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1. Describe the process of calcification 

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1. Describe the process of calcification 

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Calcification is the accumulation of calcium salts in a body tissue, it normally occurs when calcium builds up in blood vessels, body tissue, or organs. The process in which calcium builds up can harden and disrupt body’s normal processes. In addition, calcium is transported through the bloodstream. It is also found in every cell. As a result, calcification can occur in almost any part of the body (Healthline, 2018)

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2. Choose one (1) principal effect of ageing on Francine’s bone tissue which may have contributed to her fracture. Describe the effect and identify a possible consequence /disease that may occur as a result

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2. Choose one (1) principal effect of ageing on Francine’s bone tissue which may have contributed to her fracture. Describe the effect and identify a possible consequence /disease that may occur as a result

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Low calcium in bone tissue is one of the significant effects to cause Francine’s femur fracture. Because it contributes to decrease bone density, and increase risk of fractures. Moreover, a lack of calcium plays a role in development of osteoporosis. As a result, the possible disease that may occur is osteoporosis (Mecialnewstoday, 2021).

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3. Healing a fracture can sometimes take months. Provide a detailed rationale as to why this occurs

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3. Healing a fracture can sometimes take months. Provide a detailed rationale as to why this occurs

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After a fracture, a hematoma forms that provides building blocks for healing. Thus, reabsorption occurs of the 1 to 2 mm of bone at the fracture edges that have lost their blood supply (Uptodate, 2021). Once the bone fragments receive an adequate supply of blood and nutrients, the new tissue merges the fragments together into a single bone. A fracture in which the bone does produce new tissue but does so very slowly—over months.

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4. Francine underwent a bone mineral density [BMD] test. She was diagnosed with osteoporosis. Outline three(3) factors that may contribute to porous bones. 

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4. Francine underwent a bone mineral density [BMD] test. She was diagnosed with osteoporosis. Outline three(3) factors that may contribute to porous bones. 

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Dietary factors, steroids and other medications and lifestyle choices contribute to porous bones. Firstly, osteoporosis is more likely to occur in people who have low calcium intake, eating disorders, gastrointestinal surgery. Secondly, steroids and other medications, long-term use of oral or injected corticosteroid medications, interfers with the bone-rebuilding process. Thirdly, people’s lifestyle choices, some bad habits can increase your risk of osteoporosis such as excessive alcohol consumption and tobacco use (Mayo Clinic, 2021).

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5. Diet plays an important role in the ongoing management of Francine’s condition. Choose three (3) nutrientsthat impact the skeletal system and describe how they contribute to bone metabolism and repair. 

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5. Diet plays an important role in the ongoing management of Francine’s condition. Choose three (3) nutrientsthat impact the skeletal system and describe how they contribute to bone metabolism and repair. 

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Three nutrients are protein, calcium and vitamin D. Firstly, protein makes up roughly 50% of the volume of bone, and the bone protein matrix go through continuous turnover and remodelling. In bone, secondly, calcium offers skeletal strength to maintain constant blood calcium levels. Thus, calcium is required for skeletal growth, development and maintenance. Thirdly, Vitamin D improves your body's ability to absorb calcium and improves bone health in other ways (Cells&materials, 2021).

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1. Name the collective structure where Botox exerts its action and identity specific components (minimum of four) within the structure. 

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1. Name the collective structure where Botox exerts its action and identity specific components (minimum of four) within the structure. 

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Botox acts at the neuromuscular junction to make muscle paralysis by inhibiting the release of acetylcholine from presynaptic motor neurons (NCBI, 2021). Four specific components are muscle fibre contracts in regard to muscle action potential, synaptic cleft to separate the neuron and the muscle cell, axon terminal and ACh receptor.

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2. Outline the role that calcium plays in the initiation of a muscle action potential. 

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2. Outline the role that calcium plays in the initiation of a muscle action potential. 

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Ca ions plays a crucial role in both muscle cell contraction and relaxation. It binds to the troponin complex, causing tropomyosin bound along the actin strands to shift position and expose the myosin binding sites on the thin filament. When calcium binds to troponin, the troponin changes shape, removing tropomyosin from the binding sites. The sarcoplasmic reticulum stores calcium ions, which it releases when a muscle cell is stimulated, the calcium ions then enable the cross-bridge muscle contraction cycle.

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3. How does Botulinum Neurotoxin A prevent the initiation of a muscle action potential at the structure identified in Q. 1?

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3. How does Botulinum Neurotoxin A prevent the initiation of a muscle action potential at the structure identified in Q. 1?

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Botox provides chemodenervation and temporary muscle paralysis by inhibiting the presynaptic release of ACh. ACh attaches to receptors on the muscle cells and causes the cells to contract. Botox injections prevent the release of ACh, which stops the muscle cells from contracting. In this way, the toxin helps the muscles to become less stiff.

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4. Outline the role that sodium plays in the production of a muscle action potential. 

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4. Outline the role that sodium plays in the production of a muscle action potential. 

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ACh binds to postsynaptic receptors on the sarcolemma. This binding causes ion channels to open and allows sodium and other cations to flow across the membrane into the muscle cell. The flow of sodium ions across the membrane into and potassium ions out of the muscle cell generates an action potential, which travels to the myofibril and results in muscle contraction

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5. Botulinum Neurotoxin A can also be used for dystonic conditions. Define muscle tone and outline the mechanism by which muscles maintain it. Identify which tonic disorder can be treated by Botox. 

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5. Botulinum Neurotoxin A can also be used for dystonic conditions. Define muscle tone and outline the mechanism by which muscles maintain it. Identify which tonic disorder can be treated by Botox. 

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Muscle TONE is defined as the tension in a muscle at rest (Breakthrough ,2017). It is the muscle’s response to an outside force, such as a stretch or change in direction (Breakthrough ,2017). Appropriate muscle tone enables our bodies to quickly respond to a stretch (Breakthrough, 2017). For example, if someone took your arm and quickly straightened your elbow, your biceps muscle would automatically respond and contract in response to protect you from injury (Breakthrough ,2017).

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1. Name the specific neuronal component that is affected in the disease and describe its associated structure (including the neuroglia involved).

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1. Name the specific neuronal component that is affected in the disease and describe its associated structure (including the neuroglia involved).

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CNS includes brain and spinal cord. And neuroglia makes up half volume of CNS, the main function of neuroglia is support and protect neurons and axon. And neuroglia includes four types of cells, which are astrocytes, oligodendrocytes, ependymal cells and microglia. If neuroglia damaged, it will reduce the level of protection of CNS, the disease will happen (Healthline, 2021).

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2. Outline how damage to the above component affects the functioning of the neuron and why axons in the CNS display minimal regeneration after injury. 

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2. Outline how damage to the above component affects the functioning of the neuron and why axons in the CNS display minimal regeneration after injury. 

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The four types of neuroglia are, 1st, astrocytes attach to blood vessels, star-shaped cells, provide nourishment and support; 2nd, oligodendrocytes form myelin in brain and spinal cord; 3rd, Microglia-if bacteria comes in brain it will clean them out and help fight; last one is ependymal. Inhibitors exists in the environment, it affects the generation of axon.

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3. Compare and contrast continuous and saltatory conduction of the nerve impulse. Answer must include at least one similarity.

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3. Compare and contrast continuous and saltatory conduction of the nerve impulse. Answer must include at least one similarity.

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Saltatory and continuous conduction are two types of transmission of action potentials along the nerves. The main difference between saltatory and continuous conduction is that saltatory conduction is the propagation of action potential along myelinated axons while continuous conduction is the propagation of action potential along unmyelinated axons (Difference between, 2019). Saltatory conduction occurs in myelinated axons from one node of Ranvier to the next node. Therefore, the action potential is only generated at the neurofibrils in myelinated axons. Hence, it carries impulses at a faster rate than continuous propagation. On the other hand, continuous conduction is slow because there is always voltage-gated Na⁺ channels opening, and more and more Na⁺ is rushing into the cell.

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4. Many individuals with MS experience impairment of proprioception and vibrational sensation. Name and describe the function of each of the components of the somatosensory pathways.

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4. Many individuals with MS experience impairment of proprioception and vibrational sensation. Name and describe the function of each of the components of the somatosensory pathways.

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Proprioception sensation is the sense that lets us perceive the position of the body and its parts (Science direct, 2018). For examples, if proprioception sensation damaged, when people close their eyes, they cannot even find their nose.

Vibratory sensation is the sense of vibration, and may refer to: Vibration as a modality of cutaneous receptors (on the skin), referred to as pallesthesia. Hearing, which is sensation of air vibrations (Science direct, 2018). For instance, people got vibration sensation damaged, won’t be able to feel the vibrations.

