The Nocebo Effect: A Bias in Clinical Practice-An Ethical Approach.

BACKGROUND: The nocebo effect is often disregarded in medical practice and is certainly much less known than the placebo effect, although, in reality, both can influence therapeutic decision making and the quality of life of patients. However, the nocebo effect raises a number of issues not only of a practical nature related to clinical activity but also ethical dilemmas related to the observance of the patient's autonomy, nonmaleficence, or informed consent and the information on which it is based. AREAS OF UNCERTAINTY: The ethical dilemmas raised by the nocebo effect revolve around how informed consent can be achieved, the accuracy and volume of information that is transmitted to the patient, and how to report negative side effects of therapeutic treatment. DATA SOURCES: In September 2023, a narrative analysis of the literature was conducted using a combination of keywords such as nocebo, placebo, ethics, therapeutic relationship from PubMed, Scopus, Google Scholar, and so on, as well as from official documents developed at an international level (World Health Organization), for a period of 10 years (2012-2021). RESULTS: Analyzing the articles that remarked upon the significant impact of ethics in nocebo research or in the therapeutic relationship, we can state that the existence of several relevant issues of interest have been detected regarding the ethical use of nocebo and its impact in research or in clinics and thus the need for proper knowledge and management of the impact of nocebo effects. The ethical paradox of obtaining informed consent with the 2 goals, first, the need for complete information and second, the preservation of the autonomy of the patient, respectively, that of "primum non-nocere" and of avoiding unnecessary harm by revealing probable adverse effects is a point of interest for numerous studies. The potential for a nocebo effect is present when we inform patients about the risks and benefits of treatment, there being a clear link between the moral and ethical duty to inform patients and the need to avoid situations that increase the nocebo impact on how the disease or the adverse effects of the treatment are perceived. Adapting information about the side effects of medicines should focus on ensuring a balance between transparency and caution, especially in patients with a high potential for nocebo effect. CONCLUSIONS: The nocebo effect had for a long time been unknown or denied, although it can interfere with the results of the treatment used. As the nocebo phenomenon becomes increasingly known in medical practice, the clinical and ethical implications are identified by medical staff, and nocebo's adverse responses are no longer ignored.

Inappropriate Use of Emergency Services from the Perspective of Primary Care Underutilization in a Local Romanian Context: A Cross-Sectional Study.

Background: The underutilization of primary care services is a possible factor influencing inappropriate emergency service presentations. The objective of this study was to evaluate the proportion and characteristics of patients inappropriately accessing emergency room services from the perspective of primary care underutilization. Methods: This cross-sectional study included patients who visited the emergency room of a County Hospital, initially triaged with green, blue, or white codes, during a 2-week period in May 2017. Two primary care physicians performed a structured analysis to correlate the initial diagnosis in the emergency room with the final diagnosis to establish whether the patient's medical complaints could have been resolved in primary care. Results: A total of 1269 adult patients were included in this study. In total, the medical problems of 71.7% of patients could have been resolved by a primary care physician using clinical skills, extended resources, or other ambulatory care and out-of-hours services. Conclusions: Low awareness of out-of-hours centers and a lack of resources for delivering more complex services in primary care can lead to inappropriate presentations to the emergency services. Future research on this topic needs to be conducted at the national level.

Royal Jelly and Fermented Soy Extracts-A Holistic Approach to Menopausal Symptoms That Increase the Quality of Life in Pre- and Post-menopausal Women: An Observational Study.

BACKGROUND: The objective of this study was to determine the effects of royal jelly and fermented soy extracts on menopausal symptoms and on quality of life in pre- and post-menopausal women. MATERIALS AND METHOD: This prospective observational study was carried out in a Clinical Hospital of Brasov, Romania, during June 2020 and December 2021. Eighty pre- and post-menopausal women, aged between 45 and 60 years, were included in two groups. The first group (40 women) received a dietary supplement with fermented soy extract twice a day for eight weeks and the second group (40 women) received the same dietary supplement with fermented soy extracts and 1500 mg of royal jelly capsules for eight weeks. After the treatment, the MENQOL score, DASS-21 score, and the mean number and intensity of daily hot flushes were recorded and compared with baseline values. RESULTS: After eight weeks of treatment, the score of the MENQOL questionnaire and all its domains' scores decreased in comparison with the baseline in both groups (p < 0.001). Also, the DASS-21 score (p < 0.001), depression score (p < 0.001), anxiety score (p < 0.001), and stress score (p < 0.001) improved. The mean number and the intensity of hot flushes decreased in both groups (p < 0.001). Comparing these variables after the treatment in both groups, we observed that the women who received dietary supplements with fermented soy extracts and royal jelly capsules recorded better scores for MENQOL (vasomotor, physical, and psychosocial domains) and a more reduced mean number of daily hot flushes. CONCLUSIONS: This observational study suggests that both dietary fermented soy supplements and royal jelly capsules possess beneficial effects against menopausal symptoms, increase the quality of life in pre- and post-menopausal women, and that the effects might be significantly improved if those dietary supplements are administered in association.

