Management and outcomes of myocardial infarction in people with impaired kidney function in England

Abstract Background Acute myocardial infarction (AMI) causes significant mortality and morbidity in people with impaired kidney function. Previous observational research has demonstrated reduced use of invasive management strategies and inferior outcomes in this population. Studies from the USA have suggested that disparities in care have reduced over time. It is unclear whether these findings extend to Europe and the UK. Methods Linked data from four national healthcare datasets were used to investigate management and outcomes of AMI by estimated glomerular filtration rate (eGFR) category in England. Multivariable logistic and Cox regression models compared management strategies and outcomes by eGFR category among people with kidney impairment hospitalised for AMI between 2015–2017. Results In a cohort of 5 835 people, we found reduced odds of invasive management in people with eGFR < 60mls/min/1.73m2 compared with people with eGFR ≥ 60 when hospitalised for non-ST segment elevation MI (NSTEMI). The association between eGFR and odds of invasive management for ST-elevation MI (STEMI) varied depending on the availability of percutaneous coronary intervention. A graded association between mortality and eGFR category was demonstrated both in-hospital and after discharge for all people. Conclusions In England, patients with reduced eGFR are less likely to receive invasive management compared to those with preserved eGFR. Disparities in care may however be decreasing over time, with the least difference seen in patients with STEMI managed via the primary percutaneous coronary intervention pathway. Reduced eGFR continues to be associated with worse outcomes after AMI

Impact of chronic kidney disease on case ascertainment for hospitalised acute myocardial infarction: an English cohort study.

OBJECTIVES: Acute myocardial infarction (AMI) case ascertainment improves for the UK general population using linked health data sets. Because care pathways for people with chronic kidney disease (CKD) change based on disease severity, AMI case ascertainment for these people may differ compared with the general population. We aimed to determine the association between CKD severity and AMI case ascertainment in two secondary care data sets, and the agreement in estimated glomerular filtration rate (eGFR) between the same data sets. METHODS: We used a cohort study design. Primary care records for people with CKD or risk factors for CKD, identified using the National CKD Audit (2015-2017), were linked to the Myocardial Ischaemia National Audit Project (MINAP, 2007-2017) and Hospital Episode Statistics (HES, 2007-2017) secondary care registries. People with an AMI recorded in either MINAP, HES or both were included in the study cohort. CKD status was defined using eGFR, derived from the most recent serum creatinine value recorded in primary care. Moderate-severe CKD was defined as eGFR <60 mL/min/1.73 m2, and mild CKD or at risk of CKD was defined as eGFR ≥60 mL/min/1.73 m2 or eGFR missing. CKD stages were grouped as (1) At risk of CKD and Stages 1-2 (eGFR missing or ≥60 mL/min/1.73 m2), (2) Stage 3a (eGFR 45-59 mL/min/1.73 m2), (3) Stage 3b (eGFR 30-44 mL/min/1.73 m2) and (4) Stages 4-5 (eGFR <30 mL/min/1.73 m2). RESULTS: We identified 6748 AMIs: 23% were recorded in both MINAP and HES, 66% in HES only and 11% in MINAP only. Compared with people at risk of CKD or with mild CKD, AMIs in people with moderate-severe CKD were more likely to be recorded in both MINAP and HES (42% vs 11%, respectively), or MINAP only (22% vs 5%), and less likely to be recorded in HES only (36% vs 84%). People with AMIs recorded in HES only or MINAP only had increased odds of death during hospitalisation compared with those recorded in both (adjusted OR 1.61, 95% CI 1.32 to 1.96 and OR 1.60, 95% CI 1.26 to 2.04, respectively). Agreement between eGFR at AMI admission (MINAP) and in primary care was poor (kappa (K) 0.42, SE 0.012). CONCLUSIONS: AMI case ascertainment is incomplete in both MINAP and HES, and is associated with CKD severity

Postcoloniality without race? Racial exceptionalism and south-east European cultural studies

The black Dutch feminist Gloria Wekker, assembling past and present everyday expressions of racialized imagination which collectively undermine hegemonic beliefs that white Dutch society has no historic responsibility for racism, writes in her book White Innocence that ‘one can do postcolonial studies very well without ever critically addressing race’ (p. 175). Two and a half decades after the adaptation of postcolonial thought to explain aspects of cultural politics during the break-up of Yugoslavia created important tools for understanding the construction of national, regional and socio-economic identities around hierarchical notions of ‘Europe’ and ‘the Balkans’ in the Yugoslav region and beyond, Wekker’s observation is still largely true for south-east European studies, where no intervention establishing race and whiteness as categories of analysis has reframed the field like work by Maria Todorova on ‘balkanism’ or Milica Bakić-Hayden on ‘symbolic geographies’ and ‘nesting orientalism’ did in the early 1990s. Critical race theorists such as Charles Mills nevertheless argue that ‘race’ as a structure of thought and feeling that legitimised colonialism and slavery (and still informs structural white supremacy) involved precisely the kind of essentialised link between people and territory that south-east European cultural theory also critiques: the construction of spatialised hierarchies specifying which peoples and territories could have more or less access to civilisation and modernity. South-east European studies’ latent racial exceptionalism has some roots in the race-blind anti-colonial solidarities of state socialist internationalism (further intensified for Yugoslavia through the politics of Non-Alignment) but also, this paper suggests, in deeper associations between Europeanness, whiteness and modernity that remain part of the history of ‘Europe’ as an idea even if, by the end of the 20th century, they were silenced more often than voiced

The misasandry myth: An inaccurate stereotype about feminists' attitudes toward men

In six studies, we examined the accuracy and underpinnings of the damaging stereotype that feminists harbor negative attitudes toward men. In Study 1 (n = 1,664), feminist and nonfeminist women displayed similarly positive attitudes toward men. Study 2 (n = 3,892) replicated these results in non-WEIRD countries and among male participants. Study 3 (n = 198) extended them to implicit attitudes. Investigating the mechanisms underlying feminists’ actual and perceived attitudes, Studies 4 (n = 2,092) and 5 (nationally representative UK sample, n = 1,953) showed that feminists (vs. nonfeminists) perceived men as more threatening, but also more similar, to women. Participants also underestimated feminists’ warmth toward men, an error associated with hostile sexism and a misperception that feminists see men and women as dissimilar. Random-effects meta-analyses of all data (Study 6, n = 9,799) showed that feminists’ attitudes toward men were positive in absolute terms and did not differ significantly from nonfeminists'. An important comparative benchmark was established in Study 6, which showed that feminist women's attitudes toward men were no more negative than men's attitudes toward men. We term the focal stereotype the misandry myth in light of the evidence that it is false and widespread, and discuss its implications for the movement

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes