Perioperative intravenous lidocaine in thoracoscopic surgery for improved postoperative pain control: a randomized, placebo-controlled, double-blind, superiority trial.

Background: Pain, including associated pain management, remains a burden on patients after thoracic surgery. Our objective was to investigate whether perioperative intravenous administration of lidocaine reduces postoperative morphine consumption and pain intensity after video-assisted thoracoscopic surgery (VATS). Methods: In this double-blind, placebo-controlled superiority trial, patients undergoing VATS with a planned duration of ≤90 minutes were randomized within an intention-to-treat setting. Patients received either intravenous lidocaine or placebo as a bolus of 1.5 mg/kg 30 minutes before incision, followed by a continuous infusion of 3.0 mg/kg/hour until 2 hours after skin closure. Pain and morphine consumption were evaluated when resting and when coughing 1, 2, 4, 8, 16, 24, and 48 hours after skin closure and in a follow-up 14, 90, and 180 days postoperatively. Results: Twenty-eight patients were included in the lidocaine group, 24 in the placebo group. Patients' characteristics and preoperative pain scores were similar in both groups. When coughing, patients of the lidocaine group had less pain within 24 hours after skin closure than the placebo group (4.60±1.64 vs. 5.52±1.65; P=0.02). Morphine consumption was not statistically significantly lower in lidocaine group (18.22±12.87 vs. 21.26±9.39 mg; P=0.26). There were no significant differences between groups in secondary outcomes. Conclusions: Our results suggest that perioperative intravenous lidocaine administration reduces pain scores after VATS. The beneficial clinical effects are limited. Nevertheless, intravenous lidocaine may be helpful as part of a multimodal analgesia protocol or with patients in whom the use of other analgesics is contraindicated. Trial Registration: ClinicalTrials.gov NCT03677817.

Boosting open-label placebo effects in acute induced pain in healthy adults (BOLPAP-study): study protocol of a randomized controlled trial.

Introduction: Pain is a highly prevalent symptom in the hospital setting, but treatment options remain limited. Harnessing the placebo effect in an ethical manner could provide a new possibility to reduce pain in clinical practice. So called open-label placebos (OLP) have been shown to elicit significant effects in reducing acute pain. But, before implementation, more knowledge concerning the properties of OLPs is needed. This study aims to assess the duration of analgesic effects from OLP and to determine the possibility of boosting such effects. Methods and analysis: This is the protocol of an ongoing (first patient enrolled in March 2023) single-site randomized trial investigating OLPs in two parts (i.e., substudies). In both parts, pain will be induced in healthy adults using an intradermal electrical stimulation model. Participants in Part 1 will have two study visits: An interventional visit with one OLP injection accompanied by an evidence-based treatment rationale and a control visit with no treatment. For Part 2, participants will be randomized into three groups: (1) A fixed-time "Booster" group including one single repetition of the OLP injection at a fixed time point, (2) an on-demand "Booster" group including one single repetition of the OLP injection on-demand, and (3) a control group who will receive just one OLP injection. Differences in pain ratings over time (using the Numeric Rating Scale) will be analyzed with several two-sample t-tests. The time point for a fixed-time "Booster" in Part 2 will be derived from Part 1 with additional statistical tools such as a broken-stick mixed-effect model. Discussion: This study aims to further characterize the analgesic effects of OLPs. In doing so, it will provide valuable information needed for later implementation of OLPs in clinical practice, where they could play a role in multimodal analgesic concepts. Ethics and dissemination: The "Ethikkommission Nordwest- und Zentralschweiz" (BASEC 2023-00296) approved the study protocol. Results of the analysis will be submitted for publication in a peer-reviewed journal. Clinical Trial Registration: This study is registered at ClinicalTrials.gov (NCT05819476) and is listed in the Swiss National Registry at kofam.ch (SNCTP000005470).

Targeted Preparation and NMR Spectroscopic Characterization of Lys11-Linked Ubiquitin Trimers.

