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Desai KG. Subcutaneous Administration of Therapeutic Monoclonal Antibody Drug Products Using a Syringe in Blinded Clinical Trials: Advances and Key Aspects Related to Blinding/Matching/Masking Strategies for Placebo Formulation. Mol Pharm 2025. [PMID: 39745002 DOI: 10.1021/acs.molpharmaceut.4c01166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
Abstract
Therapeutic monoclonal antibody (mAb) drug products are increasingly used to treat both chronic and acute diseases. These mAb drug products are often developed for subcutaneous (SC) injection to simplify dosing compared with intravenous (IV) infusion. For SC injection, the mAb liquid drug product is typically filled in a vial for use with a syringe or in a prefilled syringe, which can then be assembled into a safety syringe device or an autoinjector for direct administration. A placebo is an inert formulation (one without an active ingredient) that lacks pharmacological activity or a therapeutic effect. It serves as a control in blinded clinical trials to evaluate the efficacy of a new treatment. A suitable blinding/matching/masking strategy is crucial to ensure that study participants cannot distinguish between the active mAb formulation and the placebo. The success of these strategies is pivotal in ensuring the accuracy and reliability of clinical trial results. This Review summarizes recent advances and key considerations related to placebo strategies. It covers the benefits and challenges of SC injection of therapeutic mAbs compared to IV infusion, the placebo effect, the significance of blinding/matching/masking, and various strategies. Strategies discussed include the use of traditional placebos (e.g., normal saline, 5% w/v dextrose solution, and formulation buffer of the active mAb), syringe blinding, the use of different gauge syringe needles, novel (custom) placebos, dilution, independent administration, and multiple injections. Additional topics covered include the incidence of antidrug antibodies (ADAs), the benefits and challenges associated with different strategies, and regulatory expectations regarding custom placebos. By addressing these critical aspects, the Review aims to contribute to the growing body of knowledge and ongoing efforts to enhance the effectiveness of formulation blinding, matching, and masking in clinical trials.
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Affiliation(s)
- Kashappa Goud Desai
- Drug Product Development-Steriles, Medicine Development and Supply, GSK, 1250 S. Collegeville Road, Collegeville, Pennsylvania 19426, United States
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Dehghani A, Bango C, Murphy EK, Halter RJ, Wager TD. Independent effects of transcranial direct current stimulation and social influence on pain. Pain 2025; 166:87-98. [PMID: 39167466 PMCID: PMC11649493 DOI: 10.1097/j.pain.0000000000003338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 05/28/2024] [Indexed: 08/23/2024]
Abstract
ABSTRACT Transcranial direct current stimulation (tDCS) is a noninvasive neuromodulatory technique with the potential to provide pain relief. However, tDCS effects on pain are variable across existing studies, possibly related to differences in stimulation protocols and expectancy effects. We investigated the independent and joint effects of contralateral motor cortex tDCS (anodal vs cathodal) and socially induced expectations (analgesia vs hyperalgesia) about tDCS on thermal pain. We employed a double-blind, randomized 2 × 2 factorial cross-over design, with 5 sessions per participant on separate days. After calibration in Session 1, Sessions 2 to 5 crossed anodal or cathodal tDCS (20 minutes 2 mA) with socially induced analgesic or hyperalgesic expectations, with 6 to 7 days between the sessions. The social manipulation involved videos of previous "participants" (confederates) describing tDCS as inducing a low-pain state ("analgesic expectancy") or hypersensitivity to sensation ("hyperalgesic expectancy"). Anodal tDCS reduced pain compared with cathodal stimulation (F(1,19.9) = 19.53, P < 0.001, Cohen d = 0.86) and analgesic expectancy reduced pain compared with hyperalgesic expectancy (F(1,19.8) = 5.62, P = 0.027, Cohen d = 0.56). There was no significant interaction between tDCS and social expectations. Effects of social suggestions were related to expectations, whereas tDCS effects were unrelated to expectancies. The observed additive effects provide novel evidence that tDCS and socially induced expectations operate through independent processes. They extend clinical tDCS studies by showing tDCS effects on controlled nociceptive pain independent of expectancy effects. In addition, they show that social suggestions about neurostimulation effects can elicit potent placebo effects.
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Affiliation(s)
- Amin Dehghani
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, NH, USA
| | - Carmen Bango
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, NH, USA
| | - Ethan K. Murphy
- Thayer School of Engineering and Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Ryan J. Halter
- Thayer School of Engineering and Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Tor D. Wager
- Department of Psychological and Brain Sciences, Dartmouth College, Hanover, NH, USA
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Moreno RJ, Ashwood P. An Update on Microbial Interventions in Autism Spectrum Disorder with Gastrointestinal Symptoms. Int J Mol Sci 2024; 25:13078. [PMID: 39684788 PMCID: PMC11641496 DOI: 10.3390/ijms252313078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2024] [Revised: 11/24/2024] [Accepted: 11/29/2024] [Indexed: 12/18/2024] Open
Abstract
In the United States, autism spectrum disorder (ASD) affects 1 in 33 children and is characterized by atypical social interactions, communication difficulties, and intense, restricted interests. Microbial dysbiosis in the gastrointestinal (GI) tract is frequently observed in individuals with ASD, potentially contributing to behavioral manifestations and correlating with worsening severity. Moreover, dysbiosis may contribute to the increased prevalence of GI comorbidities in the ASD population and exacerbate immune dysregulation, further worsening dysbiosis. Over the past 25 years, research on the impact of microbial manipulation on ASD outcomes has gained substantial interest. Various approaches to microbial manipulation have been preclinically and clinically tested, including antibiotic treatment, dietary modifications, prebiotics, probiotics, and fecal microbiota transplantation. Each method has shown varying degrees of success in reducing the severity of ASD behaviors and/or GI symptoms and varying long-term efficacy. In this review, we discuss these microbiome manipulation methods and their outcomes. We also discuss potential microbiome manipulation early in life, as this is a critical period for neurodevelopment.
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Affiliation(s)
- Rachel J. Moreno
- Department of Medical Microbiology and Immunology, University of California, Davis, CA 95616, USA
- The M.I.N.D. Institute, University of California, Davis, CA 95817, USA
| | - Paul Ashwood
- Department of Medical Microbiology and Immunology, University of California, Davis, CA 95616, USA
- The M.I.N.D. Institute, University of California, Davis, CA 95817, USA
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Liu SL, Li XY, Yang JH, Wen DX, Guo SS, Liu LT, Li YF, Luo MJ, Xie SY, Liang YJ, Sun XS, Yang ZC, Lv XF, Luo DH, Li JB, Liu Q, Wang P, Guo L, Mo HY, Sun R, Yang Q, Lan KQ, Jia GD, Li R, Zhao C, Xu RH, Chen QY, Tang LQ, Mai HQ. Neoadjuvant and adjuvant toripalimab for locoregionally advanced nasopharyngeal carcinoma: a randomised, single-centre, double-blind, placebo-controlled, phase 2 trial. Lancet Oncol 2024; 25:1563-1575. [PMID: 39522541 DOI: 10.1016/s1470-2045(24)00504-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 09/05/2024] [Accepted: 09/05/2024] [Indexed: 11/16/2024]
Abstract
BACKGROUND Patients with locoregionally advanced nasopharyngeal carcinoma with a high pretreatment plasma concentration of Epstein-Barr virus (EBV) DNA remain at high risk for recurrence after concurrent chemoradiotherapy. This study aimed to compare the efficacy and safety of neoadjuvant-adjuvant treatment with the PD-1 inhibitor toripalimab and concurrent chemoradiotherapy versus placebo and concurrent chemoradiotherapy in patients with locoregionally advanced nasopharyngeal carcinoma. METHODS This randomised, single-centre, double-blind, placebo-controlled, phase 2 trial was conducted at Sun Yat-sen University Cancer Centre in Guangzhou, China. Adult patients (aged 18-65 years) with newly diagnosed high-risk stage III-IVa locoregionally advanced nasopharyngeal carcinoma, with a pretreatment plasma EBV DNA concentration of at least 1500 copies per mL and an Eastern Cooperative Oncology Group performance score of 0-1, were eligible. Patients were randomly assigned (2:1) using an interactive web response system (block size of six), stratified by TNM stage (III vs IVa), to neoadjuvant toripalimab (240 mg intravenously) or placebo once every 2 weeks for two cycles, followed by concurrent cisplatin (100 mg/m2 intravenously) on days 1, 22, and 43 during intensity-modulated radiotherapy and adjuvant toripalimab (240 mg intravenously) or placebo once every 3 weeks for up to eight cycles. The primary endpoint was 2-year progression-free survival in the intention-to-treat population. This study was registered with ClinicalTrials.gov, NCT03925090, and is closed to enrolment; follow-up is ongoing. FINDINGS Between Dec 6, 2019, and Dec 9, 2021, 150 patients were enrolled and randomly assigned to the toripalimab group (n=100) or placebo group (n=50). 115 (77%) patients were male and 35 (23%) were female. As of data cutoff (May 31, 2024), median follow-up for progression-free survival was 37·8 months (IQR 34·2-46·5) for the intention-to-treat population analyses. 2-year progression-free survival was higher in the toripalimab group (92·0% [95% CI 86·7-97·3]) than in the placebo group (74·0% [61·8-86·2]; stratified hazard ratio 0·40 [95% CI 0·18-0·89]; log-rank p=0·019). The most common grade 3 or worse acute adverse events (occurring within 1 year of randomisation) were leukopenia (40 [40%] of 99 patients in the toripalimab group vs 22 [44%] of 50 patients in the placebo group), mucositis (28 [28%] vs ten [20%]), neutropenia (17 [17%] vs nine [18%]), anaemia (16 [16%] vs five [10%]), and weight loss (12 [12%] vs six [12%]). The most common grade 3 or worse late adverse events (occurring >1 year after randomisation) was auditory or hearing loss (eight [8%] vs four [8%]). Immune-mediated adverse events of grade 3 or worse occurred in ten (10%) patients only in the toripalimab group. One (2%) of 50 patients in the placebo group died due to septic shock caused by bacteraemia considered not treatment related. There were no treatment-related deaths in the toripalimab group. INTERPRETATION Our findings suggested that a so-called sandwich approach involving toripalimab (in the neoadjuvant and adjuvant phases) combined with concurrent chemoradiotherapy could be a highly promising therapy for the treatment of locoregionally advanced nasopharyngeal carcinoma. Phase 3 non-inferiority trials are warranted comparing neoadjuvant and adjuvant toripalimab versus cisplatin plus gemcitabine neoadjuvant chemotherapy combined with concurrent chemoradiotherapy. FUNDING National Key Research and Development Program of China, National Natural Science Foundation of China, Guangdong Basic and Applied Basic Research Foundation, Science and Technology Program of Guangzhou, Sun Yat-sen University Clinical Research 5010 Program, Innovative Research Team of High-level Local Universities in Shanghai, Postdoctoral Innovative Talent Support Program, Planned Science and Technology Project of Guangdong Province, Key Youth Teacher Cultivating Program of Sun Yat-sen University, and Fundamental Research Funds for the Central Universities. TRANSLATION For the Chinese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Sai-Lan Liu
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiao-Yun Li
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jin-Hao Yang
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Dong-Xiang Wen
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shan-Shan Guo
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Li-Ting Liu
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yi-Fu Li
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Mei-Juan Luo
- Department of Radiology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Si-Yi Xie
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yu-Jing Liang
- Department of Radiology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xue-Song Sun
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Zhen-Chong Yang
- Department of Nuclear Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiao-Fei Lv
- Department of Radiology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Dong-Hua Luo
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Ji-Bin Li
- Clinical Trials Center, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Qing Liu
- Clinical Trials Center, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Pan Wang
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Ling Guo
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Hao-Yuan Mo
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Rui Sun
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Qi Yang
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Kai-Qi Lan
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Guo-Dong Jia
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Ru Li
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chong Zhao
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Rui-Hua Xu
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Qiu-Yan Chen
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Lin-Quan Tang
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Hai-Qiang Mai
- Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, China; State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Collaborative Innovation Center for Cancer Medicine, and Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China.
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Thakker A, Ramchandani JP, Divall P, Sutton A, Johnson N, Dias J. What Are the Most Clinically Effective Nonoperative Interventions for Thumb Carpometacarpal Osteoarthritis? An Up-to-date Systematic Review and Network Meta-analysis. Clin Orthop Relat Res 2024:00003086-990000000-01807. [PMID: 39560669 DOI: 10.1097/corr.0000000000003300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Accepted: 10/11/2024] [Indexed: 11/20/2024]
Abstract
BACKGROUND Thumb carpometacarpal osteoarthritis (CMC-1 OA) is a common and debilitating condition, particularly among older adults and women. With the aging population, the prevalence of CMC-1 OA is expected to rise, emphasizing the need to find effective nonoperative strategies. So far, for determining the most effective nonoperative interventions in CMC-1 OA, two network meta-analyses (NMAs) have been published. However, these NMAs were limited to specific intervention types: one comparing multiple splints and the other comparing different intraarticular injections. Therefore, an NMA that compared all nonoperative intervention types is urgently needed. QUESTIONS/PURPOSES This study aimed to assess and compare the effectiveness of available nonoperative interventions (both nonpharmacologic and pharmacologic) for CMC-1 OA to establish which nonoperative options are more effective than control in terms of (1) pain, (2) function, and (3) grip strength. METHODS We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) NMA guidelines (PROSPERO: CRD2021272247) and conducted a comprehensive search across Medline, Embase, CENTRAL, and CINAHL up to March 2023. We included randomized controlled trials (RCTs) and quasi-RCTs evaluating nonoperative interventions for symptomatic CMC-1 OA, excluding inflammatory or posttraumatic arthritis. Studies comparing ≥ 2 interventions or against a control, focusing on pain reduction, functional improvement, and grip strength, were selected. We assessed methodologic quality using the modified Coleman Methodology Score, including only studies scoring > 70. Risk of bias was evaluated with the Risk of Bias 2.0 tool, and evidence quality with Confidence in Network Meta-Analysis (CINeMA). Of 29 screened studies, 22 (21 RCTs and one quasi-RCT) were included, involving 1631 women and 331 men. We analyzed eight different nonoperative interventions, including splints, hand exercises, injections, and multimodal treatment (≥ 2 nonpharmacologic interventions or nonpharmacologic with a pharmacologic intervention). Six studies had a low risk of bias, eight had a high risk, and the remainder were moderate. We extracted mean and SD scores, and NMA and pairwise analyses were performed at short- (≤ 3 months) and medium-term (> 3 to ≤ 12 months) time points. Standardized mean differences were re-expressed into common units for interpretation, which were the VAS (range 0 to 10) for pain, the DASH test (range to 100) for function, and pounds for grip strength. Clinical recommendations were considered strong if the mean differences exceeded the minimum clinically important difference-1.4 points for VAS, 10 points for DASH, and 14 pounds for grip strength-and were supported by moderate or high confidence in the evidence, as assessed using CINeMA methodology. RESULTS Our NMA (based on moderate or high confidence) showed a clinically important reduction in pain at the short-term time point for multimodal treatment and hand exercises versus control (mean difference VAS score -5.3 [95% confidence interval (CI) -7.6 to -3.0] and -5.0 [95% CI -8.5 to -1.5]). At the medium-term time point, only the rigid carpometacarpal-metacarpophalangeal (CMC-MCP) splint was superior to control (mean difference VAS score -1.9 [95% CI -3.1 to -0.6]) and demonstrated clinical importance. For function, only the rigid CMC-MCP splint demonstrated a clinically important improvement at the medium-term time point versus control (mean difference DASH score -11 [95% CI -21 to -1]). Hand exercises resulted in a clinically important improvement in short-term grip strength versus control (mean difference 21 pounds [95% CI 11 to 31]). CONCLUSION This systematic review and NMA show that multimodal treatment and hand exercises reduce short-term pain and improve grip strength, while a rigid CMC-MCP splint enhances medium-term function. Future research should evaluate long-term efficacy. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Arjuna Thakker
- Academic Team of Musculoskeletal Surgery, Leicester General Hospital, Leicester, UK
| | | | | | | | | | - Joseph Dias
- Academic Team of Musculoskeletal Surgery, Leicester General Hospital, Leicester, UK
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6
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Lopes Alves R, Zortea M, Vicuña Serrano P, Laranjeira VDS, Franceschini Tocchetto B, Ramalho L, Fernanda da Silveira Alves C, Brugnera Tomedi R, Pereira de Almeida R, Machado Bruck S, Medeiros L, R. S. Sanches P, P. Silva D, Torres ILS, Fregni F, Caumo W. Modulation of neural networks and symptom correlated in fibromyalgia: A randomized double-blind multi-group explanatory clinical trial of home-based transcranial direct current stimulation. PLoS One 2024; 19:e0288830. [PMID: 39536019 PMCID: PMC11560039 DOI: 10.1371/journal.pone.0288830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 09/02/2024] [Indexed: 11/16/2024] Open
Abstract
BACKGROUND Transcranial direct current stimulation (tDCS) might modulate neural activity and promote neural plasticity in patients with fibromyalgia (FM). This multi-group randomized clinical trial compared home-based active tDCS (HB-a-tDCS) on the left dorsolateral prefrontal cortex (l-DLPFC) or home-based sham tDCS (HB-s-tDCS), and HB-a-tDCS or HB-s-tDCS on the primary motor cortex (M1) in the connectivity analyses in eight regions of interest (ROIs) across eight resting-state electroencephalography (EEG) frequencies. METHODS We included 48 women with FM, aged 30 to 65, randomly assigned to 2:1:2:1 to receive 20 sessions during 20 minutes of HB-a-tDCS 2mA or HB-s-tDCS, over l-DLPFC or M1, respectively. EEG recordings were obtained before and after treatment with eyes open (EO) and eyes closed (EC). RESULTS In the EC condition, comparing pre to post-treatment, the HB-a-tDCS on l-DLPFC decreased the lagged coherence connectivity in the delta frequency band between the right insula and left anterior cingulate cortex (ACC) (t = -3.542, p = .048). The l-DLPFC HB-a-tDCS compared to HB-s-tDCS decreased the lagged coherence connectivity in the delta frequency band between the right insula and left ACC (t = -4.000, p = .017). In the EO condition, the l-DLPFC HB-a-tDCS compared to M1 HB-s-tDCS increased the lagged coherence connectivity between the l-DLPFC and left ACC in the theta band (t = -4.059, p = .048). Regression analysis demonstrated that the HB-a-tDCS effect on the l-DLPFC was positively correlated with sleep quality. On the other hand, the HB-a-tDCS on l-DLPFC and HB-s-tDCS on M1 were positively correlated with pain catastrophizing. CONCLUSIONS These results show that HB-a-tDCS affects the neural connectivity between parts of the brain that control pain's emotional and attentional aspects, which are most noticeable at lower EEG frequencies in a rest state. This effect on neural oscillations could serve as a neural marker associated with its efficacy in alleviating fibromyalgia symptoms. CLINICAL TRIAL REGISTRATION identifier [NCT03843203].
