Resilience over recovery: A feasibility study on a self-taught resilience programme for paramedics

Research within the last 20 years has suggested that the prevalence of post-traumatic stress disorder (PTSD) is greater in paramedics than the general population. However, while treatment options are available, there are few approaches aiming to prevent or reduce the onset of PTSD by fostering resilience. Research suggests that resilience training may be promising in reducing rates of mental distress such as PTSD, and that digitally supported self-administered learning and therapies are effective in treating mental distress in a variety of population groups. In accordance with MRC guidelines on developing and evaluating an intervention, my thesis aimed to develop a self-taught resilience promoting intervention delivered by a computer platform, and implement this in the course of a feasibility study using paramedic students. The intervention is referred to as ‘self-taught digital resilience training’ (STDRT). An exploratory sequential design was used to develop a resilience fostering intervention; starting with a narrative literature review and qualitative online forum study. The narrative literature review highlighted resilience factors across a variety of populations, while the online forum study identified resilience factors specific to paramedics. There were 583 forum users across 87 forum threads in total. Together, these qualitative studies informed the development of the STDRT designed to teach resilience to paramedics. A feasibility study was then conducted to evaluate the STDRT in order to obtain information pertaining to the feasibility of a randomised controlled trial (RCT). This involved the administration of the STDRT to a sample of five paramedic students while their resilience and trauma symptomology were measured before and after 6 months. The outcome suggested that a larger scale RCT is viable. Additionally, preliminary results suggested that the STDRT may be effective in increasing resilience, but not reducing PTSD associated with chronic trauma. Therefore, a follow-up main RCT is feasible. The thesis contains further conclusions and original contributions to knowledge. I propose that resilience is not a fixed universal trait, but varies in its properties depending on individuals or groups. Additionally, I conclude that the chronic stressors that paramedics face across their work are associated with forms of PTSD more characterised by affective symptoms. Furthermore, the historical account of PTSD in paramedics, the narrative literature review and online forum study stand alone as original pieces of research, as well as contributing to the thesis overall

Stroke in India: a systematic review of the incidence, prevalence and case fatality

Background: The burden of stroke is increasing in India; stroke is now the fourth leading cause of death and the fifth leading cause of disability. Previous research suggests that the incidence of stroke in India ranges between 105 and 152/100,000 people per year. However, there is a paucity of available data and a lack of uniform methods across published studies. Aim: To identify high-quality prospective studies reporting the epidemiology of stroke in India. Summary of review: A search strategy was modified from the Cochrane Stroke Strategy and adapted for a range of bibliographic databases from January 1997 to August 2020. From 7,717 identified records, nine studies were selected for inclusion; three population-based registries, a further three population-based registries also using community-based ascertainment and three community-based door-to-door surveys. Studies represented the four cities of Mumbai, Trivandrum, Ludhiana, Kolkata, the state of Punjab and 12 villages of Baruipur in the state of West Bengal. The total population denominator was 22,479,509 and 11,654 (mean 1,294 SD 1,710) people were identified with incident stroke. Crude incidence of stroke ranged from 108 to 172/100,000 people per year, crude prevalence from 26 to 757/100,000 people per year and one-month case fatality rates from 18% to 42%. Conclusions: Further high-quality evidence is needed across India to guide stroke policy and inform the development and organisation of stroke services. Future researchers should consider the World Health Organisation STEPwise approach to Surveillance (STEPS) framework, including longitudinal data collection, the inclusion of census population data and a combination of hospital-registry and comprehensive community ascertainment strategies to ensure complete stroke identification