Ubiquitylation refers to the attachment of mono- or poly-ubiquitin molecules to a substrate protein. To shield ubiquitin chains against potential hydrolysis, a facile, click-chemistry based approach was recently established for the generation of site-specifically conjugated ubiquitin dimers relying on triazole-linkage. Here, the preparation of such ubiquitin chains was advanced by the generation of homotypic Lys11-linked ubiquitin trimers considering an isotopic labeling scheme in a moiety-wise manner. The structural and dynamical impact on the ubiquitin unit at proximal, central, or distal position that is potentially invoked by the respective other two moieties was systematically probed by heteronuclear high-resolution NMR spectroscopic approaches. As a result, conjugating a third ubiquitin moiety to the proximal or distal site of a ubiquitin dimer does not alter structural and dynamical characteristics as it has been seen for ubiquitin dimers. This observation suggests that recognition of a homotypically assembled ubiquitin chain by a potential substrate is primarily done by screening the length of a ubiquitin chain rather than relying on subtle changes in structure or dynamic properties of single ubiquitin moieties composing the chain.

Simultaneous application of lidocaine and ketamine during ambulatory infusion therapy: a retrospective analysis.

Background: Infusions with lidocaine or ketamine have been separately established in the treatment of chronic pain. This study aims to retrospectively evaluate the effect of combined infusions of lidocaine and ketamine. Materials & methods: Patient records were screened for receipt of combined ambulatory infusions of lidocaine and ketamine from 2012 through 2021. A scoring system was designed to assess pain response retrospectively. Results: A total of 319 patients were included. Median pain reduction in days was 10.00 (interquartile range: 13.25). Side effects were limited to the acute phase of infusions. A total of 41.4% of patients who received concomitant pain medication reported a dose reduction. Conclusion: Our data support combined infusions as a safe therapy option, with good short-, medium- and long-term reductions in pain and great heterogeneity in treatment response. Clinical trial registration: ClinicalTrials.gov (NCT05103319).

What is this study about? This study examined data of patients with chronic pain who received an infusion at our hospital with two drugs, lidocaine and ketamine, in an effort to reduce pain. We examined the records of 319 patients and a total of 2995 infusion protocols to gather our data. We wanted to know how much and for how long pain was reduced by these infusions. Additionally, we tried to identify the specific features of patients who profited the most during our infusions. We also had a look at the side effects of the infusions and wanted to know if patients could reduce their daily pain medication intake when receiving infusions. What were the results? On average, people had less pain for 10 days after the infusions. Women seemed to benefit more than men. Otherwise, we were unable to identify specific features that predicted how much a patient would benefit. Side effects occurred only during the infusions and for a short period afterward. In addition, 41.4% of patients who took pain medication daily were able to reduce their intake. What do the results mean? These results support our clinical experience that infusions with lidocaine and ketamine are safe and can contribute to reduced pain in patients with chronic pain, at least in the short term, and for some patients even longer.

Specifying conformational heterogeneity of multi-domain proteins at atomic resolution.

The conformational landscape of multi-domain proteins is inherently linked to their specific functions. This also holds for polyubiquitin chains that are assembled by two or more ubiquitin domains connected by a flexible linker thus showing a large interdomain mobility. However, molecular recognition and signal transduction are associated with particular conformational substates that are populated in solution. Here, we apply high-resolution NMR spectroscopy in combination with dual-scale MD simulations to explore the conformational space of K6-, K29-, and K33-linked diubiquitin molecules. The conformational ensembles are evaluated utilizing a paramagnetic cosolute reporting on solvent exposure plus a set of complementary NMR parameters. This approach unravels a conformational heterogeneity of diubiquitins and explains the diversity of structural models that have been determined for K6-, K29-, and K33-linked diubiquitins in free and ligand-bound states so far. We propose a general application of the approach developed here to demystify multi-domain proteins occurring in nature.

Predicting chaotic statistics with unstable invariant tori.