Can Medication be a Factor that Can Negatively Affect the Effect of Transcranial Magnetic Stimulation in Depression?

BACKGROUND: This study aims to evaluate the efficacy of transcranial magnetic stimulation (TMS) in patients with depression and whether concurrent psychotropic medication use negatively affects the treatment outcome of TMS. Patients' characteristics, predictors of treatment response, the relationship between demographics, and the selection of TMS as a treatment modality were also analyzed. STUDY QUESTION: Can psychotropic medication be a factor that can negatively affect the efficacy of TMS in patients with depression? STUDY DESIGN: This pilot-controlled study included 40 subjects from Romanian clinical practice who were treated with pharmacological treatment and TMS for major depressive disorder. The severity of depression and anxiety symptoms was measured using validated scales at baseline (day 1) and follow-up (day 30). DATA SOURCES: All patients' characteristics and information were collected manually from the clinic's medical records, deidentified, and then introduced into an electronic database for analysis. LIMITATIONS: Conducting the study in a clinical routine practice, it was not possible to include an active and/or sham control group. In addition, because TMS is not used as a monotherapy in this type of practice, we could not evaluate its safety and efficacy without concomitant pharmacological treatment. The study sample is small; therefore, the results cannot be generalized. RESULTS: Sixty percentage of patients (n = 24) included in this study obtained a clinical response, and 30% of patients (n = 12) obtained remission of depression. The group with pharmacological treatment obtained clinical responses in 80% of patients (n = 16) and remission of depression in 45% of patients (n = 9). The group with pharmacological treatment and TMS obtained clinical responses in 40% of patients (n = 8) and remission of depression in 15% (n = 3) of cases. CONCLUSIONS: The study results show a lack of efficacy for TMS as an adjunctive therapy to pharmacological treatment for patients with depression. In addition, a negative impact of psychotropic medication on TMS efficacy is observed in our study sample.

Pharmacological Management of Cholera: A Century of Expert Opinions in Cecil Textbook of Medicine.

BACKGROUND: Cholera is a potentially lethal diarrheal disease produced by Vibrio cholerae serotypes O1 El Tor and O139. Known since antiquity, the condition causes epidemics in many areas, particularly in Asia, Africa, and South America. Left untreated, the mortality may reach 50%. The crucial therapeutic intervention is intravenous or oral rehydration and correction of acidosis, dyselectrolytemia, and renal impairment. Antibiotic use represents the main pharmacological intervention. STUDY QUESTION: What are the milestones of the antibiotics use recommended by experts for the pharmacological management of cholera in the past century? STUDY DESIGN: To determine the changes in the experts' approach to the management of cholera and particularly the use of antibiotics as presented in a widely used textbook in the United States. DATA SOURCES: The chapters describing the management of cholera in the 26 editions of Cecil Textbook of Medicine published from 1927 through 2020. RESULTS: Sulfonamides were recommended in 1947, followed by the introduction of tetracyclines, chloramphenicol, and furazolidone in 1955. The options were restricted in 2000 to doxycycline. In the past decade, patients infected with strains known to have a degree a resistance to tetracyclines were treated with azithromycin or ciprofloxacin. Antibiotic use decreases the volume of stool and the duration of diarrhea but has not been considered lifesaving. Drugs with antimotility, antiemetic, or antisecretory properties are not useful. CONCLUSIONS: The utility of antibiotic use in cholera has been endorsed by experts, but only as an adjunct to rapid and complete fluid and electrolyte replacement.

The New Mythology of the Body and the Transformation of the Therapeutic Space.

