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David Spiegel

Bio: David Spiegel is an academic researcher from Stanford University. The author has contributed to research in topics: Medicine & Breast cancer. The author has an hindex of 106, co-authored 733 publications receiving 46276 citations. Previous affiliations of David Spiegel include Tel Aviv University & University of Adelaide.


Papers
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Journal ArticleDOI
21 Oct 2004-BMJ
TL;DR: Doctors use them, they work in some conditions, but the authors don't know how they work.
Abstract: Placebo comes from the Latin for “I will please.” Pleasing a patient would seem to be a good thing to do. Yet considerable controversy exists about the use of a biologically inert or irrelevant substance with therapeutic intent. Nitsan and Lichtenberg show in this issue (p 944) that placebos are often used in modern medicine.1 Their survey of 89 doctors and nurses providing hospital based and ambulatory care in Israel found that 60% used placebos in their practice, most often (43%) to fend off an “unjustified” demand for medication, to calm a patient (38%), as an analgesic (38%), or, more problematically, as a diagnostic tool (28%). The paper makes it clear that the placebo pleases modern doctors. Should it? If the placebo effect is real, is it right to use it? Most of medicine used placebos at one time. Medicine in the 20th century was supposed to end this. We would use only scientifically proved active pharmacological and surgical interventions. Yet only about half of medical treatments are supported by evidence.2 A conference held at the National Institutes of Health in the United States in 2002 reviewed the evidence and concluded that we needed more science, not fewer placebos.3 It called for research on brain and body pathways that mediate placebo effects, and for optimising the use of the placebo phenomenon while attending to ethical and practical concerns about it. The response to placebos varies widely across different cultures, but the myth that placebo responders are uneducated, unintelligent, free of serious medical illness, or histrionic was not supported by current research.w1 The conference also noted the importance of the nocebo effect—negative expectations can produce negative results.w2 In the 19th century, for example, tomatoes were believed to be poisonous, and many people were treated in hospitals for symptoms of tomato poisoning.w3 Doubts have been raised about the usefulness of the placebo in conditions other than pain. A recent meta-analysis and related Cochrane report found little evidence that using a placebo improved symptoms, with the exception of pain relief.4,5 This meta-analysis had numerous problems.6 It lumped together 40 heterogeneous outcome assessments and further restricted the power to detect an effect by dichotomising them as improved or not, rather than treating these outcomes as continuous variables. The one analysis that did treat outcome continuously found a significant effect—reduction in pain. What this meta-analysis really showed is not that the placebo doesn't cure anything, but rather that it does not cure everything. Despite such scientific scepticism, the placebo phenomenon seems to influence the behaviour of patients and doctors. The growth of patients' interest in integrative or holistic medicine in the past decade is perhaps a reaction to the growth of evidence based medicine.7,8 Most placebos are relatively harmless. Modern medicine involves treatments, such as surgery, chemotherapy, and bone marrow transplantation, that are effective but also toxic. Many patients may choose integrative medicine as a kinder and gentler treatment that harnesses rather than eschews the placebo effect and engages them as participants in their care, especially in the treatment of chronic problems such as anxiety and pain that are often not well managed in medicine.w4 That an idea, feeling, or relationship can have a real effect on the body is now established. Scientific domains such as psychoneuroimmunology and psychoneuroendocrinology are helping us to understand mechanisms whereby belief in benefit might affect resistance to disease, for example as a form of stress reduction with physiological consequences. Considerable evidence indicates that depression, for example, affects outcome in heart disease and cancer.9,10 In the survey by Nitsan and Lichtenberg, few doctors (15%) used placebos without deception.1 However, deception is not a necessary component of the placebo response. Many have justifiable ethical concerns about deliberately deceiving patients regarding the nature of their treatment. But perhaps therapeutic intent and expectation are sufficient to mobilise healing in patients.w5 The use of the placebo as a diagnostic tool by 28% of respondents is more troubling, as the authors note. That a patient gets pain relief from a placebo does not imply that the pain is not real or organic in origin. Ample evidence shows that psychological interventions such as hypnosis can alter the perception of pain dramatically. Beecher noted that grievously wounded soldiers on the Anzio beachhead required less analgesia than less seriously injured patients in Boston.11 Their intense desire to survive overrode their focus on the pain of their injuries. Psychological factors such as redirected attention, distraction, and changes in perceived meaning of real pain can alter its intensity. Thus the use of the placebo for “diagnosis” of whether or not pain is real is misguided. The placebo effect, thought of as the result of the inert pill, can be better understood as an effect of the relationship between doctor and patient.12 Adding the doctor's caring to medical care affects the patient's experience of treatment, reduces pain, and may affect outcome. This survey makes it clear that doctors continue to use placebos, and most think they help. We cannot afford to dispense with any treatment that works, even if we are not certain how it does.

43 citations

Journal ArticleDOI
TL;DR: There was no significant difference in change scores on any of the traditional risk factors or C-reactive protein, cortisol measures, or cardiovascular physiology, except for triglyceride levels and heart rate, which were significantly lower in treatment compared to control subjects.

