Critical Care Medicine
Electroacupuncture Improves Survival in Rats with Lethal Endotoxemia via the Autonomic Nervous System
Song, Jian-gang M.D.*; Li, Hong-hai M.D.†; Cao, Yun-fei M.D.‡; Lv, Xin M.D.§; Zhang, Ping M.D.#; Li, Ye-sheng M.D.‖; Zheng, Yong-jun M.D.*; Li, Qi M.D.**; Yin, Pei-hao M.D.**; Song, Shao-li M.D.††; Wang, Hong-yang M.D.‡‡; Wang, Xiang-rui M.D.§§
Background: Recent advances have indicated a complex interplay between the autonomic nervous system and the innate immune system. Targeting neural networks for the treatment of sepsis is being developed as a therapeutic strategy. Because electroacupuncture at select acupoints can modulate activities of the autonomic nervous system, we tested the hypothesis that electroacupuncture at specific acupoints could modulate systemic inflammatory responses and improve survival via its impact on the autonomic nervous system in a rat model of sepsis.
Methods: Sprague-Dawley male rats received electroacupuncture for 45 min before and at 1, 2, or 4 h after a lethal dose of intraperitoneal lipopolysaccharide injection (6 mg/kg). Outcomes included survival and systemic cytokine responses. Also, the possible roles of neural circuitry, including the hypothalamic-pituitary-adrenal axis and the autonomic nervous system, were evaluated.
Results: Electroacupuncture pretreatment at the Hegu acupoints significantly attenuate systemic inflammatory responses and improve survival rate from 20% to 80% in rats with lethal endotoxemia. Such a site-specific effect requires the activation of muscarinic receptors in the central nervous system, but not increasing central sympathetic tone. In the periphery synergistic, rather than independent, action of the sympathetic and parasympathetic systems is also necessary.
Conclusions: Electroacupuncture pretreatment has a dramatic survival-enhancing effect in rats with lethal endotoxemia, which involves the activation of efferent neural circuits of the autonomic nervous system (e.g., cholinergic antiinflammatory pathway). This approach could be developed as a prophylactic treatment for sepsis or perioperative conditions related to excessive inflammation.
What We Already Know about This Topic
* There are complex interactions between the autonomic nervous system and the innate immune system
What This Article Tells Us That Is New
* Rats pretreated with electroacupuncture at a specific acupoint that affects the efferent neural circuits of the autonomic nervous system attenuated their systemic inflammatory responses and improved their survival from lethal endotoxin administration
DESPITE more than 20 yr of extensive research and development, the incidence of sepsis and the number of sepsis-related deaths are rising. Depending upon the standards of medical care, mortality of sepsis could vary between 30% and 70%.1
Sepsis is a heterogeneous, dynamic syndrome and involves a complex interplay of different biologic systems, most notably the immune system, the coagulation system, and the autonomic nervous system (ANS).3
Recent advances in the field of neuroimmunology have shown that the ANS is one of the key pathways in the neuroimmune modulating network, and the balance between the two branches of the ANS (e.g.
, sympathetic and parasympathetic) is important in directing the inflammatory response toward either pro- or antiinflammatory outcomes.4
Consequently, methods that target the brain-to-immune neural circuits to control excessive immune responses while maintaining optimal host defense, such as transcutaneous vagus nerve stimulation and pharmacologic inhibition of sympathetic nervous system, are being developed for sepsis.5
Acupuncture is a 5,000-plus-year-old practice that is still widely used in many countries today.7
Accumulating evidence has demonstrated that acupuncture at select acupoints can modulate activities of the ANS. For example, electroacupuncture at Neiguan (Pc-6; located in the groove caudal to the flexor carpi radialis and cranial to the superficial digital flexor muscles) significantly increases vagal activity, as measured by spectral analysis of heart rate variability.8
In contrast, electroacupuncture at Hegu (Li-4; located at the junction of the first and second metacarpal bones) increases sympathetic tone, as evidenced by elevation of blood pressure and increased renal and adrenal nerve activities.10
Based on these data, we tested the hypothesis that electroacupuncture at specific acupoints could inhibit systemic inflammatory responses and improve survival via
its impact on the ANS in a rat model of sepsis (systemic administration of endotoxin).
