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Köteles F. Vague sensations. About the background and consequences of discordance between actual and perceived physiological changes. Clin Psychol Rev 2024; 108:102382. [PMID: 38218123 DOI: 10.1016/j.cpr.2024.102382] [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: 05/06/2023] [Revised: 10/28/2023] [Accepted: 01/05/2024] [Indexed: 01/15/2024]
Abstract
Empirical evidence consistently shows that discordance, also called dissociation or discrepancy, between actual physiological (mainly visceral) events and their perceived counterparts is substantial. On the one hand, we typically do not perceive actual visceral events occurring in our bodies; on the other hand, sometimes we do perceive bodily changes that do not really take place. This narrative review presents the available empirical findings on the discordance, and summarizes possible explanations that approach the phenomenon from the viewpoint of evolution, cognitive development, and predictive processing. Also, the role of top-down factors, such as expectations and experiences is discussed. Finally, practically relevant consequences of the discordance are presented using the examples of mind-body practices, the placebo and nocebo phenomenon, and medically unexplained symptoms. It is concluded that the discordance between actual and perceived body changes can have a negative impact on health, mainly through issues with adherence and other behavioral factors. The existence of actual-perceived discordance should be taught and demonstrated in the elementary and high school, as well as in many areas of higher education.
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Affiliation(s)
- Ferenc Köteles
- Institute of Psychology, Károli Gáspár University of the Reformed Church in Hungary, Budapest, Hungary; Ádám György Psychophysiology Research Group, Budapest, Hungary.
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Jędrusik P, Placha G, Gaciong Z. Efficacy and safety of bisoprolol 5 mg plus amlodipine 5 mg in patients with hypertension uncontrolled on monotherapy with 5 mg of amlodipine, a phase III multicenter, randomized, double-blind, placebo-controlled clinical trial - the AMCOR study. Curr Med Res Opin 2023; 39:939-946. [PMID: 37300442 DOI: 10.1080/03007995.2023.2223915] [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: 10/15/2022] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To evaluate the antihypertensive effect and safety of bisoprolol 5 mg (BISO5mg) and amlodipine 5 mg (AMLO5mg) combination in comparison to AMLO5mg in hypertensive subjects uncontrolled with AMLO5mg. METHODS Phase III, prospective, randomized, double-blind, placebo-controlled, 8-week trial with parallel design (EudraCT Number: 2019-000751-13). RESULTS 367 patients aged 57.58 ± 14.62 years were randomized to BISO5mg once daily on top of AMLO5mg (n = 181) or placebo on top of AMLO5mg (n = 186). Systolic/diastolic blood pressure (SBP/DBP) in the bisoprolol-treated group was reduced by 7.2 ± 12.74/3.95 ± 8.85 mmHg at 4 weeks (both p < .0001) and by 5.5 ± 12.44/3.84 ± 9.46 mmHg at 8 weeks (p < .0001/p < .0002) compared to placebo control. Bisoprolol-treated group had lower heart rate than placebo control (difference -7.23 ± 9.84/-6.25 ± 9.26 beats per minute at 4 and 8 weeks, respectively, both p < .0001). Both target SBP and DBP was achieved at 4 weeks by 62 vs. 41% (p = .0002) and at 8 weeks by 65 vs. 46% (p = .0004) of bisoprolol-treated patients and placebo group patients, respectively. SBP <140 mmHg was achieved at 4 and 8 weeks in 68 and 69% of bisoprolol-treated patients and 45 and 50% of placebo group patients, respectively. No deaths and serious adverse events were reported. Adverse events occurred in 34 bisoprolol-treated patients vs. 22 patients in the placebo group (p = .064). Bisoprolol was withdrawn due to adverse events in 7 patients, mostly (n = 4) due to asymptomatic bradycardia. CONCLUSIONS Addition of bisoprolol to patients uncontrolled with amlodipine monotherapy significantly improves blood pressure control. We can expect additional 7.2/3.95 mmHg SBP/DBP lowering effect by adding bisoprolol 5 mg to amlodipine 5 mg.
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Affiliation(s)
- Piotr Jędrusik
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Placha
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Zbigniew Gaciong
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
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Silverman JM, Zhu CW, Schmeidler J, Lee PG, Alexander NB, Guerrero-Berroa E, Beeri MS, West RK, Sano M, Nabozny M, Karran M. Does computerized cognitive training improve diabetes self-management and cognition? A randomized control trial of middle-aged and older veterans with type 2 diabetes. Diabetes Res Clin Pract 2023; 195:110149. [PMID: 36427629 PMCID: PMC9908839 DOI: 10.1016/j.diabres.2022.110149] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/17/2022] [Accepted: 11/06/2022] [Indexed: 11/23/2022]
Abstract
AIMS This randomized control trial compared an adaptive computerized cognitive training intervention with a non-adaptive version. The primary hypothesis predicted better diabetes self-management in type 2 diabetes patients at 6 months post-intervention than baseline in the adaptive arm, with seven secondary outcomes. METHODS Intent-to-treat analysis of veterans without dementia aged 55+ from the Bronx, NY and Ann Arbor, MI (N = 90/per arm) used linear mixed model analyses. RESULTS Contrary to the hypothesis, only memory showed more improvement in the adaptive arm (p < 0.01). Post-hoc analyses combined the two arms; self-management improved at six-months post-intervention (p < 0.001). Memory, executive functions/attention, prospective memory, diastolic blood pressure, and systolic blood pressure improved (p < 0.05); hemoglobin A1c and medication adherence did not improve significantly. CONCLUSIONS The adaptive computerized cognitive training was not substantially better than non-adaptive, but may improve memory. Post-hoc results for the combined arms suggest computer-related activities may improve diabetes self-management and other outcomes for middle-aged and older patients with type 2 diabetes. Practice effects or awareness of being studied cannot be ruled out.
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Affiliation(s)
- Jeremy M Silverman
- Research & Development, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Carolyn W Zhu
- Brookdale Department of Geriatrics & Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Geriatric Research, Education, and Clinical Center (GRECC), James J. Peters VA Medical Center, Bronx, NY, USA
| | - James Schmeidler
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Pearl G Lee
- Veterans Affairs Ann Arbor Geriatric Research Education and Clinical Center, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA; Department of Internal Medicine and Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Neil B Alexander
- Veterans Affairs Ann Arbor Geriatric Research Education and Clinical Center, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA; Department of Internal Medicine and Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth Guerrero-Berroa
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Psychology, Lehman College, City University of New York, Bronx, NY, USA
| | - Michal S Beeri
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA; The Joseph Sagol Neuroscience Center, Sheba Medical Center, Ramat Gan, Israel
| | - Rebecca K West
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary Sano
- Research & Development, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA; Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Martina Nabozny
- Veterans Affairs Ann Arbor Geriatric Research Education and Clinical Center, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA; Department of Internal Medicine and Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Martha Karran
- Research & Development, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA
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Sorkin BC, Kuszak AJ, Bloss G, Fukagawa NK, Hoffman FA, Jafari M, Barrett B, Brown PN, Bushman FD, Casper S, Chilton FH, Coffey CS, Ferruzzi MG, Hopp DC, Kiely M, Lakens D, MacMillan JB, Meltzer DO, Pahor M, Paul J, Pritchett-Corning K, Quinney SK, Rehermann B, Setchell KD, Sipes NS, Stephens JM, Taylor DL, Tiriac H, Walters MA, Xi D, Zappalá G, Pauli GF. Improving natural product research translation: From source to clinical trial. FASEB J 2020; 34:41-65. [PMID: 31914647 PMCID: PMC7470648 DOI: 10.1096/fj.201902143r] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/12/2019] [Accepted: 10/21/2019] [Indexed: 12/28/2022]
Abstract
While great interest in health effects of natural product (NP) including dietary supplements and foods persists, promising preclinical NP research is not consistently translating into actionable clinical trial (CT) outcomes. Generally considered the gold standard for assessing safety and efficacy, CTs, especially phase III CTs, are costly and require rigorous planning to optimize the value of the information obtained. More effective bridging from NP research to CT was the goal of a September, 2018 transdisciplinary workshop. Participants emphasized that replicability and likelihood of successful translation depend on rigor in experimental design, interpretation, and reporting across the continuum of NP research. Discussions spanned good practices for NP characterization and quality control; use and interpretation of models (computational through in vivo) with strong clinical predictive validity; controls for experimental artefacts, especially for in vitro interrogation of bioactivity and mechanisms of action; rigorous assessment and interpretation of prior research; transparency in all reporting; and prioritization of research questions. Natural product clinical trials prioritized based on rigorous, convergent supporting data and current public health needs are most likely to be informative and ultimately affect public health. Thoughtful, coordinated implementation of these practices should enhance the knowledge gained from future NP research.
