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de Bruijn CM, Hovy SW, Tromp E, Benninga MA, Hall KT, Vlieger AM. Do Polymorphisms Predict Hypnotherapy Response in Children With Functional Abdominal Pain Disorders: An Explorative Study. J Pediatr Gastroenterol Nutr 2023; 77:486-490. [PMID: 37490618 PMCID: PMC10501350 DOI: 10.1097/mpg.0000000000003895] [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: 11/22/2022] [Accepted: 07/11/2023] [Indexed: 07/27/2023]
Abstract
Genetic variations, in specific COMT , OPRM1 , and MAO-A polymorphisms, have been associated with hypnotizability in adults. The aim of this exploratory study was to investigate whether these polymorphisms are also associated with response to hypnotherapy (HT) in children. Patients (8-18 years, n = 260) diagnosed with a functional abdominal pain disorder (FAPD) from a previous trial assessing HT efficacy were approached for participation and 144 agreed to collect a buccal sample. Primary aim was to explore the association between COMT , OPRM1 , and MAO-A polymorphisms with treatment success (TS) after 3-month HT. Additionally, associations between these polymorphisms and adequate relief, anxiety, depression, quality of life, somatization, hypnotic susceptibility, expectations, pain beliefs, and coping strategies were evaluated. Participants with different variations of COMT , MAO-A , and OPRM1 achieved similar TS levels ( P > 0.05). No associations were found between these polymorphisms and secondary outcomes. This suggest that in pediatric patients with FAPDs, COMT , OPRM1 , and MAO-A polymorphisms do not predict HT response.
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Affiliation(s)
- Clara M.A. de Bruijn
- From the Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Hepatology and Nutrition, Amsterdam, The Netherlands
| | - Stefan W. Hovy
- the Department of Pediatrics, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Ellen Tromp
- the Department of Statistics, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marc A. Benninga
- From the Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology, Hepatology and Nutrition, Amsterdam, The Netherlands
| | - Kathryn T. Hall
- the Division of Preventive Medicine, Brigham and Womens Hospital and Harvard Medical School, Boston, and Boston Public Health Commission, Boston, MA
| | - Arine M. Vlieger
- the Department of Pediatrics, St. Antonius Hospital, Nieuwegein, The Netherlands
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2
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Rossettini G, Campaci F, Bialosky J, Huysmans E, Vase L, Carlino E. The Biology of Placebo and Nocebo Effects on Experimental and Chronic Pain: State of the Art. J Clin Med 2023; 12:4113. [PMID: 37373806 DOI: 10.3390/jcm12124113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
(1) Background: In recent years, placebo and nocebo effects have been extensively documented in different medical conditions, including pain. The scientific literature has provided strong evidence of how the psychosocial context accompanying the treatment administration can influence the therapeutic outcome positively (placebo effects) or negatively (nocebo effects). (2) Methods: This state-of-the-art paper aims to provide an updated overview of placebo and nocebo effects on pain. (3) Results: The most common study designs, the psychological mechanisms, and neurobiological/genetic determinants of these phenomena are discussed, focusing on the differences between positive and negative context effects on pain in experimental settings on healthy volunteers and in clinical settings on chronic pain patients. Finally, the last section describes the implications for clinical and research practice to maximize the medical and scientific routine and correctly interpret the results of research studies on placebo and nocebo effects. (4) Conclusions: While studies on healthy participants seem consistent and provide a clear picture of how the brain reacts to the context, there are no unique results of the occurrence and magnitude of placebo and nocebo effects in chronic pain patients, mainly due to the heterogeneity of pain. This opens up the need for future studies on the topic.
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Affiliation(s)
| | - Francesco Campaci
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, 10124 Turin, Italy
| | - Joel Bialosky
- Department of Physical Therapy, University of Florida, Gainesville, FL 32611, USA
- Clinical Research Center, Brooks Rehabilitation, Jacksonville, FL 32211, USA
| | - Eva Huysmans
- Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussels, Belgium
- Department of Physical Medicine and Physiotherapy, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, 8000 Aarhus, Denmark
| | - Elisa Carlino
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, 10124 Turin, Italy
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3
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Wang R, Loscalzo J. Network module-based drug repositioning for pulmonary arterial hypertension. CPT Pharmacometrics Syst Pharmacol 2021; 10:994-1005. [PMID: 34132494 PMCID: PMC8452304 DOI: 10.1002/psp4.12670] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/12/2021] [Accepted: 05/10/2021] [Indexed: 01/05/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a progressive disorder characterized by pulmonary vascular remodeling leading to increased pulmonary vascular resistance and pulmonary arterial pressure. PAH is a highly morbid cardiopulmonary disease adversely affecting lifespan and quality of life. Despite increased awareness and advances of medical therapies in recent decades, long-term prognosis and survival remain poor for patients with PAH. Novel therapies that can target the underlying pathobiology of PAH and reverse pulmonary vascular remodeling are clearly needed. In this study, we develop a network module-based framework to examine potential drug repositioning for PAH. The rationale for this approach is that in order to have therapeutic effects, the targets of potential drugs must be significantly proximate to the disease module of interest in the human protein-protein interactome. Based on 15 existing drugs for treating PAH, our framework integrates drug-drug interactions, drug-drug chemical similarity, drug targets, and PAH disease proteins into the human interactome, and prioritizes candidate drugs for PAH. We identified 53 drugs that could potentially be repurposed for PAH. Many of these candidates have strong literature support. Compared to black-box-like machine learning models, network module-based drug repositioning can provide mechanistic insights into how repositioned drugs can target the underlying pathobiological mechanisms of PAH.
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Affiliation(s)
- Rui‐Sheng Wang
- Department of Medicine, Cardiovascular DivisionBrigham and Women’s HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Joseph Loscalzo
- Department of Medicine, Cardiovascular DivisionBrigham and Women’s HospitalHarvard Medical SchoolBostonMassachusettsUSA
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Hoenemeyer TW, Baidwan NK, Hall K, Kaptchuk TJ, Fontaine KR, Mehta TS. An Exploratory Analysis of the Association Between Catechol-O-Methyltransferase and Response to a Randomized Open-Label Placebo Treatment for Cancer-Related Fatigue. Front Psychiatry 2021; 12:684556. [PMID: 34267689 PMCID: PMC8275998 DOI: 10.3389/fpsyt.2021.684556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/28/2021] [Indexed: 12/12/2022] Open
Abstract
Previous studies have identified catechol-O-methyltransferase (COMT), as a key enzyme influencing sympathetic function. Although the COMT SNP rs4680 and rs4818, are well-studied, little is known about their influence on cancer-related fatigue (CrF) and placebo response. In this study, we examined whether genetic variation in COMT, at the functional SNP rs4680 and linked rs4818, influenced open-label placebo (OLP) responses found in cancer survivors reporting moderate to severe CrF. We randomized cancer survivors (N = 74) reporting moderate-to-severe CrF to receive OLP or to treatment-as-usual (TAU) and assessed if rs4680 and rs4818 were associated with changes in fatigue severity and fatigue-distressed quality of life. At the end of the initial 21 days, the treatments were crossed over and both groups were re-assessed. Participants with the rs4680 high-activity G-allele (G/G or G/A) or rs4818 C/G genotypes reported significant decreases in fatigue severity and improvements in fatigue-distressed quality of life. The COMT rs4818 findings replicated findings in a similar study of OLP in cancer fatigue. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02522988.
