Patient Preferences for Treatment of Psoriasis with Biologicals: A Discrete Choice Experiment

Treatment dissatisfaction and non-adherence are common among patients with psoriasis, partly due to discordance between individual preferences and recommended treatments. However, patients are more satisfied with biologicals than with other treatments. The aim of our study was to assess patient preferences for treatment of psoriasis with biologicals by using computer-based conjoint analysis. Biologicals approved for psoriasis in Germany were decomposed into outcome (probability of 50% and 90% improvement, time until response, sustainability of success, probability of mild and severe adverse events (AE), probability of American College of Rheumatology (ACR) 20 response) and process attributes (treatment location, frequency, duration and delivery method). Impact of sociodemographic and socioeconomic characteristics and disease severity on Relative Importance Scores (RIS) of each attribute was assessed with analyses of variance, post hoc tests, and multivariate regression. Averaged across the cohort of 200 participants with moderate-to-severe psoriasis, preferences were highest for avoiding severe AE (RIS = 17.3), followed by 90% improvement (RIS = 14.0) and avoiding mild AE (RIS = 10.5). Process attributes reached intermediate RIS (8.2–8.8). Men were more concerned about efficacy than women (50% improvement: RIS = 6.9 vs. 9.5, p = 0.008; β = -0.191, p = 0.011 in multivariate models; 90% improvement: RIS = 12.1 vs. 15.4, p = 0.002; β = -0.197, p = 0.009). Older participants judged the probability of 50% and 90% improvement less relevant than younger ones (50% improvement: Pearson’s Correlation (PC) = -0.161, p = 0.022; β = -0.219, p = 0.017; 90% improvement: PC = -0.155, p = 0.028; β = -0.264, p = 0.004) but worried more about severe AE (PC = 0.175, p = 0.013; β = 0.166, p = 0.082). In summary, participants with moderate-to-severe psoriasis were most interested in safety of biologicals, followed by efficacy, but preferences varied with sociodemographic characteristics and working status. Based on this knowledge, physicians should identify preferences of each individual patient during shared decision-making in order to optimize treatment satisfaction, adherence and outcome.     

Patients’ preferences for osteoporosis drug treatment: a discrete-choice experiment

Introduction

The patient’s perspective is becoming increasingly important in clinical and policy decisions. In this study, we aimed to evaluate the preferences of patients with, or at risk of, osteoporosis for medication attributes, and to establish how patients trade between these attributes.

Methods

A discrete choice experiment survey was designed and patients were asked to choose between two hypothetical unlabelled drug treatments (and an opt-out option) that vary in five attributes: efficacy in reducing the risk of fracture, type of potential common side-effects, mode and frequency of administration and out-of-pocket costs. An efficient experimental design was used to construct the treatment option choice sets and a mixed logit panel data model was used to estimate patients’ preferences and trade-offs between attributes.

Results

A total of 257 patients with, or at risk of, osteoporosis completed the experiment. As expected, patients preferred treatment with higher effectiveness and lower cost. They also preferred either an oral monthly tablet or 6-month subcutaneous injection above weekly oral tablets, 3-month subcutaneous, 3-month intravenous or yearly intravenous injections. Patients disliked being at risk of gastro-intestinal disorders more than being at risk of skin reactions and flu-like symptoms. There was significant variation in preferences across the sample for all attributes except subcutaneous injection.

Conclusions

This study revealed that osteoporotic patients preferred 6-month subcutaneous injection and oral monthly tablet, and disliked gastro-intestinal disorders. Moreover, patients were willing to pay a personal contribution or to trade treatment efficacy for better levels of other attributes. Preferences for treatment attributes varied across patients and this highlights the importance of clinical decision-making taking individual preferences into account to improve osteoporosis care.     

