Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke.

BACKGROUND: Surgical occlusion of the left atrial appendage has been hypothesized to prevent ischemic stroke in patients with atrial fibrillation, but this has not been proved. The procedure can be performed during cardiac surgery undertaken for other reasons. METHODS: We conducted a multicenter, randomized trial involving participants with atrial fibrillation and a CHA2DS2-VASc score of at least 2 (on a scale from 0 to 9, with higher scores indicating greater risk of stroke) who were scheduled to undergo cardiac surgery for another indication. The participants were randomly assigned to undergo or not undergo occlusion of the left atrial appendage during surgery; all the participants were expected to receive usual care, including oral anticoagulation, during follow-up. The primary outcome was the occurrence of ischemic stroke (including transient ischemic attack with positive neuroimaging) or systemic embolism. The participants, research personnel, and primary care physicians (other than the surgeons) were unaware of the trial-group assignments. RESULTS: The primary analysis population included 2379 participants in the occlusion group and 2391 in the no-occlusion group, with a mean age of 71 years and a mean CHA2DS2-VASc score of 4.2. The participants were followed for a mean of 3.8 years. A total of 92.1% of the participants received the assigned procedure, and at 3 years, 76.8% of the participants continued to receive oral anticoagulation. Stroke or systemic embolism occurred in 114 participants (4.8%) in the occlusion group and in 168 (7.0%) in the no-occlusion group (hazard ratio, 0.67; 95% confidence interval, 0.53 to 0.85; P = 0.001). The incidence of perioperative bleeding, heart failure, or death did not differ significantly between the trial groups. CONCLUSIONS: Among participants with atrial fibrillation who had undergone cardiac surgery, most of whom continued to receive ongoing antithrombotic therapy, the risk of ischemic stroke or systemic embolism was lower with concomitant left atrial appendage occlusion performed during the surgery than without it. (Funded by the Canadian Institutes of Health Research and others; LAAOS III ClinicalTrials.gov number, NCT01561651.).

Towards a context-specific approach to understanding lawyers' well-being: a synthesis review and future research agenda.

Legal sector organisations face mounting pressure to protect and promote lawyers' well-being. However, knowledge is fragmented, hindering research and practice development. Our review investigated current conceptual understanding and empirical evidence of contextual influences. We systematically mapped the global scholarly and grey literature published since 1970, reviewing 145 relevant publications. Lawyers' well-being is conceptualised primarily as ill-being, despite well-being's positive facets. Empirical consideration of work context is mostly absent, though we deduce a focus on large commercial law firm practice and public service/legal aid. Our explanatory synthesis is abductive, coalescing Bourdieu's concepts of field and habitus with Hobfoll's conservation of resources theory to explain how context influences lawyers' well-being via distinct resource losses. We urge theoretical development to elucidate the role of context and theory-driven research on the cumulative effects of resource loss and gain. Recommendations for practice include a renewed focus on job design and line management upskilling.

Doctors' perceived working conditions, psychological health and patient care: a meta-analysis of longitudinal studies.

OBJECTIVES: Studies have demonstrated an association between doctors' perceived working conditions, and their psychological well-being and patient care. However, few have examined inter-relationships among these three domains, and even fewer using longitudinal designs. Using meta-analytical structural equation modelling, we tested longitudinal relationships among doctors' perceived working conditions, their psychological well-being and patient care. We further tested if doctors' psychological well-being mediates the relationship between perceived working conditions and patient care. METHODS: We carried out a systematic review using Academic Search Premier, Business Source Premier, PsycInfo, PsycArticles and Medline for the 20-year period between January 2000 and the start of the pandemic (January 2020). We included studies with practising doctors as participants, and that reported a quantifiable bivariate effect size between at least two of the three constructs of interest-perceived working conditions (ie, job demands, job resource), psychological well-being (ie, emotional exhaustion, work engagement) and patient care (ie, clinical care, patient safety). We pooled relationship effect sizes using random-effects meta-analysis, before testing for indirect effects using two-stage structural equation modelling. RESULTS: Twenty-three samples from 11 countries representing 7275 doctors were meta-analysed. The results indicated that job resources predicted work engagement (ρ=0.18; 95% CI 0.11 to 0.24) and emotional exhaustion (ρ=-0.21; 95% CI -0.31 to -0.11), while job demands predicted emotional exhaustion (ρ=0.27; 95% CI 0.17 to 0.36). Better clinical care was also associated with higher levels of job resources (ρ=0.16; 95% CI 0.04 to 0.29), and lower levels of emotional exhaustion (ρ=-0.21; 95% CI -0.37 to -0.12) and job demands (ρ=-0.27; 95% CI -0.43 to -0.10). Both factors of the work environment were associated with clinical care through doctors' emotional exhaustion, but there were insufficient studies to test the indirect effects for work engagement or patient safety. CONCLUSION: Our results demonstrate the need for a systems perspective to address working conditions to support both doctors' psychological well-being and patient care. Interventions should target doctors' job resources as they are more strongly associated with psychological well-being. However, given that job demands were strongly associated with emotional exhaustion, and in turn, clinical care, there is a need to better manage doctors' workload, conflict and pressure to support the current psychological well-being crises among this occupational group. PROSPERO REGISTRATION NUMBER: CRD42020189070.