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Affiliation(s)
- Teri W. Hoenemeyer
- Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Navneet Kaur Baidwan
- Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kathryn Hall
- Division of Preventive Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Ted J. Kaptchuk
- Program of Placebo Studies and the Therapeutic Encounter, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Kevin R. Fontaine
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Tapan S. Mehta
- Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States
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5
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Flowers KM, Patton ME, Hruschak VJ, Fields KG, Schwartz E, Zeballos J, Kang JD, Edwards RR, Kaptchuk TJ, Schreiber KL. Conditioned open-label placebo for opioid reduction after spine surgery: a randomized controlled trial. Pain 2021; 162:1828-1839. [PMID: 33449503 PMCID: PMC8378225 DOI: 10.1097/j.pain.0000000000002185] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/31/2020] [Indexed: 12/19/2022]
Abstract
ABSTRACT Placebo effects have traditionally involved concealment or deception. However, recent evidence suggests that placebo effects can also be elicited when prescribed transparently as "open-label placebos" (OLPs), and that the pairing of an unconditioned stimulus (eg, opioid analgesic) with a conditioned stimulus (eg, placebo pill) can lead to the conditioned stimulus alone reducing pain. In this randomized control trial, we investigated whether combining conditioning with an OLP (COLP) in the immediate postoperative period could reduce daily opioid use and postsurgical pain among patients recovering from spine surgery. Patients were randomized to COLP or treatment as usual, with both groups receiving unrestricted access to a typical opioid-based postoperative analgesic regimen. The generalized estimating equations method was used to assess the treatment effect of COLP on daily opioid consumption and pain during postoperative period from postoperative day (POD) 1 to POD 17. Patients in the COLP group consumed approximately 30% less daily morphine milligram equivalents compared with patients in the treatment as usual group during POD 1 to 17 (-14.5 daily morphine milligram equivalents; 95% CI: [-26.8, -2.2]). Daily worst pain scores were also lower in the COLP group (-1.0 point on the 10-point scale; 95% CI: [-2.0, -0.1]), although a significant difference was not detected in average daily pain between the groups (-0.8 point; 95% CI: [-1.7, 0.2]). These findings suggest that COLP may serve as a potential adjuvant analgesic therapy to decrease opioid consumption in the early postoperative period, without increasing pain.
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Affiliation(s)
- Kelsey M. Flowers
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Megan E. Patton
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Valerie J. Hruschak
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Kara G. Fields
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Emily Schwartz
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Jose Zeballos
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - James D. Kang
- Departments of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Rob R. Edwards
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Ted J. Kaptchuk
- Program in Placebo Studies and Therapeutic Encounter, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Kristin L. Schreiber
- Departments of Anesthesiology, Perioperative, and Pain Medicine Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
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The Effect of Information Placebo on Physical Activity in Overweight and Obese Children. Pediatr Exerc Sci 2021; 33:120-124. [PMID: 33958501 DOI: 10.1123/pes.2020-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 12/18/2020] [Accepted: 02/03/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE To assess the effect of 1 week of consuming a placebo "energy drink" compared with a week of drinking regular water on daily physical activity in obese children participating in a weight reduction multidisciplinary program. METHODS Seventeen prepubertal (age = 128.7 [26.6] m) overweight and obese children (7 females and 10 males) participated in the study. Participants received 7 bottles of mineral water per week for 2 weeks. Different types of information were randomly provided regarding the drink consumed in each week: standard (water) versus deliberate positive information (presumed energy drink and placebo). Daily step count was measured using pedometers and compared using paired t test. RESULTS After consuming the placebo drink, children demonstrated a significantly higher average daily step number (10,452 [4107]) compared with the days they drank water (8168 [2928], P < .005). This difference was attributed mainly to male participants. CONCLUSION The use of placebo in the form of deliberate positive information was associated with a significant increase in real-life physical activity in overweight and obese children, especially in boys. Positive information may be used to encourage children with obesity to enhance daily physical activity and energy expenditure.
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Özdemir V. A Placebogenomics/Nocebogenomics Challenge to Pharmacogenomics, Nutrigenomics, and Vaccinomics: Why Should We Rethink Association Study Designs? OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2021; 25:133-135. [PMID: 33513040 DOI: 10.1089/omi.2021.0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Vural Özdemir
- OMICS: A Journal of Integrative Biology, New Rochelle, New York, USA
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8
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Brand A, Evangelatos N, Özdemir V. Placebogenomics: A New Concept and Tool for Personalized Medicine and Public Health. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2021; 25:76-78. [PMID: 33428508 DOI: 10.1089/omi.2020.0221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Angela Brand
- UNU-MERIT (United Nations University-Maastricht Economic and Social Research Institute on Innovation and Technology), Maastricht University, Maastricht, The Netherlands.,Department of International Health, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.,Department of Public Health Genomics, Manipal School of Life Sciences (MSLS), Manipal Academy of Higher Education, Manipal, India
| | - Nikolaos Evangelatos
- UNU-MERIT (United Nations University-Maastricht Economic and Social Research Institute on Innovation and Technology), Maastricht University, Maastricht, The Netherlands.,Intensive Care Medicine Unit, Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University (PMU), Nuremberg, Germany
| | - Vural Özdemir
- OMICS: A Journal of Integrative Biology, New Rochelle, New York, USA
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Özdemir V, Endrenyi L. Rethinking Clinical Trials and Personalized Medicine with Placebogenomics and Placebo Dose. OMICS-A JOURNAL OF INTEGRATIVE BIOLOGY 2020; 25:1-12. [PMID: 33305994 DOI: 10.1089/omi.2020.0208] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pharmacogenomics, nutrigenomics, vaccinomics, and the nascent field of plant omics are examples of variability science. They are embedded within an overarching framework of personalized medicine. Across these public health specialties, the significance and biology of the placebo response have been historically neglected. A placebo is any substance such as a sugar pill administered in the guise of medication, but one that does not have pharmacological activity. Placebos do have clinical effects, however, that can be substantive in magnitude and vary markedly from person-to-person depending, for example, on the type of disease, symptoms, or clinical trial design. Research over the past several decades attests to a genuine neurobiological basis for placebo effects. All drugs have placebo components that contribute to their overall treatment effect. Placebos are used in clinical trials as control groups to ascertain the net pharmacological effect of a drug candidate. Not only less well known but also relevant to rational therapeutics and personalized medicine is the nocebo. A nocebo effect occurs when an inert substance is administered in a context that induces negative expectations, worsening patients' symptoms. With the COVID-19 pandemic, there are high public expectations for new vaccines and medicines to end the contagion, while at the same time antiscience, post-truth, and antivaccine movements are worrisomely on the rise. These social movements, changes in public health cultures, and conditioned behavioral responses can trigger both placebo and nocebo effects. Hence, in clinical trials, forecasting and explaining placebo and nocebo variability are more important than ever for robust science and personalized health care. Against this overarching context, this article provides (1) a brief history of placebo and (2) a discussion on biology, mechanisms, and variability of placebo effects, and (3) discusses three emerging new concepts: placebogenomics, nocebogenomics, and augmented placebo, that is, the notion of a "placebo dose." We conclude with a roadmap for placebogenomics, its synergies with the nascent field of social pharmacology, and the ways in which a new taxonomy of drug and placebo variability can be anticipated in the next decade.