It has recently been speculated that long-time average quantities of hyperchaotic dissipative systems may be approximated by weighted sums over unstable invariant tori embedded in the attractor, analogous to equivalent sums over periodic orbits, which are inspired by the rigorous periodic orbit theory and which have shown much promise in fluid dynamics. Using a new numerical method for converging unstable invariant two-tori in a chaotic partial differential equation (PDE), and exploiting symmetry breaking of relative periodic orbits to detect those tori, we identify many quasiperiodic, unstable, invariant two-torus solutions of a modified Kuramoto-Sivashinsky equation. The set of tori covers significant parts of the chaotic attractor and weighted averages of the properties of the tori-with weights computed based on their respective stability eigenvalues-approximate average quantities for the chaotic dynamics. These results are a step toward exploiting higher-dimensional invariant sets to describe general hyperchaotic systems, including dissipative spatiotemporally chaotic PDEs.

Jacobian-free variational method for computing connecting orbits in nonlinear dynamical systems.

One approach for describing spatiotemporal chaos is to study the unstable invariant sets embedded in the chaotic attractor of the system. While equilibria, periodic orbits, and invariant tori can be computed using existing methods, the numerical identification of heteroclinic and homoclinic connections between them remains challenging. We propose a robust matrix-free variational method for computing connecting orbits between equilibrium solutions. Instead of a common shooting-based approach, we view the identification of a connecting orbit as a minimization problem in the space of smooth curves in the state space that connect the two equilibria. In this approach, the deviation of a connecting curve from an integral curve of the vector field is penalized by a non-negative cost function. Minimization of the cost function deforms a trial curve until, at a global minimum, a connecting orbit is obtained. The method has no limitation on the dimension of the unstable manifold at the origin equilibrium and does not suffer from exponential error amplification associated with time-marching a chaotic system. Owing to adjoint-based minimization techniques, no Jacobian matrices need to be constructed. Therefore, the memory requirement scales linearly with the size of the problem, allowing the method to be applied to high-dimensional dynamical systems. The robustness of the method is demonstrated for the one-dimensional Kuramoto-Sivashinsky equation.

Optimized Electrical Stimulation of C-Nociceptors in Humans Based on the Chronaxie of Porcine C-Fibers.

Classically, to electrically excite C-nociceptors, rectangular pulses are used with a duration close to the estimated chronaxie of C-fibres (about 2 ms). Recent results using slow depolarizing stimuli suggest longer chronaxies. We therefore set out to optimize C-fiber stimulation based on recordings of single C-nociceptors in-vivo and C-fiber compound-action-potentials (C-CAP) ex-vivo using half-sine shaped stimuli of durations between 1 and 250ms. Single fiber (n = 45) recording in pigs revealed high chronaxie values for C-touch fibers (15.8 ms), polymodal- (14.2 ms) and silent-nociceptors (16.8 ms). Activation thresholds decreased 2 to 3-fold in all fibre classes when increasing the duration of half-sine pulses from 1 to 25 ms (P < .05). C-CAPs strength-duration curves of the pig saphenous nerve (n = 7) showed the highest sensitivity for half-sine durations between 10 and 25 ms. Half-maximum currents for C-CAPS were reduced 3-fold compared to rectangular pulses (P < .01) whereas the opposite was found for A-fiber compound action potentials. Psychophysics in humans (n = 23) revealed that half-sine stimulus durations >10 ms reduced detection thresholds, pain thresholds, and stimulus current amplitudes required to generate a pain rating of 3 on an 11-point Numeric Rating Scale (NRS) as compared to 1 ms rectangular pulses (P < 0.05). Increasing the duration from 1 to 25 ms led to a 4-fold amplitude reduction for pain-thresholds and stimuli caused an axon-reflex flare. Excitability of single polymodal nociceptors in animals paralleled human psychophysics and we conclude optimized half-sine pulses facilitate C-nociceptor activation. PERSPECTIVE: Electrical stimulation with longer lasting half-sine wave pulses preferentially activates C-nociceptors and changes in the strength duration curve may identify nociceptor hyperexcitability in patients with neuropathic pain.

Invariant tori in dissipative hyperchaos.

