#topic: placebo effect

[tayfabe75]

"That's the end of Act I, ladies and gentlemen. Thank you very much, now I can snap into broad TV presenter mode. 'How you feeling, London?' Actually, I don't feel like that. I'll tell you a funny story. We had a guy on tour with us 'cause George had a funny arm and he was trying to fix it, and one night there was a case of root beer on the bus, and he was quite a naive young guy, and he drank the root beers thinking it was beer and then he pretended to be drunk in front of everybody. And instead of laughing at him, I felt a bit sorry for him. I tell you what, now I feel sorry for him, because the placebo effect or the idea of… what I'm trying to do, simulating a breakdown, really, is like… as you know, the walls get a bit thin. Do you know what I mean? I know, it's all good. I'm all right. Thank you though. Like, genuinely. Thank you a lot."

February 13, 2024: On night two at the O2 in London, Matty shares a story about someone pretending to be drunk on root beer, drawing comparisons with his on-stage simulation of a breakdown.

[archersgoon]

actually on the topic of quelch that thing they did a few years ago where they switched to 2 packs (berry & tropical) is so stupid. first of all none of the new flavours (pineapple raspberry strawberry) are good enough to justify this. secondly forcing me to buy two packs if i want both mango and blackcurrant in my house is cruel and unusual punishment

[guksfairy]

`✦ˑ ִֶ 𓂃⊹LATE NIGHT KOO 23:29 `✦ˑ ִֶ 𓂃⊹

in which Jungkook tells you about a thing he used to do as a kid

notes: I learned abt this bc my bias talked abt it once and I’ve not stopped thinking abt it lol

Enjoy !

wc: 598

The tv displays funny acts of the yellow sponge and his pink star friend as you and Jungkook laughed every now and then at their shenanigans. It was a Friday night and neither one of you felt like going out with your friends so you packed an overnight bag and headed to your boyfriend’s house for a nice evening.

Jungkook, earlier in the day, had bought a ton of different ramen packs that he thought you’d both enjoy. You had scolded him saying that it was a waste of money and in return he replied I’m not wasting if I’m spending it on you.

“Love can you get the water,” Jungkook yells from the living room, lowering the volume for dinner.

You turn around to the boiling water and…you’re not sure why you did it. Or how it happened.

You’re not dense. You know that the handle of a pot can be hot when there’s boiling water inside of it.

Yet you completely skip over the oven mitt Jungkook left beside it and went directly to grab the handle, burning yourself in the process.

“Ow!” in an instant, Jungkook is back inside the kitchen watching you flick your hand back and forth as a reaction to the heat.

“Touch your ears!”

“What?” you stare at your boyfriend when he simply repeats it again.

“Touch your ears,” this time he’s calm and walking towards you as you do as he says. Your hand doesn’t burn as much as it did a moment ago but you still grab both of your ears gently, rubbing the skin.

Jungkook walks past you and takes the oven mitt to remove the pot from the stove. He places it on the trivet and turns back to you, who is still doing the same action.

He internally coos at you and moves your hands back down.

“Are you okay?” you nod and his worry is put at ease, “You don’t need any ice?” You shake your head.

“Why’d you tell me to touch my ears?” You giggle at his funny request.

“What?”

“Just now, when you told me to touch my ears,” you recall.

“Oh it’s what my mom used to tell me when I was a kid. If I burned myself I should touch my ears,” your eyebrows furrow and he continues.

“Yeah apparently your ears are usually the coolest part of your body, so when you burn yourself you’re supposed to touch your ears to dissipate the heat,” he explains pouring the boiling water into the cup of noodles.

“Is that true?” you ask in awe. You’ve never personally heard of this in your lifetime.

“Probably not? But as a kid, I believed and trusted my mom and, maybe it was a placebo effect, but it always comforted me,” he says and you verbally coo.

“You’re so cute,” you pinch his cheek and he smiles with a playful eye roll as he removes your hand.

“Yeah yeah,”

“Are you gonna teach that to our kid when they’re growing up?” you ask without thinking. The flush in Jungkook’s cheeks visible and only then did you realize the topic you brought up.

“Our kid?” He shyly repeats.

“Yeah…our kid,” you state and he sniffles a small laugh, leaning forward to engulf your body in a warm hug.

“Sure, I’ll teach them the same,” he says and you giggle thinking about Jungkook telling your son or daughter to touch their ears like he did just now.

[princessaffirms]

hey,how you do all your research on shifting/manifestation? its rlly impressive

hi! thanks so much, i’m glad you enjoy my posts! ₊˚⊹♡ if you’re referring to the scientific evidence i bring up in my posts, i mainly use 🔗 PUBMED and other research websites to find peer-reviewed scientific papers!

occasionally, i’ll also refer to some science-based youtube channels such as:

🔗 DEVI SIETARAM (PhD chemical engineering)

🔗 SABINE HOSSENFELDER (PhD physics)

🔗 SCISHOW PSYCH (science communication channel)

regardless, i always do my best to ensure that all the scientific information i mention is ultimately backed by peer-reviewed research for reliability!

the further you go down the rabbit hole of scientific research that correlates with shifting/law of assumption concepts, the more undeniable it feels! here are some of the TOPICS i typically read about:

(non-local) consciousness research

the observer effect

neuroplasticity

post-materialist science (regarding consciousness as fundamental, not matter)

quantum superposition

placebo effect

bayesian brain theory

neuroconstructivism

quantum immortality

bell’s theorem + aspect’s experiments

the delayed-choice quantum eraser experiment

the double slit experiment

studies on monks and their unusual brain wave activity during deep meditation (gamma waves)

lucid dream + regular dream research

out of body experiences

…just to name a few! 🥹🫶

sending so much love and light <3

[candle-lamp]

Hello, can you do headcannons for sbg post all the phantom stuff living together? (You know, to cope with their PTSD)

of course ^^

- they all cook together bc it would be way too much work for one person to cook for six, usually they just make a ton at the beginning of the week and eat leftovers

- everyone has a room/personal space but most days everyone just falls asleep in one big pile in the living room

- I imagine this is while they're in college so group study sessions are common (and as they have fewer classes together, they still like to study in the same room)

- after all the phantom stuff, none of them like the dark, so every room has night lights and/or LED strips

- whenever someone gets sick, they rotate out who stays to take care of them (once, the whole group came down with the flu at the same time, whoever felt the least awful at any given moment took care of things)

- speaking of getting sick, the ones who gets sick most to least often are: Tyler, Taylor, Aiden, Logan, Ashlyn, Ben. Tyler will deny this fact, and usually ignores his sickness

- over time, Ashlyn became more comfortable with the group touching her hair, and there have been competitions of who can braid it the best (current rankings: Ben, Taylor, Logan, Tyler, Aiden (he tries so hard, but usually gets his fingers tangled up))

- the group was essentially immune to melatonin so they decided to try going a while without it to get rid of their tolerance for it. it was awful, but when they finally caved and went back to it, it worked like a charm (Logan is still convinced it's the placebo effect, but he doesn't really care)

- in their group chat, they send updates on what they're doing constantly as a way of showing they're okay, when someone doesn't text for more than a few hours everyone gets concerned

- there's always music playing in the house, be it from someone's phone/speaker or someone actually playing it, but it was a habit they fell into to show someone was home

- on the topic of music, Ben gave everyone at least a few guitar lessons

- Taylor convinced everyone to have an at-home spa day with facemasks and manicures, everyone ended up enjoying it and it became a monthly tradition

- every few days they have a mental check up where the group talks about any struggles they've had recently, usually stuff like nightmares and flashbacks, but also stress in their current activities

And that's all ^^ these were super fun to write, thank you for the request!

[ratinacoat]

I saw in your anti-endo explanation post that you'd be willing to change your stance on endogenic plurality if there were hard evidence for it. I wonder if you've seen the fMRI study? I searched your blog and couldn't find a mention of it. The paper isn't out yet, but the author gave a layman-accessible talk about it on youtube: https://youtu.be/qZSaGV0M7yI Tulpa switching causes noticeable changes in a specific region of the brain! While it isn't concrete evidence for the entire phenomenon, tulpa switching does cause noticeable changes in brain activity. Thought you might find that cool :)

Yes I have seen something about this actually! I've seen and read a couple things from Lifshitz about tulpamancy. I find it all interesting as someone who enjoys researching religion. The only things in this video I haven't previously seen were the second half of the brain scan results. Someone sent me a link to another video of his where he showed the brain scans of the Evangelicals he compares tulpamancers to, but he didn't show the tulpamancers results of the scans. His explanations on it did give a better understanding and more "complex" thoughts on the topics, but I am not convinced of the existence of a separate entity in ones mind or making your imagination independently sentient.

I'll explain my thoughts and other things I've found in depth, I'm in the mood to rant.

Previously I had thought tulpamancy was more than imagining something until it's "there", but I have a better understanding of it. I like the comparisons he does with religious, specifically Christian Evangelical, prayer. He shows how similarly the two affect the brain, but how different they are from one another in spite of that. To me, that further backs my stance that endogenic plurality is not only something comparable to religion, but is almost identical to religious practices in some cases. Tulpamancy being one of these cases, according to the brain scans Lifshitz shows.

Lifshitz's work doesn't prove tulpamancy to be creating separate sentience within your own mind, but he rather demonstrates how your mind can subconsciously preform actions you previously had to think about over a period of time if you truly believe it to be happening. If you convince yourself it's there, you'll really start to believe it. Lifshitz talks about different forms of this a lot, researching things like the placebo effect, prayer, and psychedelics. This is why I think anti endos who try tulpamancy just for the hell of it fail, they go in knowing that it won't work while people who believe they can create a tulpa genuinely believe they can do it. I wouldn't be able to do it because I already have a pre existing opinion, while someone who believes in tulpamancy will succeed as belief in it is all it takes.

The process of creating a tulpa as Lifshitz explains (creating it's appearance, talking to it as if it's there, meditating, visualizing it, interacting with it as if it's there all the time) backs my thoughts on that further. The things done to create a tulpa are convincing yourself something is there until you genuinely believe it and subconsciously experience it. Similar to a placebo effect or even convincing yourself you're sick until you start experiencing false symptoms.

I do believe tulpamancers are experiencing some of the things they say, but I don't believe it is actually a separate being within their mind. I believe they truly do believe what they say, and it's a practice they choose to engage in. The research I have seen shows that some aspects of it can be true but what someone believes those aspects are depends on the person, it is subjective no matter how identical. Lifshitz's interest in this actually came from tulamancers using the concept of sentient imaginary friends as something therapeutic and tulpamancers expressing interest in a study on Evangelicals believing they have a relationship with God. Here are some quotes from another video of his.