Pacemaker after Sutureless and Rapid-Deployment Prostheses: A Progress Report from the SURD-IR.

OBJECTIVES: The aim of this study was to investigate the need for postoperative permanent pacemaker implantation (PPI) following sutureless and rapid-deployment aortic valve replacement (SuRD-AVR) in the context of a progress report from a large multicenter international registry (SURD-IR). METHODS: We retrospectively analyzed 4,166 patients who underwent SuRD-AVR between 2008 and 2019. The primary outcome was the need for PPI before discharge. The study population was analyzed separately according to the implanted prostheses (Su cohort and RD cohort). Each cohort was divided into two groups based on the operation date: an early group ("EG" = 2008-2016) and a late group ("LG" = 2017-2019). RESULTS: The rate of PPI decreased significantly in the Su cohort over time (EG = 10.8% vs LG = 6.3%, p < 0.001). In the Su cohort, a decrease in age, risk profile, and incidence of bicuspid aortic valve, increased use of anterior right thoracotomy, reduction of cardiopulmonary bypass time and of associated procedures, and more frequent use of smaller prostheses were observed over time. In the RD cohort, the rate of PPI was stable over time (EG = 8.8% vs LG = 9.3%, p = 0.8). In this cohort, a younger age, lower risk profile, and higher incidence of concomitant septal myectomy were observed over time. CONCLUSION: Our analysis showed a significant decrease in the PPI rate in patients who underwent Su-AVR over time. Patient selection as well as surgical improvements and a more accurate sizing could be correlated with this phenomenon. The RD cohort revealed no significant differences either in patient's characteristics or in PPI rate between the two time periods.

Factors Contributing to Stress and Well-Being Among Trainee Psychiatrists in Victoria, Australia.

Doctors in training experience stress, as they balance the demands of working and studying at the same time. As evidenced by reports of suicides among trainee doctors, it is clear that the level of stress they experience is dangerously high. Long working hours, which can lead to exhaustion, burnout, and time taken away from meaningful activities and relationships outside of work, are a large contributor to trainee stress and increase the likelihood of mental illness and suicidal ideation. For psychiatry trainees, this workload burden is also compounded by a high emotional burden associated with the nature of their work, including patient suicides, aggression, and threats. This study sought to investigate the factors that contribute to the stress and well-being of psychiatry trainees, through in-depth interviews analyzed via qualitative, template analysis. The main sources of stress identified were workload, aspects related to the psychiatry training program, and workplace-based aggression. Supervision, external supports such as family and health professionals, and distraction or "switching off" were the main sources of well-being support. Overall, this study highlighted the importance of structural factors in the workplace and training program in psychiatry trainee stress and well-being levels. Workload and training commitments limited the amount of time trainees could devote to well-being-related activities, despite their awareness of these. This study contributes useful insights into how we can better look after the mental health and well-being of psychiatry trainees, as future leaders of our mental health system.

The Impact of Changes in Mental Health Legislation on Psychiatry Trainee Stress in Victoria, Australia.

