text:
HIV remains a significant global health concern with 36.7 million people living with HIV worldwide.130 The availability of combined antiretroviral therapy (cART) has drastically improved life expectancy.9,93,120 In well-resourced countries, and increasingly in less well-resourced regions, the shift in HIV from a terminal illness to a chronic condition has led to a focus on disease and symptom management.59
Chronic pain is a common symptom in people with HIV. Data from one systematic review indicate that 54% to 83% of people with HIV may experience clinically meaningful persistent pain, and these estimates seem to be stable from the pre- to current-cART era.80 Neuropathic pain is a frequent complication of HIV and/or antiretroviral therapy.15 Approximately 42% to 66% of people with HIV have peripheral sensory neuropathy (HIV-SN), and around 54% to 78% of these experience neuropathic pain.84,88,129 Importantly, pain in people with HIV is associated with increased disability and reduced quality of life.27
There are few pharmacological options for managing chronic HIV-related pain. A systematic review of 14 randomized controlled trials (RCTs) of pharmacotherapy for painful HIV-SN found efficacy only for topical capsaicin, smoked cannabis, and subcutaneous nerve growth factor.85 However, nerve growth factor is not clinically available, capsaicin is not feasible in lower-resourced settings, and a subsequent review of cannabis showed no effect on neuropathic pain and concerns about long-term side effects.32 Additional negative RCTs of pregabalin, capsaicin, and amitriptyline have been published.17,24,103
In the wider literature, psychological approaches are common in chronic pain management.34 Psychological treatments, including cognitive–behavioural therapy (CBT), are associated with improved functioning and mood for chronic pain that is primarily musculoskeletal.124 However, research on psychological treatments for pain in HIV is less well developed. Only 2 RCTs have examined CBT for people with HIV and chronic pain, but interpretation of these trials is hampered by small samples118 and high dropout rates.29 An observational study of CBT for HIV-related pain showed similarly poor treatment completion.21,113 There is a clear need for improving psychological treatments for people with HIV-related pain.
Improving psychological approaches for chronic pain in HIV will require consideration of the psychosocial complexities associated with HIV. For example, stigma, mental health problems, and substance abuse may influence pain and treatment engagement in people with HIV.36,69,71,111,123,132 However, research has not systematically examined psychosocial factors associated with pain in this context. The systematic review by Parker et al. (2014), which estimated the prevalence of pain in HIV, described 5 studies reporting psychosocial factors. However, that review did not specifically include assessment of psychosocial factors in the eligibility criteria. Furthermore, 33 potentially eligible studies were excluded due to low-quality ratings,80 which limits our understanding of the range of psychosocial factors examined in this context. Therefore, we conducted a systematic review and meta-analyses to examine the associations between psychosocial factors and persistent pain in HIV. Because the aims of the review were exploratory, we did not formulate specific hypotheses about the associations between these variables.
The review protocol was registered with PROSPERO (http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42016036329).
2.1. Inclusion and exclusion criteria
- (1) People with HIV aged 18 years and older.
- (2) The original protocol specified the study must have a “(sub)sample with average pain duration of ≥3 months.” After piloting this criterion, a large number of studies did not define or report pain duration. We contacted authors to enquire about pain chronicity; however, these data were generally not available. Given the potentially high prevalence of chronic pain in HIV,80 we decided to include studies with (sub)samples of ambiguous pain duration, provided that “pain” vs “no pain” subgroup analyses were reported in studies for which chronic pain was not an eligibility criterion or which did not report pain duration.
- (3) Data on presence of pain, pain intensity, functioning, and/or quality of life.
- (4) Data on one or more psychosocial variable, representing any potentially modifiable cognitive, affective, behavioural, or interpersonal process. Adherence to antiretroviral therapy and health care use variables represent modifiable behaviour patterns. Therefore, we considered these as psychosocial variables eligible for this review.
- (5) Observational (cross-sectional, case-control, or prospective) or experimental studies (RCTs) reporting between- or within-groups associations between pain and psychosocial variables in a (sub)sample with pain.
- (6) Any language, from any region, from 1981 onwards (the date that HIV was identified in the literature).
- (7) Studies (published and unpublished) with an available full-text. Where only abstracts or trial registration summaries were available, the authors provided unpublished data for the review. Unpublished studies are commonly included in systematic reviews, given recognition of overestimation of effects in published research.62 In addition, studies conducted in lower-resourced countries where HIV is particularly prevalent may not always proceed through to publication. Therefore, the inclusion of unpublished studies and dissertations may help overcome this disparity and allows us to consider potential contextual differences.
- (1) Studies only measuring associations between unchangeable demographic factors (eg, age, ethnicity) and pain. While piloting the eligibility criteria, we found a number of studies reporting history of injecting drug use as participants' HIV risk factor. Given lack of further information about substance abuse history or current abuse, we excluded studies for which injecting drug use history was the only psychosocial factor. Likewise, we excluded studies reporting only average units of alcohol consumed, rather than alcohol abuse.
- (2) Qualitative studies.
2.2. Search strategy
We searched the following databases during March 2016: Medline, EMBASE, CINAHL, PsycINFO, Cochrane, and Web of Science. We also searched ISRCTN, clinicaltrials.gov, and EU Clinical Trials Register. Reference lists of eligible studies were searched and key authors were contacted. We reran the search in August 2017. The search included terms for the target population (HIV or AIDS), outcome (chronic pain), and exposure measurement (psychosocial factors). Relevant search terms were identified from previous reviews on pain in HIV,80,124 psychosocial factors in HIV,99 and psychosocial factors in chronic pain40 (Appendix A, available at http://links.lww.com/PAIN/A643).
2.3. Data extraction
Two reviewers (W.S. and C.A.) independently screened titles/abstracts and full-texts for eligibility. The following data were extracted from eligible studies: year; design; country; sample size; demographics (ie, age, sex, and race/ethnicity); clinical factors (ie, HIV duration, use of ART, CD4+ count and viral load, and pain duration and type); assessment of pain and psychosocial variables; and, statistical analyses. In cases where both cross-sectional and prospective data reported the same (or an overlapping) cohort and variables, the prospective analyses were extracted. Data were extracted from all studies by W.S., and independently by C.A. and K.K. who each extracted data from approximately half of the studies. Disagreements regarding eligibility and data extraction were discussed to reach consensus and, where discrepancies remained, W.S. discussed these with the wider team. The reviewers were not blinded to the authorship of the studies reviewed.