One approach to understand the chaotic dynamics of nonlinear dissipative systems is the study of non-chaotic yet dynamically unstable invariant solutions embedded in the system's chaotic attractor. The significance of zero-dimensional unstable fixed points and one-dimensional unstable periodic orbits capturing time-periodic dynamics is widely accepted for high-dimensional chaotic systems, including fluid turbulence, while higher-dimensional invariant tori representing quasiperiodic dynamics have rarely been considered. We demonstrate that unstable 2-tori are generically embedded in the hyperchaotic attractor of a dissipative system of ordinary differential equations; tori can be numerically identified via bifurcations of unstable periodic orbits and their parameteric continuation and characterization of stability properties are feasible. As higher-dimensional tori are expected to be structurally unstable, 2-tori together with periodic orbits and equilibria form a complete set of relevant invariant solutions on which to base a dynamical description of chaos.

Electrostatic and steric effects underlie acetylation-induced changes in ubiquitin structure and function.

Covalent attachment of ubiquitin (Ub) to proteins is a highly versatile posttranslational modification. Moreover, Ub is not only a modifier but itself is modified by phosphorylation and lysine acetylation. However, the functional consequences of Ub acetylation are poorly understood. By generation and comprehensive characterization of all seven possible mono-acetylated Ub variants, we show that each acetylation site has a particular impact on Ub structure. This is reflected in selective usage of the acetylated variants by different E3 ligases and overlapping but distinct interactomes, linking different acetylated variants to different cellular pathways. Notably, not only electrostatic but also steric effects contribute to acetylation-induced changes in Ub structure and, thus, function. Finally, we provide evidence that p300 acts as a position-specific Ub acetyltransferase and HDAC6 as a general Ub deacetylase. Our findings provide intimate insights into the structural and functional consequences of Ub acetylation and highlight the general importance of Ub acetylation.

Analgesic benefit of metamizole and ibuprofen vs. either medication alone: a randomized clinical trial.

BACKGROUND: Postoperative pain relief remains a key problem after surgery. Multimodal pain therapy has proven beneficial in alleviating pain to a certain extent. However, when combining non-opioids, the focus has been on NSAIDs and paracetamol, but effects of combined use are only moderate. Metamizole could be a potent adjunct, due to its preclusion in several countries, data on its combined use are sparse, despite its common use in many countries. The aim of this study was to examine whether the combination of metamizole and ibuprofen is superior in relieving postoperative pain to either drug alone. METHODS: For this randomized, placebo-controlled, cross-over study, 35 patients undergoing bilateral lower third molar extraction were randomized. Each patient received three applications of 1000 mg metamizole + 400 mg ibuprofen for surgery on one side and either 1000 mg metamizole + placebo or 400 mg ibuprofen + placebo on the other side. Pain ratings, rescue-medication (tramadol), and sleep were assessed for 18 hours. RESULTS: The combined treatment of metamizole and ibuprofen showed lower mean pain scores over 12 hours than ibuprofen (2.4±1.3 vs 3.8±1.6; P=0.005). Further, combined treatment showed lower mean pain scores over 6 hours than ibuprofen (2.0±1.2 vs. 3.1±1.6; P=0.022) or metamizole alone (2.0±1.2 vs. 3.3±1.7; P=0.015). Consumption of rescue medication was lowest in the combination-group (25% vs. 46%-metamizole; 50%-ibuprofen). The trial was stopped prematurely as the COVID-pandemic halted elective surgeries. CONCLUSIONS: Combined use enables superior pain control compared to ibuprofen after molar extraction and tends to be superior to metamizole alone. The premature study-termination may overestimate this effect.

Direct conversion of white phosphorus to versatile phosphorus transfer reagents via oxidative onioation.

The main feedstock for the value-added phosphorus chemicals used in industry and research is white phosphorus (P4), from which the key intermediate for forming P(III) compounds is PCl3. Owing to its high reactivity, syntheses based on PCl3 are often accompanied by product mixtures and laborious work-up procedures, so an alternative process to form a viable P(III) transfer reagent is desirable. Our concept of oxidative onioation, where white phosphorus is selectively converted into triflate salts of versatile P1 transfer reagents such as [P(LN)3][OTf]3 (LN is a cationic, N-based substituent; that is, 4-dimethylaminopyridinio), provides a convenient alternative for the implementation of P-O, P-N and P-C bonds while circumventing the use of PCl3. We use p-block element compounds of type RnE (for example, Ph3As or PhI) to access weak adducts between nitrogen Lewis bases LN and the corresponding dications [RnELN]2+. The proposed equilibrium between [RnELN]2+ + LN and [RnE(LN)2]2+ allows for the complete oxidative onioation of all six P-P bonds in P4 to yield highly reactive and versatile trications [P(LN)3]3+.