The way he explains people using it as a coping mechanism made it easier to understand why people engage in it, especially younger children going through tough times finding internet spaces that talk of this stuff. I won't say they are 100% wrong about if the practice is possible or not but I simply don't believe it is actually a separate consciousness. I choose not to engage in it but I respect those who do if they can respect that I don't. Similarities between the two practices, even down to the results of the brain scans, explained to me what tulpamancy is and how it works in a way, but it wasn't evidence for the actual existence of separate consciousness. If this was proof of tulpas being separate consciousness, it would also be proof of God, which it isn't. It'd be cool if it were though. But I don't think you could prove this aspect of it, in the same way you can't prove someone is actually communicating with a god during prayer. If there is proof for that part though, I'd find it interesting. As for now, after all I've read/watched from Lifshitz my stance is some what the same.

Thank you for linking me to this video! I enjoy when people give any evidence they have. Even if it isn't what would convince me I like learning stuff about people and beliefs. Sorry it took me a bit (I think, don't remember) to respond to this, I had this in my drafts and forgot to post it lol

TL;DR: The research doesn't prove there's a separate consciousness but rather you can convince yourself something is happening until you do it subconsciously if you really believe it to be true. Similar to praying and speaking in tongues. My views haven't changed drastically since seeing this, but I understand more what it is. In my eyes it's still a belief that I simply don't hold, but I don't hate on people who do hold it.

[2024-grimoire-challenge]

October Week 1 - Laws of Magic

This week we’re going to be looking at generally held laws and ideas about how magic, manifestation and prayer work. These are broad ideas and not all of them are going to pertain to you and your practice. Let’s dive in, cause this week is a full one!

(Feel free to make a page or multiple pages for all of these topics. Even if you don’t make actual pages for them, it can be helpful just to take notes on some loose paper or in your lab notebook!)

Monday - for each of the laws listed every day this week, the prompt will be the same research prompt! For the laws listed below look up where they came from, who posited them, who tends to follow them, what the law itself states and means and how it does (if it does) pertain to your practice, craft and way of thinking!

Research - Law of Attraction

Research- Law of assumption

Practical - Write a spell! No matter what it is for, who it is for, do it! Lay out the time, place, ingredients, tools, words and steps and if you’re feeling extra groggy, perform it! Write it all out in your lab notebook for future use and tweaking, then journal about the experience and outcome!

Tuesday - For the laws listed below look up where they came from, who posited them, who tends to follow them, what the law itself states and means and how it does (if it does) pertain to your practice, craft and way of thinking!

Research - Law: Placebo effect

Research - Law of Vibration

Research/ New Page -Gemstone Study- like before, pick a gemstone from your list and learn all you can about it! Magical, mundane, scientific, spiritual, and practical!

Wednesday - For the laws listed below look up where they came from, who posited them, who tends to follow them, what the law itself states and means and how it does (if it does) pertain to your practice, craft and way of thinking!

Research - Shadow Work - this one isn’t necessarily a law of magic, and is actually a psychological term. Where did it come from? Who came up with it? What is it? How can it be used in conjunction with witchcraft? How can it help you understand yourself and your craft?

Research - Law of Polarity

Research - Law of Synchronicity

Research/ New Page - Herbal Study - pick another herb from your list and learn everything you can about it! Magical and mundane, medicinal and culinary, myth and legend, history and how to grow it!

Thursday -For the laws listed below look up where they came from, who posited them, who tends to follow them, what the law itself states and means and how it does (if it does) pertain to your practice, craft and way of thinking!

Research - Law of Rhythm

Research - Law of Similarity

Research - Law of Contagion

Friday - For the laws listed below look up where they came from, who posited them, who tends to follow them, what the law itself states and means and how it does (if it does) pertain to your practice, craft and way of thinking!

Research - Law of Correspondences

Research - Law of Personification

Bonus: many of these are from the 26 Laws of Magic which are generally held ideas about how magic, manifestation and prayer generally work from a pseudo-psychology point of view. Look up the rest of these laws and think about how those above and those not listed pertain to your craft if at all.

Apologies if formatting this week is a little wonky! I worked on this one on my phone at work the last couple nights as I haven’t been home long enough to be on my computer!

-Mod Hazel

[evidence-based-activism]

Hi, @peaktransd, you asked a question on this post about "studies about hormones and the placebo effect". I've looked into this and found some relevant information!

---

No high quality research on transgender affirming hormone care

The first, important, aspect here is that there is little to no high quality research on the use of hormones for transgender affirming care.

By this point we've all heard of the Cass review [1, emphasis mine] which found:

For puberty blockers: "The review of the evidence looked at nine studies that met the inclusion criteria. A key limitation of all the studies examined was the lack of reliable comparative studies, as well as of clear expected outcomes. All the studies were small uncontrolled observational studies, and all the results were of low certainty. Many did not report statistical significance."

For hormones: "Ten uncontrolled observational studies met the inclusion criteria. Again, the key limitation to identifying the effectiveness and safety of gender-affirming hormones for children and adolescents with gender dysphoria was the lack of reliable comparative studies."

Notably the important point here is that all of the research is uncontrolled observational studies, which do not allow for the examination of the placebo effect. Also, to preempt any objections, the Cass review team has created a website with FAQs [2] to address the mis- and disinformation being spread about the review.

Further, this article [3] argues "that although [gender affirming treatment] for [gender dysphoric] youth lacks a rigorous evidence base, it is undertaken as routine medical treatment in a strongly placebo effect enhancing environment", highlighting why we absolutely need good quality evidence into this topic.

The state of research for adults is similar. There are no comprehensive reviews about adult treatment, and some of this is by design. By this I mean, WPATH (the World Professional Association for Transgender Health) has purposefully suppressed unfavorable evidence.

There's a compounding issue here; in the reviews that do exist they tend to find very little evidence base for supporting hormone use and then make a recommendation in support of hormones anyway. These studies are often used as evidence by proponents who do not read past the abstract of the study.

Some studies on hormones and mood in transgender adults [all emphasis mine]:

This 2016 review [4] indicated: "Hormone therapy interventions to improve the mental health and quality of life in transgender people with gender dysphoria have not been evaluated in controlled trials. Low quality evidence suggests that hormone therapy may lead to improvements in psychological functioning."

This 2016 review [5] claimed a positive conclusion ("gender dysphoria-related mental distress may benefit from hormonal treatment") but proceeds to note that "results mentioned earlier need to be considered in light of certain limitations". These limitations include: single site studies, small sample size, type/dose of hormone restatement usually not reported (and poor consistency when reported), “more than half the studies did not mention/control for psychiatric comorbidity”, and “recruitment/follow-up attrition represented an issue". They also hide this key point: "most importantly, as no study used a blinded randomized controlled trial design, results could have also different explanations because of the study design" in the limitations section. Given the extent of the issue, these limitations should have at least been mentioned in the abstract and the researchers should not have suggested such a definitive conclusion.

This 2018 review [6] indicated that "although the existing body of research supports [gender-affirming hormone therapy] improving mental wellness, many studies used cross-sectional and uncontrolled observational methods relying on self-report." Again, this important caveat was hidden in the conclusion; with the abstract making far bolder claims than supported by evidence.

This 2019 review [7] concluded that "because the certainty of this evidence was very low to low, recommendations for hormone use to improve quality of life, depression and anxiety could not be made."

This 2021 review [8] came to the same conclusion stating "certainty in this conclusion is limited by high risk of bias in study designs, small sample sizes, and confounding with other interventions."

Even for the very few "controlled" studies, they are not randomized control trials. Instead they are before treatment – after treatment comparisons for transgender individuals or cross sectional studies comparing transgender and "cisgender" comparison groups. Notably, neither of these designs allow the researcher to elucidate the origin of observed effects (e.g., is improvement coming from hormone therapy or social affirmation?).

(And as a side note, this Cochrane (the "gold standard" for those unaware) review [9] concluded: "We found insufficient evidence to determine the efficacy or safety of hormonal treatment approaches for transgender women in transition. This lack of studies shows a gap between current clinical practice and clinical research. Robust RCTs and controlled cohort studies are needed".)

---

Confounding factors: the effect of hormone therapy on non-transgender individuals

There's a particularly important confounding factor here; we have evidence that hormone therapy is associated with improved mood. As such, improved mood with gender affirming care may simply be the result of this natural physiological effect.

This 2023 systematic review and meta-analysis [10] with "14 eligible randomized controlled trials (RCTs) ... to investigate the effect of exogenous estrogen on depressive mood in women" found "strong evidence that exogenous estrogen exerts its antidepressant effect by stabilizing estrogen levels".

This 2009 systematic review and meta-analysis [11] with "seven studies (N=364) ... that included a placebo-control group in a double-blind design" found "[testosterone] may have an antidepressant effect in depressed [men], especially those with hypogonadism".

This 2014 systematic review and meta-analysis [12] of "sixteen trials with a total of 944 subjects ... showed a significant positive impact of testosterone on mood" and ultimately concluded "Testosterone may be used as a monotherapy in dysthymia and minor depression or as an augmentation therapy in major depression in middle-aged hypogonadal men".

This 2019 systematic review and meta-analysis [13] of "27 randomized placebo-controlled clinical trials involving a total of 1890 men found that testosterone treatment was associated with a significant reduction of depressive symptoms, particularly in participants who received higher-dosage regimens."

Further, the fact that these results were all the strongest in people with lower endogenous hormone levels, lends support to the hypothesis that this effect would be substantial in cross sex supplementation given the naturally low endogenous hormone levels for these individuals. (Please note, however, that this hypothesis has not yet been investigated.)

This isn't a placebo effect, since the randomized controlled trials above indicate that the effect on mood is above and beyond any placebo effect. However, I believe it's a related point.

---

Hormones on cognitive function

To address the other point in that post, there really isn't evidence that women would "get smarter" if they take testosterone or men would "get dumber" if they take estrogen. Again, there's no high quality studies on transgender individuals, but there is some adjacent evidence for non-transgender individuals.

There is evidence that the reduction of estrogen levels in older women may be associated with cognitive decline. [14]

This review [15] and this study [16] both link higher endogenous testosterone levels in women (i.e., in women with PCOS) with lower cognitive performance.

That being said, this "randomized, placebo-controlled trial" [17] manipulated the levels of testosterone in women with PCOS and did not record changes in their cognitive function. This may be because the sample size was simply too small (n=29), or there could be a "critical window" in which testosterone effects women's cognitive performance, or any number of other possibilities.

