miraculous Pivot), however, there is a lack of scientific evidence to prove it. This current study was designed to elucidate the effect of electroacupuncture (EA) stimulation of bilateral Feng-Chi (GB20) acupoints on the epileptic activity by employing an animal model of focal epilepsy.
    METHODS:
    Administration of pilocarpine into the left central nucleus of amygdala (CeA) induced the focal epilepsy in rats. Rats received a 30-min 100 Hz EA stimulation of bilateral Feng-Chi acupoints per day, beginning at 30 minutes before the dark period and performing in three consecutive days. The broad-spectrum opioid receptor antagonist (naloxone), mu-receptor antagonist (naloxonazine), delta-receptor antagonist (naltrindole) and kappa-receptor antagonist (nor-binaltorphimine) were administered directly into the CeA to elucidate the involvement of CeA opioid receptors in the EA effect.
    RESULTS:
    High-frequency (100 Hz) EA stimulation of bilateral Feng-Chi acupoints did not suppress the pilocarpine-induced epileptiform electroencephalograms (EEGs), whereas it further increased the duration of epileptiform EEGs. We also observed that epilepsy occurred while 100 Hz EA stimulation of Feng-Chi acupoints was delivered into naive rats. EA-induced augmentation of epileptic activity was blocked by microinjection of naloxone, mu- (naloxonazine), kappa- (nor-binaltorphimine) or delta-receptor antagonists (natrindole) into the CeA, suggesting that activation of opioid receptors in the CeA mediates EA-exacerbated epilepsy.
    CONCLUSIONS:
    The present study suggests that high-frequency (100 Hz) EA stimulation of bilateral Feng-Chi acupoints has no effect to protect against pilocarpine-induced focal epilepsy; in contrast, EA further exacerbated focal epilepsy induced by pilocarpine. Opioid receptors in the CeA mediated EA-induced exacerbation of focal epilepsy

    		Zhongguo Zhen Jiu. 2013 Jul;33(7):640-4.





    Anat Res Int. 2013;2013:780193. doi: 10.1155/2013/780193. Epub 2013 Oct 10.
    Relationship of sternal foramina to vital structures of the chest: a computed tomographic study.
    Gossner J.
    Source
    Evangelisches Krankenhaus Göttingen-Weende, Department of Clinical Radiology, An der Lutter 24, 37074 Göttingen, Germany.
    Abstract
    Sternal foramina are a well-known variant anatomy of the sternum and carry the risk of life-threatening complications like pneumothorax or even pericardial/cardial punction during sternal biopsy or acupuncture. There have been numerous studies numerous studies examinimg prevalence of sternal foramina, but the study of the exact anatomical relationship to intrathoracic structures has received little attention. In a retrospective study of 15 patients with sternal foramina, the topographical anatomy in respect to vital chest organs was examined. In most patients, the directly adjacent structure was the lung (53.3%) or mediastinal fat (33.3%). Only in three patients, the heart was located directly adjacent to a sternal foramen (20%). Theoretically, if the needle is inserted deep enough it will at some point perforate the pericardium in all examined patients. There was no correlation between the patient habitus (i.e., thickness of the subcutaneous fat) and the distance to a vital organ. In this sample, pericardial punction would have not occured if the needle is not inserted deeper than 2.5 cm. Given the preliminary nature of the data, general conclusions of a safe threshold for needle depth should be made with caution. To minimize the risk of hazardous complications, especially with sternal biopsy, preprocedural screening or image guidance is advocated.




    Clin Infect Dis. 2013 Nov 18. [Epub ahead of print]
    Mycobacterium chelonae infections associated with bee venom acupuncture.
    Cho SY, Peck KR, Kim J, Ha YE, Kang CI, Chung DR, Lee NY, Song JH.
    Source
    Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
    Abstract
    We report three cases of Mycobacterium chelonae infections after bee venom acupuncture. All were treated with antibiotics and surgery. M. chelonae infections should be included in the differential diagnosis of chronic skin and soft tissue infections following bee venom acupuncture.




    Pietrzak A1, Bartosińska J1, Dreiher J2, Szepietowski JC3, Gawlik-Dziki U4, Maciejewski R5, Podhorecka M6, Chodorowska G1.
    Author information:
    1Chair and Department of Dermatology, Venereology and Paediatric Dermatology, Medical University of Lublin, Poland.
    2Division of Health in the Community, Ben-Gurion University of the Negev, Beer Sheva, Israel.
    3Chair and Department of Dermatology, Venereology and Allergology, Medical University, Wroclaw, Poland.
    4Department of Biochemistry and Food Chemistry, University of Life Sciences, Lublin, Poland.
    5Department of Human Anatomy, Medical University of Lublin, Poland.
    6Chair and Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Poland.

    Abstract
    Psoriasis is a chronic, systemic and difficult to treat condition which negatively affects the patient`s quality of life. Frustrated and unsatisfied with the conventional therapies, psoriatic patients start looking for alternative treatment which they believe to be safe and effective. Very common traditional Chinese medicine (TCM) appears to offer various topical and systemic herbal preparations, as well as massages, acupuncture, diet and lifestyle alternations. The presented study concerns a 48-year-old female patient with exacerbated psoriatic skin lesions (tending to become erythrodermic), and certain systemic complications that appeared after taking a TCM herbal medication, Fu Fang Quing Dai Wan, as well as the use of a Chinese herbal bath gel and staying on a diet rich in meat. After in vitro examinations were made of the herbal preparation and its biological properties determined, it was concluded that the TCM herbal preparation should not be considered harmless. Therefore, patients should be made aware of its adverse reactions.




    Quality of acupuncture needles is less than perfect and must improve

    The quality of acupuncture needles is high, but should still be universally improved to avoid potential problems, such as pain and skin reactions, finds research published online in Acupuncture in Medicine (AiM).
    Deleterious effects of traditional Chinese medicine preparations on the course of psoriasis - a case report.
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    Despite improvements to the manufacturing process, surface irregularities and bent tips have not been completely eliminated, say the researchers.
    In China, traditional Chinese medicine including acupuncture, accounts for 40% of all medical treatment, while in the West, acupuncture is one of the most frequently used complementary therapies.
    An estimated 1.4 billion acupuncture needles are used each year worldwide, with China, Japan, and Korea the main suppliers. China provides up to 90% of the world's needles.
    The growing popularity of acupuncture in recent decades has led to an increased focus on the safety and quality of this therapy, and adoption of single-use disposable needles has reduced the risk of infection.
    But a study of widely used acupuncture needles published a decade ago in     AiM showed that several had surface irregularities or distorted points which could have led to allergic or painful reactions. Since then, there has been no further research in this area.
    A team of researchers in Australia therefore looked at the surface conditions and other physical properties of the two most commonly used stainless steel acupuncture needle brands.
    Scanning electron microscope images were taken of 10 randomly chosen needles from each brand, while further images were taken after each of these needles underwent a standard manipulation - the equivalent of using them on human skin - with an acupuncture needling practice gel.
    The researchers also compared forces and torques during the needling process.
    The images revealed significant surface irregularities and inconsistencies at the needle tips, especially for needles from one of the brands which had been manufactured in China.
    Metallic lumps and small, loosely attached pieces of material were observed on the surfaces of some needles. Some of this residue disappeared after the acupuncture manipulation.
    If these needles had been used on patients, the metallic residue could have been deposited in human tissues, potentially causing reactions, such as dermatitis, although these reactions are reported extremely rarely, say the authors.
    Malformed needle tips could also have caused other problems, including bleeding, bruising, or strong     pain during needling, which are quite common, they suggest.
    Acupuncture, overall, is very safe, but it should be made even safer, say the researchers. "Acupuncture needle manufacturers, including the well established ones, should review and improve their quality control procedures for fabrication of needles," they conclude.
    In an accompanying podcast, Dr Mike Cummings, medical director of the British Medical Acupuncture Association and associate editor of the journal, comments that the pictures taken for the current study indicate that the needles "look as awful as they did 10 years ago."
    He adds: "We don't know if [this problem] is common to all needles, but it seems like it does happen with acupuncture needles."
    But he emphasises that acupuncture is safe, pointing out that "It's highly unlikely that [poor needle quality] will affect patient health."
    If people experience pain during     acupuncture, they should ask their practitioner to check on the quality of the needles they use, he advises.




    Chinese Man Detained in US Airport over Chinese Medicine
       2014-02-19 15:27:39    CRIENGLISH.com      Web Editor: Zhangpeng
    A Chinese man and his 12-year-old daughter were thrown out of the US and banned from returning for five years after trying to bring in 16 bottles of Chinese medicine pills that customs officials discovered were laced with cocaine, according to the World Journal, a Chinese newspaper based in North America.
    The man, identified by the newspaper as Wu, was detained by customs officers at Los Angeles International Airport when he was found carrying 16 bottles of compound licorice tablets, Chinese medicine used for treating bronchial asthma, for a friend. However, a survey report by the US Food and Drug Administration (FDA) showed the presence of cocaine in the tablets.
    Wu was reportedly asked to bring the medicine to a female acquaintance, identified by reports only as Yu, in Los Angeles. She originally told Wu that the medicine was prescribed by a doctor and was safe to use.
    Customs officers handcuffed Wu and took him into custody. After hearing about this, Yu and her lawyer arrived at the airport to meet Wu, but they were turned away by authorities. After negotiations, Wu and his daughter were allowed to return to China, but were banned from stepping on US soil for five years.
    Chinese traveling abroad with traditional medicine is very common. However, many of them don't declare the medicines to customs.
    Lawyer Deng Hong says violators could face huge fines and jail-time if found to be carrying illegal substances into the United States. In light of this, the punishment Wu received is light.
    Deng adds that the majority of Chinese traveling with traditional medicines are doing so to help their friends and relatives with health problems. However, Chinese patent medicines are considered as banned substances by US customs, since there is no way to verify the ingredients in the medicines. Customs officers generally confiscate and destroy them, unless their numbers are limited and a legitimate doctor's prescription is attached.
    US Customs and Border Protection urges international passengers to declare items when they enter the country. Those medicines without the verification of the FDA should not be brought into the US.



    Acupunct Med. 2014 Feb 19. doi: 10.1136/acupmed-2013-010480. [Epub ahead of print]
    The safety of acupuncture during pregnancy: a systematic review.
    Park J1, Sohn Y, White AR, Lee H.
    Author information


    Abstract
    OBJECTIVE:
    Although there is a growing interest in the use of acupuncture during pregnancy, the safety of acupuncture is yet to be rigorously investigated. The objective of this review is to identify adverse events (AEs) associated with acupuncture treatment during pregnancy.
    METHODS:
    We searched Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED) and five Korean databases up to February 2013. Reference lists of relevant articles were screened for additional reports. Studies were included regardless of their design if they reported original data and involved acupuncture needling and/or moxibustion treatment for any conditions in pregnant women. Studies of acupuncture for delivery, abortion, assisted reproduction or postpartum conditions were excluded. AE data were extracted and assessed in terms of severity and causality, and incidence was determined.
    RESULTS:
    Of 105 included studies, detailed AEs were reported only in 25 studies represented by 27 articles (25.7%). AEs evaluated as certain, probable or possible in the causality assessment were all mild/moderate in severity, with needling pain being the most frequent. Severe AEs or deaths were few and all considered unlikely to have been caused by acupuncture. Total AE incidence was 1.9%, and the incidence of AEs evaluated as certainly, probably or possibly causally related to acupuncture was 1.3%.
    CONCLUSIONS:
    Acupuncture during pregnancy appears to be associated with few AEs when correctly applied.
    KEYWORDS:
    Acupuncture, Gynaecology, Obstetrics, Systematic Reviews



    Korean J Intern Med. 2014 Jan;29(1):130. doi: 10.3904/kjim.2014.29.1.130. Epub 2014 Jan 2.
    Acupuncture needle: an obscure cause of anal pain.
    Lee TH, Lee JS.
    Author information

    Institute for Digestive Research, Digestive Disease Center, Soonchunhyang University Hospital, Seoul, Korea.






