***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: A group of 200 patients who presented in general practice with symptoms but no abnormal physical signs and in whom no definite diagnosis was made were r and omly selected for one of four consultations : a consultation conducted in a " positive manner , " with and without treatment , and a consultation conducted in a " non-positive manner , " called a negative consultation , with and without treatment . Two weeks after consultation there was a significant difference in patient satisfaction between the positive and negative groups but not between the treated and untreated groups . Similarly , 64 % of those receiving a positive consultation  got better , compared with 39 % of those who received a negative consultation ( p = 0.001 ) and 53 % of those treated got better compared with 50 % of those not treated ( p = 0.5 ) Summary This multifactorial mixed‐ methods r and omized controlled trial quantified the specific and nonspecific factors of acupuncture , and found that the practitioner , not the treatment , has the strongest effect on outcome . Abstract The nonspecific effects of acupuncture are well documented ; we wished to quantify these factors in osteoarthritic ( OA ) pain , examining needling , the consultation , and the practitioner . In a prospect i ve r and omised , single‐blind , placebo‐controlled , multifactorial , mixed‐ methods trial , 221 patients with OA awaiting joint replacement surgery were recruited . Interventions were acupuncture , Streitberger placebo acupuncture , and mock electrical stimulation , each with empathic or nonempathic consultations . Interventions involved eight 30‐minute treatments over 4 weeks . The primary outcome was pain ( VAS ) at 1 week posttreatment . Face‐to‐face qualitative interviews were conducted ( purposive sample , 27 participants ) . Improvements occurred from baseline for all interventions with no significant differences between real and placebo acupuncture ( mean difference −2.7 mm , 95 % confidence intervals −9.0 to 3.6 ; P = .40 ) or mock stimulation ( −3.9 , −10.4 to 2.7 ; P = .25 ) . Empathic consultations did not affect pain ( 3.0 mm , −2.2 to 8.2 ; P = .26 ) but practitioner 3 achieved greater analgesia than practitioner 2 ( 10.9 , 3.9 to 18.0 ; P = .002 ) . Qualitative analysis indicated that patients ’ beliefs about treatment veracity and confidence in outcomes were reciprocally linked . The supportive nature of the trial attenuated differences between the different consultation styles . Improvements occurred from baseline , but acupuncture has no specific efficacy over either placebo . The individual practitioner and the patient ’s belief had a significant effect on outcome . The 2 placebos  were equally as effective and credible as acupuncture . Needle and nonneedle placebos are equivalent . An unknown characteristic of the treating practitioner predicts outcome , as does the patient ’s belief ( independently ) . Beliefs about treatment veracity shape how patients self‐report outcome , complicating and confounding study interpretation OBJECTIVE To examine the causal effects of doctor-patient relations and the severity of a medical outcome on medical patient perceptions and mal practice intentions in the event of an adverse medical outcome . DESIGN R and omized between-subjects experimental design . Patients were given scenarios depicting interactions between an obstetric patient and her physician throughout the patient 's pregnancy , labor , and delivery . PARTICIPANTS One hundred twenty-eight postpartum obstetric patients were approached for participation , of whom 104 completed the study . Main outcome measures Patients ' perceptions of physician competence and intentions to file a mal practice cl aim . RESULTS Positive physician communication behaviors increased patients ' perceptions of physician competence and decreased mal practice cl aim intentions toward both the physician and the hospital . A more severe outcome increased only patients ' intentions to sue the hospital . CONCLUSION These results provide empiric evidence for a direct , causal effect of the doctor-patient relationship on medical patients ' treatment perceptions and mal practice cl aim intentions in the event of an adverse medical outcome Background Placebo effects contribute substantially to outcome in most fields of medicine . While clinical trials typically try to control or minimize these effects , the potential of placebo mechanisms to improve outcome is rarely used . Patient expectations about treatment efficacy and outcome are major mechanisms that contribute to these placebo effects . We aim ed to optimize these expectations to improve outcome in patients undergoing coronary artery bypass graft ( CABG ) surgery . Methods In a prospect i ve