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Affiliation(s)
- Rael Lopes Alves
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Maxciel Zortea
- Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Health School, University of Vale do Rio dos Sinos, São Leopoldo, Porto Alegre, Brazil
| | - Paul Vicuña Serrano
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Vani dos Santos Laranjeira
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Betina Franceschini Tocchetto
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Leticia Ramalho
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Camila Fernanda da Silveira Alves
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Rafaela Brugnera Tomedi
- Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | | | - Samara Machado Bruck
- Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Liciane Medeiros
- Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Post-Graduate Program in Health and Human Development, Universidade La Salle, Canoas, Brazil
| | - Paulo R. S. Sanches
- Laboratory of Biomedical Engineer, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Danton P. Silva
- Laboratory of Biomedical Engineer, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Iraci L. S. Torres
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Pharmacology of Pain and Neuromodulation: Pre-Clinical Investigations Research Group, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Felipe Fregni
- Laboratory of Neuromodulation and Center for Clinical Research Learning, Physics and Rehabilitation Department, Spaulding Rehabilitation Hospital, Boston, Massachusetts, United States of America
| | - Wolnei Caumo
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Laboratory of Pain and Neuromodulation, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Pain and Palliative Care Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Department of Surgery, School of Medicine, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
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7
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Treister R, Cohen V, Issa L, Beiruti Wiegler K, Izakson A, Agostinho M. The Power of a Good Word: Enhancing the Efficacy of Analgesics in Clinical Settings. PSYCHOTHERAPY AND PSYCHOSOMATICS 2024:1-8. [PMID: 39496250 DOI: 10.1159/000541810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Accepted: 10/02/2024] [Indexed: 11/06/2024]
Abstract
INTRODUCTION Communication between medical staff and patients about treatment efficacy elicits expectations of benefit and improves treatment outcomes. While demonstrated in multiple studies via different research methodologies, uniform communication protocols have not been adopted in clinical practice. Here, we summarize the results of two sister studies aimed at bridging this gap. METHODS Women undergoing C-section (study 1, randomized controlled trial) and patients undergoing general or otolaryngologic surgeries (study 2, control group design) were recruited and assigned to the "regular communication" (RC) or "enhanced communication" (EC) arms. The EC arm received positive information about treatment, while the RC arm received no such information. In both studies, the primary outcome was change in pain intensity; in study 2, an additional outcome was morphine consumption. RESULTS Eighty women successfully completed study 1, and 102 patients successfully completed study 2. In both studies, significant time*group interactions were observed (p < 0.001). The analgesic effect was virtually twice as large in the EC arm compared to the RC arm. In study 2, in the last two timepoints of assessment, participants in the EC arm also consumed fewer doses of opioids than participants in the RC arm (p < 0.001). No significant differences were found in vital signs. CONCLUSIONS We provide ecological evidence that positive information about treatment significantly decreases pain and opioid consumption during routine clinical care. This study and others could encourage healthcare providers to harness the powerful effects of patients' expectations of benefit to improve analgesics outcomes and, potentially, the outcomes of other symptoms.
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Affiliation(s)
- Roi Treister
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Vered Cohen
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
- Maternity Unit, Carmel Medical Center, Haifa, Israel
| | - Limor Issa
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
- Recovery Department, Ziv Medical Center, Safed, Israel
- Research Wing, Ziv Medical Center, Safed, Israel
| | - Karine Beiruti Wiegler
- Recovery Department, Ziv Medical Center, Safed, Israel
- Research Wing, Ziv Medical Center, Safed, Israel
| | | | - Mariana Agostinho
- The Cheryl Spencer Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel,
- CIIS, Center for Interdisciplinary Health Research, Universidade Católica Portuguesa, Lisbon, Portugal,
- Faculty of Health Sciences and Nursing, Universidade Católica Portuguesa, Lisbon, Portugal,
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8
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Soliman N, Kersebaum D, Lawn T, Sachau J, Sendel M, Vollert J. Improving neuropathic pain treatment - by rigorous stratification from bench to bedside. J Neurochem 2024; 168:3699-3714. [PMID: 36852505 DOI: 10.1111/jnc.15798] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 02/10/2023] [Accepted: 02/22/2023] [Indexed: 03/01/2023]
Abstract
Chronic pain is a constantly recurring and persistent illness, presenting a formidable healthcare challenge for patients and physicians alike. Current first-line analgesics offer only low-modest efficacy when averaged across populations, further contributing to this debilitating disease burden. Moreover, many recent trials for novel analgesics have not met primary efficacy endpoints, which is particularly striking considering the pharmacological advances have provided a range of highly relevant new drug targets. Heterogeneity within chronic pain cohorts is increasingly understood to play a critical role in these failures of treatment and drug discovery, with some patients deriving substantial benefits from a given intervention while it has little-to-no effect on others. As such, current treatment failures may not result from a true lack of efficacy, but rather a failure to target individuals whose pain is driven by mechanisms which it therapeutically modulates. This necessitates a move towards phenotypical stratification of patients to delineate responders and non-responders in a mechanistically driven manner. In this article, we outline a bench-to-bedside roadmap for this transition to mechanistically informed personalised pain medicine. We emphasise how the successful identification of novel analgesics is dependent on rigorous experimental design as well as the validity of models and translatability of outcome measures between the animal model and patients. Subsequently, we discuss general and specific aspects of human trial design to address heterogeneity in patient populations to increase the chance of identifying effective analgesics. Finally, we show how stratification approaches can be brought into clinical routine to the benefit of patients.
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Affiliation(s)
- Nadia Soliman
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Dilara Kersebaum
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Timothy Lawn
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Juliane Sachau
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Manon Sendel
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, UK
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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9
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Anbar RD, Spence NA. Hypnosis in the treatment of retrograde cricopharyngeus dysfunction: A case report. AMERICAN JOURNAL OF CLINICAL HYPNOSIS 2024; 66:350-356. [PMID: 37703128 DOI: 10.1080/00029157.2023.2249535] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Retrograde cricopharyngeus dysfunction (R-CPD) causes an inability to belch. This case report describes the successful treatment of R-CPD with the use of hypnosis. Thereafter, the patient was able to burp small amounts of air, and was encouraged to continue his use of hypnosis as needed. Hypnosis and possibly other noninvasive treatments should be used for R-CPD before employment of more invasive and costly treatments such as botulinum toxin administration.
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10
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Guthrie SE, Luensmann D, Schulze MM, Woods J, Jones L. Investigation of Delefilcon A Contact Lenses for Symptomatic Daily Disposable Contact Lens Wearers with Dry Eye Disease: A Prospective Comparative Study. Clin Ophthalmol 2024; 18:2999-3008. [PMID: 39463852 PMCID: PMC11512522 DOI: 10.2147/opth.s482568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2024] [Accepted: 10/04/2024] [Indexed: 10/29/2024] Open
Abstract
Purpose This prospective comparative study aimed to assess the effects on contact lens comfort, dryness, and wear time when symptomatic daily disposable (DD) contact lens (CL) wearers were refit with delefilcon A (DT1) lenses. Patients and Methods Thirty five symptomatic DD CL wearers with dry eye disease as determined according to the TFOS DEWS 2 guidelines, were enrolled and completed the study. Participants wore their habitual DD CLs during an initial assessment and were subsequently refit with DT1 for 1 month. Participants were masked to the study lens type. Subjective ratings of end-of-day comfort and dryness, average wear time, and comfortable wear time were evaluated as primary endpoints. Results Of the 35 participants, two participants were classified as aqueous deficient dry eye, while the remaining participants exhibited symptoms primarily due to evaporative causes. The median CLDEQ-8 score for dryness significantly improved from 17 (fair) with habitual lenses to 13 (good) with DT1 lenses (p < 0.01). Participants reported significantly better end-of-day comfort (p = 0.01) and less end-of-day dryness (p = 0.01) with DT1 compared to their habitual DD lenses. The comfortable wear time was significantly longer with DT1 (8.5 ± 4.1 hours) compared to habitual DD lenses (6.7 ± 3.2 hours) (p = 0.04). No significant differences were observed in vision ratings (p = 0.07). Conclusion Refitting symptomatic DD CL wearers with DT1 resulted in improved end-of-day comfort, reduced end-of-day dryness, and extended comfortable wear time compared to their habitual lenses. These findings suggest that DT1 may offer benefits for symptomatic DD wearers with dry eye disease.
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Affiliation(s)
- Sarah E Guthrie
- Centre for Ocular Research & Education (CORE), School of Optometry & Vision Science, University of Waterloo, Waterloo, Ontario, N2L 3G1, Canada
| | - Doerte Luensmann
- Centre for Ocular Research & Education (CORE), School of Optometry & Vision Science, University of Waterloo, Waterloo, Ontario, N2L 3G1, Canada
| | - Marc-Matthias Schulze
- Centre for Ocular Research & Education (CORE), School of Optometry & Vision Science, University of Waterloo, Waterloo, Ontario, N2L 3G1, Canada
| | - Jill Woods
- Centre for Ocular Research & Education (CORE), School of Optometry & Vision Science, University of Waterloo, Waterloo, Ontario, N2L 3G1, Canada
| | - Lyndon Jones
- Centre for Ocular Research & Education (CORE), School of Optometry & Vision Science, University of Waterloo, Waterloo, Ontario, N2L 3G1, Canada
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11
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Lecorps B, Weary D. Animal affect, welfare and the Bayesian brain. Anim Welf 2024; 33:e39. [PMID: 39464389 PMCID: PMC11503760 DOI: 10.1017/awf.2024.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 06/04/2024] [Accepted: 06/25/2024] [Indexed: 10/29/2024]
Abstract
According to the Bayesian brain hypothesis, the brain can be viewed as a predictive machine, such that predictions (or expectations) affect how sensory inputs are integrated. This means that in many cases, affective responses may depend more on the subject's perception of the experience (driven by expectations built on past experiences) rather than on the situation itself. Little research to date has applied this concept to affective states in animals. The aim of this paper is to explore how the Bayesian brain hypothesis can be used to understand the affective experiences of animals and to develop a basis for novel predictions regarding animal welfare. Drawing from the literature illustrating how predictive processes are important to human well-being, and are often impaired in affective disorders, we explore whether the Bayesian brain theories may help understanding animals' affective responses and whether deficits in predictive processes may lead to previously unconsidered welfare consequences. We conclude that considering animals as predictive entities can improve our understanding of their affective responses, with implications for basic research and for how to provide animals a better life.
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Affiliation(s)
- Benjamin Lecorps
- Bristol Veterinary School, University of Bristol, Bristol BS40 5DU, UK
| | - Daniel Weary
- Animal Welfare Program, Faculty of Land and Food Systems, 2357 Main Mall, University of British Columbia, Vancouver BC V6T 1Z6, Canada
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12
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Adindu E, Singh D, Geck M, Stokes J, Truumees E. How Minimal Clinically Important Difference and Patient Acceptable Symptom State Relate to Patient Expectations and Satisfaction in Spine Surgery: A Review. Clin Spine Surg 2024; 37:323-328. [PMID: 39072525 DOI: 10.1097/bsd.0000000000001672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 06/28/2024] [Indexed: 07/30/2024]
Abstract
This narrative review seeks to enhance our comprehension of how Minimal Clinically Important Difference (MCID) and Patient Acceptable Symptom State (PASS) values in established Patient Reported Outcome Measures (PROMs) for spine surgery correspond with patient preoperative expectations and postoperative satisfaction. Through our literature search, we found that both MCID and PASS serve as dependable indicators of patient expectations. However, MCID may be more susceptible to a floor effect. This implies that PASS may offer a more accurate reflection of how patients anticipate surgery to address their symptoms. Nevertheless, it is crucial to recognize that achieving MCID or PASS may not be an absolute prerequisite for patients to be satisfied with their treatment.
