A Q-methodology study of patients' subjective experiences of TIA

Background. An expanding body of research has focused on a range of consequences of TIA. However, no work has been conducted on the patient’s subjective experience of TIA. Aim. To capture patients’ first-hand experiences of TIA. Method. Using Q-methodology which employs both qualitative and quantitative approaches, 39 statements relating to the clinical, physical, affective, and psychological impact of TIA were distilled from the literature and from patient narratives. Consistent with conventional Q-methodology, a purposive sample of twentythree post-TIA patients sorted these statements into a normally-distributed 39-cell grid, according to the extent to which each represented their experience of TIA. Results. Casewise factoranalysis was conducted on the sorted statements. Eight factors emerged which were labelled: lack of knowledge/awareness of TIA; life impact; anxiety; interpersonal impact; depression; physical consequences; cognitive avoidance/denial; constructive optimism. Conclusions. Five of the eight factors confirmed existing research on the impact of TIA, but three new issues emerged: deep-seated anxiety, denial and constructive optimism. The emerging perspectives highlight areas to target in the management of TIA and could inform health education messages, patient information, individualised caremanagement, and enhancement of coping strategies. With development, the findings could be used as a basis for psychometric risk assessment of TIA patients

An assessment of small vessel disease in human post-mortem tissue through radiology and histology

Sporadic human cerebral small vessel disease (SVD) is a significant problem in our aging population. It is the most common cause of haemorrhagic stroke, causes one quarter of all ischaemic strokes, causes vascular dementia and synergistically worsens other dementias. It also causes a range of other psychological and physical problems and is increasingly common with increased age. SVD is well characterised on neuroimaging, with lesions throughout the brain, and particularly in the white matter. The cause(s) and pathophysiological mechanisms underlying the development of SVD, however, remain poorly understood with poor correlations between the abnormalities seen at the cellular level, on neuroimaging, and clinically. There are many theories as to the cause of SVD. However, observational studies and experimental evidence point towards an abnormality in the small vasculature of the brain initiating a cascade of events leading to a variety of vascular and brain parenchymal lesions. What these abnormalities are, and how exactly they result in the pathology seen, is unknown. Different structural components of the vessel wall and parenchymal brain cells appear to be involved, as well as functional abnormalities such as abnormal vascular reactivity. Risk factors also play a role, hypertension being the most significant, but how these interact with the normal vasculature is not fully understood. To provide an overview of our current understanding of SVD in human tissue I first completed a systematic review of the literature comparing the appearances of SVD on post-mortem imaging and histology. This revealed the inconsistency in methods and reporting in these studies and the lack of histopathology agreement on SVD terminology and definitions. I then studied the histological appearances of the lesions identified by post-mortem imaging to provide a reliable precise histological-imaging correlation. I developed a new protocol for ex vivo 7 Tesla magnetic resonance imaging (7T MRI) scanning of human brain tissue on post-mortem material and developed a grading system to assess SVD burden on MRI and histology with histological definitions, to try to encourage standardised, comprehensive and transparent reporting so that results in small studies can be more easily compared. I studied human post-mortem brain tissue to better investigate the disease in the appropriate context. In our cases from individuals with haemorrhagic SVD, normal aging and young controls, the most severe SVD pathology on ex vivo imaging and histology was, as expected, in the haemorrhagic SVD group. The normal aging group also had significant levels of pathology, perhaps representing the increasing burden of disease present but not necessarily detected clinically with increased age. It is possible the underlying pathophysiology in this group might develop by different mechanisms compared to the haemorrhagic group. Directly comparing the imaging and histological lesions confirmed the histological appearances of some lesions on imaging such as enlarged perivascular spaces, lacunes, microinfarcts and microbleeds. However, making direct comparisons is complex. Some lesions, such as small vessel fibrinoid necrosis, presumed to be below the resolution for detection on 7T MRI, were identified on both histology and imaging. Some features seen on histology in association with recognised SVD lesions, such as perivascular inflammation in an area of white matter rarefaction, were present in a variety of different histological contexts with no apparent correlation on imaging. And some lesions, such as white matter rarefaction around enlarged perivascular spaces, were present often on both imaging and histology, but their significance and contribution to SVD is unknown. To try to further understand the mechanisms underlying SVD and the lesions seen on imaging I undertook biochemical studies of protein expression in the deep white matter of the haemorrhagic SVD group, young controls and an Alzheimer’s disease group, who also have white matter pathology on neuroimaging. Increased fibrinogen levels suggested vascular leakage in both disease groups. However, haemorrhagic SVD had more severe white matter hypoxic changes and increased vasoconstrictor levels while in Alzheimer’s disease there was increased amyloid 42 and levels of a pericyte marker, possibly reflecting different pathophysiological mechanisms causing the similar appearing radiological changes. When assessing radiologically defined white matter hyperintensities (WMH) I found hypoxic-induced changes throughout brains with WMH, including in normal appearing areas of white matter. This suggests these brains have abnormalities in areas that appear radiologically normal, as found in in vivo imaging studies. To conclude, this work has confirmed the importance of reaching a consensus in histopathological reporting, terminology and definitions which is a basic requirement before we can better understand the pathophysiology of SVD. This has led to the formation of definitions and a practical grading system that could be used as a basis upon which to build a future agreement. The complexity of the histological lesions underlying radiological SVD changes was apparent, and the frequency with which some other potentially important histological changes were identified suggests these have not, to date, been fully appreciated. Investigating the underlying mechanisms of white matter hyperintensities showed vascular leakage was a shared abnormality in two different diseases with white matter changes on imaging, suggesting it may be a common factor upon which variable pathways converge. Future work is needed to further understand the importance of these less well characterised histological features. Investigating the role of vascular leakage and exploring drugs that maintain or improve vascular integrity could be a potential route for helping to treat SVD. Studies into underlying transcriptomic abnormalities around vascular leakage in human tissue may be informative