Materials and Methods
Animals and Reagents
All studies were conducted in accordance with institutional animal care guidelines and approved by the Animal Care Committee of Shanghai Jiao Tong University (Shanghai, China). Adult male Sprague-Dawley rats (200–300g), provided by Sino-British SIPPR/BK Lab Animal Ltd. Co. (Shanghai, China), were housed at 22°C on a 12-h light/dark cycle.
Lipopolysaccharide (Escherichia coli 0111:B4), propranolol, phentolamine, clonidine, and mecamylamine were obtained from Sigma (St. Louis, MO). Atropine methyl nitrate was obtained from International Laboratory USA (San Bruno, CA). All test reagents were dissolved in physiologic saline.
The acupuncture points used in this study were Hegu (Li-4), located at the junction of the first and the second metacarpal bones, and Neiguan (Pc-6), located in the groove caudal to the flexor carpi radialis and cranial to the superficial digital flexor muscles. A set of nonacupoints located on the ulna side of the metacarpus served as controls. Stainless needles were inserted bilaterally to a depth of 5 mm and then held in place by plastic adhesive tape. Stimulation (current of 4 mA, alternating dense-and-disperse mode, 2 Hz [0.6-ms pulse width] vs. 100 Hz stimulation [0.2-ms pulse width], each lasting for 3 s) was delivered using an electrical stimulation device (HANS LH-202, Huawei Co. Beijing, China) for 45 min.
Rats received a subcutaneous injection of 100 mg/kg guanethidine sulfate (Tokyo Chemical Industry Co. Ltd., Tokyo, Japan), dissolved in 0.9% NaCl, pH adjusted to 7.4, or vehicle of same volume for 2 consecutive days.12
Under anesthesia and sterile condition, the right cervical vagus nerve of rats was exposed, ligated with a 4-0 silk suture, and transected. In sham-operated animals, the cervical vagus nerve was visualized, but was neither isolated from the surrounding tissues nor transected. Rats were allowed to recover for 4 days before the lipopolysaccharide challenge.
Under anesthesia and sterile condition, the spleen of rats was identified through a midline laparotomy incision and removed using routine surgical technique. Sham animals received laparotomy without splenectomy. Nine days were allowed for recovery.
Experiment 1: Effect of Electroacupuncture on Survival
Under sodium pentobarbital anesthesia (50 mg/kg, intraperitoneal injection), rats received electroacupuncture 45 min before and at 1, 2, or 4 h after intraperitoneal lipopolysaccharide injection (6 mg/kg) at the following site: Hegu, Neiguan, or nonacupoints. A group of rats that received pentobarbital anesthesia and lipopolysaccharide, but not electroacupuncture, was included as a blank control. The survival rate was observed within the following 7 days. Each group included 20 rats. This experiment demonstrated superior protective efficacy of electroacupuncture at Hegu, relative to Neiguan and nonacupoints, but only before lipopolysaccharide challenge (fig. 1
). Thus, electroacupuncture pretreatment at Hegu acupoints was chosen for subsequent experiments.
Experiment 2: Effect of Electroacupuncture on the Systemic Inflammatory Response
Rats received electroacupuncture at Hegu or electrostimulation at nonaccupoints before lipopolysaccharide challenge. A group of rats receiving lipopolysaccharide and anesthesia was included as additional controls. Serum pro-inflammatory cytokines (tumor necrosis factor (TNF) -α, interleukin (IL)-6, and IL-1β) and a prototype antiinflammatory cytokine (IL-10) were measured at 2, 4, and 6 h after lipopolysaccharide injection with ELISA (R&D Systems; Minneapolis, MN). At each time point, three groups as mentioned above (n = 6 or 10 per group) were included for obtaining blood samples.