Oxytocin and Social Preference in Female House Mice (Mus musculus domesticus)

In social species, same‐sex individuals may form social bonds behaviourally expressed as individual preferences, resulting in fitness benefits such as increased offspring survival, longevity and group cohesion. As a result of individual preferences, female house mice (Mus musculus domesticus) form social affiliations while communally nursing and may do so with kin or non‐kin. However, the mechanisms behind the formation of such preferences are unknown. Oxytocin has been linked to a range of social behaviours including bond facilitation, social memory and parental care. Here, we experimentally increased oxytocin in pairs of unfamiliar, unrelated females and predicted that females with elevated oxytocin would demonstrate increased affiliative behaviours compared against a control. Subsequently, we tested for the formation of a social preference, using a preference test with the previous partner and a new unfamiliar female. Our results indicated no significant effect of treatment on positive and negative behaviours between females during the three initial cohabitation days. In both treatments, females demonstrated increased socio‐positive behaviours and cohabitation time with their partner and decreased socio‐negative behaviours and latency to meet, over the 3‐d period. During the partner preference test, control but not oxytocin females demonstrated a significant preference for their cohabitation partner, and oxytocin females spent similar amounts of time with both stimulus females. Therefore, increasing peripheral oxytocin appears not to be involved in the facilitation of initial encounters with a stranger but may hinder the formation of a preference for this new partner.     

Are All Placebo Effects Equal? Placebo Pills,Sham Acupuncture,Cue Conditioning and Their Association

Placebo treatments and healing rituals have been used to treat pain throughout history. The present within-subject crossover study examines the variability in individual responses to placebo treatment with verbal suggestion and visual cue conditioning by investigating whether responses to different types of placebo treatment, as well as conditioning responses, correlate with one another. Secondarily, this study also examines whether responses to sham acupuncture correlate with responses to genuine acupuncture. Healthy subjects were recruited to participate in two sequential experiments. Experiment one is a five-session crossover study. In each session, subjects received one of four treatments: placebo pills (described as Tylenol), sham acupuncture, genuine acupuncture, or no treatment rest control condition. Before and after each treatment, paired with a verbal suggestion of positive effect, each subject''s pain threshold, pain tolerance, and pain ratings to calibrated heat pain were measured. At least 14 days after completing experiment one, all subjects were invited to participate in experiment two, during which their analgesic responses to conditioned visual cues were tested. Forty-eight healthy subjects completed experiment one, and 45 completed experiment two. The results showed significantly different effects of genuine acupuncture, placebo pill and rest control on pain threshold. There was no significant association between placebo pills, sham acupuncture and cue conditioning effects, indicating that individuals may respond to unique healing rituals in different ways. This outcome suggests that placebo response may be a complex behavioral phenomenon that has properties that comprise a state, rather than a trait characteristic. This could explain the difficulty of detecting a signature for “placebo responders.” However, a significant association was found between the genuine and sham acupuncture treatments, implying that the non-specific effects of acupuncture may contribute to the analgesic effect observed in genuine acupuncture analgesia.     

Using Discrete Choice Experiment to elicit patient preferences for osteoporosis drug treatments: where to from here?