These reviews [18, 19] found low testosterone levels are associated with with cognitive impairment in men although the effects of testosterone substitution are mixed. This appears to support the hypothesis that testosterone suppression may reduce cognitive performance, but in reality "the ability of the body to convert testosterone into estrogen suggests that part of the actions of testosterone could be mediated by estrogen". So, any decrease due to testosterone suppression would likely be offset by estrogen supplementation. In fact this review [20] discusses the evidence for this.

---

The stereotype threat

As suggested by @mycodyke, an important factor here is the stereotype threat. This refers to how "behavior can be a consequence of priming effects, ... when a stereotype becomes activated, stereotype-consistent behavior may follow automatically from that activation" [21].

The study she linked [22] goes into this, finding that men performed the same in a cognitive task regardless of priming condition, whereas women performed worse only when primed with female condition. This replicated an earlier study [23] that found "no sex differences were observed" when the task instructions didn't emphasize sex-stereotypes.

Other similar studies:

This study [24] found "sex difference was reliably elicited and eliminated by controlling or manipulating participants’ confidence"

This meta-analysis [25] suggested that "male superiority on spatial ability tasks ... is related to the implementation of time limits".

This study [26] also suggested this, finding that "the magnitude of gender differences was linearly related to the amount of time available for test completion".

All of this indicates that sex differences on this task (and likely in other similar situations) are the result of individual expectations about their performance. This is also commonly brought up for self-fulfilling prophecies; that is, if someone believes they will succeed/fail they are more likely to succeed/fail.

And this has real-world consequences. For example, in this study [27], "in a simulated job interview, [participants] … were confronted with either sexist … or non-sexist … behavior … [and] results indicated that female participants in the sexist condition performed significantly worse on the mathematical test than female participants in the control condition … suggest[ing] an influence of psychological and interpersonal processes on seemingly objective test outcomes."

---

Conclusion

I hope this helps! To sum up:

There is little to no high-quality research into the effects, benefits, or harms of hormone therapy for transgender adults or adolescents

There is evidence suggesting that hormone supplementation effects mood in non-transgender adults, indicating an important confounding factor for transgender hormone research

There is no evidence that testosterone makes women smarter or that estrogen makes men dumber; there is, in fact, some limited evidence suggesting the opposite

The belief in the above is likely a result of the stereotype threat; transgender individuals who have started hormone therapy are likely to perform worse/better because they believe they should perform worse/better as a result of ingrained stereotypes

References below the cut:

Cass, H. (2024). Independent review of gender identity services for children and young people.

Final report – FAQs. (n.d.). The Cass Review. https://cass.independent-review.uk/home/publications/final-report/final-report-faqs/

Clayton, A. (2023). Gender-affirming treatment of gender dysphoria in youth: a perfect storm environment for the placebo effect—the implications for research and clinical practice. Archives of Sexual Behavior, 52(2), 483-494.

White Hughto JM, Reisner SL. A Systematic Review of the Effects of Hormone Therapy on Psychological Functioning and Quality of Life in Transgender Individuals. Transgend Health. 2016 Jan;1(1):21-31. doi: 10.1089/trgh.2015.0008. Epub 2016 Jan 13. PMID: 27595141; PMCID: PMC5010234.

Costa, R., & Colizzi, M. (2016). The effect of cross-sex hormonal treatment on gender dysphoria individuals’ mental health: a systematic review. Neuropsychiatric Disease and Treatment, 1953-1966.

Nguyen HB, Chavez AM, Lipner E, Hantsoo L, Kornfield SL, Davies RD, Epperson CN. Gender-Affirming Hormone Use in Transgender Individuals: Impact on Behavioral Health and Cognition. Curr Psychiatry Rep. 2018 Oct 11;20(12):110. doi: 10.1007/s11920-018-0973-0. PMID: 30306351; PMCID: PMC6354936.

Rowniak, S., Bolt, L., & Sharifi, C. (2019). Effect of cross-sex hormones on the quality of life, depression and anxiety of transgender individuals: a quantitative systematic review. JBI Evidence Synthesis, 17(9), 1826-1854.

Baker, K. E., Wilson, L. M., Sharma, R., Dukhanin, V., McArthur, K., & Robinson, K. A. (2021). Hormone therapy, mental health, and quality of life among transgender people: a systematic review. Journal of the Endocrine Society, 5(4), bvab011.

Haupt C, Henke M, Kutschmar A, Hauser B, Baldinger S, Saenz SR, Schreiber G. Antiandrogen or estradiol treatment or both during hormone therapy in transitioning transgender women. Cochrane Database of Systematic Reviews 2020, Issue 11. Art. No.: CD013138. DOI: 10.1002/14651858.CD013138.pub2.

Zhang, J., Yin, J., Song, X., Lai, S., Zhong, S., & Jia, Y. (2023). The effect of exogenous estrogen on depressive mood in women: A systematic review and meta-analysis of randomized controlled trials. Journal of psychiatric research, 162, 21-29.

Zarrouf, F. A., Artz, S., Griffith, J., Sirbu, C., & Kommor, M. (2009). Testosterone and depression: systematic review and meta-analysis. Journal of Psychiatric Practice®, 15(4), 289-305.

Amanatkar, H. R., Chibnall, J. T., Seo, B. W., Manepalli, J. N., & Grossberg, G. T. (2014). Impact of exogenous testosterone on mood: a systematic review and meta-analysis of randomized placebo-controlled trials. Ann Clin Psychiatry, 26(1), 19-32.

Walther, A., Breidenstein, J., & Miller, R. (2019). Association of testosterone treatment with alleviation of depressive symptoms in men: a systematic review and meta-analysis. JAMA psychiatry, 76(1), 31-40.

Sherwin, B. B. (2003). Estrogen and cognitive functioning in women. Endocrine reviews, 24(2), 133-151.

Perović, M., Wugalter, K., & Einstein, G. (2022). Review of the effects of polycystic ovary syndrome on Cognition: Looking beyond the androgen hypothesis. Frontiers in Neuroendocrinology, 67, 101038.

Sukhapure, M., Eggleston, K., Douglas, K., Fenton, A., Frampton, C., & Porter, R. J. (2022). Free testosterone is related to aspects of cognitive function in women with and without polycystic ovary syndrome. Archives of Women's Mental Health, 25(1), 87-94.

Schattmann, L., & Sherwin, B. B. (2007). Effects of the pharmacologic manipulation of testosterone on cognitive functioning in women with polycystic ovary syndrome: a randomized, placebo-controlled treatment study. Hormones and Behavior, 51(5), 579-586.

Mohamad, N. V., Ima-Nirwana, S., & Chin, K. Y. (2018). A review on the effects of testosterone supplementation in hypogonadal men with cognitive impairment. Current drug targets, 19(8), 898-906.

Zhang, Z., Kang, D., & Li, H. (2021). Testosterone and cognitive impairment or dementia in middle-aged or aging males: causation and intervention, a systematic review and meta-analysis. Journal of Geriatric Psychiatry and Neurology, 34(5), 405-417.

Janowsky, J. S. (2006). The role of androgens in cognition and brain aging in men. Neuroscience, 138(3), 1015-1020.

Spencer, S. J., Logel, C., & Davies, P. G. (2016). Stereotype threat. Annual review of psychology, 67(1), 415-437.

Ortner, T.M., Sieverding, M. Where are the Gender Differences? Male Priming Boosts Spatial Skills in Women. Sex Roles 59, 274–281 (2008). https://doi.org/10.1007/s11199-008-9448-9

Sharps, M. J., Price, J. L., & Williams, J. K. (1994). Spatial cognition and gender instructional and stimulus influences on mental image rotation performance. Psychology of Women Quarterly, 18(3), 413-425.

Estes, Z., Felker, S. Confidence Mediates the Sex Difference in Mental Rotation Performance. Arch Sex Behav 41, 557–570 (2012). https://doi.org/10.1007/s10508-011-9875-5

Maeda, Y., Yoon, S.Y. A Meta-Analysis on Gender Differences in Mental Rotation Ability Measured by the Purdue Spatial Visualization Tests: Visualization of Rotations (PSVT:R). Educ Psychol Rev 25, 69–94 (2013). https://doi.org/10.1007/s10648-012-9215-x

Voyer, D. Time limits and gender differences on paper-and-pencil tests of mental rotation: a meta-analysis. Psychon Bull Rev 18, 267–277 (2011). https://doi.org/10.3758/s13423-010-0042-0

Koch, S.C., Konigorski, S. & Sieverding, M. Sexist Behavior Undermines Women’s Performance in a Job Application Situation. Sex Roles 70, 79–87 (2014). https://doi.org/10.1007/s11199-014-0342-3

[valentine-cafe]

Hello. How are you? I hope I'm not bothering you. Which tablet and program do you use for drawing? Do you have any advice on drawing?

﹙ 🍒. ﹚ ─── Hello dear!!! Here's what Eden and I use for art!

Eden has a samsung tablets and uses Hipaint ( I don't know which tablet version it is specifically - )

I use an Ipad pro and operate on Procreate and Hipaint! My most frequently used brushes are from this lovely artist Nurin ( SUPPORT HER SHE IS SO TALENTED LAWD. )

As for some advice?

Well, brace yourself bbg, imma bout to get ya some.

References:

Never forget to use references. It is so important. Don't listen to all of those artists out there telling you it's cheating and to wing it and learn that way ( reality of it all is you won't learn much because you don't sit down and study the way things work. )

Concept art / general art:

If you are doing concept art, and you have a finish deadline, don't sit and worry on imperfections during the sketch or the midway process. Go with your intuiton and what feels right and then, you can focus on the details and rendering stuff to look the way you want it to when you're getting to the end

STUDYING OTHER ART STYLES !!!

This one has become such a controversial topic over the years and I don't know for what fucking reason, how are we supposed to improve and learn if we can't be inspired by other art styles? Look, in each and every style we come across that we enjoy, utilise some of the things you see! put it all together and make it your own style. It's so important.

Look at professional artists and hear their advice:

One thing I ( howl ) learnt as a self-taught artist, is that you're gonna have to get out of your shell of learning all by yourself and get advice and help from other professional artists, whether it's someone you know in your daily life or it is video lessons you sit down and watch, free or not.

I highly recommend looking at artists like: TB choi, Sinix, Samdoesart, Coleshairlesscat, Nirami, and there are probably many more ( I am forgetful baby ).

Allow yourself to take in the advice given and you will see improvements q u i c k.

keep sketchin:

This is also such an annoying thing to hear as an artist. New or not. Especially if you've struggled with sketching in the past or now. It is vital to sketch. Whether that becomes a full illustration or not, that's okay. What is important is that you keep your hands busy and acquaint them with the memory of the flow you are most comfortable with artstyle considered.