    Surg Case Rep. 2014 May 29;2014(5). pii: rju055. doi: 10.1093/jscr/rju055. Print 2014 May.
    Isolated partial, transient hypoglossal nerve injury following acupuncture.
    Harrison AM1, Hilmi OJ2.
    Author information


    Abstract
    We report a case of isolated unilateral hypoglossal nerve injury following ipsilateral acupuncture for migraines in a 53-year-old lady. The palsy was partial, with no associated dysarthria, and transient. Further examination and imaging was negative. Cranial nerve injuries secondary to acupuncture are not reported in the literature, but are a theoretical risk given the location of the cranial nerves in the neck. Anatomical knowledge is essential in those administering the treatment, and those reviewing patients with possible complications.
    Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2014.




    Scand J Infect Dis. 2013 Sep;45(9):722-4. doi: 10.3109/00365548.2013.795658. Epub 2013 Jun 9.
    An uncommon cause of Staphylococcus aureus sepsis.
    Maas ML1, Wever PC, Plat AW, Hoogeveen EK.
    Author information


    Abstract
    We describe a case of Staphylococcus aureus sepsis after acupuncture for chronic fatigue syndrome (CFS). Sepsis is a rare, but potentially fatal complication of acupuncture. The most common cause of bacterial infection after acupuncture is S. aureus. The effectiveness of acupuncture for the treatment of CFS is not proven, therefore the potential benefits should be weighed against the risks.




    PLoS One. 2014 Jun 24;9(6):e100377. doi: 10.1371/journal.pone.0100377. eCollection 2014.
    Analysis of 30 Patients with Acupuncture-Induced Primary Inoculation Tuberculosis.
    Liu Y1, Pan J2, Jin K3, Liu C1, Wang J1, Chen L4, Chen L1, Yuan J1.
    Author information


    Abstract
    Primary inoculation tuberculosis is a skin condition that develops at the site of inoculation of Mycobacterium tuberculosis in tuberculosis-free individuals. This report describes the diagnosis, treatment and >1 year follow-up of 30 patients presenting with acupuncture-induced primary inoculation tuberculosis. Our data provide a deeper insight into this rare route of infection of tuberculosis. We also review effective treatment options.




    Evid Based Complement Alternat Med. 2014;2014:729091. doi: 10.1155/2014/729091. Epub 2014 May 22.
    Correlation between the Effects of Acupuncture at Taichong (LR3) and Functional Brain Areas: A Resting-State Functional Magnetic Resonance Imaging Study Using True versus Sham Acupuncture.
    Wu C1, Qu S1, Zhang J1, Chen J1, Zhang S1, Li Z2, Chen J2, Ouyang H1, Huang Y1, Tang C3.
    Author information


    Abstract
    Functional magnetic resonance imaging (fMRI) has been shown to detect the specificity of acupuncture points, as proved by numerous studies. In this study, resting-state fMRI was used to observe brain areas activated by acupuncture at the Taichong (LR3) acupoint. A total of 15 healthy subjects received brain resting-state fMRI before acupuncture and after sham and true acupuncture, respectively, at LR3. Image data processing was performed using Data Processing Assistant for Resting-State fMRI and REST software. The combination of amplitude of low-frequency fluctuation (ALFF) and regional homogeneity (ReHo) was used to analyze the changes in brain function during sham and true acupuncture. Acupuncture at LR3 can specifically activate or deactivate brain areas related to vision, movement, sensation, emotion, and analgesia. The specific alterations in the anterior cingulate gyrus, thalamus, and cerebellar posterior lobe have a crucial effect and provide a valuable reference. Sham acupuncture has a certain effect on psychological processes and does not affect brain areas related to function.


    Surg Radiol Anat. 2014 Jul 15. [Epub ahead of print]
    Frequency of sternal foramen evaluated by MDCT: a minor variation of great relevance.
    Babinski MA1, de Lemos L, Babinski MS, Gonçalves MV, De Paula RC, Fernandes RM.
    Author information


    Abstract
    Due to inadvertent cardiac or great vessel injury, sternal foramina may pose as a great hazard during sternal puncture. They can also be misinterpreted as osteolytic lesions in cross-sectional imaging of the sternum. The distribution of these variations differs between populations, but data from Brazilians are scarcely reported. Therefore, this study aimed to verify the frequency of midline sternal foramen and double-ended xiphoid process, as developmental variations, in order to avoid fatal complications following sternal puncture of sternal acupuncture treatment. A total of 114 chest computed tomograms were evaluated. The frequency of midline sternal foramen in a complication risk bearing feature is of approximately 10.5 %. The double-ended xiphoid process was present in 17.5 %. We conclude that sternal acupuncture should be planned in the region of corpus-previous CT should be done to rule out this variation. Furthermore, we strongly recommend the acupuncture technique which prescribes a safe superficial-oblique approach to the sternum.




    Spine J. 2013 Oct;13(10):e59-63. doi: 10.1016/j.spinee.2013.06.024. Epub 2013 Oct 2.
    Acute spinal subdural hematoma with hemiplegia after acupuncture: a case report and review of the literature.
    Park J1, Ahn R, Son D, Kang B, Yang D.
    Author information


    Abstract
    BACKGROUND CONTEXT:
    Subdural spinal hematoma (SDH) is a very rare entity; however, it can lead to serious complications resulting from injuries to the spinal cord and roots. Although acupuncture has been a popular method for the management of pain control, we encountered the first case of SDH after acupuncture.
    PURPOSE:
    The purpose of this case report was to present the first case of subdural hematoma after acupuncture and the reasons for the risks of blind cervical acupuncture.
    STUDY DESIGN:
    A case report and review of the previous literature are presented.
    METHODS:
    A 69-year-old man complained of progressive weakness in the right upper and lower extremities 2 hours after acupuncture on the cervical spine and back. The diagnosis was delayed because of unilateral weakness, and the symptom was initially misinterpreted as a transient ischemic attack because of no sensory change and pain and normal findings of two brain magnetic resonance imaging (MRI).
    RESULTS:
    Cervical MRI 36 hours after onset revealed acute hematoma from the C3-C5 level; hematoma showed an isointensity on T1-weighted image (WI) with the preservation of epidural fat and a hypointensity on T2WI. A decompressive surgery was scheduled to perform within 2 days after the cervical MRI scan because of a previous anticoagulation therapy, but the patient refused it. Finally, 9 days after the onset, surgical decompression and removal of hematoma were performed. Three months postoperatively, the patient had fully recovered demonstrating fine hand movement and good ability to walk up and down the stairs.
    CONCLUSIONS:
    Our study indicates that it is essential to perform cervical MRI when a patient does not show an improvement in the neurologic deficit and has a negative brain MRI after acupuncture. In addition, blind acupuncture if not correctly practiced may be harmful to the cervical structures.
    Copyright © 2013 Elsevier Inc. All rights reserved.




    Spine J. 2013 Jul;13(7):e9-e12. doi: 10.1016/j.spinee.2013.02.012. Epub 2013 Mar 21.
    Myositis ossificans in the paraspinal muscles of the neck after acupuncture: a case report.
    Lee DG1, Lee SH, Hwang SW, Kim ES, Eoh W.
    Author information


    Abstract
    BACKGROUND CONTEXT:
    Although traumatic myositis ossificans (MO) has been reported occasionally, MO of paraspinal muscles has been rarely seen in the cervical spine after minor injury. This is difficult to distinguish from benign and malignant soft lesions in cases of a lack of definite trauma history.
    PURPOSE:
    We report a case of MO in the cervical paraspinal muscle after acupuncture and describe methods for diagnosis and proper treatment, including classification, etiology, and radiologic and histologic features.
    STUDY DESIGN:
    Case report.
    METHODS:
    A 26-year-old woman complained of posterior neck pain that had began 2 months earlier and neck swelling after acupuncture. No abnormal finding existed on the X-ray except soft tissue swelling. Magnetic resonance imaging was evaluated because of constant neck pain. To obtain more accurate assessment, computed tomography-guided biopsy was performed and a diagnosis of MO was made.
    RESULTS:
    The patient was conservatively treated through rest and analgesics. Posterior neck pain and swelling improved for a several months. The hyperdensity was comparable with the bony density, and the size of the calcified lesion on X-ray diminished until the last follow-up.
    CONCLUSIONS:
    Myositis ossificans that can occur after acupuncture should be recognized as a possible cause of persistent neck pain and swelling despite no definite trauma after thorough evaluation of the neoplasm and infection.
    Copyright © 2013 Elsevier Inc. All rights reserved.




    Acupunct Med. 2014 Feb;32(1):77-80. doi: 10.1136/acupmed-2013-010457. Epub 2013 Oct 17.
    Infectious sacroiliitis caused by Staphylococcus aureus following acupuncture: a case report.
    Tseng YC1, Yang YS, Wu YC, Chiu SK, Lin TY, Yeh KM.
    Author information


    Abstract
    Determination of the origin of infectious sacroiliitis (ISI), a rare form of septic arthritis, is often time consuming and clinically difficult owing to its various presentations, which include joint, skin and urinary tract infections. This report describes the diagnosis, determination of infectious origin and treatment of a case of ISI attributed to the use of acupuncture for the treatment of lower back pain. We report on a 61-year-old man who developed right hip pain and fever 3 days after undergoing acupuncture over the right buttock region for the treatment of lower back pain. Blood culture showed infection with methicillin-susceptible Staphylococcus aureus and MRI disclosed the presence of an inflamed area over the right iliac bone and the right portion of the sacrum. The patient was cured after a 4-week course of antimicrobial treatment. Clinicians should take a history of acupuncture use when evaluating patients presenting with fever of unknown origin and/or bacteraemia and consider the possibility of ISI when evaluating patients with hip pain and infectious signs after acupuncture or other possible causes of infection. This indicates the importance of performing clinically clean procedures to prevent septic complications when treating patients with acupuncture.
    KEYWORDS:

    Zhongguo Zhen Jiu. 2014 Jan;34(1):20.
    [Seventy-eight cases of humeral epicondylitis treated by pricking and cupping combined with moxibustion].
    [Article in Chinese]
    Ning GL, He SY, Liu XL.