43 citations

Journal ArticleDOI
TL;DR: A plantigrade foot was achieved in 46 feet (84%) without an extensive soft-tissue release or bony procedure, although under-correction was common, and longer-term follow-up will be required to assess the outcome.
Abstract: Our goal was to evaluate the use of Ponseti's method, with minor adaptations, in the treatment of idiopathic clubfeet presenting in children between five and ten years of age. A retrospective review was performed in 36 children (55 feet) with a mean age of 7.4 years (5 to 10), supplemented by digital images and video recordings of gait. There were 19 males and 17 females. The mean follow-up was 31.5 months (24 to 40). The mean number of casts was 9.5 (6 to 11), and all children required surgery, including a percutaneous tenotomy or open tendo Achillis lengthening (49%), posterior release (34.5%), posterior medial soft-tissue release (14.5%), or soft-tissue release combined with an osteotomy (2%). The mean dorsiflexion of the ankle was 9° (0° to 15°). Forefoot alignment was neutral in 28 feet (51%) or adducted ( 10° in seven feet (13%). Hindfoot alignment was neutral or mild valgus in 26 feet (47%), mild varus ( 10°) in ten feet (18%). Heel-toe gait was present in 38 feet (86%), and 12 (28%) exhibited weight-bearing on the lateral border (out of a total of 44 feet with gait videos available for analysis). Overt relapse was identified in nine feet (16%, six children). The parents of 27 children (75%) were completely satisfied. A plantigrade foot was achieved in 46 feet (84%) without an extensive soft-tissue release or bony procedure, although under-correction was common, and longer-term follow-up will be required to assess the outcome.

43 citations

Journal ArticleDOI
TL;DR: The results indicate that the ARBQ has good psychometric characteristics, supporting the feasibility of its use in measuring abuse-related beliefs in research on survivors of childhood sexual abuse.

43 citations


Cited by
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28 Jul 2005
TL;DR: PfPMP1)与感染红细胞、树突状组胞以及胎盘的单个或多个受体作用,在黏附及免疫逃避中起关键的作�ly.
Abstract: 抗原变异可使得多种致病微生物易于逃避宿主免疫应答。表达在感染红细胞表面的恶性疟原虫红细胞表面蛋白1(PfPMP1)与感染红细胞、内皮细胞、树突状细胞以及胎盘的单个或多个受体作用,在黏附及免疫逃避中起关键的作用。每个单倍体基因组var基因家族编码约60种成员,通过启动转录不同的var基因变异体为抗原变异提供了分子基础。

18,940 citations

Journal ArticleDOI
TL;DR: Correlational, quasi-experimental, and laboratory studies show that the MAAS measures a unique quality of consciousness that is related to a variety of well-being constructs, that differentiates mindfulness practitioners from others, and that is associated with enhanced self-awareness.
Abstract: Mindfulness is an attribute of consciousness long believed to promote well-being. This research provides a theoretical and empirical examination of the role of mindfulness in psychological well-being. The development and psychometric properties of the dispositional Mindful Attention Awareness Scale (MAAS) are described. Correlational, quasi-experimental, and laboratory studies then show that the MAAS measures a unique quality of consciousness that is related to a variety of well-being constructs, that differentiates mindfulness practitioners from others, and that is associated with enhanced selfawareness. An experience-sampling study shows that both dispositional and state mindfulness predict self-regulated behavior and positive emotional states. Finally, a clinical intervention study with cancer patients demonstrates that increases in mindfulness over time relate to declines in mood disturbance and stress. Many philosophical, spiritual, and psychological traditions emphasize the importance of the quality of consciousness for the maintenance and enhancement of well-being (Wilber, 2000). Despite this, it is easy to overlook the importance of consciousness in human well-being because almost everyone exercises its primary capacities, that is, attention and awareness. Indeed, the relation between qualities of consciousness and well-being has received little empirical attention. One attribute of consciousness that has been much-discussed in relation to well-being is mindfulness. The concept of mindfulness has roots in Buddhist and other contemplative traditions where conscious attention and awareness are actively cultivated. It is most commonly defined as the state of being attentive to and aware of what is taking place in the present. For example, Nyanaponika Thera (1972) called mindfulness “the clear and single-minded awareness of what actually happens to us and in us at the successive moments of perception” (p. 5). Hanh (1976) similarly defined mindfulness as “keeping one’s consciousness alive to the present reality” (p. 11). Recent research has shown that the enhancement of mindfulness through training facilitates a variety of well-being outcomes (e.g., Kabat-Zinn, 1990). To date, however, there has been little work examining this attribute as a naturally occurring characteristic. Recognizing that most everyone has the capacity to attend and to be aware, we nonetheless assume (a) that individuals differ in their propensity or willingness to be aware and to sustain attention to what is occurring in the present and (b) that this mindful capacity varies within persons, because it can be sharpened or dulled by a variety of factors. The intent of the present research is to reliably identify these inter- and intrapersonal variations in mindfulness, establish their relations to other relevant psychological constructs, and demonstrate their importance to a variety of forms of psychological well-being.

9,818 citations

01 Jan 2014
TL;DR: These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care.
Abstract: XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

9,618 citations

Journal ArticleDOI
TL;DR: The following Clinical Practice Guidelines will give up-to-date advice for the clinical management of patients with hepatocellular carcinoma, as well as providing an in-depth review of all the relevant data leading to the conclusions herein.

7,851 citations