Functional and emotional outcomes after transient ischaemic attack: A 12-month prospective controlled cohort study

Background: Symptoms of transient ischemic attack are believed to fully resolve within 24 h of onset. Emerging evidence suggests that there may be prolonged functional and psychological impact, although studies have not been able to robustly identify whether these are the effect of transient ischemic attack or changes usually associated with ageing. We describe trajectories of disability and risk of anxiety and depression among patients seen at transient ischemic attack clinics over 12 months, compared to healthy controls. Methods: Thirty transient ischemic attack clinics across England participated. A total of 1320 participants were included: 373 diagnosed with transient ischemic attack, 186 with minor stroke, 310 with “possible transient ischemic attack,” 213 with another condition mimicking a transient ischemic attack and 238 controls recruited from primary care providers. Participants completed questionnaires after diagnosis then after 3, 6 and 12 months. Outcomes were the Nottingham Extended Activities of Daily Living Scale and the Hospital Anxiety and Depression Scale. Mixed effects regression was used to estimate group differences and trajectories. Results: At baseline, confirmed transient ischemic attack patients scored 1.31 HADS-Anxiety points (s.e. = 0.28; p < 0.001), 0.51 HADS-Depression points (s.e. = 0.26; p = 0.056), and 2.6 NEADL points (s.e. = 1.1; p = 0.020) worse than controls. At 12 months, the deficits were 0.78 (s.e. = 0.30; p = 0.008), 0.97 (s.e. = 0.23; p < 0.001), and 0.96 (s.e. = 0.92; p = 0.294) respectively. Differences among patients diagnosed with minor stroke were like or worse than transient ischemic attack patients. Conclusions: Transient ischemic attack clinic patients may have functional and emotional impairments compared to the general population irrespective of final diagnosis. The presence of emotional symptoms or risk of developing anxiety or depression did not always fully recover and may increase

Early Contrast Enhancement: a novel Magnetic Resonance Imaging biomarker of pleural malignancy

Introduction: Pleural Malignancy (PM) is often occult on subjective radiological assessment. We sought to define a novel, semi-objective Magnetic Resonance Imaging (MRI) biomarker of PM, targeted to increased tumour microvessel density (MVD) and applicable to minimal pleural thickening. Materials and methods: 60 consecutive patients with suspected PM underwent contrast-enhanced 3-T MRI then pleural biopsy. In 58/60, parietal pleura signal intensity (SI) was measured in multiple regions of interest (ROI) at multiple time-points, generating ROI SI/time curves and Mean SI gradient (MSIG: SI increment/time). The diagnostic performance of Early Contrast Enhancement (ECE; which was defined as a SI peak in at least one ROI at or before 4.5 min) was compared with subjective MRI and Computed Tomography (CT) morphology results. MSIG was correlated against tumour MVD (based on Factor VIII immunostain) in 31 patients with Mesothelioma. Results: 71% (41/58) patients had PM. Pleural thickening was &#60;10 mm in 49/58 (84%). ECE sensitivity was 83% (95% CI 61–94%), specificity 83% (95% CI 68–91%), positive predictive value 68% (95% CI 47–84%), negative predictive value 92% (78–97%). ECE performance was similar or superior to subjective CT and MRI. MSIG correlated with MVD (r = 0.4258, p = .02). Discussion: ECE is a semi-objective, perfusion-based biomarker of PM, measurable in minimal pleural thickening. Further studies are warranted

Remaking critical care:Place, body work and the materialities of care in the COVID intensive care unit