    J Shoulder Elbow Surg. 2013 Aug;22(8):1053-62. doi: 10.1016/j.jse.2012.10.045. Epub 2013 Jan 24.
    Clinical effectiveness of bee venom acupuncture and physiotherapy in the treatment of adhesive capsulitis: a randomized controlled trial.
    Koh PS1, Seo BK, Cho NS, Park HS, Park DS, Baek YH.
    Author information


    Abstract
    BACKGROUND:
    Bee venom acupuncture (BVA) has been used in the treatment of adhesive capsulitis (AC) in the clinical field. This study aimed to investigate whether the addition of BVA to physiotherapy (PT) would be more effective in the management of AC, and whether BVA would have a dose-dependent effect.
    MATERIALS AND METHODS:
    Sixty-eight patients diagnosed with AC were recruited into 3 groups; BV 1 (1:10,000 BVA plus PT), BV 2 (1:30,000 BVA plus PT), and group 3 (normal saline (NS) injection, as a control, plus PT). PT was composed of 15 minutes of transcutaneous electrical nerve stimulation (TENS), transcutaneous infrared thermotherapy (TDP), and manual PT. Treatments were given in 16 sessions within 2 months. Shoulder pain and disability index (SPADI), pain visual analogue scale (VAS), and 3) active/passive range of motion (ROM) were measured before treatment and at 2, 4, 8, and 12 weeks after the treatment.
    RESULTS:
    All 3 groups showed statistically significant improvements in SPADI, pain VAS scores, and active/passive ROM. The BV 1 group showed significantly better outcomes in SPADI at 8 and 12 weeks, in pain VAS (at rest) at 8 weeks, and in pain VAS (during exercise) at 12 weeks than the NS group. No significant differences were found in active/passive ROM among all the groups.
    CONCLUSION:
    BVA in combination with PT can be more effective in improving pain and function than PT alone in AC. However, the effectiveness of BVA was not shown in a dose-dependent manner.
    Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.
    KEYWORDS:
    Adhesive capsulitis; Level I; Randomized Controlled Trial; Treatment Study; bee venom acupuncture; physiotherapy




    Acupunct Med. 2014 Sep 30. pii: acupmed-2014-010635. doi: 10.1136/acupmed-2014-010635. [Epub ahead of print]
    Risk factors associated with adverse events of acupuncture: a prospective study.
    Chung KF1, Yeung WF2, Kwok CW1, Yu YM1.
    Author information


    Abstract
    OBJECTIVE:
    Mild adverse events (AEs) are common with acupuncture, but the risk factors remain unclear. A prospective study using a standardised AE assessment and acupuncture protocol was undertaken to address the question.
    METHODS:
    A 20-item AE report form investigated local and systemic AEs in 150 adults with insomnia randomised to receive traditional, minimal and non-invasive sham acupuncture. Sociodemographic, clinical and psychological variables at baseline and past history and perceived credibility of acupuncture were assessed.
    RESULTS:
    The incidence of any AEs per patient was 42.4% with traditional acupuncture, 40.7% with minimal acupuncture and 16.7% with non-invasive sham acupuncture. Traditional and minimal acupuncture were associated with a greater number of local AEs, while the presence of a chronic medical condition was predictive of fewer local and systemic AEs. Greater severity of insomnia, anxiety, depression, somatic symptoms and pain catastrophising thoughts were associated with lower risk, but most of the significant correlations disappeared after logistic regression. Divorce and widowhood were the only significant sociodemographic variables, while previous acupuncture treatment and perceived credibility of acupuncture were found to be unrelated. The risk of any AEs was higher in participants receiving traditional acupuncture (OR 4.26) and minimal acupuncture (OR 4.27) and in those without medical comorbidity (OR 3.39).
    CONCLUSIONS:
    The prevalence of AEs was higher than usual, probably due to the low threshold in our definition of AEs and the systematic collection from the patients' perspective. Baseline variables were largely unable to predict AEs associated with acupuncture. Further studies should explore the roles of practitioners, patients' anxiety during treatment and patient-practitioner interactions.
    TRIAL REGISTRATION NUMBER:
    NCT01707706.
    Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.


    Chest. 2014 Oct 1;146(4_MeetingAbstracts):331A. doi: 10.1378/chest.1959165.
    Get to the Point: A 44-Year-Old Female Presents to the Emergency Department With Chest Pain.
    Smith P, Perkins M.
    Abstract
    SESSION TITLE:
    Miscellaneous Case Report Posters IISESSION TYPE: Affiliate Case Report PosterPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Chest pain is one of the most common complaints encountered in the emergency department. We present an unusual case of chest pain in a young, healthy female.CASE PRESENTATION: A 44 year-old female with history of lumbago reported to the emergency department (ED) with complaints of chest pain shortly after she was treated with acupuncture in the internal medicine clinic. This was the patient's second acupuncture session for treatment of her lower back pain, which consisted of inserting needles into her scalp, neck, and lumbar paraspinal region. However, 1 hour after the treatment, the patient began experiencing right-sided chest pain with accompanying dyspnea. A chest X-ray obtained in the ED demonstrated a 2.1 cm right-sided apical pneumothorax which was enlarged on a follow up CXR obtained two hours later. The patient remained hemodynamically stable. An aspiration was performed with removal of 150 mL of air. A small pneumothorax remained after the procedure and she was admitted for observation. The pneumothorax resolved on hospital day 2 without any additional intervention.DISCUSSION: Acupuncture is an alternative medicine procedure that has been practiced in China for more than 2000 years, and has been gaining in popularity in the United States since the 1970's. Pneumothorax has been identified as an adverse event associated with this procedure. However, pneumothorax following acupuncture is extremely rare, with one study reporting only 2 occurrences out of 2.2 treatment sessions in approximately 230,000 patients. Despite its extremely low incidence, pneumothorax associated with acupuncture can be fatal. We believe that our patient's pneumothorax is a direct consequence of acupuncture. The pneumothorax was located on the same side of her treatment and there was a close temporal relationship to the onset of symptoms. Our patient had a thin chest wall (BMI of 18), which may have increased the risk of puncturing the pleura during the acupuncture sessions.CONCLUSIONS: We present a rare case of an iatrogenic pneumothorax following the administration of acupuncture. Although infrequent in occurrence, all health care providers should be fully aware of this potentially life threatening adverse event from the administration of this alternative therapy.Reference #1: Stenger M, Bauer NE, Licht PB. Is pneumothorax after acupuncture so uncommon? J Thoracic Dis 2013;5(4): E144-E146.Reference #2: Olusanya O, Mansuri I. Pneumothorax following acupuncture. JABFP 1997;10(4): 296-297.DISCLOSURE: The following authors have nothing to disclose: Patrick Smith, Michael PerkinsNo Product/Research Disclosure Information.





    Rapidly Progressive Disseminated MSSA: Septic Emboli Causing Quadriplegia.
    Sternschein R, Adelman DM, Mahmoudi M, Chitkara N.
    Abstract
    SESSION TITLE:
    Infectious Disease Student/Resident Case Report Posters ISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: We present a case of disseminated MSSA infection causing devastating ischemic sequelae of septic emboli.CASE PRESENTATION: The patient is a 66 year-old man presenting to the ER after he fell off his couch and could not get up. He had chronic back pain and weakness and swelling of both legs. His medical history included recent dental work, acupuncture for shoulder pain, and ORIF for bilateral wrist fractures. On presentation, he was febrile, tachycardic, tachypneic, and hypoxemic, with 4/5 muscle strength throughout. Chest X-ray showed lower lobe infiltrates. Urinalysis suggested infection. He was given broad-spectrum antibiotics and IV fluids. He was transferred to the medical ICU for hypotension. His weakness rapidly progressed to quadriplegia, with shallow, labored breathing. He was intubated for hypoxemic respiratory failure and septic shock requiring vasopressors. CT imaging of the head, cervical and thoracic spine was negative. Lumbar puncture retrieved purulent CSF with a neutrophilic pleocytosis and gram-positive cocci. Dexamethasone was added for bacterial meningitis. A cervical spine MRI showed C3-C7 cord signal abnormality of the central gray matter, concerning for spinal cord infarction. MSSA grew from blood, urine and CSF cultures. Antibiotics were narrowed to nafcillin. A chest CT showed peripheral septic emboli in the lungs. A transthoracic echocardiogram showed large, shaggy aortic and tricuspid valve vegetations. The patient developed massive upper GI bleeding. Endoscopy revealed diffuse ischemic ulcerations, requiring radiologically-guided embolization for hemostasis. His mental status remained depressed; he intermittently answered questions by blinking. He did not regain any neurologic function. He developed progressive multiorgan system failure. After discussion with his family, in keeping with his known wishes in the case of a terminal condition, the patient was palliatively extubated and expired soon thereafter.
    DISCUSSION:
    Our patient represents an uncommon case of widely disseminated MSSA infection due to infective endocarditis of the tricuspid and aortic valves. The sequelae included a descending UTI, septic emboli to the lungs, and septic emboli causing ischemic ulceration of the duodenal mucosa, vertebral artery occlusion, and cervical spinal cord infarction resulting in quadriplegia. The patient's MSSA infection was likely due to bacteremia resulting from acupuncture treatments for shoulder pain. He was hyperglycemic on admission, his HbA1c was 6.7%. Impaired glucose tolerance or uncontrolled undiagnosed diabetes mellitus likely predisposed the patient to dissemination of MSSA infection.CONCLUSIONS: This case illustrates rapidly progressive MSSA infective endocarditis, with ischemic injury from septic emboli contributing to multiorgan system failure and devastating neurologic injury.Reference #1: Murry, R. "Staphylococcus aureus infective endocarditis: diagnosis and management guidelines" Int Med Journ 2005; 35: S25-44.DISCLOSURE: The following authors have nothing to disclose: Rebecca Sternschein, Dr. Mark Adelman, Mandana Mahmoudi, Nishay ChitkaraNo Product/Research Disclosure Information.


    J Altern Complement Med. 2014 Oct 29. [Epub ahead of print]
    "Well I'm Safe Because…"-Acupuncturists Managing Conflicting Treatment Recommendations When Treating Threatened Miscarriage: A Mixed-Methods Study.
    Betts D1, Smith CA, Dahlen HG.
    Author information


    Abstract
    Abstract Objective: To explore how contraindications to the use of acupuncture during pregnancy are managed in clinical practice. Design: Acupuncturists' views on their management of threatened miscarriage were sought by using a mixed-methods design involving a self-completed questionnaire and semi-structured interviews. An online survey was distributed through the Australian and New Zealand acupuncture associations requesting practitioners' to access an online link to a questionnaire hosted by Survey Monkey. This questionnaire examined acupuncturist's views on safety and the use of Traditional Chinese Medicine treatment modalities. Descriptive and bivariate statistics were used to analyze data. Thirteen participants were purposefully selected from the survey responses to further explore treatment management. These interviews were recorded via Skype, transcribed, and analyzed by using thematic analysis. Results: Of 370 respondents, 214 (58%) had treated women for threatened miscarriage within the previous year. Approximately half (58%) had treated four or fewer women, while a minority (14%) had treated 15 or more. The use of abdominal and blood invigorating points reflected diverse treatment strategies within acupuncture textbooks. While the majority avoided acupuncture points traditionally cautioned against in pregnancy, 13% would use LI 4, 22% would use SP 6, and 31% would use BL 32. Two safety themes emerged: "Well I'm safe because…justifying diverse approaches" and "A limited knowledge base-sorting it out for yourself," illustrating how practitioners justified safe practice and had difficulty obtaining trustworthy treatment knowledge. Conclusion: Practitioners demonstrated interest in treating threatened miscarriage. All practitioners saw themselves as providing safe treatment. Those using historically contraindicated points justified their use on the basis of personal opinion, advice from trusted others, and clinical experience with a small number of women. In treating at-risk pregnancies, these justifications may be inadequate. Further research exploring the views of practitioners who are experienced in this specialized area would inform clinical practice for this common complication of early pregnancy.