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5. Which specific somatosensory pathway is affected when an individual with MS experiences the loss of the sensations identified in Q. 4? Name two (2) specific areas in the cerebral cortex that may be affected when experiencing loss of vibrational sensation and proprioception and provide rationale for answer. 

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5. Which specific somatosensory pathway is affected when an individual with MS experiences the loss of the sensations identified in Q. 4? Name two (2) specific areas in the cerebral cortex that may be affected when experiencing loss of vibrational sensation and proprioception and provide rationale for answer. 

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Somatosensory Cortex Primary somatosensory cortex (SI) is located in the post central gyrus (Brodmann's areas 1,2,3) (Lumen,2021). This contains a somatotopic map, as does the thalamus, and in both structures the map of the body surface is distorted, depending on the density of sensory innervation in each part of the body (Lumen,2021). The hands, feet, genitalia and lips are the most sensitive areas (with the most dense innervation relative to the other areas) and these areas of the body surface have a relatively huge representation on the cortex. Therefore, the sensory homunculus is grossly distorted with large areas of cortex given over to handling information arising in the most sensitive areas of the body. Damage to the sensory cortex results in decreased sensory thresholds, an inability to discriminate the properties of tactile stimuli or to identify objects by touch (Lumen, 2021)

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1. Name the two (2) thyroid hormones affected by the above disease and identify the cells that produce them. 

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1. Name the two (2) thyroid hormones affected by the above disease and identify the cells that produce them. 

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Two thyroid hormones are triiodothyronine (T3) and thyroxine (T4), and follicular cells are the derivates of endoderm and secrete thyroid hormone and produce (T3) and (T4).

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2. Describe the mechanism of action of thyroid hormones from release into the blood stream through to the response of the target cell.

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2. Describe the mechanism of action of thyroid hormones from release into the blood stream through to the response of the target cell.

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1.Lodide trapping is the first step in the metabolism of iodine and, found in the basolateral membrane of the follicular cells

2.Synthesis of thyroglobulin (TGB) then release into lumen

3. Oxidation of iodide to iodine (I2)

4. Iodination of tyrosine in colloid (tyrosine + 1I2=T1) (tyrosine + 2I2=T2)

5. Coupling of T1 & T2 to form T3 & T4

6. Pinocytosis & digestion of colloid into follicular cell; merges with lysosome; T3&T4 cleaved from TGB

7. Secretion of T3 & T4 into blood

8. Thyroid hormone cannot exist in blood by itself, it needs to combine with thyroxine-binding globulin (TBG) and transported into blood.

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3. The synthetic thyroid hormone replaces the deficient production of the endogenous thyroid hormone. Discuss two (2) actions of thyroid hormone within the body. 

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3. The synthetic thyroid hormone replaces the deficient production of the endogenous thyroid hormone. Discuss two (2) actions of thyroid hormone within the body. 

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The thyroid hormones act on nearly every cell in the body. It acts to increase the basal metabolic rate, affect protein synthesis, help regulate long bone growth and neural maturation, and increase the body's sensitivity to catecholamines by permissiveness. And also, thyroid hormone stimulates Na-K-APTASE activity in responsive tissues and differentially regulates Na-K-ATPase isoforms.

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4. Hormonal axes are pathways that direct neuroendocrine function. Identify the relevant axis, in this case, and describe the associated control and regulation of thyroid hormones. Include the relevant organs, hormones and cells from which they are released/produced 

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4. Hormonal axes are pathways that direct neuroendocrine function. Identify the relevant axis, in this case, and describe the associated control and regulation of thyroid hormones. Include the relevant organs, hormones and cells from which they are released/produced 

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To reach a particular threshold, the homeostasis of circulating thyroid hormone levels is maintained by negative feedback loops repressing thyroid-stimulating hormone-releasing hormone (TRH) and TSH production and release by the hypothalamus and the pituitary gland, respectively. In addition, T4 and T3 can then exert negative feedback on TSH levels (high levels of T3/T4 decrease TSH release from the anterior pituitary, while low levels of T3/T4 increase TSH release). Firstly, Low blood levels of T3 & T4, stimulates release of TRH from hypothalamus. Then next, TRH, carried by hypophyseal portal veins to anterior pituitary, stimulates release of TSH by thyrotroph. Thirdly, TSH released into blood stimulates thyroid follicular cells. Then, T3 and T4 released into blood by follicular cells. And the last step is elevated T3 inhibits release of TRH and TSH.

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Nutrients and Dietary Patterns Related to Osteoporosis

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Nutrients and Dietary Patterns Related to Osteoporosis

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2. Osteoporosis and Related Nutrients

2.1. Calcium, Vitamin D and Dairy Products

Calcium and vitamin D form part of the bone mineral matrix as calcium phosphate (hydroxyapatite crystals) and are required for bone strength. The best way to achieve adequate calcium intake is through adhering to a healthy diet. However, sometimes dietary sources are insufficient or poorly tolerated, and, in those situations, pharmacological calcium supplementation could be useful. This is the recommendation of most clinical practice guidelines [ 4, 5, 6, 7]. However, some authors are critical of this recommendation due to its low efficacy and the possibility of adverse effects [ 7]. The most important sources of calcium in the diet are dairy products (milk, yogurt and cheese), fish (especially sardines with bones), pulses and a few vegetables and fruits (particularly nuts and seeds).

Calcium homeostasis is, predominantly, regulated by vitamin D. A total of 80-90% of vitamin D is obtained from cutaneous synthesis after sunlight exposure, and 10-20%, from a limited number of foods, such as oily fish, mushrooms and some fortified dairy products. Nevertheless, no foods can provide enough vitamin D to meet requirements. There is a potential role for the fortification of different foods to increase vitamin D intakes.

Adequate sunlight exposure is important for preventing and correcting vitamin D insufficiency. Vitamin D deficiency has deleterious consequences for health outcomes, and this vitamin is extremely important for bone health maintenance. In elderly or postmenopausal women, vitamin D deficiency may aggravate osteoporosis. Additionally, adequate concentrations of 25-hydroxyvitamin D (25(OH)D) are necessary for maximizing the efficacy of anti-osteoporotic drugs [ 8]. Furthermore, vitamin D is involved in maintaining muscle mass and strength as well as bone structure. High efficacy has been demonstrated for certain vitamin D-fortified foods, such as reduced-fat cheese and vitamin D-biofortified eggs [ 9, 10].

A recent meta-analysis of the impact of vitamin D-fortified foods on serum 25(OH)D levels, bone mineral density (BMD) and bone turnover markers (BTM) showed significant effects, with an increase in serum 25(OH)D and BMD and decrease in parathormone (PTH) levels. No significant beneficial effect on BTM was found [ 11].

Dairy products are the main food sources providing bone-beneficial nutrients, such as calcium, phosphorus and magnesium and these elements have a morphological role in bone healthy structure. Dairy products are also a source of protein, vitamin B-12, zinc, potassium and riboflavin. Dairy products could also be considered as a remarkable source of vitamin D if fortified with such. Vitamin D concentrations based on weight are higher in yogurt and cheese than in milk, but the serving sizes are typically smaller for these products than for milk. shows the main nutrient content per 100 g of commonly consumed foods.

Table 1

Therefore, the regular consumption of plain dairy products or those fortified with calcium and/or vitamin D may increase the total body bone mineral content (BMC). However, this association varies depending on ethnicity. In Caucasian and Chinese women, calcium from (fortified) dairy products increased BMD by 0.7-1.8% over 2 years, depending on the site of measurement (lumbar spine, total hip, femoral neck or total body). In adult Caucasian women, a daily intake of 200-250 mL of milk has been associated with a 5% or higher reduction in fracture risk [ 12]. Another large prospective study recently showed a significant 8% reduction in the risk of hip fracture for each daily serving of milk, in men and women combined, which was evaluated every 4 years. Moreover, milk intake was shown to reduce the risk of osteoporotic fractures by 5-15% in an individual patient data cohort, especially in older patients (80 years or more) [ 13]. In a cohort of postmenopausal healthy women, the daily consumption of milk fortified with calcium and vitamin D significantly improved vitamin D status and BMD at the femoral neck, as well as having favorable effects on glucose and lipid profiles [ 14]. The data on this effect in males are more limited.

Fermented milk products, such as yogurt or soft cheese, are also an important source of calcium, phosphorus, and protein. Fermented milk is interesting because it may contain prebiotics and provide probiotics. For example, inulin (a prebiotic) may be added to yogurt. Furthermore, probiotics are able to improve intestinal calcium absorption and bone metabolism. Bone mass balance and the attenuation of sex hormone deficiency-induced bone loss (especially important after menopause) seemed to improve after the intake of calcium, protein, prebiotics and probiotics. These compounds may change the gut microbiota composition and metabolism. Fermented milk product consumption might also be considered as a marker of healthy lifestyle promoting bone maintenance [ 15].

