PRISM, a Novel Visual Metaphor Measuring Personally Salient Appraisals, Attitudes and Decision-Making: Qualitative Evidence Synthesis

Visual Assessment of Therapeutic Relationships in Psychiatric Patients: A Pilot Study Using the Pictorial Representation of Illness and Self Measure

BACKGROUND

Although the therapeutic relationship (or 'alliance') is well known to be a key component of psychiatric treatment, there has been no simple way to objectively measure the patient-therapist relationship. Here, we measured the psychological distance between patients and their therapists by using the Pictorial Representation of Illness and Self Measure (PRISM).

PATIENTS AND METHODS

We analyzed the patient-therapist relationship of 112 patients from two hospitals in Japan (54 males, 57 females, 1 unknown; age 46.20 ± 15.03 years [mean ± SD]) who completed the PRISM and self report questionnaires (LSNS-6, K6, and BASIS-32) about their social network, psychological distress, and outcomes of mental health treatment.

RESULTS

PRISM measurements were available for all patients who consented to participate. In the comparison by disease category, schizophrenia recorded the closest distance to the psychiatrist in charge, followed by bipolar disorder, depression, and neurotic disorder. Regarding the distance to the psychiatrist in charge, PRISM showed a weak negative correlation (r = -0.23, p < 0.05) with age, indicating that with increasing age, the therapeutic rela tionship was more important to the patients.

CONCLUSION

Our findings indicate the possibility of implementing PRISM to assess the impact of the therapeutic relationship in patients with a wide range of psychiatric disorders, and they suggest that PRISM holds great potential for clinical application.

Illustration of self-perceived knowledge, skills, and interests in undergraduate dental students using a visual metaphor- results of a monocentric cross-sectional study

BACKGROUND

Self-assessment and self-reflection of competencies are crucial skills for undergraduate students. This monocentric cross-sectional study aims to assess the self-perceived knowledge, skills and interests in conservative dentistry and periodontology of third-, fourth-, and fifth-year dental students by the Pictorial Representation of Illness and Self-measure (PRISM).

METHODS

Seventy-five undergraduate dental students (n = 25 of each year) who studied between 2021 and 2022 at the Department of Cariology, Endodontology and Periodontology at the University of Leipzig, Germany, were included. All of them underwent a PRISM-based interview regarding their perceived knowledge, practical skills, and interests in conservative dentistry as well as its sub-disciplines. The distances in the PRISM task (in millimeters) were measured and compared between the groups. Spearman's Rho was used to reveal correlations between knowledge, skills, and interests in the cohort.

RESULTS

Perceived theoretical knowledge and practical skills differed significantly between groups for the sub-disciplines periodontology, cariology, restorative dentistry and preventive dentistry (p < 0.05). However, students' interests did not significantly vary between groups (p > 0.05). In the field of conservative dentistry and its sub-disciplines, significant moderate to high positive correlations were found between knowledge and skills (p < 0.01), and weak to moderate positive correlations were found between interests and knowledge (p < 0.05). Regarding the relationship between perceived interests and skills, only restorative dentistry, endodontology and periodontology were significant and only moderate to weak correlations were found (p < 0.05).

CONCLUSION

PRISM revealed differences in perceived knowledge and skills between third-, fourth-, and fifth-year dental students. Correlations were found between perceived knowledge and skills, as well as between interests and knowledge. PRISM may be a promising tool to support students and teachers in dental education.

Agreement between patients and physicians on scores of inflammatory bowel disease activity and burden assessed on a telemonitoring platform

BACKGROUND AND AIMS

Telemonitoring is increasingly used in the management of IBD patients. We investigated the agreement between patients and physicians on scores of disease activity and burden.

METHODS

Consecutive outpatients at one IBD clinic were recruited between February and December 2021. Enrolled patients completed a questionnaire for disease activity (Harvey-Bradshaw Index [HBI] for Crohn's disease or Simple Clinical Colitis Activity Index [SCCAI] for ulcerative colitis) and a test of disease burden (Pictorial Representation of Illness and Self Measure [PRISM]). They did the tests within 5 days of an outpatient visit, working independently on IBD Tool, a new web-based telemonitoring application. Concomitantly, the senior and junior physicians who examined them completed the same tests. The agreement was tested for every pair of scores.

RESULTS

Five hundred and sixty patients (289 Crohn's disease; 271 ulcerative colitis) completed disease questionnaires on IBD Tool (in total, 742 times). By Spearman's correlation, the agreement was substantial both for HBI (rho 0.685-0.837) and SCCAI (rho 0.694-0.888) for comparisons between patients, junior and senior physicians. The agreement was moderate-to-substantial for PRISM (rho 0.406-0.725) for the same comparisons. The correlation between disease activity (HBI/SCCAI) and PRISM scores was substantial for senior (rho 0.757-0.788) or junior (rho 0.746-0.753) physicians and moderate for patients (rho 0.458-0.486). The median PRISM score difference was 2.3-1.6 points lower between patients and senior-junior physicians.