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Affiliation(s)
- Vural Özdemir
- OMICS: A Journal of Integrative Biology, New Rochelle, New York, USA
| | - Laszlo Endrenyi
- Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, Canada
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10
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Li JL, Liu CZ, Zhang N, Yan CQ, Tu JF, Wang LQ, Qi YS, Liu JH, Wang X. Neurological and psychological mechanisms of the specific and nonspecific effects of acupuncture on knee osteoarthritis: study protocol for a randomized, controlled, crossover trial. Trials 2020; 21:989. [PMID: 33256796 PMCID: PMC7706223 DOI: 10.1186/s13063-020-04908-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 11/16/2020] [Indexed: 12/31/2022] Open
Abstract
Background Acupuncture, as one of the promising non-pharmacological interventions, has been proved to be beneficial for patients. However, the magnitude of acupuncture’s specific and nonspecific effects, as well as their neurological and psychological determinants, remains unclear. Therefore, this study is designed to examine the acupuncture efficacy, investigate whether the brain mechanisms between the specific and nonspecific effects of acupuncture are different, and to evaluate how psychological factors affect the acupuncture effects. Methods This is a randomized, controlled, crossover clinical trial. A total of 60 patients with knee osteoarthritis will receive 4 weeks of acupuncture treatment and 4 weeks of sham acupuncture treatment in a random order separated by a washout period of 2 weeks. The changes in clinical characteristics based on pain-related scales will be assessed to investigate the clinical efficacy of acupuncture. Resting state functional magnetic resonance imaging (fMRI) scans will be used to identify the brain activity changes related to the specific and nonspecific effects of acupuncture. The questionnaires of psychological factors will be used to evaluate patients’ psychological properties. Correlation and mediation analyses will be conducted among psychological factors, brain activity changes, and symptoms improvement to explore the neurological and psychological correlates of the acupuncture effects. Discussion This study will concentrate on distinguishing and clarifying the specific and nonspecific effects of acupuncture. The results of this study may contribute to rationally optimize the acupuncture therapies by flexible application of the specific and nonspecific effects of acupuncture. Trial registration Chinese Clinical Trial Registry ChiCTR1900025807. Registered on 9 September 2019 Supplementary information The online version contains supplementary material available at 10.1186/s13063-020-04908-9.
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Affiliation(s)
- Jin-Ling Li
- Acupuncture Research Center, School of Acupuncture, Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Cun-Zhi Liu
- Acupuncture Research Center, School of Acupuncture, Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Na Zhang
- Acupuncture Research Center, School of Acupuncture, Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Chao-Qun Yan
- Acupuncture Research Center, School of Acupuncture, Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Jian-Feng Tu
- Acupuncture Research Center, School of Acupuncture, Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Li-Qiong Wang
- Acupuncture Research Center, School of Acupuncture, Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - You-Sheng Qi
- Nanyuan Community Health Service Center, Fengtai District, Beijing, 100076, China
| | - Jun-Hong Liu
- Nanyuan Community Health Service Center, Fengtai District, Beijing, 100076, China
| | - Xu Wang
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, 100029, China.
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Sochacki KR, Mather RC, Nwachukwu BU, Dong D, Nho SJ, Cote MP, Harris JD. Sham Surgery Studies in Orthopaedic Surgery May Just Be a Sham: A Systematic Review of Randomized Placebo-Controlled Trials. Arthroscopy 2020; 36:2750-2762.e2. [PMID: 32417564 DOI: 10.1016/j.arthro.2020.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the limitations of randomized sham surgery-controlled trials in orthopaedic sports medicine and fidelity of the trials' conclusions. METHODS Randomized placebo surgery-controlled trials in orthopaedic sports medicine were included in this Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided systematic review. Several aspects of investigation design and conduct were analyzed: genetic analysis for propensity to placebo response, equipoise of informed consent process, geography of trial subjects, percentage of eligible subjects willing to be randomized, changes from protocol publication to results publication, and perioperative complications. RESULTS Seven sham surgery-controlled trials (845 subjects [370 knees, 449 shoulders, 26 elbows]; 5 from Europe, 1 from North America, and 1 from Australia; all superiority model, efficacy design) were analyzed. There were consistent methodologic deficiencies across studies. No studies reported genetic analysis of susceptibility to placebo response. Three studies (43%) were underpowered. Crossover rates ranged from 8% to 36%, which led to un-blinding in up to 100% of subjects. There were low enrollment rates of eligible subjects (up to 57% refused randomization). Follow-up was short term (2 years or less in all but one study). Complication rates ranged from 0% to 12.5%, with complications occurring in both groups (no significant difference between groups in any study). CONCLUSIONS Randomized sham-controlled studies in orthopaedic sports medicine have significant methodologic deficiencies that may invalidate their conclusions. Randomized trial design (with or without placebo control) may be optimized through the inclusion of per-protocol analysis, blinding index, equivalence or noninferiority trial design, and a nontreatment group. LEVEL OF EVIDENCE Level II Systematic Review of Level II studies.
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Affiliation(s)
- Kyle R Sochacki
- Houston Methodist Orthopedic and Sports Medicine, Houston, Texas, U.S.A
| | - Richard C Mather
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, U.S.A
| | | | - David Dong
- Houston Methodist Orthopedic and Sports Medicine, Houston, Texas, U.S.A
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Mark P Cote
- UConn Musculoskeletal Institute at UConn Health, Farmington, Connecticut, U.S.A
| | - Joshua D Harris
- Houston Methodist Orthopedic and Sports Medicine, Houston, Texas, U.S.A..
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Meissner K, Lutter D, von Toerne C, Haile A, Woods SC, Hoffmann V, Ohmayer U, Hauck SM, Tschoep MH. Molecular classification of the placebo effect in nausea. PLoS One 2020; 15:e0238533. [PMID: 32966280 PMCID: PMC7511022 DOI: 10.1371/journal.pone.0238533] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/18/2020] [Indexed: 12/12/2022] Open
Abstract
In this proof-of-concept study, we tested whether placebo effects can be monitored and predicted by plasma proteins. In a randomized controlled design, 90 participants were exposed to a nauseating stimulus on two separate days and were randomly allocated to placebo treatment or no treatment on the second day. Significant placebo effects on nausea, motion sickness, and (in females) gastric activity could be verified. Using label-free tandem mass spectrometry, 74 differentially regulated proteins were identified as correlates of the placebo effect. Gene ontology (GO) enrichment analyses identified acute-phase proteins and microinflammatory proteins to be involved, and the identified GO signatures predicted day-adjusted scores of nausea indices in the placebo group. We also performed GO enrichment analyses of specific plasma proteins predictable by the experimental factors or their interactions and identified 'grooming behavior' as a prominent hit. Finally, Receiver Operator Characteristics (ROC) allowed to identify plasma proteins differentiating placebo responders from non-responders, comprising immunoglobulins and proteins involved in oxidation reduction processes and complement activation. Plasma proteomics is a promising tool to identify molecular correlates and predictors of the placebo effect in humans.