Osteoporosis is a disease that increases skeletal fracture risk and places a significant health and economic burden on patients, families, and health systems. Many treatment options exist, but patient use is suboptimal, thus undermining the potential cost-effectiveness of treatments. In the previous issue of Arthritis Research & Therapy, Hiligsmann and colleagues expanded the findings of previous studies to report, from a sample of 257 patients with osteoporosis, the preference to trade off clinical outcomes for the amenity provided by convenient dosing regimens. This editorial critiques the strengths and limitations of the methods, discusses the potential utility of patient treatment preferences, and suggests avenues for further research.In the previous issue of Arthritis Research & Therapy, Hiligsmann and colleagues explored the treatment preferences of patients with, or at risk of, osteoporosis [1]. Osteoporosis is a disease characterized by impaired bone quality, leading to increased fracture risk at multiple skeletal sites and significant morbidity and mortality [2]. The health and economic burden of osteoporosis to individuals, families, and health systems is substantial, and osteoporotic fractures represent 0.83% of the global burden of non-communicable diseases [3]. Currently, the prevalence of osteoporosis is higher in females, although men have higher fracture-related mortality rates [4]. The prevalence of osteoporosis and incidence of osteoporotic fractures are expected to increase, particularly as the population ages.Preventing osteoporotic fractures, such as through the use of cost-effective drug treatment, is critical to sustainable health budgets worldwide. Several cost-effective treatment options are known to exist, offering patients a variety of dosing frequencies (for example, weekly and annually) and routes (for example, oral and intravenous). However, patients may for various reasons fail to take up or persist with osteoporotic treatments [5]. Understanding patient preferences for treatments can help clinicians prescribe treatments that patients like (and presumably will take) and can assist health-care funders identify treatments that are more likely to be cost-effective in practice.In the study by Hiligsmann and colleagues [1], Discrete Choice Experiment (DCE) was used to elicit treatment preferences. DCE is a robust survey methodology that presents respondents with successive choices between hypothetical treatments. An underlying assumption is that choice is driven by trading between treatment attributes (for example, side effects and efficacy). When econometric modeling is used, the relative importance of attributes and the extent to which respondents trade between attributes of treatment decisions can be quantified [6]. DCE is used widely in health to address problems ranging from assessing medication adherence [7,8] to predicting the uptake of government health policies [9].The capacity of a DCE to accurately understand behavior is dependent on the choice of attributes posed to respondents. The attributes used by Hiligsmann and colleagues [1] include efficacy (that is, reduction of fracture risk), side effects, administration mode and frequency, and patient costs. Importantly, these attributes were determined though the analysis of qualitative data collected from patients with osteoporosis [10]. Furthermore, a ‘no treatment’ option was posed, thereby mimicking real-life choices. These methodological features strengthen the research findings.In light of the current literature assessing osteoporosis treatment preferences, the findings that patients prefer treatments offering higher efficacy, lower costs, and less frequent dosing regimens and that not all patients have the same preferences are not surprising. This study does, however, evaluate additional administration routes currently or soon to be available, the side effects deemed important by patients, and the perspectives of men - currently under-represented in the literature yet predicted to contribute significantly to the total cost burden of osteoporosis [4]. Furthermore, the extent of efficacy and personal monetary cost that participants were willing to forego in exchange for desired dosing characteristics were quantified. For decision-makers, this evidence demonstrates that maximizing treatment efficacy and safety is not unequivocally important to all patients, particularly if at the cost of less convenient administration attributes.There are some caveats to these findings and thus room for further research. First, all DCEs are subject to hypothetical bias: what respondents say they would do may differ from what they actually do, especially when experiencing the consequence of a choice. Hypothetical bias is unavoidable in DCEs but can be minimized. Combining results with actual choice data (for example, real-world data capturing actual choices by patients) is one technique that needs further exploration in health.Second, preferences were captured from consecutive patients attending one osteoporosis center and at one point in time. In addition to investigating the external validity of the findings, the temporal variations in preferences need to be better understood, particularly as patient preferences are likely to change over the course of treatment.Finally, further work is needed to understand preferences in subgroups. For instance, the results comparing preferences of high- versus low-risk patients suggest that patients at high risk have an increased preference for medication with lower efficacy compared with low-risk patients; this is somewhat counterintuitive and needs further investigation. Research into the preferences of men and racial and ethnic minorities is needed given the rapidly increasing share of the osteoporosis disease burden projected in such populations [4].In summary, Hiligsmann and colleagues have provided further evidence of the treatment preferences of patients with osteoporosis, highlighting the willingness of patients to trade off clinical outcomes for the amenity provided by convenient dosing regimens. The authors have good reasons to believe that this information will be of interest to clinicians and health-care decision-makers. However, given the suboptimal use of osteoporotic medications by patients, more work is needed to further understand how stated treatment preferences translate to real-world patient use of medications over time. Ultimately, this will better inform the interpretation of cost-effectiveness evidence for osteoporosis treatments and promote more effective and cost-effective treatment of this condition.     