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Affiliation(s)
- Ebubechi Adindu
- Department of Surgery and Perioperative Care, The University of Texas Dell Medical School
| | - Devender Singh
- Department of Spine Surgery, Ascension Texas Spine and Scoliosis
| | - Matthew Geck
- Department of Spine Surgery, The University of Texas Dell Medical School, Ascension Texas Spine and Scoliosis
| | - John Stokes
- Department of Spine Surgery, Ascension Texas Spine and Scoliosis
| | - Eeric Truumees
- Department of Spine Surgery, The University of Texas Dell Medical School, Ascension Texas Spine and Scoliosis, Austin, TX
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13
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Mertens M. The self-fulfilling prophecy in medicine. THEORETICAL MEDICINE AND BIOETHICS 2024; 45:363-385. [PMID: 39120693 PMCID: PMC11358258 DOI: 10.1007/s11017-024-09677-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/30/2024] [Indexed: 08/10/2024]
Abstract
This article first describes the mechanism of any self-fulfilling prophecy through discussion of its four conditions: credibility, employment, employment sensitivity, and realization. Each condition is illustrated with examples specific to the medical context. The descriptive account ends with the definition of self-fulfilling prophecy and an expansion on collective self-fulfilling prophecies. Second, the normative account then discusses the moral relevance of self-fulfilling prophecies in medicine. A self-fulfilling prophecy is typically considered problematic when the prediction itself changes the predicted outcome to match the prediction (transformative self-fulfillment). I argue that also self-fulfilling prophecies that do not change the outcome but change the ways in which the outcome was realized (operative self-fulfillment), have significant ethical and epistemic ramifications. Because it is difficult to distinguish, retrospectively, between a transformative and an operative self-fulfilling prophecy, and thus between a false or true positive, it becomes equally difficult to catch mistakes. Moreover, since the prediction necessarily turns out true, there is never an error signal warning that a mistake might have been made. On the contrary, accuracy is seen as the standard for quality assurance. As such, self-fulfilling prophecies inhibit our ability to learn, inviting repetition and exacerbation of mistakes. With the rise of automated diagnostic and prognostic procedures and the increased use of machine learning and artificial intelligence for the development of predictive algorithms, attention to self-fulfilling feedback loops is especially warranted. This account of self-fulfilling prophecies is practically relevant for medical research and clinical practice. With it, researchers and practitioners can detect and analyze potential self-fulfilling mechanisms in any medical case and take responsibility for their ethical and epistemic implications.
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Affiliation(s)
- Mayli Mertens
- Department of Philosophy, Center for Ethics, University of Antwerp, Antwerp, Belgium.
- Department of Public Health, Center for Medical Science and Technology Studies, University of Copenhagen, Copenhagen, Denmark.
- Atlas Bioethics Center, Andalusia, Spain.
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14
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Cheng C, Guo Y, Liu B, Wruck L, Li F, Li F. Multiply robust estimation of principal causal effects with noncompliance and survival outcomes. Clin Trials 2024; 21:553-561. [PMID: 38813813 DOI: 10.1177/17407745241251773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Treatment noncompliance and censoring are two common complications in clinical trials. Motivated by the ADAPTABLE pragmatic clinical trial, we develop methods for assessing treatment effects in the presence of treatment noncompliance with a right-censored survival outcome. We classify the participants into principal strata, defined by their joint potential compliance status under treatment and control. We propose a multiply robust estimator for the causal effects on the survival probability scale within each principal stratum. This estimator is consistent even if one, sometimes two, of the four working models-on the treatment assignment, the principal strata, censoring, and the outcome-is misspecified. A sensitivity analysis strategy is developed to address violations of key identification assumptions, the principal ignorability and monotonicity. We apply the proposed approach to the ADAPTABLE trial to study the causal effect of taking low- versus high-dosage aspirin on all-cause mortality and hospitalization from cardiovascular diseases.
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Affiliation(s)
- Chao Cheng
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Yueqi Guo
- Department of Statistical Science, Duke University, Durham, NC, USA
| | - Bo Liu
- Department of Statistical Science, Duke University, Durham, NC, USA
| | - Lisa Wruck
- Department of Biostatistics and Bioinformatics, School of Medicine, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Fan Li
- Department of Statistical Science, Duke University, Durham, NC, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
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15
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Ausi Y, Yunivita V, Santoso P, Sunjaya DK, Barliana MI, Ruslami R. A Mixed-Method Study of Medication-Related Burden Among Multi-Drug Resistant Tuberculosis Patients in West Java, Indonesia. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:707-719. [PMID: 39345348 PMCID: PMC11438463 DOI: 10.2147/ceor.s473768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Accepted: 09/11/2024] [Indexed: 10/01/2024] Open
Abstract
Background Multidrug-resistant tuberculosis presents a challenging obstacle in global TB control. It necessitates complex and long-term therapy, which can potentially lead to medication-related burdens that may ultimately reduce therapy adherence and quality of life. Purpose This study aimed to gain a deep understanding of the medication-related burdens experienced by multidrug-resistant tuberculosis patients. Methods The study was conducted using a convergent mixed-method approach involving MDR-TB patients and their caregivers. Qualitative data were collected through semi-structured in-depth interviews, while quantitative data were gathered using the validated Living with Medicine Questionnaire 3. In the quantitative part, associations between patients' characteristics and burden levels were analysed using bivariate and multivariate analyses. Results Seventy-four participants were involved in the study, with 71 of them completing the questionnaire and 36 participating in interviews. The qualitative results revealed the subjectivity of medication-related burden perception, which could not be fully captured by the quantitative method. Four themes of medication-related burdens emerged: personal beliefs, regimen burdens, socioeconomic burdens, and healthcare burdens. The quantitative results provided a generalized representation of the population. Age and side effects were found to be significantly associated with higher burden levels, with those aged 18-30 having an odds ratio (OR) of 7.303 (95% CI: 1.045-51.034), and those aged 31-40 having an OR of 6.53 (95% CI: 1.077-39.607). Additionally, experiencing side effects had a substantial impact, with an OR of 46.602 (95% CI: 2.825-768.894). Both sets of results are valuable for designing patient-centered care. Conclusion MDR-TB therapy imposes a significant burden, particularly regarding the characteristics of regimen. By understanding this burden, healthcare professionals can help improve the quality of life for these patients.
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Affiliation(s)
- Yudisia Ausi
- Department of Biological Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Sumedang, West Java, Indonesia
| | - Vycke Yunivita
- Division of Pharmacology and Therapy, Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Prayudi Santoso
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia
- Hasan Sadikin General Hospital, Bandung, West Java, Indonesia
| | - Deni Kurniadi Sunjaya
- Department of Public Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Melisa Intan Barliana
- Department of Biological Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Sumedang, West Java, Indonesia
- Center of Excellence for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, West Java, Indonesia
| | - Rovina Ruslami
- Division of Pharmacology and Therapy, Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia
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16
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Pan Y, Gorenflo MP, Davis PB, Kaelber DC, De Luca S, Xu R. Suicidal ideation following ketamine prescription in patients with recurrent major depressive disorder: a nation-wide cohort study. Transl Psychiatry 2024; 14:327. [PMID: 39122686 PMCID: PMC11315997 DOI: 10.1038/s41398-024-03033-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 07/14/2024] [Accepted: 07/19/2024] [Indexed: 08/12/2024] Open
Abstract
Ketamine has gained attention for its effective treatment for patients with major depressive disorder (MDD) and suicidal ideation; Despite numerous studies presenting the rapid efficacy, long-term benefit in real-world populations remains poorly characterized. This is a retrospective cohort study using TriNetX US Collaborative Network, a platform aggregating electronic health records (EHRs) data from 108 million patients from 62 health care organizations in the US, and the study population includes 514,988 patients with a diagnosis of recurrent MDD who were prescribed relevant treatment in their EHRs. The prescription of ketamine was associated with significantly decreased risk of suicidal ideation compared to the prescription of other common antidepressants: HR = 0.63 (95% CI: 0.53-0.76) at 1 day - 7 days, 0.67 (95% CI: 0.59-0.77) at 1 day - 30 days, 0.69 (95% CI: 0.62-0.77) at 1 day - 90 days, 0.74 (95% CI: 0.67-0.81) at 1 day - 180 days, and 0.78 (95% CI: 0.69-0.83) at 1 day - 270 days. This trend was especially robust among adults over 24 years of age, females, males, and White patients with recurrent MDD. This study provides real-world evidence that ketamine has long-term benefits in mitigating suicidal ideation in patients with recurrent MDD. Future work should focus on optimizing dosage regimens for ketamine, understanding the mechanism, and the difference in various demographic subpopulations.
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Affiliation(s)
- Yiheng Pan
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Computer and Data Science, Case Western Reserve University, Cleveland, OH, USA
| | - Maria P Gorenflo
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Pamela B Davis
- Center for Community Health Integration, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - David C Kaelber
- Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH, USA
| | - Susan De Luca
- Population Health Research Institute, The MetroHealth System, Cleveland, OH, USA
| | - Rong Xu
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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17
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Chen C, Niehaus JK, Dinc F, Huang KL, Barnette AL, Tassou A, Shuster SA, Wang L, Lemire A, Menon V, Ritola K, Hantman AW, Zeng H, Schnitzer MJ, Scherrer G. Neural circuit basis of placebo pain relief. Nature 2024; 632:1092-1100. [PMID: 39048016 PMCID: PMC11358037 DOI: 10.1038/s41586-024-07816-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 07/11/2024] [Indexed: 07/27/2024]
Abstract
Placebo effects are notable demonstrations of mind-body interactions1,2. During pain perception, in the absence of any treatment, an expectation of pain relief can reduce the experience of pain-a phenomenon known as placebo analgesia3-6. However, despite the strength of placebo effects and their impact on everyday human experience and the failure of clinical trials for new therapeutics7, the neural circuit basis of placebo effects has remained unclear. Here we show that analgesia from the expectation of pain relief is mediated by rostral anterior cingulate cortex (rACC) neurons that project to the pontine nucleus (rACC→Pn)-a precerebellar nucleus with no established function in pain. We created a behavioural assay that generates placebo-like anticipatory pain relief in mice. In vivo calcium imaging of neural activity and electrophysiological recordings in brain slices showed that expectations of pain relief boost the activity of rACC→Pn neurons and potentiate neurotransmission in this pathway. Transcriptomic studies of Pn neurons revealed an abundance of opioid receptors, further suggesting a role in pain modulation. Inhibition of the rACC→Pn pathway disrupted placebo analgesia and decreased pain thresholds, whereas activation elicited analgesia in the absence of placebo conditioning. Finally, Purkinje cells exhibited activity patterns resembling those of rACC→Pn neurons during pain-relief expectation, providing cellular-level evidence for a role of the cerebellum in cognitive pain modulation. These findings open the possibility of targeting this prefrontal cortico-ponto-cerebellar pathway with drugs or neurostimulation to treat pain.
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Affiliation(s)
- Chong Chen
- Department of Cell Biology and Physiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Neuroscience Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Pharmacology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jesse K Niehaus
- Department of Cell Biology and Physiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Neuroscience Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Pharmacology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Fatih Dinc
- Department of Applied Physics, Stanford University, Stanford, CA, USA
- CNC Program, Stanford University, Stanford, CA, USA
| | - Karen L Huang
- Department of Cell Biology and Physiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Neuroscience Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Pharmacology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alexander L Barnette
- Department of Cell Biology and Physiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Neuroscience Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Pharmacology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adrien Tassou
- Department of Cell Biology and Physiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Neuroscience Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Pharmacology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - S Andrew Shuster
- Department of Neurobiology, Harvard Medical School, Boston, MA, USA
| | - Lihua Wang
- Janelia Research Campus, Howard Hughes Medical Institute, Ashburn, VA, USA
| | - Andrew Lemire
- Janelia Research Campus, Howard Hughes Medical Institute, Ashburn, VA, USA
| | - Vilas Menon
- Department of Neurology, Columbia University, New York, NY, USA
| | - Kimberly Ritola
- UNC Neuroscience Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Pharmacology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adam W Hantman
- Department of Cell Biology and Physiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Neuroscience Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Hongkui Zeng
- Allen Institute for Brain Science, Seattle, WA, USA
| | - Mark J Schnitzer
- Department of Applied Physics, Stanford University, Stanford, CA, USA
- CNC Program, Stanford University, Stanford, CA, USA
- Department of Biology, Stanford University, Stanford, CA, USA
- Department of Neurosurgery, Stanford University, Stanford, CA, USA
- James H. Clark Center for Biomedical Engineering & Sciences, Stanford University, Stanford, CA, USA
- Howard Hughes Medical Institute, Stanford University, Stanford, CA, USA
| | - Grégory Scherrer
- Department of Cell Biology and Physiology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- UNC Neuroscience Center, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Department of Pharmacology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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18
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Emadi Andani M, Barbiani D, Bonetto M, Menegaldo R, Villa-Sánchez B, Fiorio M. Preserving the placebo effect after disclosure: A new perspective on non-deceptive placebos. Br J Psychol 2024; 115:437-453. [PMID: 38226695 DOI: 10.1111/bjop.12696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/07/2023] [Accepted: 01/08/2024] [Indexed: 01/17/2024]
Abstract
The present study explores whether a particular style of placebo disclosure could serve as a tool to foster a renewed trust in one's own inherent resources and elicit a meaningful placebo effect. In a motor performance task, two placebo groups received inert transcutaneous electrical nerve stimulation (TENS) in each of four sessions along with information on its force-enhancing properties. Before the final session, one of the placebo groups was informed about the placebo, which was portrayed as a means to unleash an inherent potential. Along with force, we systematically monitored task-specific self-efficacy to test whether this variable would be differentially modulated in the two placebo groups. Compared to two control groups, placebo groups showed higher force and self-efficacy in the last session. No differences in self-efficacy were observed in the placebo groups even after revealing the placebo procedure, suggesting that the disclosure was effective in 'safeguarding' individuals' self-efficacy. These findings may have important implications, paving the way for the use of placebos that not only are ethically permissible but also support individuals' self-efficacy.
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Affiliation(s)
- Mehran Emadi Andani
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Diletta Barbiani
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Marco Bonetto
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Rudy Menegaldo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | | | - Mirta Fiorio
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
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19
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Westendorp J, van Vliet LM, Meeuwis SH, Olde Hartman TC, Sanders ARJ, Jutten E, Dirven M, Peerdeman KJ, Evers AWM. Optimizing placebo and minimizing nocebo effects through communication: e-learning and virtual reality training development. BMC MEDICAL EDUCATION 2024; 24:707. [PMID: 38951784 PMCID: PMC11218054 DOI: 10.1186/s12909-024-05671-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 06/18/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND The effects of many treatments in healthcare are determined by factors other than the treatment itself. Patients' expectations and the relationship with their healthcare provider can significantly affect treatment outcomes and thereby play a major role in eliciting placebo and nocebo effects. We aim to develop and evaluate an innovative communication training, consisting of an e-learning and virtual reality (VR) training, for healthcare providers across all disciplines, to optimize placebo and minimize nocebo effects through healthcare provider-patient communication. The current paper describes the development, mid-term evaluation, optimization, and final evaluation of the communication training, conducted in The Netherlands. METHODS The development of both the e-learning and the VR training consisted of four phases: 1) content and technical development, 2) mid-term evaluation by healthcare providers and placebo/communication researchers, 3) optimization of the training, and 4) final evaluation by healthcare providers. To ensure the success, applicability, authenticity, and user-friendliness of the communication training, there was ongoing structural collaboration with healthcare providers as future end users, experts in the field of placebo/communication research, and educational experts in all phases. RESULTS Placebo/communication researchers and healthcare providers evaluated the e-learning positively (overall 7.9 on 0-10 scale) and the content was perceived as useful, accessible, and interesting. The VR training was assessed with an overall 6.9 (0-10 scale) and was evaluated as user-friendly and a safe method for practicing communication skills. Although there were some concerns regarding the authenticity of the VR training (i.e. to what extent the virtual patient reacts like a real patient), placebo and communication researchers, as well as healthcare providers, recognized the significant potential of the VR training for the future. CONCLUSIONS We have developed an innovative and user-friendly communication training, consisting of an e-learning and VR training (2D and 3D), that can be used to teach healthcare providers how to optimize placebo effects and minimize nocebo effects through healthcare provider-patient communication. Future studies can work on improved authenticity, translate the training into other languages and cultures, expand with additional VR cases, and measure the expected effects on providers communication skills and subsequently patient outcomes.
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Affiliation(s)
- Janine Westendorp
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Wassenaarseweg 52, 2333 AK, Leiden, The Netherlands.
