Reliability of proxy reports on patient reported outcomes measures in stroke: An updated systematic review.

OBJECTIVES: With the rising global burden of stroke-related morbidity, and increased focus on patient-centered healthcare, patient reported outcome measures (PROMs) are increasingly used to inform healthcare decision-making. Some stroke patients with cognitive or motor impairments are unable to respond to PROMs, so proxies may respond on their behalf; the reliability of which remains unclear. The aim of the study is to update a 2010 systematic review to investigate the inter-rater reliability of proxy respondents answering PROMs for stroke patients. MATERIALS AND METHODS: Studies on the reliability of proxy respondents in stroke were searched within CINAHL, Embase, PsycInfo, and WoS databases (01/07/22, 08/07/22). Fifteen studies were included for review. ICC and k-statistic were extracted for PROMs scales and categorized as poor (0.80). Bias was assessed using the CCAT. RESULTS: Five studies reported PROMs with inter-rater reliability scores ranging from 0.80. Two studies reported activities of daily living (ADLs) scores ranging from 0.41 to 0.80 and 8 studies reported quality of life (QoL) measures with scores ranging from 0.80. Subcategories of these scales included physical (ICC/k-statistic 0.41- >0.8), cognitive (ICC/k-statistic 0.40-0.80), communication (ICC/k-statistic <0.4-0.80,) and psychological (ICC/k-statistic <0.40-0.60) measures. CONCLUSIONS: Proxy respondents are reliable sources for PROM reports on physical domains in ADLs, PROMs and QoL scales. Proxy reports for measures of communication and psychological domains had greater variability in reliability scores, ranging from poor to substantial; hence, caution should be applied when interpreting proxy reports for these domains.

Medical students, mental health and the role of resilience - A cross-sectional study.

BACKGROUND: Medical students have reported high prevalence of mental health difficulties and burnout. However, there are limited investigations examining the association between resilience and these difficulties. We investigated: (1) depression, anxiety, personal and professional burnout, and comorbidity; (2) demographic and education characteristics associated with these outcomes; (3) the association between resilience and these outcomes; and (4) whether these results were attributable to sampling bias. METHODS: Participants were n = 521 medical students from RCSI University of Medicine and Health Sciences. Outcomes were measured using validated scales. We report descriptive statistics, and risk factors for the difficulties were investigated using generalized linear modelling. RESULTS: One-in-three students reported incidence of depression or anxiety (24.5% co-morbidity). 8.9% of students reported all four difficulties. Difficulties were more common in female students and those in middle years of the programme. Resilience was negatively correlated with all outcomes and stable across demographic and educational variables. Weighting the data for sampling bias did not affect these results. CONCLUSIONS: Our results emphasise the high incidence of depression, anxiety, burnout, and comorbidity in students. We advocate for further investigation into the role of resilience as a modifiable factor that may ameliorate the incidence of depression, anxiety, and burnout in medical students.

Designing stroke services for the delivery of cognitive rehabilitation: A qualitative study with stroke rehabilitation professionals.

This qualitative study explored the potential to deliver cognitive rehabilitation for post-stroke cognitive impairment (PSCI), with a specific focus on barriers and facilitators to its delivery from the perspective of Irish stroke rehabilitation professionals. Sixteen semi-structured interviews were completed with healthcare professionals in both hospital and community settings. The sample comprised physiotherapists, occupational therapists, nurses, a stroke physician, a psychologist, a neuropsychologist, a speech and language therapist, a dietician, and a public health nurse. Interviews were audio-recorded and analysed in NVivo using inductive Thematic Analysis. Barriers and facilitators to the delivery of cognitive rehabilitation were identified and described under four key themes: (i) Cognitive screening; (ii) Cognitive rehabilitation: no one size fits all; (iii) Psychology: the lost dimension of stroke rehabilitation; and (iv) Joining the dots in the community. Staffing required to deliver cognitive rehabilitation for PSCI was highlighted as under-resourced in the Republic of Ireland. Inadequate resourcing of neuropsychology and stroke-related psychological services, in particular, has had negative implications for the delivery of cognitive rehabilitation. Stroke-specific cognitive rehabilitation expertise is virtually inaccessible in the community, highlighting an urgent need for investment in specialist rehabilitation teams to deliver cognitive rehabilitation in this setting.

Interventions for increasing immunosuppressant medication adherence in solid organ transplant recipients.