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Affiliation(s)
- Karin Meissner
- Institute of Medical Psychology, Faculty of Medicine, LMU Munich, Munich, Germany
- Division of Health Promotion, Coburg University of Applied Sciences, Coburg, Germany
| | - Dominik Lutter
- Institute of Diabetes and Obesity, Helmholtz Diabetes Center, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Neuherberg, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Christine von Toerne
- Research Unit Protein Science, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Neuherberg, Germany
| | - Anja Haile
- Institute of Medical Psychology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Stephen C. Woods
- Department of Psychiatry and Behavioral Neuroscience, Metabolic Diseases Institute, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Verena Hoffmann
- Institute of Medical Psychology, Faculty of Medicine, LMU Munich, Munich, Germany
| | - Uli Ohmayer
- Research Unit Protein Science, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Neuherberg, Germany
| | - Stefanie M. Hauck
- Research Unit Protein Science, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Neuherberg, Germany
| | - Matthias H. Tschoep
- Institute of Diabetes and Obesity, Helmholtz Diabetes Center, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Neuherberg, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Division of Metabolic Diseases, Department of Medicine, Technische Universität München, Munich, Germany
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13
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Kumar T, Blondel L, Extavour CG. Topology-driven protein-protein interaction network analysis detects genetic sub-networks regulating reproductive capacity. eLife 2020; 9:54082. [PMID: 32901612 PMCID: PMC7550192 DOI: 10.7554/elife.54082] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 09/01/2020] [Indexed: 12/23/2022] Open
Abstract
Understanding the genetic regulation of organ structure is a fundamental problem in developmental biology. Here, we use egg-producing structures of insect ovaries, called ovarioles, to deduce systems-level gene regulatory relationships from quantitative functional genetic analysis. We previously showed that Hippo signalling, a conserved regulator of animal organ size, regulates ovariole number in Drosophila melanogaster. To comprehensively determine how Hippo signalling interacts with other pathways in this regulation, we screened all known signalling pathway genes, and identified Hpo-dependent and Hpo-independent signalling requirements. Network analysis of known protein-protein interactions among screen results identified independent gene regulatory sub-networks regulating one or both of ovariole number and egg laying. These sub-networks predict involvement of previously uncharacterised genes with higher accuracy than the original candidate screen. This shows that network analysis combining functional genetic and large-scale interaction data can predict function of novel genes regulating development.
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Affiliation(s)
- Tarun Kumar
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, United States
| | - Leo Blondel
- Department of Molecular and Cellular Biology, Harvard University, Cambridge, United States
| | - Cassandra G Extavour
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, United States.,Department of Molecular and Cellular Biology, Harvard University, Cambridge, United States
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14
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Wang RS, Croteau-Chonka DC, Silverman EK, Loscalzo J, Weiss ST, Hall KT. Pharmacogenomics and Placebo Response in a Randomized Clinical Trial in Asthma. Clin Pharmacol Ther 2019; 106:1261-1267. [PMID: 31557306 DOI: 10.1002/cpt.1646] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 09/21/2019] [Indexed: 12/24/2022]
Abstract
Genetic variation may differentially modify drug and placebo treatment effects in randomized clinical trials. In asthma, although lung function and asthma control improvements are commonplace with placebo, pharmacogenomics of placebo vs. drug response remains unexamined. In a genomewide association study of subjective and objective outcomes with placebo treatment in Childhood Asthma Management Program of nedocromil/budesonide vs. placebo (N = 604), effect estimates for lead single nucleotide polymorphisms (SNPs) were compared across arms. The coughing/wheezing lead SNP, rs2392165 (β = 0.94; P = 1.10E-07) mapped to BBS9, a gene implicated in lung development that contains a lung function expression quantitative trait locus. The effect was attenuated with budesonide (Pinteraction = 1.48E-07), but not nedocromil (Pinteraction = 0.06). The lead forced vital capacity SNP, rs12930749 (β = -5.80; P = 1.47E-06), mapped to KIAA0556, a locus genomewide associated with respiratory diseases. The rs12930749 effect was attenuated with budesonide (Pinteraction = 1.32E-02) and nedocromil (Pinteraction = 1.09E-02). Pharmacogenomic analysis revealed differential effects with placebo and drug treatment that could potentially guide precision drug development in asthma.
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Affiliation(s)
- Rui-Sheng Wang
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Damien C Croteau-Chonka
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Edwin K Silverman
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - J Loscalzo
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Scott T Weiss
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kathryn T Hall
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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15
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Hall KT, Loscalzo J. Drug-Placebo Additivity in Randomized Clinical Trials. Clin Pharmacol Ther 2019; 106:1191-1197. [PMID: 31502253 DOI: 10.1002/cpt.1626] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 08/15/2019] [Indexed: 12/11/2022]
Abstract
In randomized clinical trials (RCTs), it is assumed that nonspecific effects beyond action of pharmacological agents are roughly equivalent in drug and placebo treatment groups. Hence, since the inception of RCTs, drug efficacy is determined by comparing outcomes in active to those in placebo control arms. However, quantitation of efficacy is based on an unproven assumption, that drug and placebo responses are always additive. Response to treatment in RCTs can be differentially influenced by the perturbing effects of patient expectations, side effects, and pharmacogenomic interactions in both drug and placebo arms. Ability to control for these effects requires understanding of when and where they arise, how to mitigate, analyze, and even leverage their impact. Here, we examine three factors that influence additivity: expectation, side effects, and pharmacogenomics. Furthermore, to provide novel insights into nonadditivity and solutions for managing it, we introduce systems pharmacogenomics, a network approach to integrating and analyzing the effects of the numerous interacting perturbations to which a patient is exposed in RCTs.
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Affiliation(s)
- Kathryn T Hall
- Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph Loscalzo
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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16
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Cai L, He L. Placebo effects and the molecular biological components involved. Gen Psychiatr 2019; 32:e100089. [PMID: 31552390 PMCID: PMC6738668 DOI: 10.1136/gpsych-2019-100089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/18/2019] [Accepted: 07/30/2019] [Indexed: 12/20/2022] Open
Abstract
Pharmacologically inactive substances have been used in medicine for more than 700 years and can trigger beneficial responses in the human body, which is referred to as the placebo effects or placebo responses. This effect is robust enough to influence psychosocial and physiological responses to the placebo and to active treatments in many settings, which has led to increased interest from researchers. In this article, we summarise the history of placebo, the characteristics of placebo effects and recent advancements reported from the studies on placebo effects and highlight placebome studies to identify various molecular biological components associated with placebo effects. Although placebos have a long history, the placebome concept is still in its infancy. Although behavioural, neurobiological and genetic studies have identified that molecules in the dopamine, opioid, serotonin and endocannabinoid systems might be targets of the placebo effect, placebome studies with a no-treatment control (NTC) are necessary to identify whole-genome genetic targets. Although bioinformatics analysis has identified the molecular placebome module, placebome studies with NTCs are also required to validate the related findings.
