Technological advances in acupoint thread embedding treatment: Effects on NIHSS score,Serum SIRT1,HIF-1α,and macrophage efferocytosis in stroke patients

Abstract

Background

Acupoint thread embedding treatment (ATET) is a traditional therapeutic approach used in stroke rehabilitation.

Objective

To explore the application of ATET in combination with modern medical technology, examining its effects on neurological function and key serum biomarkers in stroke patients.

Methods

A total of 108 stroke patients were randomly assigned to ATE treatment group (n = 52) and Control Group (n = 56). Various parameters including baseline characteristics, levels of inflammatory markers, macrophage efferocytosis-related factors, the National Institutes of Health Stroke Scale (NIHSS) scores, therapeutic efficacy, and adverse events were assessed and compared between the two groups.

Results

A significant improvement in NIHSS scores was observed in the treatment group compared to the control group. Additionally, serum levels of SIRT1, HIF-1α, and macrophage efferocytosis-related factors were significantly altered, suggesting that ATET may influence biological pathways involved in stroke recovery.

Conclusion

The application of ATET, supported by advanced diagnostic technologies, shows promising effects in stroke rehabilitation. This study highlights the potential for integrating traditional therapies with modern medicine to improve clinical outcomes in stroke patients.

Keywords

Acupoint thread embedding treatment NIHSS score SIRT1 HIF-1α macrophage efferocytosis-related factors stroke

1. Introduction

Stroke is a leading cause of disability and death worldwide, placing a substantial burden on healthcare systems and society.^1,2 Ischemic stroke occurs when blood flow to an area of the brain is suddenly reduced. This causes tissue hypoxia, metabolic problems, and eventually brain damage.^3–5 Despite improvements in acute treatment and rehabilitation, stroke remains a major cause of illness and death, highlighting the urgent need for novel and effective treatments to improve patient outcomes.^6–8

Acupoint thread embedding (ATE) is a traditional Chinese medicine technique that involves inserting absorbable threads into specific acupoints for therapeutic effects.⁹ Recent research has shown growing interest in using ATE and other traditional Chinese medicine approaches for neurological disorders, including stroke.^10–12 Several studies suggest that ATE may modulate inflammatory responses, improve tissue reperfusion, and enhance neuroprotective mechanisms through multiple pathways, making it a potential adjunctive treatment for stroke.^13–15 ATE is believed to modulate inflammatory responses, improve tissue reperfusion, and enhance neuroprotective mechanisms through complex and multifaceted pathways.¹⁶ However, the precise mechanisms underlying the effects of ATE in stroke remain poorly understood.

Sirtuin 1 (SIRT1), hypoxia-inducible factor 1-alpha (HIF-1α), and macrophage efferocytosis-related factors are key molecular targets in stroke pathophysiology.^17–19 SIRT1, a member of the sirtuin family of proteins, regulates cellular stress responses and promotes cell survival.²⁰ HIF-1α, a transcription factor, helps cells adapt to hypoxia and by controlling genes associated with angiogenesis, energy metabolism, and erythropoiesis.²¹ Additionally, macrophage efferocytosis, the process by which macrophages engulf apoptotic cells, contributes to the resolution of inflammation and tissue repair following stroke-induced injury.²²

Given the potential interaction between ATE treatment and these molecular pathways, investigating ATE's effects on serum levels of SIRT1, HIF-1α, and macrophage efferocytosis-related factors in stroke patients could yield important findings. Furthermore, the National Institutes of Health Stroke Scale (NIHSS) is a widely used tool for assessing the severity of stroke and has been extensively validated for predicting patient outcomes.²³ Understanding the association between ATE treatment and changes in NIHSS scores can provide valuable insights into the clinical efficacy of ATE in stroke management. ATET, a distinctive therapy in traditional Chinese medicine, combines the immediate effects of acupuncture treatment with the long-term stimulating effects of implanted threads on tissues. As demonstrated in the relevant literature,²⁴ the selection of acupoints for ATET treatment of stroke is currently focused on limb acupoints, or alternatively combined with trunk acupoints. The emphasis is placed on Yangming meridian acupoints and specific acupoints, combining distal and local acupoint selection. Acupoint thread implantation therapy has been incorporated into the clinical diagnostic and treatment guidelines for stroke, a priority disease of this research group. The selection of acupoints primarily focuses on back shu acupoints and trunk acupoints.

This study aims to investigate the impact of ATE treatment on NIHSS scores and the serum levels of SIRT1, HIF-1α, and macrophage efferocytosis-related factors in patients with stroke. By elucidating the molecular and clinical effects of ATE, we seek to contribute to a better understanding of its therapeutic potential and pave the way for the development of novel adjunctive treatments for stroke.

2. Methods

2.1. Research participants

We selected patients who had been treated at our hospital for ischemic stroke from February 2023 to August 2023 and categorized them into a control group and an experimental group. This study primarily employs the NIHSS score as the primary analytical index, utilizing the overall mean hypothesis test of the two groups in accordance with the findings of analogous published literature. It has been established that the NIHSS score of the experimental group (rehabilitation therapy + acupuncture treatment group) post-treatment is 9.46 ± 0.85, whereas the NIHSS score of the control group (rehabilitation therapy group) post-treatment is 10.09 ± 0. The level of two-sided test α was set at 0.05, the test efficacy 1-β at 0.9, and the NIHSS scores were calculated by using Two-Sample T-Tests Allowing Unequal Variance under the Means menu of the PASS 2021 software. It was concluded that a sample size of 46 cases was required for both groups. However, considering the shedding rate of 15%, it was calculated that at least 54 cases were required for each group, totaling 108 subjects included in the study. The control group received standard treatment for ischemic stroke, while the experimental group received acupoint thread-embedding treatment in addition to standard care. In consideration of the operational characteristics inherent to ATET, it proved unfeasible to blind the subjects. However, it should be noted that all outcome assessors (including NIHSS scorers and molecular testing personnel) were unaware of the subject grouping information, and independent coding was used throughout the operational process to maintain assessment blinding. The NIHSS score was administered by stroke assessment specialists certified by the National Health Commission. All assessors received standardized training and possessed professional qualifications prior to scoring.

2.2. Diagnosis and inclusion/exclusion criteria

Diagnosis criteria: Patients had to meet the diagnostic requirements outlined in the “Guidelines for the Diagnosis and Treatment of Acute Ischemic Stroke in China 2014” issued by the Neurology Branch of the Chinese Medical Association in 2015, or the “Guidelines for the Diagnosis and Treatment of Cerebral Infarction in Traditional Chinese and Western Medicine in China (2017)”.⁴ Additionally, they had to have clear evidence of ischemic stroke through CT or magnetic resonance imaging (MRI), with no significant brain edema or bleeding tendency. For those with cerebral hemorrhage, CT or MRI had to indicate hematoma liquefaction and absorption, with equal or decreased density changes in the surrounding brain tissue.

Inclusion criteria: Patients had to satisfy the diagnostic criteria and the CT/MRI diagnostic standards, be aged between 35 and 75 years, regardless of gender, be in a stable phase of the condition within one month to one year from the onset, without severe diseases such as heart disease, liver or kidney disorders, no history of seizures or trauma, no limb edema, lymphatic reflux disorders, or coagulation abnormalities, and no malignant tumors. They also had to voluntarily participate in the study and provide informed consent.

Exclusion criteria: Individuals with a history of mental illness or cognitive impairment that would hinder examination or treatment, those with a known hypersensitivity constitution unsuitable for thread-embedding treatment, those with severe cardiovascular or cerebrovascular diseases, active liver disease, malignant tumors, or other infectious diseases, and those with reduced deep and superficial sensory function or abnormal proprioception with a high risk of falling were excluded from the study.

2.3. Treatment methods

The control group received conventional Western medical treatment, including the following: (1) Enteric-coated aspirin (100 mg per tablet), taken orally at a dose of 100 mg once daily in the evening. For those intolerant to aspirin, clopidogrel hydrogen sulfate tablets (75 mg (calculated as C₁₆H₁₆ClNO₂S)) were administered at a dose of 75 mg once daily in the morning. (2) Atorvastatin calcium tablets (20 mg (calculated as atorvastatin C₃₃H₃₅FN₂O₅)), taken orally at a dose of 20 mg once daily before bedtime. (3) Intravenous injection of edaravone (20 ml: 30 mg), with a dose of 30 mg given twice daily in the morning and evening. (4) Protection of brain cells and prevention of infection. (5) Control of blood pressure and blood sugar levels. (6) Symptomatic supportive treatment according to the patient's condition and active prevention of complications.

The experimental group received acupoint thread-embedding treatment in addition to conventional therapy. Acupoints included bilateral Hegu, Jianyu, Ququan, Zusanli, Tianzhu, and Shenshu. The thread-embedding method involved disinfecting the local skin at the acupoints with iodine, using absorbable collagen threads (4-0, BODA, China) inserted through a disposable No. 7 embedding needle. The patient lay supine during the procedure, and after swift needle insertion and confirmation of qi arrival, the needle core was pushed while withdrawing the needle. The collagen thread should not protrude from the skin. After thread insertion, the needle hole was immediately pressed with a sterile dry cotton ball until no bleeding occurred. Treatment was administered once every two weeks for a total of six weeks.

2.4. Laboratory parameters

2.4.1. Inflammatory markers

Peripheral blood samples (5 ml) were obtained from fasting patients before and after treatment. Blood samples were collected at baseline (prior to intervention) and 3 months post-intervention, both scheduled uniformly between 8:00–9:00 AM, ensuring patients remained fasting to avoid circadian rhythm interference. Enzyme-linked immunosorbent assay (ELISA) was used to measure the levels of various inflammatory factors, including tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-10 (IL-10), and interleukin-12 (IL-12). The ELISA method involved the following steps: coating with the antibody (Ab-1) at 4°C overnight, washing with PBS for 5 min * 3 times, adding the test antigen (Ag) at 37°C for 60 min, washing with PBS for 5 min * 3 times, adding specific antibodies produced from a different species (Ab-2) at 37°C for 60 min, washing with PBS for 5 min * 3 times, adding enzyme-labeled anti-Ab-2 antibodies (AB-3) at 37°C for 60 min, incubating with substrate solution at 37°C for 20 min, and measuring the optical density (OD) using an ELISA reader.

Immunoturbidimetric assay to measure the levels of C-reactive protein (CRP) in the two groups. The method included preparing the sample by adding it to a test tube, adding a known concentration of antibodies to the sample to bind with the antigen, thoroughly mixing the sample and antibody to ensure complete reaction, centrifuging the mixed sample to precipitate the complex, and comparing the turbidity of the supernatant to determine the concentration of the antigen or antibody.

2.4.2. Detection of SIRT1 and HIF-1α expression levels by qrt-PCR

Total RNA from samples in each group was extracted using the Trizol method and then converted into cDNA. Quantitative reverse transcription polymerase chain reaction (qRT-PCR) with designed primers was performed. The reaction conditions included an initial denaturation at 95°C for 2 min, followed by 40 cycles of denaturation at 94°C for 30 s, annealing at 60°C for 60 s, and extension at 72°C for 30 s. The relative expression levels were indicated as 2-ΔΔCT. Each experiment was repeated three times for each group.

2.4.3. Assessment of therapeutic efficacy

The therapeutic efficacy was determined based on the NIHSS score, and the criteria were as follows: Complete recovery - disappearance of relevant symptoms in the patient, with a reduction in NIHSS score of over 90% after treatment compared to before; Significant improvement - significant amelioration of relevant symptoms in the patient, with a decrease in NIHSS score of over 70% but less than 90% after treatment compared to before; Improvement - some amelioration of relevant symptoms in the patient, with a decrease in NIHSS score of over 30% but less than 70% after treatment compared to before; Ineffective - no improvement in relevant symptoms in the patient, with a decrease in NIHSS score of 30% or less after treatment compared to before; Deterioration - worsening of relevant symptoms in the patient, with a post-treatment NIHSS score higher than before.

2.4.4. Adverse events

The incidence of adverse events, including hematoma, bleeding, infection, and allergies, was compared between the two groups to determine the proportion of individuals experiencing adverse reactions during the treatment period.

2.5. Statistical analysis

Statistical analysis was performed using the Statistic Package for Social Science (SPSS) 22.0 software package (IBM, Armonk, NY, USA). Quantitative data were expressed as mean ± standard deviation ( $\bar{x} \pm s$ ), while frequency data were expressed as number of cases and percentages. For normally distributed measurement data, intergroup comparisons were conducted using the t-test. Non-normally distributed data were described using M (P25, P75), and intergroup comparisons were made using the Wilcoxon signed-rank test. Frequency data were described using the number of cases and rates, and intergroup comparisons were conducted using the paired chi-square test, specifically using the McNemar test for differences between binary variables and the Bowker test for differences between multiple categorical variables. The significance level was set at α=0.05. Normality of continuous variables was assessed using the Shapiro-Wilk test before applying parametric tests, as detailed in Supplementary Table S1, with Q–Q plots shown in Supplementary Figure S1. All variables met the normality assumption (p > 0.05), justifying the use of t-tests.

3. Results

3.1. Baseline characteristics

The impact of ATE treatment on NIHSS score and the serum levels of SIRT1, HIF-1α, and macrophage efferocytosis-related factors in patients with stroke was assessed through a comparative study involving a control group and an ATE treatment group (Table 1). There were no significant differences in baseline characteristics between the ATE and control groups, including age, gender, time since stroke, BMI, smoking history, alcohol intake, and the prevalence of hypertension, diabetes, hyperlipidemia, and weight status. These findings indicate that the baseline characteristics were well-balanced between the two groups, laying the foundation for investigating the specific impact of ATE treatment on the designated outcome measures.

Table 1.
Baseline characteristics of participants.

Parameter Control Group ATE Treatment Group t/χ2 p-value

Age 60.02 ± 5.02 61.53 ± 6.04 1.404 0.164

Gender (M/F) 32 (57.14%) / 24 (42.86%) 28 (53.85%) / 24 (46.15%) 0.023 0.880

Time Since Stroke 6.04 ± 2.06 5.57 ± 1.52 1.353 0.179

BMI 25.01 ± 2.04 24.56 ± 2.56 0.997 0.321

Smoking history (pack-years) 28.52 ± 7.24 26.44 ± 6.55 1.562 0.121

Alcohol intake (g/week) 20.15 ± 4.53 18.93 ± 3.85 1.504 0.136

Hypertension (n(%)) 28 (50%) 24 (46.15%) 0.043 0.836

Diabetes(n(%)) 17 (30.36%) 14 (26.92%) 0.033 0.856

Hyperlipidemia (n(%)) 24 (42.86%) 21 (40.38%) 0.004 0.948

Weight status (n(%))

-normal 41 (73.21%) 42 (80.77%) 1.099 0.577

-overweight 6 (10.71%) 5 (9.62%)

-underweight 9 (16.07%) 5 (9.62%)

Parameter	Control Group	ATE Treatment Group	t/χ2	p-value
Age	60.02 ± 5.02	61.53 ± 6.04	1.404	0.164
Gender (M/F)	32 (57.14%) / 24 (42.86%)	28 (53.85%) / 24 (46.15%)	0.023	0.880
Time Since Stroke	6.04 ± 2.06	5.57 ± 1.52	1.353	0.179
BMI	25.01 ± 2.04	24.56 ± 2.56	0.997	0.321
Smoking history (pack-years)	28.52 ± 7.24	26.44 ± 6.55	1.562	0.121
Alcohol intake (g/week)	20.15 ± 4.53	18.93 ± 3.85	1.504	0.136
Hypertension (n(%))	28 (50%)	24 (46.15%)	0.043	0.836
Diabetes(n(%))	17 (30.36%)	14 (26.92%)	0.033	0.856
Hyperlipidemia (n(%))	24 (42.86%)	21 (40.38%)	0.004	0.948
Weight status (n(%))
-normal	41 (73.21%)	42 (80.77%)	1.099	0.577
-overweight	6 (10.71%)	5 (9.62%)
-underweight	9 (16.07%)	5 (9.62%)

3.2. Inflammatory markers

Significant differences in inflammatory markers (e.g., CRP, IL-6, TNF-α, IL-10, IL-8, IL-12, TGF-β) were observed between the ATE and control groups, suggesting a potential anti-inflammatory effect of ATE treatment (Table 2). These findings suggest that ATE treatment may have a favorable impact on the inflammatory response in patients with stroke, as evidenced by the observed differences in inflammatory marker levels between the treated and control groups.

Table 2.
Comparison of inflammatory markers of patients between the two groups.