Acupuncture or Low Frequency Infrared Treatment for Low Back Pain in Chinese Patients: A Discrete Choice Experiment

Acupuncture is a popular but controversial treatment option for low back pain. In China, it is practised as traditional Chinese medicine; other treatment strategies for low back pain are commonly practised as Western medicine. Research on patient preference for low back-pain treatment options has been mainly conducted in Western countries and is limited to a willingness-to-pay approach. A stated-preference, discrete choice experiment was conducted to determine Chinese patient preferences and trade-offs for acupuncture and low frequency infrared treatment in low back pain from September 2011 to August 2012 after approval from the Department of Scientific Research in the study settings. Eight-six adult outpatients who visited the ‘traditional medicine department’ at a traditional Chinese medicine hospital and the ‘rehabilitation department’ at a Western medicine hospital in Guangdong Province of China for chronic low back pain during study period participated in an interview survey. A questionnaire containing 10 scenarios (5 attributes in each scenario) was used to ask participants'' preference for acupuncture, low frequency infrared treatment or neither option. Validated responses were analysed using a nested-logit model. The decision on whether to receive a therapy was not associated with the expected utility of receiving therapy, female gender and higher out-of-pocket payment significantly decreased chance to receive treatments. Of the utility of receiving either acupuncture or low frequency infrared treatment, the treatment sensation was the most important attribute as an indicator of treatment efficacy, followed by the maximum efficacy, maintenance duration and onset of efficacy, and the out-of-pocket payment. The willingness-to-pay for acupuncture and low frequency infrared treatment were about $618.6 and $592.4 USD per course respectively, demonstrated patients'' demand of pain management. The treatment sensation was regarded as an indicator of treatment efficacy and the most important attribute for choosing acupuncture or low frequency infrared treatment. The high willingness-to-pay demonstrated patients'' demand of pain management. However, there may be other factors influencing patients'' preference to receive treatments.     

Effects of repeated damage and fertilization on palatability of Vaccinium myrtillus to grey sided voles, Clethrionomys rufocanus

In this study we examined the responses of the dominant understorey plant species, Vaccinium myrtillus, in a Swedish boreal forest to nitrogen applications and repeated damage by clipping. Four years of clipping V. myrtillus reduced its abundance, regardless of whether the clipping was combined with fertilization or not. The treatments also induced changes in growth form and concentration of phenolic compounds in the shoots. Repeated damage to the shrub caused reductions in both the length and diameter of the shoots, while fertilization alone increased their diameter. Fertilization also decreased the concentration of condensed tannins in shoots of V. myrtillus, while clipping had no significant effect in this respect. Condensed tannin concentrations were higher in shoots given the combined fertilization and clipping treatment than in shoots that were fertilized but not clipped. The effect on tannins is in accordance with the predictions of the CNB‐hypothesis. Among the seven individual phenolic compounds analysed only one, a cinnamic acid derivate, showed a significant effect of the treatments. Repeated damage resulted in decreased concentration of this phenolic acid. In addition there was a tendency towards treatment effects on both nitrogen and carbon concentration of the V. myrtillus shoots, but none of these effects were statistically significant. The treatment‐induced changes in V. myrtillus also affected the food preferences of grey‐sided voles (Clethrionomys rufocanus), resulting in the following order of preference among the treatments: 1) fertilization and clipping, 2) fertilization, 3) control and 4) clipping. Not only biochemical changes, but also changes in growth form were found to influence the preferences, as the voles avoided the smallest shoots. This size‐dependent feeding may partly explain the observed differences in their preferences. Thus, induced changes in growth form need to be considered when conclusions about changes in herbivores’ preference are made.     

The relations between early-life stress and risk,time, and prosocial preferences in adulthood: A meta-analytic review

This meta-analytic review aims to address the mixed findings in previous research by quantifying the associations between early-life stress and risk, time, and prosocial preferences, and testing the boundary conditions of these associations. We meta-analyze 123 articles reporting 867 effect sizes among 199,019 adults to test different predictions from a life history perspective, a sensitization perspective, and an uncertainty management perspective about how early-life stress is associated with risk, time, and prosocial preferences. First, we find relatively small effect sizes indicating that early-life stress is associated with greater risk taking (r = .123), more present orientation (r = .126), and less prosociality (r = -.085), and its positive association with present orientation is stronger in currently stressful situations. Second, these observed associations do not vary significantly for harshness and unpredictability dimensions of early-life stress. Notably, moderation analyses across different types of preference measures only reveal an overall pattern of associations of early-life stress with self-report measures of risk, time, and prosocial preferences. By contrast, early-life stress is not significantly associated with risk preference or prosocial preference measured with hypothetical choice tasks or laboratory behavior tasks. Taken together, although the overall pattern of results supports a life history perspective, a cautious interpretation is warranted by the variation in the results across different preference measures and potential publication bias in the results. More pre-registered studies are needed to test the extent to which preferences measured with arbitrary laboratory-based tasks capture real-world behaviors and to increase the ecological validity of laboratory-based measures.     