Experiment 3: The Role of Hypothalamic-Pituitary-Adrenal Axis
The hypothalamic-pituitary-adrenal axis is one of the major gateways through which the central nervous system modulates the immune function, and provides an important physiologic feedback loop of inflammation through the antiinflammatory effects of corticosteroids.4
To examine whether activation of hypothalamic-pituitary-adrenal axis is involved in the protective effect of electroacupuncture, serum corticosteroid was measured immediately after electroacupuncture pretreatment or electrical-stimulation at nonacupoints and at 2 h after lipopolysaccharide challenge. A group of rats receiving lipopolysaccharide and anesthesia and a group of rats receiving only anesthesia were included as additional controls (n = 10 per group). Corticosterone levels were determined using an immunoassay kit (R&D Systems).
Experiment 4: The Role of Sympathetic Nervous System
In this series of experiments, rats were treated with the following agents at 10 min before electroacupuncture at Hegu: centrally acting α2-agonist clonidine (20 μg/kg, intraperitoneal injection), α-adrenergic antagonist phentolamine (1 mg/kg, intraperitoneal injection), β-adrenoceptor antagonist propranolol (5 mg/kg, intraperitoneal injection), or saline (n = 20 per group), and then subjected to lipopolysaccharide challenge. A separate group of rats received chemical sympathectomy before electroacupuncture and lipopolysaccharide challenge. Survival was the primary endpoint. In a separate experiment of the same design, serum TNF-α at 2 h after lipopolysaccharide was examined (n = 6 per group).
Experiment 5: The Role of Parasympathetic Nervous System
In this series of experiments, rats were treated with the following agents before electroacupuncture at Hegu: muscarinic receptor antagonist atropine methyl nitrate (5 μg/kg in 5 μl; intracerebroventricular injection under anesthesia; coordinates: 0.8 mm posterior to bregma, 1.5 mm lateral to midline, and 4.0 mm below the skull surface); nicotinic receptor antagonist mecamylamine (1 mg/kg; intraperitoneal injection); atropine methyl nitrate (1 mg/kg; intraperitoneal injection); or saline (intracerebroventricular injection as a control for atropine methyl nitrate; intraperitoneal injection as a control for mecamylamine or atropine methyl nitrate; n = 20 per group), and then subjected to lipopolysaccharide challenge. Of note, mecamylamine, at the dose 1 mg/kg used in this study, predominantly antagonizes peripheral and nonspecific nicotinic receptors,13
and atropine methyl nitrate is unable to penetrate the blood-brain barrier.14
Separate groups of rats receiving vagotomy, splenectomy, or sham surgery before the electroacupuncture pretreatment and lipopolysaccharide challenge were also included in this experiments (n = 20 per group). Survival was the primary endpoint. In a separate experiment of the same design, serum TNF-α was examined at 2 h after lipopolysaccharide challenge (n = 6 per group).
Data are expressed as mean ± SD. In Experiments 2 and 3, comparison of serum inflammatory cytokines and corticosterone levels in the different treatment groups and different time points was carried out by using two-way ANOVA with the Tukey test. In Experiments 4 and 5, the differences of serum TNF-α at 2 h after lipopolysaccharide exposure among different treatment groups were analyzed using one-way ANOVA followed by post hoc Bonferroni correction for multiple comparisons. For survival analysis, Kaplan–Meier analysis was used followed by a log-rank test. P value <0.05 was considered statistically significant (two-tailed). All statistical analyses were performed by SPSS 16.0 for Windows (SPSS Inc., Chicago, IL).
Electroacupuncture Pretreatment at Hegu Improved Survival in Rats with Lethal Endotoxemia
Three out of 20 rats receiving electroacupuncture treatment at nonacupoints before lipopolysaccharide challenge survived the endotoxemia (fig. 1
). Electroacupuncture at Hegu before lipopolysaccharide challenge conferred dramatic protection: 16 of 20 rats survived the endotoxemia (P
< 0.0001 vs.