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Affiliation(s)
- Lei Cai
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Collaborative Innovation Center of Genetics and Development, Shanghai Jiaotong University, Shanghai 200240, China
| | - Lin He
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Collaborative Innovation Center of Genetics and Development, Shanghai Jiaotong University, Shanghai 200240, China
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18
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Colloca L, Wang Y, Martinez PE, Christy Chang YP, Ryan KA, Hodgkinson C, Goldman D, Dorsey SG. OPRM1 rs1799971, COMT rs4680, and FAAH rs324420 genes interact with placebo procedures to induce hypoalgesia. Pain 2019; 160:1824-1834. [PMID: 31335650 PMCID: PMC6668362 DOI: 10.1097/j.pain.0000000000001578] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Genetics studies on the placebo hypoalgesic effect highlight a promising link between single nucleotide polymorphisms (SNPs) in the dopamine, opioid, and endocannabinoid genes and placebo hypoalgesia. However, epistasis and replication studies are missing. In this study, we expanded on previous findings related to the 3 SNPs in the opioid receptor mu subunit (OPRM1 rs1799971), catechol-O-methyltransferase (COMT rs4680), and fatty acid amide hydrolase (FAAH rs324420) genes associated with placebo hypoalgesia and tested the effect of a 3-way interaction on placebo hypoalgesia. Using 2 well-established placebo procedures (verbal suggestion and learning paradigm), we induced significant placebo hypoalgesic effects in 160 healthy participants. We found that individuals with OPRM1 AA combined with FAAH Pro/Pro and those carrying COMT met/met together with FAAH Pro/Pro showed significant placebo effects. Participants with COMT met/val alleles showed significant placebo effects independently of OPRM1 and FAAH allele combinations. Finally, the model that included the placebo procedure and genotypes predicted placebo responsiveness with a higher accuracy (area under the curve, AUC = 0.773) as compared to the SNPs alone indicating that genetic variants can only partially explain the placebo responder status. Our results suggest that the endogenous mu-opioid system with a larger activation in response to pain in the met/val allele carriers as well as the synergism between endogenous mu-opioid system and cannabinoids might play the most relevant role in driving hypoalgesic responses. Future epistasis studies with larger sample sizes will help us to fully understand the complexity of placebo effects and explain the mechanisms that underlie placebo responsiveness.
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Affiliation(s)
- Luana Colloca
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, USA
- Departments of Anesthesiology and Psychiatry, School of Medicine, University of Maryland, Baltimore, University of Maryland, Baltimore, USA
- Center to Advance Chronic Pain Research, University of Maryland, Baltimore, USA
| | - Yang Wang
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, USA
- Center to Advance Chronic Pain Research, University of Maryland, Baltimore, USA
| | | | | | | | - Colin Hodgkinson
- Laboratory of Neurogenetics, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, 20892, USA
| | - David Goldman
- Laboratory of Neurogenetics, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, 20892, USA
| | - Susan G. Dorsey
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, USA
- Departments of Anesthesiology and Psychiatry, School of Medicine, University of Maryland, Baltimore, University of Maryland, Baltimore, USA
- Center to Advance Chronic Pain Research, University of Maryland, Baltimore, USA
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Polonowita AD, Thomson WM, Thorburn DN. Clinical efficacy of a simplified approach to managing chronic temporomandibular disorders: evidence from a 1-year case series. Oral Surg Oral Med Oral Pathol Oral Radiol 2019; 128:227-234. [PMID: 31285165 DOI: 10.1016/j.oooo.2019.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 05/26/2019] [Accepted: 06/07/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Chronic temporomandibular disorder (cTMD) produces orofacial pain and limited jaw function and impacts on quality of life. A clinical case series of patients referred to a hospital specialist service is described here. STUDY DESIGN In a 1-year consecutive case series of 162 patients with cTMDs, each patient had been managed with self-awareness and jaw exercises, as well as oral appliances. Pain severity and chewing function were scored by using a visual analogue scale (VAS), and quality of life was assessed by using the Oral Health Impact Profile-Temporomandibular Dysfunction (OHIP-TMD). RESULTS Females comprised 87% (average age 49 years). Treatment time averaged 20.8 months, and the average pain duration was 2.8 years. The mean VAS pain score fell from 6.9 (standard deviation [SD] 1.6) to 2.0 (SD 1.9) after treatment, giving a "large" effect size of 3.1. Chewing difficulty improvement also showed a "large" effect size (2.5). For the 33 patients for whom longitudinal OHIP-TMD data were available, the mean pretreatment and posttreatment scores of 51.2 (SD 20.9) and 26.2 (SD 17.7) showed a "large" effect size of 1.2. CONCLUSIONS A simple noninvasive protocol for managing cTMD with self-help, exercises, and oral devices resulted in clinically and statistically meaningful improvements in pain, function, and quality of life.
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Affiliation(s)
- Ajith D Polonowita
- Oral Medicine Specialist, Christchurch Hospital, NZ; Head of Discipline in Oral Medicine, The University of Otago, Dunedin, New Zealand.
| | - W Murray Thomson
- Professor of Dental Epidemiology and Public Health, The University of Otago, Dunedin, New Zealand
| | - Dennis N Thorburn
- Formerly Oral Medicine specialist, Christchurch Hospital, New Zealand
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20
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Hall KT, Loscalzo J, Kaptchuk TJ. Systems pharmacogenomics - gene, disease, drug and placebo interactions: a case study in COMT. Pharmacogenomics 2019; 20:529-551. [PMID: 31124409 PMCID: PMC6563236 DOI: 10.2217/pgs-2019-0001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 03/11/2019] [Indexed: 02/07/2023] Open
Abstract
Disease, drugs and the placebos used as comparators are inextricably linked in the methodology of the double-blind, randomized controlled trial. Nonetheless, pharmacogenomics, the study of how individuals respond to drugs based on genetic substrate, focuses primarily on the link between genes and drugs, while the link between genes and disease is often overlooked and the link between genes and placebos is largely ignored. Herein, we use the example of the enzyme catechol-O-methyltransferase to examine the hypothesis that genes can function as pharmacogenomic hubs across system-wide regulatory processes that, if perturbed in andomized controlled trials, can have primary and combinatorial effects on drug and placebo responses.
