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Concept: Medical ethics


Placebos are widely used in clinical practice in spite of ethical restrictions. Whether such use is justified depends in part on the relative benefit of placebos compared to ‘active’ treatments. A direct test for differences between placebo and ‘active’ treatment effects has not been conducted.

Concepts: Clinical trial, Medical ethics, Medical statistics, Effectiveness, Clinical research, Nocebo, Placebo, Bioethics


Placebo and nocebo effects are embodied psycho-neurobiological responses capable of modulating pain and producing changes at different neurobiological, body at perceptual and cognitive levels. These modifications are triggered by different contextual factors (CFs) presented in the therapeutic encounter between patient and healthcare providers, such as healing rituals and signs. The CFs directly impact on the quality of the therapeutic outcome: a positive context, that is a context characterized by the presence of positive CFs, can reduce pain by producing placebo effects, while a negative context, characterized by the presence of negative CFs, can aggravate pain by creating nocebo effects. Despite the increasing interest about this topic; the detailed study of CFs as triggers of placebo and nocebo effects is still lacked in the management of musculoskeletal pain.Increasing evidence suggest a relevant role of CFs in musculoskeletal pain management. CFs are a complex sets of internal, external or relational elements encompassing: patient’s expectation, history, baseline characteristics; clinician’s behavior, belief, verbal suggestions and therapeutic touch; positive therapeutic encounter, patient-centered approach and social learning; overt therapy, posology of intervention, modality of treatment administration; marketing features of treatment and health care setting. Different explanatory models such as classical conditioning and expectancy can explain how CFs trigger placebo and nocebo effects. CFs act through specific neural networks and neurotransmitters that were described as mediators of placebo and nocebo effects.Available findings suggest a relevant clinical role and impact of CFs. They should be integrated in the clinical reasoning to increase the number of treatment solutions, boosts their efficacy and improve the quality of the decision-making. From a clinical perspective, the mindful manipulation of CFs represents a useful opportunity to enrich a well-established therapy in therapeutic setting within the ethical border. From a translational perspective, there is a strong need of research studies on CFs close to routine and real-world clinical practice in order to underline the uncertainty of therapy action and help clinicians to implement knowledge in daily practice.

Concepts: Psychology, Medicine, Clinical trial, Medical ethics, Neuroscience, Cognition, Nocebo, Placebo


Digital therapeutics are evidence-based behavioral treatments delivered online that can increase accessibility and effectiveness of health care. However, few studies have examined long-term clinical outcomes of digital therapeutics.

Concepts: Health care, Cohort study, Medicine, Public health, Epidemiology, Clinical trial, Medical ethics, The Canon of Medicine


Psychological disorders including depression and anxiety are not rare in primary care clinics. The Patient Health Questionnaire (PHQ) is a clinical diagnostic tool that is widely utilized by primary health care physicians worldwide because it provides a practical in-clinic tool to screen for psychological disorders. This study evaluated the validity of the Arabic version of the PHQ in all six modules including depression, anxiety, somatic, panic, eating, and alcohol abuse disorders.

Concepts: Health care, Psychology, Medicine, Medical ethics, Illness, General practitioner, Major depressive disorder, Primary care


In facing the challenge of taking better care of more patients at lower cost, health care organizations can learn from safety-net systems: one innovation prompted by clinical exigencies, eReferral, offers a new model for integrating primary and specialty care.

Concepts: Health care, Health care provider, Medicine, Health, Clinical trial, Medical ethics, Illness, Economics


Efforts to promote the completion of advance directives implicitly assume that completion rates of these documents, which help ensure care consistent with people’s preferences in the event of incapacity, are undesirably low. However, data regarding completion of advance directives in the United States are inconsistent and of variable quality. We systematically reviewed studies published in the period 2011-16 to determine the proportion of US adults with a completed living will, health care power of attorney, or both. Among the 795,909 people in the 150 studies we analyzed, 36.7 percent had completed an advance directive, including 29.3 percent with living wills. These proportions were similar across the years reviewed. Similar proportions of patients with chronic illnesses (38.2 percent) and healthy adults (32.7 percent) had completed advance directives. The findings provide benchmarks for gauging future policies and practices designed to motivate completion of advance directives, particularly among those people most likely to benefit from having these documents on record.

Concepts: Medicine, Medical ethics, Completeness, Metalogic, Consistency, Health care proxy, Advance health care directive, Five Wishes


Globally, more than 70% of people with mental illness receive no treatment from health care staff. Evidence suggests that factors increasing the likelihood of treatment avoidance or delay before presenting for care include (1) lack of knowledge to identify features of mental illnesses, (2) ignorance about how to access treatment, (3) prejudice against people who have mental illness, and (4) expectation of discrimination against people diagnosed with mental illness. In this article, we reviewed the evidence on whether large-scale anti-stigma campaigns could lead to increased levels of help seeking. (Am J Public Health. Published online ahead of print March 14, 2013: e1-e4. doi:10.2105/AJPH.2012.301056).

Concepts: Health care, Health economics, Medicine, Public health, Health, Epidemiology, Medical ethics, Illness


The integration of frailty measures in clinical practice is crucial for the development of interventions against disabling conditions in older persons. The frailty phenotype (proposed and validated by Fried and colleagues in the Cardiovascular Health Study) and the Frailty Index (proposed and validated by Rockwood and colleagues in the Canadian Study of Health and Aging) represent the most known operational definitions of frailty in older persons. Unfortunately, they are often wrongly considered as alternatives and/or substitutables. These two instruments are indeed very different and should rather be considered as complementary. In the present paper, we discuss about the designs and rationals of the two instruments, proposing the correct ways for having them implemented in the clinical setting.

Concepts: Present, Clinical trial, Medical ethics, Cardiovascular disease, Proposal, Musical instrument, Operational definition


In a Perspective, Joshua Knowles and Euan Ashley discuss the potential for use of genetic risk scores in clinical practice.

Concepts: Medicine, Medical ethics, Cardiovascular disease, Scores


On January 10, 2014, the Centers for Medicare and Medicaid Services (CMS) and the State of Maryland jointly announced the launch of a statewide model that will transform Maryland’s health care delivery system. Although some aspects of the new approach may be unique to Maryland and not applicable elsewhere, both the principles of this model and the process that led to its development may serve as a guide for future federal-state partnership efforts aiming to improve health care and to lower costs through an all-payer approach. Since the late 1970s, Maryland has operated what is now the country’s only all-payer . . .

Concepts: Health care, Medicare, Medicine, Health insurance, Health, Medical ethics, Centers for Medicare and Medicaid Services, Massachusetts