4/20 in the blank control). No further dropouts within an observation period of 7 days indicates that electroacupuncture pretreatment conferred a lasting protection and did not merely delay the onset of death. Less protective effects were observed in rats receiving electroacupuncture at Neiguan before lipopolysaccharide challenge (survival rate: 10/20; P
= 0.049 vs.
Hegu). When delivered after lipopolysaccharide challenge, electroacupuncture treatment did not affect the survival rate at either Hegu or Neiguan.
Electroacupuncture Pretreatment Attenuated the Systemic Inflammatory Response to Lipopolysaccharide
A displays that serum TNF-α was approximately 900 pg/ml at 2 h after the lipopolysaccharide challenge, and decreased to a level less than 60 pg/ml at 4 and 6 h. Such a temporal profile is consistent with previous reports.15
Electroacupuncture pretreatment at Hegu (but not electro-stimulation at nonaccupoints) significantly decreased serum TNF-α level at 2 h after lipopolysaccharide challenge (P
< 0.0001). TNF-α level at 4 (P
= 0.23) and 6 h was not affected (P
= 0.11). Figure 2
B displays that serum IL-1β was approximately 1,000 pg/ml at 2 h after the lipopolysaccharide challenge, and reached a plateau at 4 h after lipopolysaccharide challenge. Electroacupuncture pretreatment at Hegu significantly decreased IL-1β throughout the entire observation period (P
< 0.0001). Figure 2
C displays that serum IL-6 was approximately 6,500 pg/ml at 2 h after the lipopolysaccharide challenge, and reached a plateau at 4 h after lipopolysaccharide challenge. Electroacupuncture pretreatment at Hegu significantly decreased IL-6 throughout the entire observation period (P
< 0.0001). Figure 2
D displays that the prototype antiinflammatory cytokine IL-10 was not affected by electroacupuncture pretreatment (P
= 0.76, 0.45, and 0.63, respectively).
The Protective Effect of Electroacupuncture Pretreatment Could Not Be Attributed to the Activation of Hypothalamic-Pituitary-Adrenal Axis
Serum corticosteroid in rats receiving lipopolysaccharide challenge was significantly decreased, rather than increased, by electroacupuncture pretreatment at Hegu as well as at nonacupoints (P
< 0.0001 for both; fig. 3
). Electroacupuncture at Hegu or nonacupoints alone also significantly decreased serum corticosteroid levels in rats not exposed to lipopolysaccharide (P
< 0.0001 for both; fig. 3
). Thus, the beneficial effect of electroacupuncture is not associated with increasing corticosteroid levels.
Peripheral Sympathetic Nervous System and Particularly β-adrenoceptors, but Not Increased Central Sympathetic Tone, Are Necessary for the Protective Action of Electroacupuncture
Consistent with a previous study of sympathectomy with 6-hydroxydopamine in an animal model of thermal injury with sepsis,16
ablation of the sympathetic nervous system with guanethedine before lipopolysaccharide challenge significantly increased survival rate (10/20 vs.
3/20 in the control rats; P
= 0.025) and attenuated serum TNF level (P
< 0.0001). However, electroacupuncture pretreatment at the Hegu did not confer further protection in sympathectomized rats (survival rate: 8/20 vs.
10/20 in sympathectomized rats without electroacupuncture; P =
0.66; fig. 4
A). Also, serum TNF level did not differ between sympathectomized rats with or without electroacupuncture pretreatment (P
= 0.49; fig. 4
B). Pretreatment with the β-antagonist propranolol (survival rate: 3/20; P
< 0.0001; TNF-α: P
< 0.0001), but not the α-antagonist phentolamine (survival rate: 16/20; P
= 0.67; TNF-α: P
= 0.55; figs. 4
C and D) completely abolished the effects of electroacupuncture on survival and serum TNF. Somewhat surprisingly, pretreatment with clonidine, a centrally acting α2
-agonist that decreases central sympathetic tone,17
did not block the effects of electroacupuncture (survival rate: 18/20; P
= 0.44; TNF-α: P
= 0.68; figs. 4
E and F).
