Impact of a referral management “gateway” on the quality of referral letters; a retrospective time series cross sectional review

Background Referral management centres (RMC) for elective referrals are designed to facilitate the primary to secondary care referral path, by improving quality of referrals and easing pressures on finite secondary care services, without inadvertently compromising patient care. This study aimed to evaluate whether the introduction of a RMC which includes triage and feedback improved the quality of elective outpatient referral letters. Methods Retrospective, time-series, cross-sectional review involving 47 general practices in one primary care trust (PCT) in South-East England. Comparison of a random sample of referral letters at baseline (n = 301) and after seven months of referral management (n = 280). Letters were assessed for inclusion of four core pieces of information which are used locally to monitor referral quality (blood pressure, body mass index, past medical history, medication history) and against research-based quality criteria for referral letters (provision of clinical information and clarity of reason for referral). Results Following introduction of the RMC, the proportion of letters containing each of the core items increased compared to baseline. Statistically significant increases in the recording of ‘past medical history’ (from 71% to 84%, p < 0.001) and ‘medication history’ (78% to 87%, p = 0.006) were observed. Forty four percent of letters met the research-based quality criteria at baseline but there was no significant change in quality of referral letters judged on these criteria across the two time periods. Conclusion Introduction of RMC has improved the inclusion of past medical history and medication history in referral letters, but not other measures of quality. In approximately half of letters there remains room for further improvement

Contact heat evoked potentials using simultaneous EEG and fMRI and their correlation with evoked pain

BACKGROUND: The Contact Heat Evoked Potential Stimulator (CHEPS) utilises rapidly delivered heat pulses with adjustable peak temperatures to stimulate the differential warm/heat thresholds of receptors expressed by Adelta and C fibres. The resulting evoked potentials can be recorded and measured, providing a useful clinical tool for the study of thermal and nociceptive pathways. Concurrent recording of contact heat evoked potentials using electroencephalogram (EEG) and functional magnetic resonance imaging (fMRI) has not previously been reported with CHEPS. Developing simultaneous EEG and fMRI with CHEPS is highly desirable, as it provides an opportunity to exploit the high temporal resolution of EEG and the high spatial resolution of fMRI to study the reaction of the human brain to thermal and nociceptive stimuli. METHODS: In this study we have recorded evoked potentials stimulated by 51° C contact heat pulses from CHEPS using EEG, under normal conditions (baseline), and during continuous and simultaneous acquisition of fMRI images in ten healthy volunteers, during two sessions. The pain evoked by CHEPS was recorded on a Visual Analogue Scale (VAS). RESULTS: Analysis of EEG data revealed that the latencies and amplitudes of evoked potentials recorded during continuous fMRI did not differ significantly from baseline recordings. fMRI results were consistent with previous thermal pain studies, and showed Blood Oxygen Level Dependent (BOLD) changes in the insula, post-central gyrus, supplementary motor area (SMA), middle cingulate cortex and pre-central gyrus. There was a significant positive correlation between the evoked potential amplitude (EEG) and the psychophysical perception of pain on the VAS. CONCLUSION: The results of this study demonstrate the feasibility of recording contact heat evoked potentials with EEG during continuous and simultaneous fMRI. The combined use of the two methods can lead to identification of distinct patterns of brain activity indicative of pain and pro-nociceptive sensitisation in healthy subjects and chronic pain patients. Further studies are required for the technique to progress as a useful tool in clinical trials of novel analgesics

Humiliation's Media Cultures: On the Power of the Social to Oblige Us

Humiliation, which Silvan Tomkins paired with shame (‘shame-humiliation’), has not received much attention in queer, feminist and cultural analysis. This article addresses this omission by putting forward an account of humiliation’s eventful ‘structure of feeling’. In line with Raymond Williams’ original conception, and in conversation with affect studies, my account links humiliation’s structure to the broader socio-political tensions it articulates: especially, the tension between individualisation and collective social experience within neoliberalism. The cultural economy of reputation in particular reveals how, from within the eventful structure of humiliation, we become attuned to the social as that which affectively obliges us. By mediating the affective obligation of the social, media cultures train us in an affective sociality. My analysis questions the deeper reasoning that subtends humiliation and the repercussions of the affective obligation of the social for how we think about culture, identity and power in the context of networked media

MRI/PET Brain Imaging

Multimodal brain imaging has become an established clinical and research tool for diagnosis and disease progression of brain disorders. Among available imaging modalities, magnetic resonance imaging (MRI) and positron-emission tomography (PET) can provide a wide spectrum of data for the in vivo mapping of neurobiological functions and brain morphology while demonstrating to relationships between behavioral and neurobiological factors. Since MRI mostly uses endogenous contrast mechanisms to visualize and quantify tissue characteristics, optimal sequence design is essential for the diagnostic information of MRI. On the other hand, PET imaging is always based on the exogenous contrast of an injected PET tracer. Therefore, characteristics of the PET tracer determine the quantitative and diagnostic potential of PET. This chapter will focus on both of these modalities and shortly discuss the potential of multimodal or hybrid MR/PET imaging. We will not cover MR spectroscopy nor specific applications of H215O PET since this will be discussed in other chapters of this book.</p

Factors associated with Quitline and pharmacotherapy utilisation among low-socioeconomic status smokers

Doran, CM ORCiD: 0000-0002-9009-4906Aims: To examine factors associated with Quitline and pharmacotherapy utilisation in low socioeconomic status (low-SES) smokers enrolled in a smoking cessation trial. Methods: Baseline data was used from a large-scale smoking cessation randomised controlled trial (RCT). Logistic regression models were used to examine predictors of treatment utilisation prior to entering the RCT and perceived effectiveness of past and future use. Results: A total of 1047 smokers consented and prior to enrolment 92% had previously tried to quit smoking, 86% had ever used quit support, 83% had used pharmacotherapy at least once and 38% had ever utilised Quitline. For those who had used pharmacotherapies, 71% used NRT, of which 21% had used dual NRT products. In the last 12-months, 27% utilised Quitline and 50% utilised NRT. Ever use of Quitline was negatively associated with self-efficacy to quit (OR: 0.80; 95% CI: 0.68, 0.94 p <.01) and positively associated with being diagnosed with a mental health condition (OR: 1.50; 95% CI: 1.01, 2.25 p <.05). Recent use of NRT was positively associated with mental health condition (OR: 1.39; 95% CI: 1.02, 1.90 p <.05) and negatively associated with alcohol consumption (OR: 0.69; 95% CI: 0.52, 0.92 p <.01). Conclusion: Past use of Quitline and pharmacotherapy treatment was associated with self-efficacy to quit, sociodemographic variables, mental health conditions and alcohol consumption. Community-based strategies that target smoking, mental health and drug and alcohol problems may overcome some of the barriers that prevent low-SES populations from engaging with smoking cessation support. © 2018 Elsevier Lt