Pain response to cannabidiol in opioid-induced hyperalgesia, acute nociceptive pain, and allodynia using a model mimicking acute pain in healthy adults in a randomized trial (CANAB II).

ABSTRACT: Opioids in general and remifentanil in particular can induce hyperalgesia. Preclinical data suggest that cannabidiol might have the capacity to reduce opioid-induced hyperalgesia (OIH). Thus, we investigated the effect of oral cannabidiol on OIH in healthy volunteers using an established pain model. Twenty-four healthy participants were included in this randomized, double-blinded, crossover study and received either a 1600-mg single-dose oral cannabidiol or placebo. Hyperalgesia, allodynia, and pain were induced by intracutaneous electrical stimulation. To provoke OIH, participants recieved an infusion of 0.1 µg/kg/min remifentanil over a time frame of 30 minutes, starting 100 minutes after oral cannabidiol ingestion. The primary outcome was the area of hyperalgesia (in square centimetres) up to 60 minutes after remifentanil administration. The area of allodynia (in square centimetres) and pain (numeric rating scale) were also assessed.Cannabidiol had no significant effect on hyperalgesia, allodynia, or pain at any time point of measurement compared with placebo. The area of hyperalgesia after remifentanil administration significantly increased compared with baseline (17.0 cm 2 [8.1-28.7] vs 25.3 cm 2 [15.1-39.6]; P = 0.013). Mean cannabidiol blood levels were 4.1 ± 3.0 µg/L (mean ± SD) at 130 minutes after ingestion and were 8.2 µg/L ± 6.9 µg/L (mean ± SD) at 200 minutes. Cannabidiol was well tolerated. We conclude that a high single-oral dose of 1600-mg cannabidiol is not effective in reducing OIH. Before excluding an effect of cannabidiol on OIH, research should focus on drug formulations enabling higher cannabidiol concentrations.

Prolonged drying trend coincident with the demise of Norse settlement in southern Greenland.

Declining temperature has been thought to explain the abandonment of Norse settlements, southern Greenland, in the early 15th century, although limited paleoclimate evidence is available from the inner settlement region itself. Here, we reconstruct the temperature and hydroclimate history from lake sediments at a site adjacent to a former Norse farm. We find no substantial temperature changes during the settlement period but rather that the region experienced a persistent drying trend, which peaked in the 16th century. Drier climate would have notably reduced grass production, which was essential for livestock overwintering, and this drying trend is concurrent with a Norse diet shift. We conclude that increasingly dry conditions played a more important role in undermining the viability of the Eastern Settlement than minor temperature changes.

Human practices behind the aquatic and terrestrial ecological decoupling to climate change in the tropical Andes.

Anthropogenic climate change and landscape alteration are two of the most important threats to the terrestrial and aquatic ecosystems of the tropical Americas, thus jeopardizing water and soil resources for millions of people in the Andean nations. Understanding how aquatic ecosystems will respond to anthropogenic stressors and accelerated warming requires shifting from short-term and static to long-term, dynamic characterizations of human-terrestrial-aquatic relationships. Here we use sediment records from Lake Llaviucu, a tropical mountain Andean lake long accessed by Indigenous and post-European societies, and hypothesize that under natural historical conditions (i.e., low human pressure) vegetation and aquatic ecosystems' responses to change are coupled through indirect climate influences-that is, past climate-driven vegetation changes dictated limnological trajectories. We used a multi-proxy paleoecological approach including drivers of terrestrial vegetation change (pollen), soil erosion (Titanium), human activity (agropastoralism indicators), and aquatic responses (diatoms) to estimate assemblage-wide rates of change and model their synchronous and asynchronous (lagged) relationships using Generalized Additive Models. Assemblage-wide rate of change results showed that between ca. 3000 and 400 calibrated years before present (cal years BP) terrestrial vegetation, agropastoralism and diatoms fluctuated along their mean regimes of rate of change without consistent periods of synchronous rapid change. In contrast, positive lagged relationships (i.e., asynchrony) between climate-driven terrestrial pollen changes and diatom responses (i.e., asynchrony) were in operation until ca. 750 cal years BP. Thereafter, positive lagged relationships between agropastoralism and diatom rates of changes dictated the lake trajectory, reflecting the primary control of human practices over the aquatic ecosystem prior European occupation. We interpret that shifts in Indigenous practices (e.g., valley terracing) curtailed nutrient inputs into the lake decoupling the links between climate-driven vegetation changes and the aquatic community. Our results demonstrate how rates of change of anthropogenic and climatic influences can guide dynamic ecological baselines for managing water ecosystem services in the Andes.