    Retin Cases Brief Rep. 2014 Spring;8(2):116-119.
    UNUSUAL OCULAR INJURY BY AN ACUPUNCTURE NEEDLE.
    You TT1, Youn DW, Maggiano J, Chen S, Alexandrescu B, Casiano M.
    Author information


    Abstract
    PURPOSE::
    To educate ophthalmologists on the potential dangers of periocular acupuncture and to describe an unusual mechanism of retinal injury.
    METHODS::
    A 42-year-old woman who presented with blurred central vision and loss of peripheral vision. Her medical history was significant for hemifacial spasms related to a facial nerve injury, for which she had sought treatment. Clinical examination showed vertically oriented subretinal track measuring 12 mm in length, contiguous to the macula, with normal optic nerve appearance and foveal reflexes. Spectral domain optical coherence tomography showed a full-thickness perforation of the neurosensory retina at the inferior retinal arcade. Visual field testing 3 weeks after her injury showed 90% loss of her nasal hemifield. Electroretinography performed 8 weeks postinjury showed a 50% decrease in the right B-wave. Multifocal electroretinography showed a mild decrease in the recording of the right eye versus that of the left eye.
    CONCLUSION::
    Based on the history and clinical findings, the acupuncture needle penetrated the inferior globe and created a subretinal track. The particular location of the needle entry into the eye and the extreme malleability of the acupuncture needle created a long subretinal track. Ophthalmologists should be familiar with the ocular injuries caused by periocular acupuncture therapies.



    Perm J. 2014 Nov 24. doi: 10.7812/TPP/14-057. [Epub ahead of print]
    Acupuncture Safety in Patients Receiving Anticoagulants: A Systematic Review.
    Mcculloch M1, Nachat A2, Schwartz J3, Casella-Gordon V4, Cook J5.
    Author information


    Abstract
    INTRODUCTION:
    Theoretically, acupuncture in anticoagulated patients could increase bleeding risk. However, precise estimates of bleeding complication rates from acupuncture in anticoagulated patients have not been systematically examined.
    OBJECTIVE:
    To critically evaluate evidence for safety of acupuncture in anticoagulated patients.
    METHODS:
    We searched PubMed, EMBASE, the Physiotherapy Evidence Database, and Google Scholar.
    RESULTS:
    Of 39 potentially relevant citations, 11 met inclusion criteria: 2 randomized trials, 4 case series, and 5 case reports. Seven provided reporting quality sufficient to assess acupuncture safety in 384 anticoagulated patients (3974 treatments). Minor-moderate bleeding related to acupuncture in an anticoagulated patient occurred in one case: a large hip hematoma, managed with vitamin K reversal and warfarin discontinuation following reevaluation of its medical justification. Blood-spot bleeding, typical for any needling/injection and controlled with pressure/cotton, occurred in 51 (14.6%) of 350 treatments among a case series of 229 patients. Bleeding deemed unrelated to acupuncture during anticoagulation, and more likely resulting from inappropriately deep needling damaging tissue or from complex anticoagulation regimens, occurred in 5 patients. No bleeding was reported in 2 studies (74 anticoagulated patients): 1 case report and 1 randomized trial prospectively monitoring acupuncture-associated bleeding as an explicit end point. Altogether, 1 moderate bleeding event occurred in 3974 treatments (0.003%).
    CONCLUSION:
    Acupuncture appears to be safe in anticoagulated patients, assuming appropriate needling location and depth. The observed 0.003% complication rate is lower than the previously reported 12.3% following hip/knee replacement in a randomized trial of 27,360 anticoagulated patients, and 6% following acupuncture in a prospective study of 229,230 all-type patients. Prospective trials would help confirm our findings.




    Spine J. 2014 Nov 14. pii: S1529-9430(14)01714-8. doi: 10.1016/j.spinee.2014.11.007. [Epub ahead of print]
    Three Cases of Hemiplegia after Cervical Paraspinal Muscle Needling.
    Ji GY1, Oh CH2, Choi WS2, Lee JB3.
    Author information


    Abstract
    BACKGROUND CONTEXT:
    Muscle needling therapy is common for chronic pain management, but the development of unusual complications such as hemiplegia is not well understood.
    PURPOSE:
    We report on three cases with hemiplegia after cervical paraspinal muscle needling and propose possible explanations for these unusual complications.
    STUDY DESIGN:
    Case report METHODS: The authors retrospectively reviewed medical charts from a decade (2002∼2013) of records at Korea university hospital. The records were systematically searched, and hemiplegia (grade < 3) after needling therapy were collected. No conflict of interest reported. No funding received.
    RESULTS:
    A 54-year-old woman, 38-year-old woman, and a 60-year-old man with hemiplegia by cervical subdural or epidural hematoma after cervical posterior paraspinal muscle needling without direct invasion (intramuscular stimulation, acupuncture or intramuscular lidocaine) were observed. All patients were taken for emergent decompressive laminectomy, and their postoperative motor function improved substantially.
    CONCLUSION:
    Spinal hematoma after muscle needling is unusual, but was thought to result after a rupture of the epidural or subarachnoid veins by a sharp increase in blood pressure delivered in the intraabdominal or intrathoracic areas after needling therapy.
    Copyright © 2014 Elsevier Inc. All rights reserved.
    KEYWORDS:
    Bleeding dynamics; Cervical; Complication; Needling therapy; Pain management; Spinal hematoma



    Leg Med (Tokyo). 2014 Nov 11. pii: S1344-6223(14)00165-5. doi: 10.1016/j.legalmed.2014.11.001. [Epub ahead of print]
    An autopsy case of vagus nerve stimulation following acupuncture.
    Watanabe M1, Unuma K1, Fujii Y1, Noritake K1, Uemura K2.
    Author information


    Abstract
    Acupuncture is one of the most popular oriental medical techniques in China, Korea and Japan. This technique is also popular as alternative therapy in the Western World. Serious adverse events are rare following acupuncture, and fatal cases have been rarely reported. A male in his late forties died right after acupuncture treatment. A medico-legal autopsy disclosed severe haemorrhaging around the right vagus nerve in the neck. Other organs and laboratory data showed no significant findings. Thus, it was determined that the man could have died from severe vagal bradycardia and/or arrhythmia resulting from vagus nerve stimulation following acupuncture. To the best of our knowledge, this is the first report of a death due to vagus nerve injury after acupuncture.
    Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.




    Holist Nurs Pract. 2015 January/February;29(1):33-36.
    Successful Treatment of Chronic Nausea and Vomiting Related to Body Piercing and Tattooing With Integrative Medicine Interventions.
    Chung MK1, LaRiccia PJ.
    Author information


    Abstract
    Chronic nausea and vomiting of uncertain etiology can be debilitating and uncomfortable for patients while frustrating for clinicians. This article presents the case of a young woman with chronic nausea and vomiting of unknown etiology resulting from body piercing and tattoo scars on body areas that Chinese Medicine asserts are related to the gastrointestinal system. The patient had long-term total resolution after 1 treatment session consisting of neural therapy for scars resulting from a tongue ring, belly ring, and tattoo near her left wrist along with acupuncture treatment. The research community is called to further evaluate the possible association of body piercing and tattooing with nausea and vomiting along with the possible treatment options of neural therapy and acupuncture.




    Holist Nurs Pract. 2015 Jan-Feb;29(1):33-6. doi: 10.1097/HNP.0000000000000059.
    Successful treatment of chronic nausea and vomiting related to body piercing and tattooing with integrative medicine interventions.
    Chung MK1, LaRiccia PJ.
    Author information


    Abstract
    Chronic nausea and vomiting of uncertain etiology can be debilitating and uncomfortable for patients while frustrating for clinicians. This article presents the case of a young woman with chronic nausea and vomiting of unknown etiology resulting from body piercing and tattoo scars on body areas that Chinese Medicine asserts are related to the gastrointestinal system. The patient had long-term total resolution after 1 treatment session consisting of neural therapy for scars resulting from a tongue ring, belly ring, and tattoo near her left wrist along with acupuncture treatment. The research community is called to further evaluate the possible association of body piercing and tattooing with nausea and vomiting along with the possible treatment options of neural therapy and acupuncture.




    Pneumologie. 2014 Dec;68(12):799-801. Epub 2014 Dec 9.
    [Bilateral Pneumothorax Following Acupuncture.]
    [Article in German]
    Deterding L1, Bräunlich J1, Borte G2, Seyfarth HJ1, Wirtz H1.
    Author information


    Abstract
    Acupuncture, a subsection of traditional Chinese medicine, plays an important role as an alternative healing method. Even though there is little proof of its efficacy, acupuncture is becoming more and more popular in the Western world, especially because it is considered almost free of side effects. However, severe complications may occur and have previously been described.We will present a patient who suffered from bilateral pneumothoraces after acupuncture into the paravertebral area. This complication was not considered as a differential diagnosis thus even worsening the patient's life-threatening condition.



    J Acupunct Meridian Stud. 2014 Apr;7(2):95-7. doi: 10.1016/j.jams.2013.05.001. Epub 2013 May 23.
    A case study of pigmentation and textural changes associated with needling Yin Tang.
    Cooper F1.
    Author information


    Abstract
    In this article, a case is presented in which repeated needling of the Yin Tang point over the course of 6 years was perceived to cause pigmentation and textural changes to the skin. Others have reported changes to pigmentation, but those changes were either shorter lived and associated with strong stimulation, or were associated with implanting a silver needle for several years.
    Copyright © 2014. Published by Elsevier B.V.



    J Mal Vasc. 2015 Jan 23. pii: S0398-0499(14)00268-6. doi: 10.1016/j.jmv.2014.11.001. [Epub ahead of print]
    Popliteal pseudoaneurysm and arteriovenous fistula after acupuncture.
    Soumer K1, Benomrane S2, Derbel B3, Laribi J4, Benmrad M5, Elleuch N6, Kalfat T7, Khayati A8.
    Author information


    Abstract
    Most popliteal arteriovenous fistula and pseudoaneurysm formation are related to trauma. Few cases have previously been reported after acupuncture therapy. Such events are typically observed when the procedure is performed by non-medical acupuncturist. They may present with acute ischemia, recent claudication, distal emboli, or less commonly rupture. Duplex ultrasound should be considered as the 1st method of investigation. Computed tomography scanning is particularly accurate in making the diagnosis. Treatment strategies consist of surgery or endovascular management. The most commonly performed surgical technique for popliteal pseudoaneurysm repair is resection with bypass grafting, whereas popliteal arteriovenous fistula are usually treated surgically with ligation and primary repair. Endovascular procedure using a stent-graft is thought to be a reasonable option for treating popliteal false aneurysm or even arteriovenous fistula. We will describe two cases of an arteriovenous fistula and pseudoaneurysm of the popliteal artery that developed after acupuncture needling in the region of the popliteal artery.



    Clin Microbiol Infect. 2014 Nov 14. pii: S1198-743X(14)00089-5. doi: 10.1016/j.cmi.2014.10.023. [Epub ahead of print]
    Outbreak of extrapulmonary tuberculosis infection associated with acupuncture point injection.
    Jia Z1, Chen S2, Hao C3, Huang Y4, Liu Z2, Pan A2, Liao R5, Wang X6, Lu Z7.
    Author information


    Abstract
    Mycobacterium tuberculosis infection is rarely reported to be associated with acupuncture practices. We performed a retrospective outbreak investigation of a unique outbreak of 33 extrapulmonary M. tuberculosis infections related to acupuncture point injection therapy (AIT) among clients who visited a private traditional Chinese medicine clinical centre in China. The lumps, abscesses and ulcers occurred mostly on the neck, shoulders, waist, knees and hips, localized at acupuncture point meridian sites. These symptoms appeared from January to November 2011, with a peak cluster of infections in September 2011 (nine cases). M. tuberculosis Beijing strain was isolated and confirmed by DNA sequencing. All diagnosed patients were treated empirically with appropriate antibiotic treatment, and their condition improved. Our study indicated that this outbreak was most likely resulted from contaminated AIT. Drafting standard guidelines for AIT is urgently needed, and routine medical supervision should be provided, including obligating health providers to perform routine physical examinations that include testing for infectious diseases.


