Objectives: The study objectives were to identify baseline predictors of low back pain severity changes over a one-year period among patients attending multidisciplinary tertiary clinics and determine whether health care utilization impacts on this outcome.Methods: This is a retrospective cohort study using the Quebec Pain Registry (QPR). A total of 686 low back pain (LBP) patients (55.8% females; mean age = 56.51±14.5 years) from the QPR were selected for this study. Patients completed self-report questionnaires and nurse-administered questionnaires before their first appointment at a multidisciplinary pain treatment center. Analysis was conducted using linear growth model.Results: There was a modest (10%) improvement in pain severity scores over a 12month period. Pain catastrophizing and depressive symptoms predicted higher baseline levels of pain severity (p < 0.001)Having used self-management approaches over the past 6 months was associated with higher levels of pain severity at 12 months (p < 0.001).Discussion: Results from this study showed no clear pattern of association between the use of different treatment disciplines and pain severiy over the first year following multidisciplinary treatment intervention. These results raise an important question as to the best way of utilizing scarce multidisciplinary resources to optimize cost-effectiveness and improve outcomes among complex, chronic LBP patients.

The supportive and palliative care needs of patients with advanced heart failure have been highlighted in recent years and there is growing interest in extending palliative care services to such patients. The National Service Framework for Coronary Disease called for a palliative approach and access to specialist palliative care (SPC) services for appropriate patients with advanced heart failure. 1 A theoretical basis for palliative care intervention can be drawn from the field of oncology, from qualitative studies in heart failure patients and audit data emerging from the few SPC services currently managing heart failure patients. However, there is an urgent call for relevant, well constructed studies to provide an evidence base to enable health commissioners and providers to develop services in a cost-effective way and to reduce the current geographical inequity of service provision.Thus a meeting of invited delegates from primary care, palliative care, cardiology and health services research, known for either their active participation or interest in research in this area, was convened. It was hoped that by bringing together different disciplines interested in the same field, relevant, networked projects may develop. Three research themes of narrative-based, service provision and symptom control research were carried through the day, initially with summary, 'Where are we now?' plenary presentations, followed by similarly themed workstreams to agree priority areas for research in these areas. Theme 1. Narrative based researchPlenary. Dr Kendall (Edinburgh) summarized how narrative-based studies have helped patients and carers describe how it feels to live with heart failure, and how this method of research has helped provide meaning rather than measurement, thus complementing more quantitative studies, as well as giving rise to important new research questions. Such studies have illuminated the range of problems experienced by patients, and family carers, including problems with service co-ordination, information needs, communication and issues relating to death and dying.Work-stream (facilitated by Dr Kendall). It was felt that narrative-based research was particularly helpful used in mixed-method studies, adding in another perspective, and helping to ensure that studies remain patientfocussed. The priorities for research were suggested:(a) assessment of complex intervention; (b) identifying when a palliative care approach should be used; (c) advanced planning; (d) communication with relatives and with professionals; (e) management of the last days. Theme 2. Service provision researchPlenary. Ms Selman (London) outlined the problem that while supportive and palliative care provision was being integrated into national policy, there was very little evidence of service effectiveness, or any guidance as to which service model was appropriate in which setting. She described six service descriptions in the literature, but only one -a small study of palliative medicine out patient consultations -had been formally e...

Death is an everyday reality for those working in palliative care, and with death often come expressions of loss, sadness, relief and grief. One of the common responses to these emotions is crying and yet, despite the frequency with which we are confronted with tears, we know remarkably little about why we cry. Tom Lutz has written a wonderful text exploring the natural and cultural history of tears drawing on work from the fields of literature, history, sociology, anthropology, psychology and physiology. Ranging from early Greek philosophers and writers through to the modern portrayal of tears in films and literature, Lutz broadens our understanding of this uniquely human phenomenon. Tears are often a human expression of emotion when adequate words cannot be found, but why do we start to cry and how do we stop? This book explores the psychology of tears, different patterns of crying of infants, men and women, the cultures of mourning and the phenomenon of tears of revenge, seduction, escape and empathy. In a book that is so wide ranging, aspects such as the culture of mourning are not as widely dealt with as in some other, more specialist texts but nevertheless this work draws together a vast array of work that would otherwise be hard to assimilate. The book is not only thought-provoking but informative and entertaining and provides a clearer understanding about this aspect of our everyday work.

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