CONCLUSION

Agreement between IBD patients and physicians was substantial for disease activity and moderate for disease impact. The inclusion of disease burden scoring in telemonitoring platforms provides important information for the management of IBD patients.Study highlightsWhat IS known•Continuous response to treatments and patient-reported outcomes became an essential goal for IBD patient management.•The use of tele-monitoring and eHealth technologies allows for regular disease assessments and for managing more efficiently IBD patients; disease questionnaires and tests are key to support eHealth tools.What is new here•Agreement between IBD patients and physicians was substantial for disease activity and moderate for disease burden, while agreement among junior and senior physicians was substantial for both.•PRISM performs as well for ulcerative colitis as for Crohn's patients.•The inclusion of disease burden tests might add to eHealth platforms valuable information, complemental to disease activity questionnaires.

Comparison of PRISM and numeric scale for self-assessment of learning progress during a clinical course in undergraduate dental students

OBJECTIVES

To compare Pictorial Representation of Illness and Self-Measure (PRISM) and a numeric scale for self-reflection in dental students.

METHODS

Fourth year dental students were randomly assigned to each receive one interview based on PRISM or a numeric scale to self-assess their competencies at the beginning (t1), the middle (t2) and the end (t3) of integrated clinical course. Questionnaires were used to assess self-perceived benefit of the interviews at each time points.

RESULTS

Students in PRISM group perceived a higher benefit regarding the self-assessment of their practical skills at all time points (P < 0.05), for theoretical knowledge at t2 and t3 (P < 0.05) and reaching the course objectives at t3 (P = 0.04). At all time points, PRISM group rated their interview (P = 0.04), the applied instrument (PRISM, P = 0.01) and the benefit of the combination of both higher than numeric scale group (P < 0.05).

CONCLUSION

In this preliminary study, PRISM was superior against a numeric scale and can be recommended for dental education to facilitate self-assessment.

Research behind a webcam: an exploration of virtual interviewing with children and young people

BACKGROUND

Societal use of digital technology rapidly increased during the COVID-19 pandemic. Face-to-face services converted to online provision where possible. This affected many nurse researchers.

AIM

To explore conducting research interviews online with children and young people (CYP) about sensitive topics.

DISCUSSION

This article considers digital inclusion, as well as ethical issues surrounding safety, support and consent, along with choosing tools for collecting data. It also presents a discussion of physical proximity in qualitative interviews with this population and its role in data quality. The authors investigate benefits in the context of researchers' personal experiences. They acknowledge the disadvantages of conducting interviews online and discuss ways to mitigate these.

CONCLUSION

The advantages for researchers include cost-effectiveness, time-efficiency and greater geographical reach of participants. However, CYP's perspectives are unknown and the specific ethical issues of using this method with CYP need careful consideration.

IMPLICATIONS FOR PRACTICE

More research is needed to examine virtual interviews from the perspectives of CYP as participants. Virtual acquisition of consent and assent should be investigated to standardise good research practices.

Mental pain as a global person-centered outcome measure

BACKGROUND

Mental pain has been proposed as a global person-centered outcome measure. The aim of this cross-sectional study was to test an essential requisite of such a measure, namely that mental pain incorporates independent contributions from a range of discrete but disparate outcome measures.

METHODS

Two hundred migraine patients were assessed concerning migraine disability, psychosomatic syndromes, mental pain, depression, anxiety, and psychosocial dimensions. General linear models were tested to verify which measures would individually make unique contributions to overall mental pain.

RESULTS

The final model, accounting for 44% of variance, identified that higher mental pain was associated with more severe depressive symptoms, higher migraine disability, lower well-being, and poorer quality of life.

CONCLUSION

In this sample, mental pain was shown to behave as expected of a global outcome measure, since multiple measures of symptomatology and quality of life showed modest but significant bivariate correlations with mental pain and some of these measures individually made unique contributions to overall mental pain.

PRISM: A Novel Visual Instrument to Facilitate Self-Reflection and Learning Progress in Undergraduate Dental Education

Objectives

PRISM (Pictorial Representation of Illness and Self-Measure) is a simple visual tool that has been successfully used as a visual metaphor in medicine. In this pilot study, PRISM was used for the first time to test its potential to support self-reflection and expectations of learning in dental students.

Methods

Dental student volunteers (25 3^rd year, 10 4^th year, and 10 5^th year) participated. Using both quantitative and qualitative methods, PRISM interviews were compared with a numerical scale in assessing learning objectives concerning theoretical knowledge, practical skills, interest, and training need in the field of conservative dentistry.

Results

Overall, 71% of total student group stated that they would draw personal consequences for their studies due to participating in the PRISM interviews. Compared to the numeric scales, PRISM was rated as more helpful regarding appraisal of students' theoretical knowledge (p = 0.02), practical skills (p < 0.01), training needs (p < 0.01), importance of dental subspecialties (p < 0.01), and facilitating self-reflection (p = 0.02). In focus groups, students commented that PRISM fostered the development of a trusting relationship with their teacher. Strengths of PRISM mentioned by the students included being able to observe and manipulate a visual summary of their individual learning needs and seeing their different learning needs in relation to one another.

Conclusion

In this pilot study, dental students evaluated PRISM to be superior against numeric scales. Furthermore, it ameliorated the communication with teachers. The PRISM task is both simple and brief and warrants further exploration as a useful tool for self-reflection in dental education.

Pilot study to evaluate a novel measure of self-perceived competencies among dental students

BACKGROUND

PRISM is a novel approach to support self-reflection and learning appraisal in dental students, based on a visual metaphor. The aim of this study was to evaluate whether PRISM measurments would be reproducible and sensitive to detect learning progress in undergraduate dental students in their clinical years.

