Myocardial infarction after acute ischaemic stroke: incidence, mortality, and risk factors

Objectives: To determine the risk factor profiles associated with post-acute ischaemic stroke (AIS) myocardial infarction (MI) over long-term follow-up. Methods: This observational study includes prospectively identified AIS patients (n=9840) admitted to a UK regional centre between January 2003-December 2016 (median follow-up: 4.72 years). Predictors of post-stroke MI during follow up were examined using logistic and Cox regression models for in-hospital and post-discharge events, respectively. MI incidence was determined using a competing risk non-parametric estimator. The influence of post-stroke MI on mortality was examined using Cox regressions. Results: Mean age (SD) of study participants was 77.3(12.2) years (48% males). Factors associated with in-hospital MI (OR(95%CI)) were increasing blood glucose (1.80(1.17-2.77) per 10mmol/L), total leukocyte count (1.25(1.01-1.54) per 10x109/L), and CRP (1.05(1.02-1.08) per 10mg/L increase). Age (HR(95%CI) =1.03(1.01-1.06)), coronary heart disease (1.59(1.01-2.50)), chronic kidney disease (2.58(1.44-4.63)), and cancers (1.76(1.08-2.89)) were associated with incident MI between discharge and one year follow-up. Age ((1.02(1.00-1.03)), diabetes (1.96(1.38-2.65)), congestive heart failure (2.07(1.44-2.99), coronary heart disease (1.81(1.31-2.50)), hypertension (1.86(1.24-2.79)), and peripheral vascular disease (2.25(1.40-3.63)) were associated with incident MI between 1-5 years after discharge. Diabetes (2.01(1.09-3.72)), hypertension (3.69(1.44-9.45)), and peripheral vascular disease (2.46(1.02-5.98)) were associated with incident MI between 5-10 years after discharge. Cumulative MI incidence over 10 years was 5.4%. MI during all follow-up periods (discharge-1 year, 1-5 years, 5-10 years) was associated with increased risk of death (respective HR(95%CI)=3.26(2.51-4.15), 1.96(1.58-2.42) and 1.92(1.26-2.93)). Conclusions: In conclusion, prognosis is poor in post-stroke MI. We highlight a range of potential areas to focus preventative efforts

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic

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An exploratory evaluation of a community interactive training programme for parents of children aged birth to five