2.4. Quality assessment
We assessed the methodological quality of studies using an adapted version of quality assessment tools used in previous systematic reviews of observational studies relevant to pain and HIV.3,40,80 The quality assessment tool contained items assessing: study purpose, recruitment, response rates, sample description, assessment measurements, data analysis, and confounding/matching (Appendix B, available at http://links.lww.com/PAIN/A643). Additional items assessed features specific to prospective designs. Thus, quality scores differed for cross-sectional and prospective studies. In some cases, the overall study design did not correspond to the nature of the data extracted for the purpose of this review. In addition, in some cohorts, a cross-sectional design was used to examine one psychosocial variable, whereas a prospective design was used to examine another variable using the same sample. In all cases, the quality assessment was applied to the design used for the nature of the data extracted for a given psychosocial variable. Quality assessment items were rated as “positive” (1), “negative” (0), or “unclear” (?), and total scores were computed and classified as low (<50%), medium (50%-80%), and high (>80%).3,40 W.S. completed quality assessment ratings for all studies, whereas C.A. and K.K. each independently completed the quality assessment for approximately half of the studies. The strength of evidence was assessed according to the levels outlined by Ariëns et al.3 in a systematic review of observational studies of psychosocial risk factors for neck pain: (1) Strong: consistent results in multiple high-quality prospective and/or case-control studies; (2) Moderate: consistent results in multiple prospective and/or case-control studies; (3) Some Evidence: findings in one prospective or case-control study, or consistent findings in multiple cross-sectional studies with at least one high-quality study; and (4) Inconclusive: Inconsistent findings in multiple studies or consistent findings in multiple low-quality cross-sectional studies.3
2.5. Data synthesis
Meta-analyses were conducted using Stata 15.0 where there were at least 2 studies43 with the same design and effect estimate of the association between the same pain (eg, intensity) and psychosocial variables (eg, depression). We took a broad approach to the meta-analyses,37,45 and grouped psychosocial variables on the basis that they reflected conceptually similar underlying constructs with overlapping measurement content. All analyses were conducted using random effects, given likely heterogeneity.43 Between-study heterogeneity (I2 statistic) was interpreted as low (<25%), medium (25%-50%), and high (>50%).124 For between-groups comparisons of continuous data, mean values, SDs, and sample sizes were extracted to compute the pooled standardized mean difference (SMD). For between-groups comparisons of dichotomous data, events data and sample sizes were extracted. Where events data were not reported, odds or hazard ratios, 95% confidence intervals (95% CIs), and sample sizes were extracted. To aggregate studies reporting a mixture of odds ratios (ORs) and events data, ORs were first computed from studies reporting events data and then pooled with ORs reported in other studies. Odds ratios and hazard ratios were analysed separately. Where applicable, correlation coefficients (Pearson r) were extracted with sample sizes. We transformed r to Fisher z and computed 95% CIs of z to compute the pooled estimate.18,100
Data extracted were from bivariate analyses. Multivariate data (eg, adjusted ORs) were only extracted where bivariate data were not available. We focused on bivariate analyses because many studies did not report multivariate analyses. Moreover, studies that reported multivariate models varied substantially with respect to control variables included and inconsistently used psychosocial variables as independent or dependent variables. Taken together, these differences limit meaningful interpretation of multivariate analyses across studies.
Several studies presented data on more than 2 pain/no pain groups, often with idiosyncratic group definitions, which limited our ability to compare studies. Where studies reported 3 or more groups, we collapsed these into 2 to represent groups with and without pain (eg, frequent/moderate/severe vs infrequent/mild/none), and computed effects between these. This approach facilitated more direct comparison across studies and thus enabled us to include a larger number of studies in the analyses. For studies comparing participants on the presence of neuropathy, we prioritised extracting data from these comparisons in the following order depending on the data reported: (1) painful vs nonpainful neuropathy; (2) painful neuropathy vs no neuropathy; and (3) neuropathy vs no neuropathy. Where there was more than one measure of the same variable, we extracted data for the measure with the widest usage or the longer measure to increase reliability.124 Our protocol specified that funnel plots would be inspected to assess for publication bias. However, due to the relatively small number of studies in each meta-analysis and the likelihood of high heterogeneity, inspection of funnels plots was not appropriate109 and, therefore, was not undertaken.
We conducted sensitivity analyses to examine the influence of the following study and patient characteristics on the findings: certainty of pain chronicity, pain type, immune functioning and viral suppression, ART treatment era, and health care system. With the exception of the pain chronicity analysis, these sensitivity analyses were prespecified. Given the large number of potential analyses, we restricted sensitivity analyses to the between-groups SMDs for depression because this was the analysis with the largest number of studies.
Forty-six studies were included in the review (13,480 participants) and 37 of these provided data for meta-analyses (12,493 participants; Fig. 1). Most (83%) were conducted in the United States, with 4 studies from South Africa,79,88,121,122 and one each from the United Kingdom,84 Thailand,89 Uganda,95 and Russia.114 Participants were primarily recruited from HIV clinics or using multifaceted strategies that also included recruitment from substance abuse clinics and community outreach. One study recruited exclusively from a methadone clinic,8 whereas 2 others recruited in high-poverty areas.39,110 The samples comprised predominantly men in 41 studies, with the proportion of men in these studies ranging from 51%50 to 100%.28,104 Five studies (4 from South Africa and 1 from the United States) recruited women exclusively79,92 or predominantly (proportion of women ranging from 72% to 88%).88,121,122 The mean age ranged from 30.1 (SD = 5.2)114,115 to 51.0 (SD = 9.3) years.119 HIV duration was not consistently reported; however, of the studies providing data, duration ranged from 2.09 (SD = 1.22)102 to 16.95 years (SD = 8.70).119 Eighteen studies (39%) reported on mixed HIV/AIDS samples (reported proportion with AIDS ranged from 10% to 74%). Four studies included only participants with AIDS, one study excluded patients with AIDS, whereas 23 studies did not clearly report the proportion (if any) with AIDS. Supplemental Table 1 shows further demographic characteristics of the study samples (available at http://links.lww.com/PAIN/A643).
Table 1 provides a summary of study designs, quality, and evidence level for each psychosocial factor. The studies showed substantial variability in the measurement of pain and psychosocial variables. Most studies (63%) were of medium quality. Fifteen studies were of low quality, and only 2 were of high quality.79,84 The most common limitations included unclear reporting of response rates, no a priori sample size justification, and poor reporting of HIV and pain characteristics. There is no single agreed upon strategy to best address low-quality studies within meta-analyses, an issue which is compounded by the arbitrary nature of study quality scoring and cutoff points.43 This can be dealt with by only including high-quality studies, performing sensitivity analyses, or including all studies irrespective of quality and discussing risk of bias.43 Given that only 2 of 46 studies were rated as high quality, a meta-analysis of these cannot be regarded as reflecting most of the studies. Sensitivity analyses would likewise not be meaningful. Including all studies is thus the most justifiable approach for the current data. Although we have chosen to focus on data from bivariate analyses for reasons outlined in the Methods, studies that reported a multivariate model of the association between psychosocial and pain variables are shown in bold in Table 1 for ease of reference.