In animal models, probiotics have been shown to inhibit the bone loss associated with estrogen deficiency, diabetes, or glucocorticoid treatments, by regulating both bone resorption and formation [ 16]. In humans, probiotics alter 25(OH)D levels and calcium absorption, and slightly decrease bone loss in elderly postmenopausal women to a similar extent as vitamin D supplements with or without calcium combination [ 17]. Fermented dairy products are an important dietary source of probiotics, which can improve calcium homeostasis, prevent secondary hyperparathyroidism, and inhibit age-related increases in bone resorption and bone loss. Further studies are needed to establish whether probiotics or any other intervention targeting the gut microbiota and its metabolites may be considered as adjuvant treatments for use alongside calcium and vitamin D supplementation or anti-osteoporotic drugs for the management of patients with fragility and low bone mass [ 18].

Unfortunately, a low calcium intake and a suboptimal vitamin D status are very common in the elderly in Europe. The daily consumption of calcium and vitamin D-fortified food products (most commonly yogurt or milk) can help to improve vitamin D intake [ 19]. Yogurt consumption may guarantee a more regular ingestion of dairy products and higher adherence to their consumption, because of various flavors and sweetness levels. However, not enough studies addressing bone remodeling markers, other than BMD or BMC, allowing a good comparison between the effect of dairy products and other food sources on bone quality are available.

Not all of the available information supports the idea of a high intake of dairy products being beneficial for bone [ 20]. In the US, data from the NHANES III population-based survey, including a cohort of nearly 10,000 women and men, showed no correlation between calcium intake and BMD at the hip site, and the correlation was more applicable for subjects with higher levels of 25(OH)D [ 21]. Only women with higher 25(OH)D levels seemed to benefit from a higher calcium intake. Other meta-analyses based on prospective studies were not able to associate a higher milk intake or total dairy product consumption with the risk of hip fracture in women or men [ 22, 23]. The Study of Women's Health Across the Nation (SWAN) recently tried to demonstrate the benefits of dairy intake for bones, but its results were not positive for long-term bone health. It is important to mention that this study was a multicenter, multi-ethnic, community-based longitudinal cohort project that included women during their middle years around the menopause transition period [ 24]. The benefit of dairy consumption for preserving BMD or preventing fractures could not be established. However, when interpreting these results, the authors reported that dairy intake was low among SWAN participants, and this fact could have influenced their results.

The potential beneficial role of dairy products in the prevention of fractures is controversial [ 25]. Moreover, a higher consumption of milk or yogurt could be related with a lower risk of hip fracture although with some differences between populations with different characteristics [ 26]. The inconsistent results found regarding the possible association between milk consumption and the risk of hip fracture could be partially explained by the differences in policies about vitamin D fortification across different countries.

In conclusion, the beneficial role of dairy products in bone health has been more extensively established in Chinese and Caucasian girls and women [ 27], but these results could not be replicated for other populations. Nevertheless, the available evidence is insufficient because studies on calcium alone and other dairy products are limited in size, number, and duration and advanced research on the influence of dairy products within the context of bone health-promoting diets in specific ethnic groups, other than the above-mentioned studies, is needed [ 27].

In summary, it is very difficult to differentiate between the effects of dairy intake and those of other components of diet and lifestyle. No large randomized clinical trials evaluating dairy intake over long periods of time are available. Therefore, we must assume this limitation and establish our recommendations based on the best observational studies and on the previously known biological premises.

2.2. Other Minerals

Other minerals, such as potassium or magnesium, also have an important role in bone health.

Dietary potassium may reduce the acid load and, thus, calcium depletion from bones. Apart from its role in the maintenance of an alkaline state in the body, potassium can also increase the accumulation of calcium in the kidneys. In a nationwide Korean population study, the highest intake of potassium was associated with greater lumbar, total hip, and femur neck BMD in men older than 50 years and postmenopausal women [ 28]. This association was demonstrated in a population with a low calcium intake. The meta-analysis performed by Lambert et al. confirmed that supplementation with alkaline potassium salts was associated with a significant reduction in renal calcium excretion and acid excretion. These salts significantly lowered the bone resorption marker cross-linked N-telopeptides of type I collagen (NTX) but with no effect on bone formation markers or BMD. The reduction in bone resorption indicates a potential advantage for bone health [ 29].

Magnesium is also necessary for calcium metabolism [ 30]. After potassium, magnesium is the second most abundant intracellular cation, with a concentration of 10-30 mM in the human body. Magnesium is found in most whole foods, such as green leafy vegetables, legumes and nuts. The recommended daily allowances of magnesium are 310-360 mg and 400-420 mg for women and men, respectively. The requirements vary between individuals according to age, sex and previous nutritional status [ 31].

Magnesium is also involved in the exchange of calcium and potassium ions across cell membranes, and it is essential for neuronal activity and muscle contractions. Approximately 50-60% of the total body magnesium content is accumulated in the bone. In the bone's structure, magnesium ions bind at the surface of the hydroxyapatite crystals, improve the solubility of phosphorous and calcium hydroxyapatite and, thereby, influence crystal size and formation. Furthermore, magnesium induces osteoblast proliferation; therefore, its deficiency is associated with reduced bone formation [ 32]. Magnesium is also necessary for the activation of vitamin D because most of the enzymes involved in vitamin D metabolism require magnesium [ 33].

Populations that consume more processed food (more refined grains, sugars and fats) have lower levels of magnesium, as is typical in the United States [ 34]. A significant problem arises from the soil used for agriculture, which is becoming increasingly deficient in essential minerals such as magnesium.

No randomized studies evaluating the effect of magnesium on bone disease are available, but small-size studies have associated low serum magnesium levels with osteoporosis [ 35, 36]. In older subjects, a low intake of magnesium causes excessive calcium release from the bone, which further worsens bone fragility and increases the risks of fractures and falls [ 37]. A cross-sectional analysis of a cohort of subjects in the UK evaluating the influence of dietary magnesium and potassium intakes on bone density and fracture risk found a lower hip fracture risk in both men and women with a higher intake of these minerals, but these results did not hold after adjustment for multiple testing [ 38]. summarizes the main influence of some important nutrients on bone health.

2.3. Protein Intake

Protein intake is also essential for bone health. Approximately 50% of bone volume and about a third of bone mass is composed of proteins. They are integrated into the organic matrix of bone as part of the collagen structure when mineralization occurs. Dietary proteins also affect the secretion and action of insulin-like growth factor I (IGF-I), an orthotropic hormone important for bone formation. The IGF-I hormone improves calcium and phosphorus absorption in the gut; it is involved in the synthesis of calcitriol, and it increases the rate of phosphate reabsorption from the kidney. An adequate amount of dietary protein is therefore required for the maintenance of bone health. The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) recommends a dietary protein intake of 1.0-1.2 g/kg body weight/day, with at least 20-25 g of high-quality protein at each main meal [ 39]. The main sources of protein in healthy diets come from meat, fish, poultry, eggs and dairy products. Adequate protein intake is imperative for bone matrix formation and maintenance. However, it was previously believed that excessively high protein intake might induce a negative calcium balance, based on the "nutritional acid load hypothesis". This hypothesis relates a higher protein intake (especially that of animal origin, with more sulfur amino acids) to increased acid production and bone resorption, and thus, the development of deleterious hypercalciuria and bone loss, leading to osteoporosis and an increased risk of fragility fractures [ 40]. More recent meta-analyses have reported that a higher protein intake-more than 0.8 g/kg body weight/day, higher than the general dietary recommendations-is associated with a higher BMD, reduced risk of hip fracture and slower rate of bone loss. It is especially important in older people with osteoporosis and must always be accompanied by adequate dietary calcium intakes [ 41]. It is also important to take into account the anabolic effect of protein intake that, together with physical activity, is a main driver of muscle protein synthesis. When practicing exercise, muscle mass and strength improve, and the combination of adequate protein intake and exercise induces a greater degree of muscle protein accretion than either intervention alone. In the same way, a balanced dietary protein intake in combination with resistance exercise is an important contributor to the maintenance of bone strength.

It has been demonstrated that there is no adverse effect of higher protein intakes on bone. Furthermore, they are beneficial in attenuating age-related bone loss and reducing hip fracture risk in older subjects [ 42]. No significant differences in hip fracture outcomes between animal and vegetable protein consumption within the limits of a balanced diet have been found. However, as previously mentioned, all of these positive outcomes depend on adequate calcium intakes. Dairy product intake is probably very helpful because these products are a source of both proteins and calcium, since 1 L of milk provides 32 g of protein and 1200 mg of calcium. Furthermore, in some countries, yogurts are supplemented with milk powder, resulting in a 50% increased content of these nutrients compared with that in yogurt prepared from plain milk. The combination of protein and calcium in dairy products has positive effects on calciotropic hormones. They produced a reduction in circulating PTH, an increase in IGF-I and, consequently, a decrease in bone resorption markers, as well as improving BMD [ 15]. Therefore, much more severe problems are found for diets with inadequate protein than for those with an excess.