- Center for Interdisciplinary Placebo Studies (IPS) Leiden, Leiden, The Netherlands.
| | - Liesbeth M van Vliet
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Wassenaarseweg 52, 2333 AK, Leiden, The Netherlands
- Center for Interdisciplinary Placebo Studies (IPS) Leiden, Leiden, The Netherlands
| | - Stefanie H Meeuwis
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Wassenaarseweg 52, 2333 AK, Leiden, The Netherlands
- Center for Interdisciplinary Placebo Studies (IPS) Leiden, Leiden, The Netherlands
| | - Tim C Olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ariëtte R J Sanders
- General Medical Practice Van Lennep Huisartsenpraktijk, Driebergen, The Netherlands
| | - Eric Jutten
- The Simulation Crew (TSC), Nijmegen, The Netherlands
| | - Monique Dirven
- Dutch Institute for Rational Use of Medicine (IVM), Utrecht, The Netherlands
| | - Kaya J Peerdeman
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Wassenaarseweg 52, 2333 AK, Leiden, The Netherlands
- Center for Interdisciplinary Placebo Studies (IPS) Leiden, Leiden, The Netherlands
| | - Andrea W M Evers
- Health, Medical and Neuropsychology Unit, Institute of Psychology, Leiden University, Wassenaarseweg 52, 2333 AK, Leiden, The Netherlands
- Center for Interdisciplinary Placebo Studies (IPS) Leiden, Leiden, The Netherlands
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20
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Pascolutti M, Tomic A, Milleman KR, Milleman JL, Walsh LJ. Safety and Effectiveness of a Novel Color Corrector Serum for Causing Temporary Changes to Tooth Shade: A Randomized Controlled Clinical Study. Dent J (Basel) 2024; 12:197. [PMID: 39056984 PMCID: PMC11276226 DOI: 10.3390/dj12070197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/18/2024] [Accepted: 06/21/2024] [Indexed: 07/28/2024] Open
Abstract
Tooth color is a major driver of facial esthetics. While permanent changes in tooth shade can be achieved by bleaching and restorations, there is a need for cosmetic products that can cause reversible color changes. This randomized controlled clinical study assessed the effectiveness and safety of a novel color-correcting product (Hismile™ V34 Color Corrector Serum™) versus a placebo (vehicle control lacking the color-change dyes). A single-center, randomized, controlled, examiner-blind, two-group, parallel design, single-use study design was followed. The test products were applied on a cotton bud for 30 s, and then, rinsed off. Tooth shade for maxillary central incisors was measured at baseline, immediately, and at 30 and 60 min, using the Vita Bleachedguide 3D-Master® Shade Guide and the EasyShade Advanced 4.0 spectrophotometer (for determining values of L*a*b*). The subjects (N = 60) had a baseline shade of 1M2 (rank 9) or darker. A single application of the test product resulted in an immediate and significant (p < 0.001) three shade improvement (26.2%) according to the shade guide, and the same significant benefits extended to 30 and 60 min. The placebo product did not alter tooth shade (p = 0.326). These changes were accompanied by significant improvements in the L value (whiteness) up to 30 min, and a reduction in b* (yellowness) for up to 60 min. Two-thirds of subjects using the test product stated in a survey that their teeth appeared both whiter and brighter. No safety issues arose from the use of the test product or vehicle control. These results indicate that using a color corrector can achieve worthwhile changes to tooth shade for up to 60 min.
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Affiliation(s)
| | | | | | | | - Laurence J. Walsh
- School of Dentistry, The University of Queensland, Herston, QLD 4006, Australia;
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21
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Chiamulera C, Benvegnù G, Piva A, Paolone G. Ecocebo: How the interaction between environment and drug effects may improve pharmacotherapy outcomes. Neurosci Biobehav Rev 2024; 161:105648. [PMID: 38565340 DOI: 10.1016/j.neubiorev.2024.105648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/19/2024] [Accepted: 03/29/2024] [Indexed: 04/04/2024]
Abstract
This narrative review describes the research on the effects of the association between environmental context and medications, suggesting the benefit of specific design interventions in adjunction to pharmacotherapy. The literature on Evidence-Based Design (EBD) studies and Neuro-Architecture show how contact with light, nature, and specific physical features of urban and interior architecture may enhance the effects of analgesic, anxiolytics, and antidepressant drugs. This interaction mirrors those already known between psychedelics, drugs of abuse, and setting. Considering that the physical feature of space is a component of the complex placebo configuration, the aim is to highlight those elements of built or natural space that may help to improve drug response in terms of efficacy, tolerability, safety, and compliance. Ecocebo, the integration of design approaches such as EBD and Neuro-Architecture may thus contribute to a more efficient, cost-sensitive, and sustainable pharmacotherapy.
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Affiliation(s)
- Cristiano Chiamulera
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy.
| | - Giulia Benvegnù
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Alessandro Piva
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Giovanna Paolone
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
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22
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Moretti A, Snichelotto F, Liguori S, Paoletta M, Toro G, Gimigliano F, Iolascon G. The challenge of pharmacotherapy for musculoskeletal pain: an overview of unmet needs. Ther Adv Musculoskelet Dis 2024; 16:1759720X241253656. [PMID: 38799611 PMCID: PMC11119417 DOI: 10.1177/1759720x241253656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 04/10/2024] [Indexed: 05/29/2024] Open
Abstract
Musculoskeletal disorders are characterized by several impairments, including pain, affecting muscles, bones, joints and adjacent connective tissue, resulting in temporary or permanent functional limitations and disability. Musculoskeletal pain is particularly prevalent worldwide and greatly impacts the quality of life, social participation and economic burden. To date, several issues persist about the classification of musculoskeletal pain and its management strategies and resources. The treatment of musculoskeletal pain conditions is complex and often requires a multimodal approach, including pharmacological and non-pharmacological therapy that might be ineffective in many cases, resulting in poor patient satisfaction and controversial expectations about the potential benefits of available interventions. This manuscript provides an overview of unmet needs in managing musculoskeletal pain, particularly focusing on pharmacotherapeutic pitfalls in this context.
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Affiliation(s)
- Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples 80138, Italy
| | - Francesco Snichelotto
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Sara Liguori
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Marco Paoletta
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Francesca Gimigliano
- Department of Physical and Mental Health and Preventive Medicine, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
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23
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Trepp R, Muri R, Maissen-Abgottspon S, Haynes AG, Hochuli M, Everts R. Cognition after a 4-week high phenylalanine intake in adults with phenylketonuria - a randomized controlled trial. Am J Clin Nutr 2024; 119:908-916. [PMID: 38569786 DOI: 10.1016/j.ajcnut.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 10/30/2023] [Accepted: 11/15/2023] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Phenylketonuria (PKU) is an autosomal recessive metabolic disorder characterized by increased phenylalanine (Phe) concentrations in the blood and brain. Despite wide agreement on treatment during childhood, recommendations for adults are still controversial. OBJECTIVE To assess the impact of a 4-week increase in Phe intake (simulating normal dietary Phe consumption) on cognition, mood, and depression in early-treated adults with PKU in a double-blind, randomized controlled trial (RCT). METHODS In a single-site crossover trial, 30 adult patients with classical PKU diagnosed at birth were recruited. All patients underwent a 4-week period of oral Phe administration (1500-3000 mg Phe/d) and a 4-week placebo period in a randomly assigned order with age, sex, and place of usual medical care as stratification factors. Analyses were based on the intention-to-treat (ITT) and per protocol (PP) approach to claim noninferiority (noninferiority margin -4%), with working memory accuracy as the primary endpoint and additional cognitive domains, mood, and depression as secondary endpoints. RESULTS For the primary endpoint, a 4-week increase of Phe intake was noninferior to placebo with respect to working memory accuracy in both the ITT [point estimate 0.49; lower limit 95% confidence interval (CI): -1.99] and the PP analysis (point estimate -1.22; lower limit 95% CI: -2.60). Secondary outcomes (working memory reaction time, manual dexterity, mood, and depression) did not significantly differ between the Phe and placebo period, except for sustained attention (point estimate 31.0; lower limit 95% CI: 9.0). Adverse events were more frequent during the Phe than during the placebo period (95% CI: 1.03, 2.28, P = 0.037). CONCLUSIONS In early-treated adult patients with PKU, a 4-week high Phe intake was noninferior to continuing Phe restriction regarding working memory accuracy, and secondary outcomes did not differ except for sustained attention. Longer-term RCTs are required to determine whether low Phe levels need to be maintained throughout different periods of adulthood. This trial was registered at the clinicaltrials.gov as NCT03788343.
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Affiliation(s)
- Roman Trepp
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Raphaela Muri
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland; Support Center for Advanced Neuroimaging (SCAN), Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Stephanie Maissen-Abgottspon
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Alan G Haynes
- Institute of Social and Preventive Medicine and Clinical Trials Unit, University of Bern, Bern, Switzerland
| | - Michel Hochuli
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Regula Everts
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland; Division of Neuropaediatrics, Development and Rehabilitation, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Switzerland.
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24
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Walters RK, Durrant FG, Nguyen SA, Meyer TA, Lambert PR. The Placebo Effect on Tinnitus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Otol Neurotol 2024; 45:e263-e270. [PMID: 38361332 DOI: 10.1097/mao.0000000000004139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVE To quantify the placebo effect in randomized clinical trials treating tinnitus with oral or intratympanic placebo treatment. DATA SOURCES CINAHL, PubMed, and Scopus were searched for articles from conception to October 2022. MESH and key terms such as "tinnitus," "placebo," and "medication" were used to find randomized, placebo-controlled trials. The search was limited to articles in English. METHODS Randomized controlled trials with adult subjects evaluating tinnitus pretreatment and posttreatment with an oral or intratympanic medication versus a placebo arm were included. Crossover studies, studies involving middle/inner ear operations or devices, and studies that exclusively included nonidiopathic etiologies of tinnitus were excluded. Mean tinnitus symptom survey scores for the Tinnitus Handicap Inventory (THI), Tinnitus Severity Index, Tinnitus Functional Index, Tinnitus Handicap Questionnaire, and Visual Analog Scales for tinnitus Intensity/Loudness (VAS-L), Annoyance (VAS-An), and Awareness (VAS-Aw) were extracted for both placebo and experimental groups. RESULTS 953 studies were screened with 23 studies being included in the final analysis. Meta-analysis of mean difference (MD) was calculated using RevMan 5.4. MD between pretreatment and posttreatment THI scores of the placebo arms was 5.6 (95% confidence interval, 3.3-8.0; p < 0.001). MD between pretreatment and posttreatment VAS scores of the placebo groups for Loudness, Annoyance, and Awareness were 0.8 (0.0 to 1.6, p = 0.05), 0.2 (-0.2 to 0.5, p = 0.34), and 0.3 (-0.0 to 0.7, p = 0.08), respectively. CONCLUSIONS Placebo treatment has shown effectiveness in improving patient-reported evaluations of tinnitus when using some standardized metrics such as THI and VAS-L; however, the improvement is not as substantial as nonplacebo treatment.
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Affiliation(s)
| | - Frederick G Durrant
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Ted A Meyer
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Paul R Lambert
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
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Nikolakopoulou A, Chaimani A, Furukawa TA, Papakonstantinou T, Rücker G, Schwarzer G. When does the placebo effect have an impact on network meta-analysis results? BMJ Evid Based Med 2024; 29:127-134. [PMID: 37385716 PMCID: PMC10982636 DOI: 10.1136/bmjebm-2022-112197] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2023] [Indexed: 07/01/2023]
Abstract
The placebo effect is the 'effect of the simulation of treatment that occurs due to a participant's belief or expectation that a treatment is effective'. Although the effect might be of little importance for some conditions, it can have a great role in others, mostly when the evaluated symptoms are subjective. Several characteristics that include informed consent, number of arms in a study, the occurrence of adverse events and quality of blinding may influence response to placebo and possibly bias the results of randomised controlled trials. Such a bias is inherited in systematic reviews of evidence and their quantitative components, pairwise meta-analysis (when two treatments are compared) and network meta-analysis (when more than two treatments are compared). In this paper, we aim to provide red flags as to when a placebo effect is likely to bias pairwise and network meta-analysis treatment effects. The classic paradigm has been that placebo-controlled randomised trials are focused on estimating the treatment effect. However, the magnitude of placebo effect itself may also in some instances be of interest and has also lately received attention. We use component network meta-analysis to estimate placebo effects. We apply these methods to a published network meta-analysis, examining the relative effectiveness of four psychotherapies and four control treatments for depression in 123 studies.
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Affiliation(s)
- Adriani Nikolakopoulou
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Anna Chaimani
- Centre of Research in Epidemiology and Statistics (CRESS-U1153), Inserm, Université Paris Cité, Paris, France
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Theodoros Papakonstantinou
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Gerta Rücker
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Guido Schwarzer
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
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26
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Jornada MND, Antunes LC, Alves C, Torres ILS, Fregni F, S Sanches PR, P Silva D, Caumo W. Impact of multiple-session home-based transcranial direct current stimulation (M-HB-tDCS) on eating behavior in fibromyalgia: A factorial randomized clinical trial. Brain Stimul 2024; 17:152-162. [PMID: 38336340 DOI: 10.1016/j.brs.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Multiple-session home-based self-applied transcranial direct current stimulation (M-HB-self-applied-tDCS) has previously been found to effectively reduce chronic pain and enhance cognitive function. However, the effectiveness of this method for disordered eating behavior still needs to be studied. OBJECTIVE This study aimed to assess whether 20 sessions of M-HB-self-applied-tDCS, administered over four weeks to either the left dorsolateral prefrontal cortex (L-DLPFC) or primary motor cortex (M1), could improve various aspects of eating behavior, anthropometric measures, and adherence. METHODS We randomly assigned 102 fibromyalgia patients between the ages of 30 and 65 to one of four tDCS groups: L-DLPFC (anodal-(a)-tDCS, n = 34; sham-(s)-tDCS, n = 17) or M1 (a-tDCS, n = 34; s-tDCS, n = 17). Patients self-administered 20-min tDCS sessions daily with 2 mA under remote supervision following in-person training. RESULTS Generalized linear models revealed significant effects of M-HB-self-applied-tDCS compared to s-tDCS on uncontrolled eating (UE) (Wald χ2 = 5.62; df = 1; P = 0.018; effect size, ES = 0.55), and food craving (Wald χ2 = 5.62; df = 1; P = 0.018; ES = 0.57). Regarding fibromyalgia symptoms, we found a differentiated impact of a-tDCS on M1 compared to DLPFC in reducing food cravings. Additionally, M-HB-a-tDCS significantly reduced emotional eating and waist size. In contrast, M1 stimulation was more effective in improving fibromyalgia symptoms. The global adherence rate was high, at 88.94%. CONCLUSION These findings demonstrate that M-HB-self-applied-tDCS is a suitable approach for reducing uncontrolled and emotional eating, with greater efficacy in L-DLPFC. Furthermore, these results revealed the influence of fibromyalgia symptoms on M-HB-self-applied-tDCS's, with M1 being particularly effective in mitigating food cravings and reducing fibromyalgia symptoms.
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Affiliation(s)
- Manoela N da Jornada
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Brazil; Laboratory of Pain and Neuromodulation at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Luciana C Antunes
- Health Science Center, Nutrition Department, Clinical Nutrition Division, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Camila Alves
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Brazil; Laboratory of Pain and Neuromodulation at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Iraci L S Torres
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Brazil; Laboratory of Pain Pharmacology and Neuromodulation, Preclinical Investigations, Experimental Research Center, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
| | - Felipe Fregni
- Laboratory of Neuromodulation and Center for Clinical Research Learning, Physics and Rehabilitation Department, Spaulding Rehabilitation Hospital, Boston, MA, USA
| | | | - Danton P Silva
- Laboratory of Biomedical Engineer at HCPA, Porto ALegre, Brazil
| | - Wolnei Caumo
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Brazil; Laboratory of Pain and Neuromodulation at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil; Laboratory of Neuromodulation and Center for Clinical Research Learning, Physics and Rehabilitation Department, Spaulding Rehabilitation Hospital, Boston, MA, USA; Pain and Palliative Care Service at HCPA, Brazil; Department of Surgery, School of Medicine, UFRGS, Porto Alegre, Brazil.