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Affiliation(s)
- Barbara C. Sorkin
- Office of Dietary Supplements, National Institutes of Health (NIH), Bethesda, MD, US
| | - Adam J. Kuszak
- Office of Dietary Supplements, National Institutes of Health (NIH), Bethesda, MD, US
| | - Gregory Bloss
- National Institute on Alcohol Abuse and Alcoholism, NIH, Bethesda, MD, US
| | | | | | | | | | - Paula N. Brown
- British Columbia Institute of Technology, Burnaby, British Columbia, Canada
| | | | - Steven Casper
- Office of Dietary Supplement Programs, Center for Food Safety and Applied Nutrition, Food and Drug Administration (FDA), Hyattsville, MD, US
| | - Floyd H. Chilton
- Department of Nutritional Sciences and the BIO5 Institute, University of Arizona, Tucson, AZ, US
| | | | - Mario G. Ferruzzi
- Plants for Human Health Institute, North Carolina State University, Kannapolis, NC, US
| | - D. Craig Hopp
- National Center for Complementary and Integrative Health, NIH, Bethesda, MD, US
| | - Mairead Kiely
- Cork Centre for Vitamin D and Nutrition Research, School of Food and Nutritional Sciences, University College Cork, Ireland
| | - Daniel Lakens
- Eindhoven University of Technology, Eindhoven, Netherlands
| | | | | | | | - Jeffrey Paul
- Drexel Graduate College of Biomedical Sciences, College of Medicine, Evanston, IL, US
| | | | | | - Barbara Rehermann
- National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD, US
| | | | - Nisha S. Sipes
- National Institute of Environmental Health Sciences, NIH, Research Triangle Park, NC, US
| | | | | | - Hervé Tiriac
- University of California, San Diego, La Jolla, CA, US]
| | - Michael A. Walters
- Institute for Therapeutics Discovery and Development, University of Minnesota, Minneapolis, MN, US
| | - Dan Xi
- Office of Cancer Complementary and Alternative Medicine, National Cancer Institute, NIH, Shady Grove, MD, US
| | | | - Guido F. Pauli
- CENAPT and PCRPS, University of Illinois at Chicago College of Pharmacy, Chicago, IL, US
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Gklinos P, Papadopoulos D, Mitsikostas DD. Nocebo in multiple sclerosis trials: A meta-analysis on oral and newer injectable disease-modifying treatments. Mult Scler Relat Disord 2019; 36:101389. [DOI: 10.1016/j.msard.2019.101389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/31/2019] [Accepted: 09/07/2019] [Indexed: 12/31/2022]
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Svensberg K, Nordeng H, Gaffari S, Faasse K, Horne R, Lupattelli A. Perceived sensitivity to medicines: a study among chronic medicine users in Norway. Int J Clin Pharm 2019; 41:804-812. [DOI: 10.1007/s11096-019-00826-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 04/10/2019] [Indexed: 01/19/2023]
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Fernet M, Beckerman B, Abreu P, Lins K, Vincent J, Burgess E. Antihypertensive effect of the mineralocorticoid receptor antagonist eplerenone: a pooled analysis of patient-level data from comparative trials using regulatory-approved doses. Vasc Health Risk Manag 2018; 14:233-246. [PMID: 30275698 PMCID: PMC6157540 DOI: 10.2147/vhrm.s170141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose Several options are available for the treatment of hypertension; however, many treated patients are still not below blood pressure (BP) target. Eplerenone, a selective mineralocorticoid receptor antagonist, is an approved treatment option for the management of patients with hypertension in a number of countries. This patient-level pooled analysis was conducted to document the efficacy and safety/tolerability of eplerenone at the dosages approved for use in hypertension in comparison to placebo or other approved antihypertensive agents. Methods Seventeen Phase III studies conducted in patients with mild-to-moderate hypertension in the Eplerenone Hypertension Clinical Program were reviewed; eleven met the selection criteria. The primary endpoint was change from baseline in seated diastolic BP and seated systolic BP measured at the end of the study. Results A total of 2,698 patients were included in this per-protocol analysis. In patients treated for at least 6 weeks with a stable dose of eplerenone, doses of 50 mg daily and 100 mg daily were associated with greater reductions of seated systolic BP and seated diastolic BP compared with placebo (P<0.001) and active-controlled studies (P< 0.033). In the analysis of covariance model testing of the contribution of four factors (age, body mass index [BMI], history of cardiovascular disease, and diabetes) on the BP lowering effects of eplerenone, only BMI and age were associated with small though statistically significant changes in BP (<0.2 mmHg). Eplerenone was well tolerated; headache was the most common adverse event for patients in any group. Severe hyperkalemia (serum potassium level >6.0 mmol/L) occurred in up to 0.4% in the eplerenone groups, 0.4% in the placebo group, and 0.1% in the active-control group. Conclusion This patient-level pooled analysis provides robust evidence that eplerenone, at 50 mg or 100 mg daily, was effective in lowering BP in patients with mild-to-moderate hypertension and was well tolerated.
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Affiliation(s)
- Mireille Fernet
- Department of Medical Affairs, Pfizer Canada Inc., Kirkland, QC, Canada
| | - Bruce Beckerman
- Department of Clinical Affairs, Pfizer Inc., New York, NY, USA
| | - Paula Abreu
- Department of Clinical Affairs, Pfizer Inc., New York, NY, USA
| | - Katharina Lins
- Department of Medical Affairs, Pfizer Ltd., Tadworth, UK
| | - John Vincent
- Department of Clinical Affairs, Pfizer Inc., New York, NY, USA
| | - Ellen Burgess
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada,
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Evaluation of the antihypertensive effect of nocturnal administration of acetylsalicylic acid: a cross-over randomized clinical trial. J Hypertens 2018; 37:406-414. [PMID: 30095728 DOI: 10.1097/hjh.0000000000001887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Several studies have shown that evening intake of aspirin has antihypertensive effect in healthy adults, which has not been proven in patients with cardiovascular disease, who mostly take aspirin in the morning. We have evaluated the antihypertensive effect of bedtime administration of aspirin in patients with cardiovascular disease already treated for hypertension. METHODS This is a multicenter randomized triple-blind placebo-controlled crossover trial, with hypertensive patients treated with aspirin for secondary prevention. There was a baseline-randomized assignment to 2-month periods of bedtime aspirin (100 mg) first and morning-time aspirin later, or inversely, both periods separated by an open label 2-4 weeks period of morning-time aspirin. At the start and end of each treatment period, a 24-h ambulatory blood pressure monitoring was performed. The main outcome measure was mean 24-h blood pressure. The analyses were performed according to the intention-to-treat principle. RESULTS Overall, 225 patients were randomized. No significant differences were observed in ambulatory blood pressure by time of intake of usual low doses of aspirin. The mean SBP/DBP was 123.2/69.9 (95% CI 121.58-124.9/68.86-76.86) with bedtime administration and 122.4/68.8 (95% CI 120.76-124.01/67.85-69.83) with daytime administration (P = 0.3 and P = 0.23 for SBP and DBP, respectively). CONCLUSION Administering aspirin at bedtime rather than in the morning does not modify the 24-h ambulatory blood pressure in hypertensive patients in secondary cardiovascular prevention.The trial was registered with ClinicalTrials.gov (number NCT01741922).
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Abstract
: Although antihypertensive medication is usually continued indefinitely, observations during wash-out phases in hypertension trials have shown that withdrawal of antihypertensive medication might be well tolerated to do in a considerable proportion of people. A systematic review was completed to determine the proportion of people remaining normotensive for 6 months or longer after cessation of antihypertensive therapy and to investigate the safety of withdrawal. The mean proportion adjusted for sample size of people remaining below each study's threshold for hypertension treatment was 0.38 at 6 months [95% confidence interval (CI) 0.37-0.49; 912 participants], 0.40 at 1 year (95% CI 0.40-0.40; 2640 participants) and 0.26 at 2 years or longer (95% CI 0.26-0.27; 1262 participants). Monotherapy, lower blood pressure before withdrawal and body weight were reported as predictors for successful withdrawal. Adverse events were more common in those who withdrew but were minor and included headache, joint pain, palpitations, oedema and a general feeling of being unwell. Prescribers should consider offering patients with well controlled hypertension a trial of withdrawal of antihypertensive treatment with subsequent regular blood pressure monitoring.
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Does the rising placebo response impact antihypertensive clinical trial outcomes? An analysis of data from the Food and Drug Administration 1990-2016. PLoS One 2018; 13:e0193043. [PMID: 29489874 PMCID: PMC5831097 DOI: 10.1371/journal.pone.0193043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 02/02/2018] [Indexed: 12/03/2022] Open
Abstract
Background Recent studies show that placebo response has grown significantly over time in clinical trials for antidepressants, ADHD medications, antiepileptics, and antidiabetics. Contrary to expectations, trial outcome measures and success rates have not been impacted. This study aimed to see if this trend of increasing placebo response and stable efficacy outcome measures is unique to the conditions previously studied or if it occurs in trials for conditions with physiologically-measured symptoms, such as hypertension. Method For this reason, we evaluated the efficacy data reported in the US Food and Drug Administration Medical and Statistical reviews for 23 antihypertensive programs (32,022 patients, 63 trials, 142 treatment arms). Placebo and medication response, effect sizes, and drug-placebo differences were calculated for each treatment arm and examined over time using meta-regression. We also explored the relationship of sample size, trial duration, baseline blood pressure, and number of treatment arms to placebo/drug response and efficacy outcome measures. Results Like trials of other conditions, placebo response has risen significantly over time (R2 = 0.093, p = 0.018) and effect size (R2 = 0.013, p = 0.187) drug-placebo difference (R2 = 0.013, p = 0.182) and success rate (134/142, 94.4%) have remained unaffected, likely due to a significant compensatory increase in antihypertensive response (R2 = 0.086, p<0.001). Treatment arms are likely overpowered with sample sizes increasing over time (R2 = 0.387, p<0.0001) and stable, large effect sizes (0.78 ±0.37). The exploratory analysis of sample size, trial duration, baseline blood pressure, and number of treatment arms yielded mixed results unlikely to explain the pattern of placebo response and efficacy outcomes over time. The magnitude of placebo response had no relationship to effect size (p = 0.877), antihypertensive-placebo differences (p = 0.752), or p-values (p = 0.963) but was correlated with antihypertensive response (R2 = 0.347, p<0.0001). Conclusions As hypothesized, this study shows that placebo response is increasing in clinical trials for hypertension without any evidence of this increase impacting trial outcomes. Attempting to control placebo response in clinical trials for hypertension may not be necessary for successful efficacy outcomes. In exploratory analysis, we noted that despite finding significant relationships, none of the trial or patient characteristics we examined offered a clear explanation of the rise in placebo and stability in outcome measures over time. Collectively, these data suggest that the phenomenon of increasing placebo response and stable efficacy outcomes may be a general trend, occurring across trials for various psychiatric and medical conditions with physiological and non-physiological endpoints.