Constructing periodic orbits of high-dimensional chaotic systems by an adjoint-based variational method.

Chaotic dynamics in systems ranging from low-dimensional nonlinear differential equations to high-dimensional spatiotemporal systems including fluid turbulence is supported by nonchaotic, exactly recurring time-periodic solutions of the governing equations. These unstable periodic orbits capture key features of the turbulent dynamics and sufficiently large sets of orbits promise a framework to predict the statistics of the chaotic flow. Computing periodic orbits for high-dimensional spatiotemporally chaotic systems remains challenging as known methods either show poor convergence properties because they are based on time-marching of a chaotic system causing exponential error amplification, or they require constructing Jacobian matrices which is prohibitively expensive. We propose a new matrix-free method that is unaffected by exponential error amplification, is globally convergent, and can be applied to high-dimensional systems. The adjoint-based variational method constructs an initial value problem in the space of closed loops such that periodic orbits are attracting fixed points for the loop dynamics. We introduce the method for general autonomous systems. An implementation for the one-dimensional Kuramoto-Sivashinsky equation demonstrates the robust convergence of periodic orbits underlying spatiotemporal chaos. Convergence does not require accurate initial guesses and is independent of the period of the respective orbit.

Sediment Soot Radiocarbon Indicates that Recent Pollution Controls Slowed Fossil Fuel Emissions in Southeastern China.

Fossil fuel (FF) combustion emissions account for a large, but uncertain, amount of the soot in the atmosphere, play an important role in climate change, and adversely affect human health. However, historical estimates of FF contributions to air pollution are limited by uncertainties in fuel usage and emission factors. Here, we constrained FF soot emissions from southeastern China over the past 110 years, based on a novel radiocarbon method applied to sedimentary soot. The reconstructed soot accumulations reflect the integrated effects of increased FF use caused by economic development and reductions in emissions due to pollution controls. A sharp increase in FF soot started in 1950 as southeastern China industrialized and developed economically, but decreased FF soot fluxes in recent years suggest that pollution controls reduced soot emissions. We compare FF soot history to changes in CO2 emissions, industrial and economic activities, and pollution controls and show that FF soot fluxes are more readily controlled than atmospheric CO2. Our independent FF soot record provides insights into the effects of economic development and controls on air pollution and the environmental impacts from the changes in soot emissions.

Pain response to cannabidiol in induced acute nociceptive pain, allodynia, and hyperalgesia by using a model mimicking acute pain in healthy adults in a randomized trial (CANAB I).

ABSTRACT: Preclinical studies have demonstrated the analgesic potential of cannabidiol (CBD). Those suggesting an effect on pain-processing receptors have brought CBD back into focus. This study assessed the effect of CBD on acute pain, hyperalgesia, and allodynia compared with placebo. Twenty healthy volunteers were included in this randomized, placebo-controlled, double-blinded, crossover study assessing pain intensities (using numeric rating scale), secondary hyperalgesia (von Frey filament), and allodynia (dry cotton swab) in a well-established acute pain model with intradermal electrical stimulation. The authors compared the effect of 800-mg orally administered CBD on pain compared with placebo. They further examined the effect on hyperalgesia and allodynia. Cannabidiol whole blood levels were also measured. Pain ratings (mean ± SD) did not differ significantly after CBD application compared with placebo (5.2 ± 0.7 vs 5.3 ± 0.7, P-value 0.928), neither did the areas of hyperalgesia and allodynia differ significantly after CBD application compared with placebo (hyperalgesia 23.9 ± 19.2 cm2 vs 27.4 ± 17.0 cm2, P-value 0.597; allodynia 16.6 ± 13.1 cm2 vs 17.3 ± 14.1 cm2, P-value 0.884). The CBD whole blood level (median, first to third quartile) was 2.0 µg/L (1.5-5.1) 60 minutes and 5.0 µg/L (4.0-10.4) 130 minutes after CBD application. Although the oral application of 800-mg CBD failed to show a significant effect, it is important to focus future research on different dosing, routes of administration, and CBD as a part of multimodal treatment strategies before negating its effects on acute pain.