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27
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Taniguchi AN, Sutton SR, Mills JF, Nguyen SA, Rizk HG, Meyer TA, Nguyen JP, Lambert PR. Placebo effect in randomized controlled trials for Meniere's disease: A meta-analysis. Am J Otolaryngol 2024; 45:104178. [PMID: 38101129 DOI: 10.1016/j.amjoto.2023.104178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/06/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE Meniere's Disease is a condition known for its recurrent vertigo, fluctuating sensorineural hearing loss, aural fullness, and tinnitus. Previous studies have demonstrated significant influence of placebo treatments. Our objective was to quantify the magnitude of the placebo effect in randomized controlled trials for Meniere's Disease. MATERIALS AND METHODS A systematic review was performed by searching PubMed, SCOPUS, CINAHL, and Cochrane databases from inception through September 27, 2022. Data extraction, quality rating, and risk of bias assessment were performed by two independent reviewers. A meta-analysis of mean differences with 95 % confidence interval, weighted summary proportions, and proportion differences were calculated using random and fixed effects models. RESULTS A total of 15 studies (N = 892) were included in the review. Significant improvement was seen in the functional level scores of the pooled placebo groups, with a mean difference of -0.6 points, (95%CI: -1.2 to -0.1). There was no difference in pure tone audiometry, speech discrimination score, or vertigo frequency at 1 and 3 months for the placebo group. Patient-reported vertigo episodes were improved in 52.5 % (95%CI: 39.2 to 65.5) of the placebo group and was significantly less than the pooled experimental group (90.1 %, 95%CI: 39.2 to 65.5, p < 0.001). CONCLUSIONS The placebo effect in Meniere's Disease trials is associated with some symptomatic improvement in subjective outcomes, such as patient reported vertigo episodes. However, the clinical significance is questionable across other outcomes measures, especially when analyzing objective data. The extent and strength of the placebo effect continues to be a hurdle in the search for better treatment options.
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Affiliation(s)
- April N Taniguchi
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, USA; University of Central Florida, College of Medicine, 6850 Lake Nona Blvd, Orlando, FL 32827, USA
| | - Sarah R Sutton
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, USA; University of Nevada, Reno School of Medicine, 1664 N Virginia St, Reno, NV 89557, USA
| | - John F Mills
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, USA
| | - Shaun A Nguyen
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, USA.
| | - Habib G Rizk
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, USA
| | - Ted A Meyer
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, USA
| | | | - Paul R Lambert
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, Charleston, SC 29425, USA
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Pepoyan E, Marotta F, Manvelyan A, Galstyan A, Stepanyan L, Grigoryan H, Grigoryan L, Mikayelyan M, Balayan M, Harutyunyan N, Mirzabekyan S, Tsaturyan V, Torok T, Pepoyan A. Placebo-resistant gut bacteria: Akkermansia muciniphila spp. and Familial Mediterranean fever disease. Front Cell Infect Microbiol 2024; 14:1336752. [PMID: 38465231 PMCID: PMC10920240 DOI: 10.3389/fcimb.2024.1336752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 12/19/2023] [Indexed: 03/12/2024] Open
Abstract
Introduction Despite numerous investigations into the impact of drugs/probiotics on the gut microbiota composition in Familial Mediterranean Fever (FMF) patients, the question as to whether there exists a significant bacterial diversity(ies) independent of the placebo effect that can be reliably considered in clinical and nutritional trials remains unresolved. Methods This study represents the in augural analysis of the placebo's influence on the gut microbiota of both healthy individuals and FMF afflicted men, utilizing previously collected data from PhyloChip™ DNA microarray experiments. A total of 15 healthy and 15 FMF male volunteers, aged 18 to 50, participated in this partially randomized placebo trial, which is accessible through the GEO Series accession number GSE111835. Results and Discussion Key findings from current investigations include i. the anticipated divergence in gut bacteria resistance to placebo between healthy and FMF individuals, ii. the minor impact of placebo on gut bacterial diversities in healthy individuals, with Enterobacteriaceae diversities identified as placebo-resistant among "healthy" gut bacteria, and iii. the comprehensive influence of placebo on all bacterial phyla in the gut microbiome of FMF patients, extending to nearly all bacterial genera, except for the resilience of gut Akkermansia muciniphila spp. to placebo in FMF patients. This study underscores the susceptibility of Faecalibacterium, Blautia, and Clostridium genera to placebo. Consequently, this investigation holds significance for the proper design of placebo-controlled trials and establishes a foundation for further exploration of the gut-brain axis. Furthermore, it contributes valuable insights to discussions regarding proposals for probiotic therapies, particularly focusing on Faecalibacterium spp., Blautia spp., and Clostridium spp.
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Affiliation(s)
- Elya Pepoyan
- Food Safety and Biotechnology Department, Scientific Research Institute of Food Science and Biotechnology, Armenian National Agrarian University, Yerevan, Armenia
- International Association for Human and Animals Health Improvement, Yerevan, Armenia
- Faculty of Military Medicine, Yerevan State Medical University, Yerevan, Armenia
| | | | - Anahit Manvelyan
- Food Safety and Biotechnology Department, Scientific Research Institute of Food Science and Biotechnology, Armenian National Agrarian University, Yerevan, Armenia
- International Association for Human and Animals Health Improvement, Yerevan, Armenia
| | - Artak Galstyan
- Faculty of Military Medicine, Yerevan State Medical University, Yerevan, Armenia
| | - Lena Stepanyan
- Food Safety and Biotechnology Department, Scientific Research Institute of Food Science and Biotechnology, Armenian National Agrarian University, Yerevan, Armenia
- International Association for Human and Animals Health Improvement, Yerevan, Armenia
| | - Hasmik Grigoryan
- Food Safety and Biotechnology Department, Scientific Research Institute of Food Science and Biotechnology, Armenian National Agrarian University, Yerevan, Armenia
- International Association for Human and Animals Health Improvement, Yerevan, Armenia
| | - Liana Grigoryan
- Food Safety and Biotechnology Department, Scientific Research Institute of Food Science and Biotechnology, Armenian National Agrarian University, Yerevan, Armenia
| | - Mikayel Mikayelyan
- Food Safety and Biotechnology Department, Scientific Research Institute of Food Science and Biotechnology, Armenian National Agrarian University, Yerevan, Armenia
- International Association for Human and Animals Health Improvement, Yerevan, Armenia
| | - Marine Balayan
- Food Safety and Biotechnology Department, Scientific Research Institute of Food Science and Biotechnology, Armenian National Agrarian University, Yerevan, Armenia
- International Association for Human and Animals Health Improvement, Yerevan, Armenia
| | - Natalya Harutyunyan
- Food Safety and Biotechnology Department, Scientific Research Institute of Food Science and Biotechnology, Armenian National Agrarian University, Yerevan, Armenia
- International Association for Human and Animals Health Improvement, Yerevan, Armenia
| | - Susanna Mirzabekyan
- Food Safety and Biotechnology Department, Scientific Research Institute of Food Science and Biotechnology, Armenian National Agrarian University, Yerevan, Armenia
- International Association for Human and Animals Health Improvement, Yerevan, Armenia
| | - Vardan Tsaturyan
- International Association for Human and Animals Health Improvement, Yerevan, Armenia
- Faculty of Military Medicine, Yerevan State Medical University, Yerevan, Armenia
| | - Tamas Torok
- Lawrence Berkeley National Laboratory, Berkeley, CA, United States
| | - Astghik Pepoyan
- Food Safety and Biotechnology Department, Scientific Research Institute of Food Science and Biotechnology, Armenian National Agrarian University, Yerevan, Armenia
- International Association for Human and Animals Health Improvement, Yerevan, Armenia
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de Leeuw M, Laager M, Gaab J, Ruppen W, Schneider T. Boosting open-label placebo effects in acute induced pain in healthy adults (BOLPAP-study): study protocol of a randomized controlled trial. Front Med (Lausanne) 2024; 11:1238878. [PMID: 38420356 PMCID: PMC10900763 DOI: 10.3389/fmed.2024.1238878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 01/22/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction Pain is a highly prevalent symptom in the hospital setting, but treatment options remain limited. Harnessing the placebo effect in an ethical manner could provide a new possibility to reduce pain in clinical practice. So called open-label placebos (OLP) have been shown to elicit significant effects in reducing acute pain. But, before implementation, more knowledge concerning the properties of OLPs is needed. This study aims to assess the duration of analgesic effects from OLP and to determine the possibility of boosting such effects. Methods and analysis This is the protocol of an ongoing (first patient enrolled in March 2023) single-site randomized trial investigating OLPs in two parts (i.e., substudies). In both parts, pain will be induced in healthy adults using an intradermal electrical stimulation model. Participants in Part 1 will have two study visits: An interventional visit with one OLP injection accompanied by an evidence-based treatment rationale and a control visit with no treatment. For Part 2, participants will be randomized into three groups: (1) A fixed-time "Booster" group including one single repetition of the OLP injection at a fixed time point, (2) an on-demand "Booster" group including one single repetition of the OLP injection on-demand, and (3) a control group who will receive just one OLP injection. Differences in pain ratings over time (using the Numeric Rating Scale) will be analyzed with several two-sample t-tests. The time point for a fixed-time "Booster" in Part 2 will be derived from Part 1 with additional statistical tools such as a broken-stick mixed-effect model. Discussion This study aims to further characterize the analgesic effects of OLPs. In doing so, it will provide valuable information needed for later implementation of OLPs in clinical practice, where they could play a role in multimodal analgesic concepts. Ethics and dissemination The "Ethikkommission Nordwest- und Zentralschweiz" (BASEC 2023-00296) approved the study protocol. Results of the analysis will be submitted for publication in a peer-reviewed journal. Clinical Trial Registration This study is registered at ClinicalTrials.gov (NCT05819476) and is listed in the Swiss National Registry at kofam.ch (SNCTP000005470).
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Affiliation(s)
- Matthijs de Leeuw
- Pain Unit, Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Mirjam Laager
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Jens Gaab
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Wilhelm Ruppen
- Pain Unit, Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Tobias Schneider
- Pain Unit, Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
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Kalchev E. Beyond the Sound Waves: A Comprehensive Exploration of the Burn-In Phenomenon in Audio Equipment Across Physiological, Psychological, and Societal Domains. Cureus 2024; 16:e53097. [PMID: 38414701 PMCID: PMC10898501 DOI: 10.7759/cureus.53097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2024] [Indexed: 02/29/2024] Open
Abstract
Audio burn-in, often referred to as the process by which audio equipment undergoes a series of played sounds to achieve optimal performance, remains a topic of significant debate within both audiophile communities and relevant scientific fields. While some attribute perceived changes in sound quality to actual physical changes in the equipment, an emerging perspective points to the interplay of physiological, psychological, and social factors that might influence these perceptions. This narrative review delves into the intricate layers of auditory physiology, cognitive sound interpretation, and the wider societal beliefs around burn-in. We underscore the importance of discerning between actual physical changes in audio gear and the multifaceted human factors that potentially modulate our perception of sound. Through a comprehensive exploration, this article illuminates the complexities of this phenomenon, offering insights for both medical professionals and passionate audio enthusiasts and proposing directions for future research.
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Affiliation(s)
- Emilian Kalchev
- Diagnostic Imaging, St. Marina University Hospital, Varna, BGR
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31
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De Simone M, De Feo R, Choucha A, Ciaglia E, Fezeu F. Enhancing Sleep Quality: Assessing the Efficacy of a Fixed Combination of Linden, Hawthorn, Vitamin B1, and Melatonin. Med Sci (Basel) 2023; 12:2. [PMID: 38249078 PMCID: PMC10801487 DOI: 10.3390/medsci12010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/24/2023] [Accepted: 12/18/2023] [Indexed: 01/23/2024] Open
Abstract
Sleep is essential for overall health, yet various sleep disorders disrupt normal sleep patterns, affecting duration, quality, and timing. This pilot study investigate the impact of a food supplement (SPINOFF®) on both sleep quality and mental well-being in 41 participants (mean age: 45.3 years). Initial assessments revealed sleep disturbances (Pittsburgh Sleep Quality Index-PSQ-mean score: 8.2) and insomnia symptoms (Insomnia Severity Index-ISI- mean score: 12.7). Mental health assessments showed psychological distress (Dass-21 Depression mean score: 4.2, Anxiety mean score: 6.9, Stress mean score: 11.6, Total mean score: 22.7). This study assessed sleep continuity using Awakenings per Night (ApN) via a smartwatch (HELO HEALTH®) and conducted the study in two phases: baseline (T0) and after 30 days of treatment (T1) (Phase A). No placebo-control was used in this study. After 30 days (Phase B), 21 patients were selected for reassessment. Eleven continued treatment for another 30 days (T2), while ten discontinued. Following the intervention, we observed remarkable improvements in sleep quality and mental distress. The SPINOFF® supplement significantly reduced the PSQI scores (22.4%), indicating enhanced sleep quality. Additionally, there was a 19.6% decrease in ISI scores, demonstrating a reduction in insomnia symptoms. Moreover, overall psychological distress decreased by 19.5% signifying improved psychological well-being. In the second phase, participants who continued treatment experienced more substantial improvements, with a mean decrease of 0.8 points in PSQI scores (±0.9) and a mean decrease of 0.9 points in ISI scores. Our findings suggest that the SPINOFF® supplement has the potential to effectively address both sleep disturbances and psychological distress in our study population.
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Affiliation(s)
- Matteo De Simone
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Via Salvatore Allende, 84081 Baronissi, Italy; (R.D.F.); (E.C.)
| | - Rosario De Feo
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Via Salvatore Allende, 84081 Baronissi, Italy; (R.D.F.); (E.C.)
| | - Anis Choucha
- Department of Neurosurgery, Aix Marseille University, APHM, UH Timone, 13005 Marseille, France;
| | - Elena Ciaglia
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Via Salvatore Allende, 84081 Baronissi, Italy; (R.D.F.); (E.C.)
| | - Francis Fezeu
- Department of Neurology & Neurological Surgery, Brain Global, 27659 Arabian Drive, Salisbury, MD 21801, USA;
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32
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Wang L, Chen X, Gu X, De Smedt H, Popova V, Fu DJ, Canuso CM, Drevets WC, Chen G. A Meta-Analysis of the Antidepressant Responses in Pivotal Trials on Esketamine Nasal Spray and Atypical Antipsychotics. Neuropsychiatr Dis Treat 2023; 19:2857-2870. [PMID: 38161513 PMCID: PMC10757775 DOI: 10.2147/ndt.s417027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024] Open
Abstract
Purpose This meta-analysis assessed whether atypical antipsychotics (AAPs) and esketamine nasal spray (ESK-NS), which are mechanistically distinct, differ in antidepressant outcomes. Patients and Methods Data were extracted from 12 trials of ESK-NS or AAPs in depressed patients (4276) with inadequate response or resistance to conventional antidepressants. Montgomery-Åsberg Depression Rating Scale (MADRS) score reductions from baseline and response rates (≥50% reduction) were analyzed. Results At endpoint, the estimated MADRS score reduction of pooled ESK-NS arms was greater than pooled AAP arms (+9.16 points, p < 0.0001). The reduction also was greater in the pooled control arms of the ESK-NS trials than the pooled control arms of the AAP trials (+7.57 points, p < 0.0001). The mean difference in the reductions between pooled ESK-NS and control arms was 1.87 points greater than that between pooled AAP and control arms, but this difference was not significant (95% CI: -4.49, 0.74, p = 0.16). Relative to their respective control arms, the mean difference in response rates was 25% for the pooled ESK-NS and 9% for the pooled AAP arms; the mean response rate was 16% greater in the pooled ESK-NS studies than the pooled AAP studies (p = 0.0004). Comparisons against specific AAPs showed mean differences in the MADRS score reductions at 1 week between the experimental and control arms that were numerically larger in the ESK-NS trials than in the aripiprazole trials (mean difference of 1.71 points, p = 0.06) and the brexpiprazole trials (mean difference of 2.05 points, p = 0.02). Conclusion The ESK-NS arms showed numerically larger MADRS score reductions at week-1 and endpoint, and a significantly larger response rate compared with AAP arms. Prospective studies involving direct comparisons are warranted to compare the relative efficacy between these treatment regimens.