    Acupunct Med. 2015 Mar 19. pii: acupmed-2014-010700. doi: 10.1136/acupmed-2014-010700. [Epub ahead of print]
    Acupuncture-induced haemothorax: a rare iatrogenic complication of acupuncture.
    Karavis MY1, Argyra E2, Segredos V3, Yiallouroy A2, Giokas G2, Theodosopoulos T2.
    Author information


    Abstract
    This paper reports a rare iatrogenic complication of acupuncture-induced haemothorax and comments on the importance and need for special education of physicians and physiotherapists in order to apply safe and effective acupuncture treatment. A 37-year-old healthy woman had a session of acupuncture treatments for neck and right upper thoracic non-specific musculoskeletal pain, after which she gradually developed dyspnoea and chest discomfort. After some delay while trying other treatment, she was eventually transferred to the emergency department where a chest X-ray revealed a right pneumothorax and fluid collection. She was admitted to hospital and a chest tube inserted into the right hemithorax (under ultrasound guidance) drained 800 mL of bloody fluid (haematocrit (Hct) 17.8%) in 24 h and 1200 mL over the following 3 days. Her blood Hct fell from 39.0% to 30.8% and haemoglobin from 12.7 to 10.3 g/dL. The patient recovered completely and was discharged after 9 days of hospitalisation. When dyspnoea, chest pain and discomfort occur during or after an acupuncture treatment, the possibility of secondary (traumatic) pneumo- or haemopneumothorax should be considered and the patient should remain under careful observation (watchful waiting) for at least 48 h. To maximise the safety of acupuncture, specific training should be given for the safe use of acupuncture points of the anterior and posterior thoracic wall using dry needling, trigger point acupuncture or other advanced acupuncture techniques.
    Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.



    1.
    Acupunct Med. 2015 Mar 20. pii: acupmed-2014-010717. doi: 10.1136/acupmed-2014-010717. [Epub ahead of print]
    Unusual case of pyogenic spondylodiscitis, vertebral osteomyelitis and bilateral psoas abscesses after acupuncture: diagnosis and treatment with interventional management.
    He C1, Wang T1, Gu Y1, Tian Q1, Zhou B1, Wu C1.
    Author information:
    1Department of Diagnostic and Interventional Radiology, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China.

    Abstract
    BACKGROUND:
    We report, for the first time, a case of pyogenic spondylodiscitis combined with vertebral osteomyelitis and bilateral psoas abscesses after acupuncture.
    CASE HISTORY:
    A 60-year-old man was diagnosed with rectal cancer, and radical rectectomy and permanent colostomy were carried out. However, 3 years after the surgery the patient complained of pain in the lower back, and the symptoms worsened after seven sessions of acupuncture. Technetium 99m-labelled methylene diphosphonate (99mTc-MDP) bone scintigraphy (BS) revealed abnormal uptake of 99mTc-MDP in the L4 and L5 vertebrae. He was admitted to our hospital because of suspected bone metastases from rectal cancer. He was diagnosed with infection based on a history of acupuncture and the findings of enhanced MRI and CT. Percutaneous lumbar discectomy (PLD), external drainage and irrigation using antibiotics were carried out to treat the L4-5 disc. Pathological analyses and bacterial culture of the resected disc confirmed infection with group C streptococcus. Postoperative antibiotic treatment resulted in significant pain relief on the third day and gradual complete relief. Considerable improvement was seen on CT and MRI at follow-up.
    CONCLUSIONS:
    We consider it highly likely that this patient's infection was caused by acupuncture. In patients with malignancy, abnormal uptake of 99mTc-MDP in BS may signify bone metastasis but can also be observed in bone infections. PLD can be used to resect diseased discs to relieve pain quickly and to prevent herniation of lumbar discs. After PLD, external drainage can be employed for abscess drainage, decompression and perfusion of antibiotics. PLD may serve as an alternative to open surgery for pyogenic spondylodiscitis.
    Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to     http://group.bmj.com/group/


    Diabetic boy, 7, dies after TCM slapping therapy

    		Chest. 2014 Oct 1;146(4_MeetingAbstracts):162A. doi: 10.1378/chest.1994955.
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    Monday, May 04, 2015
    AsiaOne
    By Lam Min Lee
    A boy died in a hotel room on Apr 27 while attending a health seminar in Sydney.
    Seven-year-old Aidan Fenton was found unconscious and later pronounced dead at the scene after paramedics failed to revive him with cardiopulmonary resuscitation (CPR).
    BBC reported that Fenton's mother had signed the diabetic boy up for an alternative therapy workshop conducted by the visiting Chinese healer Xiao Hongchi.

    1047789576231139970
    Attendees paid AU$1,800 (S$1,900) for the Traditional Chinese Medicine (TCM) seminar held at the Pan Health Medical Centre from Apr 22 to 28.
    BBC added that the New South Wales police are investigating the boy's death and whether he had stopped taking insulin and only relied on the alternative therapy to manage his condition.
    According to the Sydney Morning Herald, the Chinese therapist left Australia after he was interviewed by the police as part of standard procedure for an unexplained death.
    The alternative therapy practised by Xiao, "PaiDaLaJin", involves slapping parts of the body repeatedly until bruises appear, and stretching the body in order to cure illnesses.
    He says that "PaiDaLaJin" clears the patient's meridian system from blockages, promotes the circulation of 'qi' and purges toxins from the body.
    However, medical experts in China have expressed doubts over Xiao's claims that his alternative therapy helps the body to self-heal and cure all diseases.
    In Sep 2012, China's state media Xinhua ran an expose on the shady practices of Xiao who is not a certified medical practitioner.
    It uncovered how the ex-investment banker became a 'God of medicine' in the country within the short span of two years.
    Xiao had written books on the alternative treatment that became bestsellers in China and Taiwan.
    He also set up numerous clinics across the country run by his disciples who taught patients how to use "PaiDaLaJin" to cure chronic conditions such as hypertension, diabetes, and heart disease.
    A Chinese reporter who attended one of the workshops to verify the miraculous claims made an alarming discovery - patients were asked to stop taking medication for their conditions and to fast for three days.
    The credibility of Xiao's alternative therapy was also diminished by many accounts of patients' conditions deteriorating after receiving the treatment.
    In addition, he was fined TWD$50,000 (S$2,200) by Taipei's Department of Health and deported from Taiwan five years ago for conducting a series of health workshops in the city without holding a medical licence.
    Sina News reported that in recent years, Xiao has been promoting the therapy in the US, Germany, India, South Africa, New Zealand and Australia.
    According to Xinhua, Xiao's lucrative business in China generated about 180 million yuan (S$39 million) from book sales and health seminars in 2011.


    Acupuncture needle left in man's groin, lawsuit claims
    Steven DuBois, Associated Press 8:16 a.m. PDT June 16, 201

    PORTLAND, Ore. (AP) - A Portland man has filed a lawsuit seeking more than $3 million from an acupuncturist he says left two needles in his skin, including one that later broke off and became embedded in his groin.
    The lawsuit says acupuncturist Lihua Wang of the China Acupuncture and Herb Center in Portland failed to do pre- and post-session needle counts during an October 2013 appointment, and then didn't inspect Robert Shipp's body for leftover needles before sending him home.
    Shipp had gone to the acupuncturist to alleviate pain after an auto accident, his attorney, James Shadduck, said Monday.
    Shipp felt the needles in his skin not long after the session, Shadduck said. He removed one of the needles, but the other broke off into a part of his pelvis and has been embedded into the area ever since, completely beneath the surface of the skin.
    "He couldn't walk at all using his left leg, the pain so severe, stabbing into a nerve," he said.
    The lawsuit filed against the clinic in Multnomah County Circuit Court says Shipp was bedridden for months, still has trouble walking and can no longer work as an arborist. One surgical attempt to remove the needle failed, and he will undergo another procedure next month to try to get it out, Shadduck said.
    Wang and another clinic representative referred questions Monday to the American Acupuncture Council, which provides malpractice insurance. Attorney and council Vice President Mike Schroeder said he couldn't discuss the specifics of Shipp's case because of laws regarding medical privacy.
    "We are not aware of any proof that the metal object in question is an acupuncture needle," Schroeder said by phone from Southern California. "Since 1986, when the American Acupuncture Council was formed, there has never been a recorded case of an acupuncture needle breaking into pieces.
    "You can bend them many, many times and they don't break."
    Shadduck says X-rays clearly show a foreign object consistent with an acupuncture needle.
    Shipp, 34, is married with three children. Besides $2.5 million for Shipp's pain and suffering, the lawsuit seeks $650,000 for the losses his family faces without a fully functioning husband and father.



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    J Environ Sci Health A Tox Hazard Subst Environ Eng. 2015;50(3):260-71. doi: 10.1080/10934529.2015.981112.
    Human exposure to airborne aldehydes in Chinese medicine clinics during moxibustion therapy and its impact on risks to health.
    Hsu YC1, Chao HR, Shih SI.
    Author information


    Abstract
    Many air toxicants, and especially aldehydes, are generated by moxibustion, which means burning Artemisia argyi. Our goal was to investigate indoor-air aldehyde emissions in Chinese medicine clinics (CMCs) during moxibustion to further evaluate the potential health risks, including cancer risk and non-cancer risk, to the medical staff and adult patients. First, the indoor-air-quality in 60 public sites, including 15 CMCs, was investigated. Four CMCs with frequent use of moxibustion were selected from the 15 CMCs to gather the indoor airborne aldehydes in the waiting and therapy rooms. The mean values of formaldehyde and acetaldehyde in the CMCs' indoor air were 654 and 4230 μg m(-3), respectively, in the therapy rooms, and 155 and 850 μg m(-3), respectively, in the waiting rooms. The average lifetime cancer risks (Rs) and non-cancer risks (hazard quotients: HQs) of airborne formaldehyde and acetaldehyde among the CMC medical staff exceeded the acceptable criteria (R < 1.00 × 10(-3) and HQ < 1.00) for occupational workers. The patients' Rs and HQs were also slightly higher than the critical values (R = 1.00 × 10(-6) and HQ = 1.00). Our results indicate that airborne aldehydes pose a significant threat to the health of medical staff, and slightly affected the patients' health, during moxibustion in the CMCs.