BACKGROUND: The history of medicine has flowed in the wake of knowledge and social perceptions about the body and corporeality. There is no idea of health without reference to the notion of body (although "health" can have other meanings, figuratively). Considering the same history, the body was the subject of numerous segregations and categorizations due to which it was and is a "social object" and a "political object." In turn, the spatial and cultural framework was the environment and determinant of the medicine development which is not only a science but also an inter-human interactive practice. AREAS OF UNCERTAINTY: In this article, we will analyze the current social (re)construction of the notions of body and space by referring to the technological and structural changes that are manifested in medicine and society and their ethical implications. DATA SOURCES: A review of the specialized literature was performed in June-July 2023, using keywords like human enhancement, therapeutic enhancement, transhumanist medicine, ethics from PubMed, Scopus, Web of Science, and Google Scholar, and official documents issued at the international level (World Health Organization, European Commission). ETHICS AND THERAPEUTIC ADVANCES: This literature review suggests that few practical solutions to human enhancement, both curative and preventive, whether cognitive or physical, have been approached entirely from an ethical point of view. The historical evolution of the concept of human enhancement has led to debates between "transhumanists" and "bioconservatives" depending on how they relate to the improvement of the human condition without or with reticence interventions to improve human capabilities being related to various interventions, from pharmacological, surgical ones to those in the field of genetics, nanomedicine, or cybernetics. In addition to the technical aspects, which are often the major concern of researchers and those applying new technologies, there are also ethical and legislative aspects, to better understand the impact that the dynamics and diffusion of these processes have on the evolution of the human species. CONCLUSIONS: In interference with these technologies, the body is exposed to possibilities of change and evolution with colossal (expected) social impact that can change norms and values that have been stable for centuries. Social space and place are also proving to be "processes in the making'" for which we need to detect what developments are possible or have already imposed themselves as a trend in the social and medical world.

Bed Rest After Acute Myocardial Infarction: A Century of Expert Opinions in Cecil Textbook of Medicine.

BACKGROUND: Complete bed rest has been a component of the management of acute myocardial infarction, which was first diagnosed in the United States in 1912. The prescribed duration of bed rest has been progressively shortened in the past century. STUDY QUESTION: What are the milestones of the changes in the expert approach to the duration of bed rest for patients with acute myocardial infarction? STUDY DESIGN: To determine the changes in the experts' approach to the duration of bed rest after a diagnosis of acute myocardial infarction, as presented in a widely used textbook in the United States. DATA SOURCES: The chapters presenting the management of myocardial infarction in the 26 editions of Cecil Textbook of Medicine published from 1927 through 2020. RESULTS: Complete rest for 2-6 weeks was recommended by the Cecil's experts from 1927 through 1967. The practice was questioned since the early 1950s, but the recommended duration of bed rest was decreased to 3-4 days only in 1971, after most US hospitals opened coronary care units. The required time in bed was further decreased to 1 day in 1992 and to 12 hours in 2004. By 2007, the literature contained data from 15 trials with a total of 1471 patients kept in bed "longer" and 1487 patients who had been prescribed bed rest for "shorter" periods after an acute uncomplicate myocardial infarction and there was no difference between the groups regarding reinfarction, cardiac mortality, or all-cause mortality. CONCLUSIONS: The duration of bed rest after acute myocardial infarction recommended by experts in the United States has had a downward trend with an inflection point in the early 1970s. The change reflected experts' opinion, rather than evidence produced by randomized controlled trials.

Reimplantation of Implantable Cardiac Devices-An Ethical Controversy?

BACKGROUND: Cardiovascular diseases are an important public health problem, the main cause of death in both men and women, with a continuous increasing prevalence and consequences upon morbidity in economic, physical, and psychological terms.The new technology have made possible the development of innovative devices, which have increased the possibility of therapeutic interventions today, extending the life of the population with cardiovascular pathology, transforming the patient care, and providing a complex, personalized therapeutic approach. FIELDS OF UNCERTAINTY: The aim of the study was to evaluate from an ethical perspective the need, feasibility, and safety of reusing cardiac pacemakers to revise the legal terms and requirements.In recent years, the problem of accessibility to cardiovascular drugs has been increasingly accompanied by the accessibility to technology, interventional cardiology advancing recently, and becoming an increasingly important standard of care. DATA SOURCES: A review of the specialized literature was performed in March 2023, using keywords such as implantable cardiac devices, reuse, ethics from PubMed, Scopus, Web of Science, and Google Scholar, as well as official documents issued at the international level (World Health Organization). ETHICS AND THERAPEUTIC ADVANCES: An ethical analysis assesses the extent to which a medical act (PM reimplantation) is covered by the 4 universally accepted principles: nonmaleficence, beneficence, autonomy (respect for the person), and social justice, the analysis addressing to the risk-benefit ratio based on studies that analyzed the phenomenon over the past 50 years. The ethical analyzed issues start from the fact that although 80% of pacemakers, most of them working perfectly, with a battery life of more than 7 years are buried with their owners, while approximately 3 million patients die annually due to the lack of access to these devices in undeveloped and developing countries.But beyond the ethical issues, legal practice has meant that in many countries, reusing of these devices is prohibited, mostly being single-use devices. Low-income countries continue to accept this practice as the only one economically accessible to them, considering the prohibition of reusing them to be an economic rather than a medical issue. CONCLUSIONS: Reusing implantable cardiac devices is of great interest because of the costs, being in certain situations, the only possibility that certain people can have access to a therapeutic method that ensures their health recovery and increases their quality of life. But this is not possible without clear procedures, without clear criteria on how sterilization should be performed, how the technique should be performed, without obtaining a truly informed consent, and especially without a proper patient's follow-up.

Influence of Clinical Factors on the Quality of Life in Romanian People with Epilepsy-A Follow-Up Study in Real-Life Clinical Practice.

BACKGROUND: This study aimed to assess the influence of various clinical factors on the quality of life perception of patients with epilepsy over a follow-up period in current clinical practice. METHODS: Thirty-five PWE evaluated via video-electro-encephalography in the Clinical Hospital of Psychiatry and Neurology in Brasov, Romania, were included, and the quality of life was assessed using the Romanian version of the QOLIE-31-P questionnaire. RESULTS: At baseline, the mean age was 40.03 (±14.63) years; the mean duration of epilepsy was 11.46 (±12.90) years; the mean age at the first seizure was 28.57 (±18.72); and the mean duration between evaluations was 23.46 (±7.54) months. The mean (SD) QOLIE-31-P total score at the initial visit (68.54 ±15.89) was lower than the mean (SD) QOLIE-31-P total score at the follow-up (74.15 ± 17.09). Patients with epileptiform activity recorded via video-electro-encephalography, using polytherapy, those with uncontrolled seizures, and those with one or more seizures per month had statistically significantly lower QOLIE-31-P total scores at baseline and follow-up. Multiple linear regression analyses revealed seizure frequency as a significant inverse predictor of quality of life in both evaluations. CONCLUSIONS: The QOLIE-31-P total score was improved during the follow-up period, and medical professionals should use instruments to evaluate quality of life and identify patterns while trying to improve the outcomes of patients with epilepsy.

Against Authority: The Bioethics of Ivermectin Use for COVID-19 Infection.

BACKGROUND: The COVID-19 pandemic has brought new ethical challenges to both health care professionals and the general public. Among the ethical problems amplified during this period were the making of medical decisions to quickly introduce some drugs into therapeutic practice with unproven or insufficiently proven effects (such as ivermectin), the validity of drug testing, and the allocation of limited resources. FIELDS OF UNCERTAINTY: The COVID-19 pandemic brought to the attention of the entire scientific world a new problem, which exceeded the guidelines and rules known until then. Out of the desire to quickly solve this medical problem, a series of measures were taken, however not sufficiently validated in scientific terms; the recommendations regarding the use of drugs known for their properties to treat a greater number of conditions, such as ivermectin, was tried. DATA SOURCES: A narrative review of the specialized literature was carried out using keywords such as COVID-19, ivermectin, ethics, and off-label medication from Scopus and Google Scholar but also of official documents developed at the international level (World Health Organization). ETHICS AND THERAPEUTIC ADVANCES: The off-label use of ivermectin alone or in combination with other medications during COVID pandemic raised problems related to the demonstration of its effectiveness, but also to ethics, starting from the expectations that both the medical staff and the population had of it. Ivermectin therapy was also evaluated by analyzing the behavior of ivermectin based on ethical principles (nonmaleficence, beneficence, and respect for one's autonomy) or on justice. Even in times of pandemic, exceptionalism must not triumph, and finding an effective treatment must be done through studies that respect ethical standard. CONCLUSIONS: The failures or rather lack of success in decision making during the pandemic showed that alongside scientific knowledge and the development of health policies, it is necessary to constantly evaluate the measures and decisions from an ethical point of view, and the prevention of slippages and abuses is not only necessary but even mandatory.