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Juhasz A, Wu J, Hisada M, Tsukada T, Jeong MH. Efficacy and safety of azilsartan medoxomil, an angiotensin receptor blocker, in Korean patients with essential hypertension. Clin Hypertens 2018; 24:2. [PMID: 29445520 PMCID: PMC5804062 DOI: 10.1186/s40885-018-0086-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/15/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND This was a phase 3, randomized, double-blind, placebo-controlled study. METHODS Adult Korean patients with essential hypertension and a baseline mean sitting clinic systolic blood pressure (scSBP) ≥150 and ≤180 mmHg were randomized to 6-week treatment with placebo (n = 65), azilsartan medoxomil (AZL-M) 40 mg (n = 132), or AZL-M 80 mg (n = 131). The primary endpoint was the change from baseline to week 6 in trough scSBP. RESULTS The least-squares mean (standard error) change from baseline in trough scSBP in the placebo, AZL-M 40-mg, and 80-mg groups at week 6 were - 8.8 (2.00), - 22.1 (1.41), and - 23.7 (1.40) mmHg, respectively (p < 0.001 for AZL-M 40 and 80 mg vs placebo). No clinically meaningful heterogeneity in efficacy was observed between subgroups (age, sex, diabetes status) and the overall population. Treatments were well tolerated and adverse events were similar between groups. CONCLUSIONS Results of this study confirm a positive benefit-risk profile of AZL-M for essential hypertension in Korean adults. TRIAL REGISTRATION Clinicaltrial.gov; identifier number: NCT02203916. Registered July 28, 2014 (retrospectively registered).
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Affiliation(s)
- Attila Juhasz
- Takeda Development Center Europe, Ltd., 61 Aldwych, London, WC2B 4AE UK
- Present at GE Healthcare, Little Chalfont, UK
| | - Jingtao Wu
- Takeda Development Center Americas, Inc., One Takeda Parkway, Deerfield, IL USA
| | - Michie Hisada
- Takeda Development Center Americas, Inc., One Takeda Parkway, Deerfield, IL USA
| | - Tomoka Tsukada
- Takeda Development Center Asia, Pte. Ltd., 21 Biopolis Road, Nucleos North Tower, Level 4, Singapore, Singapore
- Present at Takeda Pharmaceutical Company Ltd., Osaka, Japan
| | - Myung Ho Jeong
- Department of Cardiovascular Medicine, Chonnam National University Hospital, 42, Jebong-ro, Dong-gu, Gwangju, 61469 Korea
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Jung JH, Kim J, MacDonald R, Reddy B, Kim MH, Dahm P. Silodosin for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database Syst Rev 2017; 11:CD012615. [PMID: 29161773 PMCID: PMC6486059 DOI: 10.1002/14651858.cd012615.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND A variety of alpha-blockers are used for treating lower urinary tract symptoms (LUTS) in men with benign prostatic hyperplasia (BPH). Silodosin is a novel, more selective alpha-blocker, which is specific to the lower urinary tract and may have fewer side effects than other alpha-blockers. OBJECTIVES To assess the effects of silodosin for the treatment of LUTS in men with BPH. SEARCH METHODS We performed a comprehensive search using multiple databases (Cochrane Library, MEDLINE, EMBASE, Scopus, Google Scholar, and Web of Science), trials registries, other sources of grey literature, and conference proceedings with no restrictions on the language of publication or publication status up until 13 June 2017. SELECTION CRITERIA We included all parallel, randomized controlled trials. We also included cross-over designs. DATA COLLECTION AND ANALYSIS Two review authors independently classified studies and abstracted data from the included studies. We performed statistical analyses using a random-effects model and interpreted them according to the Cochrane Handbook for Systematic Reviews of Interventions. We rated the quality of evidence according to the GRADE approach. MAIN RESULTS We included 19 unique studies with 4295 randomized participants across four comparisons for short-term follow-up. The mean age, prostate volume, and International Prostate Symptom Score were 66.5 years, 38.2 mL, and 19.1, respectively. Silodosin versus placeboBased on four studies with a total of 1968 randomized participants, silodosin may reduce urologic symptom scores in an appreciable number of men (mean difference (MD) -2.65, 95% confidence interval (CI) -3.23 to -2.08; low-quality evidence). Silodosin likely does not result in a clinically important reduction in quality of life (MD -0.42, 95% CI -0.71 to -0.13; moderate-quality evidence). It may not increase rates of treatment withdrawal for any reason (relative risk (RR) 1.08, 95% CI 0.70 to 1.66; low-quality evidence). We are uncertain about the effect of silodosin on cardiovascular adverse events (RR 1.28, 95% CI 0.67 to 2.45; very low-quality evidence). Silodosin likely increases sexual adverse events (RR 26.07, 95% CI 12.36 to 54.97; moderate-quality evidence); this would result in 180 more sexual adverse events per 1000 men (95% CI 82 more to 388 more). Silodosin versus tamsulosinBased on 13 studies with a total of 2129 randomized participants, silodosin may result in little to no difference in urologic symptom scores (MD -0.04, 95% CI -1.31 to 1.24; low-quality evidence) and quality of life (MD -0.15, 95% CI -0.53 to 0.22; low-quality evidence). We are uncertain about treatment withdrawals for any reason (RR 1.02, 95% CI 0.62 to 1.69; very low-quality evidence). Silodosin may result in little to no difference in cardiovascular adverse events (RR 0.77, 95% CI 0.53 to 1.12; low-quality evidence). Silodosin likely increases sexual adverse events (RR 6.05, 95% CI 3.55 to 10.31; moderate-quality evidence); this would result in 141 more sexual adverse events per 1000 men (95% CI 71 more to 261 more). Silodosin versus naftopidilBased on five studies with a total of 763 randomized participants, silodosin may result in little to no differences in urologic symptom scores (MD -0.85, 95% CI -2.57 to 0.87; low-quality evidence), quality of life (MD -0.17, 95% CI -0.60 to 0.27; low-quality evidence), treatment withdrawal for any reason (RR 1.25, 95% CI 0.81 to 1.93; low-quality evidence), and cardiovascular adverse events (RR 1.02, 95% CI 0.41 to 2.56; low-quality evidence). Silodosin likely increases sexual adverse events (RR 5.93, 95% CI 2.16 to 16.29; moderate-quality evidence); this would result in 74 more sexual adverse events per 1000 men (95% CI 17 more to 231 more). Silodosin versus alfuzosinBased on two studies with a total of 155 randomized participants, silodosin may or may not result in a clinically important increase in urologic symptom scores (MD 3.83, 95% CI 0.12 to 7.54; low-quality evidence). Silodosin likely results in little to no difference in quality of life (MD 0.14, 95% CI -0.46 to 0.74; moderate-quality evidence). We found no event of treatment withdrawal for any reason. Silodosin may not reduce cardiovascular adverse events (RR 0.67, 95% CI 0.36 to 1.24; low-quality evidence) but likely increases sexual adverse events (RR 37.21, 95% CI 5.32 to 260.07; moderate-quality evidence); this would result in 217 more sexual adverse events per 1000 men (95% CI 26 more to 1000 more). AUTHORS' CONCLUSIONS Silodosin may reduce urologic symptom scores in an appreciable number of men compared to placebo. Quality of life and treatment withdrawals for any reason appears similar. Its efficacy appears similar to that of other alpha blockers (tamsulosin, naftopidil and alfuzosin) but the rate of sexual side effects is likely higher. Our certainty in the estimates of effect was lowered due to study limitations, inconsistency and imprecision.
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Affiliation(s)
- Jae Hung Jung
- Yonsei University Wonju College of MedicineDepartment of Urology20 Ilsan‐roWonjuGangwonKorea, South26426
- University of MinnesotaDepartment of UrologyMinneapolisMinnesotaUSA
- Minneapolis VA Health Care SystemUrology SectionMinneapolisMinnesotaUSA
| | - Jiye Kim
- Yonsei University Wonju College of MedicineDepartment of Plastic SurgeryWonjuKorea, South
| | - Roderick MacDonald
- Minneapolis VA Medical CenterGeneral Internal Medicine (111‐0)One Veterans DriveMinneapolisMinnesotaUSA55417
| | - Balaji Reddy
- Massachusetts General HospitalDepartment of Urology55 Fruit StreetBostonUSAMA 02114
| | - Myung Ha Kim
- Yonsei University Wonju College of MedicineYonsei Wonju Medical LibraryWonjuKorea, South
| | - Philipp Dahm
- University of MinnesotaDepartment of UrologyMinneapolisMinnesotaUSA
- Minneapolis VA Health Care SystemUrology SectionMinneapolisMinnesotaUSA
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Breithaupt-Groegler K, Coch C, Coenen M, Donath F, Erb-Zohar K, Francke K, Goehler K, Iovino M, Kammerer KP, Mikus G, Rengelshausen J, Sourgens H, Schinzel R, Sudhop T, Wensing G. Who is a 'healthy subject'?-consensus results on pivotal eligibility criteria for clinical trials. Eur J Clin Pharmacol 2017; 73:409-416. [PMID: 28064353 PMCID: PMC5350217 DOI: 10.1007/s00228-016-2189-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 12/20/2016] [Indexed: 11/22/2022]
Abstract
Introduction/Methods A discussion forum was hosted by the German not-for-profit Association for Applied Human Pharmacology (AGAH e.V.) to critically review key eligibility criteria and stopping rules for clinical trials with healthy subjects, enrolling stakeholders from the pharmaceutical industry, contract research organisations, academia, ethics committees and competent authority. Results Pivotal eligibility criteria were defined for trials with new investigational medicinal products (IMPs) or with clinically established IMPs. In general, a pulse rate ranging between 50 and 90 beats/min is recommended for first-in-human (FIH) trials, while wider ranges seem acceptable for trials with clinically established IMPs, provided there are no indications of thyroid dysfunction. Hepatic laboratory parameters not to exceed the upper limit of normal (ULN) comprise ALT (alanine aminotransferase) and AST (aspartate aminotransferase) in FIH trials, whereas slight elevations (10% above ULN) seem acceptable in trials with clinically established IMPs without known hepatotoxicity. A normal renal function is required for any clinical trial in healthy subjects. A risk-adapted approach for stopping rules was adopted. Stopping rules for an individual subject are one adverse event of severe intensity or one serious adverse event. In case of a severe adverse event, some stakeholders demand a causal relationship with the IMP (i.e. an adverse reaction). Stopping rules for a cohort are one serious adverse reaction or ≥50% of subjects experiencing any adverse reaction of moderate or severe intensity. Consequences The application of this consensus resulted in a reduction in protocol deficiencies issued by the competent authority.