Don't. Force. Yourself:

Now with the topic up above, if you feel as though you aren't drawing enough and you need to draw more and you have to and- woah. man. calm down. That becomes very stressing, doesn't it?

You have to allow yourself to take breaks in art, and stop fearing whether or not you will lose all the knowledge you know. Because the truth is, if you force yourself to do art that doesn't come with natural inspiration, you propably still won't be satisfied with it ( if you end up being and it helps you, great, proud of you! )

there are times in the work of a fulltime artist where this will be necessary to force yourself a little, but don't do it to the extent that you burn out.

You give yourself a little nudge and say: lets go. Rather than push yourself into waters you currently can't swim in.

Stop telling yourself you have art blockage:

I learnt this one from Cole !!! The more you start telling yourself you can't draw because "something is in the way" the more you create a placebo effect of you actually not being able to draw. You will always be able to draw! You will always be able to make art. Whether you think it's good or not. It's still art that you have made, and it's still beautiful. Stop telling yourself you have a block for inspiration and will to do art, because you don't. You can and will always be able to create art.

Some advice from Eden and I:

don't stress yourself with the process of art, it is something you are supposed to enjoy. Yes. When you feel the frustration creep up ( because all artists do in their life at one point ) walk away from it.

Take a breather. a 15 minute or more breather, for your eyes to adjust to how everything looks on your canvas. And then you can decide whether you like it or not. But don't get disappointed, or mad at yourself for not doing so, instead, be inspired, try to be inspired by this and then say: "okay, then we try again." And the more you keep going, the further you'll come and at the end, you'll be satisfied.

Also important!!! Don't be ashamed of not having as many illustrations as big pieces done as sketches guys ( fluttering eyelashes ) you should see my folders and the average folder of bigger artists as well KEKW

I truly hoped that this helped darlin'!

Have a good one, and to all of you, always remember to support your fellow artists!!

[crystallinehell]

Silence is something most would take over being in danger. That's what he thinks, after all. But being here for ages, not having any way to tell the time, made him debate it internally.

He used to be sore when he began to endlessly walk, but now he wasn't. He had left his crown in a safe place, a marker of his one place of rest; a placebo effect making him think it was more comfortable than the rest.

His legs no longer hurt, his mind only served to get fuzzier and fuzzier. He used to call out for his old hacker friends, but he knew they were long gone; in the banlands.

He just wanted to get them out, by any means. They were his ride or dies, and he was theirs.

But this felt like punishment for every crime he ever did, or considered doing. His mind had gone over every topic, every idea, every thought he could have. It was him and him alone in this hell.

Maybe he deserved it- scratch that, he knew he did. The Darkheart's effects really helped show that. Now he couldn't even see out of an eye, and felt as though he was forever scarred.

He couldn't even tell, though- he had no mirrors here.

So he kept walking. Just him here. It was an everyday routine, if there even were days here.

Because maybe he'd find a way out.

What would he say if he saw people from the past? A simple 'I'm sorry' would never cut it. He had recited apologies and bouts of rage and curses in his mind alike. None felt fitting.

He'd try to speak, he imagined. But he couldn't even tell if he had a voice anymore. He hadn't spoken in almost the entire time he was here, aside from screaming from the nightmares he'd occasionally have.

.. He'd sell his soul to get out of here.

Did he even have one anymore, though?

[omegaversetheory]

Is there such a thing as fertility meds? Like to make an omega more fertile. Like perhaps if the omega is getting close to omegapause and they want to have a pup or something...

Yes, there are fertility treatments that you can go through, here are some of the most common ones.

-----

Treatment for alphas with uteruses can kickstart their hormones and help them get pregnant. Female alphas, for example, are the least likely of any potential baby-carrying person to get pregnant. This treatment introduces high-dose hormones that are normally found in omegas to the alpha's system. This is normally administered as a series of injections over 90 days, which would be one "cycle".

Treatment for impregnators to increase their sperm count/mobility. Users have the option of a topical cream that needs to be applied three times a day during a 120 day cycle, or as a once-a-week injectable over six months.

Ovulation triggers - this is a medication that can increase the span of ovulation to open up the window of time an individual could become pregnant. This comes as a set of pills that need to be taken daily, with a few placebos (like birth control). Best results occur when you've been on the medication for 3-6 months, and should be continued steadily until you become pregnant.

Egg health and maturation -a combination of pills and injections that should be administered twice a week for best results. This will help keep your eggs healthy while you are ovulating.

Implantation - normally a hormone shot, but can also be a topical/internal cream that helps the embryo embed into the uterine lining. This is something that should be used directly after copulation with your partner.

---

if you are close to going through menopause (aka pre-menopause), which can affect people from any dynamic as long as they have a uterus, getting a consult with a doctor is very important. They will prescribe you and possibly your partner some of this medication and may put you on additional hormone treatment to suspend the effects of menopause. Once your menopause begins though, there isn't much that can be done. Your doctor will be able to talk you through other options, such as fostering and adoption if you are up for it.

[gardenstateofmind]

also want to get up on my little soap box and say that combination cold meds are not really effective bc two of the most common ingredients in them (guaifenesin and phenylephrine) are straight up useless. guaifensin is supposed to be an expectorant, meaning it helps you clear out mucus, but there's no reliable research showing it to be more effective than placebo. topical phenylephrine can be effective at constricting blood vessels (this is the active ingredient in preparation h) but oral phenylephrine literally does nothing and the fda has been working towards taking it off shelves

cough suppressants are also not very effective, but they're not entirely useless. it really depends on the person. for some people they're really effective, for a lot of people they do nothing at all, and for most people they probably help a little? which imo makes them worth trying bc when you're coughing up a lung, you'll take any relief you can get lol

personally i like taking combination nighttime cold meds bc they contain dextromethorphan, doxylamine succinate (antihistamine very similar to benadryl), and acetaminophen, all of which do work well for me, so it's convenient to have them in one dose. the phenylephrine is just kind of there, like it doesn't help but it doesn't hurt either so it's whatever.

[alligatorhearts]

Types of Witches in the Bayou: The Traiteur

traiteur: a Cajun or Creole healer whose gifts were bestowed upon them by a higher being either at birth, through biological inheritance, or in apprenticeship

The traiteur is just as mystical as she is a practical fixture of the community. People in the community appear on her doorstep at the lowest moments of their life when they have nowhere to turn, just as they drive in from hours out of town for her otherworldly skills. The traiteur does not accept payment for her services. She was designated as a tool of God, and to expect financial benefit is to taint her practice and destroy its sanctity.

A Brief Look at the History and Practices:

Traiteur's traditionally believe that their powers not only come from God but that their practice is in line with the Catohlic faith. However, this is not always true despite being reported as factual in most spaces where information is available online.

They can treat people with their hands, with blessed medicine made by those hands, or through prayer.

The proof is in the innocent - many traiteurs (who still exist and practice today) have a track record of healing newborns and young infants, who would not be vulnerable to the psychosomatic "placebo" effect or other phenomenon.

Different traiteurs prescribe to different practices, but the vast majority treat topical wounds and ailments but are not suited to treating more complex medical maladies.

Patients of traiteurs report feeling that the healers often also treat their burdens of mind and spirit, perhaps suggesting that the practice is related to the theory that our heart can affect the afflictions of our bodies.

[siryouarebeingmocked]

Jack Reacher: The Secret (is that little bro fell off)

The Jack Reacher thriller series was created by Lee Child. It's very popular. Like a lot of authors, he handed it off to someone else; his brother Andrew.

And maybe it's the placebo effect, but I've noticed a drop in quality. Full spoilers for various books.

A previous book revolved around a Russian misinformation operation on American soil, and ransomware. Came out 2020.

The Secret is from 2023, and set in 1992, when Reacher was still an Army MP. It involves a series of murders connected to an American weapons development programed outsourced to the third-world. 

Which killed a lot of people, but it was covered up.

The killers are a pair of sister trying to find the people responsible. By killing and interrogating them. Not in that order. They're very good at infiltrating, beating up, and killing people. 

They're supposed to be an evil version of Reacher, who is bad at infiltration but is good at hurting people. And, of course, all three are smart investigators.

There's one fight scene where one of the girls goes for a target and runs into multiple male guards. Who mostly lemming train directly into her fists and/or feet. In fact, it heads straight into narm. She drops two guys before one tries to shoot her or really defend himself, and only the fourth, the team leader, stays out of fist range.

You know, basic tactics that any bodyguard, cop, or trained operative should probably know.

Plus, common sense.

While she's busy beating them up, she has enough spare brain cells to think about the situation and come up with a plan. Which she executes on the last guy. 

She surrenders, he has some generic sneers about teasing his men for being beaten by a girl, safety-cuffs her, offers a generic sexual threat, and she comes up with an story that sends the surveillance team outside away.

Then she drops the team lead, and sneers at him and his men for underestimating a woman.

This is a running theme.

I think it would've been better if the lead was actually concerned about his men. Make him a little less of a speed bump. You could even leave in the sexism.

The irony is, Reacher usually sticks to highly practical moves. Our girl does go for things like throat strikes, but also a high kick. Which is, I've read, rather impractical.

I certainly don’t have the flexibility to check. Even on a dummy. I may never have had it.

And frankly, it's perfectly reasonable to assume someone who is cuffed is not much of a threat.

For contrast, Reacher's next scene? He beats up four generic mooks between him and a source. He's done this several times in the series, but this time it seems pretty short and token.

I assume they wanted to keep it moving, because of pacing.

This is a series that has had a lot of capable and well-developed female characters. So this seems like an odd theme to include at this point. And it turns out the real villain of the piece is Secretary of Defense. 

No, wait, it's actually his wife. 

Who people underestimate and overlook.

Including the two killers.

Which kills them.

Oh look, irony.

The girls aren't really complex. Basically, they're Black Widow. A pair of generic foreign female infiltrators and CQC experts. Even their quest to get revenge for their father doesn't really matter, because we don't see any other evidence of their bond with him.

I think the most we get is some verbal discussion near the climax. Telling, nto showing.

And it's not like they care about the hundreds of other people who were killed and covered up. Just their dad. 

So no "Pet the Dog" moments.

Now, I'm aware that popular fiction is often Topical™. That doesn't make it bad. EG Die Hard; western terrorists, environmentalism, and Japanese business were all topical.

A previous Lee book during Reacher's MP days revolved around a closeted gay couple. Lee also wrote a 2016 book about European Neo-Nazis, and the very second book was about a far-right militia. And they were pretty good. 

I get the impression Lee leans left-wing, but so what?

It just feels like Andrew is a lot less subtle about this.