BACKGROUND: Non-adherence to immunosuppressant therapy is a significant concern following a solid organ transplant, given its association with graft failure. Adherence to immunosuppressant therapy is a modifiable patient behaviour, and different approaches to increasing adherence have emerged, including multi-component interventions. There has been limited exploration of the effectiveness of interventions to increase adherence to immunosuppressant therapy. OBJECTIVES: This review aimed to look at the benefits and harms of using interventions for increasing adherence to immunosuppressant therapies in solid organ transplant recipients, including adults and children with a heart, lung, kidney, liver and pancreas transplant. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 14 October 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA: All randomised controlled trials (RCTs), quasi-RCTs, and cluster RCTs examining interventions to increase immunosuppressant adherence following a solid organ transplant (heart, lung, kidney, liver, pancreas) were included. There were no restrictions on language or publication type. DATA COLLECTION AND ANALYSIS: Two authors independently screened titles and abstracts of identified records, evaluated study quality and assessed the quality of the evidence using the GRADE approach. The risk of bias was assessed using the Cochrane tool. The ABC taxonomy for measuring medication adherence provided the analysis framework, and the primary outcomes were immunosuppressant medication initiation, implementation (taking adherence, dosing adherence, timing adherence, drug holidays) and persistence. Secondary outcomes were surrogate markers of adherence, including self-reported adherence, trough concentration levels of immunosuppressant medication, acute graft rejection, graft loss, death, hospital readmission and health-related quality of life (HRQoL). Meta-analysis was conducted where possible, and narrative synthesis was carried out for the remainder of the results. MAIN RESULTS: Forty studies involving 3896 randomised participants (3718 adults and 178 adolescents) were included. Studies were heterogeneous in terms of the type of intervention and outcomes assessed. The majority of studies (80%) were conducted in kidney transplant recipients. Two studies examined paediatric solid organ transplant recipients. The risk of bias was generally high or unclear, leading to lower certainty in the results. Initiation of immunosuppression was not measured by the included studies. There is uncertain evidence of an association between immunosuppressant medication adherence interventions and the proportion of participants classified as adherent to taking immunosuppressant medication (4 studies, 445 participants: RR 1.09, 95% CI 0.95 to 1.20; I² = 78%). There was very marked heterogeneity in treatment effects between the four studies evaluating taking adherence, which may have been due to the different types of interventions used. There was evidence of increasing dosing adherence in the intervention group (8 studies, 713 participants: RR 1.14, 95% CI 1.03 to 1.26, I² = 61%).  There was very marked heterogeneity in treatment effects between the eight studies evaluating dosing adherence, which may have been due to the different types of interventions used. It was uncertain if an intervention to increase immunosuppressant adherence had an effect on timing adherence or drug holidays. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on persistence. There was limited evidence that an intervention to increase immunosuppressant adherence had an effect on secondary outcomes. For self-reported adherence, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants classified as medically adherent to immunosuppressant therapy (9 studies, 755 participants: RR 1.21, 95% CI 0.99 to 1.49; I² = 74%; very low certainty evidence). Similarly, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the mean adherence score on self-reported adherence measures (5 studies, 471 participants: SMD 0.65, 95% CI -0.31 to 1.60; I² = 96%; very low certainty evidence). For immunosuppressant trough concentration levels, it is uncertain whether an intervention to increase adherence to immunosuppressant medication increases the proportion of participants who reach target immunosuppressant trough concentration levels (4 studies, 348 participants: RR 0.98, 95% CI 0.68 to 1.40; I² = 40%; very low certainty evidence). It is uncertain whether an intervention to increase adherence to immunosuppressant medication may reduce hospitalisations (5 studies, 460 participants: RR 0.67, 95% CI 0.44 to 1.02; I² = 64%; low certainty evidence). There were limited, low certainty effects on patient-reported health outcomes such as HRQoL. There was no clear evidence to determine the effect of interventions on secondary outcomes, including acute graft rejection, graft loss and death. No harms from intervention participation were reported. AUTHORS' CONCLUSIONS: Interventions to increase taking and dosing adherence to immunosuppressant therapy may be effective; however, our findings suggest that current evidence in support of interventions to increase adherence to immunosuppressant therapy is overall of low methodological quality, attributable to small sample sizes, and heterogeneity identified for the types of interventions. Twenty-four studies are currently ongoing or awaiting assessment (3248 proposed participants); therefore, it is possible that findings may change with the inclusion of these large ongoing studies in future updates.