Depression was the most frequently assessed psychological variable, investigated in 29 studies. Two prospective studies reported hazard ratios for baseline depression predicting time to onset of symptomatic neuropathy. The pooled hazard ratio was significant and indicated that baseline depression was more severe in participants who developed symptomatic neuropathy at follow-up than those who did not: HR = 1.04 (95% CI 1.02-1.07), z = 3.23, P = 0.001 (supplemental Figure 1, available at http://links.lww.com/PAIN/A643). Heterogeneity was 0.0%. Two further prospective studies reported ORs. The pooled OR was significant and indicted that higher baseline depression symptoms were associated with greater likelihood of follow-up pain: OR = 2.26 (95% CI 1.47-3.47), z = 3.72, P < 0.001 (supplemental Figure 2, available at http://links.lww.com/PAIN/A643). Heterogeneity was medium (40.1%). Nine cross-sectional studies provided events data or ORs. The pooled OR was significant such that depression was more likely in participants with vs without pain: OR = 2.65 (95% CI 1.62-4.34), z = 3.90, P < 0.001 (Fig. 2). Heterogeneity was high (83.0%). Twelve cross-sectional studies provided data to compute SMDs (Fig. 3). The overall effect was significant and showed moderately greater depression in participants with vs without pain: SMD = 0.68 (95% CI 0.42-0.93), z = 5.22, P < 0.001. Heterogeneity was high (I2 = 89.2%). Another cross-sectional study that reported the median and interquartile range found no difference in depression between groups with (n = 125) and without pain (n = 72).88
Six cross-sectional studies reported correlation coefficients between depression and pain severity. The pooled correlation was small, but significant: Fisher z = 0.26 (95% CI 0.18-0.33), z = 6.77, P < 0.001. Heterogeneity was 0.0%. One additional study found a nonsignificant correlation, although the coefficient was not reported.27 Four cross-sectional studies reported correlations between depression and pain interference/disability. The pooled correlation was moderate: Fisher z = 0.48 (95% CI 0.41-0.56), z = 12.48, P < 0.001. Heterogeneity was 0.0%. Three cross-sectional studies reported correlations between depression and quality of life. The pooled correlation was large and significant: Fisher z = −0.52 (95% CI −0.75 to −0.30), z = 4.51, P < 0.001. Heterogeneity was high at 73.3% (all correlation analyses, supplemental Figure 8, available at http://links.lww.com/PAIN/A643). One final cross-sectional study (n = 120) reported a moderate correlation between pain presence and depression.55
3.2. Depression sensitivity analyses
We conducted sensitivity analyses on the SMDs for depression between pain and no pain groups (supplemental Figures 3–7, available at http://links.lww.com/PAIN/A643). We excluded data from the Kirkland study here because the SMD from this study was substantial and seemed to be driving heterogeneity in the primary meta-analysis. Excluding the Kirkland data reduced heterogeneity from I2 = 89.2% to 52.2%. Thus, 11 studies were included in sensitivity analyses.
The pooled SMD for depression was medium for studies with certain (0.61, 95% CI 0.11-1.12, z = 2.39, P = 0.02; I2 = 75.1%) and uncertain pain chronicity (0.53, 95% CI 0.41-0.64, z = 9.04, P < 0.001; I2 = 34.5%). In the analysis by pain type, the pooled SMD for depression was moderate in studies with mixed pain types (0.75, 95% CI 0.58-0.92, z = 8.51, P < 0.001; I2 = 31.7%) and for which pain type was not reported (0.52, 95% CI 0.39-0.65; z = 7.91, P < 0.001; I2 = 0.0%). By contrast, studies with neuropathic pain (0.31, 95% CI 0.11-0.52; z = 2.96, P = 0.003; I2 = 0.0%) or headache (0.38, 95% CI 0.06-0.70, z = 2.34, P = 0.02) showed small but significant differences between groups on depression.
The pooled SMD for depression was moderate for studies in which participants had less than adequate immune functioning and viral suppression (0.56, 95% CI 0.42-0.70, z = 7.77, P < 0.001; I2 = 0.0%) and for studies in which these indicators were uncertain (0.53, 95% CI 0.33-0.73, z = 5.28, P < 0.001; I2 = 69.1%). There were no studies with “adequate” functioning on these indices in this analysis. Studies from the pre-cART (0.49, 95% CI 0.32-0.66, z = 5.75, P < 0.001; I2 = 0.0%), cART (0.73, 95% CI 0.37-1.10, z = 3.91, P < 0.001), and current-cART era (0.55, 95% CI 0.38-0.72, z = 6.21, P < 0.001; I2 = 62.5%) all had moderate or near-moderate pooled SMDs. Finally, pooled SMDs for depression were similar in studies from the United States, which has a mixed health care system (0.57, 95% CI 0.43-0.72, z = 7.58, P < 0.001; I2 = 55.7%), and one study from the United Kingdom, which has universal health care (0.68, 95% CI 0.09-1.28; z = 2.25, P = 0.03). The pooled SMD of 2 studies conducted in lower- and middle-income countries was smaller, but statistically significant (0.43, 95% CI 0.14-0.72, z = 2.90, P = 0.004; I2 = 54.2%).
3.3. Psychological distress
Eighteen studies examined variables representing psychological distress, including anxiety-related constructs and the presence of “mental illness,” which generally described a combination of anxiety and depression. Five cross-sectional studies provided events data (Fig. 4). The pooled OR was significant and indicated that participants with pain were more likely to have psychological distress than those without pain: OR = 2.56 (95% CI 1.67-3.90), z = 4.34, P < 0.001. Heterogeneity was high (I2 = 68.3%). One prospective study (n = 127) found that baseline mental illness did not predict presence of pain over follow-up.54 Seven cross-sectional studies provided mean values and SDs (Fig. 5). The pooled SMD showed a large and statistically significant difference between groups such that distress was worse in participants with vs without pain (SMD = 0.85, 95% CI 0.35-1.35); z = 3.33, P = 0.001). Heterogeneity was very high (I2 = 95.4%). One further study that reported the median and interquartile range found no difference between groups.88
Four cross-sectional studies reported correlations between distress and pain severity (supplemental Figure 9, available at http://links.lww.com/PAIN/A643). The pooled correlation was moderate: Fisher z = 0.35 (95% CI 0.09-0.60), z = 2.68, P = 0.007. Heterogeneity was high (82.2%). Three cross-sectional studies reported correlations between distress and pain interference/disability. The pooled correlation was moderate: Fisher z = 0.59 (95% CI 0.24-0.93), z = 3.34, P = 0.001. Heterogeneity was high (81.2%). One prospective study (n = 45-62) found a nonsignificant correlation between change in distress and pain severity after CBT, and a significant, moderate correlation between change in distress and pain interference.44,86 Finally, one cross-sectional study reported a nonsignificant correlation between pain intensity and distress (r not reported), and a small negative correlation between distress and quality of life.88
3.4. Posttraumatic stress
Three studies investigated posttraumatic stress. These studies are reported separate from studies measuring psychological distress, given the specificity of posttraumatic stress as a variable. Different study designs and analyses precluded meta-analysis. One prospective study (n = 143) found that posttraumatic stress symptoms (PTSSs) were associated with significantly higher pain severity and interference over time in a sample with HIV and persistent pain.107 One high-quality cross-sectional study found that participants with pain (n = 170) had significantly higher PTSS than those without pain (n = 59).79 Within the pain group in this study, there was a nonsignificant correlation between PTSSs and pain severity, and small but significant correlations between PTSSs and pain interference (positive correlation) and quality of life (negative correlation).79 Posttraumatic stress disorder did not differ between groups with (n = 150) and without (n = 128) neuropathy in another cross-sectional study.31
3.5. Drug abuse
Fourteen studies examined drug abuse. We prioritised extracting opioid abuse data when multiple drug abuse categories were reported, given the relevance of opioid use in chronic pain. Two prospective studies reported ORs for pain predicting heroin use at the time of follow-up. The pooled OR indicated that participants with pain at baseline were more likely at follow-up to be using heroin: OR = 1.70 (95% CI 1.22-2.38), z = 3.13, P = 0.002 (supplemental Figure 10, available at http://links.lww.com/PAIN/A643). Heterogeneity was low (I2 = 14.0%). Conversely, another prospective study (n = 493) reported that baseline opioid use disorder history predicted new onset of neuropathic pain, OR = 2.87 (1.31-6.28), P < 0.01.60 One low-quality prospective study (n = 127) found that baseline drug abuse history did not predict the presence of pain at follow-up, 0.55 (0.25-1.21).54 These 2 studies could not be combined due to different coding of the dependent variable.
Eight cross-sectional studies reported events data (Fig. 6). The pooled OR was significant such that participants with pain were more likely to have comorbid drug abuse than those without pain: OR = 1.59 (95% CI 1.12-2.26), z = 2.58, P = 0.01. Heterogeneity was high (I2 = 69.8%), mainly attributable to one study that found the opposite effect, such that participants with symptomatic distal sensory polyneuropathy were less likely to have opioid use disorder than those with asymptomatic distal sensory polyneuropathy.76 One low-quality cross-sectional study (n = 503) found that participants with “untreated” pain had greater dependence symptoms than those with “treated” pain or without pain.110 Another low-quality cross-sectional study (n = 73) found a small positive correlation between “aberrant drug behaviours” and pain interference, but not quality of life.81
3.6. Alcohol abuse
Eleven studies investigated alcohol abuse. Two prospective studies reported ORs for baseline pain predicting subsequent alcohol abuse. The pooled OR was not significant: OR = 0.94 (95% CI 0.39-2.26), z = 0.13, P = 0.90 (supplemental Figure 11, available at http://links.lww.com/PAIN/A643). Heterogeneity was high (84.1%). Two additional prospective studies examined baseline alcohol abuse as a predictor of developing pain/neuropathy but could not be combined due to different analyses. Both studies reported a nonsignificant association between these variables.60,77 Seven cross-sectional studies provided events data or ORs. The pooled OR was not significant: OR = 1.22 (95% CI 0.92-1.62), z = 1.36, P = 0.17 (supplemental Figure 12, available at http://links.lww.com/PAIN/A643). Heterogeneity was medium (I2 = 39.0%).
3.7. Sleep disturbance
Three studies investigated sleep disturbance. Two cross-sectional studies reported mean values and SDs. The pooled effect was significant and showed moderately greater sleep problems in participants with vs without pain: SMD = 0.66 (95% CI 0.45-0.87), z = 6.12, P < 0.001. Heterogeneity was 0.0% (supplemental Figure 13, available at http://links.lww.com/PAIN/A643). Another cross-sectional (n = 45) study reported a significant correlation between pain severity and sleep disturbance, and a nonsignificant correlation between sleep and functioning.94
3.8. Antiretroviral nonadherence
Seven studies investigated the association between pain and suboptimal ART adherence. Data were analysed separately according to whether the adherence variable was coded in the direction of nonadherence or adherence. One prospective study (n = 258) reported that severe pain at baseline predicted higher odds (OR = 1.37, 95% CI 1.02-1.85) of follow-up ART nonadherence.46 One cross-sectional study provided events data, whereas another provided an OR. The pooled OR was significant and indicated that participants with pain were more likely to report nonadherence: OR = 1.40 (95% CI 1.07-1.82), z = 2.50, P = 0.01 (supplemental Figure 14, available at http://links.lww.com/PAIN/A643). Heterogeneity was 0.00%. One cross-sectional study (n = 42) found significant positive correlations between pain severity and adherence forgetfulness and fears.57
Two cross-sectional studies reported data for the association between pain and adherence (events data or OR). The pooled OR was less than one, indicating the likelihood of adherence was lower in participants with pain, but this was not statistically significant: OR = 0.32 (95% CI 0.08-1.32), z = 1.57, P = 0.12 (supplemental Figure 15, available at http://links.lww.com/PAIN/A643). Heterogeneity was high (74.3%). Finally, one low-quality cross-sectional study (n = 377) found that pain presence was not associated with adherence in a structural equation model.72
3.9. Health care use
Six studies examined health care use. One prospective study (n = 1521) found that baseline pain predicted significantly higher odds (OR = 1.6, 95% CI 1.2-2.0) of urgent care visits.68 Two cross-sectional studies reported events data. The pooled OR was not significant: OR = 0.98 (95% CI 0.58-1.66, z = 0.07, P = 0.94) (supplemental Figure 16, available at http://links.lww.com/PAIN/A643). Heterogeneity was 0.0%. Two further cross-sectional studies reported mean values and SDs. The pooled effect was small but significant, such that participants with pain had greater health care use than those without pain: SMD = 0.36 (95% CI 0.21-0.51, z = 4.66, P < 0.001). Heterogeneity was 0.0% (supplemental Figure 17, available at http://links.lww.com/PAIN/A643). One further cross-sectional study (n = 1120) found that participants with pain and daily opioid use had more clinic visits than those with pain without daily opioid use and those without pain (SD not reported).53
3.10. Missed HIV clinic visits
Two prospective studies reported ORs for baseline presence of pain predicting missed HIV clinic visits over 1-year follow-up. The pooled OR was significant, such that those with pain at baseline had higher odds of a missed HIV clinic visit: OR = 1.42 (95% CI 1.13-1.79), z = 2.98, P = 0.003 (supplemental Figure 18, available at http://links.lww.com/PAIN/A643). Heterogeneity was 0.0%.
Seven cross-sectional studies provided events data or ORs for the association between unemployment and pain. The pooled OR was significant and indicated that participants with pain had higher odds of being unemployed than those without pain: OR = 2.09 (95% CI 1.59-2.76, z = 5.25, P < 0.001) (supplemental Figure 19, available at http://links.lww.com/PAIN/A643). Heterogeneity was moderate (48.6%). One further cross-sectional study (n = 229) that did not have data available for meta-analysis likewise found that participants with pain were significantly more likely to be unemployed than those without pain.79
3.12. Protective factors
Five studies examined protective psychological factors. One prospective study (n = 62) found significant small and medium correlations between change in self-reported pain acceptance during CBT and posttreatment pain severity and interference, respectively.86 One cross-sectional case-control study observed lower resilience in participants with (n = 99) vs without pain (n = 98; medium effect); however, this study found nonsignificant correlations between resilience and pain severity and interference in the pain group.121
One high-quality cross-sectional study found that participants with pain (n = 170) reported lower disease management self-efficacy than did those without pain (n = 59) (small effect).79 Within the pain group in this study, there were nonsignificant correlations between self-efficacy and pain severity and interference, and a small positive correlation between self-efficacy and quality of life.79 One low-quality cross-sectional study found that those with greater adherence self-efficacy were less likely to report pain (n = 70).8 Finally, one low-quality cross-sectional study found lower mean self-reported optimism in participants with (n = 50) vs without pain (n = 46) (small effect).101
3.13. Social factors
Four studies investigated social factors. The BEACON study (n = 377) explored social processes across 3 papers, 2 of which describe prospective data (medium quality), whereas the third reported cross-sectional data (low quality). Baseline chronic pain predicted “negative social support” (ie, overly intrusive or insensitive responses from others and a lack of support) at 12 months, controlling for baseline social support.73 Another prospective analysis showed that no chronic pain at baseline predicted greater support reciprocity at follow-up.74 Chronic pain was associated with significantly poorer ratings of patient–provider engagement in cross-sectional analyses.72
Two studies examined self-reported stigma, but could not be combined. One medium-quality cross-sectional study (n = 50) found a moderate positive correlation between stigma and pain severity.122 One low-quality cross-sectional study (n = 201) found that participants with “pain disorder” reported higher stigma scores than those without “pain disorder.”98 One medium-quality cross-sectional study found no difference in mean number or quality of self-reported social supports between participants with (n = 274) and without pain (n = 164).91
This review including over 13,000 participants found “some” or “moderate” evidence supporting an association between pain outcomes and depression, psychological distress, posttraumatic stress, drug abuse, sleep disturbance, health care use, missed HIV clinic visits, ART adherence, unemployment, and protective psychological factors in people with HIV. Surprisingly few studies have examined protective psychological factors or social processes. There is a lack of high-quality research on psychosocial factors related to chronic pain in people with HIV. These findings can inform future research and treatment development in this area.