In Victoria, Australia, the introduction of a new state Mental Health Act (MHA) in 2014 resulted in changes to the workload and type of work undertaken by trainee psychiatrists. In addition to long working hours, workload intensity is most often cited by trainees as a factor that leads to fatigue, with trainees often taking work home or doing overtime in order to fulfill work responsibilities and satisfy training requirements. This administrative burden is compounded by the high emotional burden associated with the practice of psychiatry, including patient suicides, aggression, and threats. This study aimed to explore the impact of these legislative changes on psychiatry trainees' stress and well-being, using a qualitative research methodology involving semi-structured interviews. Despite reporting that the length and number of reports they were preparing under the new MHA had increased, as had the amount of time spent at Tribunal hearings, psychiatry trainees were understanding of the necessity of MHA changes in improving patient rights. The trainees did not express a desire for the MHA changes to be reversed, but rather recognition by their workplaces that changes are also needed at a ground level-such as an increase in staff numbers-to accommodate for these. While mental health legislative changes are designed to improve the system and better protect patient rights, measures must also be taken to ensure that any policy-level changes are adequately adjusted for in hospital staffing levels.

Recommendations for improving the working conditions and cultures of distressed junior doctors, based on a qualitative study and stakeholder perspectives.

BACKGROUND: Doctors, including junior doctors, are vulnerable to greater levels of distress and mental health difficulties than the public. This is exacerbated by their working conditions and cultures. While this vulnerability has been known for many years, little action has been taken to protect and support junior doctors working in the NHS. As such, we present a series of recommendations from the perspective of junior doctors and other relevant stakeholders, designed to improve junior doctors' working conditions and, thus, their mental health. METHODS: We interviewed 36 junior doctors, asking them for recommendations for improving their working conditions and culture. Additionally, we held an online stakeholder meeting with a variety of healthcare professionals (including junior doctors), undergraduate medical school leads, postgraduate speciality school leads and NHS policymakers where we asked what could be done to improve junior doctors' working conditions. We combined interview data with notes from the stakeholder discussions to produce this set of recommendations. RESULTS: Junior doctor participants and stakeholders made organisational and interpersonal recommendations. Organisational recommendations include the need for more environmental, staff and educational resources as well as changes to rotas. Interpersonal recommendations include changes to communication and recommendations for better support and teamwork. CONCLUSION: We suggest that NHS policymakers, employers and managers consider and hopefully implement the recommendations set out by the study participants and stakeholders as reported in this paper and that the gold standards of practice which are reported here (such as examples of positive learning environments and supportive supervision) are showcased so that others can learn from them.

A survey of cardiac surgeons to evaluate the use of sutureless aortic valve replacement in Canada.

BACKGROUND: Sutureless aortic valve replacement (SuAVR) is gaining popularity for the treatment of aortic stenosis. We aimed to describe Canadian cardiac surgeons' practice patterns and perceptions regarding SuAVR. METHODS: Content experts (clinicians and methodologists) developed the survey. Domains in the questionnaire include: respondent characteristics, factors influencing the decision to implant a SuAVR, barriers to SuAVR use, and interest in participating in a trial. RESULTS: A total of 66 cardiac surgeons (median duration of practice: 15 years; range 8-20 years) from 18 hospitals across Canada responded to the survey for a response rate of 84%. Surgeons reported that the following patient characteristics increased the likelihood they would choose SuAVR: hostile root (73%), small annular size (55%), high Society of Thoracic Surgery risk score (42%), older age (40%), to support minimally invasive surgery (25%) and redo-operation (23%). The following patient characteristics made surgeons less likely to pursue SuAVR: young age (73%), low STS score (40%), and large annular size (30%). Reported barriers to SuAVR use included: cost (33%), permanent pacemaker risk (27%) and uncertain durability (12%). Of respondents, 73% were interested in participating in a randomized controlled trial comparing SuAVR with transcatheter aortic valve replacement. CONCLUSIONS: The primary reasons for surgeons selecting SuAVR were high surgical risk and anatomical challenges. Cost is a primary factor limiting SuAVR use.

Recommendations to support the mental wellbeing of nurses and midwives in the United Kingdom: A Delphi study.

