1
|
Binetti M, Tonini V. Pain in chronic pancreatitis: What can we do today? World J Methodol 2024; 14:91169. [DOI: 10.5662/wjm.v14.i3.91169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 01/23/2024] [Accepted: 03/11/2024] [Indexed: 06/25/2024] Open
Abstract
The aim of this study is to illustrate the complexity of pain management in chronic pancreatitis (CP). In this context, pain represents the most common and debilitating symptom, and it deeply affects patient’s quality of life. Multiple rating scales (unidimensional, bidimensional and multidimensional) have been proposed to quantify CP pain. However, it represents the result of complex mechanisms, involving genetic, neuropathic and neurogenic factors. Considering all these aspects, the treatment should be discussed in a multidisciplinary setting and it should be approached in a stepwise manner. First, a lifestyle change is recommended and nonsteroidal anti-inflammatory drugs represent the gold standard among medical treatments for CP patients. The second step, after medical approach, is endoscopic therapy, especially for complicated CP. In case of failure, tailored surgery represents the third step and decompressive or resection procedures can be chosen. In conclusion, CP pain’s management is challenging considering all these complex aspects and the lack of international protocols.
Collapse
Affiliation(s)
- Margherita Binetti
- Department of Medical and Surgical Science, University of Bologna, Alma mater Studiorum, Bologna 40138, Italy
| | - Valeria Tonini
- Department of Medical and Surgical Science, University of Bologna, Alma mater Studiorum, Bologna 40138, Italy
| |
Collapse
|
2
|
Madela F, Ferndale L, Aldous C. Diagnostic Differentiation between Pancreatitis and Pancreatic Cancer: A Scoping Review. Diagnostics (Basel) 2024; 14:290. [PMID: 38337806 PMCID: PMC10855106 DOI: 10.3390/diagnostics14030290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/25/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Pancreatitis, encompassing acute and chronic forms, and pancreatic cancer pose significant challenges to the exocrine tissue of the pancreas. Recurrence rates and complications following acute pancreatitis episodes can lead to long-term risks, including diabetes mellitus. Chronic pancreatitis can develop in approximately 15% of cases, regardless of the initial episode's severity. Alcohol-induced pancreatitis, idiopathic causes, cigarette smoking, and hereditary pancreatitis contribute to the progression to chronic pancreatitis. Chronic pancreatitis is associated with an increased risk of pancreatic cancer, with older age at onset and smoking identified as risk factors. This scoping review aims to synthesise recent publications (2017-2022) on the diagnostic differentiation between pancreatitis and pancreatic cancer while identifying knowledge gaps in the field. The review focuses on biomarkers and imaging techniques in individuals with pancreatitis and pancreatic cancer. Promising biomarkers such as faecal elastase-1 and specific chemokines offer non-invasive ways to assess pancreatic insufficiency and detect early biomarkers for chronic pancreatitis. Imaging techniques, including computed tomography (CT), magnetic resonance imaging (MRI), endoscopic ultrasound (EUS), and positron emission tomography (PET), aid in differentiating between chronic pancreatitis and pancreatic cancer. However, accurately distinguishing between the two conditions remains a challenge, particularly when a mass is present in the head of the pancreas. Several knowledge gaps persist despite advancements in understanding the association between pancreatitis and pancreatic cancer, including the correlation between histopathological grading systems, non-invasive imaging techniques, and biomarkers in chronic pancreatitis to determine the risk of progression to pancreatic cancer, as well as differentiating between the two conditions. Further research is necessary to enhance our understanding of these aspects, which can ultimately improve the diagnosis and management of pancreatitis and pancreatic cancer.
Collapse
Affiliation(s)
- Fusi Madela
- Department of Surgery, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban 4000, South Africa; (L.F.)