The association between depression and poorer self-reported pain outcomes in HIV is consistent with the wider pain literature.4,64 Data from prospective studies suggest depression is a risk factor for pain. However, caution is warranted in this interpretation, given the observational nature of studies. There is likely a bidirectional relationship, with shared neurobiological pathways, cognitive appraisals, and behavioural disengagement underpinning this association.4,7,14 Evidence supporting the association between pain and sleep disturbance is consistent with the wider literature that reports reciprocal associations between pain, sleep, and depression.106
There was substantial variability in the assessment of “psychological distress,” which may have contributed to the statistical heterogeneity observed. Although different measures were used to assess variables such as pain catastrophizing, pain-related fear, stress, and general anxiety, these measures overlap conceptually and in item content. The consistency of results within the psychological distress category suggests the findings are robust across different assessment methods. Several studies assessed “mental illness” based on a range of diagnoses in participants' medical file without clear diagnostic criteria. Studies exploring mental health diagnoses should use valid and reliable criteria and, ideally, semi-structured clinician-administered interviews as the gold standard.128 In light of high rates of posttraumatic stress disorder (PTSD) in HIV,99 further research is particularly needed to understand the role of PTSD in pain in this context. Alternately, rather than focusing on specific mental health diagnoses, research investigating psychosocial processes that explain the impact of a range of psychological difficulties may prove useful moving forward.42
Few studies investigated fear-avoidance model variables, such as pain catastrophizing and pain-related fear, which have dominated the musculoskeletal pain literature. Fear of movement is strongly associated with musculoskeletal pain disability.20 However, neuropathic pain is often spontaneous and not clearly provoked by movement, although it may inhibit movement. Therefore, research is needed to determine the relevance of fear-avoidance model constructs in neuropathic pain that is common in HIV.
A bidirectional association between drug abuse and pain in HIV is suggested by prospective data showing opioid abuse as both predictor60 and outcome114 of pain. In a population where there are concerns about analgesic prescribing,58 poorly managed pain may contribute to increased abuse of nonprescribed opioids, which may be exacerbated by depression.114 Alternately, prolonged opioid abuse may disrupt descending pain inhibition, exacerbating pain.49 Differing definitions of drug and alcohol abuse across studies may account for variability in effects. Future research on substance abuse in this context should use validated assessments, either screening tools or diagnostic interviews that capture key features of abuse, such as continued use despite harm.1,41,128
Adherence to ART and retention in care are psychosocial factors unique to the HIV context and are of vital importance, given their associations with mortality, morbidity, and drug resistance.112 The finding that pain was associated with reduced ART adherence and missed HIV clinic visits highlights the necessity of adequate pain management in HIV. Understanding the links between pain, ART adherence, and retention in care likely requires consideration of other psychosocial factors, such as substance abuse and depression, which may mediate or moderate this association.68,92
Findings that pain was associated with greater unemployment and health care use highlight the individual, societal, and economic costs of pain in HIV. This is consistent with the broader literature, although health care use is typically underassessed in trials of psychotherapy for chronic pain.87 Studies assessing health care use were restricted to the United States, whereas the unemployment–pain link was consistent in studies from the United States, Russia, and South Africa. The association between pain and health care use differed across studies on the basis of the type of health care assessed. Assessment of the most frequently accessed services (eg, general practitioner visits), rather than relatively infrequent events (eg, hospitalisations), may increase the interpretability of future health care data.
Surprisingly, only 5 studies assessed protective psychological factors. The lack of studies on protective factors mirrors historical trends in the general pain literature, although there has been greater focus on protective factors more recently. The focus on “maladaptive” responses to pain is problematic because such responses can be understood as a function of their short-term utility.126 Moreover, abnormal conceptualizations often fail to specify pathways through which recovery and successful functioning occur when pain is present. The psychological flexibility model, within which pain acceptance has been conceptualised, might prove useful for future research.63
A recent proposal for updating the definition of pain highlights the central role of social factors.127 However, our review identified only 4 studies exploring interpersonal variables. The lack of research on stigma in relation to pain is particularly surprising because managing stigma is key to the success of the HIV/AIDS response.108 Stigma has recently been highlighted as important for the well-being of patients with chronic pain in general.23,125 Future research is needed to determine the function of stigma in chronic pain in people with and without HIV.
The study samples included in our review varied widely in terms of the proportion of men and women, participant age, ethnicity, and duration and severity of HIV. Our sensitivity analyses support the potential applicability of findings across pain types, ART treatment eras, and health care systems. Due to poor reporting of viral loads and CD4+ counts, our analysis stratifying by these indicators is difficult to interpret. Caution is also warranted regarding the cross-cultural applicability of the findings because most studies were from the United States. One South African study with a predominantly female sample found patients with and without pain did not differ on depression or anxiety, likely due to high scores across the sample.88 Socioeconomic factors, such as poverty and gender, may thus alter the relationships between pain, functioning, and mental health.88,121 Care is needed in applying Western psychological concepts in non-Western cultures.51,82,83 Research must also determine unique cultural features that influence the experience and expression of pain in HIV.
A guiding theoretical model is needed to integrate psychosocial processes relevant to pain and HIV. Such a model should make specific predictions about the relative contributions of cognitive, affective, behavioural, and sociocultural processes in relation to specific pain outcomes. This review identified a number of closely related psychosocial constructs. Therefore, a theoretical model may benefit from identifying a key set of nonoverlapping variables.63 This may draw on prominent models within the field of pain, such as the fear-avoidance19 and psychological flexibility models,63 and those within the HIV literature that focus heavily on sociocultural perspectives to understand the impact of processes, such as stigma, on well-being.78
The current findings suggest the relevance of psychosocial treatments to manage persistent pain in HIV. To the best of our knowledge, only 3 small RCTs have evaluated CBT and mindfulness-based treatment.29,35,118 Nonrandomized trials of CBT113 and hypnosis25 have also been conducted. Further evaluation of psychosocial treatments for HIV and chronic pain is thus needed. The development of treatments that specifically target psychosocial factors identified in this review with “some” or “moderate” evidence may prove fruitful.
Several limitations warrant consideration. We used a comprehensive search strategy that included efforts to identify gray literature to limit publication bias; however, relevant studies may have been missed, given the broad nature of the search. We used an adapted quality assessment tool. Although we based this on previously validated tools, the adaptations may have limited the reliability and validity of our quality assessment. Assessment of pain was inadequate in many studies. Future research should assess information regarding pain duration, intensity, location, and type. Studies investigating chronic pain should specify eligibility criteria in line with recognized definitions: the presence of daily, clinically meaningful pain intensity and functional interference for at least 3 months.10,26,131 Given the relevance of neuropathic pain in this population, the use of well-validated screening tools of neuropathy signs and symptoms is important.16,33,129
This review identified a large number of psychosocial factors. As evidence on specific psychosocial factors develops in this area, it may be useful for a future review to use a more targeted approach to synthesize data on a smaller number of prespecified variables. We focused on bivariate analyses and dichotomized multiple between-groups analyses to facilitate comparison across studies and minimise pairwise comparisons. However, this may have limited an in-depth understanding of psychosocial factors from multivariate models and more subtle subgroup analyses. Future research examining the association between psychosocial factors and pain outcomes in HIV should consider controlling for such variables as age, sex/gender, race/ethnicity, socioeconomic status, HIV duration, current and nadir CD4+ count and current and peak viral load, current and past ART regimens, and other medical comorbidities (eg, hepatitis C, diabetes, and tuberculosis). Where multiple psychosocial variables are included, sufficient rationale for each variable should be provided and care should be taken to minimize overlap in assessment content between variables.