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Affiliation(s)
| | - Christoph Coch
- Institute of Clinical Chemistry and Clinical Pharmacology, University of Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Martin Coenen
- Institute of Clinical Chemistry and Clinical Pharmacology, University of Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Germany.
| | - Frank Donath
- SocraTec Research and Development GmbH, D-99084, Erfurt, Germany
| | | | - Klaus Francke
- National Association of Statutory Health Insurance Funds, Medicinal Product Department, 10117, Berlin, Germany
| | - Karin Goehler
- Gruenenthal GmbH, Gruenenthal Innovation-Development-Clinical Development-Clinical Pharmacology, D-52099, Aachen, Germany
| | - Mario Iovino
- Boehringer Ingelheim Pharma GmbH & Co. KG, Translational Medicine and Clinical Pharmacology, D-88397, Biberach/Riss, Germany
| | - Klaus Peter Kammerer
- Boehringer Ingelheim Pharma GmbH & Co. KG, Translational Medicine and Clinical Pharmacology, D-88397, Biberach/Riss, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, D-69120, Heidelberg, Germany
| | - Jens Rengelshausen
- Gruenenthal GmbH, Gruenenthal Innovation-Research-Translational Science & Strategy-Early Clinical Science, D-52078, Aachen, Germany
| | | | | | - Thomas Sudhop
- Federal Institute for Drugs and Medical Devices (BfArM), D-53175, Bonn, Germany
| | - Georg Wensing
- Bayer Pharma AG, Pharmaceutical Division Clinical Pharmacology Cardiovascular/Hematology (Primary Care), D-42096, Wuppertal, Germany
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Chronotherapy for hypertension in obstructive sleep apnoea (CHOSA): a randomised, double-blind, placebo-controlled crossover trial. Thorax 2016; 72:550-558. [DOI: 10.1136/thoraxjnl-2016-209504] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/02/2016] [Accepted: 11/15/2016] [Indexed: 12/21/2022]
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Wilhelm M, Winkler A, Rief W, Doering BK. Effect of placebo groups on blood pressure in hypertension: a meta-analysis of beta-blocker trials. ACTA ACUST UNITED AC 2016; 10:917-929. [DOI: 10.1016/j.jash.2016.10.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/18/2016] [Accepted: 10/27/2016] [Indexed: 01/02/2023]
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Koonrungsesomboon N, Karbwang J. Ethical considerations in clinical research on herbal medicine for prevention of cardiovascular disease in the ageing. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2016; 23:1090-1094. [PMID: 26776958 DOI: 10.1016/j.phymed.2015.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 10/23/2015] [Accepted: 10/30/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) in the ageing is a major public health problem worldwide. The nature of most CVD is subclinical with pathological processes that can span over years. Use of preventive measures could be an appropriate approach to prevailing over CVD in the ageing, and herbal medicine is one of the promising preventive approaches and is currently of interest among medical societies. In the evidence-based era, herbal medicine is, however, often underestimated and approached with skepticism, mainly due to the paucity of scientific evidence. Properly designed clinical trials on herbal medicine for prevention of CVD in a geriatric population are thus of importance and of clinical value. PURPOSE To review ethical issues and discuss considerations when such research is proposed. CHAPTERS/SECTIONS Four ethical issues, including the scientific validity of research, risk-benefit assessments, subject selection and vulnerability, and informed consent, are structured and extensively discussed in this article. CONCLUSIONS Ethical core considerations of prevention research of CVD on herbal medicine involve particular attention on the scientific validity of research, risk-benefit assessments, subject selection and vulnerability, and informed consent. These issues and considerations are keys, although they must be adapted to an individual research setting in which a clinical study is proposed.
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Affiliation(s)
- Nut Koonrungsesomboon
- Department of Clinical Product Development, Institute of Tropical Medicine, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; Leading Program, Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Juntra Karbwang
- Department of Clinical Product Development, Institute of Tropical Medicine, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan.
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Abstract
AIMS Suppose you are the developer of a new therapy for a mental health problem or you have several years of experience working with such a therapy, and you would like to prove that it is effective. Randomised trials have become the gold standard to prove that interventions are effective, and they are used by treatment guidelines and policy makers to decide whether or not to adopt, implement or fund a therapy. METHODS You would want to do such a randomised trial to get your therapy disseminated, but in reality your clinical experience already showed you that the therapy works. How could you do a trial in order to optimise the chance of finding a positive effect? RESULTS Methods that can help include a strong allegiance towards the therapy, anything that increases expectations and hope in participants, making use of the weak spots of randomised trials (risk of bias), small sample sizes and waiting list control groups (but not comparisons with existing interventions). And if all that fails one can always not publish the outcomes and wait for positive trials. CONCLUSIONS Several methods are available to help you show that your therapy is effective, even when it is not.
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Differential Post-Exercise Blood Pressure Responses between Blacks and Caucasians. PLoS One 2016; 11:e0153445. [PMID: 27074034 PMCID: PMC4830622 DOI: 10.1371/journal.pone.0153445] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 03/29/2016] [Indexed: 11/19/2022] Open
Abstract
Post-exercise hypotension (PEH) is widely observed in Caucasians (CA) and is associated with histamine receptors 1- and 2- (H1R and H2R) mediated post-exercise vasodilation. However, it appears that blacks (BL) may not exhibit PEH following aerobic exercise. Hence, this study sought to determine the extent to which BL develop PEH, and the contribution of histamine receptors to PEH (or lack thereof) in this population. Forty-nine (22 BL, 27 CA) young and healthy subjects completed the study. Subjects were randomly assigned to take either a combined H1R and H2R antagonist (fexofenadine and ranitidine) or a control placebo. Supine blood pressure (BP), cardiac output and peripheral vascular resistance measurements were obtained at baseline, as well as at 30 min, 60 min and 90 min after 45 min of treadmill exercise at 70% heart rate reserve. Exercise increased diastolic BP in young BL but not in CA. Post-exercise diastolic BP was also elevated in BL after exercise with histamine receptor blockade. Moreover, H1R and H2R blockade elicited differential responses in stroke volume between BL and CA at rest, and the difference remained following exercise. Our findings show differential BP responses following exercise in BL and CA, and a potential role of histamine receptors in mediating basal and post-exercise stroke volume in BL. The heightened BP and vascular responses to exercise stimulus is consistent with the greater CVD risk in BL.
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Schedlowski M, Enck P, Rief W, Bingel U. Neuro-Bio-Behavioral Mechanisms of Placebo and Nocebo Responses: Implications for Clinical Trials and Clinical Practice. Pharmacol Rev 2016; 67:697-730. [PMID: 26126649 DOI: 10.1124/pr.114.009423] [Citation(s) in RCA: 197] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The placebo effect has often been considered a nuisance in basic and particularly clinical research. This view has gradually changed in recent years due to deeper insight into the neuro-bio-behavioral mechanisms steering both the placebo and nocebo responses, the evil twin of placebo. For the neuroscientist, placebo and nocebo responses have evolved as indispensable tools to understand brain mechanisms that link cognitive and emotional factors with symptom perception as well as peripheral physiologic systems and end organ functioning. For the clinical investigator, better understanding of the mechanisms driving placebo and nocebo responses allow the control of these responses and thereby help to more precisely define the efficacy of a specific pharmacological intervention. Finally, in the clinical context, the systematic exploitation of these mechanisms will help to maximize placebo responses and minimize nocebo responses for the patient's benefit. In this review, we summarize and critically examine the neuro-bio-behavioral mechanisms underlying placebo and nocebo responses that are currently known in terms of different diseases and physiologic systems. We subsequently elaborate on the consequences of this knowledge for pharmacological treatments of patients and the implications for pharmacological research, the training of healthcare professionals, and for the health care system and future research strategies on placebo and nocebo responses.
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Affiliation(s)
- Manfred Schedlowski
- Institute of Medical Psychology and Behavioral Immunobiology (M.S.) and Department of Neurology (U.B.), University Clinic Essen, Essen, Germany; Department of Internal Medicine VI, Psychosomatic Medicine, University Hospital Tübingen, Tübingen, Germany (P.E.); and Department of Psychology, University of Marburg, Marburg, Germany (W.R.)
| | - Paul Enck
- Institute of Medical Psychology and Behavioral Immunobiology (M.S.) and Department of Neurology (U.B.), University Clinic Essen, Essen, Germany; Department of Internal Medicine VI, Psychosomatic Medicine, University Hospital Tübingen, Tübingen, Germany (P.E.); and Department of Psychology, University of Marburg, Marburg, Germany (W.R.)
| | - Winfried Rief
- Institute of Medical Psychology and Behavioral Immunobiology (M.S.) and Department of Neurology (U.B.), University Clinic Essen, Essen, Germany; Department of Internal Medicine VI, Psychosomatic Medicine, University Hospital Tübingen, Tübingen, Germany (P.E.); and Department of Psychology, University of Marburg, Marburg, Germany (W.R.)
| | - Ulrike Bingel
- Institute of Medical Psychology and Behavioral Immunobiology (M.S.) and Department of Neurology (U.B.), University Clinic Essen, Essen, Germany; Department of Internal Medicine VI, Psychosomatic Medicine, University Hospital Tübingen, Tübingen, Germany (P.E.); and Department of Psychology, University of Marburg, Marburg, Germany (W.R.)