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Affiliation(s)
- Kathryn T Hall
- Department of Medicine, Brigham & Women’s Hospital, Boston, MA 02115, USA
- Division of Preventive Medicine, Brigham & Women’s Hospital, Boston, MA 02215, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Joseph Loscalzo
- Department of Medicine, Brigham & Women’s Hospital, Boston, MA 02115, USA
- Harvard Medical School, Boston, MA 02115, USA
| | - Ted J Kaptchuk
- Harvard Medical School, Boston, MA 02115, USA
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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21
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Lee LYH, Loscalzo J. Network Medicine in Pathobiology. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 189:1311-1326. [PMID: 31014954 DOI: 10.1016/j.ajpath.2019.03.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 03/05/2019] [Indexed: 12/11/2022]
Abstract
The past decade has witnessed exponential growth in the generation of high-throughput human data across almost all known dimensions of biological systems. The discipline of network medicine has rapidly evolved in parallel, providing an unbiased, comprehensive biological framework through which to interrogate and integrate systematically these large-scale, multi-omic data to enhance our understanding of disease mechanisms and to design drugs that reflect a deep knowledge of molecular pathobiology. In this review, we discuss the key principles of network medicine and the human disease network and explore the latest applications of network medicine in this multi-omic era. We also highlight the current conceptual and technological challenges, which serve as exciting opportunities by which to improve and expand the network-based applications beyond the artificial boundaries of the current state of human pathobiology.
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Affiliation(s)
| | - Joseph Loscalzo
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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22
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Petrie KJ, Rief W. Psychobiological Mechanisms of Placebo and Nocebo Effects: Pathways to Improve Treatments and Reduce Side Effects. Annu Rev Psychol 2019; 70:599-625. [PMID: 30110575 DOI: 10.1146/annurev-psych-010418-102907] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Placebo effects constitute a major part of treatment success in medical interventions. The nocebo effect also has a major impact, as it accounts for a significant proportion of the reported side effects for many treatments. Historically, clinical trials have aimed to reduce placebo effects; however, currently, there is interest in optimizing placebo effects to improve existing treatments and in examining ways to minimize nocebo effects to improve clinical outcome. To achieve these aims, a better understanding of the psychological and neurobiological mechanisms of the placebo and nocebo response is required. This review discusses the impact of the placebo and nocebo response in health care. We also examine the mechanisms involved in the placebo and nocebo effects, including the central mechanism of expectations. Finally, we examine ways to enhance placebo effects and reduce the impact of the nocebo response in clinical practice and suggest areas for future research.
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Affiliation(s)
- Keith J Petrie
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1142, New Zealand;
| | - Winfried Rief
- Division of Clinical Psychology, University of Marburg, 35032 Marburg, Germany;
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23
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Hammami MM, Hammami S, Aboushaar R, Aljomah AS. Lay People's Ethical Attitudes To Placebo Treatment: A Q-Methodology Study. Patient Prefer Adherence 2019; 13:1599-1617. [PMID: 31631979 PMCID: PMC6776293 DOI: 10.2147/ppa.s216565] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/06/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Placebo-treatment acceptability is debated among ethicists, mostly due to conflict between respect-to-autonomy and beneficence principles. It is not clear how lay people balance these and other ethical principles. METHODS One hundred and eighty-seven respondents rank-ordered 42 opinion statements covering various ethical aspects of placebo-treatment, according to a 9-category symmetrical distribution. We analyzed statements' scores using averaging-analysis and by-person factor analysis (Q-methodology). RESULTS Respondents' mean (SD) age was 34.6 (10.6) years, 54% were women, 40% healthcare-related, 68% Muslims (31% Christians), and 39% received general education in Saudi Arabia (24% in the Philippines). On averaging-analysis, the most-agreeable statements were "Acceptable if benefit to patient large" and "Acceptable with physician intent to benefit patient". The most-disagreeable statements were "Acceptable with physician self-benefit intent" and "Acceptable with large harm to other patients". Muslims gave a higher rank to "Giving no description is acceptable", "Acceptable with small benefit to patient", and "Acceptable with physician intent to benefit patient" and a lower rank to "Acceptable to describe as inactive drug", "Acceptable with physician intent to please patient caring relative", and "Acceptable with moderate harm to other patients" (p<0.01). Q-methodology detected several ethical attitude models that were mostly multi-principled and consequentialism-dominated. The majority of Christian and Philippines-educated women loaded on a "relatively family and deception-concerned" model, whereas the majority of Muslim and Saudi Arabia-educated women loaded on a "relatively common-good-concerned" model. The majority of Christian and healthcare men loaded on a "relatively deception-concerned" model, whereas the majority of Muslim and non-healthcare men loaded on a "relatively motives-concerned" model. Of nine intent-related statements, ≥2 received extreme rank on averaging-analysis and in 100% of women and men models. CONCLUSION 1) On averaging-analysis, patient's beneficence (consequentialism) followed by physician's intent (virtue ethics) were more important than deception (respect-to-autonomy). 2) Q-methodology identified several ethical attitude models that were mostly multi-principled and associated with respondents' demographics.
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Affiliation(s)
- Muhammad M Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University College of Medicine, Riyadh, Saudi Arabia
- Correspondence: Muhammad M Hammami Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh11211, Saudi ArabiaTel +966-1-442-4527Fax +966-1-442-7894 Email
| | | | | | - Ahmed S Aljomah
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Abstract
In this review, we explored different ways of controlling the placebo effects in clinical trials and described various factors that may increase/decrease the placebo effect in randomized placebo-controlled trials. These factors can be subdivided into four groups, and while not all factors are effective in every study and under all clinical conditions, they show on the whole that - even under the ideal condition of drug therapy, where blinded placebo provision is much easier and warranted than in, e.g., psychotherapy - many factors need to be controlled to ascertain that the goal of the clinical trials, fair assessment of superiority of the drug over placebo in placebo-controlled trials and fair assessment of non-inferiority of the drug compared to another drug in comparator trials, is reached. Ignorance towards the placebo effect, which was common in the past, is no longer acceptable; instead, it should be the goal of all therapeutic trials to minimize the placebo effect in clinical trials, while utilizing and maximizing it in clinical routine.
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Affiliation(s)
- Paul Enck
- Department of Internal Medicine VI: Psychosomatic Medicine and Psychotherapy , University Hospital Tübingen, Tübingen, Germany.
| | - Sibylle Klosterhalfen
- Department of Internal Medicine VI: Psychosomatic Medicine and Psychotherapy , University Hospital Tübingen, Tübingen, Germany
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25
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Mayor DF, McClure LS, Clayton McClure JH. Individual Differences in Responsiveness to Acupuncture: An Exploratory Survey of Practitioner Opinion. MEDICINES 2018; 5:medicines5030085. [PMID: 30082630 PMCID: PMC6163768 DOI: 10.3390/medicines5030085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 07/28/2018] [Accepted: 07/31/2018] [Indexed: 12/30/2022]
Abstract
Background: Previous research has considered the impact of personal and situational factors on treatment responses. This article documents the first phase of a four-stage project on patient characteristics that may influence responsiveness to acupuncture treatment, reporting results from an exploratory practitioner survey. Methods: Acupuncture practitioners from various medical professions were recruited through professional organisations to complete an online survey about their demographics and attitudes as well as 60 questions on specific factors that might influence treatment. They gave categorical (“Yes”, “No”, and “Don’t know”) and free-text responses. Quantitative and qualitative (thematic) analyses were then conducted. Results: There were more affirmative than negative or uncertain responses overall. Certain characteristics, including ability to relax, exercise and diet, were most often considered relevant. Younger and male practitioners were more likely to respond negatively. Limited support was found for groupings between characteristics. Qualitative data provide explanatory depth. Response fatigue was evident over the course of the survey. Conclusions: Targeting and reminders may benefit uptake when conducting survey research. Practitioner characteristics influence their appreciation of patient characteristics. Factors consistently viewed as important included ability to relax, exercise and diet. Acupuncture practitioners may benefit from additional training in certain areas. Surveys may produce more informative results if reduced in length and complexity.
