to summarize all reported case of cardiac tamponade after acupuncture, found 26 cases resulting in 14 deaths, with little doubt about cause in most fatal instances. the same review concluded that cardiac tamponade was a serious, usually fatal, though theoretically avoidable complication following acupuncture, and urged training to minimize risk. a 2012 review found that a number of adverse events were reported after acupuncture in the uk's national health service (nhs), 95% of which were not severe, though miscategorization and under-reporting may alter the total figures. from january 2009 to december 2011, 468 safety incidents were recognized within the nhs organizations. the adverse events recorded included retained needles (31%), dizziness (30%), loss of consciousness/unresponsive (19%), falls (4%), bruising or soreness at needle site (2%), pneumothorax (1%) and other adverse side effects (12%). acupuncture practitioners should know, and be prepared to be responsible for, any substantial harm from treatments. some acupuncture proponents argue that the long history of acupuncture suggests it is safe. however, there is an increasing literature on adverse events (e.g. spinal-cord injury). acupuncture seems to be safe in people getting anticoagulants, assuming needles are used at the correct location and depth, but studies are required to verify these findings. chinese, korean, and japanese-language a 2010 systematic review of the chinese-language literature found numerous acupuncture-related adverse events, including pneumothorax, fainting, subarachnoid hemorrhage, and infection as the most frequent, and cardiovascular injuries, subarachnoid hemorrhage, pneumothorax, and recurrent cerebral hemorrhage as the most serious, most of which were due to improper technique. between 1980 and 2009, the chinese-language literature reported 479 adverse events. prospective surveys show that mild, transient acupuncture-associated adverse events ranged from 6.71% to 15%. in a study with 190,924 patients, the prevalence of serious adverse events was roughly 0.024%. another study showed a rate of adverse events requiring specific treatment of 2.2%, 4,963 incidences among 229,230 patients. infections, mainly hepatitis, after acupuncture are reported often in english-language research, though are rarely reported in chinese-language research, making it plausible that acupuncture-associated infections have been underreported in china. infections were mostly caused by poor sterilization of acupuncture needles. other adverse events included spinal epidural hematoma (in the cervical, thoracic and lumbar spine), chylothorax, injuries of abdominal organs and tissues, injuries in the neck region, injuries to the eyes, including orbital hemorrhage, traumatic cataract, injury of the oculomotor nerve and retinal puncture, hemorrhage to the cheeks and the hypoglottis, peripheral motor-nerve injuries and subsequent motor dysfunction, local allergic reactions to metal needles, stroke, and cerebral hemorrhage after acupuncture. a causal link between acupuncture and the adverse events cardiac arrest, pyknolepsy, shock, fever, cough, thirst, aphonia, leg numbness, and sexual dysfunction remains uncertain. the same review concluded that acupuncture can be considered inherently safe when practiced by properly trained practitioners, but the review also stated there is a need to find effective strategies to minimize the health risks. between 1999 and 2010, the korean-language literature contained reports of 1104 adverse events. between the 1980s and 2002, the japanese-language literature contained reports of 150 adverse events. children and pregnancy although acupuncture has been practiced for thousands of years in china, its use in pediatrics in the united states did not become common until the early 2000s. in 2007, the national health interview survey (nhis) conducted by the national center for health statistics (nchs) estimated that approximately 150,000 children had received acupuncture treatment for a variety of conditions. in 2008 a study determined that the use of acupuncture-needle treatment on children was "questionable" due to the possibility of adverse side-effects and the pain manifestation differences in children versus adults. the study also includes warnings against practicing acupuncture on infants, as well as on children who are over-fatigued, very weak, or have over-eaten. when used on children, acupuncture is considered safe when administered by well-trained, licensed practitioners using sterile needles; however, a 2011 review found there was limited research to draw definite conclusions about the overall safety of pediatric acupuncture. the same review found 279 adverse events, 25 of them serious. the adverse events were mostly mild in nature (e.g. bruising or bleeding). the prevalence of mild adverse events ranged from 10.1% to 13.5%, an estimated 168 incidences among 1,422 patients. on rare occasions adverse events were serious (e.g. cardiac rupture or hemoptysis); many might have been a result of substandard practice. the incidence of serious adverse events was 5 per one million, which included children and adults. when used during pregnancy, the majority of adverse events caused by acupuncture were mild and transient, with few serious adverse events. the most frequent mild adverse event was needling or unspecified pain, followed by bleeding. although two deaths (one stillbirth and one neonatal death) were reported, there was a lack of acupuncture-associated maternal mortality. limiting the evidence as certain, probable or possible in the causality evaluation, the estimated incidence of adverse events following acupuncture in pregnant women was 131 per 10,000. although acupuncture is not contraindicated in pregnant women, some specific acupuncture points are particularly sensitive to needle insertion; these spots, as well as the abdominal region, should be avoided during pregnancy. moxibustion and cupping four adverse events associated with moxibustion were bruising, burns and cellulitis, spinal epidural abscess, and large superficial basal cell carcinoma. ten adverse events were associated with cupping. the minor ones were keloid scarring, burns, and bullae; the serious ones were acquired hemophilia a, stroke following cupping on the back and neck, factitious panniculitis, reversible cardiac hypertrophy, and iron deficiency anemia. risk of forgoing conventional medical care as with other alternative medicines, unethical or naïve practitioners may induce patients to exhaust financial resources by pursuing ineffective treatment. professional ethics codes set by accrediting organizations such as the national certification commission for acupuncture and oriental medicine require practitioners to make "timely referrals to other health care professionals as may be appropriate." stephen barrett states that there is a "risk that an acupuncturist whose approach to diagnosis