Central Muscarinic Receptor, Vagus Nerve, Peripheral Nicotinic Receptor, and Spleen Are Required for the Protective Action of Electroacupuncture
The vagus nerve has recently been identified as a major pathway through which immune function is regulated by the central nervous system, which is termed the “cholinergic antiinflammatory pathway.”18
Our results indicated that unilateral (right-sided) cervical vagotomy before lipopolysaccharide challenge significantly attenuated the protective effects of electroacupuncture pretreatment (survival rate: 7/20 vs.
16/20 in sham-operated rats; P
= 0.005; TNF-α: P
< 0.0001; figs. 5
A and B). Systemic treatment with the nicotinic antagonist mecamylamine (survival rate: 4/20; P
< 0.001; TNF-α: P
< 0.001), but not the muscarinic antagonist atropine methyl nitrate (survival rate: 19/20; P
= 0.32; TNF-α: P =
0.65; figs. 5
C and D), completely blocked the protective effects of electroacupuncture. Atropine methyl nitrate delivered directly into the brain completely blocked the protective effects of electroacupuncture (survival rate of 6/20 vs.
15/20 in vehicle controls; P
= 0.007; TNF-α: P
< 0.0001; figs. 5
E and F). These results are consistent with an important role of the central muscarinic receptors in modulating peripheral cytokine production.19
Recent work on the anatomical basis of the cholinergic antiinflammatory pathway indicates that the spleen is required for vagus control of inflammation, although the splenic nerve is classified as catecholaminergic.20
In our study, although splenectomy per se
significantly reduced serum TNF-α level compared with sham surgery group (P
< 0.0001; fig. 5
H), which is consistent with a previous study, 21
it did not improve the survival rate of rats challenged with a lethal dose of lipopolysaccharide (P
= 0.77; fig. 5
G). When electroacupuncture was applied to splenectomized animals, its survival-enhancing effect disappeared (survival rate of 6/20 vs.
17/20 in sham surgery controls; P
< 0.0001; fig. 5
G). Also, electroacupuncture failed to inhibit serum TNF-α level in splenectomized animals, unlike in intact animals (P
= 0.50; fig. 5
The current study for the first time demonstrated that electroacupuncture pretreatment at the Hegu acupoints can dramatically improve survival in rats with lethal endotoxemia. The production of proinflammatory cytokines (TNF-α, IL-6 and IL-1β) was also significantly attenuated, but antiinflammatory cytokine serum IL-10 was not affected.
Our study also demonstrated selectivity of the acupuncture: electroacupuncture at Hegu acupoints produced more powerful protection than electroacupuncture at Neiguan acupoints; electrostimulation at nonacupoints was not effective at all. To our knowledge, the site-specific effects of acupuncture, i.e.
, “true” treatment acupoints with selective physiologic effects, have not been fully validated or accepted. A few influential clinical trials of migraine headache failed to show significant difference between acupuncture at select acupoints versus
In the current study, the use of anesthesia during electroacupuncture excluded some likely nonspecific physiologic effects caused by electrostimulation procedure, such as pain and immobilization stress, and thus provided more solid evidence for the existence of site-specific effects.