METHODS

Voluntarily participating dental students were included. To evaluate reproducibility, a mixed cohort of 10 students each in 3^rd, 4^th and 5^th year (total n = 30) was recruited and received three identically structured PRISM interviews within one week without any other teaching events. To assess perceived learning progress, 29 volunteer 3^rd year students participated in three interviews during their clinical simulation course (beginning, middle, end). Distances between Subject and Objects was measured in millimeter; objects were classified into close or branched clusters depending on their distance from each other on the PRISM board.

RESULTS

Values for perceived competencies within PRISM interviews during one week were comparable between the three time points in the mixed cohort (n = 30; p > 0.05). Comparing the three subgroups (3^rd, 4^th and 5^th year, each n = 10), PRISM indicated that 3^rd year students perceived their competencies are significantly lower than the 4^th and 5^th year students (p < 0.01). 3^rd year students had less often a branched cluster of objects than the other two groups (p < 0.05). PRISM showed that over time, 3^rd year students perceived a gain in their competencies in conservative dentistry and its sub-disciplines (p ≤ 0.01). The PRISM data indicated that by the end of the simulation course, the students appeared to show higher discrimination of their self-perceptions between sub-topics in conservative dentistry than at the start of the course (p = 0.01).

CONCLUSION

PRISM yields a reproducible measure of individual students' learning progress. It is a promising novel approach for appraisal in dental education. Further work is needed to confirm the generalisability of the findings.

Disease activity, burden and suffering in patients with ulcerative colitis in the UK cohort recruited into the global ICONIC study

OBJECTIVE

The Understanding the Impact of Ulcerative Colitis and Its Associated Disease Burden on Patients (ICONIC) was a 2-year, global, prospective, observational study assessing disease burden in adults recently diagnosed (≤36 months) with ulcerative colitis (UC) receiving routine outpatient care, irrespective of disease severity or treatment. A subanalysis was conducted to understand the UK perspective.

DESIGN/METHOD

All eligible consenting patients enrolled in ICONIC from the UK were included in the subanalysis of patient-reported and physician-reported outcomes at baseline and year 2 (Y2).

RESULTS

Sixty-three UK patients were included (mean age 43.4 years, 58.7% female). At baseline and Y2, the mean (±SD) Simple Clinical Colitis Activity Index (SCCAI) scores were 3.6 (±3.3) and 1.5 (±1.5); Patient Modified Simple Clinical Colitis Activity Index (P-SSCAI) were 4.9 (±4.0) and 2.6 (±2.6), respectively. Physician-reported Pictorial Representation of Illness and Self Measure (PRISM) median scores (assessing inverse of suffering) were 3.5 (IQR 2.0-6.8) at baseline and 5.5 (IQR 3.6-6.9) at Y2; patient-reported PRISM scores were 4.7 (IQR 2.6-6.9) and 5.4 (IQR 3.2-8.0), respectively. At baseline, SCCAI and P-SCCAI were strongly correlated (r=0.86, p<0.0001), and patient-reported and physician-reported PRISM scores moderately correlated (r=0.67, p<0.0001). At Y2, moderate correlations were observed (SCCAI vs P-SCCAI: r=0.72, p<0.0001; patient-reported vs physician- reported PRISM: r=0.60, p<0.0001). Rating Form of IBD Patient Concerns scores indicated patients' greatest concerns were with energy level, having an ostomy bag and effects of medication (baseline scores >3.0).

CONCLUSIONS

These findings demonstrated the multifaceted burden of disease in patients recently diagnosed with UC in the UK. Agreement between patients and physicians on disease activity/severity varied according to the instrument used.

What is Pain-Related Suffering? Conceptual Critiques, Key Attributes, and Outstanding Questions

Suffering holds a central place within pain research, theory, and practice. However, the construct of pain-related suffering has yet to be operationalized by the International Association for the Study of Pain and is largely underdeveloped. Eric Cassell's seminal work on suffering serves as a conceptual anchor for the limited pain research that specifically addresses this construct. Yet, important critiques of Cassell's work have not been integrated within the pain literature. This Focus Article aims to take a preliminary step towards an updated operationalization of pain-related suffering by 1) presenting key attributes of pain-related suffering derived from a synthesis of the literature and 2) highlighting key challenges associated with Cassell's conceptualization of suffering. We present 4 key attributes: 1) pain and suffering are inter-related, but distinct experiences, 2) suffering is a subjective experience, 3) the experience of suffering is characterized by a negative affective valence, and 4) disruption to one's sense of self is an integral part of suffering. A key outstanding challenge is that suffering is commonly viewed as a self-reflective and future-oriented process, which fails to validate many forms of suffering and marginalizes certain populations. Future research addressing different modes of suffering - with and without self-reflection - are discussed. PERSPECTIVE: This article offers a preliminary step toward operationalizing the construct of pain-related suffering and proposes priorities for future research. A robust operationalization of this construct is essential to developing clinical strategies that aim to better recognize and alleviate suffering among people living with pain.