| | | | | |
Collapse
|
3
|
Koulouris A, Baio G, Clark A, Alexandre L. Opioid burden in patients with inoperable pancreatic adenocarcinoma and the development of a multivariable risk prediction model for opioid use: A retrospective cohort study. Pancreatology 2023; 23:818-828. [PMID: 37741797 DOI: 10.1016/j.pan.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/26/2023] [Accepted: 08/26/2023] [Indexed: 09/25/2023]
Abstract
INTRODUCTION Risk prediction models to guide patient selection for early pre-emptive endoscopic ultrasound guided coeliac plexus neurolysis are lacking. This study aimed to determine in patients with inoperable pancreatic cancer: (1) opioid burden, (2) the relationship between opioid use and all-cause mortality, (3) risk factors for opioid use, and (4) develop and internally validate a risk prediction model for opioid use at three months. METHODS This was a single-centre retrospective cohort study of patients with confirmed pancreatic cancer. Cox proportional hazard regression estimated the association between opioid use at baseline and all-cause mortality. Logistic regression estimated the associations between clinical and radiological variables with opioid use by three months. Two risk prediction models were developed for opioid use (clinical and clinical-radiological). Model discrimination and calibration was assessed. RESULTS In total, 383 patients with inoperable pancreatic cancer were included. Prevalence of pain ranged between 37% and 47% at three monthly intervals in the first year of diagnosis. Opioid use at baseline was associated with poorer survival. Age, pain at presentation, performance status, tumour distance from the right ganglion, the anterior-posterior and the latero-lateral tumour dimensions were independent risk factors for the opioid use at three months. The Area Under Curve (AUC) for the clinical and clinical-radiological models was 0.81 and 0.84, respectively. Models were well calibrated. CONCLUSIONS Opioid use is prevalent in patients with pancreatic cancer, associated with poor prognosis, and can be predicted based on clinical and radiological variables. External validation of this predictive model is required.
Collapse
Affiliation(s)
- Andreas Koulouris
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital, Norwich, Colney Lane, NR4 7UY, United Kingdom.
| | - Gabriella Baio
- Norfolk and Norwich University Hospital, Norwich, Colney Lane, NR4 7UY, United Kingdom
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, NR4 7TJ, United Kingdom
| | - Leo Alexandre
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk, NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital, Norwich, Colney Lane, NR4 7UY, United Kingdom
| |
Collapse
|
4
|
Hickman K, Godfrey E, Ajithkumar T. Endoscopic ultrasound-guided neurolysis in advanced pancreatic cancer: current status. BMJ Support Palliat Care 2021; 12:22-28. [PMID: 34635545 DOI: 10.1136/bmjspcare-2021-002905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 07/11/2021] [Indexed: 11/04/2022]
Abstract
Pancreatic cancer has a very poor prognosis with patients often presenting with locally advanced, inoperable or metastatic disease. A significant proportion of patients have visceral pain due to perineural infiltration or coeliac plexus involvement by the tumour. This pain is difficult to control and may become refractory to conventional pain management. Therefore, coeliac plexus neurolysis (CPN) has been proposed to ablate the neuronal transmission pathway of pain permanently. CPN is recommended for those who have uncontrolled pain, are experiencing unacceptable opioid adverse effects or are receiving escalating doses of analgesics. It is not known whether CPN performed at diagnosis as the first-line treatment ('early') would impact short-term and long-term pain control and quality of life. NICE has recommended (2018) a randomised trial comparing early endoscopic ultrasound-guided coeliac plexus neurolysis (EUS-CPN) with on-demand EUS-CPN in pancreatic cancer. In this context, we will review the current evidence on its clinical benefits.
Collapse
Affiliation(s)
- Katy Hickman
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Edmund Godfrey
- Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Thankamma Ajithkumar
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| |
Collapse
|
5
|
Abstract
PURPOSE OF REVIEW To update on recent advances in interventional endoscopic ultrasound (INVEUS) techniques. RECENT FINDINGS The introduction of linear echoendoscopes with larger instrument channels and the combined development of new tools and devices have enabled various new applications of minimally invasive endoscopic ultrasound (EUS)-guided transluminal interventions of the pancreas, biliary system and peri-gastrointestinal structures. In this review, EUS-guided interventions are discussed and evaluated: drainage of peripancreatic fluid collections, access and drainage of bile ducts, gallbladder and pancreatic duct, treatment of gastrointestinal haemorrhage, coeliac plexus block and coeliac plexus neurolysis, fiducial placement, solid and cystic tumour ablation, drug delivery and brachytherapy, gastroenterostomy, angiotherapy and other EUS-guided applications. The EUS-guided interventions are classified based on the available evidence as established or experimental, standardized or nonstandardized procedures in common or rare diseases with well or little known complications and their established or nonestablished treatment. SUMMARY Some EUS-guided interventions have sparse published evidence with only single-centre studies, case series or individual case reports, others like drainage of peripancreatic fluid collections have become widely accepted practice. INVEUS has been accepted as an alternative to several surgical approaches, EUS-guided techniques result in faster recovery times, shorter hospital stay and lower costs.