The impact of stroke, cognitive function and post-stroke cognitive impairment (PSCI) on healthcare utilisation in Ireland: a cross-sectional nationally representative study.

BACKGROUND: Cognitive impairment after stroke is associated with poorer health outcomes and increased need for long-term care. The aim of this study was to determine the impact of stroke, cognitive function and post-stroke cognitive impairment (PSCI) on healthcare utilisation in older adults in Ireland. METHODS: This cross-sectional study involved secondary data analysis of 8,175 community-dwelling adults (50 + years), from wave 1 of The Irish Longitudinal Study on Ageing (TILDA). Participants who had been diagnosed with stroke by a doctor were identified through self-report in wave 1. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA). The main outcome of the study was healthcare utilisation, including General Practitioner (GP) visits, emergency department visits, outpatient clinic visits, number of nights admitted to hospital, and use of rehabilitation services. The data were analysed using multivariate adjusted negative binomial regression and logistic regression. Incidence-rate ratios (IRR), odds ratios (OR) and 95% confidence intervals (CI) are presented. RESULTS: The adjusted regression analyses were based on 5,859 participants who completed a cognitive assessment. After adjusting for demographic and clinical covariates, stroke was independently associated with an increase in GP visits [IRR (95% CI): 1.27 (1.07, 1.50)], and outpatient service utilisation [IRR: 1.49 (1.05, 2.12)]. Although participants with poor cognitive function also visited the GP more frequently than participants with normal cognitive function [IRR: 1.07 (1.04, 1.09)], utilisation of outpatient services was lower in this population [IRR: 0.92 (0.88, 0.97)]. PSCI was also associated with a significant decrease in outpatient service utilisation [IRR: 0.75 (0.57, 0.99)]. CONCLUSIONS: Stroke was associated with higher utilisation of GP and outpatient services. While poor cognitive function was also associated with more frequent GP visits, outpatient service utilisation was lower in participants with poor cognitive function, indicating that cognitive impairment may be a barrier to outpatient care. In Ireland, the lack of appropriate neurological or cognitive rehabilitation services appears to result in significant unaddressed need among individuals with cognitive impairment, regardless of stroke status.

Regulating emotional responses to aphasia to re-engage in life: a qualitative interview study.

BACKGROUND: People with post-stroke aphasia (PWA) are more likely to experience serious mood disorders compared with those without. Emotional regulation may be important for influencing life participation after stroke. Understanding emotional regulation in the context of aphasia is important for promoting personally defined recovery, psychological well-being and life participation. AIMS: To explore how individuals experience and regulate negative emotional responses to aphasia as part of re-engaging with life. METHODS & PROCEDURES: In-depth semi-structured qualitative interviews with 14 PWA were conducted. The focus and design were developed with public and patient involvement contributors. Reflexive thematic analysis was applied. OUTCOMES & RESULTS: Analysis generated three themes, which captured inherent diversity across participants in terms of emotional experiences, responses and regulation strategies: (1) emotional upheaval at all stages of recovery; (2) regulating emotional upheaval; and (3) discerning possibilities for life participation. Emotional regulation occurred both within and without the context of formal support services. CONCLUSIONS & IMPLICATIONS: Individuals may be differently (en)abled in responding positively, with implications for aphasia psychological support and self-management interventions. The findings may inform future interventions to optimize well-being and personally meaningful outcomes for PWA. WHAT THIS PAPER ADDS: What is already known on the subject PWA experience significant psychosocial upheaval and are at risk of mood disorders. Emotional regulation may be important for influencing one's emotional state, social participation and relationships after stroke. There is a need to better understand the ways in which PWA experience and regulate their emotions to develop better support for personally defined recovery. What this paper adds to existing knowledge PWA may experience significant and pervasive mood disorders in the long term after stroke. This may be compounded by worries for their children's well-being. Some, but not all, regulate emotions by drawing on positivity, determination, gratitude or stoicism. Having (supportive) opportunities to experience the impact of aphasia is important for discerning helpful strategies and participation opportunities. What are the potential or actual clinical implications of this work? Confronting altered abilities requires supportive, responsive opportunities sensitive to emotional responses. Opportunities for peer support and/or meaningful emotional support and compassion from family and friends are important therapeutic targets. Therapeutic input should pay attention to any familial and parenting concerns that may be compounding low mood. Although emotional regulation and recovery may occur without formal support, mental health services must be organized in such a way that PWA can access as needed.