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Affiliation(s)
- David F Mayor
- Department of Allied Health Professions and Midwifery, School of Health and Social Work, University of Hertfordshire, Hatfield AL10 9AB, UK.
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Polich G, Iaccarino MA, Kaptchuk TJ, Morales-Quezada L, Zafonte R. Placebo Effects in Traumatic Brain Injury. J Neurotrauma 2018; 35:1205-1212. [PMID: 29343158 PMCID: PMC6016098 DOI: 10.1089/neu.2017.5506] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In recent years, several randomized controlled trials evaluating pharmaceutical treatments for traumatic brain injury (TBI) have failed to demonstrate efficacy over placebo, with both active and placebo arms improving at comparable rates. These findings could be viewed in opposing ways, suggesting on the one hand failure of the tested outcome, but on the other, representing evidence of robust placebo effects in TBI. In this article, we examine several of the primary psychological processes driving placebo effects (verbal suggestion, cognitive re-framing, interpersonal interactions, conditioning, therapeutic alliance, anxiety reduction) as well as placebo neurobiology (top-down cortical regulation, reward system activation, dopaminergic and serotonergic neurotransmission). We then extrapolate from the literature to explore whether something inherent in TBI makes it particularly responsive to placebos. Viewed as such here, placebos may indeed represent a powerful and effective treatment for a variety of post-TBI complaints.
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Affiliation(s)
- Ginger Polich
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
| | - Mary Alexis Iaccarino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
- MassGeneral Hospital for Children Sport Concussion Program, Boston, Massachusetts
- Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, Massachusetts
| | - Ted J. Kaptchuk
- Program in Placebo Studies and Therapeutic Encounter, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Leon Morales-Quezada
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
| | - Ross Zafonte
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
- Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, Massachusetts
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27
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Wang RS, Loscalzo J. Network-Based Disease Module Discovery by a Novel Seed Connector Algorithm with Pathobiological Implications. J Mol Biol 2018; 430:2939-2950. [PMID: 29791871 DOI: 10.1016/j.jmb.2018.05.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/30/2018] [Accepted: 05/10/2018] [Indexed: 01/09/2023]
Abstract
Understanding the genetic basis of complex diseases is challenging. Prior work shows that disease-related proteins do not typically function in isolation. Rather, they often interact with each other to form a network module that underlies dysfunctional mechanistic pathways. Identifying such disease modules will provide insights into a systems-level understanding of molecular mechanisms of diseases. Owing to the incompleteness of our knowledge of disease proteins and limited information on the biological mediators of pathobiological processes, the key proteins (seed proteins) for many diseases appear scattered over the human protein-protein interactome and form a few small branches, rather than coherent network modules. In this paper, we develop a network-based algorithm, called the Seed Connector algorithm (SCA), to pinpoint disease modules by adding as few additional linking proteins (seed connectors) to the seed protein pool as possible. Such seed connectors are hidden disease module elements that are critical for interpreting the functional context of disease proteins. The SCA aims to connect seed disease proteins so that disease mechanisms and pathways can be decoded based on predicted coherent network modules. We validate the algorithm using a large corpus of 70 complex diseases and binding targets of over 200 drugs, and demonstrate the biological relevance of the seed connectors. Lastly, as a specific proof of concept, we apply the SCA to a set of seed proteins for coronary artery disease derived from a meta-analysis of large-scale genome-wide association studies and obtain a coronary artery disease module enriched with important disease-related signaling pathways and drug targets not previously recognized.
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Affiliation(s)
- Rui-Sheng Wang
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Joseph Loscalzo
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Castelnuovo G, Giusti EM, Manzoni GM, Saviola D, Gabrielli S, Lacerenza M, Pietrabissa G, Cattivelli R, Spatola CAM, Rossi A, Varallo G, Novelli M, Villa V, Luzzati F, Cottini A, Lai C, Volpato E, Cavalera C, Pagnini F, Tesio V, Castelli L, Tavola M, Torta R, Arreghini M, Zanini L, Brunani A, Seitanidis I, Ventura G, Capodaglio P, D'Aniello GE, Scarpina F, Brioschi A, Bigoni M, Priano L, Mauro A, Riva G, Di Lernia D, Repetto C, Regalia C, Molinari E, Notaro P, Paolucci S, Sandrini G, Simpson S, Wiederhold BK, Gaudio S, Jackson JB, Tamburin S, Benedetti F. What Is the Role of the Placebo Effect for Pain Relief in Neurorehabilitation? Clinical Implications From the Italian Consensus Conference on Pain in Neurorehabilitation. Front Neurol 2018; 9:310. [PMID: 29867723 PMCID: PMC5968866 DOI: 10.3389/fneur.2018.00310] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 04/19/2018] [Indexed: 12/12/2022] Open
Abstract
Background It is increasingly acknowledged that the outcomes of medical treatments are influenced by the context of the clinical encounter through the mechanisms of the placebo effect. The phenomenon of placebo analgesia might be exploited to maximize the efficacy of neurorehabilitation treatments. Since its intensity varies across neurological disorders, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCP) summarized the studies on this field to provide guidance on its use. Methods A review of the existing reviews and meta-analyses was performed to assess the magnitude of the placebo effect in disorders that may undergo neurorehabilitation treatment. The search was performed on Pubmed using placebo, pain, and the names of neurological disorders as keywords. Methodological quality was assessed using a pre-existing checklist. Data about the magnitude of the placebo effect were extracted from the included reviews and were commented in a narrative form. Results 11 articles were included in this review. Placebo treatments showed weak effects in central neuropathic pain (pain reduction from 0.44 to 0.66 on a 0-10 scale) and moderate effects in postherpetic neuralgia (1.16), in diabetic peripheral neuropathy (1.45), and in pain associated to HIV (1.82). Moderate effects were also found on pain due to fibromyalgia and migraine; only weak short-term effects were found in complex regional pain syndrome. Confounding variables might have influenced these results. Clinical implications These estimates should be interpreted with caution, but underscore that the placebo effect can be exploited in neurorehabilitation programs. It is not necessary to conceal its use from the patient. Knowledge of placebo mechanisms can be used to shape the doctor-patient relationship, to reduce the use of analgesic drugs and to train the patient to become an active agent of the therapy.