PRISM (Pictorial Representation of Illness and Self-Measure) as Visual Tool to Support Oral Health Education Prior to Endoprosthetic Joint Replacement-A Novel Approach in Dentistry

Objective: This study aims to evaluate the application of Pictorial Representation of Illness and Self-Measure (PRISM) in educating patients regarding oral health before endoprosthesis (EP). Methods: The study consisted of two parts: (I) a cross-sectional study, where patients received a PRISM interview, oral health briefing and oral examinations (treatment need, oral focus). (II) In an observational part, patients were randomly assigned to either PRISM task (Test) or flyer-based verbal briefing (Control). Before and after the interviews, patients answered a questionnaire regarding importance of oral health for EP. Results: (I) 122 patients were included. The distance between subject (“myself”) and objects (oral health issues or EP) in the PRISM task were mainly not associated with age, gender, and oral conditions. In part (II), 80 patients (PRISM: n = 40, Control: n = 40) were included. After the interview, the values for perceived relationship between EP and teeth (p < 0.01), EP and gums (p < 0.01), and EP and dental consultations (p < 0.01) significantly increased in both groups. Both groups perceived a high benefit of the interview and felt well educated. Conclusions: PRISM has comparable positive effects like a flyer-based verbal briefing. PRISM as a novel visual tool can support the patient education regarding oral health before EP.

Measuring perception of mental well-being in patients under isolation precautions: a prospective comparative study

OBJECTIVES

Isolation precautions (IP) are applied to prevent transmission of pathogens in healthcare settings. Potential negative health outcomes experienced by patients have been previously described but results remain conflicting. We aimed at evaluating the psychological impact of IP in adult patients in isolation using a novel psychological assessment tool.

STUDY DESIGN

Prospective matched cohort study.

SETTING

Tertiary care centre in Switzerland.

PARTICIPANTS

Hospitalised patients under IP and non-isolated patients were matched by ward, age and illness severity.

OUTCOME MEASURES

We measured surrogates of mental and social well-being by using the Pictorial Representation of Illness and Self Measure (PRISM) instrument once during hospitalisation. PRISM is a visual psychometric instrument that has been validated as a quantitative measure of suffering. Smaller distance in self-to-illness separation (SIS) signifies higher importance for a patient.

RESULTS

156 patients agreed to participate of which 63 were under IP and 93 were matched controls. Median (IQR) duration of isolation was 5 days (2-10). The median SIS (IQR) for perceived inferior nurses' care was 22.8 (18.5-24.3) and 23.8 (23.3-25.5) for isolated and non-isolated patients, respectively (p<0.001). Similarly, median SIS (IQR) was significantly smaller in isolated than non-isolated patients for avoidance by visitors with 17.5 (7.7-22.0) and 22.2 (21.8-22.6), for loneliness with 7.5 (3.6-16.0) and 18 (10.2-21.6) and for feeling impure with 19 (17.0-21.5) and 21.5 (18.9-22.1), respectively (all p values<0.05).

CONCLUSIONS

IP to prevent transmission of pathogens may negatively impact mental and social well-being. Measures to alleviate adverse effects of IP should be taken routinely.

Risk Perception of Natural and Human-Made Disasters-Cross Sectional Study in Eight Countries in Europe and Beyond

Each year, emergency and disaster situations claim a heavy toll in human lives and economic loss. Civilian populations that are more aware and prepared for emergencies are more resilient. The aim of this study was to explore similarities and differences in risk perception of emergencies and disasters across different societies and its association with individual resilience. A cross sectional study that explored attitudinal factors, as expressed by diverse samples of target countries across Europe and beyond, took place during the months of January-February 2021. Diverse samples (N ≥ 500) of adults from 8 countries (Italy, Romania, Spain, France, Sweden, Norway, Israel, and Japan) were engaged in this study. This study used the Pictorial Representation of Illness and Self-Measure (iPRISM) tool to assess risk perception. The results suggest that for the overall sample (N = 4,013), pandemics were the risk of which participants showed the highest concern, followed by critical infrastructure fail, social disturbance, natural hazards, and extreme weather events. It was found that religiosity is associated with risk perception, with highly religious and non-religious reporting elevated risk perception (F = 5.735, df = 2, p = 0.003), however country-specific analysis revealed that this finding varies depending on local contexts. The analysis also revealed differences in risk perception depending on age and type of risk. The results of this study present that there are commonalities and differences between societies across Europe and beyond concerning societal resilience at large, including risk perception. The dependency of risk perception on local context suggests that a regional-based approach for disaster risk reduction may be called for to adapt and adjust to local socio-cultural characteristics of each population.

Lay causal beliefs about PTSD and cultural correlates in five countries

Background

To date, cultural clinical research has primarily focused on differences between ethnic groups when investigating causal beliefs about mental disorders. While individual as well as contextual factors are considered important for gaining a better understanding of cultural influences, research on causal beliefs about post-traumatic stress disorder (PTSD) and cultural correlates in laypersons is scarce.

Objective

This study aimed at gain a better understanding of the association between causal beliefs about PTSD and cultural aspects, as well as other contextual and individual correlates of causal beliefs.

Method

We conducted a cross-sectional, vignette-based online survey with 737 laypersons from Mexico, Ecuador, Germany, Greece, and Russia. Participants completed the illness perception questionnaire revised (IPQ-R) and reported several cultural and sociodemographic (e.g. country of residence, gender, personal values) as well as mental health-related variables (e.g. PTSD symptoms, previous seeking of help). Latent class analysis (LCA) was performed to identify subgroups of individuals expressing similar causal beliefs for PTSD. Multinomial logistic regression was used to analyse covariates of class membership.