Despite these limitations, this is the first systematic review to specifically explore psychosocial variables associated with persistent pain in HIV. From this review, it is recommended that researchers (1) focus greater attention on protective psychological factors and social processes, such as stigma and processes to undermine stigma; (2) use higher-quality assessment tools; and (3) develop and test treatments to target key psychosocial factors to improve pain outcomes in HIV. Improving quality of life is a priority as people with HIV live longer. Adequate, whole-person pain management is vital to achieve this goal.
Conflict of interest statement
The authors have no conflict of interest to declare.
This research is an independent work supported by the National Institute for Health Research (NIHR Postdoctoral Fellowship, W. Scott, PDF-2015-08-059). L.M. McCracken is partly funded through the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health. Dr. Kemp reports grants from the European Commission (FP7 Neuropain #HEALTH F2-2013-602891) during the conduct of the study. Dr. Rice reports grants from Orion Pharma, other from Spinifex/Novartis, personal fees from Imperial College Consultants, outside the submitted work. In addition, Dr. Rice has a patent, Rice A.S.C., Vandevoorde S. and Lambert D.M Methods using N-(2-propenyl)hexadecanamide and related amides to relieve pain. WO 2005/079771 pending, and a patent, Okuse K. et al., Methods of treating pain by inhibition of vgf activity EP13702262.0/ WO2013 110945, pending.
Appendix A. Supplemental digital content
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BR-864: Tone Load - Changing the Pan Position of the Drum Sounds
1. Press [TONE LOAD].
2. Press CURSOR [>] to move the cursor to PAN, and press [ENTER].
3. Turn the TIME/VALUE dial to specify the drum kit whose panning you want to change, then press [ENTER].
(S15: Song Drum Kit 15)
4. Use [CURSOR] and the TIME/VALUE dial to specify the drum sound whose panning is being changed and the pan setting.
* When you press [RHYTHM PAD], causing the indicator to light/flash, you can then set the drum sounds by tapping REC TRACK [1/5][4/8], [V-TRACK], and [TAP].
* Pressing [ENTER] sets this to C00 (Center).
5. Press [TONE LOAD] (or press [EXIT] repeatedly) to return to the Play screen.


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Hello, and welcome to this week’s Ireland’s Own. It’s the horse race that stops a nation and this week Gerry Breen takes a look at the atmosphere and excitement of the Aintree Grand National.
Eileen Casey examines the life and career of Irish artist, Phoebe Anna Traquair while Margaret Smith profiles the Irish-born American religious sister, Sr. Ignatia Gavin, who became involved in the care of those suffering from alcoholism. Because of her work she became known as the alcoholic’s ‘Angel of Hope’.
In his Role of the Irish in WW2 series Con McGrath tells the story of Sir Edgar Ludlow-Hewitt, the Cork-born commander of RAF Bomber Command from 1937-40. John Corbett takes a look back at practices and events associated with the month of April in the Irish countryside and for keen gardeners there are tips and hints from our gardening expert, Aileen Atcheson.
In an interesting piece on First Felines of the United States, Pauline Murphy takes a look at some of the cats who took up residence at 1600 Pennsylvania Avenue. Scott Joplin, The King of Ragtime, is profiled by Jim Rees.
Mary Sherin continues her series marking the 90th anniversary of Ireland’s broadcasting service, whie this week’s original short story is Reactive Age Group by Breda Nathan.
Martyn Baguley tells the story of Sir Hans Sloane, the ‘Father of the British Museum’. Born in Co. Down in 1660, Sir Hans Sloane was a major figure of the 18th century who had a lifelong interest in natural history and it was his collection that was the foundation of the British Museum. Ita Marguet offers an insight into the life of the noble Irish-Spaniard, Don Leopoldo O’Donnell.
We have all this for you to enjoy alongside your weekly favourites. Enjoy the read, and I look forward to talking to you next week.
Seán Nolan, Editor, Ireland’s Own
Sing along with your favourite Irish songs – The Rising of the Moon And come tell me Sean O’Farrell, tell me why you hurry so, Hush a bhuachaill, hush and listen and his cheeks were all aglow, I bear orders from the captain, get you ready quick and soon, For the pikes must be together at the rising of the moon

domain: history


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Also known as fat-free milk, skim milk contains only trace amounts of fat. This low-calorie alternative to whole-fat milk varieties provides a nutrient-dense and healthy food option.
Making Skim Milk
Most types of dairy milk naturally contain higher levels of fat. Making skim milk involves a simple skimming process that removes excess cholesterol and saturated fats from the milk after it has been extracted from the cow.
Skim Milk Nutrition
Most of the sugars in skim milk are derived from lactose, therefore those who are lactose intolerant often choose a different milk option. Soy milk is a very popular choice.
Skim milk has a moderate amount of sugars per serving which accounts for the 12 grams of carbohydrates that it contains. This fat-free choice also contains 8 grams of protein per 1-cup serving.
Unlike whole milk, the skim choice has only 5 mg of cholesterol in every 8-oz serving. Skim milk has 50% of your daily recommended value of calcium and has plentiful amounts of B vitamins as well. Other nutrients found in skim milk include vitamin A, vitamin C, phosphorus and potassium. For those who looking to manage their weight, this fat-free choice serves as an ideal substitute in place of high-fat milks.

domain: food


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East Man drops total fire. Get on it
pretty good! the mixing is quite harsh thought. vocals need some tweaking and levels a tad messed. feels a bit amateur to me
Nah m8, it’s raw innit.
it is what it is. u can call it raw
So good! there isn’t an East Man release that I haven’t liked. That 2002 Grime/Sublow aesthetic still has mileage
edit: cover photo is so amazing too
Totally! He’s breathed some fresh life into the sound I reckon. Everything he does is ace tbh. His Basic Rhythm stuff is top notch as well. He did some noisey experimentalish stuff under the name Imaginary Forces which is pretty cool too if yer into that sorta stuff. Hasn’t used that name for a while, but did a cracking little mixtape for Halcyon Veil which I recommend.

domain: artistic


Selfmadegod Records is proud to announce the re-release of Polish goregrind kings SQUASH BOWELS‘ rare first album, Tnyribal!
Tnyribal is no doubt one of the most brutal, and thus most important grindcore albums of the last century. Initially released in 2000 via infamous Czech record label Obscene Productions, this landmark release from SQUASH BOWELS now sees an official reintroduction to the world with an official re-release of the album via Polish metal label Selfmadegod Records. The new Selfmadegod version of the album is housed in a 6-panel digipak with completely new artwork and fully redesigned layout.