Advances in Genetic Editing of the Human Embryo.

BACKGROUND: Genetic engineering has allowed a major development of research in this field, with specialists attempting to edit the human genome, after the successful editing of the genomes of plants and animals. However, human gene editing technologies are at the center of ethical debates around the world. AREAS OF UNCERTAINTY: Ethical concerns about genetic editing of the human embryo raise several issues that can be viewed through the prism of optimism and reluctance leading to a number of recommendations regarding the acceptance of what may soon become a reality. DATA SOURCES: A literature search was conducted through PubMed, MEDLINE, Plus, Scopus, and Web of Science (2015-2022) using combinations of keywords, including: human genome or gene editing plus ethics. ETHICS AND THERAPEUTIC ADVANCES: Gene therapy is seen by researchers as a way to solve congenital diseases, multifactorial diseases in general or specific diseases such as cystic fibrosis, muscular dystrophy, or can increase resistance to HIV infection. Genome editing technologies, germline gene editing, clustered regularly interspaced short palindromic repeats gene editing technology, technologies such as zinc finger nucleases are not only advanced gene therapies that require solving technical problems, but also techniques that require complex and complete analysis of ethical problems. Genetic engineering raises many ethical concerns such as: safety concerns especially the risk of off-target effects; autonomy of the individual-with the limitation of the future generations to consent for an intervention over their genome; social justice-keeping in mind the costs of the procedures and their availability to the general population. Discussions can go further from questions such as "How can we do this?" to questions such as "Should we do this?" or "Is society ready to accept this technology and is it able to manage it rationally?" CONCLUSIONS: The ethics of biomedical research should be based on global dialogue, on the involvement of experts and the public, to achieve a broad social consensus. The fundamental review of the ethics of genetics is a desire and an opportunity of the current period.

Impact of Clinical and Socio-Demographic Factors on the Quality of Life in Romanian People with Epilepsy.

This study investigates the impact of different clinical and demographic factors on the quality of life in people with epilepsy hospitalized at a health institution of Brasov County, Romania, using a QOLIE-31-P questionnaire and to reflect on the opportunities and limitations of incorporating such an instrument into the clinical practice. Methods: Ninety-one patients with a diagnosis of epilepsy evaluated by video-electroencephalography in the Clinical Hospital of Psychiatry and Neurology in Brasov, Romania, were recruited. After the confirmation of the diagnosis based on clinical, electrophysiological and imagistic examination, and of their compliance with the hospitalization criteria, the patients filled in the QOLIE-31-P questionnaire. Socio-demographic and clinical data were collected. Results: The seizure frequency was negatively correlated with almost all QOLIE-31-P domains (p < 0.05). Age, employment status, level of education and uncontrolled disease were significant factors associated with a low quality of life. The mean (SD) QOLIE-31-P scores were 64.89 (14.72), the mean age was 43.04 (14.92) years, with the average age of the first seizure onset 30.66 (17.45) years. Conclusion: The use of measuring instruments to assess the quality of life of patients with epilepsy despite the challenges should become a routine practice, the information collected in this way can improve the outcomes in the care of these patients. In addition to the goal of reducing the frequency of seizures, physicians must also take into account other parts of the experiences of people with epilepsy.

Pharmacological Management of Pulmonary Tuberculosis: A Century of Expert Opinions in Cecil Textbook of Medicine.