The Effect of Treatment History on Therapeutic Outcome: Psychological and Neurobiological Underpinnings

It is increasingly recognized that the efficacy of medical treatments is determined in critical part by the therapeutic context in which it is delivered. An important characteristic of that context is treatment history. We recently reported first evidence for a carry-over of treatment experience to subsequent treatment response across different treatment approaches. Here we expand on these findings by exploring the psychological and neurobiological underpinnings of the effect of treatment experience on future treatment response in an experimental model of placebo analgesia with a conditioning procedure. In a combined behavioral and neuroimaging study we experimentally induced positive or negative experiences with an analgesic treatment in two groups of healthy human subjects. Subsequently we compared responses to a second, different analgesic treatment between both groups. We found that participants with an experimentally induced negative experience with the first treatment showed a substantially reduced response to a second analgesic treatment. Intriguingly, several psychological trait variables including anxiety, depression and locus of control modulate the susceptibility for the effects of prior treatment experiences on future treatment outcome. These behavioral effects were supported by neuroimaging data which showed significant differences in brain regions encoding pain and analgesia between groups. These differences in activation patterns were present not only during the pain phase, but also already prior to painful stimulation and scaled with the individual treatment response. Our data provide behavioral and neurobiological evidence showing that the influence of treatment history transfers over time and over therapeutic approaches. Our experimental findings emphasize the careful consideration of treatment history and a strictly systematic treatment approach to avoid negative carry-over effects.     

Advice to use topical or oral ibuprofen for chronic knee pain in older people: randomised controlled trial and patient preference study

Objective To determine whether older patients with chronic knee pain should be advised to use topical or oral non-steroidal anti-inflammatory drugs (NSAIDs).Design Randomised controlled trial and patient preference study.Setting 26 general practices.Participants People aged ≥50 with knee pain: 282 in randomised trial and 303 in preference study. Interventions Advice to use topical or oral ibuprofen.Primary outcome measures WOMAC (Western Ontario and McMaster Universities) osteoarthritis index, major and minor adverse effects.Results Changes in global WOMAC scores at 12 months were equivalent. In the randomised trial the difference (topical minus oral) was two points (95% confidence interval −2 to 6); in the preference study, it was one point (−4 to 6). There were no differences in major adverse effects in the trial or study. The only significant differences in secondary outcomes were in the randomised trial. The oral group had more respiratory adverse effects (17% v 7%,95% confidence interval for difference −17% to −2%), the change in serum creatinine was 3.7 mmol/l less favourable (0.9 µmol/l to 6.5 µmol/l); and more participants changed treatments because of adverse effects (16% v 1%, −16% to −5%). In the topical group more participants had chronic pain grade III or IV at three months, and more participants changed treatment because of ineffectiveness.Conclusions Advice to use oral or topical preparations has an equivalent effect on knee pain over one year, and there are more minor side effects with oral NSAIDs. Topical NSAIDs may be a useful alternative to oral NSAIDs.Trial registration ISRCTN 79353052.     

The effects of habitat‐ and diet‐based cues on association preferences in the three‐spined stickleback (Gasterosteus aculeatus)

A number of recent papers have investigated the potential of familiarity to organize the distributions of free‐ranging animals. It is not clear, however, to which extent individual recognition or a more general recognition of a group odour is responsible for familiarity preferences. First, we tested the sensory basis of the recognition of familiars in three‐spined stickleback ( Gasterosteus aculeatus ). When allowed to choose between a familiar and an unfamiliar stimulus shoal on the basis of both visual and chemical communication, visual communication only and chemical communication only, the preference of focal fish for familiars was shown to be dependent on the presence of chemical cues. We subsequently investigated the mechanisms underlying such association preferences, specifically the effects of recent habitat and diet on preferences. Experimental fish were divided into four treatment groups consisting of two environment treatments (saline and freshwater) and two diet treatments ( Daphnia spp. and chironimid larvae). Focal fish subsequently showed significant association preferences for groups of unfamiliar fish that had undergone the same environment or diet treatment as themselves, suggesting self‐referent matching. These data indicate that individual recognition is not a pre‐requisite for the expression of familiarity preferences.     