And that's coming from someone who's enjoyed books by a literal socialist.

[jcsmicasereports]

Use of acupressure to reduce nausea and vomiting in cancer patients receiving chemotherapy (literature study) by Maher Battat in Journal of Clinical Case Reports Medical Images and Health Sciences

Abstract

Nausea and vomiting are distressing and serious problems for cancer patients receiving chemotherapy despite the fact that they are receiving antiemetics according to the standard guidelines which this problem is a huge challenge to nurses involved in cancer care.

Purpose: To explore and assess the effectiveness of using acupressure as a non-pharmacological intervention in addition to pharmacological interventions in reducing nausea and vomiting in cancer patients receiving chemotherapy.

Method: A literature review was conducted of 8 articles published between 2006 and 2014. These included one study of a randomized, double-blind, placebo controlled trial; one quasi-experimental model with a control group; four articles reporting on randomized control trials (RCTs); one systematic review study; and one review study. Key Findings: Seven of the articles we read supported the effect of an acupressure P6 Wristband in reducing chemotherapy induced nausea and vomiting in cancer patients and other databases also supported that finding. The one article with neutral results showed that there was no difference between a combination of acupuncture and acupressure treatment at P6 and at the sham point for the nausea score, but the level of nausea was very low in both groups.

Conclusion: We conclude that the acupressure P6 wrist band when applied to acupuncture point P6 is effective, safe, convenient, cost effective, and provides an easy, self-administrated, non-pharmacological intervention that can be used to reduce chemotherapy induced nausea and vomiting.

Keywords: Acupressure, Chemotherapy, Nausea and Vomiting, Cancer patients, Chemotherapy-induced nausea and vomiting.

Introduction

Nausea and vomiting are serious and troublesome side effects of cancer therapy. We chose this research topic in order to become familiar with the topic of the nausea and vomiting facing cancer patients during their chemotherapy treatment, which we have observed during our experience in the Oncology departments.

As nurses, we normally use updated and standard guidelines for managing clinical challenges. We reviewed the literature to explore whether there are alternative approaches to pharmacological management that might reduce or eliminate this problem. We found there are many interventions, such as music, acupuncture, acupressure, and yoga. We decided to assess the effectiveness of using acupressure to reduce the nausea and vomiting in cancer patients receiving chemotherapy. Acupressure is a type of complementary and alternative medicine which the National Cancer Institute (NCI Dictionary of Cancer Terms) defines as follows: “Acupressure is the application of pressure or localized massage to specific sites on the body to control symptoms such as pain or nausea".

The Research Question

Can acupressure reduce nausea and vomiting in cancer patients receiving chemotherapy?

We have chosen to use the definitions of the NCI Dictionary of Cancer Terms:

“Nausea is an unpleasant wavelike feeling in the back of the throat and/or stomach that may lead to vomiting", and “Vomiting is throwing up the contents of the stomach through the mouth”.

Nausea and vomiting affect the patient’s whole life. These side effects lead to metabolic imbalance, fatigue, distress, and lowered quality of life. We would like to fine a simple, effective and cost effective way to manage these problems so we can put it to use in our hospital.

Method

A literature study is, “A critical presentation of knowledge from various academic written sources, and a discussion of the sources in view of a particular research question" (Synnes 2014). There are many challenges when doing a literature study. There are many databases and much literature and our search process had to find the correct, scientific and relevant databases. It required a lot of time and effort to find the full text of all relevant articles. Fortunately, we received excellent help from the librarian at the Betanien University High school.

We started the search process by making a PICO outline to narrow down the search and to find the correct key words and mesh terms.

P: (Population or participants) Cancer patients experiencing chemotherapy-induced nausea and vomiting.

I:  (Intervention or indicator) Acupressure.

C: (Comparator or control) No comparison or placebo.

O: (Outcome) Reduce nausea and vomiting.

We used PUBMED, Google scholar, scholar.najah.edu and other search engines. When we used Acupressure as a search word we found more than 800 studies. When we added chemotherapy, cancer patients, and nausea and vomiting, we brought this down to 14 articles. We read these and decided to use 8 articles only, one of which was a systematic review. We also used an unpublished Master’s thesis from An Najah National University. This thesis was cited in one of the articles that we decided to review. The key words used were: Acupressure, Chemotherapy, Nausea and Vomiting, Cancer patients, Chemotherapy-induced nausea and vomiting, with Acupressure as a mesh term.

We then critically appraised all the articles according to our checklist. We included only those articles that followed the IMRAD style (i.e. those including an introduction, method, results and discussion section). We excluded all articles that were more than ten years old (i.e. published before 2004), except for two articles: one was about the mechanism of acupressure, which seemed to be directly relevant to our research topic, while the second article was used in the discussion section to discuss certain factors related to the topic. We also excluded one of the review articles because its method appeared to be weak. One of the Cochran reviews was also dropped because it had not been updated.

Despite applying these strict criteria, we were still concerned lest we had left out some important articles or included an inappropriate one. However, we were reassured by the fact that the librarian at Betanien had guided us in our search.

Theoretical part

Nursing Need Theory and basic human needs

The Nursing Need Theory was developed by Virginia A. Henderson to define the unique focus of nursing practice. The theory focuses on the importance of increasing the patients’ independence to hasten their progress in the hospital. Henderson’s theory emphasizes the basic human needs and how nurses can assist in meeting those needs.

The 14 components of Need Theory present a holistic approach to nursing that covers the patient’s physiological, psychological, spiritual and social needs.

Physiological components

Breathe normally.

Eat and drink adequately.

Eliminate body wastes.

Move and maintain desirable postures.

Sleep and rest.

Select suitable clothes – dress and undress.

Maintain body temperature within normal range by adjusting clothing and modifying the environment.

Keep the body clean and well groomed and protect the integument.

Avoid dangers in the environment and avoid injuring others.

Psychological aspects of communicating and learning

Communicate with others in expressing emotions, needs, fears, or opinions. Spiritual and moral

Worship according to one’s faith. Sociologically oriented to occupation and recreation

Work in such a way that there is sense of accomplishment.

Play or participate in various forms of recreation.

Learn, discover, or satisfy the curiosity that leads to normal development and health, and use the available health facilities.

There is much similarity between Henderson’s 14 components and Abraham Maslow’s Hierarchy of Needs. Henderson’s Components 1 to 9 are comparable to Maslow’s physiological needs, with the 9th component also being a safety need. Henderson’s 10th and 11th components are similar to Maslow’s love and belonging needs, while her 12th, 13th and 14th components match Maslow’s self-esteem needs (Vera 2014).

The second of Henderson’s physiological needs is the need to “Eat and drink adequately”. Only the need to breathe is given a higher priority than the need for adequate nutrition. For cancer patients receiving chemotherapy and suffering from chemotherapy-induced nausea and vomiting, this need is the most critical.

Cancer prevalence and treatment

Cancer is a group of diseases characterized by uncontrolled growth and the spread of abnormal cells. It may be caused by internal factors, such as an inherited mutation, or a hormonal or immune condition, or it may result from a mutation from metabolism, or from external sources, such as tobacco use, radiation, chemicals and infectious organisms. Cancer is prevalent all over the world, in both developed and developing nations; it affects both sexes at all ages (Said 2009). The American Cancer Society (2010) estimated that 1,529,560 new cases of cancer were diagnosed in 2010 and that 80 % would be treated with chemotherapy; this means more than 1 million patients will be undergoing chemotherapy in any given year (Lee et al. 2010).

Cancer treatment may be based on chemotherapy, radiotherapy and surgical interventions. Chemotherapy is an important treatment in cancer care but it is associated with several side effects, such as bone marrow suppression, increased susceptibility to infection, diarrhea, hair loss, appetite changes, nausea and vomiting, among others (NCI Chemotherapy Side Effects Series, 2014).

Chemotherapy-induced nausea and vomiting (CINV) is the most prevalent and one of the hardest side effects to manage (Suh 2012).

Nausea and vomiting

Nausea and vomiting (N&V) can be acute or delayed. The incidence of acute and delayed N&V was investigated in highly and moderately emetogenic chemotherapy treatment regimens. Patients were recruited from 14 oncology practices in six countries. Overall, more than 35% of patients experienced acute nausea, and 13% experienced acute emesis. In patients receiving highly emetogenic chemotherapy, 60% experienced delayed nausea and 50% experienced delayed emesis. In patients receiving moderately emetogenic chemotherapy, 52% experienced delayed nausea and 28% experienced delayed emesis. CINV was a substantial problem for patients receiving moderately emetogenic chemotherapy in ten community oncology clinics. Thirty-six percent of patients developed acute CINV, and 59% developed delayed CINV (NCI, Nausea and Vomiting, 2015).

Chemotherapy is the most common treatment-related cause of N&V. The incidence and severity of acute emesis in persons receiving chemotherapy varies according to many factors, including the particular drug, dose, schedule of administration, route, and individual patient variables.

Risk factors for acute emesis include:

Poor control with prior chemotherapy

Female gender

Younger age

Emetic classification:

The American Society of Clinical Oncology has developed a rating system for chemotherapeutic agents with their respective risk for acute and delayed emesis.

High risk: Emesis has been documented to occur in more than 90% of patients on the following chemotherapeutic agents:

Cisplatin (Platinol).

Mechlorethamine (Mustargen).

Streptozotocin (Zanosar).

Cyclophosphamide (Cytoxan), 1,500 mg/m2 or more.

Carmustine (BiCNU).

Dacarbazine (DTIC-Dome).

Moderate risk: Emesis has been documented to occur in 30% to 90% of patients on the following chemotherapeutic agents:

Carboplatin (Paraplatin).

Cyclophosphamide (Cytoxan), less than 1,500 mg/m2.

Daunorubicin (DaunoXome).

Doxorubicin (Adriamycin).

Epirubicin (Pharmorubicin).

Idarubicin (Idamycin).

Oxaliplatin (Eloxatin).

Cytarabine (Cytosar), more than 1 g/m2.

Ifosfamide (Ifex).

Irinotecan (Camptosar).

Low risk: Emesis that has been documented to occur in 10% to 30% of patients on the following chemotherapeutic agents:

Mitoxantrone (Novantrone).

Paclitaxel (Taxol).

Docetaxel (Taxotere).

Mitomycin (Mutamycin).

Topotecan (Hycamtin).

Gemcitabine (Gemzar).

Etoposide (Vepesid).

Pemetrexed (Alimta).

Methotrexate (Rheumatrex).

Cytarabine (Cytosar), less than 1,000 mg/m2.

Fluorouracil (Efudex).

Bortezomib (Velcade).

Cetuximab (Erbitux).