BACKGROUND: Advances in drug therapy for pulmonary tuberculosis have had an extraordinary impact on the incidence of tuberculosis in the United States in the past century, which has decreased from 113/100,000 persons in 1920 to 2.2/100,000 in 2020. Modern treatments have contributed to a remarkable decrease in hospitalizations and mortality and have had a significant impact on the duration and severity of illness, quality of life, and work potential of affected persons. STUDY QUESTION: What are the milestones of the changes in the expert approach to the pharmacological management of pulmonary tuberculosis in the past century? STUDY DESIGN: To determine the changes in the experts' approach to the management of pulmonary tuberculosis, as presented in a widely used textbook in the United States. DATA SOURCES: The chapters describing the management of pulmonary tuberculosis in the 26 editions of Cecil Textbook of Medicine published from 1927 through 2020. RESULTS: In the preantibiotic era (1927-1943), the Cecil authors emphasized rest, good food, and fresh air as the treatment pillars for pulmonary tuberculosis. The modern era (1947-1971) recorded the discovery of all the drugs that are still used for the initial treatment, in the following order: streptomycin, para-aminosalicylic acid, isoniazid, pyrazinamide, ethambutol, cycloserine, kanamycin, ethionamide, capreomycin, and rifampin. In the postmodern era (1975-2020), therapeutic advances continued with trials of many drug combinations aimed at ameliorating the duration of treatment, drug resistance adverse effects, and poor the recent addition of fluoroquinolones, bedaquiline, and clofazimine. CONCLUSIONS: The pharmacological management of tuberculosis has remained archaic until the middle of the 20th century. Fundamental progress occurred in a very short period (1947-1971) and was because of the recognition of the antituberculous effect of many antibiotics and chemotherapy agents. The challenges created by mycobacterial infections resistant to multiple drugs remain and have prompted the addition of new drugs in the past decade.

Misinformation about medication during the COVID- 19 pandemic: A perspective of medical staff.

BACKGROUND: Healthcare professionals had to face numerous challenges during the pandemic, their professional activity being influenced not only by the virus, but also by the spread of medical misinformation. In this regard, we aimed to analyze, from the perspective of medical staff, the way medical and non-medical information about the virus was communicated during the pandemic to encourage the development of future research or interventions in order to raise awareness about the way misinformation affected medical staff. METHODS AND FINDINGS: The study was conducted on Romanian healthcare professionals. They were asked to answer to a questionnaire and the sample of the research includes 536 respondents. The findings revealed that most respondents stated that information about alternative treatments against the virus affected the credibility of health professionals, and that younger professionals believed to a greater extent that trust in doctors was affected. The research also showed that respondents were well informed about the drugs used in clinical trials in order to treat the virus. CONCLUSIONS: Healthcare professionals declared that the spread of misinformation regarding alternative treatments, affected their credibility and the relationship with their patients. Healthcare professionals had knowledge about the drugs used in clinical trials, and they acknowledged the role of social media in spreading medical misinformation. However, younger professionals also believed that social media could be used to share official information about the virus.

Pharmacological Management of Inflammatory Bowel Disease: a Century of Expert Opinions in Cecil Textbook of Medicine.

BACKGROUND: Advances in drug therapy for inflammatory bowel disease (IBD) [Crohn disease and ulcerative colitis (UC)] have contributed to a decrease in the severity of these chronic and disabling conditions. STUDY QUESTION: What are the milestones of the changes in the expert approach to the pharmacological management of IBD in the past century? STUDY DESIGN: To determine the changes in the experts' approach to the management of regional ileitis and UC, as presented in a widely used textbook in the United States. DATA SOURCES: The chapters presenting the management of IBD in the 26 editions of Cecil Textbook of Medicine published from 1927 through 2020. RESULTS: No specific interventions existed from 1927 through 1942. The pharmacological management of IBD has had 3 slightly overlapping eras starting in 1943. During the first period (1943-1951), the medical management relied on antibiotics, primarily sulfonamides and chloramphenicol. In the second (1955-75), experts recommended the use of adrenocorticotropic hormone or corticosteroids and 5-aminosalicylate. In the third era, which commenced in 1979 and is continuing to date, the pharmacological interventions have been expanded and refined to include 5 main drug classes, 5-aminosalicylates (sulfasalazine, mesalamine, and olsalazine), corticosteroids (prednisone and budesonide), immunomodulators (azathioprine, 6-mercaptopurine, cyclosporine, and tofacitinib), biologics (infliximab adalimumab certolizumab pegol, and natalizumab), and antibiotics (metronidazole and ciprofloxacin). A consensus exists that the monoclonal antibodies again tumor necrosis factor alpha are cost-effective for induction and maintenance of clinical remission in both UC (golimumab) and Crohn disease (certolizumab pegol). The newer agents ustekinumab (a monoclonal antibody to the interleukin p40 subunit) and vedolizumab (a monoclonal antibody to the homing receptor integrin complex) have also performed well. CONCLUSIONS: The pharmacological management of IBD has been the focus of intense research and development in the past 60 years. The pillars of drug treatment have been 5-aminosalicylates and corticosteroids. Recent pharmacological innovations (immunomodulators and biologicals) constitute an encouraging paradigm shift in the treatment of UC and Crohn disease.