Octopamine influences honey bee foraging preference

Colony condition and differences in individual preferences influence forage type collected by bees. Physiological bases for the changing preferences of individual foragers are just beginning to be examined. Recently, for honey bees octopamine is shown to influence age at onset of foraging and probability of dance for rewards. However, octopamine has not been causally linked with foraging preference in the field. We tested the hypothesis that changes in octopamine may alter forage type (preference hypothesis). We treated identified foragers orally with octopamine or its immediate precursor, tyramine, or sucrose syrup (control). Octopamine-treated foragers switched type of material collected; control bees did not. Tyramine group results were not different from the control group. In addition, sugar concentrations of nectar collected by foragers after octopamine treatment were lower than before treatment, indicating change in preference. In contrast, before and after nectar concentrations for bees in the control group were similar. These results, taken together, support the preference hypothesis.     

Examination of the interaction between peripheral diclofenac and gabapentin on the 5% formalin test in rats

It has been shown that the association of diclofenac with other analgesic agents can increase its antinociceptive activity, allowing the use of lower doses and thus limiting side effects. Therefore, the aim of the present study was to examine the possible pharmacological interaction between diclofenac and gabapentin at the peripheral level in the rat using the 5% formalin test and isobolographic analysis. Diclofenac, gabapentin or a fixed-dose ratio diclofenac-gabapentin combination were administrated locally in the formalin-injured paw and the antinociceptive effect was evaluated using the 5% formalin test. All treatments produced a dose-dependent antinociceptive effect. ED30 values were estimated for the individual drugs and an isobologram was constructed. The derived theoretical ED30 for the diclofenac-gabapentin combination was 597.5+/-87.5 microg/paw, being significantly higher than the actually observed experimental value, 170.9+/-26.07 microg/paw. These results correspond to a synergistic interaction between diclofenac and gabapentin at the peripheral level, potency being about three times higher with regard to that expected from the addition of the effects of the individual drugs. Data suggest that low doses of the diclofenac-gabapentin combination can interact synergistically at the peripheral level and therefore this drug association may represent a therapeutic advantage for the clinical treatment of inflammatory pain.     

Preference Alters Consumptive Effects of Predators: Top-Down Effects of a Native Crab on a System of Native and Introduced Prey

Top-down effects of predators in systems depend on the rate at which predators consume prey, and on predator preferences among available prey. In invaded communities, these parameters might be difficult to predict because ecological relationships are typically evolutionarily novel. We examined feeding rates and preferences of a crab native to the Pacific Northwest, Cancer productus, among four prey items: two invasive species of oyster drill (the marine whelks Urosalpinx cinerea and Ocenebra inornata) and two species of oyster (Crassostrea gigas and Ostrea lurida) that are also consumed by U. cinerea and O. inornata. This system is also characterized by intraguild predation because crabs are predators of drills and compete with them for prey (oysters). When only the oysters were offered, crabs did not express a preference and consumed approximately 9 juvenile oysters crab⁻¹ day⁻¹. We then tested whether crabs preferred adult drills of either U. cinerea or O. inornata, or juvenile oysters (C. gigas). While crabs consumed drills and oysters at approximately the same rate when only one type of prey was offered, they expressed a strong preference for juvenile oysters over drills when they were allowed to choose among the three prey items. This preference for oysters might negate the positive indirect effects that crabs have on oysters by crabs consuming drills (trophic cascade) because crabs have a large negative direct effect on oysters when crabs, oysters, and drills co-occur.     