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Affiliation(s)
- Lien Wang
- Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, Shanghai, People’s Republic of China
- Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, Brisbane, CA, USA
| | - Xiaowei Chen
- Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, Shanghai, People’s Republic of China
| | - Xiaojing Gu
- Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, Shanghai, People’s Republic of China
| | - Heidi De Smedt
- Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium
| | - Vanina Popova
- Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium
| | - Dong-Jing Fu
- Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, Raritan, NJ, USA
| | - Carla M Canuso
- Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, Raritan, NJ, USA
| | - Wayne C Drevets
- Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, Brisbane, CA, USA
| | - Guang Chen
- Janssen Research & Development, LLC, Janssen Pharmaceutical Companies of Johnson & Johnson, Brisbane, CA, USA
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Gadanec LK, Swiderski J, Apostolopoulos V, Kelaidonis K, Vidali VP, Canko A, Moore GJ, Matsoukas JM, Zulli A. Existence of Quantum Pharmacology in Sartans: Evidence in Isolated Rabbit Iliac Arteries. Int J Mol Sci 2023; 24:17559. [PMID: 38139391 PMCID: PMC10744031 DOI: 10.3390/ijms242417559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/09/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023] Open
Abstract
Quantum pharmacology introduces theoretical models to describe the possibility of ultra-high dilutions to produce biological effects, which may help to explain the placebo effect observed in hypertensive clinical trials. To determine this within physiology and to evaluate novel ARBs, we tested the ability of known angiotensin II receptor blockers (ARBs) (candesartan and telmisartan) used to treat hypertension and other cardiovascular diseases, as well as novel ARBs (benzimidazole-N-biphenyl tetrazole (ACC519T), benzimidazole-bis-N,N'-biphenyl tetrazole (ACC519T(2)) and 4-butyl-N,N0-bis[[20-2Htetrazol-5-yl)biphenyl-4-yl]methyl)imidazolium bromide (BV6(K+)2), and nirmatrelvir (the active ingredient in Paxlovid) to modulate vascular contraction in iliac rings from healthy male New Zealand White rabbits in responses to various vasopressors (angiotensin A, angiotensin II and phenylephrine). Additionally, the hemodynamic effect of ACC519T and telmisartan on mean arterial pressure in conscious rabbits was determined, while the ex vivo ability of BV6(K+)2 to activate angiotensin-converting enzyme-2 (ACE2) was also investigated. We show that commercially available and novel ARBs can modulate contraction responses at ultra-high dilutions to different vasopressors. ACC519T produced a dose-dependent reduction in rabbit mean arterial pressure while BV6(K+)2 significantly increased ACE2 metabolism. The ability of ARBs to inhibit contraction responses even at ultra-low concentrations provides evidence of the existence of quantum pharmacology. Furthermore, the ability of ACC519T and BV6(K+)2 to modulate blood pressure and ACE2 activity, respectively, indicates their therapeutic potential against hypertension.
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Affiliation(s)
- Laura Kate Gadanec
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3030, Australia; (L.K.G.); (J.S.); (V.A.)
| | - Jordan Swiderski
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3030, Australia; (L.K.G.); (J.S.); (V.A.)
| | - Vasso Apostolopoulos
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3030, Australia; (L.K.G.); (J.S.); (V.A.)
- Immunology Program, Australian Institute for Musculoskeletal Science (AIMSS), Melbourne, VIC 3021, Australia
| | | | - Veroniki P. Vidali
- Institute of Nanoscience and Nanotechnology, National Centre for Scientific Research “Demokritos”, Ag. Paraskevi, 153 41 Athens, Greece; (V.P.V.); (A.C.)
| | - Aleksander Canko
- Institute of Nanoscience and Nanotechnology, National Centre for Scientific Research “Demokritos”, Ag. Paraskevi, 153 41 Athens, Greece; (V.P.V.); (A.C.)
| | - Graham J. Moore
- Pepmetics Inc., 772 Murphy Place, Victoria, BC V6Y 3H4, Canada;
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - John M. Matsoukas
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3030, Australia; (L.K.G.); (J.S.); (V.A.)
- NewDrug PC, Patras Science Park, 26 504 Patras, Greece;
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4N1, Canada
- Department of Chemistry, University of Patras, 265 04 Patras, Greece
| | - Anthony Zulli
- Institute for Health and Sport, Victoria University, Melbourne, VIC 3030, Australia; (L.K.G.); (J.S.); (V.A.)
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Franco-Alvarenga PE, Cechetti MDS, Barcelos D, Canestri R, Brietzke C, Vinicius Í, Goethel MF, Ferreira GA, Pires FO. Ice Massage on the Calf Improves 4-km Running Time Trial Performance in a Normothermic Environment. RESEARCH QUARTERLY FOR EXERCISE AND SPORT 2023; 94:1126-1132. [PMID: 36121708 DOI: 10.1080/02701367.2022.2120948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 08/29/2022] [Indexed: 06/15/2023]
Abstract
Purpose: Local cooling with ice massage is a practical and inexpensive technique to decrease perceptual stress and improve motor performance in hot environments. However, it is unknown whether local cooling with ice massage reduces perceptual responses to exercise and improves performance in a normothermic environment. Thus, we investigated whether ice massage on the calf muscles before a 4 km running time trial (TT4km) reduced the ratings of perceived exertion (RPE) and perceived muscle pain, thereby improving exercise performance in a normothermic environment. Methods: After familiarizations, fourteen recreationally endurance-trained men (age = 21.3 ± 1.2 years; body weight = 67.5 ± 9.2 kg; height = 173.0 ± 5.0 cm) underwent two TT4km on a 400 m track in normothermic conditions with or without ice massage before the trial. The time of running, RPE, and pain perception were recorded every 400 m throughout the TT4km. Results: The local cooling with ice massage increased the mean speed (~ 5.2%, p = 0.03) and decreased the time to complete the TT4km (~ 5.5%, p = 0.03). Accordingly, ice massage also reduced the exercise-derived pain perception (p = 0.028), although no effect has been found in the RPE during the TT4km (p = 0.32). Conclusion: Together, these results showed that local cooling with ice massage before the exercise reduced the exercise-derived pain perception, enabling runners to increase the speed for a comparable RPE during exercise, thereby improving the TT4km performance in a normothermic environment.
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Basedow LA, Fischer A, Benson S, Bingel U, Brassen S, Büchel C, Engler H, Mueller EM, Schedlowski M, Rief W. The influence of psychological traits and prior experience on treatment expectations. Compr Psychiatry 2023; 127:152431. [PMID: 37862937 DOI: 10.1016/j.comppsych.2023.152431] [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: 07/21/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Placebo and nocebo responses are modulated by the treatment expectations of participants and patients. However, interindividual differences predicting treatment expectations and placebo responses are unclear. In this large-scale pooled analysis, we aim to investigate the influence of psychological traits and prior experiences on treatment expectations. METHODS This paper analyses data from six different placebo studies (total n = 748). In all studies, participants' sociodemographic information, treatment expectations and prior treatment experiences and traits relating to stress, somatization, depression and anxiety, the Big Five and behavioral inhibition and approach tendencies were assessed using the same established questionnaires. Correlation coefficients and structural equation models were calculated to investigate the relationship between trait variables and expectations. RESULTS We found small positive correlations between side effect expectations and improvement expectations (r = 0.187), perceived stress (r = 0.154), somatization (r = 0.115), agitation (r = 0.108), anhedonia (r = 0.118), and dysthymia (r = 0.118). In the structural equation model previous experiences emerged as the strongest predictors of improvement (β = 0.32, p = .005), worsening (β = -0.24, p = .005) and side effect expectations (β = 0.47, p = .005). Traits related to positive affect (β = - 0.09; p = .007) and negative affect (β = 0.04; p = .014) were associated with side effect expectations. DISCUSSION This study is the first large analysis to investigate the relationship between traits, prior experiences and treatment expectations. Exploratory analyses indicate that experiences of symptom improvement are associated with improvement and worsening expectations, while previous negative experiences are only related to side effect expectations. Additionally, a proneness to experience negative affect may be a predictor for side effect expectation and thus mediate the occurrence of nocebo responses.
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Affiliation(s)
- Lukas A Basedow
- Philipps-Universität Marburg, Department of Clinical Psychology and Psychotherapy, 35037 Marburg, Germany.
| | - Anton Fischer
- Philipps-Universität Marburg, Department of Differential Psychology and Personality Research, 35037 Marburg, Germany.
| | - Sven Benson
- Institute of Medical Psychology and Behavioral Immunobiology, Center for Translational Neuro- and Behavioral Sciences, University Hospital of Essen, Essen, Germany.
| | - Ulrike Bingel
- Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, Essen, DE, Germany.
| | - Stefanie Brassen
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Christian Büchel
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Harald Engler
- Institute of Medical Psychology and Behavioral Immunobiology, Center for Translational Neuro- and Behavioral Sciences, University Hospital of Essen, Essen, Germany.
| | - Erik M Mueller
- Philipps-Universität Marburg, Department of Differential Psychology and Personality Research, 35037 Marburg, Germany.
| | - Manfred Schedlowski
- Institute of Medical Psychology and Behavioral Immunobiology, Center for Translational Neuro- and Behavioral Sciences, University Hospital of Essen, Essen, Germany; Osher Center for Integrative Health, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Winfried Rief
- Philipps-Universität Marburg, Department of Clinical Psychology and Psychotherapy, 35037 Marburg, Germany.
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Frisaldi E, Shaibani A, Benedetti F, Pagnini F. Placebo and nocebo effects and mechanisms associated with pharmacological interventions: an umbrella review. BMJ Open 2023; 13:e077243. [PMID: 37848293 PMCID: PMC10582987 DOI: 10.1136/bmjopen-2023-077243] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/27/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVES This review aimed to summarise the existing knowledge about placebo and nocebo effects associated with pharmacological interventions and their mechanisms. DESIGN Umbrella review, adopting the Assessment of Multiple Systematic Reviews 2 tool for critical appraisal. DATA SOURCES MEDLINE/PubMed, Scopus, Web of Science, PsycINFO, Cochrane Central Register of Controlled Trial were searched in September 2022, without any time restriction, for systematic reviews, narrative reviews, original articles. Results were summarised through narrative synthesis, tables, 95% CI. OUTCOME MEASURES Mechanisms underlying placebo/nocebo effects and/or their effect sizes. RESULTS The databases search identified 372 studies, for a total of 158 312 participants, comprising 41 systematic reviews, 312 narrative reviews and 19 original articles. Seventy-three per cent of the examined systematic reviews were of high quality.Our findings revealed that mechanisms underlying placebo and/or nocebo effects have been characterised, at least in part, for: pain, non-noxious somatic sensation, Parkinson's disease, migraine, sleep disorders, intellectual disability, depression, anxiety, dementia, addiction, gynaecological disorders, attention-deficit hyperactivity disorder, immune and endocrine systems, cardiovascular and respiratory systems, gastrointestinal disorders, skin diseases, influenza and related vaccines, oncology, obesity, physical and cognitive performance. Their magnitude ranged from 0.08 to 2.01 (95% CI 0.37 to 0.89) for placebo effects and from 0.32 to 0.90 (95% CI 0.24 to 1.00) for nocebo effects. CONCLUSIONS This study provides a valuable tool for clinicians and researchers, identifying both results ready for clinical practice and gaps to address in the near future. FUNDING Università Cattolica del Sacro Cuore, Milan, Italy with the 'Finanziamento Ponte 2022' grant. PROSPERO REGISTRATION NUMBER CRD42023392281.
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Affiliation(s)
- Elisa Frisaldi
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Aziz Shaibani
- Muscle and Nerve Center, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Fabrizio Benedetti
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Francesco Pagnini
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
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Lipton RB, Melo-Carrillo A, Severs M, Reed M, Ashina S, Houle T, Burstein R. Narrow band green light effects on headache, photophobia, sleep, and anxiety among migraine patients: an open-label study conducted online using daily headache diary. Front Neurol 2023; 14:1282236. [PMID: 37859647 PMCID: PMC10582938 DOI: 10.3389/fneur.2023.1282236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 09/11/2023] [Indexed: 10/21/2023] Open
Abstract
Background Narrow band green light (NbGL) has been shown to relieve headache in small numbers of subjects but large-scale real-world assessments are lacking. The goal of this prospective, observational, open-label, real world study was to determine whether treatment with NbGL during the ictal phase of migraine, improves patients' perception of their headache, photophobia, anxiety and same-night sleep. Methods The study was conducted in purchasers of the NbGL Lamp in two phases. In Phase I purchasers of the Lamp completed a survey and were asked to participate in a 6-week diary study. In Phase 2 participants completed daily diaries for 6 weeks. Specifically, they were asked to use their judgement/impression/perception when choosing between headache-improved or headache-unimproved after using the NbGL during acute attacks. Diary outcomes of interest included rates of attacks improve in responders (≥50%), non-responders (<50%), super-responders (≥75%), and super non-responders (<30%). Results Of 3,875 purchasers of the Lamp for migraine, 698 (18%) agreed to participate, filled out a pre-study survey, and agreed to a 6-week daily headache diary. Complete data were provided by 181 (26%) participants. Using criteria above, 61, 39, 42, and 27% of participants were classified responder, non-responder, super-responder and super non-responder, respectively. Headache improved in 55% of all 3,232 attacks, in 82% of the 1,803 attacks treated by responders, and in 21% of the 1,429 attacks treated by non-responders. Photophobia improved in 53% of all attacks, 68% of the attacks in responders and in 35% of the attacks in non-responders. Anxiety improved in 34% of all attacks, 46% of the responders' attacks, and 18% of the non-responders' attacks. Sleep improved in 49% of all attacks, 59% of the responders' attacks, and 36% of the non-responders' attacks. Conclusion This open-label real world study suggests that 2 h of treatment with the lamp during migraine attacks is associated with relief of pain and photophobia, reduction in anxiety, and improved sleep. The absence of rigorous diagnosis and a blinded contemporaneous control group limits the rigor of this interpretation. Improvement in photophobia, anxiety and sleep among the responders may be secondary to the improvement in the headache itself. Clinical trial registration ClinicalTrial.gov (NCT04841083).