Results

LCA resulted in a three-class solution of casual beliefs: a traumatic event-focused class (41.1%); an intrapersonal causes class (40.1%); and a multiple causes class (18.0%). Multinomial logistic regression analysis revealed country of residence, gender, personal value of security, PTSD symptoms, and mental health literacy as significant covariates of class membership.

Conclusions

Integrating a more diverse concept of culture into cultural clinical research can be a valuable addition to group comparisons based on nationality or ethnicity. Cultural clinical research needs to move towards a more integrated approach that accounts for the complexity of culture. Including additional contextual and sociodemographic factors can help to reach a more accurate understanding of the cultural influences on the development of causal beliefs and mental health.

The effectiveness of Pictorial Representation of Illness and Self Measure (PRISM) for the assessment of the suffering and quality of interpersonal relationships of patients with chronic pain

Background

Pictorial Representation of Illness and Self Measure (PRISM) is a tool that can be used to visualize and evaluate the burden of suffering caused by an illness. The aim of this study was to identify which aspects of the burden of chronic pain patients are associated with Self/illness separation (SIS), an indicator of the magnitude of suffering. We also examined the effectiveness of PRISM for evaluating changes in the relationships between patients and their medical care and significant others due to our inpatient treatment.

Methods

Seventy-two patients with chronic pain who were outpatients or admitted to the Department of Psychosomatic Medicine completed PRISM, depression and anxiety scales, and three types of pain-related self-assessment questionnaires (Brief Pain Inventory, Short-form McGill Pain Questionnaire, and Pain Catastrophizing Scale). Outpatients were queried at the time of outpatient visits and inpatients at the time of admission. In addition to PRISM disks related to illness, we asked each patient to place disks related to things important to them and their medical care. Of the inpatients, 31 did PRISM at the time of discharge. Among the reported important factors, which significant other was placed at the time of admission and discharge was evaluated. The distances of self/medical care separation (SMcS) and self/significant others separation (SSoS) were measured.

Results

Of the 21 scales measured, 10 showed a significant correlation with SIS. Factor analysis of these 10 scales extracted three factors, Life interferences, Negative affects, and Pain intensity. The SMcS and SSoS distances were shorter at discharge than at admission.

Conclusions

PRISM for patients with chronic pain is an integrated evaluation method that reflects three aspects of pain. By adding medical care and significant others to the usual method of placing only illness on the sheet it became possible to assess changes in the quality of interpersonal relationships.

A Mixed-Methods Investigation into Patients' Decisions to Attend an Emergency Department for Chronic Pain

OBJECTIVE

This study explored factors that underpin decisions to seek emergency department (ED) care for chronic noncancer pain in patients identifying as culturally and linguistically diverse (CALD) or Australian born.

DESIGN AND METHODS

This mixed-methods study was underpinned by the Behavioral Model of Health Services Use conceptual framework. Consenting consecutive patients attending the ED for a chronic pain condition were recruited to a CALD (n = 45) or Australian-born (n = 45) cohort. Statistical comparisons compared the demographic, pain, health literacy, and episode of care profiles of both cohorts. Twenty-three CALD and 16 Australian-born participants consented to an audio-recorded semi-structured interview (n = 24) or focus group (n = 5 focus groups) conducted in their preferred language. Interviews were translated and transcribed into English for analysis using applied thematic analysis, guided by the conceptual framework. Data were triangulated to investigate the patterns of ED utilization and contributing factors for both cohorts.

RESULTS

ED attendance was a product of escalating distress, influenced by the degree to which participants' perceived needs outweighed their capacity to manage their pain. This interaction was amplified by the presence of predisposing factors, including constrained social positions, trauma exposure, and biomedical health beliefs. Importantly, experiences varied between the two cohorts with higher degrees of pain catastrophizing, lower health literacy, and greater social challenges present for the CALD cohort.

CONCLUSION

This study highlights the role contextual factors play in amplifying pain-related distress for CALD and Australian-born patients with chronic pain. The findings support a need for health care providers to recognize features of higher vulnerability and consider streamlining access to available support services.

Influence of weekday of admission and level of distress on length of hospital stay in patients with low back pain: a retrospective cohort study

BACKGROUND

Low back pain (LBP) is often a complex problem requiring interdisciplinary management to address patients' multidimensional needs. Providing inpatient care for patients with LBP in primary care hospitals is a challenge. In this setting, interdisciplinary LBP management is often unavailable during weekends. Delays in therapeutic procedures may result in a prolonged length of hospital stay (LoS). The impact of delays on LoS might be strongest in patients reporting high levels of psychological distress. Therefore, this study investigates the influence of weekday of admission and distress on LoS of inpatients with LBP.

METHODS

This retrospective cohort study was conducted between 1 February 2019 and 31 January 2020. In part 1, a negative binomial model was fitted to LoS with weekday of admission as a predictor. In part 2, the same model included weekday of admission, distress level, and their interaction as covariates. Planned contrast was used in part 1 to estimate the difference in log-expected LoS between group 1 (admissions Friday/Saturday) and the reference group (admissions Sunday-Thursday). In part 2, the same contrast was used to estimate the corresponding difference in (per-unit) distress trends.