Tnyribal track listing:
1. Stranger Mind: Possessed – Amssend – Passage
2. Dark Corridors: Xabon – Refractive – Naxaru – Ytarb
3. Zema Inpa: Fear – Doldrums – Liberate Me! – Dizziness – Effluvium
4. Zonhori Nteve: Blood – Soulless – Radiate – Transmit
5. Bad Sector: Melzu Nepa – Sybba – Rezom – Dergi
6. Black Thing: The Shape – TMA – 3 – Error
“Hyper-produced, blasting grindcore from this incredible and outstanding Polish act. The drummer is one of the fastest and tightest ever heard… Brutal rapid tracks mixed with a cyber-noise soundtrack that could be the soundtrack of your worst nightmare. Definitely a classic in brutality!!!” – Giulio The Bastard [Cripple Bastards]


Norma Bondstrike Ammunition is specifically designed for hunters who require both extreme accuracy and dependable terminal performance from their centerfire rifles. Whether you’re hunting running moose in Sweden or baited hogs in Texas, Bondstrike ammunition offers consistent weight retention and penetration, ensuring that a well-placed shot delivers the knockdown power necessary for a quick and humane harvest, no matter the range.
Norma Bondstrike Ammunition is a cutting-edge hunting round that combines an aerodynamic polymer tip, a match-style boat tail, and proprietary bonding technology for exceptional accuracy and terminal performance at all distances. Available in multiple configurations, including popular calibers like the 6.5 Creedmoor, .308 Win, and .300 Win Mag, Bondstrike ensures both long-range precision and devastating impact. Whether you’re a seasoned hunter or new to the game, Bondstrike is a trusted choice for delivering reliability and performance in the field.
What makes Bondstrike unique in terms of accuracy?
Bondstrike combines an aerodynamic polymer tip and a match-style boat tail for unparalleled accuracy.
What Bullet does Norma Bondstrike Use?
Norma Bondstrike uses a bullet that features an aerodynamic polymer tip and a match-style boat tail for extreme accuracy. The bullet also incorporates unique bonding technology for high weight retention and penetration. This combination of features is designed to offer superior terminal performance at all distances
Is this ammo suitable for long-range hunting?
Absolutely, Bondstrike’s design ensures both speed and extreme precision at long ranges.
What calibers is Bondstrike available in?
It is available in several popular hunting calibers including 6.5 Creedmoor, .308 Win 180gr, .30-06 180gr, .300 Win Mag, .300 WSM 180gr, and .300 RUM 180gr.
How does Bondstrike ensure weight retention and penetration?
It features power bonding technology that keeps the bullet intact, ensuring high residual weight and penetration.


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Harrisburg, PA - Brian Broderick pitched six strong innings and Sandy Leon had a pair of hits, but the Harrisburg Senators fell to the Altoona Curve 3-1 in the series opener at Metro Bank Park.
Neither team recorded a base hit until the fifth inning, when Jarek Cunningham doubled to lead off the frame. With two outs and runners on the corners, Broderick's mound opponent Casey Sadler came through with a two-run single to break the scoreless tie.
In the bottom of the fifth with two outs and Justin Bloxom on first, Leon picked up the first Senators hit with a line drive single into center field. The ball skipped past Mel Rojas, Jr. and allowed Bloxom to come around and score the lone Senators run.
Broderick pitched six innings and allowed just three hits, but suffered the loss. Sadler tossed eight innings, surrendering only the unearned run to Harrisburg. Tim Alderson pitched the ninth and recorded his second save.
Tomorrow, the Senators continue their three-game series with the Altoona Curve at Metro Bank Park. Game time is 7:00 p.m. and the game can be heard on 1460am The Ticket, on the Internet through the Senators website, and it's available through iHeart Radio beginning with the pregame show at 6:45 p.m.

domain: news


Inaccurate flow control, leakage, and even safety hazards—these are just a few of the valve issues that precision components prevent. When designing custom valve systems and flow control products, your ability to accurately manufacture parts with extremely tight tolerances makes your products safer, more reliable, and more cost-effective. Precision components manufacturers ensure that valve systems not only work, but work well and safely.
In our previous article, we explored the benefits you reap from building a relationship with a contract manufacturer for valves and flow control components. Contract manufacturers help your business produce reliable parts at scale if you lack your own in-house capabilities. Now we will delve into one specific benefit of choosing a precision contract manufacturer—consistently producing precision components for valve systems.
What are precision components in valve systems?
Valve systems across a wide range of industries depend on precision to deliver consistent, reliable performance. Components built to extremely tight tolerances ensure efficiency in the flow of liquids, gases, and slurries. These precision components include:
- Valve seats, such as disks or plugs, that form tight seals for closed valves
- Seals and gaskets that prevent leakage around valve components
- Valve stems and actuators that control the opening and closing of a valve
- Flow control orifices that precisely regulate flow rate
- Spindles and guides that prevent valve misalignment
- Spring mechanisms in pressure relief valves
- Valve bodies and bonnets
Why Precision Parts Manufacturers Matter
These precision components have extremely small and complex geometries and depend on extremely tight tolerances. If these small, complex features cannot be consistently and accurately machined, the parts will not function efficiently. As a result, the valves as a whole will provide inconsistent performance. Failure to regulate fluid flow or pressure can even prove catastrophic for piping systems. Valve components that are poorly manufactured are more difficult and expensive to maintain, and they also have shorter lifespans.
For these reasons, when you need contract manufacturing services, you need to make sure you choose a precision parts manufacturer.
The Benefits of Precision Components Manufacturing
A contract precision parts manufacturer provides cost-effective assurance that your valve products meet high standards for performance and safety. The key advantages you reap by hiring a precision contract manufacturer include:
- Expertise in precision machining components for specific use cases or industries
- Cost-effective access to state-of-the-art machining equipment and techniques
- Rigorous quality control processes including inspection and testing
- Flexibility and scalability in production volume
- Shortened time-to-market for your valve products
- Mitigation of production risks, such as equipment maintenance, skilled labor availability, and regulatory compliance
Ultimately, contracting out precision parts manufacturing is a cost-effective, low-risk way to produce safe, reliable valve components.
How to Choose a Precision Component Manufacturer
In our previous article, we shared general tips for finding and building a relationship with a contract manufacturer. Here, we will focus on how to evaluate a contract manufacturer’s precision parts manufacturing capabilities.
- Evaluate the contract manufacturer’s experience in your industry. Look for a track record of successfully producing precision components and working in your industry’s regulatory landscape.
- Assess their precision parts manufacturing capabilities. Pay close attention to the technologies they use for precision machining, such as:
- CNC machining centers
- CNC lathes
- Precision surface grinders, cylindrical grinders, and centerless grinders
- EDM (Electrical Discharge Machining) processes
- Coordinate Measuring Machines (CMMs)
- Micro machining centers for extremely small-scale precision machining
- Ultrasonic machining systems
- Optical comparators and surface profilometers for quality assurance
- Tool presetters for consistent achievement of tight tolerances
- Inquire about the types of materials your prospective precision contract manufacturer can work with.
- Pay close attention to the manufacturer’s quality management system. ISO certifications are a reliable sign of their ability to consistently produce quality parts.
- Ask about their methods and equipment for quality control. Precision components manufacturers must have rigorous techniques in place to measure and verify dimensional accuracy, surface finish, and other critical features.
- Investigate where the manufacturer sources their materials. High-quality materials are the foundation of reliable precision components.
- Evaluate the capabilities of their in-house engineering experts, including their knowledge of DFMA (Design for Manufacturability and Assembly) principles
Discover Tailored Solutions for Precision Contract Manufacturing
For over three generations, Dante Valve has excelled in manufacturing valves to the highest specifications. We hold ourselves to manufacturing excellence as well as integrity and responsibility to our customers. We provide precision parts manufacturing for custom valve designs. Explore our comprehensive manufacturing capabilities and our specialties in custom designs.