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Gee LC, Ahluwalia A. Dietary Nitrate Lowers Blood Pressure: Epidemiological, Pre-clinical Experimental and Clinical Trial Evidence. Curr Hypertens Rep 2016; 18:17. [PMID: 26815004 PMCID: PMC4729801 DOI: 10.1007/s11906-015-0623-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Nitric oxide (NO), a potent vasodilator critical in maintaining vascular homeostasis, can reduce blood pressure in vivo. Loss of constitutive NO generation, for example as a result of endothelial dysfunction, occurs in many pathological conditions, including hypertension, and contributes to disease pathology. Attempts to therapeutically deliver NO via organic nitrates (e.g. glyceryl trinitrate, GTN) to reduce blood pressure in hypertensives have been largely unsuccessful. However, in recent years inorganic (or 'dietary') nitrate has been identified as a potential solution for NO delivery through its sequential chemical reduction via the enterosalivary circuit. With dietary nitrate found in abundance in vegetables this review discusses epidemiological, pre-clinical and clinical data supporting the idea that dietary nitrate could represent a cheap and effective dietary intervention capable of reducing blood pressure and thereby improving cardiovascular health.
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Affiliation(s)
- Lorna C Gee
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
| | - Amrita Ahluwalia
- William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
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Abstract
Although the early antidepressant trials which included severely ill and hospitalized patients showed substantial drug-placebo differences, these robust differences have not held up in the trials of the past couple of decades, whether sponsored by pharmaceutical companies or non-profit agencies. This narrowing of the drug-placebo difference has been attributed to a number of changes in the conduct of clinical trials. First, the advent of DSM-III and the broadening of the definition of major depression have led to the inclusion of mildly to moderately ill patients into antidepressant trials. These patients may experience a smaller magnitude of antidepressant-placebo differences. Second, drug development regulators, such as the U.S. Food and Drug Administration and the European Medicines Agency, have had a significant, albeit underappreciated, role in determining how modern antidepressant clinical trials are designed and conducted. Their concerns about possible false positive results have led to trial designs that are poor, difficult to conduct, and complicated to analyze. Attempts at better design and patient selection for antidepressant trials have not yielded the expected results. As of now, antidepressant clinical trials have an effect size of 0.30, which, although similar to the effects of treatments for many other chronic illnesses, such as hypertension, asthma and diabetes, is less than impressive.
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Affiliation(s)
- Arif Khan
- Northwest Clinical Research CenterBellevue, WA, USA,Department of Psychiatry and Behavioral Science, Duke University School of MedicineDurham, NC, USA
| | - Walter A Brown
- Department of Psychiatry and Human Behavior, Brown UniversityProvidence, RI, USA
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Winkler A, Rief W. Effect of Placebo Conditions on Polysomnographic Parameters in Primary Insomnia: A Meta-Analysis. Sleep 2015; 38:925-31. [PMID: 25515108 DOI: 10.5665/sleep.4742] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 10/30/2014] [Indexed: 01/28/2023] Open
Abstract
STUDY OBJECTIVES Little is known about the role of placebo response in the pharmacotherapy of primary insomnia, especially about the effect of placebo intake on objectively assessed outcome variables. Our aim was therefore to conduct an effect-size analysis of placebo conditions in randomized controlled drug trials addressing primary insomnia also including polysomnography. DESIGN We conducted a comprehensive literature search using PubMed, PsycINFO, PSYNDEX, PQDT OPEN, OpenGREY, ISI Web of Knowledge, Cochrane Clinical Trials, and the World Health Organization International Clinical Trials Registry Platform. The meta-analysis used a random effects model and was based on 32 studies reporting 82 treatment conditions covering a total of 3,969 participants. Special emphasis was given to the comparison of objective and subjective outcomes and the proportion of the placebo response to the drug response. MEASUREMENTS AND RESULTS Effect sizes estimates (Hedges g) suggest that there is a small to moderate yet significant and robust placebo response reducing the symptoms of insomnia in terms of sleep onset latency (-0.35), total sleep time (0.42), wake after sleep onset (-0.29), sleep efficiency (0.31), subjective sleep onset latency (-0.29), subjective total sleep time (0.43), subjective wake after sleep onset (-0.32), subjective sleep efficiency (0.25) and sleep quality (0.31). Thus, the placebo response was also evident in objective, physiological (polysomnographic) variables. Our results indicate that 63.56% of the drug responses are achieved even in the placebo groups. CONCLUSIONS In light of these strong placebo responses, future studies should investigate how to exploit placebo mechanisms in clinical practice.
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Affiliation(s)
- Alexander Winkler
- University of Marburg, Department for Clinical Psychology and Psychotherapy, Marburg, Germany
| | - Winfried Rief
- University of Marburg, Department for Clinical Psychology and Psychotherapy, Marburg, Germany
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Faasse K, Grey A, Horne R, Petrie KJ. High perceived sensitivity to medicines is associated with higher medical care utilisation, increased symptom reporting and greater information-seeking about medication. Pharmacoepidemiol Drug Saf 2015; 24:592-9. [DOI: 10.1002/pds.3751] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 12/11/2014] [Accepted: 12/13/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Kate Faasse
- Department of Psychological Medicine and Department of Medicine; The University of Auckland; Auckland New Zealand
- UCL School of Pharmacy; London UK
| | - Andrew Grey
- Department of Psychological Medicine and Department of Medicine; The University of Auckland; Auckland New Zealand
- UCL School of Pharmacy; London UK
| | - Rob Horne
- Department of Psychological Medicine and Department of Medicine; The University of Auckland; Auckland New Zealand
- UCL School of Pharmacy; London UK
| | - Keith J. Petrie
- Department of Psychological Medicine and Department of Medicine; The University of Auckland; Auckland New Zealand
- UCL School of Pharmacy; London UK
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Infante de Oliveira E. Renal sympathetic denervation - phenomenon or noumenon? Rev Port Cardiol 2014; 33:205-6. [PMID: 24798063 DOI: 10.1016/j.repc.2014.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 02/24/2014] [Indexed: 10/25/2022] Open
Affiliation(s)
- Eduardo Infante de Oliveira
- Serviço de Cardiologia, Hospital de Santa Maria, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.
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Arnold MH, Finniss DG, Kerridge I. Medicine's inconvenient truth: the placebo and nocebo effect. Intern Med J 2014; 44:398-405. [DOI: 10.1111/imj.12380] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 12/29/2013] [Indexed: 12/19/2022]
Affiliation(s)
- M. H. Arnold
- Northern Clinical School; Sydney Medical School; University of Sydney; Sydney New South Wales Australia
- Centre for Values; Ethics and the Law in Medicine; School of Public Health; University of Sydney; Sydney New South Wales Australia
- Department of Rheumatology; Royal North Shore Hospital; Sydney New South Wales Australia
| | - D. G. Finniss
- Pain Management Research Institute; University of Sydney and Royal North Shore Hospital; Sydney New South Wales Australia
- School of Rehabilitation Sciences; Griffith University; Brisbane Queensland Australia
| | - I. Kerridge
- Northern Clinical School; Sydney Medical School; University of Sydney; Sydney New South Wales Australia
- Centre for Values; Ethics and the Law in Medicine; School of Public Health; University of Sydney; Sydney New South Wales Australia
- Haematology Department; Royal North Shore Hospital; Sydney New South Wales Australia
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Infante de Oliveira E. Renal sympathetic denervation – Phenomenon or noumenon? REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.repce.2014.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Renal denervation in the management of resistant hypertension: current evidence and perspectives. Curr Opin Nephrol Hypertens 2014; 22:511-8. [PMID: 23892701 DOI: 10.1097/mnh.0b013e3283640024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Catheter-based renal denervation has emerged as a novel treatment modality for resistant hypertension. This review summarizes the current evidence on this procedure in treatment of resistant hypertension, limitations of available evidence and questions to be answered. RECENT FINDINGS The SYMPLICITY studies showed that renal denervation is feasible in treating resistant hypertension, but failed to provide conclusive evidence on the size and durability of the antihypertensive, renal and sympatholytic effects, as well as the long-term safety. The definition of resistant hypertension was loose in the SYMPLICITY studies and the management of resistant hypertension was suboptimal. Future studies should have a randomized design and enroll truly resistant hypertension patients by excluding secondary hypertension, white-coat hypertension and nonadherent patients. Questions to be addressed by the ongoing and future trials include the long-term efficacy and safety of this procedure, identification of responders and uncovering of the underlying mechanisms. SUMMARY Only well-designed, randomized clinical trials addressing the limitations of the SYMPLICITY studies will be able to demonstrate whether renal denervation is an efficacious treatment modality in resistant hypertension and in which patients. For now, renal denervation remains an experimental procedure and should only be offered to truly resistant hypertensive patients in a research context after careful selection.
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Blom K, Baker B, How M, Dai M, Irvine J, Abbey S, Abramson BL, Myers MG, Kiss A, Perkins NJ, Tobe SW. Hypertension analysis of stress reduction using mindfulness meditation and yoga: results from the HARMONY randomized controlled trial. Am J Hypertens 2014; 27:122-9. [PMID: 24038797 DOI: 10.1093/ajh/hpt134] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The HARMONY study was a randomized, controlled trial examining the efficacy of an 8-week mindfulness-based stress reduction (MBSR) program for blood pressure (BP) lowering among unmedicated stage 1 hypertensive participants. METHODS Participants diagnosed with stage 1 hypertension based on ambulatory BP were randomized to either immediate treatment of MBSR for 8 weeks or wait-list control. Primary outcome analysis evaluated whether change in awake and 24-hour ambulatory BP from baseline to week 12 was significantly different between the 2 groups. A within-group before and after MBSR analysis was also performed. RESULTS The study enrolled 101 adults (38% male) with baseline average 24-hour ambulatory BP of 135±7.9/82±5.8mm Hg and daytime ambulatory BP of 140±7.7/87±6.3 mmHg. At week 12, the change from baseline in 24-hour ambulatory BP was 0.4±6.7/0.0±4.9mm Hg for the immediate intervention and 0.4±7.8/-0.4±4.6mm Hg for the wait-list control. There were no significant differences between intervention and wait-list control for all ambulatory BP parameters. The secondary within-group analysis found a small reduction in BP after MBSR compared with baseline, a finding limited to female subjects in a sex analysis. CONCLUSIONS MBSR did not lower ambulatory BP by a statistically or clinically significant amount in untreated, stage 1 hypertensive patients when compared with a wait-list control group. It leaves untested whether MBSR might be useful for lowering BP by improving adherence in treated hypertensive participants. CLINICAL TRIALS REGISTRATION NCT00825526.