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Affiliation(s)
- Gianluca Castelnuovo
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Emanuele Maria Giusti
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Gian Mauro Manzoni
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Faculty of Psychology, eCampus University, Novedrate, Italy
| | - Donatella Saviola
- Cardinal Ferrari Rehabilitation Center, Santo Stefano Rehabilitation Istitute, Fontanellato, Italy
| | | | - Marco Lacerenza
- Pain Medicine Center, San Pio X Clinic, Humanitas, Milan, Italy
| | - Giada Pietrabissa
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Roberto Cattivelli
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Chiara Anna Maria Spatola
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Alessandro Rossi
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy
| | - Giorgia Varallo
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy
| | - Margherita Novelli
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy
| | - Valentina Villa
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy
| | | | | | - Carlo Lai
- Department of Dynamic and Clinical Psychology, Sapienza University of Rome, Rome, Italy
| | - Eleonora Volpato
- Department of Psychology, Catholic University of Milan, Milan, Italy.,HD Respiratory Rehabilitation Unit, IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Cesare Cavalera
- Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Francesco Pagnini
- Department of Psychology, Catholic University of Milan, Milan, Italy.,Department of Psychology, Harvard University, Cambridge, MA, United States
| | | | - Lorys Castelli
- Department of Psychology, University of Turin, Turin, Italy
| | - Mario Tavola
- Anesthesia and Intensive Care, ASST Lecco, Lecco, Italy
| | - Riccardo Torta
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Marco Arreghini
- Istituto Auxologico Italiano IRCCS, Rehabilitation Unit, San Giuseppe Hospital, Verbania, Italy
| | - Loredana Zanini
- Istituto Auxologico Italiano IRCCS, Rehabilitation Unit, San Giuseppe Hospital, Verbania, Italy
| | - Amelia Brunani
- Istituto Auxologico Italiano IRCCS, Rehabilitation Unit, San Giuseppe Hospital, Verbania, Italy
| | - Ionathan Seitanidis
- Istituto Auxologico Italiano IRCCS, Rehabilitation Unit, San Giuseppe Hospital, Verbania, Italy
| | - Giuseppe Ventura
- Istituto Auxologico Italiano IRCCS, Rehabilitation Unit, San Giuseppe Hospital, Verbania, Italy
| | - Paolo Capodaglio
- Istituto Auxologico Italiano IRCCS, Rehabilitation Unit, San Giuseppe Hospital, Verbania, Italy
| | - Guido Edoardo D'Aniello
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Federica Scarpina
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy
| | - Andrea Brioschi
- Istituto Auxologico Italiano IRCCS, Department of Neurology and Neurorehabilitation, San Giuseppe Hospital, Verbania, Italy
| | - Matteo Bigoni
- Istituto Auxologico Italiano IRCCS, Department of Neurology and Neurorehabilitation, San Giuseppe Hospital, Verbania, Italy
| | - Lorenzo Priano
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy.,Istituto Auxologico Italiano IRCCS, Department of Neurology and Neurorehabilitation, San Giuseppe Hospital, Verbania, Italy
| | - Alessandro Mauro
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy.,Istituto Auxologico Italiano IRCCS, Department of Neurology and Neurorehabilitation, San Giuseppe Hospital, Verbania, Italy
| | - Giuseppe Riva
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Daniele Di Lernia
- Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Claudia Repetto
- Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Camillo Regalia
- Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Enrico Molinari
- Istituto Auxologico Italiano IRCCS, Psychology Research Laboratory, San Giuseppe Hospital, Verbania, Italy.,Department of Psychology, Catholic University of Milan, Milan, Italy
| | - Paolo Notaro
- Pain Medicine, Anesthesiology Department, A.O. Ospedale Niguarda ca Granda, Milan, Italy
| | | | - Giorgio Sandrini
- C. Mondino National Neurological Institute, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Susan Simpson
- University of South Australia, Adelaide, SA, Australia.,Regional Eating Disorders Unit, NHS Lothian, Livingston, United Kingdom
| | | | - Santino Gaudio
- Department of Neuroscience, Functional Pharmacology, Uppsala University, Uppsala, Sweden
| | | | - Stefano Tamburin
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Fabrizio Benedetti
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
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Abstract
There is perhaps no more important time in the history of placebos to consider their role in clinical trials and in medicine. Increasingly well-designed pharmaceutical and academic clinical trials testing promising and established drug and surgical interventions have failed to "beat" the placebo response. The collateral damage resulting from these failures is staggering; novel treatments, many with compelling mechanisms of action and promising Phase 2 trial results, never reach the patient, adversely affecting small and large pharma alike. Recent evidence suggests that variability in placebo response may be attributed in part to genetic variation. Thus, having a better understanding of the genomic underpinnings of the placebo response, the "placebome", may pave the way to innovatively and more effectively use placebos in drug development.
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Affiliation(s)
| | | | - Ted Kaptchuk
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts United States
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Carlino E, Vase L. Can knowledge of Placebo and Nocebo Mechanisms Help Improve Randomized Clinical Trials? INTERNATIONAL REVIEW OF NEUROBIOLOGY 2018; 138:329-357. [PMID: 29681333 DOI: 10.1016/bs.irn.2018.01.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Over the last decade, there has been a substantial increase in negative results from randomized controlled trials (RCTs), which may be due to an increasing placebo response among other factors. Currently, identification and exclusion of placebo responders from trials are attempted to overcome this problem, but so far the success of these approaches has been limited. At the same time, the placebo-mechanism literature has highlighted how contextual factors, such as patients' expectations, interfere with the effect of drug administration, leading to a certain degree of uncertainty in RCTs. In this chapter, we review the current challenges of RCTs including the uncertainties of the active arm, the placebo arm, the additivity assumption, and the double-blind procedure. We use the placebo-mechanism literature to debate the strengths and weaknesses of attempts to identify and exclude placebo responders from trials. Finally, we illustrate how insights from the placebo-mechanism literature may point to new ways of improving RCTs.
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Affiliation(s)
| | - Lene Vase
- School of Business and Social Sciences, Aarhus University, Aarhus, Denmark.
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Peiris N, Blasini M, Wright T, Colloca L. The Placebo Phenomenon: A Narrow Focus on Psychological Models. PERSPECTIVES IN BIOLOGY AND MEDICINE 2018; 61:388-400. [PMID: 30293977 PMCID: PMC6195310 DOI: 10.1353/pbm.2018.0051] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The placebo effect is a complex phenomenon that can be described from neurobiological, psychosocial, and epistemological perspectives. Different leaders in the field have proposed multiple theories and models that attempt to describe both the nature and the mechanisms of action underlying placebo effects. This article focuses on the most relevant psychological models that have been suggested for characterizing the different mechanisms underlying the placebo effect. We outline how the dynamic psychoneurobiological aspects of the placebo phenomenon can be a potential reliable and useful tool in daily clinical practice for illness and symptom management within a wide variety of specialties and health-care practices.
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Affiliation(s)
- Nathalie Peiris
- Department of Anesthesiology School of Medicine, University
of Maryland, Baltimore
| | - Maxie Blasini
- Department of Pain Translational Symptom Science,
School of Nursing, University of Maryland, Baltimore
| | - Thelma Wright
- Department of Anesthesiology School of Medicine, University
of Maryland, Baltimore
| | - Luana Colloca
- Departments of Anesthesiology and Psychiatry, School
of Medicine; Department of Pain Translational Symptom Science, School of Nursing;
and Center to Advance Chronic Pain Research, University of Maryland,
Baltimore
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