AIM: To use the Delphi technique to identify and prioritize recommendations for research and practice to improve the mental wellbeing of nurses and midwives in the United Kingdom (UK). BACKGROUND: Although there is evidence that self-reported mental wellbeing among nurses and midwives in the UK is poor, interventions have not adequately considered the wider context in which they work. The wide range of individual, organizational, occupational and wider sector-level factors that can influence wellbeing requires the involvement of different stakeholders to identify the most pressing actions required. DESIGN: A three-round Delphi technique was conducted in 2019. METHODS: In the first round, 16 subject matter experts generated, reviewed and discussed recommendations from a review of the research evidence with potential to support the mental wellbeing of nurses. A second group with 23 stakeholder representatives then rated and provided feedback on the developed recommendations through two additional rounds. Recommendations that received an 'essential' or 'important' rating from at least 80% of participants were retained and prioritized. RESULTS: In total, 45 recommendations met the consensus agreement and were retained. More than half (57%) involved action at the organizational level, 27% to public policy and 13% to research. Only one recommendation is related to the individual. Collectively, these recommendations highlight the importance of taking direct action to tackle poor mental wellbeing among the workforce and initiating change at the policy and organizational level. CONCLUSION: Our findings emphasize the need to take a systemic approach to improving the mental health of nurses and midwives in the UK with input from different stakeholders. There is a clear consensus that action is needed at the organization and policy levels, rather than at the individual level as is current practice. IMPACT: This study provides a framework, alongside a set of practical recommendations, that provides a starting point for different stakeholders to understand, address and support the mental wellbeing of nurses and midwives. Although UK-focused, it has relevance to healthcare workforces internationally.

Outcomes of sutureless aortic valve replacement versus conventional aortic valve replacement and transcatheter aortic valve replacement, updated systematic review, and meta-analysis.

BACKGROUND: Sutureless aortic valve replacement (SuAVR) is an alternative to surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). This study compares the effectiveness of SuAVR to SAVR and TAVR. METHODS: We searched MEDLINE and EMBASE from inception to July 2021 for studies evaluating SuAVR, SAVR, and TAVR in adults with aortic stenosis. We performed screening, full-text assessment, data collection, and risk of bias evaluation independently and in duplicate. We evaluated risk of bias using by Cochrane and CLARITY's tools, and certainty in evidence using the GRADE framework. Data were pooled using a random-effects model. RESULTS: We identified one randomized and 78 observational studies (n = 60,689; SuAVR vs. SAVR = 39,171, vs. TAVR = 21,518). All studies were at high or unclear risk of bias, with very-low certainty in effect estimates. Compared to TAVR, SuAVR demonstrates no significant difference in mortality at 30-days (odds ratio [OR]: 0.52, 95% confidence interval [CI: 0.85, 1.16], I2 = 0%), but decreased odds at 2-years (OR: 0.39, 95% CI [0.17, 0.88], I2 = 0%). SuAVR also reduced odds of mild paravalvular regurgitation (OR: 0.11, 95% CI [0.06, 0.21], I2 = 50%). Compared to SAVR, SuAVR was associated with a similar mortality at 30-days (OR: 0.99, 95% CI [0.85, 1.16], I2 = 0%) and 2-years (OR: 0.99, 95% CI [0.43-2.30], I2 = 7%). SuAVR significantly increased odds of permanent pacemaker implantation (OR: 2.5, 95% CI [2.25, 2.77], I2 = 0%). Pooled effect estimates were consistent with results from the randomized trial comparing SuAVR and SAVR. CONCLUSION: Based on very-low quality evidence, SuAVR is associated with similar short- and midterm outcomes compared to TAVR and SAVR. Comparative randomized data with long-term follow-up are required to clarify the role of SuAVR.

Individual and organizational psychosocial predictors of hospital doctors' work-related well-being: A multilevel and moderation perspective.

BACKGROUND: The high prevalence of burnout and depression among doctors highlights the need to understand the psychosocial antecedents to their work-related well-being. However, much of the existing research has been atheoretical, operationalized a narrow measurement of well-being, and predominantly examined such relationships at the individual level. PURPOSE: This study uses a multilevel perspective to examine individual (i.e., job demands and resources) and organizational-level psychosocial predictors of three measures of work-related well-being: perceived stress, presenteeism, and work engagement. The job demands-resources theory underpins the postulated relationships. METHODOLOGY: The 2014 National Health Service Staff Survey was analyzed using multilevel modeling in MPlus. The data set involved 14,066 hospital-based doctors grouped into 157 English hospital organizations (i.e., Trusts). RESULTS: Congruent with job demands-resources theory, job demands (workplace aggression and insufficient work resources) were stronger predictors of perceived stress and presenteeism than job resources. Equally, job resources (job control and manager support) were generally stronger predictors of work engagement than job demands. At the organizational level, bed occupancy rates and number of emergency admissions predicted work engagement. No hypothesized individual or multilevel interactions were observed between any of the job demands and resources. PRACTICAL IMPLICATIONS: The findings emphasize that a broader perspective of work-related well-being among hospital doctors should be employed and the empirical value of examining such relationships from a multilevel perspective. Successful health intervention should target the appropriate antecedent pathway and recognize the role of organizational-level factors when trying to manage hospital doctors' work-related well-being.