Inflammatory Marker Control Group ATE Treatment Group t P-value

CRP (mg/L) 13.24 ± 4.75 10.86 ± 3.54 2.958 0.004

IL-6 (pg/mL) 30.74 ± 6.23 27.56 ± 5.37 2.844 0.005

TNF-α (pg/mL) 18.96 ± 5.61 16.12 ± 4.36 2.946 0.004

IL-10 (pg/mL) 18.64 ± 4.58 16.83 ± 3.54 2.315 0.023

IL-8 (pg/mL) 32.94 ± 7.43 29.45 ± 6.25 2.650 0.009

IL-12 (pg/mL) 14.87 ± 3.65 12.96 ± 2.97 2.996 0.003

TGF-β (pg/mL) 42.36 ± 9.52 37.67 ± 8.11 2.761 0.007

Inflammatory Marker	Control Group	ATE Treatment Group	t	P-value
CRP (mg/L)	13.24 ± 4.75	10.86 ± 3.54	2.958	0.004
IL-6 (pg/mL)	30.74 ± 6.23	27.56 ± 5.37	2.844	0.005
TNF-α (pg/mL)	18.96 ± 5.61	16.12 ± 4.36	2.946	0.004
IL-10 (pg/mL)	18.64 ± 4.58	16.83 ± 3.54	2.315	0.023
IL-8 (pg/mL)	32.94 ± 7.43	29.45 ± 6.25	2.650	0.009
IL-12 (pg/mL)	14.87 ± 3.65	12.96 ± 2.97	2.996	0.003
TGF-β (pg/mL)	42.36 ± 9.52	37.67 ± 8.11	2.761	0.007

3.2. Macrophage efferocytosis-related factors

ATE treatment led to significant increases in the levels of SIRT1 and HIF-1α, which may influence macrophage efferocytosis-related pathways in stroke recovery (Table 3). These findings suggest that ATE treatment may have an impact on the levels of macrophage efferocytosis-related factors, specifically SIRT1 and HIF-1α, in patients with stroke, indicating its role in modulating cellular pathways associated with stroke recovery.

Table 3.
Comparison of macrophage efferocytosis-related factors of patients between the two groups.

Parameter Control Group ATE Treatment Group t p-value

SIRT1 Level 3.26 ± 0.56 3.57 ± 0.62 2.671 0.009

HIF-1α Level 4.54 ± 1.24 5.12 ± 1.34 2.339 0.021

Parameter	Control Group	ATE Treatment Group	t	p-value
SIRT1 Level	3.26 ± 0.56	3.57 ± 0.62	2.671	0.009
HIF-1α Level	4.54 ± 1.24	5.12 ± 1.34	2.339	0.021

3.3. NIHSS scores

Refer to Table 4, the comparison of NIHSS scores between the two groups showed no significant difference at baseline (8.23 ± 2.57 vs. 8.01 ± 2.35, p = 0.635). However, at the 3-month follow-up, the ATE treatment group showed significantly better neurological outcomes, as reflected by lower NIHSS scores. These results suggest that ATE treatment may contribute to improved neurological outcomes in patients with stroke, as reflected by the lower NIHSS scores observed in the treatment group at the 3-month follow-up assessment.

Table 4.
Comparison of NIHSS scores of patients between the two groups.

Parameter Control Group ATE Treatment Group t p-value

Baseline 8.23 ± 2.57 8.01 ± 2.35 0.477 0.635

3-month Follow-up 4.26 ± 1.85 3.54 ± 1.62 2.158 0.033

Parameter	Control Group	ATE Treatment Group	t	p-value
Baseline	8.23 ± 2.57	8.01 ± 2.35	0.477	0.635
3-month Follow-up	4.26 ± 1.85	3.54 ± 1.62	2.158	0.033

3.4. Efficacy

The ATE treatment group demonstrated a higher proportion of complete responses and fewer cases of progressive disease compared to the control group, suggesting enhanced efficacy (Table 5). Additionally, the treatment group demonstrated a higher proportion of patients with a partial response (28.85% vs. 17.86%) and a similar proportion of patients with stable disease (65.38% vs. 60.71%) compared to the control group. These findings suggest that ATE treatment may contribute to improved efficacy outcomes in patients with stroke, as evidenced by the higher rate of complete response and lower rate of progressive disease in the treatment group.

Table 5.
Comparison of efficacy of patients between the two groups.