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Affiliation(s)
- Kimberly Blom
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Weiss RJ, Stapff M, Lin Y. Placebo effect and efficacy of nebivolol in patients with hypertension not controlled with lisinopril or losartan: a phase IV, randomized, placebo-controlled trial. Am J Cardiovasc Drugs 2013; 13:129-40. [PMID: 23519546 DOI: 10.1007/s40256-013-0010-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Most patients with hypertension require more than one antihypertensive to achieve blood pressure (BP) control. OBJECTIVE The purpose of this trial was to assess the efficacy and tolerability of add-on nebivolol, a vasodilatory β-blocker, in patients with untreated or poorly controlled hypertension, receiving stable therapy with lisinopril (an angiotensin-converting enzyme inhibitor) or losartan (an angiotensin II receptor blocker). STUDY DESIGN This was a phase IV double-blind, placebo-controlled trial conducted from August 2008 to March 2010 (ClinicalTrials.gov identifier: NCT00734630). Patients entered a 2-week, single-blind, placebo-only washout phase, followed by a 3- to 4-week open-label lead-in phase (lisinopril, 10-20 mg/day, or losartan, 50-100 mg/day), and a 12-week randomized, double-blind add-on treatment phase with placebo or nebivolol (5-40 mg/day). SETTING This study was conducted at 76 outpatient centers in the United States. PATIENTS Participants were men and women aged 18-85 years with a diagnosis of primary hypertension and seated trough systolic BP (SBP) at screening in the range of 170-200 mmHg if untreated, 155-180 mmHg if taking 1 antihypertensive medication, or 140-170 mmHg if taking 2 antihypertensive medications. INTERVENTION The intervention was 12 weeks' treatment with nebivolol 5-40 mg/day added to a background therapy of lisinopril 10-20 mg/day or losartan 50-100 mg/day. MAIN OUTCOME MEASURES Primary and secondary efficacy parameters were changes from baseline in seated trough cuff SBP and diastolic BP (DBP) at Week 12, respectively. Tolerability was assessed by monitoring treatment-emergent adverse events (TEAEs). RESULTS A total of 491 patients were randomized to receive nebivolol (n=258) or placebo (n=233). Efficacy analyses were conducted for 256 nebivolol and 232 placebo patients (intent-to-treat population); completion rates were 88.8% and 85.8%, respectively. Mean baseline SBP/DBP values were 163.1/98.2 mmHg (nebivolol) and 162.4/96.8 mmHg (placebo). Nebivolol was associated with a non-significant mean±SD reduction in SBP (-10.1±16.9 mmHg) versus placebo (-7.3±15.9 mmHg, P=0.093) and significant mean DBP reduction (-7.8±10.1 mmHg vs -3.5±10.6 mmHg, P<0.001). Subgroup analysis suggested a significant effect on DBP for patients receiving background losartan treatment (-8.1±9.2 mmHg vs -3.1±9.4 mmHg, P<0.001), but not for those receiving lisinopril (-7.6±10.8 mmHg vs -3.8±11.6 mmHg, P=0.076). A total of 28% nebivolol-treated and 22% placebo-treated patients reported a TEAE, the most frequent being upper respiratory tract infection (4.3% and 2.1%, respectively), bradycardia (2.7% and 0%), headache (2.3% and 2.1%), and nasopharyngitis (2.3% and 0.9%). CONCLUSION These data suggest that nebivolol, when added to lisinopril or losartan, results in an additional BP reduction; however, only the effect on DBP reached statistical significance. A subanalysis suggests that the effect on DBP may be stronger in losartan-treated than lisinopril-treated patients. A relatively strong placebo effect may limit data interpretation. Nebivolol was well tolerated, as there was no difference in TEAEs between nebivolol and placebo. FUNDING This trial (NCT00734630) was funded by Forest Laboratories, Inc.
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Affiliation(s)
- Robert J Weiss
- Maine Research Associates, 2 Great Falls Plaza, Auburn, ME 04210, USA.
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Enck P, Bingel U, Schedlowski M, Rief W. The placebo response in medicine: minimize, maximize or personalize? Nat Rev Drug Discov 2013; 12:191-204. [PMID: 23449306 DOI: 10.1038/nrd3923] [Citation(s) in RCA: 454] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Lewin A, Punzi H, Luo X, Stapff M. Nebivolol monotherapy for patients with systolic stage II hypertension: results of a randomized, placebo-controlled trial. Clin Ther 2013; 35:142-52. [PMID: 23332366 DOI: 10.1016/j.clinthera.2012.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 11/20/2012] [Accepted: 12/20/2012] [Indexed: 01/13/2023]
Abstract
BACKGROUND Elevated systolic blood pressure (SBP) is an independent risk factor for cardiovascular events and mortality. OBJECTIVE The goal of this study was to assess whether nebivolol (NEB), a vasodilatory β(1)-selective blocker, is a safe and efficacious monotherapy for individuals with systolic stage II hypertension. METHODS In this multicenter trial, 18- to 64-year-olds who had not used antihypertensive treatment for at least 4 weeks and had SBP/diastolic blood pressure (DBP) of 160 to 180/90 to 110 mm Hg were randomized to receive double-blind medication for 6 weeks (NEB, n = 290; placebo [PBO], n = 142). Depending on response, the starting dose (5 mg/d) could be increased directly to 20 mg/d. Primary parameters were baseline-end point changes in trough seated SBP and DBP (intent-to-treat [ITT] population); the Hochberg method was used to control the type I error (α = 0.05). Responder analysis was also performed. Safety and tolerability assessment included monitoring of adverse events (AEs). RESULTS Mean age at baseline (ITT) was 50.7 years, and the mean SBP/DBP values were 167/101 mm Hg; 202 (47.3%) participants were women, 276 (63.9%) had body mass index ≥30 kg/m(2), 152 (35.2%) were black, and 161 (37.3%) were Hispanic. Completion rates were 79.7% (PBO) and 90.3% (NEB). After 2 weeks of treatment, 92% and 95% participants in the NEB and PBO groups, respectively, had SBP in the range of 130 to 180 mm Hg and were titrated to the 20-mg/d NEB dose or its matching PBO tablet. After 6 weeks of treatment, the NEB group experienced significant mean reductions compared with the PBO group for both SBP (-18.2 vs -12.3 mm Hg; P < 0.001) and DBP (-12.3 vs -5.7 mm Hg; P < 0.001), down to mean SBP/DBP values of 149/89 mm Hg and 155/95 mm Hg, respectively, and had a significantly higher percentage of individuals who achieved BP control (SBP/DBP <140/90 mm Hg, 30.6% vs 17.3%; P = 0.004). Post hoc analyses suggest that NEB was not efficacious in reducing SBP in black participants. Mean changes in pulse rate were -12.8 beats/min for the NEB group and -1.6 beats/min for the PBO group (P < 0.001). Rates of discontinuations due to an AE (NEB vs PBO) were 1.4% in both groups, rates of any treatment-emergent AEs were 19.7% versus 19.0%, and rates of serious AEs were 0.3% versus 2.1%. The most common AEs (NEB vs PBO) were headache (2.1% vs 2.8%) and hypertension (0.7% vs 2.1%). CONCLUSIONS NEB monotherapy was an efficacious and well-tolerated treatment option for these study individuals with systolic stage II hypertension, but most of them would need combination therapy to achieve BP control.
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Affiliation(s)
- Andrew Lewin
- National Research Institute, Los Angeles, CA 90057, USA.
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Effect of placebo on ambulatory blood pressure monitoring in children. Pediatr Nephrol 2012; 27:1937-42. [PMID: 22623022 PMCID: PMC3423579 DOI: 10.1007/s00467-012-2191-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 03/27/2012] [Accepted: 04/12/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Ambulatory blood pressure monitoring (ABPM) has been proposed as a useful tool for more accurately diagnosing hypertension (HTN) and evaluating blood pressure (BP) response in pediatric anti-hypertensive trials. ABPM captures multiple BP measurements during routine daily activities and is thus an excellent method for identifying white-coat HTN. Additionally, ABPM measurements in adults do not demonstrate the placebo effect commonly seen with casual BP measurements, although this has yet to be evaluated in children. Therefore,, the aim of this study was to assess the effect of placebo on ABPM measurements in children. METHODS A total of 141 children aged 5-16 years with elevated BP were randomized into a multi-center, single-blind, cross-over trial. Subjects received a placebo pill prior to wearing a 24-h ABPM device at one of two visits separated by 1-2 weeks. Study procedures were otherwise identical at both visits. RESULTS Mean systolic and diastolic BP for all measured time periods were similar between visits, as was the number of children diagnosed with HTN at each visit. CONCLUSION Having confirmed HTN at baseline did not affect the impact of placebo on mean BP. If confirmed, this lack of placebo effect on ABPM measurements may allow for the design of direct comparison pediatric anti-hypertensive trials without a placebo arm.
