Evaluation of the primary/secondary care interface in relation to a primary care rheumatology service

Objective The rheumatology department at The Royal Oldham Hospital developed a primary care service aimed at bridging the gap between primary and secondary care for patients with potential rheumatological conditions, and this was given the name rheumatology Tier 2. The objective of this study was to evaluate this primary care rheumatology service (Tier 2)in order to assess its validity, patient satisfaction and effectiveness. Design Ten patients participated in individual semi-structured interviews. Three GPs were interviewed individually, and two GPs formed a focus group. Thematic analysis was used to interpret the findings. Setting Patients were recruited from seven consecutive rheumatology Tier 2 clinics. GPs were recruited from Oldham Primary Care Trust (PCT) as this was the main source of patient referrals for the service. Results The key findings were in relation to the integration of primary healthcare and hospital services, i.e. the primary/secondary care interface. This highlighted the importance of early assessment, diagnosis and treatment of patients with suspected inflammatory arthritis. Conclusion Early diagnosis and treatment with disease-modifying anti-rheumatic drugs improves patients’ outcomes. The rheumatology Tier 2 service built on this evidence and provided a rapid assessment and referral to secondary care for those patients with suspected inflammatory arthritis

Neuroanatomical substrates for the volitional regulation of heart rate

The control of physiological arousal can assist in the regulation of emotional state. A subset cortical and subcortical brain regions are implicated in autonomic control of bodily arousal during emotional behaviors. Here, we combined human functional neuroimaging with autonomic monitoring to identify neural mechanisms that support the volitional regulation of heart rate, a process that may be assisted by visual feedback. During functional magnetic resonance imaging (fMRI), 15 healthy adults performed an experimental task in which they were prompted voluntarily to increase or decrease cardiovascular arousal (heart rate) during true, false, or absent visual feedback. Participants achieved appropriate changes in heart rate, without significant modulation of respiratory rate, and were overall not influenced by the presence of visual feedback. Increased activity in right amygdala, striatum and brainstem occurred when participants attempted to increase heart rate. In contrast, activation of ventrolateral prefrontal and parietal cortices occurred when attempting to decrease heart rate. Biofeedback enhanced activity within occipito-temporal cortices, but there was no significant interaction with task conditions. Activity in regions including pregenual anterior cingulate and ventral striatum reflected the magnitude of successful task performance, which was negatively related to subclinical anxiety symptoms. Measured changes in respiration correlated with posterior insula activation and heart rate, at a more lenient threshold, change correlated with insula, caudate, and midbrain activity. Our findings highlight a set of brain regions, notably ventrolateral prefrontal cortex, supporting volitional control of cardiovascular arousal. These data are relevant to understanding neural substrates supporting interaction between intentional and interoceptive states related to anxiety, with implications for biofeedback interventions, e.g., real-time fMRI, that target emotional regulation

Interactions between visceral afferent signaling and stimulus processing

Visceral afferent signals to the brain influence thoughts, feelings and behaviour. Here we highlight the findings of a set of empirical investigations in humans concerning body-mind interaction that focus on how feedback from states of autonomic arousal shapes cognition and emotion. There is a longstanding debate regarding the contribution of the body, to mental processes. Recent theoretical models broadly acknowledge the role of (autonomically mediated) physiological arousal to emotional, social and motivational behaviours, yet the underlying mechanisms are only partially characterized. Neuroimaging is overcoming this shortfall; first, by demonstrating correlations between autonomic change and discrete patterns of evoked, and task- independent, neural activity; second, by mapping the central consequences of clinical perturbations in autonomic response and; third, by probing how dynamic fluctuations in peripheral autonomic state are integrated with perceptual, cognitive and emotional processes. Building on the notion that an important source of the brain’s representation of physiological arousal is derived from afferent information from arterial baroreceptors, we have exploited the phasic nature of these signals to show their differential contribution to the processing of emotionally-salient stimuli. This recent work highlights the facilitation at neural and behavioral levels of fear and threat processing that contrasts with the more established observations of the inhibition of central pain processing during baroreceptors activation. The implications of this body-brain-mind axis are discussed

Patient and practitioner views of a new rheumatology (Tier 2) primary care service