Effect of methylprednisolone on acute kidney injury in patients undergoing cardiac surgery with a cardiopulmonary bypass pump: a randomized controlled trial.

BACKGROUND: Perioperative corticosteroid use may reduce acute kidney injury. We sought to test whether methylprednisolone reduces the risk of acute kidney injury after cardiac surgery. METHODS: We conducted a prespecified substudy of a randomized controlled trial involving patients undergoing cardiac surgery with cardiopulmonary bypass (2007-2014); patients were recruited from 79 centres in 18 countries. Eligibility criteria included a moderate-to-high risk of perioperative death based on a preoperative score of 6 or greater on the European System for Cardiac Operative Risk Evaluation I. Patients (n = 7286) were randomly assigned (1:1) to receive intravenous methylprednisolone (250 mg at anesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients, caregivers, data collectors and outcome adjudicators were unaware of the assigned intervention. The primary outcome was postoperative acute kidney injury, defined as an increase in the serum creatinine concentration (from the preoperative value) of 0.3 mg/dL or greater (≥ 26.5 µmol/L) or 50% or greater in the 14-day period after surgery, or use of dialysis within 30 days after surgery. RESULTS: Acute kidney injury occurred in 1479/3647 patients (40.6%) in the methylprednisolone group and in 1426/3639 patients (39.2%) in the placebo group (adjusted relative risk 1.04, 95% confidence interval 0.96 to 1.11). Results were consistent across several definitions of acute kidney injury and in patients with preoperative chronic kidney disease. INTERPRETATION: Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery. Trial registration: ClinicalTrials.gov, no. NCT00427388.

Organizational uncertainty and stress among teachers in Hong Kong: work characteristics and organizational justice.

A growing literature now exists examining the relationship between organizational justice and employees' experience of stress. Despite the growth in this field of enquiry, there remain continued gaps in knowledge. In particular, the contribution of perceptions of justice to employees' stress within an organizational context of uncertainty and change, and in relation to the new and emerging concept of procedural-voice justice. The aim of the current study was to examine the main, interaction and additive effects of work characteristics and organizational justice perceptions to employees' experience of stress (as measured by their feelings of helplessness and perceived coping) during an acknowledged period of organizational uncertainty. Questionnaires were distributed among teachers in seven public primary schools in Hong Kong that were under threat of closure (n = 212). Work characteristics were measured using the demand-control-support model. Hierarchical regression analyses observed perceptions of job demands and procedural-voice justice to predict both teachers' feelings of helplessness and perceived coping ability. Furthermore, teacher's perceived coping was predicted by job control and a significant interaction between procedural-voice justice and distributive justice. The addition of organizational justice variables did account for unique variance, but only in relation to the measure of perceived coping. The study concludes that in addition to 'traditional' work characteristics, health promotion strategies should also address perceptions of organizational justice during times of organizational uncertainty; and, in particular, the value and importance of enhancing employee's perceived 'voice' in influencing and shaping justice-related decisions.