StrokeCog Markov Model: Projected Prevalent and Incident Cases of Stroke and Poststroke Cognitive Impairment to 2035 in Ireland.

BACKGROUND AND PURPOSE: Cognitive impairment no dementia (CIND) and dementia are common stroke outcomes, with significant health and societal implications for aging populations. These outcomes are not included in current epidemiological models. We aimed to develop an epidemiological model to project incidence and prevalence of stroke, poststroke CIND and dementia, and life expectancy, in Ireland to 2035, informing policy and service planning. METHODS: We developed a probabilistic Markov model (the StrokeCog model) applied to the Irish population aged 40 to 89 years to 2035. Data sources included official population and hospital-episode statistics, longitudinal cohort studies, and published estimates. Key assumptions were varied in sensitivity analysis. Results were externally validated against independent sources. The model tracks poststroke progression into health states characterized by no cognitive impairment, CIND, dementia, disability, stroke recurrence, and death. RESULTS: We projected 69 051 people with prevalent stroke in Ireland in 2035 (22.0 per 1000 population [95% CI, 20.8-23.1]), with 25 274 (8.0 per 1000 population [95% CI, 7.1-9.0]) of those projected to have poststroke CIND, and 12 442 having poststroke dementia (4.0 per 1000 population [95% CI, 3.2-4.8]). We projected 8725 annual incident strokes in 2035 (2.8 per 1000 population [95% CI, 2.7-2.9]), with 3832 of these having CIND (1.2 per 1000 population [95% CI, 1.1-1.3]), and 1715 with dementia (0.5 per 1000 population [95% CI, 0.5-0.6]). Life expectancy for stroke survivors at age 50 was 23.4 years (95% CI, 22.3-24.5) for women and 20.7 (95% CI, 19.5-21.9) for men. CONCLUSIONS: This novel epidemiological model of stroke, poststroke CIND, and dementia draws on the best available evidence. Sensitivity analysis indicated that findings were robust to assumptions, and where there was uncertainty a conservative approach was taken. The StrokeCog model is a useful tool for service planning and cost-effectiveness analysis and is available for adaptation to other national contexts.

'I hated being ghosted' - The relevance of social participation for living well with post-stroke aphasia: Qualitative interviews with working aged adults.

BACKGROUND: In the context of increasing incidence of stroke in working aged adults, there is a specific need to explore the views of working aged adults with post-stroke aphasia, whose communication difficulties may result in restricted social participation, loss of employment and changed relationship and parenting roles. This study aimed to explore the perspectives of working aged adults with post-stroke aphasia in relation to social participation and living well with aphasia (LWA). DESIGN AND PARTICIPANTS: We conducted qualitative interviews with 14 people with post-stroke aphasia (PWA). Data were analysed following principles of reflexive, thematic analysis. Patient or Public Contribution: A Public and Patient Involvement aphasia advisory group inputted into the study design and interpretation of data. RESULTS: Social participation spanned 5 themes: Relationships and roles; Social support; Peer network, Aphasia awareness; and Employment and training. Meaningful, interesting social participation for LWA is individually defined. Working aged PWA may require flexible support with parenting, accessing a diverse social network and finding opportunities for meaningful social connection, training and employment. CONCLUSIONS: The findings extend knowledge of social participation in the context of LWA for working aged adults by elucidating the individually defined nature of meaningful participation and how PWA may need flexible support with parenting, accessing a diverse social network and training and employment. For aphasia research, policy and services to be relevant, it is crucial that working aged PWA are meaningfully involved in setting the aphasia agenda.

Two-State Reactivity in Iron-Catalyzed Alkene Isomerization Confers σ-Base Resistance.

A low-coordinate, high spin (S = 3/2) organometallic iron(I) complex is a catalyst for the isomerization of alkenes. A combination of experimental and computational mechanistic studies supports a mechanism in which alkene isomerization occurs by the allyl mechanism. Importantly, while substrate binding occurs on the S = 3/2 surface, oxidative addition to an η1-allyl intermediate only occurs on the S = 1/2 surface. Since this spin state change is only possible when the alkene substrate is bound, the catalyst has high immunity to typical σ-base poisons due to the antibonding interactions of the high spin state.