In terms of the nutrients required for good bone health, fruit and vegetables are rich in the previously mentioned nutrients, such as potassium and magnesium, and in vitamin C, vitamin K, folate and carotenoids [ 44, 45].

2.4. Vitamins K and C

Vitamin K is involved in bone matrix formation during mineralization. It acts as a cofactor for the microsomal γ-carboxylase, which facilitates the post-translational conversion of glutamyl to γ-carboxyglutamyl residues in osteocalcin, and it also influences other vitamin K-dependent proteins. In its γ-carboxylated state, osteocalcin is a calcium-binding protein in bone, facilitating the mineralization process. Vitamin K comprises a family of different molecular forms: vitamin K1 is a single form synthesized by plants, whereas the group of vitamins K2 comprises multiple forms, mainly synthesized by bacteria. Vitamin K1 is the major type found in human diets. A special feature of cheese is the presence of vitamin K2. A recent meta-analysis performed in 2019, including more than 11,000 patients, was conducted mainly in postmenopausal or osteoporotic patients [ 46]. It concluded that vitamin K supplementation appeared to have little clinically significant effect on BMD and vertebral fracture outcomes for these patients-in part, related to the heterogenicity in studies included, especially concerning the treatment regimes. Regarding postmenopausal women and osteoporotic patients, clinical fractures were less frequent in the vitamin K-supplemented group, but the effect appeared to be smaller when the analysis was restricted to low-risk-of-bias studies. Unfortunately, very few trials are available; therefore, it is difficult to draw conclusions for other populations based on this meta-analysis. Another systematic review found that the clinical use of oral vitamin K antagonists as part of anticoagulant therapy was neither related to nor reduced BMD, nor was it associated with an increased risk of fracture [ 47]; this supported previously reported results suggesting the absence of a clinically meaningful effect of vitamin K on BMD.

Vitamin C can improve bone health because of its antioxidant properties. It is able to suppress osteoclast activity [ 48]. It also acts as a cofactor for osteoblast differentiation and participates in collagen formation. Vitamin C is a marker of a healthy dietary pattern rich in fruit and vegetables. A systematic review and meta-analysis that compiled observational studies concluded that a greater dietary vitamin C intake was positively associated with BMD at the femoral neck and lumbar spine, although this review reported remarkable between-study heterogeneity at the femoral neck. This heterogeneity was caused by differences regarding study design, sex and age. A higher dietary vitamin C intake was correlated with a lower risk of hip fracture and osteoporosis, as well as higher BMD, at both the femoral neck and lumbar spine sites [ 49]; a more recent meta-analysis strongly reinforces the idea that increasing dietary vitamin C intake could decrease the risk of hip fractures in both males and females [ 50]. Although these bone benefits are remarkable, there is little information in clinical practice guidelines in terms of vitamin C intake recommendations, and this should be taken into account.

2.5. Omega-3 Polyunsaturated Fatty Acids and Other Nutrients

There is conflicting evidence regarding the effects of omega-3 polyunsaturated fatty acids (PUFA) on bone metabolism. The consumption of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) may influence bone growth and remodeling in humans through the inhibition of bone resorption and also by stimulating bone formation [ 51]. The mechanism by which PUFAs may affect bone turnover is not well known, but it is hypothesized that both EPA and DHA may exert their benefits by regulating osteoprotegerin (OPG)/receptor activator of nuclear factor kB (RANK), with a balance towards bone formation [ 52]. Fish and seafood are rich in PUFAs, especially n-3 FAs, which are known to have an anti-inflammatory effect that improves bone quality [ 53]. A meta-analysis conducted by Shen et al. showed that omega-3 fatty acids reduced osteocalcin serum levels in postmenopausal women, but no significant decrease in bone-specific alkaline phosphatase was found [ 54]. A study performed with a dairy product enriched in PUFAs, calcium, oleic acid and vitamins to evaluate their effects on bone metabolism in postmenopausal women showed favorable changes in some bone metabolism markers, such as an increase in vitamin D levels and a decrease in both PTH and RANKL, but did not show changes in other bone turnover markers or serum OPG [ 55]. Another Spanish study showed that the dietary intake of PUFAs was positively associated with BMD in both healthy and osteopenic Spanish women, at both the hips and lumbar spine [ 56]. A systematic review published in 2019 revealed a significant inverse association between the dietary intake of n-3 PUFAs through fish consumption and the risk of hip fracture, and that they might have protective effects on bone health [ 57].

Folate and vitamin B-12 might also influence bone by reducing homocysteine concentrations; homocysteine is linked to lower BMD and a higher risk of fracture [ 58]. A recent meta-analysis including 7475 individuals from four prospective studies showed a 4% lower fracture risk for each 50 pmol/L increase in vitamin B-12 concentration [ 59].

Zinc can be found in beans, nuts and whole grains, but the phytate in these foods makes it less bioavailable than zinc from animal-based sources. Lower serum and bone zinc concentrations have been described in patients with osteoporosis [ 60].

3. Recent Studies on Reference Dietary Patterns

Dietary pattern approaches unify contributions from various aspects of the diet. They are more useful than single-nutrient and food studies for elucidating the effects of different nutrients alone on bone health and can paint a more comprehensive picture.

In general, a dietary pattern with a high intake of fruit, vegetables, low-fat dairy products, whole grains, poultry, fish, nuts and legumes has been demonstrated to have a positive effect on bone health and directly associated with a better BMD and lower risk of fracture. Moreover, it is inversely associated with levels of bone resorption markers [ 61, 62]. In an Asian population, a dietary pattern including higher intake of fruits, vegetables and soy was associated with a lower risk of fractures and also a lower risk of osteoporosis [ 63].

3.1. Mediterranean Diet

The latest studies have shown that adherence to the Mediterranean diet (Med-Diet) is protective against osteoporosis [ 64]. Animal studies have suggested that antioxidant-rich fruits have a marked effect, increasing trabecular bone volume, number, and thickness, and decreasing trabecular separation through the stimulation of bone formation and suppression of bone resorption [ 65].

Those subjects with a higher adherence to Med-Diet showed an independent association, with an increase in 25(OH)D, suggesting that higher vitamin D levels could mediate the protective effect of the Med-Diet against osteoporosis. In postmenopausal women, it has been reported that higher Med-Diet scores were associated with a higher BMD and lower risk of hip fracture [ 66, 67]. In a cohort of Spanish premenopausal women, the evaluation of BMD showed that all, total, trabecular, and cortical bone density were positively associated with higher adherence to the Med-Diet [ 68]. These positive bone results were also demonstrated in a cohort of Italian subjects, where higher T-scores were positively associated with higher adherence to the Med-Diet [ 69]. In another study including postmenopausal women, those with higher adherence to Med-Diet had better BMD at the lumbar spine and improved muscle mass, also important for the prevention of osteoporosis and fractures [ 70]. Greater adherence to this diet was associated with a lower risk of fracture as well as a higher mean BMD, according to the meta-analysis of four effect sizes, obtained from three studies by Malmir et al. [ 71].

Considered to be at the core of the Mediterranean diet, olive oil has been reported as beneficial for bone status. Published evidence suggests that olive oil, with a high proportion of phenols, can be beneficial by preventing the loss of bone mass [ 72]. It has been demonstrated that the phenolic compounds can modulate the growing capacity and cell maturation of osteoblasts by increasing alkaline phosphatase activity and contributing to the creation of the extracellular matrix. The dietary intake of olive oil was significantly associated with higher BMD in a cohort of Spanish women across a wide range of ages [ 73]. Furthermore, it was associated with a higher total osteocalcin concentration and an increase in procollagen I N-terminal propeptide in a group of men, suggesting the protective effects of olive oil on bone [ 74]. A cohort of subjects was analyzed as part of the PREDIMED study, and those participants with the highest intake of extra-virgin olive oil had the lowest risk of osteoporosis-related fractures [ 75].