Background: Conduct problems (CPs), a persistent pattern of challenging, oppositional, defiant or aggressive behaviour are a significant concern to educators, families and other professionals. CPs in preschool children are related to poorer educational and social outcomes in addition to a range of behavioural and emotional difficulties. Although there is evidence for hereditary and temperamental influences, parental factors are widely considered to be significant in the development of CPs. Parents experiencing psychological or social distress are considered to be at risk for challenging behaviour in their children. Psychologists and other theorists have suggested several possible reasons for this association. Firstly, it is possible that parents in distress have difficulty managing stress and as a result use harsh, inconsistent or coercive approaches to parenting. Secondly, parents with children who have CPs may be low in parental self efficacy, a consistent belief in their capacity to parent, which leads them to parent ineffectively and inconsistently. A third possibility is that parents in distress struggle to form stable attachments with their children which can lead to later behavioural difficulties. Finally, it is possible that parent’s distress is influenced by external contextual factors which also influence children such as family or social conflict. Studies suggest that training programmes for the parents of preschool children are effective in reducing child behaviour problems. Training approaches are influenced by a combination of psychological theories including behaviourist, social-cognitive, attachment and ecosystemic approaches. There have been many quantitative evaluations supporting the use of parent training programmes (PTPs). However, there has been limited inquiry into the process of PTPs from the perspective of those who attend them. Aims: The first part of this study was designed to evaluate vulnerability factors related to conduct problems; parental self efficacy, stress and child behaviour problems over the course of a community parent training programme designed to help participants to understand and manage the behaviour of young children. The overall research aim was to evaluate the outcomes and process, using different methodologies to address several questions. A realist methodology was applied to evaluating: 1. was there an association between parental stress, parental self efficacy and child behaviour problems at the start of the programme consistent with the established theory? 2. Did the parents attending the course experience higher than expected levels of stress and child behaviour problems? 3. Did quantitative and qualitative data indicate that these vulnerability factors changed over the duration of the course? Finally, an interpretivist methodology was used to explore how parents of young children evaluated as at risk of challenging behaviour described the experience of learning in the programme. Methods: The study utilised a pragmatic approach to evaluation with mixed methods and differing methodologies. At the start of the programme, a cohort of 38 parents agreed to participate in the study prior to the programme and completed self report measures related to parental stress and parental self efficacy. Parents with concerns about the behaviour of a child aged over three also completed a questionnaire relating to child behaviour problems. Of the original cohort, 27 completed self report measures at the end of the programme. 17 parents completed the same measures at a follow up meeting at the Children’s Centre, five to six weeks after the programme was completed. At this meeting 16 parents were interviewed to discuss their experience of the programme and any subsequent changes which had occurred. Results The results of the first part of the evaluation suggested a significant relationship between parental self-efficacy and stress and between stress and child behaviour problems. However, there was no statistical association between self-efficacy and child behaviour problems, as expected. This tentatively indicates that parental self-efficacy is less important in the development of child behaviour problems than has been previously suggested. The analysis of stress data at the start of the programme indicated that the frequency of parents reporting moderate to extremely severe stress was 4.42 times that which would be expected in a typical British cohort. At the start of the programme, frequency of child behaviour problems in the cohort were 5.9 times higher with conduct problems being 9 times what would be expected based on British norms. This suggests that the programme is being accessed by parents whose children are evidencing behaviour problems and, in particular, conduct problems. However, methodological issues are likely to have led to a slight overestimate of relative prevalence of child CPs in the cohort. Results indicated that parents reported significantly increased self efficacy, significantly reduced stress and child behaviour problems, including conduct problems, between the start and end of the programme. Thematic analysis and subsequent content analysis of outcome themes from interviews suggested that the majority of parents interviewed identified changes in parenting behaviour, knowledge, confidence, reduced stress and improved child behaviour as outcomes from the programme. However, changes in the quantitative data were not observed as frequently, reliably or to the same extent in the interview subgroup as they were in the main cohort, suggesting a sampling bias or a discrepancy in findings between methods. The self report data and interviews for all interviewees were then reviewed and interviews with six parents evaluated as having moderate to high stress, social or psychological difficulties and possible child behaviour problems were sampled. These were then re-analysed using a rigorous inductive approach to Thematic Analysis to identify emergent themes relating to the experience of participating and learning through the programme. Six themes emerged from analysis including; Understanding Difficulties, Identifying and Connecting, New Knowledge, Stopping and Thinking, Approach and Interaction and Reconstructing. The Understanding Difficulties theme described the different ways in which parents understood of their difficulties relating to themselves, their children and others which motivated them to attend the programme. The Identifying and Connecting theme described the importance to parents of personal identification with several aspects of the programme in terms of “being understood” in addition to identifying connections with established support, learning objectives and personal development goals. New Knowledge was categorised into three sub-themes of theoretical, practical and contextual. Contextual knowledge was constructed as understanding the experience of other parents, for example, identifying that other parents had similar difficulties. Theoretical knowledge about child behaviour and development encouraged parents to “stop and think” about the reasons for their children’s behaviour. Practical knowledge was constructed as parenting strategies which, when used, helped parents to feel more confident in themselves, more relaxed and more in control. The Stopping and Thinking theme described parents withholding action and considering the motivations for their children’s behaviour or the best approach to interacting with them. Approach and Interaction described changes to the way parents interacted with their children. The parents in question described changed or reconstructed understandings of their children, themselves and their difficulties as a result of participating in the programme. The theoretical implications of analysing the learning experience are that it highlights the importance of personal identification with the course objectives and experience.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Optimism and English school children : reliability, validity and use of the Children's Attributional Style Questionnaire (CASQ) and the Youth Life Orientation Test (YLOT)

This study explores the use of two tests of optimism: the Youth Life Orientation Test (YLOT) and the Children’s Attributional Style Questionnaire (CASQ) in six English primary schools with children aged between 9 years and 12 years. The study grew out of some problems I was confronted with as part of my professional practice regarding the outcomes for children in a school that was failing to meet Government Targets in attainment. In the study I worked with the staff and 9 – 11 year old children in six primary schools in rural, town, suburban and inner-city contexts. The total number of children was 305. The children were tested using the CASQ and YLOT and a range of other measures. Cronbach alpha internal consistency coefficients (coefficient alpha) and test-retest coefficients for the subscales and overall scale of the CASQ and YLOT were calculated. The validity of each measure was explored using evidence from: test content; internal structure; relations to other variables; and from the consequences of testing. Lastly the use of the YLOT as a proxy and nature of any associations between the measures used was explored looking at individual; school and community level data. The study found that the YLOT has good psychometric properties and could be used as a basis for further work both professionally and for research. The Cronbach alpha reliability coefficient for the whole scale was 0.81. The psychometric properties of the CASQ were poor in that the subscales had very low reliability coefficients and the aggregated total scale reliability coefficient was still too low at 0.53 to be able to recommend the use of the CASQ. Before the CASQ could be used there would need to be extensive work to increase its reliability and validity through lengthening the test or changing the format of the questions to reduce their specificity. The use of the YLOT as a proxy indicator of mental health and associations with school and community level data were discussed. The YLOT could provide an indication of well being particularly in relation to childhood depression. The community level data were not sensitive enough to discern hypothesised associations between communities and the children attending the schools sited in the communities.EThOS - Electronic Theses Online ServiceGBUnited Kingdo