Short-Term Air Pollution as a Risk for Stroke Admission: A Time-Series Analysis.

BACKGROUND: The harmful effects of outdoor air pollution on stroke incidence are becoming increasingly recognised. We examined the impact of different air pollutants (PM2.5, PM10, NO2, ozone, and SO2) on admission for all strokes in two Irish urban centres from 2013 to 2017. METHODS: Using an ecological time series design with Poisson regression models, we analysed daily hospitalisation for all strokes and is-chaemic stroke by residence in Dublin or Cork, with air pollution level monitoring data with a lag of 0-2 days from exposure. Splines of temperature, relative humidity, day of the week, and time were included as confounders. Analysis was also performed across all four seasons. Data are presented as relative risks (RRs) and 95% confidence intervals (95% CI) per interquartile range (IQR) increase in each pollutant. RESULTS: There was no significant association between all stroke admission and any individual air pollutant. On seasonal analysis, during winter in the larger urban centre (Dublin), we found an association between all stroke cases and an IQR increase in NO2 (RR 1.035, 95% CI: 1.003-1.069), PM10 (RR 1.032, 95% CI: 1.007-1.057), PM2.5 (RR 1.024, 95% CI: 1.011-1.039), and SO2 (RR 1.035, 95% CI: 1.001-1.071). There was no significant association found in the smaller urban area of Cork. On meta-analysis, there remained a significant association between NO2 (RR 1.013, 95% CI: 1.001-1.024) and PM2.5 (1.009, 95% CI 1.004-1.014) per IQR increase in each. DISCUSSION: Short-term air pollution in winter was found to be associated with hospitalisation for all strokes in a large urban centre in Ireland. As Ireland has relatively low air pollution internationally, this highlights the need to introduce policy changes to reduce air pollution in all countries.

Developing a national undergraduate standardized curriculum for future healthcare professionals on "Making Every Contact Count" for chronic disease prevention in the Republic of Ireland.

This report describes the development of the first national undergraduate interprofessional standardized curriculum in chronic disease prevention for healthcare professionals in the Republic of Ireland. This project brought together for the first time all higher education institutions nationwide in a novel collaboration with the national health service i.e. the Health Service Executive (HSE), to develop a standardized national curriculum for undergraduate health care professions. The curriculum sits within the framework of Making Every Contact Count, the goal of which is to re-orientate health services to embed the ethos of prevention through lifestyle behavior change as part of the routine care of health professionals. The core focus of Making Every Contact Count is chronic disease prevention, targeting four main lifestyle risk factors for chronic disease; tobacco use, alcohol consumption, physical inactivity and unhealthy eating. Making Every Contact Count is a key component of Healthy Ireland, the Irish national framework for health and wellbeing. The aim of the curriculum is to prepare newly qualified health professionals with the skills needed to support patients to achieve lifestyle behavior change delivered as part of routine clinical care.

A Dimeric Hydride-Bridged Complex with Geometrically Distinct Iron Centers Giving Rise to an S = 3 Ground State.

Structural and spectroscopic characterization of the dimeric iron hydride complex [Ph2B(tBuIm)2FeH]2 reveals an unusual structure in which a tetrahedral iron(II) site (S = 2) is connected to a square planar iron(II) site (S = 1) by two bridging hydride ligands. Magnetic susceptibility reveals strong ferromagnetic coupling between iron centers, with a coupling constant of J = +110(12) cm-1, to give an S = 3 ground state. High-frequency and -field electron paramagnetic resonance (HFEPR) spectroscopy confirms this model. A qualitative molecular orbital analysis of the electronic structure, as supported by electronic structure calculations, reveals that the observed spin configuration results from the orthogonal alignment of two geometrically distinct four-coordinate iron fragments held together by highly covalent hydride ligands.

Magnetization Slow Dynamics in Ferrocenium Complexes.