Response Control Group ATE Treatment Group P

Complete response 0 (0%) 2 (3.85%) 0.003

Partial response 10 (17.86%) 15 (28.85%)

Stable disease 34 (60.71%) 34 (65.38%)

Progressive disease 12 (21.43%) 1 (1.92%)

Response	Control Group	ATE Treatment Group	P
Complete response	0 (0%)	2 (3.85%)	0.003
Partial response	10 (17.86%)	15 (28.85%)
Stable disease	34 (60.71%)	34 (65.38%)
Progressive disease	12 (21.43%)	1 (1.92%)

3.5. Adverse events

Refer to Table 6, the comparison of adverse events between the two groups revealed that the ATE treatment group exhibited a higher incidence of bleeding compared to the control group (25.00% vs. 8.93%, p = 0.048). However, no significant differences were observed between the groups in the occurrence of scleroma (9.62% vs. 17.86%, p = 0.338), infection (7.69% vs. 5.36%, p = 0.919), and allergy (1.92% vs. 5.36%, p = 0.664). These findings suggest that while ATE treatment may be associated with a higher risk of bleeding, it does not significantly impact the occurrence of other adverse events such as scleroma, infection, and allergy when compared to the control group.

Table 6.
Comparison of adverse events of patients between the two groups.

Parameter Control Group Acupoint Thread Embedding Treatment Group χ2 p-value

Scleroma 10 (17.86%) 5 (9.62%) 0.920 0.338

Bleeding 5 (8.93%) 13 (25.00%) 3.924 0.048

Infection 3 (5.36%) 4 (7.69%) 0.010 0.919

Allergy 3 (5.36%) 1 (1.92%) 0.189 0.664

Parameter	Control Group	Acupoint Thread Embedding Treatment Group	χ2	p-value
Scleroma	10 (17.86%)	5 (9.62%)	0.920	0.338
Bleeding	5 (8.93%)	13 (25.00%)	3.924	0.048
Infection	3 (5.36%)	4 (7.69%)	0.010	0.919
Allergy	3 (5.36%)	1 (1.92%)	0.189	0.664

4. Discussion

The present study aimed to investigate the impact of ATE treatment on the NIHSS score and the serum levels of SIRT1, HIF-1α, and macrophage efferocytosis-related factors in patients with stroke. The findings from this study provide valuable insights into the potential effects of ATE treatment on neurological outcomes and molecular pathways in stroke management.

ATE is a traditional Chinese medicine technique that involves the insertion of absorbable threads into specific acupoints to achieve therapeutic effects.²⁵ In recent years, there has been increasing interest in exploring traditional Chinese medicine techniques, including ATE, as potential interventions for neurological disorders, such as stroke.⁹ The rationale for investigating ATE in stroke management stems from its purported ability to modulate inflammatory responses, improve tissue reperfusion, and enhance neuroprotective mechanisms through complex and multifaceted pathways.²⁶ In line with these concepts, our study aimed to elucidate the molecular and clinical effects of ATE in patients with stroke to contribute to a better understanding of its therapeutic potential and pave the way for the development of novel adjunctive treatments for stroke.

Baseline characteristics were balanced between the groups, ensuring any observed differences in outcomes can be attributed to the treatment. This balanced distribution lays the foundation for investigating the specific impact of ATE treatment on the designated outcome measures, ensuring that any observed differences can be attributed to the treatment intervention rather than baseline imbalances.

ATE treatment significantly modulated inflammatory markers, suggesting a potential anti-inflammatory effect in stroke patients. These findings suggest that ATE treatment may exert a favorable impact on the inflammatory response in patients with stroke. The modulation of inflammatory markers is a crucial aspect of stroke management, as excessive inflammation can exacerbate tissue damage and hinder recovery. The observed changes in inflammatory marker levels provide preliminary evidence of the potential anti-inflammatory effects of ATE treatment in the context of stroke, warranting further investigation into the underlying mechanisms and clinical implications.

ATE treatment also influenced macrophage efferocytosis-related factors, such as SIRT1 and HIF-1α, which may contribute to stroke recovery. SIRT1, a member of the sirtuin family of proteins, is known for its role in regulating cellular responses to stress and promoting cell survival.¹⁷ HIF-1α, a transcription factor, plays a central role in cellular adaptation to hypoxia and is involved in the expression of genes associated with angiogenesis, energy metabolism, and erythropoiesis.²⁷ The observed differences in SIRT1 and HIF-1α levels suggest that ATE treatment may modulate cellular pathways associated with stroke recovery, potentially influencing processes such as cellular stress response, energy metabolism, and tissue reperfusion. These findings highlight the multifaceted effects of ATE treatment and underscore the need for a comprehensive understanding of its molecular mechanisms in the context of stroke.