Methylprednisolone in patients undergoing cardiopulmonary bypass (SIRS): a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Cardiopulmonary bypass initiates a systemic inflammatory response syndrome that is associated with postoperative morbidity and mortality. Steroids suppress inflammatory responses and might improve outcomes in patients at high risk of morbidity and mortality undergoing cardiopulmonary bypass. We aimed to assess the effects of steroids in patients at high risk of morbidity and mortality undergoing cardiopulmonary bypass. METHODS: The Steroids In caRdiac Surgery (SIRS) study is a double-blind, randomised, controlled trial. We used a central computerised phone or interactive web system to randomly assign (1:1) patients at high risk of morbidity and mortality from 80 hospital or cardiac surgery centres in 18 countries undergoing cardiac surgery with the use of cardiopulmonary bypass to receive either methylprednisolone (250 mg at anaesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients were assigned with block randomisation with random block sizes of 2, 4, or 6 and stratified by centre. Patients aged 18 years or older were eligible if they had a European System for Cardiac Operative Risk Evaluation of at least 6. Patients were excluded if they were taking or expected to receive systemic steroids in the immediate postoperative period or had a history of bacterial or fungal infection in the preceding 30 days. Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcomes were 30-day mortality and a composite of death and major morbidity (ie, myocardial injury, stroke, renal failure, or respiratory failure) within 30 days, both analysed by intention to treat. Safety outcomes were also analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00427388. FINDINGS: Patients were recruited between June 21, 2007, and Dec 19, 2013. Complete 30-day data was available for all 7507 patients randomly assigned to methylprednisolone (n=3755) and to placebo (n=3752). Methylprednisolone, compared with placebo, did not reduce the risk of death at 30 days (154 [4%] vs 177 [5%] patients; relative risk [RR] 0·87, 95% CI 0·70-1·07, p=0·19) or the risk of death or major morbidity (909 [24%] vs 885 [24%]; RR 1·03, 95% CI 0·95-1·11, p=0·52). The most common safety outcomes in the methylprednisolone and placebo group were infection (465 [12%] vs 493 [13%]), surgical site infection (151 [4%] vs 151 [4%]), and delirium (295 [8%] vs 289 [8%]). INTERPRETATION: Methylprednisolone did not have a significant effect on mortality or major morbidity after cardiac surgery with cardiopulmonary bypass. The SIRS trial does not support the routine use of methylprednisolone for patients undergoing cardiopulmonary bypass. FUNDING: Canadian Institutes of Health Research.

Rationale and design of the steroids in cardiac surgery trial.

BACKGROUND: Steroids may improve outcomes in high-risk patients undergoing cardiac surgery with the use of cardiopulmonary bypass (CBP). There is a need\ for a large randomized controlled trial to clarify the effect of steroids in such patients. METHODS: We plan to randomize 7,500 patients with elevated European System for Cardiac Operative Risk Evaluation who are undergoing cardiac surgery with the use of CBP to methylprednisolone or placebo. The first coprimary outcome is 30-day all-cause mortality, and the most second coprimary outcome is a composite of death, MI, stroke, renal failure, or respiratory failure within 30 days. Other outcomes include a composite of MI or mortality at 30 days, new onset atrial fibrillation, bleeding and transfusion requirements, length of intensive care unit stay and hospital stay, infection, stroke, wound complications, gastrointestinal complications, delirium, postoperative insulin use and peak blood glucose, and all-cause mortality at 6 months. RESULTS: As of October 22, 2013, 7,034 patients have been recruited into SIRS in 82 centers from 18 countries. Patient's mean age is 67.3 years, and 60.4% are male. The average European System for Cardiac Operative Risk Evaluation is 7.0 with 22.1% having an isolated coronary artery bypass graft procedure, and 66.1% having a valve procedure. CONCLUSIONS: SIRS will lead to a better understanding of the safety and efficacy of prophylactic steroids for cardiac surgery requiring CBP.

Predictors of early and late stroke following cardiac surgery.