Collapse
Affiliation(s)
- Christoph F Dietrich
- Department Allgemeine Innere Medizin (DAIM), Kliniken Hirslanden Beau Site, Salem und Permanence, Switzerland
| | - Barbara Braden
- Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Christian Jenssen
- Department of Internal Medicine, Krankenhaus Maerkisch-Oderland, D-15344 Strausberg and Brandenburg Institute of Clinical Ultrasound at Medical University Brandenburg, Germany
| |
Collapse
|
6
|
Koulouris AI, Alexandre L, Hart AR, Clark A. Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) technique and analgesic efficacy in patients with pancreatic cancer: A systematic review and meta-analysis. Pancreatology 2021; 21:434-442. [PMID: 33461931 DOI: 10.1016/j.pan.2020.12.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic Ultrasound-guided Celiac Plexus Neurolysis (EUS-CPN) for the treatment of abdominal pain in pancreatic cancer can be administered in three different ways, depending on the site of needle insertion: central injection (CI), bilateral injection (BI) and celiac ganglia neurolysis (CGN). This meta-analysis aimed to (1) estimate the overall efficacy of the EUS-CPN; (2) compare the efficacy of each of the three techniques; and (3) investigate demographic and disease characteristics as potential predictors of treatment response. METHODS We searched MEDLINE and EMBASE for studies that reported the proportion of treatment responders to EUS-CPN overall, and according to the technique used. We performed a random effects meta-analysis of proportions, and meta-regression was used to estimate the association between technique and clinical characteristics on treatment response. The safety profile was reviewed through narrative synthesis. RESULTS Overall response rate to EUS-CPN was 68% (95% CI 61%-74%) at week two and 53% (95% CI 45%-62%) at week four. There was no evidence of a significant difference in the response rates between the three techniques. Demographics and disease characteristics were not associated with treatment response. Serious complications have been reported for BI and CGN but not for CI. Moderate to high risk of bias was observed. DISCUSSION EUS-CPN is a useful adjunct to opioids in the management of pain. There is no evidence of a difference in the efficacy among the three techniques, however, CI is the only one for which serious complications have not been reported. Future research should focus on the appropriate timing of EUS-CPN (early versus on demand) and randomised comparison to establish the comparative efficacy of each technique.
Collapse
Affiliation(s)
- A I Koulouris
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital. Norwich, Colney Lane, NR4 7UY, United Kingdom.
| | - Leo Alexandre
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital. Norwich, Colney Lane, NR4 7UY, United Kingdom
| | - A R Hart
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, United Kingdom; Norfolk and Norwich University Hospital. Norwich, Colney Lane, NR4 7UY, United Kingdom
| | - A Clark
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, Norfolk NR4 7TJ, United Kingdom
| |
Collapse
|
7
|
Facciorusso A, Antonino M, Muscatiello N. Sarcopenia represents a negative prognostic factor in pancreatic cancer patients undergoing EUS celiac plexus neurolysis. Endosc Ultrasound 2020; 9:238-244. [PMID: 32611849 PMCID: PMC7529006 DOI: 10.4103/eus.eus_24_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background and Objectives: Increasing evidence suggests a prognostic role of sarcopenia in pancreatic cancer patients. The aim of this study was to assess the influence of sarcopenia on treatment outcomes after EUS-guided celiac plexus neurolysis (CPN). Materials and Methods: Data regarding 215 patients treated with EUS CPN between 2004 and 2019 were reviewed. Determination of body composition was conducted on contrast-enhanced CT scan, and pain response was considered as the primary outcome. Univariate and multivariate logistic regression was performed to identify the independent predictors of pain response. Results: Treatment was successful in 187 patients (86.9%). The median age was 62 (range 39–84) years, and most patients were male (61.8%). Of the whole study population, 139 patients (64.6%) were defined as sarcopenic, of which 116 (83.4%) responded to the treatment and 5 (3.5%) experienced a complete response. Among 76 nonsarcopenic participants, 71 (93.4%) responded to the treatment and 22 (28.9%) obtained a complete response (P = 0.03 and <0.001, respectively). The median duration of pain relief was 8 (2–10) and 15 (8–16) weeks in sarcopenic and nonsarcopenic patients, respectively (P = 0.01). The median overall survival after neurolysis was 4 months (3–5) in sarcopenic participants and 7 months (6–8) in nonsarcopenic participants (P = 0.05). Tumoral stage, interval from the diagnosis to treatment, and sarcopenia resulted as significant prognostic factors for treatment response both in univariate and multivariate regression analyses. No severe treatment-related adverse events were reported in the whole study population, with no difference between the two groups. Conclusions: Sarcopenia represents a predictor of poorer response to EUS CPN.
