Randomized Clinical Trials and Observational Tribulations: Providing Clinical Evidence for Personalized Surgical Pain Management Care Models

Proving clinical superiority of personalized care models in interventional and surgical pain management is challenging. The apparent difficulties may arise from the inability to standardize complex surgical procedures that often involve multiple steps. Ensuring the surgery is performed the same way every time is nearly impossible. Confounding factors, such as the variability of the patient population and selection bias regarding comorbidities and anatomical variations are also difficult to control for. Small sample sizes in study groups comparing iterations of a surgical protocol may amplify bias. It is essentially impossible to conceal the surgical treatment from the surgeon and the operating team. Restrictive inclusion and exclusion criteria may distort the study population to no longer reflect patients seen in daily practice. Hindsight bias is introduced by the inability to effectively blind patient group allocation, which affects clinical result interpretation, particularly if the outcome is already known to the investigators when the outcome analysis is performed (often a long time after the intervention). Randomization is equally problematic, as many patients want to avoid being randomly assigned to a study group, particularly if they perceive their surgeon to be unsure of which treatment will likely render the best clinical outcome for them. Ethical concerns may also exist if the study involves additional and unnecessary risks. Lastly, surgical trials are costly, especially if the tested interventions are complex and require long-term follow-up to assess their benefit. Traditional clinical testing of personalized surgical pain management treatments may be more challenging because individualized solutions tailored to each patient's pain generator can vary extensively. However, high-grade evidence is needed to prompt a protocol change and break with traditional image-based criteria for treatment. In this article, the authors review issues in surgical trials and offer practical solutions.

Paraoxonase 1 (PON1) 55 polymorphism, lipid profiles and psoriasis

BACKGROUND

Paraoxonase 1 (PON1) is a serum high-density lipoprotein-bound enzyme with antioxidant function. It hydrolyses lipid peroxides, protecting low-density lipoproteins from oxidative modifications. Patients with psoriasis are at greater risk of oxidative stress, which is associated with abnormal plasma lipid metabolism.

OBJECTIVES

In this study, association of the PON1 55 M allele with serum arylesterase (ARE) activity, malondialdehyde (MDA), lipid profiles and psoriasis was investigated.

METHODS

The present case-control study consisted of 100 patients with psoriasis with and without cardiovascular diseases (mean age 35·3 years) and 100 sex- and age-matched unrelated healthy controls (mean age 35·7 years) from the population of western Iran. The PON1 55 Met>Leu polymorphism was detected by polymerase chain reaction-restriction fragment length polymorphism. Serum ARE activity, MDA, and lipid and apolipoprotein levels were determined spectrophotometrically, by high-performance liquid chromatography and by enzyme assay, respectively.

RESULTS

The presence of the PON1 55 M allele was found to be associated with psoriasis (odds ratio = 1·96, P = 0·017). The patients with psoriasis with the PON1 M (M/L + M/M) allele had higher MDA levels (4·12 ± 0·88 vs. 2·24 ± 0·55 μmol L(-1) , P < 0·001), apolipoprotein B (APOB)/APOA1 ratio (0·91 ± 0·66 vs. 0·66 ± 0·35, P = 0·004), APOB (111 ± 38·7 vs. 88·3 ± 22·5 mg mL(-1) , P = 0·001) and lipoprotein(a) [LP(a)] (21·9 ± 18·4 vs. 15·8 ± 16·6 mg mL(-1) , P = 0·034), but lower ARE activity (39·6 ± 11 vs. 45·9 ± 11·8 U mL(-1) , P = 0·031) than the control subjects. ARE activity showed a significant positive correlation with APOA1 and a negative correlation with MDA concentration in patients with psoriasis.

CONCLUSIONS

The PON1 55 M allele is a risk factor for psoriasis. Carriers of this allele have high levels of MDA, APOB and LP(a), a high APOB/APOA1 ratio and low ARE activity. These results indicate that oxidative stress, impairment of the antioxidant system and abnormal lipid metabolism may play a role in the pathogenesis and progression of psoriasis and its related complications. These data suggest that patients with psoriasis are more susceptible to vascular diseases.

Exposure to (226)Ra from consumption of vegetables in the high level natural radiation area of Ramsar-Iran

The vegetable-to-soil concentration ratio (CR) for (226)Ra and the related effective dose were studied in Talesh Mahalleh, a district of the city of Ramsar in Iran with a high level of natural radiation (HLNR). Maximum and minimum CR were measured in leafy and root vegetables with average values of 1.6 x 10(-2) and 4.0 x 10(-3), respectively. The mean effective dose resulting from (226)Ra due to consumption of edible vegetables by adults in the critical group in this region was estimated to be 72.3 microSv a(-1). This value is about 12 times greater than the average of effective dose resulting from this radionuclide due to combined intake of all foods and drinking water in normal background areas.

Effective dose to the public from 226Ra in drinking water supplies of Iran

One of the most important and prevalent isotopes of radium (Ra) in the human food chain, and especially in drinking water, is 226Ra. To determine the contribution of this radionuclide to the annual effective dose to the public in Iran, a national program for determination of this radionuclide was established. Over 500 water samples from different surface and ground water supplies including wells, rivers and springs, as well as hot springs and sea water from the Caspian Sea and Persian Gulf have been analyzed. An emanation method with a minimum detection limit of less than 2 mBq L(-1) was developed and applied in this study. Unweighted mean concentrations of 3.3 mBq L(-1) and 8.0 mBq L(-1) were determined in surface and ground drinking water supplies, respectively. Based on such values, mean unweighted annual intakes of 226Ra were found to be 0.85 Bq for an infant, 1.97 Bq for a child, and 2.82 Bq for an adult, which correspond to mean unweighted annual effective doses of 0.17 microSv y(-1), 0.39 microSv y(-1), and 0.56 microSv y(-1), respectively. The mean 226Ra concentrations in hot springs were higher with a maximum of 146.5 Bq L(-1) measured in the Ab-e-Siah hot spring in Ramsar, a town on the coast of the Caspian Sea in Iran.

[Regulative therapy: treatment with nonspecific stimulants in dermatology in traditional and modern perspectives]

Stimulation or regulation therapies are old therapeutic procedures based on models reaching back to traditional medical faculties in ancient times and in the Middle Ages. Among this heterogeneous group are acupuncture, purgative procedures (especially the Aschner methods), autohemotherapy, fasting therapy, homeopathy, microbiological and physical therapies. The basic principle underlying all of these procedures is that stimulants applied in proper doses to the organism elicit counterregulation. The counterregulation stimulates 'self-healing processes' within the organism. The efficacy of stimulation therapies was originally deduced mostly from traditional explanatory models which have lost their relevance for modern medicine. However, it has been found in applications in dermatology that many of these stimulation therapies can lead to clinical improvement in selected indications and that modern explanatory models can be found for these effects. This presentation reports on exemplary applications of stimulation therapies in dermatology. Traditional and modern concepts of action are compared.