Trastuzumab (Herceptin).

Minimal risk: Emesis that has been documented to occur in fewer than 10% of patients on the following chemotherapeutic agents:

Vinorelbine (Navelbine).

Bevacizumab (Avastin).

Rituximab (Rituxan).

Bleomycin (Blenoxane).

Vinblastine (Velban).

Vincristine (Oncovin).

Busulphan (Myleran).

Fludarabine (Fludara).

2-Chlorodeoxyadenosine (Leustatin).

In addition to the emetogenic potential of the agent, the dose and schedule used are also extremely important factors. For example, prescribing a drug with a low emetogenic potential to be given in high doses may cause a dramatic increase in its potential to induce N&V. For example, standard doses of cytarabine rarely produce N&V, but these often occur with high doses of this drug. Another factor to consider is the use of drug combinations. Because most patients receive combination chemotherapy, the emetogenic potential of all of the drugs combined needs to be considered, and not only that of individual drug doses.

Delayed (or late) N&V is that which occurs more than 24 hours after chemotherapy administration. Delayed N&V is associated with cisplatin and cyclophosphamide, and with other drugs (e.g., doxorubicin and ifosfamide) when given at high doses, or if given on 2 or more consecutive days.

Delayed emesis: Patients who experience acute emesis with chemotherapy are significantly more likely to have delayed emesis as well.

Risk factors: All the predicative characteristics for acute emesis are also considered risk factors for delayed emesis (NCI, Nausea and Vomiting, 2015).

The nausea and vomiting that are often associated with chemotherapy are a serious problem for cancer patients. Despite recent improvements in pharmaceutical technology, about 60% of cancer patients who receive antiemetic medications with their chemotherapy still suffer from nausea and vomiting, and as many as 20% of patients refuse to continue chemotherapy due to the severity of the nausea and vomiting (Shin et al. 2004). Early studies reported that patients cited nausea and vomiting as the most distressing symptoms when receiving chemotherapy. The distressing effect of severe nausea and vomiting can lead to nutritional deficiencies, dehydration, electrolyte imbalance, fatigue, depression and anxiety; they can also disrupt the activities of daily living and cause a lot of work time to be lost (Said 2009).

Uncontrolled nausea and vomiting can interfere with adherence to treatment regimens, and may cause the oncologists to reduce chemotherapy doses. Chemotherapy-induced nausea and vomiting is classified as being either “acute” if it happens within 24 hours post chemotherapy, or “delayed” if it occurs on days 2–5 of the chemotherapy cycle. The latter is particularly troublesome because there is no reliable pharmacological treatment for this problem. The American Society of Clinical Oncology’s (ASCO) recommendations include giving 5-HT3 (5-hydroxytryptamine, or serotonin) receptor antagonists plus corticosteroids before chemotherapy to patients who are at high risk for emesis. Nevertheless, many patients still experience nausea and vomiting related to chemotherapy, and approximately one-third of patients have nausea of at least moderate intensity, resulting in a significant reduced quality of life (QOL). Therefore, the experts emphasize the need for an evaluation of additional ways to reduce these symptoms (Said 2009).

Pharmacological interventions for the management of nausea and vomiting

Historically, antiemetic treatment has steadily improved since the introduction, in 1981, of high-dose metoclopramide which reduced the amount of emesis. This was followed by the development of serotonin (5-HT3) antagonist in the early 1990s, and the 5-HT3 antagonists proved to be more effective than the prior medications in preventing CINV. The concomitant use of corticosteroids was found to further improve the control of emesis. Despite these improvements, nausea and vomiting still remain a problem for many patients. Recently, a new drug, the neurokinin NK (1) receptor antagonist has been shown to be more effective at preventing both acute and delayed CINV for patients treated with highly emetogenic chemotherapy (Said 2009).

Non-pharmacological intervention for management of nausea and vomiting

Traditional Chinese medicine offers a possible intervention for the non-pharmacological treatment of nausea and vomiting in cancer patients. Traditional Chinese medicine (TCM) is a system of medical care that was developed in China over thousands of years. It looks at the interaction between mind, body and environment, and aims to both prevent and cure illness and disease.

TCM is based on Chinese views and beliefs about the universe and the natural world. It is a very complex system. In this essay we can only give a brief overview of what TCM involves. It is very different from Western medicine; Chinese medicine practitioners believe there is no separation between the mind and body and that illness of every kind can be treated through the body. They use a combination of various practices that may include:

Herbal remedies (traditional Chinese medicines).

Acupuncture or acupressure.

Moxibustion (burning moxa – a cone or stick of dried herb).

Massage therapy.

Feng shui.

Breathing and movement exercises called qi gong (pronounced chee goong).

Movement exercises called tai chi (pronounced tie chee).

TCM practitioners say that TCM can help to:

Prevent and heal illness.

Enhance the immune system.

Improve creativity.

Improve the ability to enjoy life and work in general.

Beliefs behind TCM

According to traditional Chinese belief, humans are interconnected with nature and affected by its forces. The human body is seen as an organic whole in which the organs, tissues, and other parts have distinct functions but are all interdependent. In this view, health and disease relate to the balance or imbalance between the various functions. TCM treatments aim to cure problems by restoring the balance of energies.

There are important components that underlie the basis of TCM:

Yin-yang theory is the concept of two opposing but complementary forces that shape the world and all life. A balance of yin and yang maintains harmony in the body, the mind and the universe.

Qi (pronounced chee) energy or vital life force flows through the body along pathways known as meridians, and it is affected by the balance of yin and yang. It regulates spiritual, emotional, mental, and physical health. If there is a blockage or an imbalance in the energy flow, the individual becomes ill. TCM aims to restore the balance of qi energy.

The five elements – fire, earth, metal, water, and wood – is a concept that explains how the body works, with the elements corresponding to particular organs and tissues in the body.

The TCM approach uses 8 principles to analyse symptoms and puts particular conditions into groups: cold and heat, inside and outside, too much and not enough, and yin and yang (Cancer Research, UK, 2015).

In summary, chemotherapy related nausea is not well controlled by pharmacological agents and identifying methods to prevent and alleviate treatment-related nausea remains a major clinical challenge. Non-pharmacological interventions such as music, progressive muscle relaxation (Said 2009), and ginger herbal therapy (Montazeri A et al. 2013) have all been shown to reduce CINV. Among the non-pharmacological interventions that reduce CINV are acupuncture and acupressure, based on the assumption that the individual’s welfare depends on a balance of energy in the body and their overall energy level (Said 2009). Yarbro et al. (2011, p. 645) also indicate in Cancer nursing: principles and practice book that acupuncture and acupuncture-related interventions (electroacupoint stimulation, acupressure, acustimulation wrist bands, and electroacupuncture) can be used to control nausea and vomiting in cancer patients.

Molassiotis et al. (2007) claim that the need for additional relief has led to the interest in non-pharmacological adjuncts to drugs, such as acupuncture or acupressure, since combining anti-emetics with other non-pharmacological treatments may prove to be more effective, safe and convenient in decreasing nausea than antiemetics alone.

From the National Cancer Institute website we found that acupressure is recognised as one of the non-pharmacologic strategies used to manage nausea and vomiting (Nausea and Vomiting, 3 September 2014). We used this website to get up to date, relevant information.

Acupressure

Acupressure involves putting pressure with the fingers, or with bands, on the body’s acupoints and is easy to perform, painless, inexpensive, and is effective. The P6 (Pericardium 6) point (Nei-Guan) refers to a point located on the anterior surface of the forearm, 3-finger widths up from the first wrist crease and between the tendons of flexor carpiradialis and Palmaris longus (figure1). P6 can be stimulated by various methods. The most well-known technique is manual stimulation by the insertion and manual rotation of a very fine needle (manual acupuncture). An electrical current can be passed through the inserted needle (electroacupuncture). Electrical stimulation can also be applied via electrodes on the skin surface or by a ReliefBand, a wristwatch-like device providing non-invasive electrostimulation. Pressure can be applied either by pressing the acupoint with the fingers or by wearing an elastic wristband with an embedded stud (acupressure).

Acupressure is based on the ancient Eastern concept that Chi energy travels through pathways known as meridians. Along the meridians are acu-points, which are controlling points for the Chi energy flow. If the energy flow in meridians is slowed, blocked, or hyper-stimulated, it can be rebalanced or re-stimulated either by applying pressure (acupressure) or by inserting a needle (acupuncture) into one or more of these acupoints. Two points are known for relieving nausea and vomiting: the Nei-Guan point (P6) and the Joksamly point (ST36, located at 4-finger breadths below the knee depression lateral to the tibia).

Patients tend to prefer the P6 point over the ST36 point, Because of its ease of access and the freedom from restriction. When these points are correctly located and pressure applied, either through acupressure or acupuncture, the Chi energy flow is rebalanced, resulting in relief from nausea and vomiting.

The practice of acupressure requires some training and experience, but the technique is widely accessible to any healthcare professionals, particularly to clinical nurses. This acupressure technique is an approach that should be tried not only by healthcare professionals but also by family members or the patients themselves (Shin et al. 2004).

According to the teaching of traditional Chinese medicine, illness results from an imbalance in the flow of energy through the body. This energy or Qi (chee) is restored through the use of acupuncture and acupressure at certain points on the body that have been identified through critical observation and testing over 4000 years. In scientific terms, the neurochemicals that are released after needling or pressure at a specific point may be responsible for this effect. The most commonly used point for nausea and vomiting is Pericardium 6 (Neiguan or P6), located above the wrist (Molassiotis et al. 2007).

The literature review on acupressure

Acupressure for chemotherapy-induced nausea and vomiting in breast cancer patients: a multicentre, randomised, double-blind, placebo-controlled clinical trial. (Said 2009)

For a master degree in public health from An-najah National University, Said (2009) described a randomized, double-blind, placebo controlled trial that was done in Palestine with 126 women on chemotherapy for breast cancer. In this study the researcher divided the patients into 3 groups: the first group (n=42) received acupressure with bilateral stimulation of P6, the second group (n=42) received bilateral placebo stimulation, and the third group (n=42), which served as a control group, received no acupressure wrist band, but all groups received pharmacological management of their nausea and vomiting. Acupressure was applied using a Sea-Band (Sea-Band UK Ltd, Leicestershire, England) that patients had to wear for five days following the administration of chemotherapy. Assessment of acute and delayed nausea and emesis, quality of life, patients’ satisfaction, recommendation of treatment and requests for a rescue antiemetic were obtained. Said (2009) concluded that the acupressure showed benefits for delayed nausea and the mean number of delayed emetic episodes. Acupressure may therefore offer an inexpensive, convenient, and self-administered intervention for patients on chemotherapy to reduce nausea and vomiting at home during days 2-5 after chemotherapy. In addition, the percentage of patients who were satisfied with the treatment (≥ 3 on a 0-6 scale) was 81% (35/42) in the P6-acupressure group, and 64% (27/42) in the placebo group (p= 0.0471). The percentage of patients who would recommend acupressure treatment was 79% (34/42) in the P6-acupressure group, and 62% (26/42) in the placebo group (p= 0.0533). We used this study because it had a lot of essential information, it used the IMRAD system and was also mentioned in the literature (Genç and Tan 2014). This study demonstrated that the mean scores for the acupressure group were lower for both acute and delayed nausea.