RESULTS

We identified 173 patients with LBP. The mean LoS was 7.8 days (SD = 5.59). Patients admitted on Friday (mean LoS = 10.3) and Saturday (LoS = 10.6) had longer stays, but not those admitted on Sunday (LoS = 7.1). Analysis of the weekday effect and planned contrast showed that admission on Friday or Saturday was associated with a significant increase in LoS (log ratio = 0.42, 95% CI = 0.21 to 0.63). A total of 101 patients (58%) returned questionnaires, and complete data on distress were available from 86 patients (49%). According to the negative binomial model for LoS and the planned contrast, the distress effect on LoS was significantly influenced (difference in slopes = 0.816, 95% CI = 0.03 to 1.60) by dichotomic weekdays of admission (Friday/Saturday vs. Sunday-Thursday).

CONCLUSIONS

Delays in interdisciplinary LBP management over the weekend may prolong LoS. This may particularly affect patients reporting high levels of distress. Our study provides a platform to further explore whether interdisciplinary LBP management addressing patients' multidimensional needs reduces LoS in primary care hospitals.

Development of a visual tool to assess six dimensions of health and its validation in patients with endocrine disorders

BACKGROUND

Psychosocial factors significantly influence patient care in many fields of medicine, among these in the field of endocrinology. Easily applicable validated assessment tools for such psychosocial factors are lacking. Visual instruments may facilitate doctor-patient communication. This study describes the development and validation of a multidimensional visual tool for the self-assessment of health.

METHODS

An expert panel performed the multistep development of the psychosomatic assessment health disc (PAHD). Assessment of face validity was performed by means of a focus group of medical doctors (n = 6) and patient interviews (n = 24). For determining test-retest reliability, internal consistency and construct validity, patients of an endocrine outpatient clinic in Graz, Austria, completed the PAHD and the following questionnaires: short-form 36 health survey, work ability index, Pittsburgh sleep quality index and the social life scales of the life satisfaction questionnaire.

RESULTS

A numeric six-item analogue scale was developed in the form of a disc. It addresses the following aspects of health: physical well-being, social life, sexuality, mental well-being, sleep, working ability/performance. For the validation process, 177 patients (57.1% females) participated in the study. Correlation coefficients of the six items with other questionnaires ranged between r = 0.51 (social life) and r = 0.72 (sleep). Test-retest reliability was assessed among 98 patients and was ≥ 0.74 for all 6 items, while Cronbach's alpha was 0.78.

CONCLUSION

The psychometric properties of the PAHD support its use in clinical encounters with patients suffering from endocrine disorders. Further validation studies may be required to extend its application to other fields of medicine.

Mental Pain as a Transdiagnostic Patient-Reported Outcome Measure

Patient-reported outcomes (PROs) refer to any report coming directly from patients about how they function or feel in relation to a health condition or its therapy. PROs have been applied in medicine for the assessment of the impact of clinical phenomena. Self-report scales and procedures for assessing physical pain in adults have been developed and used in clinical trials. However, insufficient attention has been dedicated to the assessment of mental pain. The aim of this paper is to outline the implications that assessment of mental pain may entail in psychiatry and medicine, with particular reference to a clinimetric index. A simple 10-item self-rating questionnaire, the Mental Pain Questionnaire (MPQ), encompasses the specific clinical features of mental pain and shows good clinimetric properties (i.e., sensitivity, discriminant and incremental validity). The preliminary data suggest that the MPQ may qualify as a PRO measure to be included in clinical trials. Assessment of mental pain may have important clinical implications in intervention research, both in psychopharmacology and psychotherapy. The transdiagnostic features of mental pain are supported by its association with a number of psychiatric disorders, such as depression, anxiety, eating disorders, as well as borderline personality disorder. Further, addressing mental pain may be an important pathway to prevent and diminish the opioid epidemic. The data summarized here indicate that mental pain can be incorporated into current psychiatric assessment and included as a PRO measure in treatment outcome studies.

A Global, Prospective, Observational Study Measuring Disease Burden and Suffering in Patients with Ulcerative Colitis Using the Pictorial Representation of Illness and Self-Measure Tool

BACKGROUND

The understanding the Impact of ulcerative COlitis aNd Its assoCiated disease burden on patients study [ICONIC] was a 2-year, global, prospective, observational study evaluating the cumulative burden of ulcerative colitis [UC] using the Pictorial Representation of Illness and Self-Measure [PRISM] tool that is validated to measure suffering, but not previously used in UC.

METHODS

ICONIC enrolled unselected outpatient clinic attenders with recent-onset UC. Patient- and physician-reported outcomes including PRISM, the Short Inflammatory Bowel Disease Questionnaire [SIBDQ], the Patient Health Questionnaire [PHQ-9], and the Simple Clinical Colitis Activity Indexes [patient: P-SCCAI; physician: SCCAI] were collected at baseline and follow-up visits every 6 months. Correlations between these measures were assessed using Spearman's rank correlation coefficient.

RESULTS

Overall, 1804 evaluable patients had ≥1 follow-up visit. Over 24 months, mean [SD] disease severity measured by P-SCCAI/SCCAI reduced significantly from 4.2 [3.6]/3.0 [3.0] to 2.4 [2.7]/1.3 [2.1] [p<0.0001]. Patient-/physician-assessed suffering, quantified by PRISM, reduced significantly over 24 months [p<0.0001]. SCCAI/P-SCCAI, and patient-/physician-assessed PRISM, showed strong pairwise correlations [rho ≥0.60, p<0.0001], although physicians consistently underestimated these disease severity and suffering measures compared with patients. Patient-assessed PRISM moderately correlated with other outcome measures, including SIBDQ, PHQ-9, P-SCCAI, and SCCAI (rho = ≤-0.38 [negative correlations] or ≥0.50 [positive correlations], p<0.0001).