three-arm r and omized clinical trial with a 6 month follow-up , 124 patients scheduled for CABG surgery were r and omized to either a brief psychological pre-surgery intervention to optimize outcome expectations ( EXPECT ) ; or a psychological control intervention focusing on emotional support and general advice , but not on expectations ( SUPPORT ) ; or to st and ard medical care ( SMC ) . Interventions were kept brief to be feasible with a heart surgery environment ; “ dose ” of therapy was identical for both pre-surgery interventions . Primary outcome was disability 6 months after surgery . Secondary outcomes comprised further clinical and immunological variables . Results Patients in the EXPECT group showed significantly larger improvements in disability ( −12.6 ; −17.6 to −7.5 ) than the SMC group ( −1.9 ; −6.6 to + 2.7 ) ; patients in the SUPPORT group ( −6.7 ; −11.8 to 1.7 ) did not differ from the SMC group . Comparing follow-up scores and controlling for baseline scores of EXPECT versus SUPPORT on the variable disability only revealed a trend in favor of the EXPECT group ( P = 0.09 ) . Specific advantages for EXPECT compared to SUPPORT were found for mental quality of life and fitness for work ( hours per week ) . Both psychological pre-surgery interventions induced less pronounced increases in pro-inflammatory cytokine concentrations reflected by decreased interleukin-8 levels post-surgery compared to changes in SMC patients and lower interleukin-6 levels in patients of the EXPECT group at follow-up . Both pre-surgery interventions were characterized by great patient acceptability and no adverse effects were attributed to them . Considering the innovative nature of this approach , replication in larger , multicenter trials is needed . Conclusions Optimizing patients ’ expectations pre-surgery helps to improve outcome 6 months after treatment . This implies that making use of placebo mechanisms has the potential to improve long-term outcome of highly invasive medical interventions . Further studies are warranted to generalize this approach to other fields of medicine . Trial registration Ethical approval for the study was obtained from the IRB of the Medical School , University of Marburg , and the trial was registered at ( NCT01407055 ) on July 25 , 2011 Variations in treatment effects between drug trials are usually attributed to different patient characteristics , variations in outcome assessment , and r and om error . We have previously hypothesized that part of the variation in treatment effects between drug trials might be caused by differences in nonspecific factors . In a r and omized clinical trial , we aim ed to investigate whether experimentally induced expectancy can modify the analgesic effect of tramadol relative to placebo in chronic pain patients . In a 2 x 2 factorial , r and omized , placebo-controlled , double-blind trial , chronic pain patients attending a chronic pain outpatient clinic were r and omized to receive a single oral dose of 50 mg tramadol or placebo , and they were further r and omized to receive positive or neutral information , verbally expressed by the physician , regarding the expected analgesic effect of the drug .  Pain intensity was measured using a 10 centimeter visual analogue scale at baseline , and 0.5 , 1 , 2 , 4 , 6 , and 8 hours after baseline . The one-hour pain intensity difference , calculated as the sum of pain intensity differences between baseline and 0.5 and 1 hour , was taken as main outcome measure . The one-hour sum of pain intensity differences of 28 patients treated after positive expectation and r and omized to tramadol was 1.4 cm , while in 27 patients r and omized to placebo , it was 0.8 cm . This corresponds with an analgesic effect of tramadol relative to placebo of 0.6 cm ( 95 % confidence interval [ CI ] , -0.5 cm to 1.8 cm ) . The 28 patients in the neutral expectancy group who were r and omized to tramadol reported a 1.4 cm decrease on the sum of pain intensity differences , while 28 patients in the placebo group reported a 0.9 cm decrease . This corresponds with an analgesic effect of tramadol relative to placebo of 0.5 cm ( 95 % CI , -0.9 cm to 1.8 cm ) . The 0.1 cm difference ( 0.6 cm - 0.5 cm ) in analgesic effect between positive and neutral expectancy group was not statistically significant ( 95 % CI , -0.7 cm to 1.0 cm ) . This trial did not discern a significant difference in the analgesic effect of tramadol between a positive and neutral expectancy group . This means that the phenomenon either does not exist , or we had an inappropriate model to demonstrate it . Regardless , this study demonstrates the type of quality trial that should be done to find out which non-specific factors , such as information regarding the expected effect , can modify treatment effects BACKGROUND Clinicians frequently warn patients of discomfort before potentially painful procedures , despite the lack of evidence that such communications are helpful . We aim ed to compare two communications ( one with , and the other without , a warning of a ' sting ' ) immediately before i.v . cannulation in order to measure differences in perceived pain by patients during the procedure . METHODS R and omly assigned patients awaiting elective surgery received a communication immediately before i.v . cannulation consisting of either ' I am going to apply the tourniquet and insert the needle in a few moments . It 's a sharp scratch and it may sting a little ' ( Group S ) or ' I am going to apply the tourniquet on the arm . As I do this many people find the arm becomes heavy , numb and tingly . This allows the drip to be placed more comfortably ' ( Group NS ) . Cannulation pain was measured by a 0 - 10 verbal numerical rating score ( VNRS ) and five-point Likert scale . RESULTS Of 101 participants , 49 were allocated to Group S and 52 to Group NS .  Median VNRS pain scores with inter-quartile ranges ( IQR ) were 1 and 2 , respectively , for both groups . Median Likert scores were 3 in Group S and 2 in Group NS with an IQR of 1 for both groups ( P = 0.13 ) . Six participants vocalized pain in Group S and none in Group NS ( P = 0.01 ) . Three participants withdrew their arm spontaneously in Group S and none in Group NS ( P = 0.11 ) . CONCLUSIONS Warning patients of a ' sting ' before i.v . cannulation may not be helpful BACKGROUND The impact of changing non-verbal consultation behaviours is unknown . AIM To assess brief physician training on improving predominantly non-verbal communication . DESIGN AND SETTING Cluster r and omised parallel group trial among adults aged ≥16 years attending general practice s close to the study coordinating centres in Southampton . METHOD Sixteen GPs were r and omised to no training  , or training consisting of a brief presentation of behaviours identified from a prior study ( acronym KEPe Warm : demonstrating Knowledge of the patient ; Encouraging [ back-channelling by saying ' hmm ' , for example ] ; Physically engaging [ touch , gestures , slight lean ] ; Warm-up : cool/professional initially , warming up , avoiding distancing or non-verbal cut-offs at the end of the consultation ) ; and encouragement to reflect on videos of their consultation . Outcomes were the Medical Interview Satisfaction Scale ( MISS ) mean item score ( 1 - 7 ) and patients ' perceptions of other domains of communication . RESULTS Intervention participants scored higher MISS overall ( 0.23 , 95 % confidence interval [ CI ] = 0.06 to 0.41 ) , with the largest changes in the distress-relief and perceived relationship subscales . Significant improvement occurred in perceived communication/partnership ( 0.29 , 95 % CI = 0.09 to 0.49 ) and health promotion ( 0.26 , 95 % CI = 0.05 to 0.46 ) . Non-significant improvements occurred in perceptions of a personal relationship , a positive approach , and underst and ing the effects of the illness on life . CONCLUSION Brief training of GPs in predominantly non-verbal communication in the consultation and reflection on consultation videotapes improves patients ' perceptions of satisfaction , distress , a partnership approach , and health promotion BACKGROUND Placebos are hypothesized to exert positive effects on medical conditions by enhancing patient expectancies . Recent review s suggest that placebo benefits are restricted to subjective responses , like pain , but might be ineffective for objective physiologic outcomes . Nevertheless , mind-body links and placebo responsivity in asthma are widely believed to exist . OBJECTIVE We carried out a r and omized , double-blind investigation to ( 1 ) determine whether placebo can suppress airway hyperreactivity in asthmatic subjects , ( 2 ) quantify the placebo effect , ( 3 ) identify predictors of the placebo response , and ( 4 ) determine whether physician interventions modify the placebo response . METHODS In a double-blind , crossover design investigation , 55 subjects with mild intermittent and persistent asthma with stable airway hyperreactivity were r and omized to placebo or salmeterol before serial methacholine challenges . Subjects were additionally r and omized to physician interactions that communicated either positive or neutral expectancies regarding drug effect . RESULTS Placebo bronchodilator administration significantly reduced bronchial hyperreactivity compared with baseline ( the calculated concentration of methacholine required to induce a 
    Output:
    
Conclusions Greater practitioner empathy or communication of positive messages can have small patient benefits for a range of clinical conditions , especially pain .