Review of Acupressure Studies for Chemotherapy-Induced Nausea and Vomiting Control. (Lee et al. 2008)

In the Journal of Pain and Symptom Management Jiyeon Lee et al. (2008) reviewed ten controlled studies on acupressure in order to evaluate the effects of a non-invasive intervention, acupressure, when combined with antiemetics for the control of CINV. The review evaluated one quasi-experimental and nine randomized clinical trials, which included two specific acupressure modalities, namely, an acupressure band and finger acupressure. The effects of the acupressure modalities were compared study by study. Four of the seven acupressure band trials supported the positive effects of acupressure, whereas three acupressure band trials did not support the effects of acupressure. However, all the studies with negative results had methodological issues. In contrast, the one quasi-experimental and two of the randomized finger acupressure trials all supported the positive effects of acupressure on CINV control. The reported effects of the two acupressure modalities produced variable results at each stage of CINV. Acupressure bands were most effective in controlling acute nausea, whereas finger acupressure controlled delayed nausea and vomiting. The overall effect of acupressure was strongly indicative but not conclusive. We used this article because it is relevant, a review study, and is from a known journal.

The effects of P6 acupressure in the prophylaxis of chemotherapy-related nausea and vomiting in breast cancer patients. (Molassiotis et al. 2007)

As reported in the journal Complementary Therapies in Medicine, acupressure was applied using wristbands (Sea-Band™) in a randomized controlled trial conducted in two centres in the UK. Patients in the experimental group had to wear these bands for the five days following their chemotherapy administration. Assessments of nausea, retching and vomiting were obtained from all patients, daily, for five days. Molassiotis et al. (2007) evaluated the effectiveness of using acupressure on the Pericardium 6 (Neiguan) acupoint in managing CINV. Thirty-six patients took part in the study, with 19 patients allocated to the control group and 17 to the experimental group. The results showed that nausea with retching, nausea, and vomiting with retching, and the accompanying distress were all significantly lower in the experimental group as compared to the control group (p < 0.05). The only exception was the vomiting, where the difference was close to significance (p = 0.06). We used this article because it had a strong study design and also used an IMRAD system.

Acupuncture and acupressure for the prevention of chemotherapy-induced nausea- a randomized cross-over pilot study. (Melchart et al. 2006)

In a randomized, cross-over trial, Melchart et al. (2006) studied 28 patients receiving moderately or highly emetogenic chemotherapy and a conventional standard antiemetic for one chemotherapy cycle, followed by a combination of acupuncture and acupressure at point P6 for one cycle, and for another cycle a combination of acupuncture and acupressure at a close sham point. The results showed that there was no difference in the nausea score between the combined acupuncture treatment at P6 and at the sham point, but the level of nausea was very low in both cases. We used this study because the article had neutral results and because we trusted the source of article, coming as it did from a cancer support care journal.

The efficacy of acupoint stimulation for the management of therapy adverse events in patients with breast cancer: a systematic review. (Chao et al. 2009)

This is a systematic review of 26 articles published between 1999 to 2008 examining the efficacy of acupressure, acupuncture or acupoint stimulation (APS) for the management of adverse events due to the treatment of breast cancer. Published online on 17 September 2009 in the Breast Cancer Research and Treatment journal, 23 trials reported revealed that APS on P6 was beneficial in treating CINV. Chao et al. (2009) also presented the findings from three high quality studies comparing APS groups with control groups, which indicated that APS is beneficial in the management of CINV and especially in the acute phase, even with the non-invasive intervention. Health care professionals should consider using APS, and in particular acupressure on the P6 acupoint, as an option for the management of CINV. Furthermore, as a cost effective intervention, it warrants further investigation. We used this article because it used the IMRAD structure.

'Until the trial is complete you can’t really say whether it helped you or not, can you?’: exploring cancer patients’ perceptions of taking part in a trial of acupressure wristbands. (Hughes et al. 2013)

In Complementary and Alternative Medicine, Hughes et al. report on qualitative research undertaken with patients receiving chemotherapy in the UK. A convenience sample of 26 patients volunteered to participate in the clinical trial and to explore their experiences of using acupressure wristbands. Participants were recruited from three geographical sites: nine were recruited from Manchester, nine from Liverpool, and eight from Plymouth and the surrounding regions. Ten of the participating patients received true acupressure during the trial, 9 received sham acupressure, and 7 received no acupressure. Hughes et al. (2013) concluded that the research provided insights into cancer patients’ motivations and experience of taking part in a clinical trial for a complementary alternative medicine intervention, in which the participants perceived acupressure wristbands to reduce the level of nausea and vomiting experienced during their chemotherapy treatment. This article is important because it includes the benefits experienced by the patients taking part in the trial. This is also the first qualitative study to explore patients’ experiences of using acupressure wristbands and their perceptions of the effects. In the study, the patients perceived the wristbands as reducing their level of nausea and vomiting experienced due to their chemotherapy treatment. The study was an RCT.

The effect of acupressure application on chemotherapy-induced nausea, vomiting, and anxiety in patients with breast cancer. (Genç and Tan 2014)

Genç and Tan (2014) reported on a quasi-experimental study in Turkey with 64 patients with stages 1–3 breast cancer who received two or more cycles of advanced chemotherapy. Thirty two patients were in the experimental group, and thirty two in the control group. To determine the effect of acupressure P6 on CINV and anxiety in these patients, the P6 acupressure wristband was applied to the experimental group. Genç and Tan (2014) concluded that the total mean scores for patients in the experimental group, for nausea, vomiting and retching, were lower than those of the patients in the control group over the five days of application. We used this article because it is a recent and quasi-experimental study and used the IMRAD system.

The effects of P6 acupressure and nurse-provided counselling on chemotherapy-induced nausea and vomiting in patients with breast cancer. (Suh 2012)

Suh (2012) reported in the Oncology Nursing Forum on a RCT in South Korea with 120 women who were receiving chemotherapy for breast cancer. These patients had all had more than mild levels of nausea and vomiting during their first cycle of chemotherapy. The participants were assigned randomly to one of four groups: a control group (a placebo on a specific location on the hand); a counselling only group; a P6 acupressure only group; and a P6 acupressure plus nurse-provided counselling group. The purpose of the study was to evaluate the effects of pericardium 6 (P6) acupressure and nurse-provided counselling on CINV in patients with breast cancer. Suh (2012) concluded that nurse-provided counselling and P6 acupressure were together the most effective in reducing CINV in patients with breast cancer. We used this article because it is the first RCT evaluating the isolated and combined effects of P6 acupressure and counselling in reducing CINV among non-Western patients. The findings of the study support the use of P6 acupressure together with counselling that is focused on cognitive awareness, affective readiness, symptom acceptance, and the use of available resources as an adjunct to antiemetic medicine for the control of CINV. The article used the IMRAD system.

Discussion

Can acupressure reduce nausea and vomiting in cancer patients receiving chemotherapy?

In our experience, we have usually used metoclopramide (pramin) plus serotonin (5-HT3) antagonist (as Ondansetron and Granisetron), plus Dexamethasone plus neurokinin NK (1) (as Emend - aprepitant) for moderate to high ematogenic chemotherapy, yet some of the patients have still suffered from nausea and vomiting. After reviewing the literature we would like to use the acupressure P6 wrist band to solve this problem as the findings of our literature review confirm that the acupressure P6 wrist band reduces CINV in cancer patients receiving chemotherapy. This result is corroborated by 7 of the articles reviewed.

The National Cancer Institute website supports the finding that acupressure is one of the non-pharmacologic strategies that may be used to manage nausea and vomiting (NCI Dictionary of Cancer Terms). Said (2009) adds that acupressure may offer an inexpensive, convenient, and self-administered intervention for patients on chemotherapy, helping to reduce nausea and vomiting at home on days 2-5 of chemotherapy. Genç and Tan (2014) conclude that the total mean scores for CINV in patients in the experimental group to whom they applied the P6 acupressure wristband were lower compared to patients in the control group over the five days of application. Lee et al. (2008) found that the two acupressure modalities produced variable results in each phase of CINV: acupressure bands were effective in controlling acute nausea, whereas acupressure controlled delayed nausea and vomiting. Molassiotis et al. (2007) showed that the experience of nausea and vomiting was significantly lower in the experimental group than in the control group. Chao et al. (2009) found that P6 acupoint stimulation was an option for the management of CINV. In the study reported by Hughes et al. (2013) the participants perceived that acupressure wristbands reduced the levels of nausea and vomiting experienced during chemotherapy treatment. Suh (2012) concluded that the synergistic effects of P6 acupressure together with nurse-provided counselling appeared to be effective in reducing CINV in patients with breast cancer.

Five of the seven articles investigating breast cancer patients, namely Said (2009), Chao et al.( 2009), Molassiotis et al. (2007), Suh (2012) and Genç and Tan (2014), involved breast cancer patients receiving highly ematogenic chemotherapy (e.g. Cisplatin and cyclophosphamide), and moderate risk ematogenic chemotherapy (like doxorubicin).

It is necessary to mention other therapeutic regimens that can also be used in cancer treatment that contain other types of chemotherapy that cause nausea and vomiting, for example, doxorubicin-containing regimens like ABVD (Adriamycin, Bleomycin, Vinblastine, Dacarbazine), CHOP (Cyclophosphamide, Adriamycin, Vincristine, Prednisone) and FAC (5-Fluorouracil, Adriamycin, Cyclophosphamide), and ACT (Adriamycin, Cyclophosphamide, Taxol) (Said 2009) and from our experience cisplatin-containing regimens which that classified as highly ematogenic chemotherapy we noticed the patients still experienced nausea and vomiting after they received the antiemitecs. We think it is necessary to use additional intervention like acupressure to be included in the nausea and vomiting management.

Based on the reviewed findings we plan to use acupressure for cancer patients receiving chemotherapy, because the acupressure in the studies conducted in breast cancer patients reported was used with highly ematogenic chemotherapy in addition to the standard antiemetic treatment, so it is reasonable to conclude that it will work equally well with other less ematogenic types of chemotherapy.