The single-molecule magnet (SMM) properties of a series of ferrocenium complexes, [Fe(η5 -C5 R5 )2 ]+ (R=Me, Bn), are reported. In the presence of an applied dc field, the slow dynamics of the magnetization in [Fe(η5 -C5 Me5 )2 ]BArF are revealed. Multireference quantum mechanical calculations show a large energy difference between the ground and first excited states, excluding the commonly invoked, thermally activated (Orbach-like) mechanism of relaxation. In contrast, a detailed analysis of the relaxation time highlights that both direct and Raman processes are responsible for the SMM properties. Similarly, the bulky ferrocenium complexes, [Fe(η5 -C5 Bn5 )2 ]BF4 and [Fe(η5 -C5 Bn5 )2 ]PF6 , also exhibit magnetization slow dynamics, however an additional relaxation process is clearly detected for these analogous systems.

Poststroke Cognitive Impairment in Model-Based Economic Evaluation: A Systematic Review.

INTRODUCTION: Cognitive impairment (CI) is a frequent consequence of stroke and is associated with increased costs and reduced quality of life. However, its inclusion in model-based economic evaluation for stroke is limited. OBJECTIVE: To identify, review, and critically appraise current models of stroke for use in economic evaluation, and to identify applicability to modeling poststroke CI. METHODS: PubMed, EMBASE, and the NHS Economic Evaluations Database (NHS EED) were systematically searched for papers published from January 2008 to August 2018. Studies that described the development or design of a model of stroke progression intended for use in economic evaluation were included. Abstracts were screened, followed by full text review of potentially relevant articles. Models that included CI were retained for data extraction, and among the remainder, models that included both stroke recurrence and disability were also retained. Relevance and potential for adaptation for modeling CI were assessed using a standard questionnaire. RESULTS: Forty modeling studies were identified and categorized into 4 groups: Markov disability/recurrence (k = 29); CI (k = 2); discrete event simulation (k = 4), and other (k = 5). Only 2 modeling studies included CI as an outcome, and both focused on narrow populations at risk of intracranial aneurysm. None of the models allowed for disease progression in the absence of a stroke recurrence. None of the included studies carried out any sensitivity analysis in relation to model design or structure. CONCLUSIONS: Current stroke models used in economic evaluation are not adequate to model poststroke CI or dementia, and will require adaptation to be used for this purpose.

Protonation Studies of Molybdenum(VI) Nitride Complexes That Contain the [2,6-(ArNCH2)2NC5H3]2- Ligand (Ar = 2,6-Diisopropylphenyl).

[Ar2N3]Mo(N)(O- t-Bu) (1), which contains the conformationally rigid pyridine-based diamido ligand [2,6-(ArNCH2)2NC5H3]2- (Ar = 2,6-diisopropylphenyl), is a catalyst for the reduction of dinitrogen with protons and electrons. Various acids have been added in order to explore where and how the first proton adds to the complex. The addition of adamantol to 1 produces a five-coordinate bis(adamantoxide), [HAr2N3]Mo(N)(OAd)2 (2a), in which one of the amido nitrogens in the ligand has been protonated and the resulting aniline nitrogen in the [HAr2N3]- ligand is not bound to the metal. The addition of [Ph2NH2][OTf] to 1 produces {[HAr2N3]Mo(N)(O- t-Bu)}(OTf) (3), in which an amido nitrogen has been protonated, but the aniline in the [HAr2N3]- ligand remains bound to the metal. Last, the addition of (2,6-lutidinium)BArF4 (BArF4 = {B(3,5-(CF3)2C6H3)4}-) to 1 yields {[Ar2N3]Mo(N)(LutH)(O- t-Bu)}BArF4, in which LutH+ is hydrogen-bonded to the nitride in the solid state and in dichloromethane with Keq = 412 ± 94 and Δ G = -3.6 ± 0.8 kcal at 22 °C. A similar hydrogen-bonded adduct was formed through the addition of (2-methylpyridinium)BArF4 to 1, but the addition of (pyridinium)BArF4 to 1 leads to the formation of (inter alia) {[HAr2N3]Mo(N)(O- t-Bu)}(BArF4), in which the amide nitrogen has been protonated. The addition of cobaltocene to 3 or {[Ar2N3]Mo(N)(LutH)(O- t-Bu)}(BArF4) leads only to the re-formation of 1. X-ray structural studies were carried out on 2a, 3, and {[Ar2N3]Mo(N)(LutH)(O- t-Bu)}(BArF4).

The Impact of Cognitive Impairment on Poststroke Outcomes: A 5-Year Follow-Up.

AIM: To explore the impact of cognitive impairment poststroke on outcomes at 5 years. METHODS: Five-year follow-up of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) prospective cohort. Two hundred twenty-six ischemic stroke survivors completed Montreal Cognitive Assessments at 6 months poststroke. Outcomes at 5 years included independence in activities of daily living, receipt of informal care, quality of life, and depressive symptoms. Data were analyzed using logistic and linear regression models. Adjusted odds ratios (ORs; 95% confidence interval [CI]) and ß coefficients (95% CI) are reported. RESULTS: One hundred one stroke survivors were followed up at 5 years. Cognitive impairment at 6 months was independently associated with worse quality of life (B [95% CI]: -0.595 [-0.943 to -0.248]), lower levels of independence (B [95% CI]: -3.605 [-5.705 to -1.505]), increased likelihood of receiving informal care (OR [95% CI]: 6.41 [1.50-27.32]), and increased likelihood of depressive symptoms (OR [95% CI]: 4.60 [1.22-17.40]). Conclusion: Cognitive impairment poststroke is associated with a range of worse outcomes. More effective interventions are needed to improve outcomes for this vulnerable group of patients.

Cognitive Impairment, Vulnerability, and Mortality Post Ischemic Stroke: A Five-Year Follow-Up of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) Cohort.

BACKGROUND: The aim of this study was to examine predictors of mortality in patients 5 years after ischemic stroke, focusing on cognitive impairment, vulnerability, and vascular risk factors assessed at 6 months post stroke. MATERIALS AND METHODS: Patients from the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) cohort were followed up 5 years post ischemic stroke. Vascular risk factors, cognitive impairment, and vulnerability were assessed at 6 months post stroke. Cognitive impairment was assessed using a cutoff score lower than 26 on the Montreal Cognitive Assessment (MoCA). Vulnerability was defined as a score of 3 or higher on the Vulnerable Elders Scale (VES). Mortality and date of death were ascertained using hospital records, death notifications, and contact with general practitioners. Predictors of mortality were explored using multivariate Cox proportional hazards models. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) are presented. RESULTS: Sixty-three of 256 patients (24.6%) assessed at 6 months post stroke had died within 5 years. Cognitive impairment (HR [95% CI]: 2.19 [1.42-3.39]), vulnerability (HR [95% CI]: 5.23 [2.92-9.36]), atrial fibrillation (AF) (HR [95% CI]: 2.31 [1.80-2.96]), and dyslipidemia (HR [95% CI]: 1.90 [1.10-3.27]) were associated with increased risk of 5-year mortality. DISCUSSION: Vulnerability, cognitive impairment, AF, and dyslipidemia at 6 months were associated with increased risks of mortality 5 years post ischemic stroke. CONCLUSION: Identification and management of these risk factors should be emphasized in poststroke care.

Spectroscopic and Computational Studies of Spin States of Iron(IV) Nitrido and Imido Complexes.

High-oxidation-state metal complexes with multiply bonded ligands are of great interest for both their reactivity as well as their fundamental bonding properties. This paper reports a combined spectroscopic and theoretical investigation into the effect of the apical multiply bonded ligand on the spin-state preferences of threefold symmetric iron(IV) complexes with tris(carbene) donor ligands. Specifically, singlet (S = 0) nitrido [{PhB(ImR)3}FeN], R = tBu (1), Mes (mesityl, 2) and the related triplet (S = 1) imido complexes, [{PhB(ImR)3}Fe(NR')]+, R = Mes, R' = 1-adamantyl (3), tBu (4), were investigated by electronic absorption and Mössbauer effect spectroscopies. For comparison, two other Fe(IV) nitrido complexes, [(TIMENAr)FeN]+ (TIMENAr = tris[2-(3-aryl-imidazol-2-ylidene)ethyl]amine; Ar = Xyl (xylyl), Mes), were investigated by 57Fe Mössbauer spectroscopy, including applied-field measurements. The paramagnetic imido complexes 3 and 4 were also studied by magnetic susceptibility measurements (for 3) and paramagnetic resonance spectroscopy: high-frequency and -field electron paramagnetic resonance (for 3 and 4) and frequency-domain Fourier-transform (FD-FT) terahertz electron paramagnetic resonance (for 3), which reveal their zero-field splitting parameters. Experimentally correlated theoretical studies comprising ligand-field theory and quantum chemical theory, the latter including both density functional theory and ab initio methods, reveal the key role played by the Fe 3dz2 (a1) orbital in these systems: the nature of its interaction with the nitrido or imido ligand dictates the spin-state preference of the complex. The ability to tune the spin state through the energy and nature of a single orbital has general relevance to the factors controlling spin states in complexes with applicability as single molecule devices.