    Acupunct Med 2014;32:517-519 doi:10.1136/acupmed-2014-010659

    Letter
    Pneumothorax complication of deep dry needling demonstration

    +

    Author Affiliations

    • British Medical Acupuncture Society, London, UK
      1
    • Pain and Rehabilitation Medicine, Bethesda, USA
      2
    • Dr Mike Cummings, British Medical Acupuncture Society, 60 Great Ormond Street, London WC1N 3HR, UK; BMASLondon@aol.com
      Correspondence to
    • 28 August 2014
      Received
    • 3 September 2014
      Accepted
    • 19 September 2014
      Published Online First
    Introduction
    Pneumothorax is a well-recognised but rare adverse event related to acupuncture or deep dry needling (DDN) over the thorax.1 ,2 This report of a pneumothorax resulting from DDN is unusual for a number of reasons: both the practitioner and the subject were doctors and both have contributed to this report; the practitioner was very experienced in DDN and had not knowingly caused such an event in the previous 45 years of practice and teaching DDN; the incident was captured on video and is presented online with this report (see online supplementary video). We hope that by reporting this event and review of the video recording we can suggest ways to reduce the risk of reoccurrence of such adverse events of DDN.
    Report of needling demonstration by practitioner
    The setting was a hands-on workshop teaching the technique of DDN for the treatment of myofascial pain syndromes. The workshop used the format of lecture, demonstration on a volunteer, and then practice by the group in groups of two or three individuals at an examination couch. Safety procedures were emphasised for each muscle considered. The safety precautions included identification of landmarks each time one prepared to needle the subject and an awareness of the local anatomy and of possible complications. During the introduction to the demonstrations the complication of pneumothorax was discussed. Symptoms were described and the advice to go to the emergency department for a chest X-ray was given.
    The muscle to be demonstrated was the iliocostalis muscle, one of the erector spinae muscles. RR-M volunteered to be the subject. The lecturer emphasised the danger of pneumothorax and spoke of the technique of ‘blocking’ the rib by placing a finger in the intercostal space on either side of it. RR-M was a lean individual, so there was no trouble identifying the rib as he lay down. A 0.3×50 mm Seirin acupuncture needle was used to demonstrate the technique of needling the iliocostalis muscle at approximately the level of the eighth rib. A taut band in the muscle was identified by palpation against the rib. The needle was prepared and held in the right hand. The muscle was again palpated, this time with the left hand. Landmarks were identified—namely, the angle of the ribs and the intercostal spaces on either side of the rib. The taut band was identified. The intercostal spaces were blocked with the index and long fingers of the left hand, the fingers lying flat in the intercostal space so that the rib was blocked for the length of the fingers. The rib between was identified and the needle tapped through the skin using the right index finger. The intercostal space-blocking left hand fingers remained in position. The needle was advanced towards the rib with the right hand. The needle continued to advance to a depth that was deeper than expected. RR-M gave an exclamation indicating that he felt pain. The needle was withdrawn back towards the skin and RR-M was asked what the pain felt like. He said that it was an aching pain. The needle was redirected within the area blocked by the fingers of the left hand. This time, when the needle was advanced, it touched the rib at about 10–15 mm depth, indicating that the needle had slid off the rib the first time. After touching the rib with the needle and needling the iliocostalis muscle against the rib, the needle was removed.
    Relevant background medical history of subject
    The subject was a 55-year-old male medical doctor of 1.86 m height and 68 kg weight (body mass index 20). He had a history of asthma since childhood and, at the time of the event, was well controlled on daily fluticasone/salmeterol (Seretide) and salbutamol as required. There had been no hospital admissions with asthma. He had no prior spontaneous or traumatic pneumothoraces and no history of other significant acute or chronic lung disease.
    Description of symptoms by the subject
    “The needling was mid-morning and by mid-day I had a deep ache and stiffness in my left chest posteriorly. It was fairly diffuse, but was centred on the scapula. This continued the rest of the day and into the next day. By the morning I was also aware of a feeling of constriction on breathing, and pain on taking or trying to take a deep breath, which I felt I couldn't actually perform fully. I also developed a dry cough, the breathlessness felt like an exacerbation of asthma symptoms (albeit more lateralised to the left) and was more noticeable on walking. I was also aware of a dull ache in the shoulder tip in the region of the acromioclavicular joint. At 2 weeks the breathlessness on exertion was lessened, but not completely gone. At 6–8 weeks I was symptom-free, but still with a pre-existing dull ache in the region of the ipsilateral acromioclavicular joint.
    ”
    Description of supplementary video
    The practitioner describes the precautions related to needling over the thorax and demonstrates identification of a taut band and how the interspaces between the ribs are ‘blocked’ by the fingers. A 50 mm (0.3 mm diameter) Seirin acupuncture needle is initially inserted over the identified rib, towards the taut band. The needle is inserted about 20 mm, then the practitioner pauses and the needle is inserted a further 20 mm. The latter insertion is most likely responsible for the needle penetrating the left lung. The needle is withdrawn and re-angled slightly inferolaterally to the original angulation. The subsequent insertion results in contact with the rib at a depth of about 20 mm. It should be noted that the slightly more oblique angulation of this insertion means that the perpendicular depth of soft tissue over the rib was slightly less than 20 mm.
    Outcome
    The subject presented for his afternoon clinic at a hospital in central London the following day at approximately 13.30. He appeared well but had a dry cough and described a feeling of being unable to take a deep breath and a sense of breathlessness on the left side. We organised a chest X-ray immediately, which demonstrated a 20% left-sided pneumothorax (see figure 1). He proceeded to see the patients who had already arrived for his medical acupuncture clinic before attending our local accident and emergency unit. He was advised to manage the pneumothorax conservatively and a repeat chest X-ray at 14 weeks after the incident demonstrated a fully inflated left lung.
    F1.medium
    Figure 1
    Chest X-ray of the patient taken approximately 24 h after the needling demonstration featured in the linked video.

    Discussion and analysis
    Pneumothorax is a recognised complication of acupuncture and DDN.1 The largest prospective survey of adverse events of acupuncture found two cases of pneumothorax related to 2.2 million acupuncture sessions in 0.22 million patients,2 but we do not know what proportion of the 2.2 million treatments surveyed involved needling over the thorax. DDN over the thorax is very likely to be associated with a higher incidence of pneumothorax.3 A variety of techniques are used to avoid puncturing the lungs and pleura when performing needling over the thorax: superficial needling (insertion a few millimetres into the first muscle layer or subcutaneous insertion); needle insertion at a tangent to the ribcage; needling over or onto a rib (the method used in this case).4 The latter is arguably the most risky, but also the most reliable way of reaching a target trigger point and, indeed, the only way of performing DDN to the target muscle layer (iliocostalis lumborum pars thoracis) in this case. It seems clear from the video that the mistake was to continue insertion beyond the first 20 mm rather than rechecking the rib position or re-angling the needle.
    We suggest that, when needling over the ribcage and targeting a rib, practitioners should estimate how far they are prepared to insert the needle before rechecking the rib position. This will vary with the constitution of the subject and the position on the thorax, but in some slim individuals it may be as little as 10 mm. In this case, over the mid to lower posterior thorax we estimate that the distance to the rib was just under 20 mm.
    Footnotes
    MC drafted the paper including contributions from RR-M and RG. RR-M provided a description of the adverse event from a patient perspective. RG provided a description of the demonstration from the perspective of a practitioner.
    Contributors
  • None.
    Competing interests
  • Not commissioned; internally peer reviewed.
    Provenance and peer review
    • References
    • White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med 2004;22:122–33. [Abstract/FREE Full text]
      . ↵
    • Witt CM, Pach D, Brinkhaus B, et al. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. ForschKomplementmed 2009;16:91–7. [Web of Science]Google Scholar
      . ↵
    • Dommerholt J, Fernández-de-las-Peñas C.eds Trigger point dry needling an evidence and clinical-based approach. 1st edn. Edinburgh: Elsevier Churchill Livingstone, 2013. Google Scholar
      . ↵
    • White A, Cummings M, Filshie J. An introduction to Western medical acupuncture. London: Churchill Livingstone, 2008.
      . ↵


    Acupunct Med. 2015 Aug 5. pii: acupmed-2015-010775. doi: 10.1136/acupmed-2015-010775. [Epub ahead of print]
    CT evaluation of acupuncture needles inserted into sacral foramina.
    Katayama Y1, Kamibeppu T1, Nishii R2, Mukai S1, Wakeda H1, Kamoto T1.
    Author information


    Abstract
    OBJECTIVE:
    To use CT scanning to evaluate the precision with which acupuncture needles can be inserted into sacral foramina to establish sacral nerve modulation by electroacupuncture.
    METHODS:
    The subjects were five adult women (mean age 71.6 years). These five cases were divided into two groups. In the first three subjects (group A) the intention was to insert acupuncture needles in the S3 and S4 foramina; in the remaining two subjects (group B) the intention was to insert acupuncture needles in the S2 and S3 foramina.
    RESULTS:
    CT scanning showed that in subject 1 of group A, the acupuncture needle intended for insertion in S3 was actually in the S4 foramen, and the acupuncture needle intended for insertion in S4 was actually distal to the sacral body. In subjects 2 and 3, the acupuncture needles were inserted accurately in the S3 and S4 foramina. In the three subjects who had acupuncture needles inserted in the S4 foramen, the tip of the acupuncture needle was an average distance of 6.0 mm from the rectum. The acupuncture needles inserted in subjects 4 and 5 of group B were inserted accurately into the S2 and S3 foramina.
    CONCLUSIONS:
    Inserting acupuncture needles into the sacral foramina of S2 and S3 at an angle of about 60° has the potential to be used for sacral nerve modulation by repeated electroacupuncture stimulation. Needling may be less accurate in subjects with higher body mass index. Because of the potential risk of perforating the rectum with the needle, this technique must be used by specialists only.



    Case Rep Med. 2015;2015:524241. doi: 10.1155/2015/524241. Epub 2015 Jul 15.
    First Reported Case of Methicillin-Resistant Staphylococcus aureus Vertebral Osteomyelitis with Multiple Spinal and Paraspinal Abscesses Associated with Acupuncture.
    Singh Lubana S1, Alfishawy M1, Singh N1, Brennessel DJ2.
    Author information


    Abstract
    Acupuncture is one of the oldest medical procedures in the world and originated in China about 2,000 years ago. Acupuncture is a form of complementary medicine and has gained popularity worldwide in the last few decades. It is mainly used for the treatment of chronic pain. Acupuncture is usually considered a safe procedure but has been reported to cause serious complications including death. It has been associated with transmission of many viruses and bacteria. Two cases of Methicillin-Resistant Staphylococcus aureus have been reported recently following acupuncture therapy. We are reporting a case of a 57-year-old Korean female who developed vertebral osteomyelitis and intraspinal and paraspinal abscesses as a complication of acupuncture. Blood cultures, skin lesion culture, and body fluid culture yielded Methicillin-Resistant Staphylococcus aureus (MRSA). Good anatomical and medical knowledge, good hygiene standards, and proper acupuncture techniques should be followed to prevent the complications. Acupuncturists should consistently review the infection control guidelines to acupuncture. This case should raise awareness of such condition and hazards of presumably benign procedures such as acupuncture.


    BMJ Case Rep. 2015 Dec 11;2015. pii: bcr2015212110. doi: 10.1136/bcr-2015-212110.
    Atlanto-axial infection after acupuncture.
    Robinson A1, Lind CR2, Smith RJ1, Kodali V3.
    Author information


    Abstract
    A 67-year-old man presented with neck cellulitis following acupuncture for cervical spondylosis. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Increased neck pain and bacteraemia prompted MRI, which showed atlanto-axial septic arthritis without signs of infection of the tissues between the superficial cellulitic area and the atlanto-axial joint, thus making direct extension of infection unlikely. It is more likely that haematogenous spread of infection resulted in seeding in the atlanto-axial joint, with the proximity of the arthritis and acupuncture site being coincidental. Acupuncture is a treatment option for some indolent pain conditions. As such, acupuncture services are likely to be more frequently utilised. A history of acupuncture is rarely requested by the admitting doctor and seldom offered voluntarily by the patient, especially where the site of infection due to haematogenous spread is distant from the needling location. Awareness of infectious complications following acupuncture can reduce morbidity through early intervention.


