From substance to process: A meta-ethnographic review of how healthcare professionals and patients understand placebos and their effects in primary care.

Research suggests that a 'placebo' can improve conditions common in primary care including pain, depression and irritable bowel syndrome. However, disagreement persists over the definition and clinical relevance of placebo treatments. We conducted a meta-ethnographic, mixed-research systematic review to explore how healthcare professionals and patients understand placebos and their effects in primary care. We conducted systematic literature searches of five databases - augmented by reference chaining, key author searches and expert opinion - related to views on placebos, placebo effects and placebo use in primary care. From a total of 34 eligible quantitative, qualitative and mixed-methods articles reporting findings from 28 studies, 21 were related to healthcare professionals' views, 11 were related to patients' views and two were related to both groups. In the studies under review, healthcare professionals reported using placebos at markedly different frequencies. This was highly influenced by how placebos were defined in the studies. Both healthcare professionals and patients predominantly defined placebos as material substances such as 'inert' pills, despite this definition being inconsistent with current scientific thinking. However, healthcare professionals also, but less prevalently, defined placebos in a different way: as contextual processes. This better concurs with modern placebo definitions, which focus on context, ritual, meaning and enactivism. However, given the enduring ubiquity of substance definitions, for both healthcare professionals and patients, we question the practical, clinical validity of stretching the term 'placebo' towards its modern iteration. To produce 'placebo effects', therefore, primary healthcare professionals may be better off abandoning placebo terminology altogether

Determinants of Newspaper Circulation

This study offers a new approach to the problem of time-series studies and attempts to set up a model to account for the growth in demand for daily newspapers Using U S data on a state-by-state basis for 1850 to 1970, we have used a marketing approach What conditions were necessary for the survival of a daily newspaper? What conditions were conducive to consolidation? What conditions were a barrier to the adoption of social and technological innovation? The data were grouped into geographic and social regions for analysis, using a special case of generalized least squares Independent variables included price as a proportion of per-capita income, percentage of the work force in nonagricultural labor, education, voting, and urbanization. Price proved the most powerful predictor Corrected R2s range from 22636 (m regions where newspaper growth took place very early or late in the period) to 67543 in the Midwest and Southwest The model will be applied to data from the industrialized countries of Western Europe in later workPeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/67057/2/10.1177_009365028000700101.pd

Impure placebo as an unsound concept and other problems in the paper by Howick et al. : [eLetter]

Kommentti artikkeliin Placebo Use in the United Kingdom: Results from a National Survey of Primary Care Practitioners, Plos One 8(3):e58247. doi: 10.1371/journal.pone.0058247Howick et al. have reported the findings of a survey that addressed the use of placebos among primary care practitioners in the United Kingdom. They adopted methodology similar to that used in previous studies performed in other countries; however, the use of this approach also means that they repeated the conceptual confusion of the previous surveys. Therefore the findings are not useful. ... The paper’s main finding “placebos are commonly used in UK primary care” is not correct. Only 0.9% of the responding general practitioners reported using pure placebos frequently. The frequency with which impure placebos are used is irrelevant because the concept is useless, as described above. Misleading a patient by administering inert substances without the explicit consent of the patient is unethical. The authors' proposal to “develop ethical and cost-effective placebos” is not possible because saving money by misleading patients is unethical. There is substantial conceptual confusion in the area of placebo and placebo-effect research, and the paper by Howick et al. does not help to reduce this confusion.Non peer reviewe

Subjunctive medicine: Enacting efficacy in general practice

Modern general practice is complex. Issues such as multimorbidity, polypharmacy and chronic illness management can make applying myriad single condition evidence-based guidelines increasingly difficult. This is compounded because the problems presented in general practice often require both clinical and social solutions. In response to these issues, generalist clinicians are now expected to practise ‘person-centred care’: enabling and empowering patients by combining the technical rationality of medical science with individual values, needs and preferences. To explore this difficult undertaking we conducted an ethnography of a general practice surgery in England, including participant observation, interviews, and focus groups with patients, clinicians, and support staff, from February 2018 to March 2019. Our findings suggest that clinicians in our study faced considerable constraints, broadly conceived as the limits of biomedicine and the structural constraints of general practice. However, they mitigated these by getting into good habits, which we conceive in two categories: using expert judgement and taking patients seriously. We further propose that clinicians did not merely will themselves towards these good habits but developed and adapted them by intuitively adopting a second-order ‘meta’ habit of enaction – treating each consultation as collaboratively co-created anew. This suggests an important feature of the general practice consultation: it is conducted as much in the subjunctive as the indicative mood. Developing this proposition, we propose a more general form of medical practice – subjunctive medicine – extolling the value of the co-created social order of the general practice consultation itself. We suggest that practising subjunctive medicine may help clinicians sustainably and resiliently achieve the aims of person-centred care in modern general practice

What trial participants need to be told about placebo effects to give informed consent: a survey to establish existing knowledge among patients with back pain.

INTRODUCTION: Patients require an accurate knowledge about placebos and their possible effects to ensure consent for placebo-controlled clinical trials is adequately informed. However, few previous studies have explored patients' baseline (ie, pretrial recruitment) levels of understanding and knowledge about placebos. The present online survey aimed to assess knowledge about placebos among patients with a history of back pain. DESIGN: A 15-item questionnaire was constructed to measure knowledge about placebos. Additional questions assessed sociodemographic characteristics, duration and severity of back pain, and previous experience of receiving placebos. SETTING: Participants recruited from community settings completed the study online. RESULTS: 210 participants completed the questionnaire. 86.7% had back pain in the past 6 months, 44.3% currently had back pain. 4.3% had received a placebo intervention as part of a clinical trial and 68.1% had previously read or heard information about placebos. Overall knowledge of placebos was high, with participants on average answering 12.07 of 15 questions about placebos correctly (SD=2.35). However, few participants correctly answered questions about the nocebo effect (31.9% correct) and the impact of the colour of a placebo pill (55.2% correct). CONCLUSIONS: The findings identified key gaps in knowledge about placebos. The lack of understanding of the nocebo effect in particular has implications for the informed consent of trial participants. Research ethics committees and investigators should prioritise amending informed consent procedures to incorporate the fact that participants in the placebo arm might experience adverse side effects

Supporting informed choice in acupuncture: effects of a new person-, evidence- and theory-based website for patients with back pain.