3.2. Western Diet

Regarding the situation in Europe, as suggested by the "Framingham study", individuals with diets high in processed protein foods (with a high percentage of protein intake from cheese, processed meat, pastries, pizza, French fries, snacks and refined grains) have shown a lower BMD compared to other groups of subject [ 76]. Furthermore, all studies alert about the risks of the unhealthy Western dietary pattern and the importance of promoting a decrease in the consumption of processed food products, sweets and desserts, soft drinks, fried foods, meat and refined grains. The risks of Western diets should be reinforced, as they are associated with lower BMD and a higher risk of fractures [ 77]. As an example, an English traditional dietary pattern-including a high intake of fried fish and potatoes, legumes, red and processed meats, and savory pies-was inversely associated with BMD in the femoral neck [ 78]. Moreover, a high fat intake, derived mostly from refined carbohydrates and fat products, can directly interfere with intestinal calcium absorption and also increase fat accumulation and obesity, which lead to a decrease in osteoblast differentiation and bone formation [ 79]. Sodium intake induces higher calciuria, which is presumed to increase bone loss and bone remodeling [ 80]. An excessive intake of inorganic phosphorus, present in processed food additives, induces a disruption of the calcium-phosphorus ratio, affecting the endocrine regulation of calcium homeostasis [ 81]. This is deleterious for bone health. However, it might be taken into consideration that this detrimental relationship between the Western dietary pattern and bone health is, in part, confounded by high net endogenous acid production. In an acidic environment, bone acts as a provider of alkali to maintain the acid-alkali balance, which leads to progressive bone loss [ 82].

3.3. Asian Diet

Asian populations have dietary patterns in which soy and fish intake are high compared to that in Western populations. They have a significantly lower incidence of osteoporotic fractures. Indeed, several meta-analyses have demonstrated that the supplementation of soy isoflavones with omega-3 fatty acids improved bone health status in women [ 83]. Evidence from epidemiological studies supports the idea that dietary soy isoflavone intake attenuates the bone loss induced by menopause, improving bone formation and decreasing bone resorption [ 84]. Another study in a Korean population showed that an increased consumption of fruits and dairy products as part of the traditional Korean diet, consisting mainly of white rice and vegetables, might decrease the risk of osteoporosis in Korean postmenopausal women [ 85] compared to the consumption of a diet rich in meat, alcohol and sugar. Furthermore, those subjects with higher intakes of white rice, kimchee and seaweed had a higher risk of osteoporosis in the lumbar spine. Another study in a cohort of Japanese postmenopausal women found that natto (fermented soybeans) consumption was positively associated with lumbar spine BMD, and its intake could be recommended for preventing postmenopausal bone loss [ 86].

A systematic review of dietary patterns involving a higher consumption of meat or processed meat (Meat Diet) or a higher consumption of fish and seafood (Fish Diet) suggested that these diets did not alter BMD or the risk of fractures. This study indicated that protein intake from fish or meat is not harmful to bone. The Meat Diet showed negative effects on bone metabolism in the setting of a Western Diet, but these could not be demonstrated in the context a Mediterranean or Asian Diet [ 87].

3.4. Vegetarian Diets

Vegetarian diets have been proven to contain lower amounts of calcium, vitamin D, vitamin B-12, protein and n-3 fatty acids, all of which have important roles in maintaining bone health. However, healthy vegetarian diets usually contain greater quantities of several protective bone-related nutrients such as magnesium, potassium, vitamin K, and antioxidant and anti-inflammatory phytonutrients. Unfortunately, the limited available evidence suggests that, on balance, vegetarians-especially vegans-may be at higher risk of low BMD and fractures [ 88]. A meta-analysis in 2009 by Ho-Pham comparing vegetarians and omnivores, including more than 2500 subjects, showed a 4% lower BMD at both the femoral neck and lumbar spine in vegetarians than in omnivores [ 89]. From this study, a subgroup analysis found that the difference was greater for vegans, who had a 6% lower BMD than omnivores.

There are few studies available examining vegetarian diets and related fractures. A prospective study of fracture risk in the United Kingdom found that fracture risk was higher in vegans as they had lower calcium intakes (<525 mg/day), but no difference was found between meat/fish eaters and lacto-ovo-vegetarians [ 90]. Vegan populations should obtain calcium from other sources-such as tofu, fortified soy products or fortified orange juice-but care is required to ensure an adequate intake. A careful selection of foods or the addition of fortified foods or supplements is needed to avoid a potential nutrient shortfall and to help ensure a healthy bone balance and reduce fracture risk in those individuals who adhere to vegetarian diets.

In the most recent meta-analysis published last year by Fabiani et al., the dietary pattern named as the "Meat/Western" pattern-characterized by a high consumption of red and processed meat, refined grains, and sweets-was positively associated with a lower BMD and a higher fracture risk. This dietary pattern was compared to "Healthy" patterns, characterized by a high consumption of fruit and vegetables, and the "Milk/Dairy" pattern, and these two patterns were associated with a decreased risk of low BMD. Moreover, the "Healthy" pattern had a significant preventive effect on fracture risk, whereas the "Meat/Western" pattern significantly increased the fracture risk [ 91]. A summary of larger studies relating bone status to each dietary pattern is found below in .

Table 2

Dietary Pattern

Name of the Study

No. Participants (Sex),
Mean Age/Age Range

Effect on BMD

Effect on Fracture Risk

Mediterranean Diet

EPIC Study [ 61]

188,795
(139,981 women and 48,814 men)
48.6 years (±10.8)

7% decrease in hip fracture incidence

CHANCES Project [ 62]

140,775
(116,176 women, 24,599 men)
60 years and older

4% decrease in hip fracture risk

Meta-analysis, Malmir et al. [ 71]

358,746
13-80 years

Positive association with lumbar spine, femoral neck and total hip BMD

21% reduced risk of hip fracture

Asian Diet

Singapore Chinese Health Study [ 63];
vegetables-fruit-soy

63,257
(35,241 women and 27,913 men)
45-74 years

34% reduced risk of hip fracture

Osteoporosis
Korean Health and
Nutrition Examination
Survey 2008-10 [ 85]

3735
(postmenopausal Women)
64 ± 9 years

Dairy and fruit pattern decreased the risk of osteoporosis of the lumbar spine (53%); white rice, kimchi and seaweed dietary pattern was negatively associated with bone health

Western Diet

Co-twin controlled study,
United Kingdom [ 78]

4928
(postmenopausal Women)
56 ± 12 years

Inversely associated with BMD in femoral neck

Framingham Offspring
Study, United States,
[ 76]

2740
(1534 women and 1206 men)
29-86 years

Higher intakes of red meat and processed food were inversely associated with femoral neck BMD

Vegetarian Diet

Bayesian meta-analysis
[ 89]

2749
(1880 women and 869 men)
20-79 years

4% lower BMD (95% CI: 2%, 7%) at femoral neck and lumbar spine

EPIC Oxford study [ 90]

34,696
(26,749 women and 7947 men)
20-89 years

Fracture incidence rate ratios: 1.00 (0.89-1.13) for vegetarians and 1.30 (1.02-1.66) for vegans

Unfortunately, we have to point out that the majority of studies developed to elucidate the association between bone mineral status or fracture risk and dietary patterns had a cross-sectional design, and this fact may have influenced their results and further conclusions.

Interdependencies among nutrients could be a part of the explanation for the heterogeneity of the results from different studies and meta-analyses. These studies based on dietary patterns are very important for translating knowledge and facilitating recommendations for practice, and they should complement studies of single nutrients and particular foods in relation to bone health. Nutrients are consumed together in one meal rather than in isolation, and often, their effects will not be visible when the intakes of other nutrients are suboptimal.

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Nutrients and Dietary Patterns Related to Osteoporosis

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Calcium and vitamin D form part of the bone mineral matrix as calcium phosphate (hydroxyapatite crystals) and are required for bone strength. The best way to achieve adequate calcium intake is through adhering to a healthy diet. However, sometimes dietary sources are insufficient or poorly tolerated, and, in those situations, pharmacological calcium supplementation could be useful.

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Imagined and Actual Acupuncture Effects on Chronic Low Back Pain: A Preliminary Study

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Imagined and Actual Acupuncture Effects on Chronic Low Back Pain: A Preliminary Study

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Background. Research suggests that imagined experiences can produce brain responses similar to those produced by actual experiences. Shared brain responses that support both imagination and perception may underlie the functional nature of mental imagery. In a previous study, we combined acupuncture and imagery to develop a new treatment method, video-guided acupuncture imagery treatment (VGAIT). We found that VGAIT significantly increased pain thresholds in healthy subjects. The aim of this study is to extend our previous finding by investigating whether VGAIT can relieve symptoms in patients with chronic low back pain. Methods. We first performed a single-arm study in which we administered video-guided acupuncture imagery treatment (VGAIT) on patients with chronic low back pain (cLBP) (Study 1, 12 females). We then compared our findings to those from a recently published study in which real or sham acupuncture treatment was applied on patients with cLBP (Study 2, 31 females) using a similar protocol. All patients in Studies 1 and 2 received 6 treatments over 4 weeks. Results. All three treatments (VGAIT, real, and sham acupuncture) significantly reduced pain severity as measured by a low back pain bothersomeness score. VGAIT produced similar effects to real acupuncture ( and nonsignificantly greater pain bothersomeness relief compared to sham acupuncture ( Additional analysis showed that there was no significant difference on the sensations evoked by different treatment modalities. Conclusion. These findings support VGAIT as a promising method for pain management.