    Fa Yi Xue Za Zhi. 2015 Aug;31(4):317-9.
    Acute Pharyngeal Hemorrhage as a Fatal Complication Arising from Acupotomy with Needle-knife: A Case Report.
    Zhang L, Duan YJ, Xing JJ, Zhou YW.




    Journal of Surgical Case Reports

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    Editor in chief
    Prof. Derek Alderson
    Editors
    Mr Julien Al Shakarchi
    Mr Tariq Ali
    Mr Varun Dewan
    Mr Khalid Hussain


    Lumbar spine osteomyelitis and epidural abscess formation secondary to acupuncture cc
    Vinesh Godhania
    DOI: http://dx.doi.org/10.1093/jscr/rjw035 rjw035 First published online: 13 March 2016


    Abstract


    A 39-year-old male with no previous medical history presented with abdominal and low back pain. Based on clinical and radiological findings he was diagnosed with L1/L2 osteomyelitis and epidural abscess. Further history taking revealed recent use of acupuncture for treatment of mechanical back pain. The patient was treated conservatively with an extended course of antibiotics, monitored with repeat MRI scans and had a full recovery with no neurological deficit. This is the first reported case of epidural abscess formation and osteomyelitis after acupuncture in the UK. As acupuncture becomes more commonly used in western countries, it is important to be aware of this rare but serious complication.
    INTRODUCTION


    Acupuncture is being more commonly used and prescribed in the UK. It is a form of alternative medicine and comes from traditional Chinese medicine. It is used in treating a wide variety of conditions such as musculoskeletal pain and headaches. It is seen as a low-risk complementary therapy that is being administered by many different health professionals. However, alternative medicine is rarely taught in medical school, so doctors may be unaware of the potential risks. This case highlights a rare complication of epidural abscess formation following acupuncture.
    CASE REPORT


    A 39-year-old man presented to the emergency department with a 1-week history of abdominal pain and 3-week history of back pain. No previous medical or surgical history. On examination the abdomen was soft with mild central tenderness. The back had mild paraspinal tenderness in the lumbar region but no neurology. He was apyrexial. Observations were normal and on admission the white cell count was 8.2 × 109/l and the CRP was 244 mg/l. The patient was referred to general surgeons due to the abdominal pain.
    The initial chest and abdominal radiographs were normal but blood tests showed a raised CRP of 244, so broad spectrum antibiotics were started. It was decided that due to the abdominal pain and raised inflammatory markers the patient required a CT abdomen/pelvis which showed para-aortic lymph nodes but no other abnormalities. Testicular lymphatic drainage goes to the para-aortic lymph nodes, so they were examined and had an ultrasound scan which were both normal. Blood cultures grew     Staphylococcus aureus and, after discussion with the microbiologist, an MRI spine was performed to rule out osteomyelitis. This showed L2/L3 osteomyelitis, epidural abscess and psoas inflammation (Fig. 1). The microbiologist also advised for a trans-oesophageal echocardiogram to rule out development endocarditis, which was normal. On further questioning, the patient had acupuncture treatment 2 weeks prior to admission for mechanical back pain. The treatment was performed by a trained physiotherapist and involved the insertion of sterile disposable needles into acupoints in the lower back to relieve pain.
    F1.medium

    Figure 1:
    Sagital T1 MRI lumbosacral spine. Osteomyelitis in L2 and L3 vertebral bodies, epidural abscess and inflammation of the psoas muscles.

    Neurosurgical advice recommended that due to the lack of neurological symptoms the patient could be treated conservatively with antibiotics. Microbiology advice was to treat the patient with IV flucloxacillin and oral rifampicin for at least 2 weeks and then to continue with oral antibiotics for at least a further 6 weeks depending on clinical improvement. Repeat bloods and MRI scans were performed to monitor the response to antibiotics (Fig. 2).
    F2.medium
    Figure 2:
    Sagital T1 MRI lumbosacral spine. 2 months later the epidural abscess has resolved and minimal marrow oedema is seen in L2 and L3 vertebra.

    The patient completed a 2-week course of IV antibiotics followed by a further 12-week oral course. The patient responded well to antibiotic therapy as evidenced by normal inflammatory markers and resolution of osteomyelitis and epidural abscess on MRI.
    DISCUSSION


    Acupuncture has developed in China over thousands of years. It has been more commonly used in the West especially for low back pain. This case highlights a rare but potentially severe complication of acupuncture. Major complications are rare, having an incidence of 0.55 per 10 000 patients according to one study [1]. Common risks of acupuncture include local cellulitis and rarer complications of neurovascular damage and pneumothorax have been reported [1].
    Spinal epidural abscess is a rare condition accounting for 1 per 20 000 hospital admissions [    2]. Predisposing risk factors for developing an epidural abscess include diabetes mellitus, chronic kidney disease, an immunocompromised status, trauma, surgery, nerve acupuncture and infection (i.e. sepsis, soft tissue infection, osteomyelitis and urinary tract infection) [3].
    Only six cases of spinal epidural abscess formation following acupuncture have been published [    3–7]. The majority of these cases are reported in China, Japan or Korea where acupuncture use is most common but this is the first reported case in the UK. Five of these cases were treated successfully with an extended course of antibiotics and serial MRIs with one case requiring total laminectomy of L3–4. Five patients had a full neurological recovery and one had paraplegia with no improvement. The most common causative pathogen is Staphylococcus aureus, which accounts four of these cases the others being Serratia marcescens and Escherichia coli.
    Although spinal epidural abscess is an uncommon disease in this case a complete history would have highlighted recent acupuncture usage and would have led to a quicker diagnosis. As acupuncture becomes more commonly used doctors should be aware of the potential benefits and complications to their patients.
    CONFLICT OF INTEREST STATEMENT


    None declare.

    • Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2016.
    This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com
    REFERENCES


    • 1. ↵White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med 2004;22:122–33.Abstract/FREE Full Text
    • 1. ↵Darouiche RO. Spinal epidural abscess. N Engl J Med 2006;355:2012–20.CrossRefMedlineWeb of Science
    • 1. ↵Yang CW, Hsu SN, Liu JS, Hueng DY. Serratia marcescens spinal epidural abscess formation following acupuncture. Intern Med 2014;53:1665–8.CrossRefMedline
    • 1. Yazawa S, Ohi T, Sugimoto S, Satoh S, Matsukura S. Cervical spinal epidural abscess following acupuncture: successful treatment with antibiotics. Intern Med 1998;37:161–5.CrossRefMedlineWeb of Science
    • 1. He C, Wang T, Gu Y, Tian Q, Zhou B, Wu C. Unusual case of pyogenic spondylodiscitis, vertebral osteomyelitis and bilateral psoas abscesses after acupuncture: diagnosis and treatment with interventional management. Acupunct Med 2015;33:154–7.Abstract/FREE Full Text
    • 1. Bang MS, Lim SH. Paraplegia caused by spinal infection after acupuncture. Spinal Cord. 2006;44:258–9.CrossRefMedlineWeb of Science
    • 1. ↵Yu HJ, Lee KE, Kang HS, Roh SY. Teaching neuroimages: multiple epidural abscesses after acupuncture. Neurology 2013;80:1–2.CrossRef

    View Abstract



    Acupunct Med. 2016 Apr;34(2):149-51. doi: 10.1136/acupmed-2015-212110rep.
    Atlanto-axial infection after acupuncture.
    Robinson A1, Lind CR2, Smith RJ1, Kodali V3.
    Author information


    Abstract
    A 67-year-old man presented with neck cellulitis following acupuncture for cervical spondylosis. Blood cultures were positive for methicillin-sensitiveStaphylococcus aureus Increased neck pain and bacteraemia prompted MRI, which showed atlanto-axial septic arthritis without signs of infection of the tissues between the superficial cellulitic area and the atlanto-axial joint, thus making direct extension of infection unlikely. It is more likely that haematogenous spread of infection resulted in seeding in the atlanto-axial joint, with the proximity of the arthritis and acupuncture site being coincidental. Acupuncture is a treatment option for some indolent pain conditions. As such, acupuncture services are likely to be more frequently utilised. A history of acupuncture is rarely requested by the admitting doctor and seldom offered voluntarily by the patient, especially where the site of infection due to haematogenous spread is distant from the needling location. Awareness of infectious complications following acupuncture can reduce morbidity through early intervention.
    Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/



    Indian J Ophthalmol. 2016 Apr;64(4):326-7. doi: 10.4103/0301-4738.182952.
    A case of perforating injury of eyeball and traumatic cataract caused by acupuncture.
    Shuang H1, Yichun K1.
    Author information


    Abstract
    Perforating globe injury is the leading cause of monocular blindness and vision loss. A 58-year-old male was injured by acupuncture needle during acupuncture treatment for his cerebral infarction. To the best of our knowledge, this is the first case report of perforating injury of the eyeball and traumatic cataract caused by acupuncture. The patient was hospitalized due to diagnosis of perforating ocular injury, traumatic cataract, and corneal and iris perforating injury. Moreover, he had to accept treatments of phacoemulsification, anterior vitrectomy along with intraocular lens implantation in the sulcus to improve his visual acuity. As acupuncture therapy has been widely performed for various diseases and achieved highly approval, the aim of this report is to remind acupuncturists operating accurately to avoid unnecessary injury during the treatment process, or the cure can also become the weapon.



    Cordyceps is one of the herbs used in traditional Chinese medicine.PHOTO: ISTOCKPHOTO
    PUBLISHEDJUN 14, 2016, 5:00 AM SGT
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    The risk of bleeding is a concern for people undergoing any medical procedure
    Joan Chew
    The safety of Chinese medicine was thrust into the spotlight recently when a 58-year-old woman died after developing extensive bleeding in the brain.
    Last month, State Coroner Marvin Bay attributed Madam Chew Kim Kee's death last year to her failure to tell doctors that she had been taking cordyceps in the week before the operation for a benign brain tumour.
    Cordyceps contain adenosine, which may impede blood platelets from clumping together and forming a plug - the first step in stopping bleeding.



    genericusersync.ashx
    This risk of bleeding is a concern for patients undergoing any medical procedures.
    Associate Professor Linn Yeh Ching, senior consultant at Singapore General Hospital's (SGH) department of haematology, said herbs may contain active compounds that either suppress the function of platelets, lower the platelet count or reduce clotting factors - proteins that are activated when a person bleeds in order to seal up the bleeding site.