The Episodic Prototypes Model (EPM): On the nature and genesis of facial representations.

Faces undergo massive changes over time and life events. We need a mental representation which is flexible enough to cope with the existing visual varieties, but which is also stable enough to be the basis for valid recognition. Two main theoretical frameworks exist to describe facial representations: prototype models assuming one central item comprising all visual experiences of a face, and exemplar models assuming single representations of each visual experience of a face. We introduce a much more ecological valid model dealing with episodic prototypes (the Episodic Prototypes Model-EPM), where faces are represented by a low number of prototypes that refer to specific Episodes of Life (EoL, e.g., early adulthood, mature age) during which the facial appearance shows only moderate variation. Such an episodic view of mental representation allows for efficient storage, as the number of needed prototypes is relatively low, and it allows for the needed variation within a prototype that keeps the everyday and steadily ongoing changes across a certain period of time. Studies 1-3 provide evidence that facial representations are highly dependent on temporal aspects which is in accord with EoL, and that individual learning history generates the structure and content of respective prototypes. In Study 4, we used implicit measures (RT) in a face verification task to investigate the postulated power of the EPM. We could demonstrate that episodic prototypes clearly outperformed visual depictions of exhaustive prototypes, supporting the general idea of our approach.

Open-Label Placebo Treatment for Acute Postoperative Pain (OLP-POP Study): Study Protocol of a Randomized Controlled Trial.

Introduction: Open-label placebos have been proposed as way of using long recognized analgesic placebo effects in an ethical manner. Recent evidence shows efficacy of open-label placebos for clinical conditions, but there is need for more research on open-label placebos in acute pain. In the treatment of acute postoperative pain, minimization of opioid related side effects remains one of the key challenges. Therefore, this study aims at investigating the potential of adding unconditioned open-label placebos to treatment as usual as a means of reducing opioid consumption and its related side effects in patients with acute postoperative pain. Methods and Analysis: This is the protocol of an ongoing single site randomized controlled trial. The first patient was enrolled in May 2020. In total, 70 patients suffering from acute postoperative pain following dorsal lumbar interbody fusion are randomized to either a treatment as usual group or an experimental intervention group. The treatment as usual group consists of participants receiving a patient-controlled morphine pump. On day 1 and 2 post-surgery, patients in the intervention group receive, in addition to treatment as usual, two open-label placebo injections per day along with an evidence-based treatment rationale explaining the mechanisms of placebos. The primary outcome is measured by means of self-administered morphine during day 1 and 2 post-surgery. Several other outcome measures including pain intensity and adverse events as well as potential predictors of placebo response are assessed. Analysis of covariance will be used to answer the primary research question and additional statistical techniques such as generalized linear mixed models will be applied to model the temporal course of morphine consumption. Discussion: This study will provide valuable insights into the efficacy of open-label placebos in acute pain and will potentially constitute an important step toward the implementation of open-label placebos in the clinical management of acute postoperative pain. In addition, it will shed light on a cost-efficient and patient-centered strategy to reduce opioid consumption and its related side effects, without any loss in pain management efficacy. Ethics and Dissemination: The "Ethikkommission Nordwest- und Zentralschweiz" (BASEC2020-00099) approved the study protocol. Results of the analysis will be submitted for publication in a peer-reviewed journal. Clinical Trial Registration: The study is registered at ClinicalTrials.gov (NCT04339023) and is listed in the Swiss national registry at kofam.ch (SNCTP000003720).