© 2023 The Authors. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for the Sociology of Health & Illness. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY), https://creativecommons.org/licenses/by/4.0/In this article, we take forward sociological ways of knowing care-in-practice, in particular work in critical care. To do so, we analyse the experiences of staff working in critical care during the first wave of the COVID-19 pandemic in the UK. This moment of exception throws into sharp relief the ways in which work and place were reconfigured during conditions of pandemic surge, and shows how critical care depends at all times on the co-constitution of place, practices and relations. Our analysis draws on sociological and anthropological work on the material culture of health care and its sensory instantiations. Pursuing this through a study of the experiences of 40 staff across four intensive care units (ICUs) in 2020, we provide an empirical and theoretical elaboration of how place, body work and care are mutually co-constitutive. We argue that the ICU does not exist independently of the constant embodied work of care and place-making which iteratively constitute critical care as a total system of relations.Peer reviewe

Critical care work during COVID-19: a qualitative study of staff experiences in the UK

Objective: To understand National Health Service (NHS) staff experiences of working in critical care during the first wave of the COVID-19 pandemic in the UK. Design: Qualitative study using semistructured telephone interviews and rapid analysis, interpreted using Baehr’s sociological lens of ‘communities of fate’. Participants: Forty NHS staff working in critical care, including 21 nurses, 10 doctors and advanced critical care practitioners, 4 allied health professionals, 3 operating department practitioners and 2 ward clerks. Participants were interviewed between August and October 2020; we purposefully sought the experiences of trained and experienced critical care staff and those who were redeployed. Setting: Four hospitals in the UK. Results: COVID-19 presented staff with a situation of extreme stress, duress and social emergency, leading to a shared set of experiences which we have characterised as a community of fate. This involved not only fear and dread of working in critical care, but also a collective sense of duty and vocation. Caring for patients and families involved changes to usual ways of working, revolving around: reorganisation of space and personnel, personal protective equipment, lack of evidence for treating COVID-19, inability for families to be physically present, and the trauma of witnessing extreme patient acuity and death on a large scale. The stress and isolation of working in critical care during COVID-19 was mitigated by strong teamwork, camaraderie, pride and fulfilment. Conclusion: COVID-19 has changed working practices in critical care and profoundly affected staff physically, mentally and emotionally. Attention needs to be paid to the social and organisational conditions in which individuals work, addressing both practical resourcing and the interpersonal dynamics of critical care provision.Peer reviewe

Biofilm and the role of the ica operon and aap in Staphylococcus epidermidis isolates causing neurosurgical meningitis.

Fifty-five Staphylococcus epidermidis isolates, classified as contaminants or causing device-related meningitis, from external ventricular drain (EVD) and non-EVD cerebrospinal fluid specimens were characterized. Thirty-three of 42 (78.6%) meningitis isolates were PCR-positive for ica and aap, known determinants of polysaccharide- and protein-mediated biofilm production, whereas five of 13 (38.5%) contaminants were ica- and aap-negative; 71.4% of meningitis isolates and 84.6% of contaminants produced biofilm. ica+aap+ meningitis isolates produced more biofilm than ica+aap- isolates (p 0.0020). ica+aap- isolates did not produce more biofilm than ica-aap+ isolates (p 0.4368). Apparently, ica and aap are associated with biofilm production in S. epidermidis device-related meningitis isolates

Barriers and system improvements for physical activity promotion after gestational diabetes: A qualitative exploration of the views of health care professionals.

Aim Physical activity is an important behaviour for managing the ten times increased risk of type 2 diabetes after gestational diabetes. Previous studies exploring physical activity promotion in healthcare focus on general practitioners but have not explored the gestational diabetes pathway. Therefore, this paper explores the barriers to and suggestions for, activity promotion along the gestational diabetes healthcare pathway. Methods The paper was written in accordance with the Standards for Reporting Qualitative Research. Patient and Public Involvement with women who had lived experiences of gestational diabetes informed purposeful sampling by identifying which healthcare professional roles should be targeted in participant recruitment. Participants were recruited through word-of-mouth, that is, email and connections with local healthcare service leads. Twelve participants took part in semi-structured one-to-one interviews, analysed using reflexive thematic analysis. Results Participants included a Public Health Midwife (n = 1), Diabetes Midwifes (n = 3), Diabetes Dietitian (n = 1), Diabetes Consultants (n = 2), Diabetes Specialist Nurse (n = 1), general practitioners (n = 2), Practice nurse (n = 1) and a Dietitian from the UK National Diabetes Prevention Program (n = 1). Six themes were generated: ‘management of gestational diabetes takes precedent’, ‘poor continuity of care’, ‘lack of capacity to promote PA’, ‘beliefs about the acceptability of PA promotion’, ‘resources to support conversations about PA’ and ‘adapting healthcare services for women post-gestational diabetes’. Conclusions During pregnancy messaging around physical activity is consistent, yet this is specific for managing gestational diabetes and is not followed through postnatally. Improvements in continuity of care are necessary, in addition to ensuring the availability and links with wider exercise and activity schemes