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Zinner NR, Ammann LP, Haas GP, Janning SW, He W, Bukofzer S. Finding unrecognized information in overactive bladder clinical trial data: a new approach to understanding placebo and treatment effects. Neurourol Urodyn 2012; 32:308-13. [PMID: 23001509 DOI: 10.1002/nau.22313] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 08/20/2012] [Indexed: 11/08/2022]
Abstract
AIMS To identify combinations of variables among overactive bladder (OAB) clinical trial subjects that allow prediction of those who are more--or less--likely to respond strongly to placebo, or to medication. METHODS Data from two Phase IIIb clinical trials of solifenacin in OAB were combined. Predictive models for placebo and treatment responses were constructed using baseline variables including individual items from the OAB questionnaire. These models were reduced to an essential subset of predictor variables. Two outcome measures are reported: urgency and incontinence. RESULTS In placebo subjects, 14 selected variables permitted distinction between those who responded with significant reductions in urgency and those who did not. A subset of nine variables in treated subjects permitted distinction between those more--or less--likely to respond to medication. Data for urgency were combined from both placebo and actively treated subjects to identify those who had one of the previously identified clusters of variables. It was possible to predict, among all subjects, who would be likely to experience a strong placebo or active treatment response and who would not. This process was also applied to incontinence data. CONCLUSIONS We have developed a new process to help understand placebo and treatment responses and their relationships to baseline conditions. The effectiveness of these methods was indicated using data from two solifenacin clinical trials and would benefit from future validation using other data sets. Methods used here are suitable for predicting the placebo effect in other clinical trials.
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Persu A, Renkin J, Thijs L, Staessen JA. Renal denervation: ultima ratio or standard in treatment-resistant hypertension. Hypertension 2012; 60:596-606. [PMID: 22851728 DOI: 10.1161/hypertensionaha.112.195263] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
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Mitsikostas DD, Chalarakis NG, Mantonakis LI, Delicha EM, Sfikakis PP. Nocebo in fibromyalgia: meta-analysis of placebo-controlled clinical trials and implications for practice. Eur J Neurol 2011; 19:672-80. [DOI: 10.1111/j.1468-1331.2011.03528.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Rief W. Lessons to be learned from placebo groups in clinical trials. Pain 2011; 152:1693-1694. [PMID: 21435789 DOI: 10.1016/j.pain.2011.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 03/04/2011] [Accepted: 03/04/2011] [Indexed: 12/19/2022]
Affiliation(s)
- Winfried Rief
- University of Marburg, Department of Psychology, Gutenbergstrasse 18, D-35032 Marburg, Germany
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Mitsikostas DD, Mantonakis LI, Chalarakis NG. Nocebo is the enemy, not placebo. A meta-analysis of reported side effects after placebo treatment in headaches. Cephalalgia 2011; 31:550-61. [PMID: 21216874 DOI: 10.1177/0333102410391485] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The aim was to determine the magnitude of the nocebo (adverse effects following placebo administration) in clinical trials for primary headache disorders. We reviewed randomized, placebo-controlled studies for migraine, tension-type headache (TTH), and cluster headache treatments published between 1998 and 2009. The frequency of nocebo was estimated by the percentage of placebo-treated patients reporting at least one adverse side effect. The dropout frequency was estimated by the percentage of placebo-treated patients who discontinued the treatment due to intolerance. In studies of symptomatic treatment for migraine, the nocebo and dropout frequencies were 18.45% and 0.33%, but rose to 42.78% and 4.75% in preventative treatment studies. In trials for prevention of TTH, nocebo and dropout frequencies were 23.99% and 5.44%. For symptomatic treatment of cluster headache, the nocebo frequency was 18.67%. Nocebo is prevalent in clinical trials for primary headaches, particularly in preventive treatment studies. Dropouts due to nocebo effect may confound the interpretation of many clinical trials.
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Affiliation(s)
- Dimos D Mitsikostas
- Neurology Department, Athens Naval Hospital, 77A Vas. Sofias Avenue, Athens, Greece.
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Treatment expectations and preferences as predictors of outcome of acupuncture for chronic back pain. Spine (Phila Pa 1976) 2010; 35:1471-7. [PMID: 20535051 PMCID: PMC2895682 DOI: 10.1097/brs.0b013e3181c2a8d3] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Preplanned secondary analysis of data from participants receiving acupuncture in a randomized clinical trial. OBJECTIVE To determine whether patients' expectations of and preferences for acupuncture predict short and long-term treatment outcomes for persons with chronic back pain. SUMMARY OF BACKGROUND DATA Although accumulating evidence suggests that patient expectations and treatment preferences may predict treatment outcomes, few studies have examined this relationship for acupuncture. METHODS Four hundred seventy-seven acupuncture-naïve participants with chronic low back pain who were randomized to 1 of 3 acupuncture or simulated acupuncture treatments were the focus of this analysis. Ten treatments were provided during a 7-week period, and participants were masked to treatment assignment. Before randomization, participants provided expectations regarding treatment success, impressions, and knowledge about acupuncture and treatment preferences. Outcomes of interest were functional status (Roland score) and symptom bothersomeness at 8 and 52 weeks postrandomization, obtained by telephone interviewers masked to treatment assignment. RESULTS Persons with high pretreatment expectations for the success of acupuncture were more likely to report greater general expectations for improvement, a preference for acupuncture, having heard acupuncture was a very effective treatment and having a very or moderately positive impression of acupuncture. However, none of these variables was a significant predictor of improvement in back-related symptoms or function at 8 or 52 weeks. After 1 treatment, participants' revised expectations of treatment success were only associated with back-symptoms at the end of treatment. After 5 treatments, revised expectation of success was predictive of both symptoms and function at 8 and 52 weeks. CONCLUSION Pretreatment expectations and preferences for acupuncture were not found predictive of treatment outcomes for patients with chronic back pain. These results differ from previous studies evaluating acupuncture for chronic back pain. These inconsistent results suggest that the relationship between expectations and outcomes may be more complex than previously believed.
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Papadopoulos D, Mitsikostas DD. Nocebo effects in multiple sclerosis trials: a meta-analysis. Mult Scler 2010; 16:816-28. [DOI: 10.1177/1352458510370793] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective: To estimate the incidence and severity of nocebo responses in trials of symptomatic treatments (STs) and disease-modifying treatments (DMTs) for multiple sclerosis (MS). Methods: We conducted a systematic Medline search for all randomised, placebo-controlled MS trials published between 1989 and 2009. Meta-analysis of the incidence of nocebo responses was performed by pooling the percentage of placebo-treated patients that exhibited adverse events. Nocebo severity was calculated from the percentage of placebo-treated patients that dropped-out due to drug-related adverse events. Results: Data were extracted from 56 DMT and 44 ST eligible trials. The pooled incidence of nocebo responses was 74.4% (95% CI: 69.92—88.30) in DMT trials and 25.3% (95% CI: 15.24—36.90) in ST trials and was significantly higher in the former ( p < 0.0001). The pooled nocebo severity was 2.1% (95% CI: 1.6—2.67) in DMT and 2.34% (95% CI: 1.54—3.29) in ST trials. Meta-regression analysis revealed a higher nocebo incidence in parallel design ST studies compared to crossover ones ( p = 0.013) and a higher nocebo severity in phase II ST studies compared to phase III ones ( p = 0.0001). Nocebo severity in DMT trials exhibited an association with the year of study publication ( p = 0.011) and the frequency of drug administration ( p = 0.0082). Conclusions: Nocebo responses in MS trials are substantial and appear to have increased significantly in recent years with important implications for both trial design and clinical practice. Furthermore, nocebo responses exhibit an association with medication and trial-related factors.
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Affiliation(s)
- D. Papadopoulos
- Department of Neurology, Athens Naval Hospital, Athens, Greece, Neurology section, Evangelismos General Hospital, Athens, Greece,
| | - DD Mitsikostas
- Department of Neurology, Athens Naval Hospital, Athens, Greece
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Rief W, Nestoriuc Y, von Lilienfeld-Toal A, Dogan I, Schreiber F, Hofmann SG, Barsky AJ, Avorn J. Differences in adverse effect reporting in placebo groups in SSRI and tricyclic antidepressant trials: a systematic review and meta-analysis. Drug Saf 2009; 32:1041-56. [PMID: 19810776 DOI: 10.2165/11316580-000000000-00000] [Citation(s) in RCA: 154] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Biases in adverse effect reporting in randomized controlled trials (RCTs) [e.g. due to investigator expectations or assessment quality] can be quantified by studying the rates of adverse events reported in the placebo arms of such trials. OBJECTIVE We compared the rates of adverse effects reported in the placebo arms of tricyclic antidepressant (TCA) trials and placebo arms of selective serotonin reuptake inhibitor (SSRI) trials. METHODS We conducted a literature search for RCTs across PUBMED, Scopus and the Cochrane Central Register of Controlled Trials (CENTRAL). Only studies allowing adverse effect analysis were included. Publication year ranged from 1981 to 2007. RESULTS Our systematic review and meta-analysis included 143 placebocontrolled RCTs and data from 12,742 patients. Only 21% of studies used structured and systematic adverse effect ascertainment strategies. The way in which trials recorded adverse events influenced the rate of adverse effects substantially. Systematic assessment led to higher rates than less systematic assessment. Far more adverse effects were reported in TCA-placebo groups compared with SSRI-placebo groups, e.g. dry mouth (odds ratio [OR] = 3.5; 95% CI 2.9, 4.2); drowsiness (OR = 2.7; 95%CI 2.2, 3.4); constipation (OR= 2.7; 95%CI 2.1, 3.6); sexual problems (OR =2.3; 95%CI 1.5, 3.5). Regression analyses controlling for various influencing factors confirmed the results. CONCLUSION Adverse effect profiles reported in clinical trials are strongly influenced by expectations from investigators and patients. This difference cannot be attributed to ascertainment methods. Adverse effect patterns of the drug group are closely related to adverse effects of the placebo group. These results question the validity of the assumption that adverse effects in placebo groups reflect the 'drug-unspecific effects'.
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Affiliation(s)
- Winfried Rief
- Department of Clinical Psychology and Psychotherapy, Philipps University, Marburg, Germany.