曲马多代谢相关基因多态性研究进展

盐酸曲马多是临床中常用的弱阿片类药物,用于治疗中度疼痛,其镇痛效果介于弱罂粟碱和吗啡之间,临床中用于术后疼痛、牙痛、和其他疼痛,镇痛效果明显,安全性好。但是由于曲马多各基因型对其药物代谢行为的影响,在临床使用中,曲马多的镇痛效果和不良反应个体差异大。为了研究对比不同种族之间曲马多代谢等位基因的分布情况,作者通过检索,对不同的人种CYP2D6的不同活性,不同人种决定该酶活性的等位基因频率,不同基因型对曲马多代谢行为的影响进行综述。     

Studies on the analgesic activities of Jia-Yuan-Qing pill and its safety evaluation in mice

The analgesic activity of Porcellio laevis Latreille, Rhizoma Corydalis, and Radix Cynanchi Paniculati have been reported in recent years. A new formula named Jia-Yuan-Qing pill (JYQP) is therefore created by combining the three herbs at 9:7:7 ratio according to traditional Chinese theories. The present study aims to evaluate the effect of JYQP as a novel painkiller in various models. Acute toxicity test was applied to evaluate the safety of JYQP. Acetic-acid-induced writhing, hot plate test, formalin test, and naloxone-pretreated writhing test were employed to elaborate the analgesic activity of JYQP and its possible mechanism. A bone cancer pain mouse model was performed to further assess the effect of JYQP in relieving cancer pain. Test on naloxone-precipitated withdrawal symptoms was conduct to examine the physical dependence of mice on JYQP. Data revealed that JYQP reduced writhing and stretching induced by acetic acid; however, this effect could not be blocked by naloxone. JYQP specifically suppressed the phase II reaction time in formalin-treated mice; meanwhile, no analgesic effect of JYQP in hot plate test was observed, indicating that JYQP exerts analgesic activity against inflammatory pain rather than neurogenic pain. Furthermore, JYQP could successfully relieve bone cancer pain in mice. No physical dependence could be observed upon long-term administration in mice. Collectively, our present results provide experimental evidence in supporting clinical use of JYQP as an effective and safe agent for pain treatment.     

Cluster analysis identifies aminoacid compositional features that indicate Toxoplasma gondii adhesin proteins

Toxoplasma gondii invade host cells using a multi-step process that depends on the regulated secretion of adhesions. To identify key primary sequence features of adhesins in this parasite, we analyze the relative frequency of individual amino acids, their dipeptide frequencies, and the polarity, polarizability and Van der Waals volume of the individual amino acids by using cluster analysis. This method identified cysteine as a key amino acid in the Toxoplasma adhesin group. The best vector algorithm of non-concatenated features was for 2 attributes: the single amino acid relative frequency and the dipeptide frequency. Polarity, polarizability and Van der Waals volume were not good classificatory attributes. Single amino acid attributes clustered unambiguously 67 apicomplexan hypothetical adhesins. This algorithm was also useful for clustering hypothetical Toxoplasma target host receptors. All of the cluster performances had over 70% sensitivity and 80% specificity. Compositional aminoacid data can be useful for improving machine learning-based prediction software when homology and structural data are not sufficient.     

Morphine and Clonidine Combination Therapy Improves Therapeutic Window in Mice: Synergy in Antinociceptive but Not in Sedative or Cardiovascular Effects

Opioids are used to manage all types of pain including acute, cancer, chronic neuropathic and inflammatory pain. Unfortunately, opioid-related adverse effects such as respiratory depression, tolerance, physical dependence and addiction have led to an underutilization of these compounds for adequate pain relief. One strategy to improve the therapeutic utility of opioids is to co-administer them with other analgesic agents such as agonists acting at α₂-adrenergic receptors (α₂ARs). Analgesics acting at α₂ARs and opioid receptors (ORs) frequently synergize when co-administered in vivo. Multimodal analgesic techniques offer advantages over single drug treatments as synergistic combination therapies produce analgesia at lower doses, thus reducing undesired side effects. This inference presumes, however, that the synergistic interaction is limited to the analgesic effects. In order to test this hypothesis, we examined the effects of α₂AR/OR combination therapy in acute antinociception and in the often-undesired side effects of sedation and cardiovascular depression in awake unrestrained mice. Morphine, clonidine or their combination was administered by spinal or systemic injection in awake mice. Antinociception was determined using the warm water tail flick assay (52.5°C). Sedation/motor impairment was evaluated using the accelerating rotarod assay and cardiovascular function was monitored by pulse oximetry. Data were converted to percent maximum possible effect and isobolographic analysis was performed to determine if an interaction was subadditive, additive or synergistic. Synergistic interactions between morphine and clonidine were observed in the antinociceptive but not in the sedative/motor or cardiovascular effects. As a result, the therapeutic window was improved ∼200-fold and antinociception was achieved at non-sedating doses with little to no cardiovascular depression. In addition, combination therapy resulted in greater maximum analgesic efficacy over either drug alone. These data support the utility of combination adrenergic/opioid therapy in pain management for antinociceptive efficacy with reduced side-effect liability.     