The assessment of NIHSS scores revealed that ATE treatment was associated with a significantly lower NIHSS score at the 3-month follow-up compared to the control group. These findings indicate that ATE treatment may contribute to improved neurological outcomes in patients with stroke. The NIHSS is a widely used tool for assessing the severity of stroke and has been extensively validated for predicting patient outcomes.²⁸ The lower NIHSS scores in the ATE group suggest that it may help improve functional recovery and reduce neurological deficits. However, further prospective studies with larger sample sizes and longer follow-up durations are warranted to confirm these findings and evaluate the long-term impact of ATE treatment on neurological outcomes in stroke patients.

The ATE group showed greater efficacy, with more patients achieving complete responses and fewer experiencing disease progression. Additionally, the treatment group demonstrated a higher proportion of patients with a partial response and a similar proportion of patients with stable disease compared to the control group. These efficacy outcomes further support the potential clinical benefits of ATE treatment in stroke management, suggesting that it may contribute to improved treatment responses and functional outcomes in patients with stroke.

Notably, the incidence of adverse events, particularly bleeding, was higher in the ATE treatment group compared to the control group. While bleeding is a known risk associated with certain traditional Chinese medicine techniques, including ATE, it is essential to carefully weigh the potential benefits of the treatment against the risk of adverse events. Future studies should focus on optimizing the ATE procedure to minimize the risk of bleeding and other adverse events while maximizing its potential therapeutic benefits in stroke management.

This study has several limitations. First, the single-center design may limit generalizability to broader populations. Second, the lack of blinding due to the nature of ATE treatment could introduce bias in outcome assessments, though objective biomarkers were used to mitigate this. Third, unmeasured lifestyle factors might have influenced the results. Finally, the 3-month follow-up may be too short to evaluate long-term effects. Future multicenter studies with longer follow-up and sham-controlled designs are needed to confirm these findings. It is also noteworthy that this study was conducted in a Chinese hospital, where TCM, including ATET, is more widely accepted and practised. The cultural context of TCM in China may have a significant impact on the outcomes observed in this study. The generalisability of these findings to international settings may be limited by varying cultural attitudes towards TCM and differences in healthcare systems. For instance, in Western countries, the acceptance and integration of TCM therapies may be lower, which could affect the widespread use of ATE for stroke rehabilitation. Furthermore, regional differences in the expertise and practices of TCM practitioners could also impact the efficacy of the treatment. Consequently, further research in a range of geographical locations and healthcare systems, as well as cross-cultural investigations, is required to validate the applicability and effectiveness of ATE treatment for stroke recovery in a more extensive international context.

5. Conclusion

In conclusion, the findings from this study shed light on the potential impact of ATE treatment on NIHSS score and the serum levels of SIRT1, HIF-1α, and macrophage efferocytosis-related factors in patients with stroke. The observed changes in inflammatory markers, molecular pathways, and clinical outcomes provide valuable insights into the potential role of ATE treatment as an adjunctive intervention for stroke. Further research is warranted to elucidate the underlying mechanisms, optimize treatment protocols, and evaluate the long-term effects of ATE treatment on stroke outcomes. At the three-month follow-up, the NIHSS scores were lower in the buried thread group than in the control group. This suggests that the buried thread group experienced more durable long-term efficacy. Overall, this study contributes to a better understanding of the therapeutic potential of ATE and paves the way for the development of novel adjunctive treatments for stroke.

Supplemental Material

sj-docx-1-thc-10.1177_09287329251363433 - Supplemental material for Technological advances in acupoint thread embedding treatment: Effects on NIHSS score, Serum SIRT1, HIF-1α, and macrophage efferocytosis in stroke patients

Supplemental material, sj-docx-1-thc-10.1177_09287329251363433 for Technological advances in acupoint thread embedding treatment: Effects on NIHSS score, Serum SIRT1, HIF-1α, and macrophage efferocytosis in stroke patients by Min Li, Wanyi Xie, Qingrui Lv, Meitang He, Hanhong Zou, Miaoying Hong, Hanyan Pang, Jingchao Cai, Jianshuang Shi andWenhao Huang in Technology and Health Care

Footnotes

Acknowledgements

The authors thank the patients and Guangdong Key Laboratory of Chinese Medicine Research and Development. We thank Meiluan Su, Xiaoyin Wang, Yanfei Zhuang, Houjuan Zhang for their contributions in this study

Ethics statement

This study protocol was reviewed and approved by Ethics Committee of Guangdong Second Traditional Chinese Medicine, approval number (2023-037-01).

