Risk of mortality 2020

Stimulated by Lin et al 2020,[1] Park et al 2020,[2] and Khan et al 2019.[3]

What is the risk of mortality associated with acupuncture?

Well, it depends on the context of course, and I am using this title to draw together a few recent papers that I want to highlight. The main paper demonstrating a reduced risk of mortality associated with acupuncture, and the others highlighting adverse effects with the potential of mortality.

The first paper, published online on 20^th May in Acupuncture in Medicine, is another of the large retrospective observational studies from Taiwan. Lin et al found 17 121 subjects who had been hospitalised with hip fracture between 2000 and 2010. This number was reduced by exclusion of open and pathological fractures to 11 551. From this sample they identified 925 who had received at least one acupuncture treatment within a year of the hip fracture. Within this group there were 292 who had received at least 6 acupuncture treatments within 183 days of hip fracture. The details of this group were then used to match with a similar group that did not receive acupuncture. This was done by using the index dates (of surgery for hip fracture), index duration (time to 6^th session of acupuncture) and propensity score matching using age, gender, calendar year of operation, status of physical therapy and index duration. A 1:3 ratio was used so that the no acupuncture matched cohort had 3 times the number (n=876).

Various outcomes were observed and compared between the cohorts, and broadly these fell into the categories of mortality, readmission and reoperation.

a reduction in mortality by more than a half

The acupuncture cohort had a markedly reduced risk in all categories, and perhaps the most striking was a reduction in mortality by more than a half (hazard ratio 0.41). Readmissions and reoperations were reduced by just over a third (hazard ratio 0.64 and 0.62 respectively).

So, this was mostly good news, but not entirely… the hazard ration for mortality was doubled for those patients with chronic obstructive pulmonary disease who received acupuncture. This nicely brings us on to the other papers I want to mention, as they are both concerning adverse events.

The first is a systematic review of cases and case series of adverse events related to electroacupuncture (EA). I take a keen interest in EA, as I use it so much in practice, and I have investigated,[4] and reported on safety aspects in the past.[5,6]

I was intrigued by the 3 reported deaths, and expected these to be cardiac in origin based on comments made by Adrian White in his review in 2004.[7] Adrian refers to 2 cardiac arrests related to EA in the neck, but these were described in a textbook with no particular detail. So, I was pleased to see more detail in this paper. More specifically the supplemental material includes details extracted from all the individual reports, many of which would not have been assessible to me before by virtue of the language.

three deaths in young women with schizophrenia

I was somewhat shocked to find that all three deaths described in this review were of relatively young women with a diagnosis of schizophrenia. One death was from cardiac injury and subsequent lung infection, and the other 2 from spinal cord injury.

Finally, we come on to a non-fatal adverse event report, but one that certainly has the potential to be fatal, particularly considering the geography. This case caught my eye because it was an unfamiliar journal to me, and because it was a haemopneumothorax, which is rather uncommon from acupuncture, this being only the third report in the English literature. Pneumothorax is the most common traumatic adverse event related to acupuncture, and I have highlighted it on the blog before. We now can estimate that the risk is around 1.75 per million treatments in at risk areas (See the previous blog: Post-acupuncture pneumothorax incidence). In this case the risk was attributed to needling at ST12, in the supraclavicular fossa at the midpoint of the clavicle. The report includes two chest x ray film images: the first demonstrating an apical left pneumothorax and a fluid level over the left lower lung field; and the second demonstrating an apical haematoma at the site of the original pneumothorax that developed after discharge. The latter required transfer from the rural area to a larger centre where evacuation was performed via video-assisted thoracic surgery.

References

1         Lin JC-F, Lin T-C, Cheng C, et al. Lower rates of mortality, readmission and reoperation in patients receiving acupuncture after hip fracture: a population-based analysis. Acupunct Med Published Online First: 20 May 2020. doi:10.1177/0964528420911664

2         Park JH, Lee J-H, Lee S, et al. Adverse events related to electroacupuncture: a systematic review of single case studies and case series. Acupunct Med Published Online First: 16 May 2020. doi:10.1177/0964528420920287

3         Khan AF, Soon D, Campbell I. Haemopneumothorax subsequent to acupuncture: a rural centre experience. ANZ J Surg 2019;:ans.15488. doi:10.1111/ans.15488

4         Thompson JW, Cummings M. Investigating the safety of electroacupuncture with a Picoscope. Acupunct Med 2008;26:133–9. doi:10.1136/aim.26.3.133

5         Cummings M. Safety aspects of electroacupuncture. Acupunct Med 2011;29:83–5. doi:10.1136/acupmed-2011-010035

6         Cummings M. Report of adverse event with electroacupuncture. Acupunct Med 2011;29:147–51. doi:10.1136/acupmed-2011-010020

7         White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med 2004;22:122–33. doi:10.1136/aim.22.3.122

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Declaration of interests MC