To hire us as your precision parts manufacturer, request a quote from us today.


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Tamara Hensick Pewter Heart Sculpture: "Friends / Through Thick & Thin"
Tamara Hensick's clever wordplay and symbolism blend magically with pewter sculpture to create inspirational themes for the special times in our lives. These are objects cheer up, console, amuse and inspire - from recognizing rites of passage to a simple "thank you" - all with a refreshing twist of whimsy.
FRIENDS THROUGH THICK & THIN… What a lovely celebration of true friendship! Heart is approx 2.75" wide. Tamara Hensick's designs are sculpted in soft jeweler's wax and then hand cast in pewter, using the centrifigul casting technique, by a family-owned business in California. Due to the nature of hand-cast pewter sculpture, you may see slight color variations in the product photography.


TEHRAN (defapress) – Israeli Consul General to New York Dani Dayan was left shocked as at least a hundred students staged a walkout during a talk he was about to give at the US’ Harvard Law School.
TEHRAN (defapress) – The director of the Russian Foreign Intelligence Service made room for doubt about the death of Abu Bakr al-Baghdadi, the former ringleader of Daesh.
TEHRAN (defapress)- US Secretary of Defense Mark Esper said South Korea “is a wealthy country” and should pay more for the cost of stationing some 28,500 US troops in the East Asian nation.
TEHRAN (defapress) – US President Donald Trump launched a Twitter attack on a former ambassador to Ukraine on Friday while she was testifying to an impeachment hearing in Congress, an extraordinary moment that Democrats said amounted to witness intimidation.
TEHRAN (defapress) – Saudi Arabia is intensifying informal talks with the Houthi Ansarullah movement to reach a ceasefire agreement in Yemen, sources familiar with the discussions said.
TEHRAN (defapress) – The UN Fourth Committee approved eight resolutions on Friday in condemnation of Israeli regime’s crimes in Palestine.
TEHRAN (defapress) – Former Bolivian president Evo Morales has warned government officials not to "stain themselves with the blood of the people," after his supporters took to the streets in support of the embattled former leader.
TEHRAN (defapress) – A US appeals court said on Wednesday it would not revisit an October decision backing a US House of Representatives subpoena issued to President Donald Trump's accounting firm for his financial records.
TEHRAN (defapress) – US firearms makers will be able to more easily export guns, including assault rifles and ammunition, as early as mid-December under rules set to be finalized by the Trump administration, people briefed on the matter said on Tuesday.
TEHRAN (defapress) – The US government is renewing the state of emergency it first imposed on Iran 40 years ago, President Donald Trump announced in a White House proclamation.


Carly, with a history of 40 years, mainly produces and sells heavy-duty mining machines with complete product models. We are committed to building crushing, industrial grinding, ore processing and green building materials, and provides intelligent solutions and mature supporting products.Inquiry Online
Undecided? Fill in your needs immediately and our engineer will send you professional solution.
Introduction. Quartz sand or sandstone from any deposit contains impurities apart from the main component. . material, apart from other impurities, contains total iron carriers Fe2O3 which are magne . from quartz raw mineral (by high gradient magnetic separators). Get Price High Quality Wet Type Permanent Magnetic Separator
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Minerals Engineering, Vol. 4, Nos 7-11, pp. 825-837, 1991 0892-6875/91 $3.00 + 000 Printed in Great Britain 1991 Pergamon Press plc RECENT DEVELOPMENTS IN MAGNETIC SEPARATION OF FEEBLY MAGNETIC MINERALS H.-D. WASMUTH and K.-H. UNKELBACH KHD Humboldt Wedag AG, K61n, Germany ABSTRACT Within the last ten years many new concepts and developments have been achieved in the magnetic …
Magnetic Separation and Iron Ore Beneficiation Magnetic separation is an old technique for the concentration of iron ores and for the removal of tramp iron. Since 1849, a number of patents on magnetic separation have been issued in USA, and texts of some of the patents before 1910 describe a variety of magnetic separators for mineral processing.
Iron ore wet magnetic separation machine supplier in China Permanent cylinder type magnetic separator: This machine is widely used in mineral processing, coal washing and chemical sectors, for wet strong magnetic mineral separation size 6-0 mm, and the mineral is devided into magnetic material and non-magnetic material of two kinds.
The Handling Materials and Description of Magnetic Separator: Magnetic separators are available in cyclic design with processing vessel diameters smaller than 3mm. Wet Magnetic Separator is one kind of efficient equipment for processing fine, feebly magnetic minerals, such as hematite, limonite, wolfram, ilmenite, and tantalum-niobium, etc.
In the early 1970s, with the introduction of commercial-scale, high-intensity magnetic separators for wire rods, the first sports magnetic separator was installed and put into use in 1976 by British Chinese Clay Company, for improving the quality of feed clay in the ceramic industry.
CT Series Wet Magnetic Separators consist of separator drum, magnetic system, separator tank, transmission. ... Dry Magnetic Separator; Flat Belt Type Magnetic Separator; ... Beneficiation Equipment ... Get Price. beneficiation equipment wet magnetic separator. ... Wet high density magnetic separator is the magnetic separation equipment for ...
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2019521 the magnetic element is the most important feature of a wet drum separator although there are several variables influencing magnetic separation the magnetic field configuration is indisputably the foremost variable for high levels of magnetite recovery eriez designs the appropriate magnetic circuit for any given application using finite.
Magnetic separation machine is mainly used in wet separating of the fine minerals with strong ferromagnetism. The wet-type drum permanent magnetic separator is mainly suitable for wet separating of the following ores with the sizes less than 3mm, which are magnetite, magnetic pyrite, baking ore, and limonite and so on. Get price
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The latest developments in material science and magnet technology have allowed high-intensity and high- gradient industrial magnetic separators with field strengths as high as 6 tesla (60,000 gauss) to be developed. Development of permanent rare-earth magnets and superconducting magnets has opened new markets for magnetic separators.
Wet High Intensity Magnetic Separators (WHIMS) | WPE ... Description. The Eriez GZRINM Wet High Intensity Magnetic Separator is a high gradient vertical ring magnetic separator. A DC current is applied to the coil to form a magnetic field in the separating compartment containing the matrix is a select type of magnetic … Read More
Magnetic separator - Ore Dressing Machine- China Large-Scale Cement... Magnetic Separators are designed to recover ferromagnetic materials.Cement production line In this step the main machinery we use is cement ball mill which is also called Cement mill for short.
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2012-8-30 · Manufacturer and Exporter of Magnetic Separators, Overband Magnetic Separators, Liquid Line Magnetic Separators, Overband Permanent Magnetic Separators, Wet High Intensity Magnetic Separators and Eddy Current Separators offered by Star Trace Private Ltd, …
In this chapter of magnetic techniques for mineral processing, theoretical principle of magnetic separations and three types of magnetic separators, i.e., low-intensity, high-intensity and high-gradient magnetic separators, and their technological innovations and operational practices are reviewed.
seeks copper mill separator . Mill-Max Mfg. Corp. Frequently Asked Questions. FAQ's Sales Customer which will be harder than the copper alloy used in Mill-Max’s Spring Pin The Mill-Max website offers five separate ways to conduct a
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