Is number sense impaired in chronic pain patients?

BACKGROUND: Recent advances in imaging have improved our understanding of the role of the brain in painful conditions. Discoveries of morphological changes have been made in patients with chronic pain, with little known about the functional consequences when they occur in areas associated with ‘number-sense’; thus, it can be hypothesized that chronic pain impairs this sense. METHODS: First, an audit of the use of numbers in gold-standard pain assessment tools in patients with acute and chronic pain was undertaken. Secondly, experiments were conducted with patients with acute and chronic pain and healthy controls. Participants marked positions of numbers on lines (number marking), before naming numbers on pre-marked lines (number naming). Finally, subjects bisected lines flanked with ‘2’ and ‘9’. Deviations from expected responses were determined for each experiment. RESULTS: Four hundred and ninety-four patients were audited; numeric scores in the ‘moderate’ and ‘severe’ pain categories were significantly higher in chronic compared with acute pain patients. In experiments (n=150), more than one-third of chronic pain patients compared with 1/10th of controls showed greater deviations from the expected in number marking and naming indicating impaired number sense. Line bisection experiments suggest prefrontal and parietal cortical dysfunction as cause of this impairment. CONCLUSIONS: Audit data suggest patients with chronic pain interpret numbers differently from acute pain sufferers. Support is gained by experiments indicating impaired number sense in one-third of chronic pain patients. These results cast doubts on the appropriateness of the use of visual analogue and numeric rating scales in chronic pain in clinics and research

Improving mental health outcomes: achieving equity through quality improvement

Objective. To investigate equity of patient outcomes in a psychological therapy service, following increased access achieved by a quality improvement (QI) initiative. Design. Retrospective service evaluation of health outcomes; data analysed by ANOVA, chi-squared and Statistical Process Control. Setting. A psychological therapy service in Westminster, London, UK. Participants. People living in the Borough of Westminster, London, attending the service (from either healthcare professional or self-referral) between February 2009 and May 2012. Intervention(s). Social marketing interventions were used to increase referrals, including the promotion of the service through local media and through existing social networks. Main Outcome Measure(s). (i) Severity of depression on entry using Patient Health Questionnaire-9 (PHQ9). (ii) Changes to severity of depression following treatment (ΔPHQ9). (iii) Changes in attainment of a meaningful improvement in condition assessed by a key performance indicator. Results. Patients from areas of high deprivation entered the service with more severe depression (M = 15.47, SD = 6.75), com-pared with patients from areas of low (M = 13.20, SD = 6.75) and medium (M = 14.44, SD = 6.64) deprivation. Patients in low

Mixed ice accretion on aircraft wings

Ice accretion is a problematic natural phenomenon that an effects a wide range of engineering applications including power cables, radio masts and wind turbines. Accretion on aircraft wings occurs when supercooled water droplets freeze instantaneously on impact to form rime ice or runback as water along the wing to form glaze ice. Most models to date have ignored the accretion of mixed ice, which is a combination of rime and glaze. A parameter we term the `freezing fraction', is defined as the fraction of a supercooled droplet that freezes on impact with the top surface of the accretion ice to explore the concept of mixed ice accretion. Additionally we consider different `packing densities' of rime ice, mimicking the different bulk rime densities observed in nature. Ice accretion is considered in four stages: rime, primary mixed, secondary mixed and glaze ice. Predictions match with existing models and experimental data in the limiting rime and glaze cases. The mixed ice formulation consequently however provides additional insight into the composition of the overall ice structure, which ultimately influences adhesion and ice thickness; and shows that for similar atmospheric parameter ranges, this simple mixed ice description leads to very different accretion rates. A simple one-dimensional energy balance was solved to show how this freezing fraction parameter increases with decrease in atmospheric temperature, with lower freezing fraction promoting glaze ice accretion

The aesthetics of ritual--contested identities and conflicting performances in the Iraqi Shi’a diaspora: Ritual, performance and identity change

What are the processes through which identity change takes place at the individual and collective level? How might a focus on embodied religious performance and ritual contribute to understandings of such identity change? Through an ethnographic analysis of the Muharram rituals of Iraqi Shi’is in London, I take religious rites as a starting point from which to theorise a performative theory of identity change to highlight the role of ritual and performance in shaping changing notions of identity at both the individual and collective level. Such a project necessarily engages both with processes of identity change and with the paradox of identity/difference, particularly the ways in which articulations of subjective identity are ontologically dependent on an external ‘other’. Ultimately, I argue that paying close critical attention to the performative and (re)iterative processes of micro-level identificatory practices allows a more nuanced understanding of the mechanisms through which identity change comes to take effect, both at the level of individual subjectivity and that of collective social belonging