Collapse
Affiliation(s)
- Antonio Facciorusso
- Department of Medical Sciences, Endoscopy Unit, University of Foggia, Foggia, Italy
| | - Matteo Antonino
- Department of Medical Sciences, Endoscopy Unit, University of Foggia, Foggia, Italy
| | - Nicola Muscatiello
- Department of Medical Sciences, Endoscopy Unit, University of Foggia, Foggia, Italy
| |
Collapse
|
8
|
Martin-Perez E, Domínguez-Muñoz JE, Botella-Romero F, Cerezo L, Matute Teresa F, Serrano T, Vera R. Multidisciplinary consensus statement on the clinical management of patients with pancreatic cancer. Clin Transl Oncol 2020; 22:1963-1975. [PMID: 32318964 PMCID: PMC7505812 DOI: 10.1007/s12094-020-02350-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 04/01/2020] [Indexed: 12/14/2022]
Abstract
Pancreatic cancer (PC) remains one of the most aggressive tumors with an increasing incidence rate and reduced survival. Although surgical resection is the only potentially curative treatment for PC, only 15–20% of patients are resectable at diagnosis. To select the most appropriate treatment and thus improve outcomes, the diagnostic and therapeutic strategy for each patient with PC should be discussed within a multidisciplinary expert team. Clinical decision-making should be evidence-based, considering the staging of the tumor, the performance status and preferences of the patient. The aim of this guideline is to provide practical and evidence-based recommendations for the management of PC.
Collapse
Affiliation(s)
- E Martin-Perez
- Department of Surgery, Hospital Universitario de La Princesa, Diego de Leon 62, 28006, Madrid, Spain.
| | - J E Domínguez-Muñoz
- Department of Gastroenterology and Hepatology, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - F Botella-Romero
- Department of Endocrinology, Hospital General Universitario, Albacete, Spain
| | - L Cerezo
- Department of Radiation Oncology, Hospital Universitario de La Princesa, Madrid, Spain
| | - F Matute Teresa
- Department of Radiology, Hospital Clínico San Carlos, Madrid, Spain
| | - T Serrano
- Department of Pathology, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain.,Oncology Program, CIBEREHD National Biomedical Research Institute on Liver and Gastrointestinal Diseases, Instituto de Salud Carlos III, Madrid, Spain
| | - R Vera
- Department of Medical Oncology, Complejo Hospitalario de Navarra, Pamplona, Spain
| |
Collapse
|
9
|
Facciorusso A, Del Prete V, Antonino M, Buccino VR, Muscatiello N. Response to repeat echoendoscopic celiac plexus neurolysis in pancreatic cancer patients: A machine learning approach. Pancreatology 2019; 19:866-872. [PMID: 31375433 DOI: 10.1016/j.pan.2019.07.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 06/09/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND /Objectives: Efficacy of repeat echoendoscopic celiac plexus neurolysis is still unclear. Aim of the study was to assess the efficacy of repeat celiac plexus neurolysis and to build an artificial neural network model able to predict pain response. METHODS Data regarding 156 patients treated with repeat celiac plexus neurolysis between 2004 and 2019 were reviewed. Artificial neural network and logistic regression models were built to predict pain response after treatment. Performance of the models was expressed in terms of accuracy, positive predictive value, and positive likelihood ratio. RESULTS Median age was 62 years (range 39-86) and most patients were male (66%) with pre-procedural visual analogue score 7. Fifty-one patients (32.6%) experienced treatment response, of which 6 (3.8%) complete pain suppression. Median duration of pain relief was 6 (2-8) weeks. Tumoral stage, interval from initial to repeat treatment, response to initial neurolysis, and tumor progression between the two treatments resulted as significant predictors of pain response. The performance of the artificial neural network in predicting treatment response was higher than regression model (area under the curve: 0.94, 0.89-0.97 versus 0.85, 0.78-0.89; p < 0.001). Positive predictive value and positive likelihood ratio resulted 90.3% and 19.35, respectively. Classification error rate was 5.7% with the artificial neural network compared to 14.7% of regression model (p < 0.001). These findings were confirmed through ten-fold cross validation. CONCLUSIONS Pain response following repeat neurolysis is generally less pronounced than after initial treatment. Artificial neural network may help to identify those subjects likely to benefit from repeat neurolysis.