CONCLUSION

Over 2 years, disease burden and suffering, quantified by PRISM, improved in patients with relatively early UC. Physicians underestimated burden and suffering compared with patients. PRISM correlated with other measures of illness perception in patients with UC, supporting its use as an endpoint reflecting patient suffering.

Pictorial Representation of Threat Perception and Its Association With Emergency Preparedness

OBJECTIVES

Emergency preparedness is a key factor in public resilience when facing adversities. It is widely agreed that populations who are better prepared for crises and emergencies cope better and sustain fewer damages. Yet, promoting readiness continues to be challenging. In an effort to assess Israeli threat perception of emergencies, a novel visual tool measuring personally salient appraisals and attitudes (the Pictorial Representation of Illness and Self-Measure [PRISM]) was used.

METHODS

A cross-sectional study of 502 participants representing the adult Jewish population was carried out. An online version of the PRISM tool was used together with a set of validated questionnaires to assess household preparedness.

RESULTS

The results suggest that preparedness for emergencies (war or earthquake) is associated with the way subjects appraise preparedness in their lives, but is not associated to the appraisal of threat objects themselves. In other words, the results suggest that preparedness has little to do with threat perception.

CONCLUSIONS

This study highlights the disparity between classic risk reduction strategies, which argue that awareness is key in promoting public preparedness, and the reality.

Correlation between chronic skin ulcers dimension and burden of suffering evaluated with PRISM test

BACKGROUND

In the practice of dermatology, many tools are available to help the physician measure the patient's quality of life. The Pictorial Representation of Illness and Self Measure (PRISM) is a novel and simple method to measure personal suffering. The aim of our study was to evaluate, using PRISM, whether the reduction of the ulcers' size positively correlated with an improvement of the patients' suffering.

METHODS

This was a multicenter national prospective study. 143 patients from five dermatological centers were enrolled in the study. At times T0 and T1 (after 1 month), the size of the ulcers was collected for each patient. At the same time, the PRISM test was also administered, in order to calculate the Self-Illness-Separation (SIS).

RESULTS

First, a substantial decrement of the size of the ulcer seemed to correlate with a significant difference between the SIS score obtained at T0 and T1. On the contrary, the duration of the wound did not seem to influence the SIS value. No relationship between the age of the patient and the SIS value was found either.

CONCLUSIONS

Our study showed that the decrease in the wound dimension positively affects the patient's suffering. In fact, ulcer's size reduction is correlated with an improvement in the patient's disease perception.

Recognising ethnocultural diversity in chronic pain assessment: validation of the Pictorial Representation of Illness and Self Measure (PRISM) for use with culturally diverse communities

BACKGROUND

A comprehensive and accurate assessment of pain is critical for successful pain management. However, there is a lack of reliable and valid assessment tools for exploring multidimensional aspects of the chronic pain experience in culturally and linguistically diverse communities. This study investigates the reliability and validity of the Pictorial Representation of Illness and Self Measure + (PRISM+) for evaluating pain-related suffering and the sociocultural context of chronic pain within culturally and linguistically diverse patient cohorts.

METHOD

Three prospective validation studies are reported for three culturally and linguistically diverse communities. Two hundred and fifty-one patients with chronic pain who self-identified as Assyrian (n = 85), Arabic (n = 83) or Vietnamese (n = 83) completed a PRISM+ assessment, alongside a battery of standardised pain assessments. To evaluate construct validity, the position of the 'pain' disk placement was correlated with the Brief Pain Inventory (BPI), Depression Anxiety and Stress Scale (DASS), and the Short-Form 36 Health Survey (SF-36). For content validity, thematic analysis of patient narratives accompanying each disk placement was conducted. Test-retest reliability of repeated 'pain' and five additional disks (PRISM+) values was analysed using intra-class correlation coefficients.

RESULTS

The PRISM pain assessment demonstrated moderate to good test-retest reliability for Arabic (ICC 0.76; 95% CI 0.65-0.84), Assyrian (ICC 0.65; 95% CI 0.50-0.76) and Vietnamese (ICC 0.82; 95% CI 0.73-0.88) patients. Moderate correlations between the PRISM 'pain' disk and sub-scores for the BPI, DASS and SF-36 were found (p < 0.001). Patient interpretations of the 'pain' disk aligned with accepted definitions of suffering, supporting content validity for PRISM. For the additional disks (PRISM+), moderate to good test-retest reliability (ICC 0.67-0.88) was observed and qualitative analysis highlighted each disk reflected social and cultural values.

CONCLUSION

The PRISM demonstrates acceptable psychometric properties for measuring pain-related suffering for participants with chronic pain across three culturally and linguistically diverse communities. The use of additional disks (PRISM+) presents a reliable and valid option for exploring social and cultural dimensions of chronic pain in clinical encounters.

Pilot cluster randomized controlled trial of a complex intervention to improve management of vertigo in primary care (PRIMA-Vertigo): study protocol

OBJECTIVES

Vertigo and dizziness are highly prevalent symptoms in primary care, frequently misdiagnosed. Based on a thorough need assessment, INDICORE (INform, DIagnose, COmmunicate, REfer), an evidence-based complex intervention has been developed to transfer knowledge of specialized tertiary clinics to primary care providers (PCPs), improve the referral process and, ultimately, improve the functioning and quality of life of patients with vertigo/dizziness. The main objective of the PRIMA-Vertigo pilot study is to examine whether the INDICORE intervention is feasible and sufficiently promising to warrant a larger trial.