is not based on scientific concepts will fail to diagnose a dangerous condition". conceptual basis acupuncturesimplified chinese针刺transcriptionsstandard mandarinhanyu pinyinzhēncì traditional main articles: qi, traditional chinese medicine, meridian (chinese medicine), and list of acupuncture points old chinese medical chart of acupuncture meridians acupuncture is a substantial part of traditional chinese medicine (tcm). early acupuncture beliefs relied on concepts that are common in tcm, such as a life force energy called qi. qi was believed to flow from the body's primary organs (zang-fu organs) to the "superficial" body tissues of the skin, muscles, tendons, bones, and joints, through channels called meridians. acupuncture points where needles are inserted are mainly (but not always) found at locations along the meridians. acupuncture points not found along a meridian are called extraordinary points and those with no designated site are called "a-shi" points. in tcm, disease is generally perceived as a disharmony or imbalance in energies such as yin, yang, qi, xuĕ, zàng-fǔ, meridians, and of the interaction between the body and the environment. therapy is based on which "pattern of disharmony" can be identified. for example, some diseases are believed to be caused by meridians being invaded with an excess of wind, cold, and damp. in order to determine which pattern is at hand, practitioners examine things like the color and shape of the tongue, the relative strength of pulse-points, the smell of the breath, the quality of breathing, or the sound of the voice. tcm and its concept of disease does not strongly differentiate between the cause and effect of symptoms. purported scientific basis modern acupuncture model many within the scientific community consider attempts to rationalize acupuncture in science to be quackery and pseudoscience. academics massimo pigliucci and maarten boudry describe it as a "borderlands science" lying between science and pseudoscience. rationalizations of traditional medicine it is a generally held belief within the acupuncture community that acupuncture points and meridians structures are special conduits for electrical signals, but no research has established any consistent anatomical structure or function for either acupuncture points or meridians. human tests to determine whether electrical continuity was significantly different near meridians than other places in the body have been inconclusive. scientific research has not supported the existence of qi, meridians, or yin and yang. a nature editorial described tcm as "fraught with pseudoscience", with the majority of its treatments having no logical mechanism of action. quackwatch states that "tcm theory and practice are not based upon the body of knowledge related to health, disease, and health care that has been widely accepted by the scientific community. tcm practitioners disagree among themselves about how to diagnose patients and which treatments should go with which diagnoses. even if they could agree, the tcm theories are so nebulous that no amount of scientific study will enable tcm to offer rational care." academic discussions of acupuncture still make reference to pseudoscientific concepts such as qi and meridians despite the lack of scientific evidence. release of endorphins or adenosine some modern practitioners support the use of acupuncture to treat pain, but have abandoned the use of qi, meridians, yin, yang and other mystical energies as an explanatory frameworks. the use of qi as an explanatory framework has been decreasing in china, even as it becomes more prominent during discussions of acupuncture in the us. many acupuncturists attribute pain relief to the release of endorphins when needles penetrate, but no longer support the idea that acupuncture can affect a disease. some studies suggest acupuncture causes a series of events within the central nervous system, and that it is possible to inhibit acupuncture's analgesic effects with the opioid antagonist naloxone. mechanical deformation of the skin by acupuncture needles appears to result in the release of adenosine. the anti-nociceptive effect of acupuncture may be mediated by the adenosine a1 receptor. a 2014 review in nature reviews cancer analyzed mouse studies that suggested acupuncture relieves pain via the local release of adenosine, which then triggered nearby a1 receptors. the review found that in those studies, because acupuncture "caused more tissue damage and inflammation relative to the size of the animal in mice than in humans, such studies unnecessarily muddled a finding that local inflammation can result in the local release of adenosine with analgesic effect." history origins acupuncture chart from the ming dynasty (c. 1368 – c. 1644) acupuncture, along with moxibustion, is one of the oldest practices of traditional chinese medicine. most historians believe the practice began in china, though there are some conflicting narratives on when it originated. academics david ramey and paul buell said the exact date acupuncture was founded depends on the extent to which dating of ancient texts can be trusted and the interpretation of what constitutes acupuncture. acupressure therapy was prevalent in india. once buddhism spread to china, the acupressure therapy was also integrated into common medical practice in china and it came to be known as acupuncture. the major points of indian acupressure and chinese acupuncture are similar to each other. according to an article in rheumatology, the first documentation of an "organized system of diagnosis and treatment" for acupuncture was in inner classic of huang di (huangdi neijing) from about 100 bc. gold and silver needles found in the tomb of liu sheng from around 100 bc are believed to be the earliest archaeological evidence of acupuncture, though it is unclear if that was their purpose. according to plinio prioreschi, the earliest known historical record of acupuncture is the shiji ("records of the grand historian"), written by a historian around 100 bc. it is believed that this text was documenting what was established practice at that time. alternate theories the 5,000-year-old mummified body of ötzi the iceman was found with 15 groups of tattoos, many of which were located at points on the body where acupuncture needles are used for abdominal or lower back problems. evidence from the body suggests ötzi had these conditions. this has been cited as evidence that practices similar to acupuncture may have been practised elsewhere in eurasia during the early bronze age; however, the oxford handbook of the history of medicine calls this theory "speculative". it is considered unlikely that acupuncture was practised before 2000 bc. acupuncture may have been practised during the neolithic era, near the end of the stone age, using sharpened stones called bian shi.: 70 many chinese texts from later eras refer to sharp stones called "plen",