Prehospital Care of Coronary Artery Disease and Its Major Risk Factors in Geropsychiatric Inpatients.

BACKGROUND: Older adults with serious mental illness have a high prevalence of coronary artery disease and of its major risk factors, that is, arterial hypertension, dyslipidemia, and diabetes mellitus. The prevalence and clinical control of these conditions have not been compared in geropsychiatric inpatients with dementia versus those with mood or psychotic disorders. STUDY QUESTION: What is the prevalence and acuity of coronary artery disease, arterial hypertension, dyslipidemia, and diabetes mellitus among patients with dementia, mood, and psychotic disorders admitted for geropsychiatric care? STUDY DESIGN: Patients 65 years of age or older were identified in a cohort of 1000 patients consecutively admitted over a 3-year period to the geropsychiatric unit of a 200-bed mental health hospital in suburban New York. All patients had a structured clinical and laboratory evaluation within 72 hours of admission. DATA SOURCES: Primary psychiatric diagnoses, medical history, the frequency of poorly controlled cardiometabolic comorbidity requiring an immediate change in the management plan, and the Charlson Comorbidity Index (CCI). RESULTS: The 65 years and older patient sample (N = 689) had a mean age of 74.8 years, and 58.8% of the subjects were women. The 205 patients with dementia were older ( P < 0.001) than the 337 patients with mood disorders and the 147 patients with psychotic syndromes. The numbers of medical conditions and the CCI after exclusion of dementia were similar in patients with dementia versus patients without dementia. A substantial number of patients had poorly controlled arterial hypertension (51.2%), dyslipidemia (25.4%), diabetes (24.2%), and coronary artery disease (15.4%). Patients with dementia had a lower prevalence of poorly controlled dyslipidemia ( P = 0.0006), diabetes ( P = 0.0089), and coronary artery disease ( P = 0.045). CONCLUSIONS: Compared with mood or psychotic disorder, a diagnosis of dementia with behavioral disturbance seemed to be associated with better control of coronary artery disease, dyslipidemia, and diabetes mellitus in geropsychiatric inpatients.

Pharmacological Management of Obesity: A Century of Expert Opinions in Cecil Textbook of Medicine.

BACKGROUND: Innovations in drug therapy for obesity have had a limited impact on the body mass index, prevalence of medical complications, quality of life, and work potential of a substantial majority of affected persons. STUDY QUESTION: What are the milestones of the changes in the expert approach to the pharmacological management of obesity in the past century? STUDY DESIGN: To determine the changes in the experts' approach to the management of obesity, as presented in a widely used textbook in the United States. DATA SOURCES: The primary sources were chapters describing the management of obesity in the 26 editions of Cecil Textbook of Medicine published from 1927 through 2020. Secondary sources were publications retrieved from Medline that clarified technical issues related to the development, regulatory approval, and use of the drugs mentioned in the Cecil Textbook of Medicine. RESULTS: Pharmacological interventions aimed at increasing caloric expenditures through thermogenesis were recommended from 1927 through 1943. Thyroid extracts were prescribed even in the absence of demonstrated hypothyroidism or decreased basal metabolic rate throughout this period. Dinitrophenol was mentioned in 1937, but was banned soon thereafter. Appetite suppression with amphetamine was considered useful from 1943 through 1988, after which the drug was replaced with other centrally acting molecules, such as fenfluramine in 1988, sibutramine in 2000, and rimonabant in 2008, which were in turn withdrawn because of major adverse effects. In the past decade, obesity has been treated with the appetite suppressants phentermine-topiramate, bupropion-naltrexone, lorcaserin, and liraglutide, and with orlistat, a drug promoting fat malabsorption. The change in weight produced by these drugs is generally modest and transient. CONCLUSIONS: The pharmacological management of obesity has remained frustratingly inefficient. The reasons for the relative lack of success may reside in the ever-growing access to dense, palatable, and relatively inexpensive food, coupled with the decrease in energy expenditure created by a sedentary lifestyle.