1. Introduction

Chronic low back pain (cLBP) is a highly prevalent and disabling disorder with few satisfactory treatment options [ 1, 2]. Opioids are the most commonly prescribed class of drugs for cLBP [ 3], but the misuse of opioids has emerged as a serious substance abuse crisis. Thus, there is an urgent need for effective, nonopioid treatments for chronic pain [ 4, 5].

Both acupuncture and imagery have long been used in medical practice, including the treatment of chronic pain [ 6- 9]. However, the mechanisms that mediate acupuncture and imagery efficacy remain poorly understood. Neuroimaging studies have found that acupuncture needle manipulation can produce wide-spread brain activations and deactivations [ 10- 14]. Studies have also found that imagined experiences can produce brain responses similar to those that occur during actual experiences [ 15- 17]. Thus, shared neurocognitive responses that support both imagination and perception may explain the functional nature of mental imagery [ 16, 18].

Accumulating evidence suggests that anticipation, attention, and belief of acupuncture needle stimulation may also produce wide-spread brain activity/connectivity changes. In an early study [ 14], Jung et al. found that both genuine and pseudostimulation resulted in brain activations in the insula, anterior cingulate cortex, secondary somatosensory cortex, superior parietal cortex, and brain deactivation in the medial prefrontal cortex, posterior cingulate cortex, inferior parietal cortex, and parahippocampus. In another study [ 19], they found that cutaneous electrical stimuli without actual stimulation on acupoints resulted in greater de qi sensation compared to the control condition. Cognitive components of cutaneous electrical stimulation are associated with brain activation in the anterior insula, presupplementary motor area, and secondary somatosensory area. The expectations of acupuncture stimulation resulted in distinct experiences of somatosensation as well as brain activations in the insula and presupplementary motor area.

Makary et al. [ 13] investigated the effect of a specific form of sham acupuncture (phantom acupuncture (PHNT)) that reproduces the acupuncture needling procedure without somatosensory tactile stimulation. They found that PHNT can produce bilateral activation in the primary and secondary somatosensory cortex in patients with low back pain. In addition, the patients reported vicarious acupuncture sensations without needling stimulation. In a later study [ 20], they found that reduced low back pain from PHNT was negatively correlated with increased posterior cingulate cortex-anterior insula connectivity and exhibited a trend towards positive correlation with decreased primary somatosensory- (S1-) posterior insula connectivity.

In a previous study, we combined acupuncture and imagery to develop a new treatment method, video-guided acupuncture imagery treatment (VGAIT). During VGAIT, the participants watch a video of acupuncture that has been previously administered to their body and imagine it being concurrently applied. We found that VGAIT significantly increases pain thresholds in healthy subjects. In addition, we found that brain activity in insula and rostral anterior cingulate cortex (rACC), key regions in pain processing and modulation, was associated with analgesia evoked by both real acupuncture and VGAIT respectively [ 21].

The present pilot study aimed to extend our previous finding by investigating whether VGAIT can relieve symptoms in patients with cLBP. Specifically, we first performed a single-arm study in which cLBP patients received 6 sessions of VGAIT over 4 weeks (Study 1). Next, we compared the findings from Study 1 with those from a recently published study (Study 2) by our group that investigated the treatment effect of acupuncture and context in cLBP subjects [ 22]. Both studies used the same treatment frequencies and clinical outcome measures.

2. Methods

2.1. Study 1: Single-Arm trial on the Effect of VGAIT in cLBP Patients

Twenty cLBP patients were recruited. All patients were allowed to continue their existing medication and treatments. The study was approved by the Partners Human Research Committee/IRB (Institutional Review Board of Massachusetts General Hospital). All subjects provided signed informed consent before starting the study.

Patients were eligible for participation if they (1) were 18 to 60 years of age and met the Classification Criteria for cLBP (having low back pain for more than 6 months), (2) were without other severe chronic pain comorbidities, (3) scored at least 4 on the 11-point (0-10) LBP severity scale, and (4) had a prior evaluation of their low back pain by a health care provider. Patients were excluded if there was / were (1) a specific cause of back pain (e.g., cancer, fractures, and infections), (2) complicated back problems (e.g., prior back surgery and medico legal issues), (3) possible contraindications for acupuncture (e.g., coagulation disorders, cardiac pacemakers, pregnancy, and seizure disorder) and conditions that might confound longitudinal effects or interpretation of results (e.g., severe fibromyalgia and rheumatoid arthritis), (4) conditions making study participation difficult (e.g., paralysis, psychoses, or other severe psychological problems as per the judgment of a study investigator), (5) intent to undergo surgery during the time of involvement in the study, (6) active substance abuse disorder in the past 24 months, as determined by self-report and/or urine toxicology, and (7) inability to provide informed consent for oneself.

Subjects participated in 8 experimental sessions. Session 1 was a baseline assessment during which subjects received acupuncture exposure for about 5 minutes that was video-recorded for use in following treatment sessions. A modified standardized acupuncture protocol based on previous cLBP clinical trials was used [ 23]. This treatment is considered effective by cLBP experts [ 24]. The 7 real acupoints used were Yaoyangguan (GV3), bilateral Shenshu (BL23), bilateral Weizhong (BL40), bilateral Taixi (KI3), and 1-3 ashi (tender) points bilaterally on the lower back and legs. The rationale for the selection of these acupoints has been published in a previous clinical trial protocol on acupuncture treatment of low back pain [ 24]. A licensed acupuncturist performed the acupuncture exposure. Detailed selection of acupoints for acupuncture exposure can be found in Supplementary 1.

Sessions 2-7 were treatment sessions, during which subjects received VGAIT. The time between Session 1 and Session 2 ranged from 1 to 7 days. At the beginning of the VGAIT session, the subjects first read a script introducing the imagery acupuncture treatment along the following lines: "First you will watch a one-minute fixation video. As you watch, relax and concentrate on your breathing. You will then see a video of acupuncture treatment being applied on your low back and leg for about 25 minutes. Focus on the needle manipulation and try to imagine there is an actual needle being placed into your low back and leg at the same spot. You may feel some soreness and an aching, dull pain, along with other sensations. You will find that you can actually feel the needle manipulation at the same spot as in the video. The more vivid and real the sensation, the more effective the treatment, so it is very important that you stay focused and try to imagine the sensation of receiving acupuncture." Session 8 was the posttreatment assessment, during which clinical assessments (identical to Session 1) were conducted (Figure 1).

2.1.1. Study Intervention

All subjects received 6 treatments over 4 weeks (twice weekly for the first 2 weeks, then once weekly for the last 2 weeks), and each VGAIT treatment lasted about 25 minutes. During VGAIT, the acupuncture needles were rotated at one acupoint and then another in 10-second rotations with 15-second breaks in between, and about 1 minute breaks after each round. Each acupoint was stimulated 4 times.

2.1.2. Outcome Measures

The primary outcome was a measure of how bothersome one's low back pain (LBP) was during the past week, rated on an 11-point visual analogue scale of 0 ("not at all bothersome") to 10 ("extremely bothersome") [ 23]. Secondary outcome measures included 8 subdomains (pain interference, depression, physical function, fatigue, anxiety, sleep disturbance, social disability, and pain intensity) that evaluated how chronic pain diminished each patient's quality of life [ 25]. These measures were assessed using the Patient Reported Outcomes Measurement Information System (PROMIS-29). In addition, given that different intensities of sensations from treatment may be a potential factor that influences clinical outcome, the Massachusetts General Hospital Acupuncture Sensation Scale (MASS) [ 26, 27] was administered to subjects in each session.

2.2. Study 2: A Randomized Clinical Trial Investigating the Effect of Acupuncture and Context in Patients with cLBP

Procedures for Study 2 were similar to those of Study 1, with the exception that subjects in Study 2 participated in 2 MRI scans before and after the 6 treatment sessions. Please see the original publication for details of the experiment [ 22]. In summary, seventy-nine subjects with cLBP were recruited into this study using the criteria identical to those of Study 1 (Figure 1).

Subjects were randomized into 4 groups (real or sham acupuncture by augmented or limited context groups). Previous studies have suggested that expectancy/context may modulate acupuncture treatment response [ 28, 29]. Thus, we also attempted to evaluate the context effect using a context manipulation model (Figure 1) [ 29]. During data acquisition, all study personnel except the acupuncturist were blinded with respect to the intervention condition. Subjects were also blinded as to whether they were receiving real or sham acupuncture. At the end of the study, an investigator debriefed the participant and explained the reason for maintaining intervention blindness.