BACKGROUND: Much is known about the short-term risks of stroke following cardiac surgery. We examined the rate and predictors of long-term stroke in a cohort of patients who underwent cardiac surgery. METHODS: We obtained linked data for patients who underwent cardiac surgery in the province of Ontario between 1996 and 2006. We analyzed the incidence of stroke and death up to 2 years postoperatively. RESULTS: Of 108,711 patients, 1.8% (95% confidence interval [CI] 1.7%-1.9%) had a stroke perioperatively, and 3.6% (95% CI 3.5%-3.7%) had a stroke within the ensuing 2 years. The strongest predictors of both early and late stroke were advanced age (≥ 65 year; adjusted hazard ratio [HR] for all stroke 1.9, 95% CI 1.8-2.0), a history of stroke or transient ischemic attack (adjusted HR 2.1, 95% CI 1.9-2.3), peripheral vascular disease (adjusted HR 1.6, 95% CI 1.5-1.7), combined coronary bypass grafting and valve surgery (adjusted HR 1.7, 95% CI 1.5-1.8) and valve surgery alone (adjusted HR 1.4, 95% CI 1.2-1.5). Preoperative need for dialysis (adjusted odds ratio [OR] 2.1, 95% CI 1.6-2.8) and new-onset postoperative atrial fibrillation (adjusted OR 1.5, 95% CI 1.3-1.6) were predictors of only early stroke. A CHADS2 score of 2 or higher was associated with an increased risk of stroke or death compared with a score of 0 or 1 (19.9% v. 9.3% among patients with a history of atrial fibrillation, 16.8% v. 7.8% among those with new-onset postoperative atrial fibrillation and 14.8% v. 5.8% among those without this condition). INTERPRETATION: Patients who had cardiac surgery were at highest risk of stroke in the early postoperative period and had continued risk over the ensuing 2 years, with similar risk factors over these periods. New-onset postoperative atrial fibrillation was a predictor of only early stroke. The CHADS2 score predicted stroke risk among patients with and without atrial fibrillation.

Work-related smartphone use during off-job hours and work-life conflict: A scoping review.

Over recent decades the use of smartphones for work purposes has burgeoned both within and beyond working hours. The aim of the study was to conduct a scoping review to explore the association between the use of smartphone technology for work purposes in off-job hours with employees' self-reported work-life conflict. Arksey and O'Malley's methodological framework was adopted. Searches were conducted in PsycINFO, International Bibliography of the Social Sciences (IBSS), Academic Search Complete, ProQuest Central, Web of Science, ProQuest Theses, Emerald, Business Source Complete, ScienceDirect, Scopus, Google Scholar. Articles were eligible that reported on a sample of workers, were published in English between 1st January 2012 and 29th November 2023. The review was conducted and reported using a quality assessment checklist and PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews). Data charting and synthesis was undertaken narratively, using the framework approach and thematic analysis. Twenty-three studies were identified, conducted in nine countries. Nineteen studies (83%) showed a significant association between increased use of smartphone for work purposes in off job-hours and increased work-life conflict, with small-to-moderate effect sizes. This relationship was mediated by psychological detachment from work, and communication about family demands with one's supervisor. Moderators either strengthened or attenuated the relationship between use of smartphone for work purposes in off job-hours and increased work-life conflict. Findings suggest that smartphone use during off-job hours is likely to impact negatively on work-life conflict, which has implications for employee wellbeing. Managers could play a key role in clarifying expectations about after-hours availability, reducing job pressure, advocating psychological detachment from work in off-job hours where it is appropriate, and creating a workplace culture where communication about the interplay between work and home life is encouraged. The protocol is registered on the Open Science Framework (OSF) (https://doi.org/10.17605/OSF.IO/WFZU6).

The last resort: reducing avoidable employee harm by improving the application of the disciplinary policy and process.

Introduction: There is growing evidence within the healthcare sector that employee investigations can harm individuals involved in the process, an organization's culture and the delivery of its services. Methods: This paper details an intervention developed by an NHS Wales organization to reduce the number of its employee investigations through an organization-wide focus that promoted a 'last resort' approach and introduced the concept of 'avoidable employee harm'. A range of associated improvement initiatives were developed to support behavior change among those responsible for determining whether an employee investigation should be initiated. Results: Over a 13-month period, organizational records showed an annual reduction of 71% in investigation cases post-intervention, resulting in an estimated 3,308 sickness days averted annually and total estimated annual savings of £738,133 (based on direct savings and costs averted). This indicates that the organization has started to embrace the "last resort" approach to using employee investigations to address work place issues. The programme was supported with training for those responsible for commissioning and leading the organization's employee investigations. Analysis of survey data from those who attended training workshops to support the programme indicated that participants showed an increased awareness of the employee investigation process post-workshop and an understanding of the concept of avoidable employee harm. Discussion: The programme is congruent with the Healthy Healthcare concept, as the study illustrates how its practices and processes have a beneficial impact on staff, as well as potentially on patients. This study highlights wider issues for consideration, including the: (1) the role of Human Resources (HR), (2) taking a multi-disciplinary approach, (3) culture and practice, (4) the responsibility of the wider HR profession.