Availability and type of stroke services across India: a survey study

Background: Stroke unit care is known to improve patient outcomes but throughout India there are few dedicated stroke units. Aim: Our aim was to undertake a survey of stroke services, stroke workforce, and engagement in stroke research across India. Design and Methods: A hospital-based survey tool, informed by the World Stroke Organization (WSO) Roadmap to Delivering Quality Stroke Care and through discussions with local stakeholders was developed. The tool explored the availability of stroke units, diagnostic services, telemedicine, thrombolysis, thrombectomy, stroke workforce, education and training opportunities, services to support stroke survivors and their families, and organisational involvement in research. Data were analysed descriptively and grouped by hospital status (private or public). Setting: A convenience sample of health care professionals representing hospitals providing stroke care in India. Participants: Respondents comprised physicians, nurses, physiotherapists, researchers and speech and language therapists. Where more than one representative from a hospital completed the survey tool, the responses from the most senior member of staff were selected and included in the analysis. Results: Ninety-five hospitals participated (December 2017 and August 2019), resulting in data representing 15 states and 2 union territories. Fifty (53%) hospitals were private and 45 (47%) were public. Fifty-six (59%) hospitals reported treating a total of 20661 stroke patients over a 12-month period (median 300; Inter Quartile Range (IQR) 173 to 461). Only half of all hospitals had a dedicated stroke unit with a total of 596 stroke beds (median 9 beds per unit; IQR 6 to 11). Limitations: The hospitals in this study were mainly recruited via two national conferences and an International conference (International Conference on the Essentials of Stroke Care); the INSTRuCT network, the Indian Stroke Association and the Indian Academy of Neurology. There was a high completion rate from representatives in Kerala; 14 States and 5 Union Territories were not represented. . We did not seek to identify all hospitals caring for stroke patients and therefore do not know the number of non-identified/ non-responding sites and as such the findings may not be representative. . It was not possible to gain individual contact information for hospital and regional government administrators who may have access to stroke data. It is likely that there have major changes to stroke services as a result of the COVID-19 pandemic. Conclusion: Dedicated stroke units, stroke-specific staff, education, training and research opportunities, diagnostic services and specialist treatments were mostly available within private hospitals however there is a paucity of available stroke services data Further research is needed to map stroke service provision in a wider range of tertiary stroke care providers and stroke units. Future Work: Currently there is variability in the levels and types of stroke unit resources) available. The recent WSO and National Accreditation Board of Hospitals and Healthcare providers (NABH) joint Stroke Centre certification programme aims to create the standardised delivery of stroke care across India.. Future work will involve working with the WSO and NABH to facilitate the inclusion criteria of evidence-based Care Bundles, as part of NABH accreditation across India. Funding Details: “This research was funded by the National Institute for Health Care Research (NIHR) Global Health Research programme (16/137/16) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the UK government. Research will be published in the NIHR Global Health Research Journal.

Intraoperative mapping and preservation of executive functions in awake craniotomy: A systematic review

Awake craniotomy (AC) allows intraoperative brain mapping (ioBM) for maximum lesion resection while monitoring and preserving neurological function. Conventionally, language, visuospatial assessment, and motor functions are mapped, while the assessment of executive functions (EF) is uncommon. Impaired EF may lead to occupational, personal, and social limitations, thus, a compromised quality of life. A comprehensive literature search was conducted through Scopus, Medline, and Cochrane Library using a pre-defined search strategy. Articles were selected after duplicate removal, initial screening, and full-text assessment. The demographic details, ioBM techniques, intraoperative tasks, and their assessments, the extent of resection (EOR), post-op EF and neurocognitive status, and feasibility and potential adverse effects of the procedure were reviewed. The correlations of tumor locations with intraoperative EF deficits were also assessed. A total of 13 studies with intraoperative EF assessment of 351 patients were reviewed. Awake-asleep-awake protocol was most commonly used. Most studies performed ioBM using bipolar stimulation, with a frequency of 60 Hz, pulse durations ranging 1-2 ms, and intensity ranging 2-6 mA. Cognitive function was monitored with the Stroop task, spatial-2-back test, line-bisection test, trail-making-task, and digit-span tests. All studies reported similar or better EOR in patients with ioBM for EF. When comparing the neuropsychological outcomes of patients with ioBM of EF to those without it, all studies reported significantly better EF preservation in ioBM groups. Most authors reported EF mapping as a feasible tool to obtain satisfactory outcomes. Adverse effects included intraoperative seizures which were easily controlled. AC with ioBM of EF is a safe, effective, and feasible technique that allows satisfactory EOR and improved neurocognitive outcomes with minimal adverse effects