Medical student INtervention to promote effective nicotine dependence and tobacco HEalthcare (MIND-THE-GAP): single-centre feasibility randomised trial results.

BACKGROUND: Although brief cessation advice from healthcare professionals increases quit rates, smokers typically do not get this advice during hospitalisation, possibly due to resource issues, lack of training and professionals' own attitudes to providing such counselling. Medical students are a potentially untapped resource who could deliver cessation counselling, while upskilling themselves and changing their own attitudes to delivering such advice in the future; however, no studies have investigated this. We aimed to determine if brief student-led counselling could enhance motivation to quit and smoking cessation behaviours among hospitalised patients. METHODS: A mixed-methods, 2-arm pilot feasibility randomised controlled trial with qualitative process evaluation enrolled 67 hospitalised adult smokers, who were recruited and randomized to receive a brief medical student-delivered cessation intervention (n = 33) or usual care (n = 34); 61 medical students received standardised cessation training and 33 were randomly assigned to provide a brief in-hospital consultation and follow-up support by phone or in-person one week post-discharge. Telephone follow-up at 3- and 6-months assessed scores on the Motivation to Stop Smoking Scale (MTSS; primary outcome) and several other outcomes, including 7-day point prevalent abstinence, quit attempts, use of cessation medication, and ratings of student's knowledge and efficacy. Data were analysed as intention to treat (ITT) using penalised imputation, per protocol, and random effects repeated measures. Focus group interviews were conducted with students post-intervention to elicit their views on the training and intervention process. RESULTS: Analyses for primary and most secondary outcomes favoured the intervention group, although results were not statistically significant. Point prevalence abstinence rates were significantly higher for the intervention group during follow-up for all analyses except 6-month ITT analysis. Fidelity was variable. Patients rated students as being "very" knowledgeable about quitting and "somewhat" helpful. Qualitative results showed students were glad to deliver the intervention; were critical of current cessation care; felt constrained by their inability to prescribe cessation medications and wanted to include cessation and other behavioural counselling in their normal history taking. CONCLUSIONS: It appears feasible for medical students to be smoking cessation interventionists during their training, although their fidelity to the intervention requires further investigation. A definitive trial is needed to determine if medical students are effective cessation counsellors and if student-led intervention could be tailored for other health behaviours. TRIAL REGISTRATION: NCT02601599 (retrospectively registered 1 day after first participant recruited on November 3rd 2015).

Access to Rehabilitation at Six Months Post Stroke: A Profile from the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) Study.

BACKGROUND AND PURPOSE: Stroke is the third leading cause of death and disability. Few studies have assessed the profile and adequacy of access to rehabilitation services after ischaemic stroke both in the inpatient and community setting. The objectives of the Action on Secondary Prevention Interventions and Rehabilitation in Stroke (ASPIRE-S) study were to assess the disability and rehabilitation profile, adherence with rehabilitation recommendations and needs of patients 6 months following hospital admission for stroke. METHODS: A rehabilitation prescription was completed before hospital discharge for each participant, and adherence to this prescription was assessed at 6 months to determine whether patients received their recommended rehabilitation needs. RESULTS: Two hundred and fifty six patients were recruited to ASPIRE-S. The average age was 69 (SD 12.8). A majority (n = 221, 86%) were referred to the hospital multidisciplinary team, 59% (n = 132) were referred to all services (physiotherapy (PT), occupational therapy (OT), speech and language therapy (SLT)). Fifty-four percent (n = 119) of patients (seen by the multidisciplinary team) were referred for further rehabilitation in the community on discharge. Of these 119 patients, 112 (95%) recalled receiving community rehabilitation services. However, while most (68%) patients were referred for several disciplines (PT, OT, SLT), the most commonly recalled therapy (55%) was from a single discipline. The most commonly recommended frequency of therapy required was on a weekly basis. Sixty-one patients (51%) reported a delay in services, with some still awaiting services at 6 months. CONCLUSION: Results from this prospective study revealed that a significant number of patients (57%) did not receive the therapy recommended on discharge. Future initiatives should include the development of policies, which support more effective, equitable multidisciplinary rehabilitation for stroke patients in the community.