OBJECTIVES: To test whether a newly developed person-, theory- and evidence-based website about acupuncture helps patients make informed decisions about whether or not to use acupuncture for back pain. METHODS: A randomised online study compared a newly developed 'enhanced website' to a 'standard website'. The enhanced website provided evidence-based information in a person-based manner and targeted psychological constructs. The standard website was based on a widely used patient information leaflet. In total, 350 adults with recent self-reported back pain were recruited from general practices in South West England. The two primary outcomes were knowledge change and making an informed choice about using acupuncture. Secondary outcomes were beliefs about and willingness to have acupuncture. RESULTS: Participants who viewed the enhanced acupuncture website had a significantly greater increase in knowledge about acupuncture (M = 1.1, standard deviation (SD) = 1.7) than participants who viewed the standard website (M = 0.2, SD = 1.1; F(1, 315) = 37.93, p < 0.001, η2 = .107). Participants who viewed the enhanced acupuncture website were also 3.3 times more likely to make an informed choice about using acupuncture than those who viewed the standard website (χ2(1) = 23.46, p < 0.001). There were no significant effects on treatment beliefs or willingness to have acupuncture. CONCLUSION: The enhanced website improved patients' knowledge and ability to make an informed choice about acupuncture, but did not optimise treatment beliefs or change willingness to have acupuncture. The enhanced website could be used to support informed decision-making among primary care patients and members of the general public considering using acupuncture for back pain

Informing Adults With Back Pain About Placebo Effects: Randomized Controlled Evaluation of a New Website With Potential to Improve Informed Consent in Clinical Research.

BACKGROUND: Placebo effects and their underpinning mechanisms are increasingly well understood. However, this is poorly communicated to participants in placebo-controlled trials. For valid informed consent, participants should be informed about the potential benefits and risks of participating in placebo-controlled trials. Existing information leaflets often fail to describe the potential benefits and adverse effects associated with placebo allocation. This study tested the effects of a new website designed to inform patients about placebo effects (The Power of Placebos, PoP). PoP was designed using qualitative methods in combination with theory- and evidence-based approaches to ensure it was engaging, informative, and addressed patients' concerns. OBJECTIVE: This study aimed to test the effects of PoP, compared with a control website, on people's knowledge about placebo and the ability to make an informed choice about taking part in a placebo-controlled trial. METHODS: A total of 350 adults with back pain recruited from 26 general practices in Southern England participated in this Web-based study. Participants were randomly assigned to PoP (which presented scientifically accurate information about placebo effects in an engaging way) or a control website (based on existing information leaflets from UK trials). Participants self-completed Web-based pre- and postintervention questionnaire measures of knowledge about placebo effects and preintervention questionnaire measures of attitudes toward and intentions to participate in a placebo-controlled trial. The 2 primary outcomes were (1) knowledge and (2) informed choice to take part in a placebo-controlled trial (computed from knowledge, attitudes, and intentions). RESULTS: After viewing PoP, participants had significantly greater knowledge about placebos (mean 8.28 [SD 1.76]; n=158) than participants who viewed the control (mean 5.60 [SD 2.24]; n=174; F1,329=173.821; P<.001; η2=.346). Participants who viewed PoP were 3.16 times more likely than those who viewed the control to make an informed choice about placebos (χ21=36.5; P<.001). CONCLUSIONS: In a sample of adults with back pain, PoP increased knowledge and rates of informed choice about placebos compared with a control website. PoP could be used to improve knowledge about placebo effects in back pain. After essential further development and testing in clinical trial settings, it could support informed consent in placebo-controlled trials

A Risk Management Approach to the “Insider Threat”

Recent surveys indicate that the financial impact and operating losses due to insider intrusions are increasing. But these studies often disagree on what constitutes an "insider;" indeed, many define it only implicitly. In theory, appropriate selection of, and enforcement of, properly specified security policies should prevent legitimate users from abusing their access to computer systems, information, and other resources. However, even if policies could be expressed precisely, the natural mapping between the natural language expression of a security policy, and the expression of that policy in a form that can be implemented on a computer system or network, creates gaps in enforcement. This paper defines "insider" precisely, in terms of these gaps, and explores an access-based model for analyzing threats that include those usually termed "insider threats." This model enables an organization to order its resources based on the business value for that resource and of the information it contains. By identifying those users with access to high-value resources, we obtain an ordered list of users who can cause the greatest amount of damage. Concurrently with this, we examine psychological indicators in order to determine which users are at the greatest risk of acting inappropriately. We conclude by examining how to merge this model with one of forensic logging and auditing

Evidence for a narrow dip structure at 1.9 GeV/c2^2 in 3π+3π−3\pi^+ 3\pi^- diffractive photoproduction

A narrow dip structure has been observed at 1.9 GeV/c$^2$ in a study of diffractive photoproduction of the $~3\pi^+3\pi^-$ final state performed by the Fermilab experiment E687.Comment: The data of Figure 6 can be obtained by downloading the raw data file e687_6pi.txt. v5 (2nov2018): added Fig. 7, the 6 pion energy distribution as requested by a reade