We prefer the use of the acupressure wrist band at P6 acupoint because it is an inexpensive, convenient, and self-administered intervention involving pressure instead of needles at the same point as that used in acupuncture. Furthermore it is safer than acupuncture and patients can easily learn to put pressure on their own wrists, whereas the acupuncture involves using needles that are about the diameter of a hair and can cause temporary discomfort during insertion (Said 2009; Molassiotis et al. 2007). Acupressure seems to be a good way to complement antiemetic pharmacotherapy as it is safe and convenient, with minimal (with bands) or no (finger acupressure) costs involved. It is thus an easy to use, cost-effective, non-invasive intervention (Lee et al. 2008; Melchart et al. 2006).

There was no study result that showed any negative effect from the acupressure wrist band at P6 point, except the review by Lee et al. (2008), which mentioned that three of the ten reported acupressure band trials did not support the possible positive effects of acupressure, but these studies all had methodological issues, such as a small sample size, no true control group, and a concern about the sham acupressure band having a possible antiemetic effect. Melchart et al. (2006) said that no difference was detected in the nausea score between the acupuncture treatment at P6 acupoint, and that at the sham point. Said (2009) mentioned that the acupressure showed no benefit in relation to the incidence of delayed vomiting, early vomiting, or acute nausea, but Melchart and Said’s studies were done with breast cancer patients and it could be that the acupressure benefits were not evident due to the breast cancer patients having had axillary lymph node resection that may have affected the meridian pathway or caused damage to the median nerve as mentioned by Roscoe et al. (2003). Consequently, we think that the evidence suggesting that there is no benefit from the acupressure method for reducing CINV is weak.

Regarding the placebo effect in the articles reviewed here, Melchart et al. (2006) indicated that there was no difference in the nausea score for the combined acupuncture treatment at p6 or that at the sham point, although the level of nausea was very low in both cases. Molassiotis et al. (2007), Said (2009) and Roscoe et al. (2003) all suggested that the placebo effect may be the result of psychological factors.

Application of acupressure in clinical practice

It is important to put this theory into practice, and health care professionals could consider using APS, in particular acupressure on the P6 acupoint, as an option in the management of CINV (Chao et al. 2009). Melchart et al. (2006) said acupressure bands can easily be used in busy oncological wards, while Suh (2012) supported the use of P6 acupressure with counselling focused on cognitive awareness, affective readiness, symptom acceptance, and the use of available resources as an adjunct to antiemetic medications for the control of CINV. Hughes et al. (2013) concluded that the research provides an insight into cancer patients’ motivations for and experiences of taking part in a clinical trial for a complementary alternative medical intervention in which the participants perceived the acupressure wristbands as reducing their level of CINV. Said (2009) suggests that oncology nurses should include acupressure in their list of options for the management of CINV, and especially delayed nausea and vomiting. Special recommendations by oncology nurses are not only useful but are also much appreciated by patients as shown in a study in which the patients were satisfied with the antiemetic treatment given by both P6-acupressure, and placebo-acupressure. The percentage of patients who were satisfied (≥ 3 on 0-6 scale) with their treatment was 81% (35/42) in the P6-acupressure group, which was in agreement with Roscoe et al. (2003), and 64% (27/42) in the placebo group (p= 0.0471). The percentage of the patients who would recommend acupressure treatment was 79% (34/42) in the P6-acupressure group, which again was in agreement with the results of Roscoe et al. (2003) and Hughes et al. (2013), compared to 62% (26/42) in the placebo group (p= 0.0533). This study presented the patients’ compliance with the use of acupressure. Acupressure is easily learnt and taught and patients should be informed about its potential role and taught how to apply it. Leaflets about acupressure for the management of nausea and vomiting could be available in chemotherapy units so that patients who are interested to use such a technique would be encouraged to come forward and learn more from nurses or other health professionals. This could add to the patients’ options for antiemetic approaches and empower them to be involved in the management of these distressing side effects. Acupressure offers a no-cost, convenient, self-administered intervention for chemotherapy patients to reduce acute nausea. Acupressure devices (i.e. Wrist Bands, travel bands, and acupressure bands) have been developed to provide passive acupressure on P6. Acupressure can be administered by healthcare providers, family members, or patients themselves, and does not involve puncture of the skin.

We therefore found that the acupressure wristband is a good way to reduce nausea and vomiting for cancer patients receiving chemotherapy by applying it in the correct position with the stud over the pericardium 6 acupoint located on the anterior surface of the forearm, 3-finger widths up from the first wrist crease, and between the tendons of flexor carpiradialis and Palmaris longus.

Lee et al. (2008) encourage the application of acupressure bilaterally, rather than unilaterally, in CINV control. They recommend three minutes of finger acupressure once daily, with additional acupressure as needed, as the optimal intervention, because both three and five minute trials have succeeded in achieving positive effects. On the other hand, Molassiotis et al. (2007) claimed that there is no correlation between the frequency of pressing the studs and the level of nausea and vomiting. Lee et al. (2008) and Molassiotis et al. (2007) therefore claim opposite results in the relationship between CINV and the frequency of pressing the stud of an acupressure P6 wrist band. But when applying the acupressure P6 wrist band bilaterally, Lee et al. (2008), Said (2009), Molassiotis et al. (2007), Suh (2012), and Genç and Tan (2014) all reported a positive effect with P6 stimulation in reducing CINV.

We would like to discuss some factors related to CINV in relation to nausea and vomiting: expectancy and gender: Roscoe et al. (2003) argued that patients who received the acustimulation bands and expected them to be effective did report having a higher quality of life and less nausea, and in relation to gender, that women are more likely to experience nausea when receiving chemotherapy. Lee et al. (2008) say this may be caused by classical conditioning and also that breast cancer patients may have had a damaged median nerve due to axillary lymph node removal, but Lee et al. (2008) also mention that P6 acupressure in younger women had a significantly greater positive effect on delayed nausea than those on a placebo or those in the no-intervention control group. On the other hand, Molassiotis et al. (2007) mentioned that younger age is associated with greater nausea. We think that men may have tolerated greater stimulation of the acupressure points, and therefore experienced greater symptom relief, so it may be that the acupressure is more effective for men than for women, but these questions of gender, age and the frequency of pressing the studs would need further investigation.

Based on the reported studies, we support the belief that acupressure on P6 is applicable in clinical practice for CINV for cancer patients provided the required education, training and counselling is given to maintain the acupressure benefits.

Acupressure side effects

The study by Molassiotis et al. (2007) found that there were no side effects from the use of the wristbands, but one patient reported that she had to take the bands off because they were too tight and left her with marks for a few days. Chao et al. (2009) also mentioned that very few minor adverse events were observed.

Melchart et al. (2006) did report adverse effects from the treatment in five cases. One suffered a hematoma when wearing the acupressure band at P6. In the sham group, one hematoma was reported after acupuncture, and another three adverse effects from the acupressure band were reported (one hematoma, one skin irritation, one eczema). Hughes et al. (2013) also reported that participants had not experienced any restrictions from wearing the wristbands in terms of everyday activities, other than when washing and bathing. As one female participant commented, for most participants the wristbands were found to be comfortable to wear. However, a few participants reported that they had experienced minor irritation, such as the wristbands feeling tight or painful, or their wrists becoming itchy. Reported adverse side effects were generally deemed minor and acceptable. In the study by Said (2009), no side effect or discomfort was noticed from wearing the acupressure wristband. Said told the patients that if the bands caused discomfort, they could be removed for 30 minutes every two hours. In this way, by taking it off for regular periods, we can prevent the side effects of acupressure, even its minor and rare effects.

Acupressure reduces CINV in cancer patients, in addition it reduces anxiety (Genç and Tan 2014) and that affects overall quality of life (Said 2009). Quality of life is defined by the NCI Dictionary of Cancer Terms as “The overall enjoyment of life and the individual’s sense of well-being and ability to carry out various activities”. Based on the physiological components of the Virginia Henderson’s theory of basic human needs and Abraham Maslow’s Hierarchy of Needs, the patient needs to eat and drink adequately, and sleep and rest (Vera, 2014). This means that when we are providing the required management for distressing symptoms, such as nausea and vomiting, by including the acupressure wrist band in addition to standard antiemetics, the patient’s appetite will improve, leading the patient to eat and drink adequately and improve their sleeping pattern. These may then also improve other aspects of the cancer patient’s life. According to the Henderson Nursing Need Theory, when we meet a patient’s needs, it results in an improved quality of life for the cancer patient receiving chemotherapy. Another way of expressing this is that it restores the balance of Yin and Yang energy that leads to reduced nausea and vomiting and improves the patient’s ability to enjoy life and work in general through a maintaining of the harmony of body and mind, as described in traditional Chinese medicine (Cancer Research UK, 2015).

We believe that it is essential for cancer patients undergoing chemotherapy treatment to have adequate nutrition to maintain their strength to fight the cancer. Different nursing actions are necessary to maintain adequate nutrition including the relieving of CINV. From this we extrapolate that using the acupressure P6 wrist band to reduce CINV improves the patient’s quality of life.

Conclusion

Chemotherapy-induced nausea and vomiting may be life threatening and is therefore a huge challenge to nurses involved in cancer care. Even with the best pharmacological management of CINV, patients continue to experience nausea and vomiting.

From a review of eight articles with strong methodology, seven supported the positive effect of an acupressure P6 wristband in reducing CINV for cancer patients. This was also supported by other databases. The one article with neutral results showed that there was no difference between a combined acupuncture and acupressure treatment at P6 and at a sham point in relation to the nausea score, but the level of nausea was very low in both groups. We conclude that the acupressure wrist band applied to acupuncture point P6 is effective, safe, convenient, cost effective, an easy and self-administrated non-pharmacological intervention from traditional Chinese medicine that reduces CINV. Solving the problem of CINV is a fundamental nursing task that can lead to improved quality of life and nutritional status, reduced anxiety and increases patient compliance. In the light of these results, and due to the effectiveness and inexpensiveness of acupressure, together with its ease of use, we suggest that it should be used in conjunction with pharmacological agents for CINV prophylaxis. To maintain the effectiveness of the acupressure, special education and training is needed to reassure the patient that the acupressure is at the correct point (P6) and counselling by the nurse is required.

We recommend the use of acupressure P6 in oncology departments and that future research should be conducted to include cancer patients receiving radiotherapy, and to investigate more about the relationship between the frequency of pressing the stud on the wrist band for acupressure P6 and CINV, and the relationship between gender and CINV, and whether it is better to apply it unilaterally or bilaterally.

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