    All food - including herbs - has distinct properties that either help to balance our bodies and make us healthy or create imbalances which ultimately result in sickness. It is why people should be aware that even supplements - herbal or otherwise - are regarded as medicine.
    Prof Linn added that a patient's platelet counts and clotting function are routinely measured before medical procedures, but not the function of platelets, which is suppressed by drugs like aspirin.
    "If there is any suspicion of a herb suppressing platelet counts, the platelet count should be repeated a few weeks after stopping the herb," she said.
    Some herbs that have been shown to suppress one's platelet function include radix salviae miltiorrhizae (danshen), radix notoginseng (tianqi), garlic extract (not garlic used in small amounts in cooking) and codonopsis root (dangshen), she said.
    It is why patients must stop taking these herbal products for between 10 and 14 days prior to a procedure. This is to ensure that platelets exposed to the herbal products have died and are completely replaced by newly-formed platelets. The lifespan of a platelet is about 10 days.
    Ms Lim Ching Hui, SGH's senior principal pharmacist, said herb- drug interactions can occur if a patient takes both at the same time and they react with one another.
    "These interactions may augment the action of the drug, reduce its effectiveness or cause unexplained side effects."
    The interactions can even alter the absorption, distribution, metabolism and excretion of the drug which, in turn, affect the drug concentration in the body.
    This can have unintended consequences.
    For instance, if herbs interacted with a diabetic drug and resulted in a low drug concentration, it could result in poorer control of blood sugar level.
    If it interacted with a drug intended to decrease blood pressure such that the concentration is high, it could cause a greater-than- expected decrease.
    Often, more than one herb or drug is involved in the interaction.
    Ms Lim said it can be difficult to determine the main causative agent, especially when a herbal product contains multiple ingredients, or when a single herb contains numerous organic and inorganic compounds.
    Ms Lim said that taking a herb and drug at two different times of the day can help reduce direct interactions in the digestive tract, but it will not affect how the body responds, such as how the drug is broken down in the body.
    Besides cordyceps, other Chinese herbs which have blood- thinning effects include Szechwan lovage rhizome (chuanxiong), radix salviae miltiorrhizae (danshen), safflower (honghua), red peony root (chishao) and motherwort herb (yimucao), said Ms Lim Lay Beng, a traditional Chinese medicine (TCM) practitioner at YS Healthcare TCM Clinic.
    As such, TCM practitioners are cautious about prescribing these herbs to patients who are taking anti-coagulants such as aspirin or warfarin for fear of the increased risk of bleeding, she added.
    But if these are deemed necessary for the patient, she will include other herbs to minimise the blood-thinning effect of the overall prescription.
    Ms Lim said: "A prescription is usually made up of a combination of various herbs that not only boosts the efficacy of the treatment, but also minimises the side effects of certain herbs."
    Such prescriptions are drawn up after taking into consideration a patient's unique body constitution and medical conditions.
    In addition, TCM physicians typically start patients on low doses of herbs to monitor their reaction, she said.
    There is limited information on herb-drug interactions in medical literature.
    TCM practitioners also warn the public to consult qualified physicians before consuming any herbs.
    Dr Clement Ng, a volunteer TCM physician at Singapore Chung Hwa Medical Institution, said all food - including herbs - has distinct properties that either help to balance our bodies and make us healthy or create imbalances which ultimately result in sickness.
    It is why people should be aware that even supplements - herbal or otherwise - are regarded as medicine, albeit taken at a lower dosage.
    He stressed that people should be educated to avoid self-medication of herbs.
    Patients who choose to withhold information of prior illnesses and medication taken when seeking consultation or surgery are solely responsible for the outcome, he added.
    "This applies to both mainstream medicine as well as TCM."


    Int J Emerg Med. 2016 Dec;9(1):22. doi: 10.1186/s12245-016-0116-5. Epub 2016 Jul 26.
    A rare case of multiple spinal epidural abscesses and cauda equina syndrome presenting to the emergency department following acupuncture.
    Chan JJ1, Oh JJ2.
    Author information


    Abstract
    BACKGROUND:
    Acupuncture is a form of traditional Chinese medicine being increasingly used as complementary therapy in many countries. It is relatively safe and rarely associated with deep infections.
    CASE PRESENTATION:
    In this case report, we describe a middle-aged Chinese patient who presented acutely to our emergency department with cauda equina syndrome secondary to acupuncture-related epidural abscesses, which were treated with surgical decompression and intravenous antibiotics. We also present a review of case reports of this rare condition in available literature.
    CONCLUSION:
    Emergency physicians should be aware that spinal abscesses may occur after acupuncture, with a broad spectrum of clinical presentations. If a history of recent acupuncture over the symptomatic area is elicited, a high index of suspicion should be maintained and appropriate imaging performed to establish the diagnosis. Treatment is directed by a number of factors, such as severity and duration of neurological deficit and progression of symptoms.



    World Neurosurg. 2016 Aug 30. pii: S1878-8750(16)30773-2. doi: 10.1016/j.wneu.2016.08.090. [Epub ahead of print]
    An Acute Cervical Subdural Hematoma as the Complication of Acupuncture; Case Report and Literature Review.
    Eghbal K1, Ghaffarpasand F2.
    Author information


    Abstract
    BACKGROUND:
    Several injuries in cervical region as complications of acupuncture have been previously reported in the literature including cord and medulla oblongata injuries, subdural empyema and cervical hematoma. Spinal cord subdural hematoma is a rare condition mainly associated with coagulopathy, trauma and iatrogenic procedures. We herein report an acute cervical subdural hematoma following cervical acupuncture for neck and shoulder pain.
    CASE DESCRIPTION:
    A 74-year-old woman presented with progressive quadriparesis and sensory deficit after receiving acupuncture in neck and shoulder. Magnetic resonance imaging of the cervical spine revealed a subdural lesion which was hyperintense mass in the T1-weighted and hypointense in T2-weighted images at the C4-C6 level, which proved to be an early subacute subdural hematoma. After surgical evacuation of the hematoma, the patient had significant neurologic improvement.
    CONCLUSIONS:
    Although rare, cervical spinal cord hematomas are disastrous complications of cervical acupuncture. These procedures should be performed under direct observation of trained physicians with appropriate knowledge of cervical anatomy in order to avoid these complications.



    Needling depth at BL52 in 13 cadavers

    +
    Author Affiliations
    • 1School of Medicine, Flinders University, Bedford Park, South Australia, Australia
    • 2Department of Anatomy and Histology, School of Medicine, Flinders University, Bedford Park, South Australia, Australia
    • Correspondence to
      Dr Kwan Leung Chia, Medical Course Administration, 5/F, Flinders Medical Centre, Flinders Drive, Bedford Park, SA 5042, Australia; chia0104@flinders.edu.au
    • Accepted 6 November 2016
    • Published Online First 28 November 2016
    Background
    BL52 is located 3 cun lateral to the lower border of the spinous process of the L2 vertebra. The needling pathway includes the skin, subcutaneous tissue, latissimus dorsi muscle, intrinsic muscles of the back, quadratus lumborum muscle, the dorsal branches of the second lumbar artery and vein, and the lateral branches containing fibres from the second lumber spinal nerve.1 Deep perpendicular needle insertion at this location in the lower back risks damage to the kidneys,2 which are located in the dorsal region of the abdominal cavity within the retroperitoneal space.
    Anatomical observation
    In 2015, we observed the needling depth at BL52 on the right side of 13 cadavers during the eighth week of medical student anatomical dissection teaching at Flinders University of South Australia (table 1). The left sides of the cadavers were not included, because they had already been dissected by the medical students. The cadavers were donated through the Body Donation Program to the school for teaching and research purposes. None of them were Australian Aboriginal or Torres Strait Islanders. Ethical approval was granted by the Southern Adelaide Clinical Human Research Ethics Committee (reference no. 245.14—HREC/14/SAC/241).
    Table 1
    General characteristics of study cadavers

    In each cadaver, a caudal-cranial sagittal dissection was performed to expose the lumbar vertebra. The interspace of L2/3 was located by visually counting the vertebra. Then, the cun measurement of each individual cadaver was obtained by measuring the width of its thumb, which was used for localisation of BL52 at the level of L2/3. Next, the depth-measuring blade of a vernier caliper was inserted dorsally and perpendicularly to the surface of the skin at BL52 to mimic acupuncture needle insertion until the deepest layer was perforated. A vernier caliper was used in order to provide precise measurement to the nearest 1 mm. The needling depth was defined as the depth at which the blade passed through all the tissue layers and entered the abdominal cavity, and the safe depth was defined as 75% of the needling depth;3 that is, safe depth increases proportionately with needling depth. The procedure was carried out by KLC, who is an experienced registered acupuncturist.
    Needling depth at BL52
    All needles inserted dorsally and perpendicularly at BL52 perforated the quadratus lumborum muscle (figure 1). In general, male subjects had a greater needling depth than female subjects (median 37 (IQR 24–59) mm vs 30 (21–46) mm). Therefore, the safe depths in males and females were estimated to be 28 (18–44) mm and 23 (16–35) mm, respectively. Overall needling depth was 32 (25–47) mm and the safe depth was 24 (18–35) mm for male and female subjects combined.
    F1.medium
    Figure 1
    Photographic (A) and graphical (B) depiction of anatomical relationships of acupuncture at BL52.

    Comment
    To our knowledge, there have been two previous published observations of needling depth at BL52. In 1998, a study of 51 cadavers in China suggested that the overall needling depth was approximately 32–35 mm.3 In 2003, another study of 10 cadavers in China reported that the overall needling depth was about 28 mm.4 Needling depth at BL52 in the present (third) study was similar in magnitude.
    The safe depth of 24 (18–35) mm suggests that the tip of the needle will typically lie between quadratus lumborum and latissimus dorsi after insertion (    figure 1). This observation suggests that needles at BL52 come into close proximity with lumbar spinal nerves, which travel anteriorly between the quadratus lumborum and latissimus dorsi muscles before entering the plane between the internal oblique and transversus abdominis muscles. Thus, needling at this site may stimulate the somatic and sympathetic nervous systems to induce local and systemic effects.5
    Conclusion
    Our observation showed that the overall needling depth and safe depth at BL52 were 32 (25–47) mm and 24 (18–35) mm, respectively, in Australian cadavers.
    Footnotes
    • Contributors KLC was responsible for the original idea of this research, study design, ethics application, data collection, statistical analysis, discussion of the research findings, and preparation of the manuscript. RVH was responsible for supervision, provision of expert opinion about the research, and discussion of the research findings. Both authors examined and approved the final manuscript.


    Spine Deform. 2016 Mar;4(2):156-161. doi: 10.1016/j.jspd.2015.09.045. Epub 2016 Feb 2.
    Deep Spine Infection After Acupuncture in the Setting of Spinal Instrumentation.
    Callan AK1, Bauer JM1, Martus JE2.
    Author information


    Abstract
    BACKGROUND:
    Acupuncture can be used to manage chronic pain. The most common complications related to acupuncture include pain, bruising, bleeding, or symptom exacerbation. Rarely, more serious adverse events occur, including infection, pneumothorax, septic arthritis, and peripheral nerve injury. To our knowledge, there are no reports of complications associated with acupuncture following spinal instrumentation.
    PURPOSE:
    To report a case of deep infection as a rare complication of acupuncture following posterior spinal fusion for adolescent idiopathic scoliosis.
    STUDY DESIGN:
    Case report.
    METHODS:
    Case report.
    RESULTS:
    A 15-year-old female presented 21 months after spinal arthrodesis for idiopathic scoliosis with a deep spine infection. The patient had recently been receiving a variation of acupuncture (dry needling therapy) in her medial periscapular region to manage chronic back and shoulder pain. She underwent serial irrigation and debridement with implant removal. Intraoperative cultures revealed pseudomonas and aerobic diptheroids. Two weeks later, the patient developed a periscapular abscess requiring additional operative debridement; cultures from this abscess were negative. After an 8-week course of antibiotics, the patient remains infection free with normalized inflammatory markers 2 years postoperatively.
    CONCLUSIONS:
    Acupuncture is sometimes pursued as part of a multimodality pain management program for back pain, but it is not without risk and can lead to infection. Deep infection from acupuncture may contaminate existing spinal instrumentation and require operative debridement, implant removal, and long-term antibiotic therapy. Accordingly, there is an increased risk for deformity progression in this scenario related to the implant removal.