The timing of electroacupuncture treatment seems critical for the “rescue” effect in our study, because electroacupuncture must be delivered before lipopolysaccharide injection to produce a protective action. We speculate that the explicit requirement for pretreatment may be specific to the lipopolysaccharide model used in this study: immune pathology of endotoxemia models using bolus injection is characterized by a very rapid and overwhelming innate immune response that is very difficult to stop once it is in motion. Although bacterial infection models do not recapitulate many important features of human sepsis, they can provide important insights into mechanisms of the host response to pathogens.24
During the past decade, the immunomodulatory efficacy of acupuncture has been supported by increasing number of randomized controlled clinical trials for a number of immune- or inflammatory-related diseases, such as allergic asthma,25
childhood persistent allergic rhinitis,26
and rheumatoid arthritis.27
Animal studies have also indicated that acupuncture pretreatment has protective effects against endotoxin-induced acute lung and kidney injuries.29
However, little is known about its biologic basis.
In this study, we found that electroacupuncture at Hegu does not enhance the release of glucocorticoids or antiinflammatory cytokines (e.g.
, IL-10), suggesting that humoral pathways are not responsible for the immunomodulatory efficacy of electroacupuncture. Instead, such an effect requires the participation of muscarinic receptors in the central nervous system, but not increasing central sympathetic tone. Synergistic, rather than independent, action of peripheral sympathetic and parasympathetic systems is also necessary. At the first glance, these results seem difficult to explain or discriminate the roles of sympathetic and parasympathetic components. However, newly identified cholinergic antiinflammatory pathway suggests that the long-standing attempt to separate the neural circuitry that controls immune responses into discrete sympathetic and parasympathetic components is imprecise. On the contrary, at least in the periphery, the involvements of sympathetic versus
parasympathetic systems are not independent, either anatomically or functionally.18
From a systematic perspective, our data strongly support this important conceptual advance. We now put forward the following framework mainly based on the cholinergic antiinflammatory pathway to explain our findings: electroacupuncture at Hegu activates a brain muscarinic receptor-mediated network possibly through somatoautonomic reflexes,31
and subsequently increases vagus nerve activity. The vagus nerve terminates in synaptic-like structures around principal cells of the celiac-superior mesenteric plexus ganglia, a site where catecholaminergic splenic fibers originate. Via
two serially connected neurons in these ganglia, vagus nerve modulates the activities of splenic nerve through nicotinic acetylcholine receptor.33
Increased norepinephrine released by the splenic nerve then acts on β-adrenergic receptors expressed on B and T cells of the spleen to produce acetylcholine.34
Enhanced acetylcholine levels in the spleen then activates nicotinic receptor expressed on macrophages to inhibit proinflammatory cytokine release.
In addition, since it has been suggested that lipopolysaccharide-induced hemodynamic instability contributes to mortality,36
a paradoxical hypertensive response mediated by stimulation at Hegu acupoints might explain electroacupuncture's survival-enhancing effect. However, both previous studies10
and our preliminary data indicated that the pressor response elicited by electroacupuncture at Hegu acupoints lasts for only 2 or 3 min after cessation of the stimulation. Also, if the protective effect is mediated by pressor effect, electroacupuncture delivered after lipopolysaccharide injection should have been more effective; however, it's clearly not the case in this study. Thus, hemodynamic effect produced by electroacupuncture cannot account for its survival-enhancing effect.
In conclusion, electroacupuncture pretreatment at the Hegu acupoints inhibited systemic inflammatory responses and enhanced survival in rats with lethal endotoxemia. The underlying mechanism involves the activation of efferent neural circuits of the ANS, e.g., the cholinergic antiinflammatory pathway. These findings encourage the development of electroacupuncture as a prophylactic treatment for sepsis or other perioperative conditions related to excessive inflammation.
1. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR: Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29:1303–10
2. Martin GS, Mannino DM, Eaton S, Moss M: The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003; 348:1546–54
3. Rittirsch D, Flierl MA, Ward PA: Harmful molecular mechanisms in sepsis. Nat Rev Immunol 2008; 8:776–87
4. Sternberg EM: Neural regulation of innate immunity: a coordinated nonspecific host response to pathogens. Nat Rev Immunol 2006; 6:318–28
5. Huston JM, Gallowitsch-Puerta M, Ochani M, Ochani K, Yuan R, Rosas-Ballina M, Ashok M, Goldstein RS, Chavan S, Pavlov VA, Metz CN, Yang H, Czura CJ, Wang H, Tracey KJ: Transcutaneous vagus nerve stimulation reduces serum high mobility group box 1 levels and improves survival in murine sepsis. Crit Care Med 2007; 35:2762–8
6. Wu R, Zhou M, Das P, Dong W, Ji Y, Yang D, Miksa M, Zhang F, Ravikumar TS, Wang P: Ghrelin inhibits sympathetic nervous activity in sepsis. Am J Physiol Endocrinol Metab 2007; 293:E1697–702
7. Zijlstra FJ, van den Berg-de Lange I, Huygen FJ, Klein J: Anti-inflammatory actions of acupuncture. Mediators Inflamm 2003; 12:59–69
8. Huang ST, Chen GY, Lo HM, Lin JG, Lee YS, Kuo CD: Increase in the vagal modulation by acupuncture at neiguan point in the healthy subjects. Am J Chin Med 2005; 33:157–64
9. Ouyang H, Yin J, Wang Z, Pasricha PJ, Chen JD: Electroacupuncture accelerates gastric emptying in association with changes in vagal activity. Am J Gastrointest Liver Physiol 2002; 282:390–6
10. Lin TB, Fu TC, Chen CF, Lin YJ, Chien CT: Low and high frequency electroacupuncture at Hoku elicits a distinct mechanism to activate sympathetic nervous system in anesthetized rats. Neurosci Lett 1998; 247:155–8
11. Lin TB, Fu TC: Effect of electroacupuncture on blood pressure and adrenal nerve activity in anesthetized rats. Neurosci Lett 2000; 285:37–40
12. Navegantes LC, Resano NM, Baviera AM, Migliorini RH, Kettelhut IC: Effect of sympathetic denervation on the rate of protein synthesis in rat skeletal muscle. Am J Physiol Endocrinol Metab 2004; 286:E642–7
13. Young JM, Shytle RD, Sanberg PR, George TP. Mecamylamine: New therapeutic uses and toxicity/risk profile. Clin Ther 2001;23:532–65
14. Pavlov VA, Parrish WR, Rosas-Ballina M, Ochani M, Puerta M, Ochani K, Chavan S, Al-Abed Y, Tracey KJ: Brain acetylcholinesterase activity controls systemic cytokine levels through the cholinergic anti-inflammatory pathway. Brain Behav Immun 2009; 23:41–5
15. Remick DG, Ward PA: Evaluation of endotoxin models for the study of sepsis. Shock 2005; 24 Suppl 1:7–11
16. Tang Y, Shankar R, Gamboa M, Desai S, Gamelli RL, Jones SB: Norepinephrine modulates myelopoiesis after experimental thermal injury with sepsis. Ann Surg 2001; 233:266–75
17. Scheinin M, Schwinn DA: The locus coeruleus. Site of hypnotic actions of α2
-adrenoceptor agonists? ANESTHESIOLOGY 1992; 76:873–5
18. Tracey KJ: Reflex control of immunity. Nat Rev Immunol 2009; 9:418–28
19. Pavlov VA, Ochani M, Gallowitsch-Puerta M, Ochani K, Huston JM, Czura CJ, Al-Abed Y, Tracey KJ: Central muscarinic cholinergic regulation of the systemic inflammatory response during endotoxemia. Proc Natl Acad Sci U S A 2006; 103:5219–23
20. Rosas-Ballina M, Ochani M, Parrish WR, Ochani K, Harris YT, Huston JM, Chavan S, Tracey KJ: Splenic nerve is required for cholinergic antiinflammatory pathway control of TNF in endotoxemia. Proc Natl Acad Sci USA 2008; 105:11008–13