2.2.1. Study Interventions

The acupoints used for real acupuncture exposure were identical to those used in Study 1. All treatments were performed by licensed acupuncturists. Each treatment lasted 25 minutes, with additional stimulation applied to elicit "de qi" by twirling the needles at 10 minutes and again just prior to needle removal.

Sham acupuncture was applied at 12 sham points with a Streitberger needle. Instead of penetrating the skin, the point of the Streitberger needle retracts up the handle shaft when the acupuncturist presses it against the skin. This sham device has been validated by studies showing that subjects cannot distinguish between real and sham needling [ 30, 31]. A detailed description of acupoints and sham points for real and sham acupuncture treatments can be found in Supplementary 1.

2.2.2. Outcome Measures

Outcome measures identical to those of Study 1 were applied, allowing comparisons to be made between the 2 studies.

2.3. Statistical Analyses

For demographic characteristics, a Chi-square test and one-way ANOVA were applied to assess gender and age differences between groups. For clinical outcomes, a paired sampled -test was performed for within-group analyses (pre- vs. posttreatment), and a one-way ANOVA was performed for between-group analyses (real vs. sham, sham vs. VGAIT, and real vs. VGAIT). All analyses were conducted using the R program incorporated in the JASP software (Version 0.8.1, http://www.jasp-stats.org). All statistical tests were 2-tailed, and values of <0.05 were considered to be statistically significant.

3. Results

Of the 20 subjects recruited for Study 1, 18 completed the study (1 subject dropped out due to scheduling conflicts and 1 subject dropped out due to discomfort while watching their VGAIT video recording). Of the 79 subjects recruited for Study 2, 50 completed the study (please see Figure 1 for subject drop out reasons). A total of 68 subjects (43 females; age years, were included in analyses ( for VGAIT, real acupuncture, and sham acupuncture groups, respectively). No significant difference across the 3 treatment groups was found for age ( and gender ( (Table 1). Study design and conduct details are shown in Figure 1.

3.1. Primary Outcome

3.1.1. Study 1

LBP bothersomeness ratings were significantly reduced after 6 VGAIT sessions compared to pretreatment ratings (

3.1.2. Study 2

LBP bothersomeness ratings were significantly reduced after the 6 treatments for all 4 groups. A two-way analysis of covariance (ANCOVA) with treatment (real vs. sham) and context (augment vs. limited) as factors indicated no significant difference between the augmented and limited context groups ( but detected a marginally significant difference between real and sham acupuncture ( Thus, the 4 groups were combined into 2 groups (real and sham acupuncture) for the following analyses. A detailed description of statistical analyses can be found in our previously published paper [ 22]. The pre- vs. posttreatment changes for LBP bothersomeness in Studies 1 and 2, as well as changes in each participant's LBP bothersomeness rating before and after treatment, can be found in Table 1 and Supplementary 2, respectively.

Comparison between VGAIT (Study 1) and real and sham acupuncture (Study 2) using ANOVA revealed a trend towards significance among the 3 groups (bothersomeness: Post hoc analysis (Tukey's correction) showed that compared with sham acupuncture, VGAIT produced a nonsignificant LBP bothersomeness reduction ( There was a comparable LBP bothersomeness reduction between real acupuncture and VGAIT ( (Figure 2(a)).

3.2. Secondary Outcomes

Analyses of the PROMIS-29 subdomains showed that after 6 VGAIT sessions, the subjects reported significant pain intensity reduction during the past week (

In Study 2, the subjects in the real acupuncture group showed significant improvements in pain interference, pain intensity, physical function, and social function ( and respectively) following the treatments. Twenty-four subjects in the sham acupuncture group completed the PROMIS questionnaire and reported significant improvements in pain interference, pain intensity, and social function ( and respectively). Detailed pre- vs. posttreatment changes for each PROMIS-29 subdomain in Studies 1 and 2 can be found in Table 1.

Between-group analyses of pre- and posttreatment changes across the 3 groups using ANOVA revealed no significant difference among the 3 groups. However, we observed a trend for anxiety ( Post hoc analysis (Tukey's correction) showed that compared with sham acupuncture, VGAIT demonstrated a marginally significant greater reduction in anxiety, as measured by PROMIS-29 ( (Figures 2(b)- 2(i)).

3.3. MASS Ratings

We also administered the MASS to measure sensations evoked by VGAIT, real acupuncture, and sham acupuncture after each treatment. The average sensation ratings evoked by the 3 treatment modalities are shown in Figure 3. Further analysis showed no significant association between the MASS score and bothersomeness rating changes ( values ranged from 0.09 to 0.77 for different MASS sensations) in the VGAIT group. ANOVA showed no significant difference in average MASS score across the 3 treatment modalities (

4. Discussion

The reported work examined the treatment effect of a novel pain management method that combines acupuncture with video-guided imagery. Our preliminary results, when compared with results from a previous study [ 22], showed that VGAIT produced similar effects as real acupuncture and a non-significant greater reduction in pain severity compared to sham acupuncture. These results support the potential of VGAIT as a novel pain management method.

Both acupuncture [ 20, 32- 34] and guided imagery treatment [ 7, 35, 36] have demonstrated efficacy as methods for pain management. We found that VGAIT, a combination of the two methods, not only relieved pain bothersomeness in patients with cLBP but also produced a marginally significant greater reduction in anxiety level compared to sham acupuncture treatment. Accumulating evidence suggests that chronic pain conditions are comorbid with psychological distress, especially anxiety [ 37]. Anxiety may play an important role in perpetuating the distress associated with cLBP, as persistent pain and limited physical movement likely impact the brain circuitry that processes emotion. This increased distress, in turn, aggravates anxiety and worsens pain perception [ 38].

The mechanism by which VGAIT reduces back pain is unclear. In a previous study, we found that VGAIT can produce greater fMRI signal decreases at the rACC in healthy subjects [ 21]. The rACC is a key region in the descending pain modulation system (DPMS) [ 39, 40]. Previous findings have suggested that the rACC plays an important role in the pathophysiology of cLBP. In addition, the ACC is a key region for interoception, which encompasses the integration of signals relayed from the body to the brain. The ACC plays an important role in maintaining the body's homeostatic conditions [ 41] and potentially aids in self-awareness [ 42]. Taken together, we speculate that VGAIT may produce its beneficial effect through the ACC and the ACC's associated pain modulation and interoception processes. Nevertheless, this hypothesis needs to be tested in future work.

Similar to our previous study [ 21], we found that VGAIT also produced sensations associated with acupuncture treatment. There was no significant difference among the three treatment modalities. The guided imagery used in VGAIT may help participants recall previous acupuncture experience and sensations. It may also induce a more goal-directed state in which patients can work towards alleviation of pain severity.

The reported findings must be viewed as preliminary, as there was no control condition in Study 1. We believe that a VGAIT control condition would produce results similar to those of sham acupuncture (Study 2); however, a randomized study that includes a VGAIT control condition is clearly needed. Also, the participants in Study 1 were recruited separately from those in Study 2. Thus, different patient consent forms were used. Patients in Study 2 also knew that they would receive real or sham acupuncture, while patients in Study 1 knew that they would receive VGAIT. Therefore, psychological characteristics of patients in Studies 1 and 2 may have differed. A follow-up session that assesses the persistence of pain alleviation should be included in future studies to evaluate the long-term effects of VGAIT and acupuncture. Finally, objective measurements such as those obtained from neuroimaging are needed to explore the potential mechanisms underlying VGAIT and acupuncture.

5. Conclusions

In summary, our preliminary results suggest that VGAIT has potential as a treatment for chronic low back pain that optimizes time, cost, and available resources. VGAIT may be considered a therapeutic option in the multidisciplinary management of chronic pain that can be combined with other treatments or independently administered for pain relief.

Data Availability

Data used to support the findings of this study are available from the corresponding author upon request.

Conflicts of Interest

J.K. has a disclosure to report (holding equity in a startup company, MNT, and pending patents to develop new neuromodulation devices). All other authors declare no conflicts of interest.

Acknowledgments

This work is supported by National Institutes of Health (NIH) funding (R01 AT008563, R33 AT009310, R33 AT009341, R34 DA046635 (through the NIH HEAL Initiative), and R01 AG063975) to Jian Kong.

Supplementary Materials

Supplementary 1: Acupoint/sham point descriptions for real and sham acupuncture treatment. Supplementary 2: Changs (pre- minus post-treatment) in each patient's LBP bothersomeness rating before and after treatment. (Supplementary Materials)

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Imagined and Actual Acupuncture Effects on Chronic Low Back Pain: A Preliminary Study

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Background . Research suggests that imagined experiences can produce brain responses similar to those produced by actual experiences. Shared brain responses that support both imagination and perception may underlie the functional nature of mental imagery. In a previous study, we combined acupuncture and imagery to develop a new treatment method, video-guided acupuncture imagery treatment (VGAIT).