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Affiliation(s)
- Richard B. Lipton
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Agustin Melo-Carrillo
- Departments of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Anesthesia, Harvard Medical School, Boston, MA, United States
| | | | - Michael Reed
- Vedanta Research, Chapel Hill, NC, United States
| | - Sait Ashina
- Departments of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Anesthesia, Harvard Medical School, Boston, MA, United States
- Departments of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Timothy Houle
- Massachusetts General Hospital, Boston, MA, United States
| | - Rami Burstein
- Departments of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
- Department of Anesthesia, Harvard Medical School, Boston, MA, United States
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Olbort C, Pfanne F, Schwahn C, Bernhardt O. Training of the lateral pterygoid muscle in the treatment of temporomandibular joint disc displacement with reduction: A randomised clinical trial. J Oral Rehabil 2023; 50:921-930. [PMID: 37226632 DOI: 10.1111/joor.13517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/04/2023] [Accepted: 05/16/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Disc displacement with reduction (DDwR) therapy should be performed only when pain or discomfort is presented. Data on treatment options for painful DDwR are very limited. OBJECTIVE The aim was to investigate whether isometric training of the lateral pterygoid muscle (LPM) is equivalent to stabilisation appliance therapy with regard to the treatment of painful DDwR. The training program is based on the science of Janda. METHODS This was a prospective, randomised study with a comparative treatment group. Sixty patients (≥18 years) with DDwR and pain were randomly assigned to two groups: (1) muscle training and (2) stabilisation appliance. The following variables were recorded at baseline examination and after 2, 4 and 6 months: changes in orofacial pain, clicking sounds of the temporomandibular joint (TMJ), force degrees for the lateral movement of the mandible and interincisal opening distance. p values of <.05 were considered statistically significant but 95% confidence intervals were also presented. RESULTS A decrease in orofacial pain intensity was seen in both groups (p < .0001). Registered TMJ clicking disappeared after 6 months of treatment in 37% (n = 11) of the patients in the training group and in 27% (n = 8) of the appliance group (p = .0009 and p = .0047). Muscle training showed 27 improvements in Janda force degrees at the end of the study (p < .0001). CONCLUSION Muscle training and appliance therapy improved mouth opening and reduced pain intensity in both patient groups. Muscle training might be a promising option in the treatment of patients suffering from painful DDwR.
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Affiliation(s)
- Christin Olbort
- Dental Practice, with Focus on Temporomandibular Disorders, Competence Centre, Steina, Germany
| | - Falk Pfanne
- Dental Practice, with Focus on Temporomandibular Disorders, Competence Centre, Steina, Germany
| | - Christian Schwahn
- Department of Prosthetic Dentistry, Gerodontology and Biomaterials, University Medicine Greifswald, Greifswald, Germany
| | - Olaf Bernhardt
- Department of Restorative Dentistry, Periodontology, Endodontology, Preventive Dentistry and Pediatric Dentistry, University Medicine Greifswald, Greifswald, Germany
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Blease C, Colagiuri B, Locher C. Replication crisis and placebo studies: rebooting the bioethical debate. JOURNAL OF MEDICAL ETHICS 2023; 49:663-669. [PMID: 36609361 DOI: 10.1136/jme-2022-108672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/30/2022] [Indexed: 06/17/2023]
Abstract
A growing body of cross-cultural survey research shows high percentages of clinicians report using placebos in clinical settings. One motivation for clinicians using placebos is to help patients by capitalising on the placebo effect's reported health benefits. This is not surprising, given that placebo studies are burgeoning, with increasing calls by researchers to ethically harness placebo effects among patients. These calls propose placebos/placebo effects offer clinically significant benefits to patients. In this paper, we argue many findings in this highly cited and 'hot' field have not been independently replicated. Evaluating the ethicality of placebo use in clinical practice involves first understanding whether placebos are efficacious clinically. Therefore, it is crucial to consider placebo research in the context of the replication crisis and what can be learnt to advance evidence-based knowledge of placebos/placebo effects and their clinical relevance (or lack thereof). In doing so, our goal in this paper is to motivate both increased awareness of replication issues and to help pave the way for advances in scientific research in the field of placebo studies to better inform ethical evidence-based practice. We argue that, only by developing a rigorous evidence base can we better understand how, if at all, placebos/placebo effects can be harnessed ethically in clinical settings.
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Affiliation(s)
- Charlotte Blease
- General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Digital Psychiatry, Department of Psychiatry, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ben Colagiuri
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Cosima Locher
- Department of Consultation-Liaison Psychiatry and Psychosomatic Medicine, University Hospital Zurich, Zurich, Switzerland
- Psychology, Plymouth University, Plymouth, UK
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Krockow EM, Emerson T, Youssef E, Scott S, Tromans S. Evidencing general acceptability of open-label placebo use for tackling overtreatment in primary care: a mixed methods study. BMC Med 2023; 21:362. [PMID: 37726759 PMCID: PMC10510165 DOI: 10.1186/s12916-023-03074-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 09/07/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Overtreatment poses a challenge to healthcare systems due to harmful consequences of avoidable side-effects and costs. This study presents the first account for examining the feasibility of placebo use for reducing overtreatment in primary care, including whether public attitudes support the use of different placebo types in place of inappropriate prescriptions of antibiotics, antidepressants, or analgesics. METHODS We used a multi-study, mixed-methods design, including patient and public (PPI) consultations, focus groups (Study 1) and two pre-registered online experiments (Studies 2 and 3). RESULTS Study 1 (N = 16) explored everyday conceptions and practicalities of potential placebo use in the context of respiratory infections. Findings highlighted the importance of trusting doctor-patient relationships and safety-netting. Study 2 employed a randomised experiment with a representative UK sample (N = 980), investigating attitudes towards 5 different treatment options for respiratory infections: (1) blinded + pure placebo, (2) open-label + pure placebo, (3) open-label + impure placebo, (4) antibiotic treatment, and (5) no treatment. Study 2 also examined how attitudes varied based on wording and individual differences. Findings indicated general support (ηp2 = .149, large effect size) for replacing inappropriate antibiotics with open-label + impure placebos, although personal placebo acceptability was lower. Also, older people, individuals suffering from chronic illness or those showing higher levels of health anxiety appeared less amenable to placebo use. Study 3 (N = 1177) compared attitudes towards treatment options across three clinical scenarios: respiratory infection, depression and pain. Findings suggested significant differences in the acceptability of placebo options based on the clinical context. In the infection scenario, options for open-label + pure placebos, open-label + impure placebos and no treatment were rated significantly more acceptable (ηp2 = .116, medium effect size) compared to the depression and pain scenarios. Again, general support for placebos was higher than placebo acceptability for personal use. CONCLUSIONS Findings from PPI and three studies indicate general support for combatting overprescribing in primary care through clinical placebo use. This is an indicator for wider UK public support for a novel, behavioural strategy to target a long-standing healthcare challenge. General acceptability appears to be highest for the use of open-label + impure placebos in the context of antibiotic overprescribing.
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Affiliation(s)
- E M Krockow
- School of Psychology and Vision Sciences, University of Leicester, Leicester, UK.
| | - T Emerson
- School of Sociology and Social Policy, University of Nottingham, Nottingham, UK
| | - E Youssef
- School of Nursing, Kingston University, London, UK
| | - S Scott
- School of Healthcare, University of Leicester, Leicester, UK
| | - S Tromans
- Department of Population Health Sciences, University of Leicester, Leicester, UK
- Adult Learning Disability Service, Leicestershire Partnership NHS Trust, Leicester, UK
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de Salles Painelli V, Fernandes E, Brietzke C, Pires FO. The placebo effect of a pink non-caloric, artificially sweetened solution on strength endurance performance and psychological responses in trained individuals. Nutr Health 2023:2601060231196590. [PMID: 37608532 DOI: 10.1177/02601060231196590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Background: The pink color enhances the perceived sweetness, increasing the individuals' expectation of the presence of sugar/carbohydrate in a beverage. Hence, it is plausible to speculate that providing a pink solution during exercise could induce an ergogenic benefit through a potential placebo effect. Aim: We examined whether ingesting a pink non-caloric, artificially sweetened solution can improve endurance strength exercise performance and psychological responses. Methods: Eighteen strength-trained individuals (34 ± 7 y; 1.74 ± 0.06 m; 79.86 ± 10.91 kg) completed three experimental trials in a randomized, single-blind, crossover counterbalanced fashion. In each trial, participants performed a 5-set strength endurance test at 70% of the one-repetition maximum in the bench press exercise, interspersed by 2 min. Before each set, participants ingested either a pink (PINK) or a transparent (TRANSP) non-caloric, artificially sweetened solution. A session without ingestion (CON) was also completed. Total number of repetitions and psychological responses such as motivation, emotional arousal, affect, and ratings of perceived exertion were obtained throughout the exercise protocol. Results: Total repetitions improved in PINK (60 ± 12 reps) compared to TRANSP (p = 0.03; 56 ± 10 reps; ES = 0.22; ±3.8%) and CON (p = 0.01; 56 ± 9 reps; ES = 0.33; ±6.6%), but no difference occurred between TRANSP and CON (p = 0.84; ES = 0.12; ±2.4%). Comparable responses were observed in motivation, emotional arousal, affect, and ratings of perceived exertion in PINK, TRANSP, and CON trials (all, p > 0.05), despite the greater total physical work performed in PINK trial. Conclusion: Ingesting a pink non-caloric, artificially sweetened solution improved strength endurance performance with comparable psychological responses. These results have implications for future nutritional studies and performance assessments in real-world sports scenarios.
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Affiliation(s)
- Vitor de Salles Painelli
- Exercise Psychophysiology Research Group, School of Arts, Sciences and Humanities, University of São Paulo, São Paulo, Brazil
- Strength Training Study and Research Group, Institute of Health Sciences, Paulista University, São Paulo, Brazil
| | - Edvania Fernandes
- Strength Training Study and Research Group, Institute of Health Sciences, Paulista University, São Paulo, Brazil
| | - Cayque Brietzke
- Exercise Psychophysiology Research Group, School of Arts, Sciences and Humanities, University of São Paulo, São Paulo, Brazil
- Human Movement Science and Rehabilitation Program, Federal University of São Paulo, Santos, Brazil
| | - Flávio O Pires
- Exercise Psychophysiology Research Group, School of Arts, Sciences and Humanities, University of São Paulo, São Paulo, Brazil
- Human Movement Science and Rehabilitation Program, Federal University of São Paulo, Santos, Brazil
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Henrich L, Wilhelm M, Lange P, Rief W. The role of the communicated treatment rationale on treatment outcome: study protocol for a randomized controlled trial. Trials 2023; 24:540. [PMID: 37592320 PMCID: PMC10433650 DOI: 10.1186/s13063-023-07557-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/30/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Placebo effects are a well-established phenomenon in the treatment of depression. However, the mechanism underlying these effects are not fully understood. Treatment expectations are considered one explanation for why placebos work. Treatment expectations are likely to be affected by clinician-patient interactions. This study aims to investigate the role of the communicated treatment rationale in modulating treatment expectations and its effects on the treatment outcomes of a pharmacological and a psychological active placebo intervention for depression. In this study, treatment expectations are modulated by presenting illness models that are either congruent or incongruent with the treatment intervention that follows. METHODS This 2 × 2 randomized controlled trial will involve patients with major depression. Participants will either receive a biological or a psychological illness model from a clinician. Following this, they are randomly assigned to receive either a pharmacological or a psychological active placebo intervention. The illness model and the treatment are either congruent or incongruent with each other, resulting in four groups. In addition, a natural course control group will be included. DISCUSSION This study will provide insights into the mechanism of expectation modulation in active placebo treatments for major depression. The results may provide insights for clinicians to improve their communication with patients by focusing on treatment expectations. By identifying the factors that contribute to placebo effects, this study has the potential to improve the effectiveness of existing depression treatments and reduce the burden of this highly prevalent mental health condition. TRIAL REGISTRATION This trial has been registered prospectively at ClinicalTrials.gov under the identifier: NCT04719663. Registered on January 22, 2021.
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Affiliation(s)
- Liv Henrich
- Department of Psychology, Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032, Marburg, Germany.
| | - Marcel Wilhelm
- Department of Psychology, Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032, Marburg, Germany
| | - Philipp Lange
- Department of Psychology, Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032, Marburg, Germany
| | - Winfried Rief
- Department of Psychology, Division of Clinical Psychology and Psychotherapy, Philipps University of Marburg, Gutenbergstraße 18, 35032, Marburg, Germany
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Liu S, Liu JT, Chen L, Fan TY, Cui XJ, Cheng SD, Chen YJ, Shi Q, Xue CC, Li XF. Efficacy of five-step shoulder manipulation for rotator cuff-related shoulder pain: protocol for a multicenter randomized controlled trial. Trials 2023; 24:498. [PMID: 37550698 PMCID: PMC10405406 DOI: 10.1186/s13063-023-07540-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 07/25/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Rotator cuff-related shoulder pain (RCRSP) is the most common cause of shoulder disorders. In China, manipulation has been used extensively for the treatment of patients with RCRSP. However, high-quality clinical evidence to support the therapeutic effect of manipulation is still limited. METHODS A multicenter, participant-, outcome assessor-, and data analyst-blinded, randomized, placebo-controlled trial will be conducted. A total of 280 participants with RCRSP will be recruited from three hospitals and randomly assigned to a five-step shoulder manipulation (FSM) group or a sham manipulation (SM) group. Each group will receive four weekly treatment sessions, with all participants performing exercises at home for 12 weeks. Assessments, namely the Constant-Murley score, visual analog scale, range of motion, and 36-Item Short Form Survey, will be made at baseline, 4, 12, 18, and 24 weeks. Adverse events during the study will also be recorded. DISCUSSION This is a pragmatic clinical trial to evaluate the efficacy and safety of FSM in patients with RCRSP. The findings of this study will provide worthy clinical evidence for manual therapy for RCRSP. TRIAL REGISTRATION China Registered Clinical Trial Registration Center ChiCTR2000037577. Registered on 29 August 2020.
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Affiliation(s)
- Shuang Liu
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, 274 Zhijiangzhong Road, Shanghai, 200071 China
- LongHua Hospital Shanghai University of Traditional Chinese Medicine, 725 Wanpingnan Road, Shanghai, 200032 China
| | - Jin-Tao Liu
- Suzhou Hospital of Traditional Chinese Medicine, 899 Wuzhongxi Road, Suzhou, 215009 Jiangsu China
| | - Lin Chen
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, 274 Zhijiangzhong Road, Shanghai, 200071 China
| | - Tian-You Fan
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, 274 Zhijiangzhong Road, Shanghai, 200071 China
| | - Xue-Jun Cui
- LongHua Hospital Shanghai University of Traditional Chinese Medicine, 725 Wanpingnan Road, Shanghai, 200032 China
| | - Shao-Dan Cheng
- Shanghai GuangHua Hospital of Integrated Traditional Chinese and Western Medicine, 540 Xinhua Road, Shanghai, 200052 China
| | - Yan-Jiao Chen
- Shanghai Research Institute of Acupuncture and Meridian, YueYang Hospital of Integrated Traditional Chinese and Western Medicine, 650 Wanpingnan Road, Shanghai, 200030 China
| | - Qi Shi
- LongHua Hospital Shanghai University of Traditional Chinese Medicine, 725 Wanpingnan Road, Shanghai, 200032 China
- Qi Shi’s Studio of Famous Chinese Medicine Physician, 274 Zhijiangzhong Road, Shanghai, 200032 China
| | - Chun-Chun Xue
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, 274 Zhijiangzhong Road, Shanghai, 200071 China
| | - Xiao-Feng Li
- Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, 274 Zhijiangzhong Road, Shanghai, 200071 China
- Qi Shi’s Studio of Famous Chinese Medicine Physician, 274 Zhijiangzhong Road, Shanghai, 200032 China
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Pan Y, Gorenflo MP, Davis PB, Kaelber DC, De Luca S, Xu R. Suicidal ideation and suicide attempt following ketamine prescription in patients with treatment-resistant depression: a nation-wide cohort study. RESEARCH SQUARE 2023:rs.3.rs-3207199. [PMID: 37609161 PMCID: PMC10441476 DOI: 10.21203/rs.3.rs-3207199/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Ketamine, including esketamine, is an effective treatment for patients with treatment-resistant depression (TRD); however, its long-term efficacy in real-world populations remains poorly characterized. This is a retrospective cohort study using TriNetX US Collaborative Network, a platform aggregating electronic health records (EHRs) data from 93 million patients from 56 health care organizations in the US, and the study population includes 321,367 patients with a diagnosis of TRD who were prescribed relevant treatment in their EHRs. The prescription of ketamine (including esketamine) was associated with significant decreased risk of suicidal ideation compared to prescription of other common antidepressants: HR = 0.65 (95% CI: 0.53 - 0.81) at 1 day - 7 days, 0.78 (95% CI: 0.66 - 0.92) at 1 day - 30 days, 0.81 (95% CI: 0.70 - 0.92) at 1 day - 90 days, 0.82 (95% CI: 0.72 - 0.92) at 1 day - 180 days, and 0.83 (95% CI: 0.74 - 0.93) at 1 day - 270 days. This trend was especially robust among adults over 24 years of age, males, and White patients with TRD. No significant difference was observed for suicide attempts, except significantly increased risk for adolescents (aged 10-24) at 1 day - 30 days with HR = 2.22 (95% CI: 1.01-4.87). This study provides real-world evidence that ketamine has long-term benefits in mitigating suicidal ideation in patients with treatment-resistant depression. Future work should focus on optimizing dosage regimens for ketamine, understanding the mechanism, and the difference in various demographic subpopulations.