21. Huston JM, Ochani M, Rosas-Ballina M, Liao H, Ochani K, Pavlov VA, Gallowitsch-Puerta M, Ashok M, Czura CJ, Foxwell B, Tracey KJ, Ulloa L: Splenectomy inactivates the cholinergic antiinflammatory pathway during lethal endotoxemia and polymicrobial sepsis. J Exp Med 2006; 203:1623–8
22. Linde K, Streng A, Jürgens S, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, Pfaffenrath V, Hammes MG, Weidenhammer W, Willich SN, Melchart D: Acupuncture for patients with migraine: A randomized controlled trial. JAMA 2005; 293:2118–25
23. Melchart D, Streng A, Hoppe A, Brinkhaus B, Witt C, Wagenpfeil S, Pfaffenrath V, Hammes M, Hummelsberger J, Irnich D, Weidenhammer W, Willich SN, Linde K: Acupuncture in patients with tension-type headache: Randomised controlled trial. BMJ 2005; 331:376–82
24. Buras JA, Holzmann B, Sitkovsky M: Animal models of sepsis: Setting the stage. Nat Rev Drug Discov 2005; 4:854–65
25. Joos S, Schott C, Zou H, Daniel V, Martin E: Immunomodulatory effects of acupuncture in the treatment of allergic asthma: a randomized controlled study. J Altern Complement Med 2000; 6:519–25
26. Ng DK, Chow PY, Ming SP, Hong SH, Lau S, Tse D, Kwong WK, Wong MF, Wong WH, Fu YM, Kwok KL, Li H, Ho JC: A double-blind, randomized, placebo-controlled trial of acupuncture for the treatment of childhood persistent allergic rhinitis. Pediatrics 2004; 114:1242–7
27. Usichenko TI, Ivashkivsky OI, Gizhko VV: Treatment of rheumatoid arthritis with electromagnetic millimeter waves applied to acupuncture points–a randomized double blind clinical study. Acupunct Electrother Res 2003; 28:11–8
28. Bernateck M, Becker M, Schwake C, Hoy L, Passie T, Parlesak A, Fischer MJ, Fink M, Karst M: Adjuvant auricular electroacupuncture and autogenic training in rheumatoid arthritis: A randomized controlled trial. Auricular acupuncture and autogenic training in rheumatoid arthritis. Forsch Komplementmed 2008; 15:187–93
29. Huang CL, Huang CJ, Tsai PS, Yan LP, Xu HZ: Acupuncture stimulation of ST-36 (Zusanli) significantly mitigates acute lung injury in lipopolysaccharide-stimulated rats. Acta Anaesthesiol Scand 2006; 50:722–30
30. Huang CL, Tsai PS, Wang TY, Yan LP, Xu HZ, Huang CJ: Acupuncture stimulation of ST36 (Zusanli) attenuates acute renal but not hepatic injury in lipopolysaccharide-stimulated rats. Anesth Analg 2007; 104:646–54
31. Haker E, Egekvist H, Bjerring P: Effect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjects. J Auton Nerv Syst 2000; 79:52–9
32. Budgell B, Sato A: Modulations of autonomic functions by somatic nociceptive inputs. Prog Brain Res 1996; 113:525–39
33. Vida G, Peña G, Deitch EA, Ulloa L: α7-cholinergic receptor mediates vagal induction of splenic norepinephrine. J Immunol 2011; 186:4340–6
34. Leaders FE, Dayrit C: The cholinergic component in the sympathetic innervation to the spleen. J Pharmacol Exp Ther 1965; 147:145–52
35. Brandon KW, Rand MJ: Acetylcholine and the sympathetic innervation of the spleen. J Physiol 1961; 157:18–32
36. Fink MP, Heard SO: Laboratory models of sepsis and septic shock. J Surg Res 1990; 49:186–96
© 2012 American Society of Anesthesiologists, Inc.
Publication of an advertisement in Anesthesiology Online does not constitute endorsement by the American Society of Anesthesiologists, Inc. or Lippincott Williams & Wilkins, Inc. of the product or service being advertised.