Collapse
Affiliation(s)
- Antonio Facciorusso
- Endoscopy Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy.
| | - Valentina Del Prete
- Endoscopy Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Matteo Antonino
- Endoscopy Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | | | - Nicola Muscatiello
- Endoscopy Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| |
Collapse
|
10
|
Molnár I, Hegyi G, Zsom L, Saahs C, Vagedes J, Kapócs G, Kovács Z, Sterner MG, Szőke H. Celiac plexus block increases quality of life in patients with pancreatic cancer. J Pain Res 2019; 12:307-315. [PMID: 30679920 PMCID: PMC6338112 DOI: 10.2147/jpr.s186659] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background Pancreatic cancer is a malignant disease with a high mortality rate and severe pain that is challenging to manage. To reduce the excruciating abdominal pain, opioids and adjuvant agents are conventionally used. Objectives PRNCPB is a treatment of neural therapy. The number of studies assessing the effect on patients' QoL is limited and inconsistent. With this study, we intended to address this issue. Study design A prospective nonrandomized study with a series of cases of unresectable pancreatic cancer was conducted. Setting The study was performed at our pain clinic under real life conditions. Materials and methods A total number of 16 patients with severe abdominal pain were enrolled in the study all of whom had responded to combined systemic analgesic therapy inadequately and had intolerable side effects contraindicating further increase in dose. The efficacy of this invasive, palliative analgesic procedure was evaluated 35 days after PRNCPB was performed. Primary outcomes were changed in pain intensity using the VAS questionnaire. Secondary outcomes were improved in QoL using the SF-36 questionnaire. Changes in pain medications and adverse reactions were monitored. Results After PRNCPB patients experienced a significant decrease (P=0.002) in pain intensity as shown by the VAS score, and a decreased opiate demand. Their QoL scores considering effect sizes also improved (P<0.001). No complications attributable to PRNCPB were observed during the study period. Additionally, no adverse drug reactions were observed. Limitations Detection, observation, and reporting bias can be estimated as moderate. Selection bias was not detected. Conclusion Our results give preliminary evidence that PRNCPB might be helpful as an additional treatment to conventional pain management in end-stage pancreatic cancer patients. PRNCPB seems to improve QoL in these patients in a time frame of at least 5 weeks after intervention.
Collapse
Affiliation(s)
- István Molnár
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary,
| | - Gabriella Hegyi
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary, .,Department of CAM, Faculty of Health Sciences, University of Pécs, Pécs, Hungary,
| | - Lajos Zsom
- Department of Nephrology, Fresenius Medical Care, Cegléd, Hungary
| | - Christine Saahs
- Department of Pediatrics, University of Vienna, Vienna, Austria.,Pediatric Outpatient Department, Krems, Austria
| | - Jan Vagedes
- University Children's Hospital, University of Tuebingen, Tuebingen, Germany.,Department of Complementary and Integrative Medicine, ARCIM Institute (Academic Research in Complementary and Integrative Medicine), Filderstadt, Germany
| | - Gábor Kapócs
- Department of Psychiatry and Psychiatric Rehabilitation, Saint John Hospital, Budapest, Hungary
| | - Zoltán Kovács
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary,
| | | | - Henrik Szőke
- Doctoral School of Health Sciences, Faculty of Health Sciences, University of Pécs, Pécs, Hungary, .,Department of CAM, Faculty of Health Sciences, University of Pécs, Pécs, Hungary,
| |
Collapse
|