Predictive Factors of the Burnout Syndrome Occurrence in the Healthcare Workers During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic is probably the most critical epidemiological situation that human civilization has faced in the last few decades. In this context, of all the professional categories involved in the management of patients with COVID-19 are the most likely to develop burnout syndrome. The main objective of this study is to analyze specific predictive factors of the occurrence and development of the burnout syndrome in the healthcare workers involved in the diagnosis and treatment of patients with COVID-19. The study focused on determining factors of the occurrence, development and maintaining the specific burnout syndrome related to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic infection. The study was conducted on a sample of 959 participants, medical personnel from all the public medical entities in Romania(including 5 hospitals): 122 male and 755 female (82 participants did not declare their gender), with a mean age of 42.29 years (SD = 9.97). The sample included 219 doctors, 477 nurses, 214 auxiliary medical personnel and 49 other types of hospital workers. A cross-sectional design was used. Three predictors of the burnout syndrome were identified: Work conditions, Fear of the consequences (including death) determined by the COVID-19 and Need for emotional support. Meaning of work had a moderating role. Several moderated mediation models were tested. The indirect relationship of Work conditions with burnout via Fear of infection was statistically significant; in addition, the indirect effect of Work conditions on burnout through both fear of infection and need for support was statistically significant. The moderation analysis showed that Meaning of work buffer the relationship between Work conditions and Fear of infection. The variance explained by the model including the moderator (30%) was higher than the variance explained by Model 1 (27%), showing that adding the moderating effect of Meaning of work to the relationship of Work conditions with burnout was relevant. The results could be used to design specific interventions to reduce the occurrence of the burnout syndrome in healthcare workers, the implementation of a strategy to motivate employees by highlighting and recognizing the high significance of the work of those in the frontline of the fight against COVID-19.

Pharmacological Management of Primary Arterial Hypertension: A Century of Expert Opinions in Cecil Textbook of Medicine.

BACKGROUND: Advances in drug therapy for primary (or essential) arterial hypertension have contributed to a significant decrease in the frequency and severity of strokes, coronary artery disease and heart failure, and chronic renal insufficiency. STUDY QUESTION: What are the milestones of the changes in the expert approach to the pharmacological management of arterial hypertension in the past century? STUDY DESIGN: To determine the changes in the experts' approach to the management of arterial hypertension, as presented in a widely used textbook in the United States. DATA SOURCES: The chapters presenting the management of arterial hypertension in the 26 editions of Cecil Textbook of Medicine published from 1927 through 2020. RESULTS: The pharmacological management of arterial hypertension has had 3 overlapping eras in the timeframe subject to our investigation. In the empiric era (1927-1947), experts were recommending nonspecific interventions for sedation. The premodern era (1955-1963) relied on ganglion blockers, sympathetic blockers, and direct vasodilators. The modern era (1967-2020), which includes drugs used in current clinical practice, saw the introduction of diuretics (1967), beta-blockers (1971), alpha-blockers (1982), calcium channel blockers (1985), angiotensin-converting enzyme inhibitors (1985), angiotensin receptor blockers (2000), and direct renin inhibitors (2008). CONCLUSIONS: The pharmacological management of arterial hypertension has been the focus of intense and successful research and development in the second half of the 20th century.

Pharmacological Management of Heroin Withdrawal Syndrome: A Century of Expert Opinions in Cecil Textbook of Medicine.

BACKGROUND: Opioid use disorder continues to have a significant impact on public health morbidity and mortality throughout the United States and elsewhere. Managing opioid withdrawal is a critical treatment goal in individuals entering treatment with an active opioid use. STUDY QUESTION: What are the milestones of the changes in the expert approach to the pharmacological management of heroin withdrawal syndrome in the past century? STUDY DESIGN: To determine the changes in the expert approach to the management of heroin withdrawal syndrome, as presented in a widely used textbook in the United States. DATA SOURCES: The chapters on opioid dependence in the 26 editions of Cecil Textbook of Medicine published from 1927 through 2020. RESULTS: Opioid replacement taper with morphine (1927-1947), codeine (1931-1943), and methadone (1951-present) administered for 3-10 days has remained the main intervention. The anticholinergic drugs, scopolamine and atropine, were recommended from 1927 to 1943, but their use has never been backed by scientific evidence. Newer approaches relied on clonidine, an alpha-2 receptor agonist used since 1982, and buprenorphine, an opioid agonist/antagonist endorsed for the treatment of heroin withdrawal in 2000. CONCLUSIONS: The pharmacological management of heroin withdrawal syndrome in the past century has progressed from the introduction of methadone to the utilization of clonidine and buprenorphine. More recent advances in treating opioid use disorder have changed the goals of opioid withdrawal management to achievement of abstinence from all opioids to facilitation of long-term treatment with medications for opioid use disorder.