The rheumatology Tier 2 service in Oldham was implemented to see patients in a primary care setting for their initial assessment. They were treated and discharged within the service, or referred on to secondary care in order to limit inappropriate attendance in secondary care and fast-track patients with inflammatory disease to the rheumatology consultant. The aim of this study was to evaluate patients’ and general practitioners’ (GPs’) views about the transfer of rheumatological services from secondary to primary care. Patients and GPs were from a single primary care trust in Oldham, north west England. A thematic analysis of interview data was taken, and findings showed high patient satisfaction with the service, favouring the primary care environment to a hospital setting. GPs reported on cost-effectiveness of the service and better management of the disease. The Tier 2 service has the potential to set a new direction for multiagency care within a primary care setting

An interoceptive predictive coding model of conscious presence

We describe a theoretical model of the neurocognitive mechanisms underlying conscious presence and its disturbances. The model is based on interoceptive prediction error and is informed by predictive models of agency, general models of hierarchical predictive coding and dopaminergic signaling in cortex, the role of the anterior insular cortex (AIC) in interoception and emotion, and cognitive neuroscience evidence from studies of virtual reality and of psychiatric disorders of presence, specifically depersonalization/derealization disorder. The model associates presence with successful suppression by top-down predictions of informative interoceptive signals evoked by autonomic control signals and, indirectly, by visceral responses to afferent sensory signals. The model connects presence to agency by allowing that predicted interoceptive signals will depend on whether afferent sensory signals are determined, by a parallel predictive-coding mechanism, to be self-generated or externally caused. Anatomically, we identify the AIC as the likely locus of key neural comparator mechanisms. Our model integrates a broad range of previously disparate evidence, makes predictions for conjoint manipulations of agency and presence, offers a new view of emotion as interoceptive inference, and represents a step toward a mechanistic account of a fundamental phenomenological property of consciousness

On the Limiting Behaviour of the Fundamental Geodesics of Information Geometry

The Information Geometry of extended exponential families has received much recent attention in a variety of important applications, notably categorical data analysis, graphical modelling and, more specifically, log-linear modelling. The essential geometry here comes from the closure of an exponential family in a high-dimensional simplex. In parallel, there has been a great deal of interest in the purely Fisher Riemannian structure of (extended) exponential families, most especially in the Markov chain Monte Carlo literature. These parallel developments raise challenges, addressed here, at a variety of levels: both theoretical and practical—relatedly, conceptual and methodological. Centrally to this endeavour, this paper makes explicit the underlying geometry of these two areas via an analysis of the limiting behaviour of the fundamental geodesics of Information Geometry, these being Amari’s (+1) and (0)-geodesics, respectively. Overall, a substantially more complete account of the Information Geometry of extended exponential families is provided than has hitherto been the case. We illustrate the importance and benefits of this novel formulation through applications

Managers on the move

The proportion of managers who change jobs in any given year has risen from about 10% in 1980 to 30% by the mid 1990s. And the results of restructuring are a major cause for this increase

Orthogonal simple component analysis: A new, exploratory approach

Combining principles with pragmatism, a new approach and accompanying algorithm are presented to a longstanding problem in applied statistics: the interpretation of principal components. Following Rousson and Gasser [53 (2004) 539--555] @p250pt@ the ultimate goal is not to propose a method that leads automatically to a unique solution, but rather to develop tools for assisting the user in his or her choice of an interpretable solution. Accordingly, our approach is essentially exploratory. Calling a vector 'simple' if it has small integer elements, it poses the open question: @p250pt@ What sets of simply interpretable orthogonal axes---if any---are angle-close to the principal components of interest? its answer being presented in summary form as an automated visual display of the solutions found, ordered in terms of overall measures of simplicity, accuracy and star quality, from which the user may choose. Here, 'star quality' refers to striking overall patterns in the sets of axes found, deserving to be especially drawn to the user's attention precisely because they have emerged from the data, rather than being imposed on it by (implicitly) adopting a model. Indeed, other things being equal, explicit models can be checked by seeing if their fits occur in our exploratory analysis, as we illustrate. Requiring orthogonality, attractive visualization and dimension reduction features of principal component analysis are retained.Comment: Published in at http://dx.doi.org/10.1214/10-AOAS374 the Annals of Applied Statistics (http://www.imstat.org/aoas/) by the Institute of Mathematical Statistics (http://www.imstat.org