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Rituximab is an acceptable alternative to ocrelizumab for treating multiple sclerosis – Yes

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Rituximab is an acceptable alternative to ocrelizumab for treating multiple sclerosis – Yes

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Clinical trials with B-cell-depleting therapies have shown efficacy in both relapsing-remitting multiple sclerosis (RRMS) and primary progressive multiple sclerosis (PPMS) and are increasingly perceived as an important addition to the existing panel of disease-modifying treatments (DMTs). Three anti-CD20 targeting monoclonal antibodies have been tested in multiple sclerosis (MS); rituximab (mouse chimeric), ocrelizumab (humanized), and ofatumumab (fully human). Ofatumumab is approved for lymphoma and is currently in phase III testing in RRMS. Given the purpose of this article, it will not be further considered here. Ocrelizumab (Ocrevus, Roche, Basel, Switzerland) was recently approved for RRMS and PPMS both in the United States and Europe. The registration program consisted of a phase II study in RRMS with four arms; ocrelizumab 600 or 2000 mg versus placebo and an open-label interferon-beta (IFNb) arm, followed by two phase III studies in RRMS evaluating 600 mg of ocrelizumab every 6 months against IFNb. In addition, a placebo-controlled phase III trial has been conducted in PPMS with the same dosing of ocrelizumab. In contrast, the development program for ocrelizumab in rheumatoid arthritis (RA) has been terminated and a negative safety signal for serious infections was evident in the phase III study. Rituximab (MabThera, Roche, Basel, Switzerland) is approved for non-Hodgkin's lymphoma, chronic lymphocytic leukemia, certain forms of vasculitis and RA with first marketing approval in 1998. Rituximab has undergone clinical testing for MS in a phase II placebo-controlled trial for RRMS and a phase II/III trial PPMS, after which further clinical development for these indications was interrupted by the manufacturer. Still, during recent years off-label use of rituximab for treating MS has increased in countries where this is possible, where Sweden stands out with an approximate 40% share of all ongoing DMT. The question that arises with the access of an approved anti-CD20 DMT is whether continued use of rituximab can be justified by medical arguments, leaving legal and cost issues aside.

To us, the medical arguments can be subdivided into three issues; efficacy, immunogenicity, and safety. With regard to efficacy, we find the data of three recent comparative effectiveness studies of particular interest. The first study compared rituximab to fingolimod in RRMS patients switching from natalizumab, showing a clearly superior effect and overall drug survival, as well as a more beneficial safety profile Discontinuation of natalizumab has been associated with a rebound in disease activity in patients with highly active disease and the striking difference between rituximab and fingolimod in this context was notable. In the second study, rituximab was compared to other DMT in a population-based sample of treatment naive RRMS, showing superior drug survival over all other DMT included in the analysis, including numerically lower relapse rates than natalizumab. Third, a registry study of 461 RRMS patients treated with rituximab, propensity matched to patients receiving either IFNb or glatiramer acetate, showed a compelling 87% advantage of rituximab in reducing relapse rate. Furthermore, ocrelizumab and rituximab have both been tested in PPMS. In the Olympus study, treatment with rituximab compared to placebo was associated with a reduction in the proportion of patients with 12 weeks confirmed disability progression with 8.3 percentage points ( p = 0.14), while the corresponding figure for ocrelizumab in Oratorio was 6.4 percentage points ( p  = 0.03). Collectively, these findings strongly support the notion of a high efficacy of rituximab in RRMS even in real-world situations for which controlled trial data are lacking, as well as a similar effect size in PPMS as for ocrelizumab.

Regarding immunogenicity, it is acknowledged that anti-drug antibodies (ADAs) may impact negatively on efficacy and tolerability of biological drugs. In three trials of rituximab in MS, ADA was found in 25% and 29% of RRMS patients and 7% in PPMS; however, there was no clear correlation with clinical outcomes. More recently, using two different assays, ADA was detectable in 37% of RRMS and 26% in progressive forms of MS with a more sensitive assay, but with decreasing percentages with increasing number of rituximab infusions. There was a significant association between presence and titers of ADA, and incomplete B-cell depletion, but not with infusion/adverse reactions or clinical outcomes at the group level. With regard to ocrelizumab, anti-drug-binding antibodies were found in 0.4% and 1.9% of RRMS and PPMS patients, respectively, with only one patient in each group developing neutralizing antibodies. While these findings clearly suggest that rituximab is more immunogenic than ocrelizumab, some caution is warranted since assay methods differ between the studies. More importantly, there are still not enough data to evaluate the clinical significance of ADA in patients treated with rituximab.

Last, regarding safety, the Food and Drug Administration (FDA) has highlighted risks with infusion reactions, serious infections, and malignancies with ocrelizumab. The number of detected malignancies was doubled in active arms of the phase III program; however, risks are difficult to correctly assess with observation times of only a few years. In contrast, rituximab has been used for other indications for almost two decades and no serious concerns for increased risks of cancer have arisen. For example, in a recent nation-wide RA cohort study, no signal for increased incidence of malignancies with rituximab was detected. Still, extrapolation to MS should be done with caution due to differences in patient populations and administration regimens. There is also a question about of dosing. In RA, a treatment cycle consists of two 1000-mg doses 2 weeks apart, a dosing regimen, repeated every 6 months, used also in the controlled trials for MS. In the observational studies referred to above, the dosing was either a single infusion of 500 or 1000 mg repeated every 6 months. Furthermore, when comparing the two doses, no differences in efficacy outcomes were noted, but a trend for better tolerability with the lower dose. In the MS phase II study, ocrelizumab was tested in two doses: 600 and 2000 mg. Since the lower dose was equally effective, only the 600-mg dose was used in the phase III studies. In RA, ocrelizumab has been tested alone or in combination with methotrexate in doses up to 1000 mg, where higher rates of serious and opportunistic infections, some of which resulted in death, have been recorded with doses ≥ 500 mg.

Collectively, we see continued use of rituximab in MS as justified given the established safety record of rituximab and accumulating evidence from comparative effectiveness studies in real-world populations that includes patients with high risk of disease breakthrough, and taking into consideration also the safety concerns that have arisen in the development program for ocrelizumab. Stringent prospective follow-up is, however, clearly motivated to allow for future comparative effectiveness studies between the two drugs. Finally, it is of interest to note that a recent meta-analysis failed to show that off-label medications proved less efficacious than approved drug treatments in randomized trials, suggesting that evidence-based treatment decisions should include all available options regardless of labeling status.

References

4.

Emery, P, Rigby, W, Tak, PP. Safety with ocrelizumab in rheumatoid arthritis: Results from the ocrelizumab phase III program. PLoS ONE 2014; 9: e87379.
Google Scholar

8.

Granqvist, M, Boremalm, M, Poorghobad, A. Comparative effectiveness of rituximab and other initial treatment choices for multiple sclerosis. JAMA Neurol. Epub ahead of print 8 January 2018. DOI:
Google Scholar

9.

Spelman, T, Frisell, T, Piehl, F. Comparative effectiveness of rituximab relative to IFN-beta or glatiramer acetate in relapsing-remitting MS from the Swedish MS registry. Mult Scler 2018; 24: 1087-1095.
Google Scholar

10.

Bachelet, D, Hassler, S, Mbogning, C. Occurrence of anti-drug antibodies against interferon-beta and natalizumab in multiple sclerosis: A collaborative cohort analysis. PLoS ONE 2016; 11: e0162752.
Google Scholar

13.

https://www.accessdata.fda.gov/drugsatfda_docs/nda/2017/761053Orig1s000RiskR.pdf
Google Scholar

16.

Ladanie, A, Ioannidis, JPA, Stafford, RS. Off-label treatments were not consistently better or worse than approved drug treatments in randomized trials. J Clin Epidemiol. Epub ahead of print 13 November 2017. DOI:
Google Scholar

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Rituximab is an acceptable alternative to ocrelizumab for treating multiple sclerosis - Yes - Fredrik Piehl, Jan Hillert, 2018

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Clinical trials with B-cell-depleting therapies have shown efficacy in both relapsing-remitting multiple sclerosis (RRMS) and primary progressive multiple sclerosis (PPMS) and are increasingly perceived as an important addition to the existing panel of disease-modifying treatments (DMTs). Three anti-CD20 targeting monoclonal antibodies have been tested in multiple sclerosis (MS); rituximab (mouse chimeric), ocrelizumab (humanized), and ofatumumab (fully human).

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Hashimoto’s thyroiditis and primary thyroid lymphoma

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Hashimoto’s thyroiditis and primary thyroid lymphoma

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Hashimoto's thyroiditis and primary thyroid lymphoma

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A 66-year-old woman was referred to the general medicine department with neck swelling and dysphagia. Thyromegaly of the left lobe, hypothyroidism and anti-thyr