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Affiliation(s)
- Yiheng Pan
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Computer and Data Science, Case Western Reserve University, Cleveland, OH, USA
| | - Maria P. Gorenflo
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Pamela B. Davis
- Center for Community Health Integration, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - David C. Kaelber
- The Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, OH, USA
| | - Susan De Luca
- Population Health Research Institute, The MetroHealth System, Cleveland, OH, USA
| | - Rong Xu
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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de Haan A, van Nes JGH, Kolff MW, van der Toorn PP, Westenberg AH, van der Vegt AE, Groen H, Overbosch J, van der Laan HP, Werker PMN, Langendijk JA, Steenbakkers RJHM. Radiotherapy for Ledderhose disease: Results of the LedRad-study, a prospective multicentre randomised double-blind phase 3 trial. Radiother Oncol 2023; 185:109718. [PMID: 37211283 DOI: 10.1016/j.radonc.2023.109718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND AND PURPOSE Radiotherapy is considered a treatment option for Ledderhose disease. However, its benefits have never been confirmed in a randomised controlled trial. Therefore, the LedRad-study was conducted. MATERIALS AND METHODS The LedRad-study is a prospective multicentre randomised double-blind phase three trial. Patients were randomised to sham-radiotherapy (placebo) or radiotherapy. The primary endpoint was pain reduction at 12 months after treatment, measured with the Numeric Rating Scale (NRS). Secondary endpoints were pain reduction at 6 and 18 months after treatment, quality of life (QoL), walking abilities and toxicity. RESULTS A total of 84 patients were enrolled. At 12 and 18 months, patients in the radiotherapy group had a lower mean pain score compared to patients in the sham-radiotherapy group (2.5 versus 3.6 (p = 0.03) and 2.1 versus 3.4 (p = 0.008), respectively). Pain relief at 12 months was 74% in the radiotherapy group and 56% in the sham-radiotherapy group (p = 0.002). Multilevel testing for QoL scores showed higher QoL scores in the radiotherapy group compared to the sham-radiotherapy group (p < 0.001). Moreover, patients in the radiotherapy group had a higher mean walking speed and step rate with barefoot speed walking (p = 0.02). Erythema, skin dryness, burning sensations and increased pain were the most frequently reported side effects. These side effects were generally graded as mild (95%) and the majority (87%) were resolved at 18 months follow-up. CONCLUSION Radiotherapy for symptomatic Ledderhose disease is an effective treatment resulting in a significant pain reduction, improvement of QoL scores and bare feet walking abilities, in comparison to sham-radiotherapy.
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Affiliation(s)
- Anneke de Haan
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands.
| | | | - M Willemijn Kolff
- Amsterdam University Medical Center, Department of Radiation Oncology, Amsterdam, the Netherlands
| | | | | | - Annelies E van der Vegt
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, the Netherlands
| | - Henk Groen
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, the Netherlands
| | - Jelle Overbosch
- University of Groningen, University Medical Center Groningen, Department of Radiology, Groningen, the Netherlands
| | - Hans Paul van der Laan
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands
| | - Paul M N Werker
- University of Groningen, University Medical Center Groningen, Department of Plastic Surgery, Groningen, the Netherlands
| | - Johannes A Langendijk
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands
| | - Roel J H M Steenbakkers
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands
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Norena AJ. The Analogy between Tinnitus and Chronic Pain: A Phenomenological Approach. Brain Sci 2023; 13:1129. [PMID: 37626486 PMCID: PMC10452332 DOI: 10.3390/brainsci13081129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/22/2023] [Accepted: 07/25/2023] [Indexed: 08/27/2023] Open
Abstract
Tinnitus is an auditory sensation without external acoustic stimulation or significance, which may be lived as an unpleasant experience and impact the subject's quality of life. Tinnitus loudness, which is generally low, bears no relation to distress. Factors other than psychoacoustic (such as psychological factors) are therefore implicated in the way tinnitus is experienced. The aim of this article is to attempt to understand how tinnitus can, like chronic pain, generate a 'crisis' in the process of existence, which may go as far as the collapse of the subject. The main idea put forward in the present article is that tinnitus may be compared to the phenomenon of pain from the point of view of the way it is experienced. Although the analogy between tinnitus and pain has often been made in the literature, it has been limited to a parallel concerning putative physiopathological mechanisms and has never really been explored in depth from the phenomenological point of view. Tinnitus is comparable to pain inasmuch as it is felt, not perceived: it springs up (without intention or exploration), abolishes the distance between the subject and the sensation (there is only a subject and no object), and has nothing to say about the world. Like pain, tinnitus is formless and abnormal and can alter the normal order of the world with maximum intensity. Finally, tinnitus and pain enclose the subject within the limits of the body, which then becomes in excess. Tinnitus may be a source of suffering, which affects not only the body but a person's very existence and, in particular, its deployment in time. Plans are thus abolished, so time is no longer 'secreted', it is enclosed in an eternal present. If the crisis triggered by tinnitus is not resolved, the subject may buckle and collapse (depression) when their resources for resisting are depleted. The path may be long and winding from the moment when tinnitus emerges to when it assaults existence and its eventual integration into a new existential norm where tinnitus is no longer a source of disturbance.
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Affiliation(s)
- Arnaud J Norena
- Laboratoire de Neurosciences Sensorielles et Cognitives, CNRS, Aix-Marseille University, 13003 Marseille, France
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Trakimas DR, Colloca L, Fakhry C, Tan M, Khan Z, Vosler PS. Study protocol: randomised controlled trial of conditioned open-label placebo (COLP) for perioperative pain management in patients with head and neck cancer. BMJ Open 2023; 13:e069785. [PMID: 37419646 PMCID: PMC10335570 DOI: 10.1136/bmjopen-2022-069785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 06/11/2023] [Indexed: 07/09/2023] Open
Abstract
INTRODUCTION Patients with head and neck cancer have a substantial risk of chronic opioid dependence following surgery due to pain and psychosocial consequences from both the disease process and its treatments. Conditioned open-label placebos (COLPs) have been effective for reducing the dose of active medication required for a clinical response across a wide range of medical conditions. We hypothesise that the addition of COLPs to standard multimodal analgesia will be associated with reduced baseline opioid consumption by 5 days after surgery in comparison to standard multimodal analgesia alone in patients with head and neck cancer. METHODS AND ANALYSIS This randomised controlled trial will evaluate the use of COLP for adjunctive pain management in patients with head and neck cancer. Participants will be randomised with 1:1 allocation to either the treatment as usual or COLP group. All participants will receive standard multimodal analgesia, including opioids. The COLP group will additionally receive conditioning (ie, exposure to a clove oil scent) paired with active and placebo opioids for 5 days. Participants will complete surveys on pain, opioid consumption and depression symptoms through 6 months after surgery. Average change in baseline opioid consumption by postoperative day 5 and average pain levels and opioid consumption through 6 months will be compared between groups. ETHICS AND DISSEMINATION There remains a demand for more effective and safer strategies for postoperative pain management in patients with head and neck cancer as chronic opioid dependence has been associated with decreased survival in this patient population. Results from this study may lay the groundwork for further investigation of COLPs as a strategy for adjunctive pain management in patients with head and neck cancer. This clinical trial has been approved by the Johns Hopkins University Institutional Review Board (IRB00276225) and is registered on the National Institutes of Health Clinical Trials Database. TRIAL REGISTRATION NUMBER NCT04973748.
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Affiliation(s)
- Danielle R Trakimas
- Otolaryngology - Head & Neck Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Luana Colloca
- Department of Pain and Translational Symptom Science | Placebo Beyond Opinion Center, University of Maryland School of Nursing, Baltimore, Maryland, USA
| | - Carole Fakhry
- Otolaryngology - Head & Neck Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Marietta Tan
- Otolaryngology - Head & Neck Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Zubair Khan
- Otolaryngology - Head & Neck Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Peter S Vosler
- Otolaryngology - Head & Neck Surgery, Johns Hopkins Medicine, Baltimore, Maryland, USA
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48
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Donovan LM, Hoyos CM, Kimoff RJ, Morrell MJ, Bosch NA, Chooljian DM, McEvoy RD, Sawyer AM, Wagner TH, Al-Lamee RR, Bishop D, Carno MA, Epstein M, Hanson M, Ip MSM, Létourneau M, Pamidi S, Patel SR, Pépin JL, Punjabi NM, Redline S, Thornton JD, Patil SP. Strategies to Assess the Effect of Continuous Positive Airway Pressure on Long-Term Clinically Important Outcomes among Patients with Symptomatic Obstructive Sleep Apnea: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2023; 20:931-943. [PMID: 37387624 DOI: 10.1513/annalsats.202303-258st] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023] Open
Abstract
Continuous positive airway pressure (CPAP) is the first-line treatment for obstructive sleep apnea (OSA). Although CPAP improves symptoms (e.g., daytime sleepiness), there is a lack of high-quality evidence that CPAP prevents many long-term outcomes, including cognitive impairment, myocardial infarction, and stroke. Observational studies suggest that patients with symptoms may be particularly likely to experience these preventive benefits with CPAP, but ethical and practical concerns limited the participation of such patients in prior long-term randomized trials. As a result, there is uncertainty about the full benefits of CPAP, and resolving this uncertainty is a key priority for the field. This workshop assembled clinicians, researchers, ethicists, and patients to identify strategies to understand the causal effects of CPAP on long-term clinically important outcomes among patients with symptomatic OSA. Quasi-experimental designs can provide valuable information and are less time and resource intensive than trials. Under specific conditions and assumptions, quasi-experimental studies may be able to provide causal estimates of CPAP's effectiveness from generalizable observational cohorts. However, randomized trials represent the most reliable approach to understanding the causal effects of CPAP among patients with symptoms. Randomized trials of CPAP can ethically include patients with symptomatic OSA, as long as there is outcome-specific equipoise, adequate informed consent, and a plan to maximize safety while minimizing harm (e.g., monitoring for pathologic sleepiness). Furthermore, multiple strategies exist to ensure the generalizability and practicality of future randomized trials of CPAP. These strategies include reducing the burden of trial procedures, improving patient-centeredness, and engaging historically excluded and underserved populations.
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Lawn T, Howard MA, Turkheimer F, Misic B, Deco G, Martins D, Dipasquale O. From neurotransmitters to networks: Transcending organisational hierarchies with molecular-informed functional imaging. Neurosci Biobehav Rev 2023; 150:105193. [PMID: 37086932 PMCID: PMC10390343 DOI: 10.1016/j.neubiorev.2023.105193] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 04/01/2023] [Accepted: 04/19/2023] [Indexed: 04/24/2023]
Abstract
The human brain exhibits complex interactions across micro, meso-, and macro-scale organisational principles. Recent synergistic multi-modal approaches have begun to link micro-scale information to systems level dynamics, transcending organisational hierarchies and offering novel perspectives into the brain's function and dysfunction. Specifically, the distribution of micro-scale properties (such as receptor density or gene expression) can be mapped onto macro-scale measures from functional MRI to provide novel neurobiological insights. Methodological approaches to enrich functional imaging analyses with molecular information are rapidly evolving, with several streams of research having developed relatively independently, each offering unique potential to explore the trans-hierarchical functioning of the brain. Here, we address the three principal streams of research - spatial correlation, molecular-enriched network, and in-silico whole brain modelling analyses - to provide a critical overview of the different sources of molecular information, how this information can be utilised within analyses of fMRI data, the merits and pitfalls of each methodology, and, through the use of key examples, highlight their promise to shed new light on key domains of neuroscientific inquiry.
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Affiliation(s)
- Timothy Lawn
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Matthew A Howard
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Federico Turkheimer
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Bratislav Misic
- Montreal Neurological Institute and Hospital, McGill University, Montreal, Québec, Canada
| | - Gustavo Deco
- Center for Brain and Cognition, Computational Neuroscience Group, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Ramon Trias Fargas 25-27, Barcelona 08005, Spain; Department of Neuropsychology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany; Institució Catalana de Recerca i Estudis Avançats (ICREA), Barcelona, Spain; Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia
| | - Daniel Martins
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ottavia Dipasquale
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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50
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Yan S, Xu M, Zou X, Xiong Z, Li H, Yang J, Cao W, Zhu Z, Liu C. Acupuncture combined with ondansetron for prevention of postoperative nausea and vomiting in high-risk patients undergoing laparoscopic gynaecological surgery: A randomised controlled trial. United European Gastroenterol J 2023. [PMID: 37318120 DOI: 10.1002/ueg2.12421] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/17/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Consensus guidelines recommend the use of multiple antiemetics as prophylaxis in patients at high risk of postoperative nausea and vomiting (PONV), but the evidence regarding combining acupuncture and antiemetics as a multimodal approach was of very low quality. OBJECTIVE This study aimed to assess the effect of combinations of acupuncture with ondansetron versus ondansetron alone for PONV prophylaxis in women at a high risk. METHODS This parallel, randomised controlled trial was conducted in a tertiary hospital in China. Patients who had three or four PONV risk factors on the Apfel simplified risk score, undergoing elective laparoscopic gynaecological surgery for benign pathology, were recruited. Patients in the combination group received two sessions of acupuncture treatment and 8 mg intravenous ondansetron, whereas those in the ondansetron group received ondansetron alone. The primary outcome was the incidence of PONV within 24 h postoperatively. Secondary outcomes included the incidence of postoperative nausea, postoperative vomiting, adverse events etc. RESULTS: Between January and July 2021, a total of 212 women were recruited, 91 patients in the combination group and 93 patients in the ondansetron group were included in the modified intention-to-treat analysis. In the first 24 h postoperatively, 44.0% of the patients in the combination group and 60.2% of the patients in the ondansetron group experienced nausea, vomiting, or both (difference, -16.3% [95% CI, -30.5 to -2.0]; risk ratio, 0.73 [95% CI, 0.55-0.97]; p = 0.03). However, the results of the secondary outcomes showed that compared to ondansetron alone, acupuncture together with ondansetron was only effective in reducing nausea but did not have a significant impact on vomiting. The incidence of adverse events was similar between the groups. CONCLUSION Acupuncture combined with ondansetron as a multimodal prophylaxis approach is more effective than ondansetron alone in preventing postoperative nausea in high-risk patients.
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Affiliation(s)
- Shiyan Yan
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Mingjun Xu
- Department of Anaesthesiology, Beijing Obstetrics and Gynaecology Hospital, Capital Medical University, Beijing, China
| | - Xuan Zou
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Zhiyi Xiong
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Hewen Li
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Jingwen Yang
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Wenchao Cao
- Department of Anaesthesiology, Beijing Obstetrics and Gynaecology Hospital, Capital Medical University, Beijing, China
| | - Ziqiong Zhu
- Department of Anaesthesiology, Beijing Obstetrics and Gynaecology Hospital, Capital Medical University, Beijing, China
| | - Cunzhi Liu
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
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