A retrospective observational analysis to identify patient and treatment-related predictors of outcomes in a community mental health programme

OBJECTIVES: This study aims to identify patient and treatment factors that affect clinical outcomes of community psychological therapy through the development of a predictive model using historic data from 2 services in London. In addition, the study aims to assess the completeness of data collection, explore how treatment outcomes are discriminated using current criteria for classifying recovery, and assess the feasibility and need for undertaking a future larger population analysis. DESIGN: Observational, retrospective discriminant analysis. SETTING: 2 London community mental health services that provide psychological therapies for common mental disorders including anxiety and depression. PARTICIPANTS: A total of 7388 patients attended the services between February 2009 and May 2012, of which 4393 (59%) completed therapy, or there was an agreement to end therapy, and were included in the study. PRIMARY AND SECONDARY OUTCOME MEASURES: Different combinations of the clinical outcome scores for anxiety Generalised Anxiety Disorder-7 and depression Patient Health Questionnaire-9 were used to construct different treatment outcomes. RESULTS: The predictive models were able to assign a positive or negative clinical outcome to each patient based on 5 independent pre-treatment variables, with an accuracy of 69.4% and 79.3%, respectively: initial severity of anxiety and depression, ethnicity, deprivation and gender. The number of sessions attended/missed were also important factors identified in recovery. CONCLUSIONS: Predicting whether patients are likely to have a positive outcome following treatment at entry might allow suitable modification of scheduled treatment, possibly resulting in improvements in outcomes. The model also highlights factors not only associated with poorer outcomes but inextricably linked to prevalence of common mental disorders, emphasising the importance of social determinants not only in poor health but also poor recovery

How to attribute causality in quality improvement: lessons from epidemiology

Quality improvement and implementation (QI&I) initiatives face critical challenges in an era of evidence-based, value-driven patient care. Whether front-line staff, large organisations or government bodies design and run QI&I, there is increasing need to demonstrate impact to justify investment of time and resources in implementing and scaling up an intervention. Decisions about sustaining, scaling up and spreading an initiative can be informed by evidence of causation and the estimated attributable effect of an intervention on observed outcomes. Achieving this in healthcare can be challenging, where interventions often are multimodal and applied in complex systems.1 Where there is weak evidence of causation, credibility in the effectiveness of the intervention is reduced with a resultant reduced desire to replicate. The greater confidence of a causal relationship between QI&I interventions and observed results, the greater our confidence that improvement will result when the intervention occurs in different settings. Guidance exists for design, conduct, evaluation and reporting of QI&I initiatives;2–4; the Standards for QUality Improvement Reporting Excellence (SQUIRE) and the Standards for Reporting Implementation Studies (STARI) guidelines were developed specifically for reporting QI&I initiatives.5 6 However, much of this guidance is targeted at larger formal evaluations, and may require levels of resource or expertise not available to all QI&I initiatives. This paper proposes QI&I initiatives, regardless of scope and resources, can be enhanced by applying epidemiological principles, adapted from those promulgated by Austin Bradford Hill.

Mapping mental health service access: achieving equity through quality improvement.

Background Improving access to psychological therapies (IAPTs) services deliver evidence-based care to people with depression and anxiety. A quality improvement (QI) initiative was undertaken by an IAPT service to improve referrals providing an opportunity to evaluate equitable access. Methods QI methodologies were used by the clinical team to improve referrals to the service. The collection of geo-coded data allowed referrals to be mapped to small geographical areas according to deprivation. Results A total of 6078 patients were referred to the IAPT service during the period of analysis and mapped to120 unique lower super output areas (LSOAs). The average weekly referral rate rose from 17 during the baseline phase to 43 during the QI implementation phase. Spatial analysis demonstrated all 15 of the high deprivation/low referral LSOAs were converted to high deprivation/high or medium referral LSOAs following the QI initiative. Conclusion This work highlights the importance of QI in developing clinical services aligned to the needs of the population through the analysis of routine data matched to health needs. Mapping can be utilized to communicate complex information to inform the planning and organization of clinical service delivery and evaluate the progress and sustainability of QI initiatives.</p