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Meta-analysis of the placebo response in antidepressant trials. J Affect Disord 2009; 118:1-8. [PMID: 19246102 DOI: 10.1016/j.jad.2009.01.029] [Citation(s) in RCA: 194] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Revised: 01/19/2009] [Accepted: 01/19/2009] [Indexed: 11/22/2022]
Abstract
UNLABELLED Improvements in placebo groups of antidepressant trials account for a major part of the expected drug effects. We aimed to determine overall effect sizes of placebo and drug effects in antidepressant trials, and to analyze whether the placebo effect in antidepressant trials also occurs for patient self-perception, general psychopathology, and quality of life. METHODS Search terms covered different variants of pharmacotherapy for patients with depressive disorders from January 1980 to December 2005 in the databases Medline/Pubmed, PsychInfo and CENTRAL, a.o. We included RCTs with a placebo group and an antidepressant group in people with depression. RESULTS We computed within group effect sizes for several outcome variables and integrated them using random-effect models. A total of 96 studies were included. Mean effect size in the placebo group for primary outcome variables was d=1.69 (95% CI=1.54-1.84) compared to 2.50 in the drug group (95% CI=2.30-2.69). There was a major difference between placebo effect sizes assessed with observer ratings (d=1.85, 95% CI=1.69-2.01) versus patient self-perception (d=0.67; 95% CI=0.49-0.85). The effect sizes in placebo groups in 2005 were more than twice as great as those in 1980, but only for observer ratings, not for patient self-ratings. The result was partly due to increased homogeneity of samples of recently published trials. CONCLUSIONS The placebo effect accounted for 68% of the effect in the drug groups. Whereas clinical trials need to control the placebo effect, clinical practice should attempt to use its full power.
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Barrios V, Brommer P, Haag U, Calderón A, Escobar C. Olmesartan Medoxomil plus Amlodipine Increases Efficacy in Patients with Moderate-to-Severe Hypertension after Monotherapy. Clin Drug Investig 2009; 29:427-439. [PMID: 19499960 DOI: 10.2165/00044011-200929070-00001] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Vivencio Barrios
- Department of Cardiology, Hospital Ramón y Cajal, Ctra., De Colmenar km 9, 100, 28034, Madrid, Spain.
| | | | - Uwe Haag
- HaaPACS GmbH, Schriesheim, Germany
| | - Alberto Calderón
- CS Rosa de Luxemburgo, San Sebastian de los Reyes (Madrid), Spain
| | - Carlos Escobar
- Department of Cardiology, Hospital Infanta Sofia, San Sebastian de los Reyes (Madrid), Spain
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Reasons for therapeutic inertia when managing hypertension in clinical practice in non-Western countries. J Hum Hypertens 2008; 23:151-9. [PMID: 18784735 DOI: 10.1038/jhh.2008.117] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Insufficient awareness of hypertension guidelines by physicians may be an impediment to achieving adequate blood pressure (BP) control rates in clinical practice. We therefore conducted an open intervention survey among primary care physicians in 1596 centres from 16 countries in four different continents to prospectively assess what is the BP goal defined by physicians for individual patients and what are the reasons for not intensifying antihypertensive treatment when BP goals are not achieved. Enrolled patients (N=35,302) were either not treated to goal (N=22,887) or previously untreated (N=12,250). Baseline systolic and diastolic BP averaged 159/95+/-15/12 mm Hg. BP goals defined by physicians averaged 136+/-6 mm Hg for systolic and 86+/-5 mm Hg for diastolic BP. Patients' individual risk stratification determined BP goals. At last visit BP averaged 132/81+/-11/8 mm Hg and values of <or=140/90 were reached in 92% of untreated and 80% of previously uncontrolled treated hypertensives. The main reasons for not intensifying antihypertensive treatment when BP remained above goal were the assumption that the time after starting the new drug was too short to attain its full effect, the satisfaction with a clear improvement of BP or with a BP nearing the goal, and the acceptance of good self-measurements. In this open intervention program in primary care, a large proportion of patients achieved recommended BP goals. The belief that a clear improvement in BP is acceptable and that the full drug effect may take up to several weeks to be reached are frequent reasons for treatment inertia when goals are not achieved.
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Rief W, Hofmann SG, Nestoriuc Y. The Power of Expectation - Understanding the Placebo and Nocebo Phenomenon. SOCIAL AND PERSONALITY PSYCHOLOGY COMPASS 2008. [DOI: 10.1111/j.1751-9004.2008.00121.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Benjamin DK, Smith PB, Jadhav P, Gobburu JV, Murphy MD, Hasselblad V, Baker-Smith C, Califf RM, Li JS. Pediatric antihypertensive trial failures: analysis of end points and dose range. Hypertension 2008; 51:829-33. [PMID: 18285612 DOI: 10.1161/hypertensionaha.107.104950] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Historically, drugs prescribed for children have not been studied in pediatric populations. Since 1997, however, a 6-month extension of marketing rights is granted if manufacturers conduct Food and Drug Administration-defined pediatric trials. In nearly half of the drugs studied, there were unexpected results in dosing, safety, or efficacy compared with adult studies, including failure of half of the antihypertensive dose-response trials, which are pivotal for deriving dosing recommendations. We sought to define design elements that might have contributed to these trial failures by combining patient-level data from 6 dose-ranging antihypertensive efficacy trials completed for pediatric exclusivity and submitted to the Food and Drug Administration from 1998 to 2005. We evaluated dosing, primary end point, and other components to assess underlying reasons for failure to show efficacy in children. Of 6 trials examined, 3 showed a dose response; 3 did not. Eligibility criteria were similar across studies, as were subject demographics. Successful studies showed large differences in doses, with little or no overlap between low, medium, and high doses; failed trials used narrow dose ranges with considerable overlap. Successful trials also provided pediatric formulations and used reduction in diastolic, not systolic, blood pressure as the primary end point. Careful attention to pediatric pharmacology and selection of primary end points can improve trial performance. We found poor dose selection, lack of acknowledgement of differences between adult and pediatric populations, and lack of pediatric formulations to be associated with failures. More importantly, our ability to combine data across trials allowed us to evaluate and potentially improve trial design.
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Affiliation(s)
- Daniel K Benjamin
- Office of Pediatric Therapeutics, US Food and Drug Administration, Rockville, MD, USA.
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van Leeuwen JHS, Castro R, Busse M, Bemelmans BLH. The Placebo Effect in the Pharmacologic Treatment of Patients with Lower Urinary Tract Symptoms. Eur Urol 2006; 50:440-52; discussion 453. [PMID: 16753253 DOI: 10.1016/j.eururo.2006.05.014] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Accepted: 05/09/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We reviewed placebo responses in randomised controlled trials (RCTs) for pharmacologic treatment of lower urinary tract symptoms (LUTS), including urinary incontinence (UI), overactive bladder, and benign prostatic hyperplasia. Review papers on placebo effects in non-urologic disorders were assessed to compare the magnitude of placebo responses in drugs for LUTS with those reported for other diseases. METHODS Data were retrieved from registration trials for LUTS drugs on the Web sites of the Food and Drugs Administration and the European Medicines Agency. Reviews were retrieved from Medline using the MeSH term "placebo effect" (English language; published between 1990 and 2005). RESULTS Placebo treatment of LUTS yields reductions in incontinence episodes (IEs) ranging from 32% to 65%, whereas prostate or UI symptom scores are reduced by 9-34%. Genuine drugs decrease IEs by 45-77% and symptom scores by 22-45%. Placebo responses are much lower when objective changes in voided volume or peak flow rate are assessed. CONCLUSIONS The placebo effect in LUTS has a strong behavioural component as patients become aware of their voiding habits and potential risk factors. Symptom severity, treatment naivety, study duration, and interaction with health care providers may also influence it. Proper patient selection, study duration, and objective and subjective outcome measures may better separate genuine treatment effects from artefacts. Observational studies with patients representative for real-life situations and covering a sufficient period of time could allow for better understanding of RCT results and their applicability in clinical practice.
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Maddens M, Imam K, Ashkar A. Hypertension in the Elderly. Prim Care 2005; 32:723-53. [PMID: 16140125 DOI: 10.1016/j.pop.2005.06.002] [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: 11/26/2022]
Abstract
Hypertension is predictive of a wide variety of subsequent adverse events in elderly patients, at least up to the age of 80 years. Treatment can reduce these adverse outcomes, although the benefits in the very elderly remain somewhat unclear. In the very elderly, there appears to be a reduction in cardiovascular events, but this reduction is perhaps at the expense of an increase in overall mortality. Target BPs in the elderly remain controversial. Among patients who have not had previous stroke or significant cardiovascular or renal disease, the benefits of reducing the SBP below 159 mm Hg are well documented. There is some evidence to suggest, however, that if doing so increases the day-night difference in BP by more than 20% or is associated with a decline in DBP below 65 mm Hg, then the benefits of treatment may be attenuated or lost. In addition, there is some suggestion that reducing SBP consistently below 135 mm Hg may accelerate cognitive decline. There appears to be a role for sodium restriction in those who can comply without otherwise compromising nutrient intake. Likewise, exercise may be beneficial and have benefits beyond simply lowering BP. Weight loss in those who are overweight may also help in lowering the BP. For most patients, low-dose thiazides such as hydrochlorothiazide are likely to be the appropriate first-line therapy (even in patients who have diabetes) unless they exacerbate or precipitate urinary incontinence or gout or complicate concomitant drug therapy (eg, lithium treatment of bipolar disorder). In very elderly patients, the apparent beneficial effects on strokes, major cardiovascular events, and heart failure rates may justify treating despite lack of benefit on overall mortality.
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Affiliation(s)
- Michael Maddens
- Division of Geriatric Medicine, William Beaumont Hospital, 3535 West 13 Mile Road, Suite 108, Royal Oak, MI 48073, USA.
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Abstract
Hypertension is a common disorder with well-recognized consequences on the heart, brain, and kidney as target organs. Guidelines espouse a treatment goal of blood pressure reduction to <140 mm Hg for the systolic pressure and <90 mm Hg for the diastolic pressure in most hypertensive patients. In this review, the basis for these recommendations, the practical achievement of these goals in various practice settings, and the risk versus the benefit of achieving such goals in most hypertensive patients are examined.
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Affiliation(s)
- Raymond R Townsend
- Department of Medicine, Renal Electrolyte Hypertension and Stone Division, University of Pennsylvania, Philadelphia, PA 19104, USA.
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