Identification and Prioritization of Important Attributes of Disease-Modifying Drugs in Decision Making among Patients with Multiple Sclerosis: A Nominal Group Technique and Best-Worst Scaling

ObjectivesUnderstanding the preferences of patients with multiple sclerosis (MS) for disease-modifying drugs and involving these patients in clinical decision making can improve the concordance between medical decisions and patient values and may, subsequently, improve adherence to disease-modifying drugs. This study aims first to identify which characteristics–or attributes–of disease-modifying drugs influence patients´ decisions about these treatments and second to quantify the attributes’ relative importance among patients.MethodsFirst, three focus groups of relapsing-remitting MS patients were formed to compile a preliminary list of attributes using a nominal group technique. Based on this qualitative research, a survey with several choice tasks (best-worst scaling) was developed to prioritize attributes, asking a larger patient group to choose the most and least important attributes. The attributes’ mean relative importance scores (RIS) were calculated.ResultsNineteen patients reported 34 attributes during the focus groups and 185 patients evaluated the importance of the attributes in the survey. The effect on disease progression received the highest RIS (RIS = 9.64, 95% confidence interval: [9.48–9.81]), followed by quality of life (RIS = 9.21 [9.00–9.42]), relapse rate (RIS = 7.76 [7.39–8.13]), severity of side effects (RIS = 7.63 [7.33–7.94]) and relapse severity (RIS = 7.39 [7.06–7.73]). Subgroup analyses showed heterogeneity in preference of patients. For example, side effect-related attributes were statistically more important for patients who had no experience in using disease-modifying drugs compared to experienced patients (p < .001).ConclusionsThis study shows that, on average, patients valued effectiveness and unwanted effects as most important. Clinicians should be aware of the average preferences but also that attributes of disease-modifying drugs are valued differently by different patients. Person-centred clinical decision making would be needed and requires eliciting individual preferences.     

Effects of stream predator richness on the prey community and ecosystem attributes

It is important to understand the role that different predators can have to be able to predict how changes in the predator assemblage may affect the prey community and ecosystem attributes. We tested the effects of different stream predators on macroinvertebrates and ecosystem attributes, in terms of benthic algal biomass and accumulation of detritus, in artificial stream channels. Predator richness was manipulated from zero to three predators, using two fish and one crayfish species, while density was kept equal (n = 6) in all treatments with predators. Predators differed in their foraging strategies (benthic vs. drift feeding fish and omnivorous crayfish) but had overlapping food preferences. We found effects of both predator species richness and identity, but the direction of effects differed depending on the response variable. While there was no effect on macroinvertebrate biomass, diversity of predatory macroinvertebrates decreased with increasing predator species richness, which suggests complementarity between predators for this functional feeding group. Moreover, the accumulation of detritus was affected by both predator species richness and predator identity. Increasing predator species richness decreased detritus accumulation and presence of the benthic fish resulted in the lowest amounts of detritus. Predator identity (the benthic fish), but not predator species richness had a positive effect on benthic algal biomass. Furthermore, the results indicate indirect negative effects between the two ecosystem attributes, with a negative correlation between the amount of detritus and algal biomass. Hence, interactions between different predators directly affected stream community structure, while predator identity had the strongest impact on ecosystem attributes.