METHODS

We plan to perform a single-blind, pragmatic cluster-randomized controlled pilot study with an accompanying process evaluation. PCPs will be the cluster units of randomization. Patients who consult these PCPs because of vertigo/dizziness symptoms will be included consecutively and considered the units of analysis. The intervention will be multi-faceted training on diagnostics targeted at the PCPs, supported by patient education material and a newly developed tool to structure the referral process. To balance the influence of non-specific effects, all clusters will receive generic communication training.

EXPECTED RESULTS

The process evaluation aims to provide results on the acceptability and feasibility of the INDICORE intervention components to PCPs and patients. Additionally, this study will provide a first estimate of the likely effectiveness of the intervention on patients' quality of life, functioning and participation.

CONCLUSIONS

The PRIMA-Vertigo pilot study will allow further tailoring of the INDICORE intervention to stakeholder needs before its effectiveness is evaluated in a large-scale main study.

Pictorial Representation of Illness and Self Measure (PRISM): A Novel Visual Instrument to Quantify Suffering in Liver Cirrhosis Patients and Liver Transplant Recipients

Background

The level of suffering of chronically ill patients does not necessarily correlate with illness severity. In this study, we evaluated the burden of suffering and its impact on health-related quality of life in liver transplant recipients and liver cirrhosis patients.

Material/Methods

The Pictorial Representation of Illness and Self Measure (PRISM) was used to explore levels of suffering in outpatients of Münster University Hospital, Germany. Self-illness separation scores were analyzed as a measure of disease-specific burden of suffering. Health-related quality of life was measured using the Short Form Health Survey (SF-36).

Results

Data from 201 subjects were statistically analyzed. Median Self-illness separation scores for liver transplant recipients and patients with liver cirrhosis were 13.5 (minimum/maximum: 0.2/25.6) cm and 6.3 (0.1/25.6) cm (p<0.001), respectively. The median SF-36 Mental Component Summary and Physical Component Summary scores were 46.4 (12.5/66.2) and 40.1 (12.3/61.1), respectively. Higher health-related quality of life was associated with greater self–illness separation. Liver transplant recipients showed normal Mental Component Summary scores compared with the general German population; patients with liver cirrhosis had significantly lower Mental Component Summary scores. Physical Component Summary scores were significantly higher in liver transplant recipients than in patients with liver cirrhosis, but still lower than in the general population.

Conclusions

PRISM is a novel, simple tool for measuring the illness burden in liver transplant recipients and patients with liver cirrhosis. This measure may help to identify patients at a higher risk of psychological disorders.

A Measure of Suffering in relation to Anxiety and Quality of Life in IBS Patients: Preliminary Results

Irritable bowel syndrome (IBS) is a chronic gastrointestinal (GI) disorder with a severe impact on quality of life (QoL). We explored the relationship of a visual measure of suffering, the PRISM-RII, with quality of life (QoL) and anxiety measures in IBS patients. Participants were 44 IBS patients who completed several questionnaires and kept a symptom diary for two weeks. The measures used were PRISM-RII (self-illness separation (SIS); illness perception measure (IPM)); IBS-36 (IBS health related QoL); SF-36 (physical and mental health related QoL); State-Trait Anxiety Inventory (STAI-T); Visceral Sensitivity Index (VSI; GI-specific anxiety); and a symptom diary. SIS was negatively correlated to VSI, while IPM was negatively correlated to SIS and the physical component of SF-36 and positively to VSI and symptom severity. We found significant differences between participants who perceive their illness as small and those who perceive it as medium in SIS, symptom severity, VSI, and the mental component of SF-36. Participants, who perceived their illness as small, represented their illness as more distant, showed lower average symptom severity, and had lower GI-specific anxiety and higher QoL. The results indicate that IPM and SIS can be useful in discriminating patients with more prominent psychological difficulties and QoL impairment.

Using the Pictorial Representation of Illness and Self Measure (PRISM) to Quantify and Compare Suffering From Trauma and Addiction

OBJECTIVE

In a sample of people with substance use disorder who had experienced psychological trauma, this study aimed to quantify differences in perceived suffering due to addiction-related problems and to trauma-related problems.

METHODS

The sample comprised 146 inpatients with substance use disorder: 25% had posttraumatic stress disorder (PTSD), 21% had subthreshold PTSD; and the remainder constituted the trauma-only group. PTSD, substance use disorder, and suffering were assessed using validated instruments. Suffering was measured using the Pictorial Representation of Illness and Self Measure (PRISM).

RESULTS

No differences were found among the PTSD, subthreshold PTSD, and trauma-only group in the suffering attributed to addiction-related problems. Those in the PTSD group appraised their suffering due to trauma-related problems as greater than the other groups. In the PTSD group, but not the subthreshold PTSD group, suffering due to trauma-related problems was appraised as greater than that due to addiction-related problems.

CONCLUSIONS

This is the first study to demonstrate quantitative comparisons between different health problems using the "common currency" of suffering. Our results indicate that even among those in an inpatient substance use disorder treatment program, comorbid PTSD may be more personally salient and cause greater suffering, with implications for therapeutic interventions available on substance use disorder treatment programs.