Author contributions

ML and MTH conceived and designed the current study. WYX, QRL, HHZ, MYH, HYP, LCC, LSS, MLS, XYW, YFZ and HJZ performed the experiments and analyzed the data. ML and MTH wrote the manuscript and WHH revised the manuscript critically for important intellectual content. All authors have read and approved the final manuscript.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by Scientific Research and Innovation Fund Project of Guangdong Second Traditional Chinese Medicine (SWZYY2023A06), Construction of an International Science, Technology and Innovation Center in the Greater Bay Area of Guangdong, Hong Kong and Macao (2022A0505020019).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

No datasets were generated or analyzed during the current study.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

Please find the following supplemental material available below.

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Technological advances in acupoint thread embedding treatment: Effects on NIHSS score,Serum SIRT1,HIF-1α,and macrophage efferocytosis in stroke patients

Abstract

Background

Objective

Methods

Results

Conclusion

Keywords

1. Introduction

2. Methods

2.1. Research participants

2.2. Diagnosis and inclusion/exclusion criteria

2.3. Treatment methods

2.4. Laboratory parameters

2.4.1. Inflammatory markers

2.4.2. Detection of SIRT1 and HIF-1α expression levels by qrt-PCR

2.4.3. Assessment of therapeutic efficacy

2.4.4. Adverse events

2.5. Statistical analysis

3. Results

3.1. Baseline characteristics

Table 3. Comparison of macrophage efferocytosis-related factors of patients between the two groups. Parameter Control Group ATE Treatment Group t p-value SIRT1 Level 3.26 ± 0.56 3.57 ± 0.62 2.671 0.009 HIF-1α Level 4.54 ± 1.24 5.12 ± 1.34 2.339 0.021

Table 4. Comparison of NIHSS scores of patients between the two groups. Parameter Control Group ATE Treatment Group t p-value Baseline 8.23 ± 2.57 8.01 ± 2.35 0.477 0.635 3-month Follow-up 4.26 ± 1.85 3.54 ± 1.62 2.158 0.033

Table 5. Comparison of efficacy of patients between the two groups. Response Control Group ATE Treatment Group P Complete response 0 (0%) 2 (3.85%) 0.003 Partial response 10 (17.86%) 15 (28.85%) Stable disease 34 (60.71%) 34 (65.38%) Progressive disease 12 (21.43%) 1 (1.92%)

5. Conclusion

Supplemental Material

sj-docx-1-thc-10.1177_09287329251363433 - Supplemental material for Technological advances in acupoint thread embedding treatment: Effects on NIHSS score, Serum SIRT1, HIF-1α, and macrophage efferocytosis in stroke patients

Footnotes

Acknowledgements

Ethics statement

Author contributions

Funding

Declaration of conflicting interests

Data availability statement

Supplemental material

References

Supplementary Material

Table 3.
Comparison of macrophage efferocytosis-related factors of patients between the two groups.

Parameter Control Group ATE Treatment Group t p-value

SIRT1 Level 3.26 ± 0.56 3.57 ± 0.62 2.671 0.009

HIF-1α Level 4.54 ± 1.24 5.12 ± 1.34 2.339 0.021

Table 4.
Comparison of NIHSS scores of patients between the two groups.

Parameter Control Group ATE Treatment Group t p-value

Baseline 8.23 ± 2.57 8.01 ± 2.35 0.477 0.635

3-month Follow-up 4.26 ± 1.85 3.54 ± 1.62 2.158 0.033

Table 5.
Comparison of efficacy of patients between the two groups.

Response Control Group ATE Treatment Group P

Complete response 0 (0%) 2 (3.85%) 0.003

Partial response 10 (17.86%) 15 (28.85%)

Stable disease 34 (60.71%) 34 (65.38%)

Progressive disease 12 (21.43%) 1 (1.92%)