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http://theses.ncl.ac.uk/jspui/handle/10443/99
2024-02-05T19:25:41ZA mixed methods study of the follow up of extremely preterm babies in the North East of England
http://theses.ncl.ac.uk/jspui/handle/10443/5246
Title: A mixed methods study of the follow up of extremely preterm babies in the North East of England
Authors: Popescu, Otilia-Ana-Maria
Abstract: 1. Background
Neonatal intensive care medicine has improved
considerably over time, leading to increased neonatal
survival, and improved survival of preterm babies (babies
born before 37 weeks gestation). In 2012, the WHO
declared their commitment to reducing the mortality and
morbidity related to prematurity by several
interventions, including updated approaches to
community-based follow up care for preterm babies.
According to the Office for National Statistics (ONS),
2,490 babies were born in England and Wales in 2018
between 23- and 27- weeks gestation, accounting for
approximately 0.3% of all live births. The 2017 National
Institute for Health and Care Excellence (NICE) guideline
made recommendations for the developmental follow up
of children and young people
born preterm and acknowledged the conditions linked to
preterm delivery. The follow up of preterm babies
determines the baby’s outcomes, their parents’ needs,
and informs planning of health and social care
resources.
Previous research on barriers and facilitators to neonatal
follow up showed that the birth of a preterm baby is a
stressful event, for both mothers and fathers. Parents
develop a different pattern of parenting, stemming from
the concept of increased vulnerability of the preterm
baby. The communication between parents and health
professionals is important, and poor communication
increases parental stress levels. Studies underlined the
relevance of the relationships established between
parents and neonatal staff to parents’ experiences.
2. Aim
This study used a mixed methods design to assess the
neonatal follow up of extremely preterm babies, focusing
on attendance rates in relation to morbidities and
demographic characteristics, as well as parents’ and
health professionals’ perceptions of the neonatal follow
up.3. Methods
This study involved two phases. Phase one was an
analysis of demographic, morbidity, mortality, and 2-
year neurodevelopmental outcomes data of a cohort of
babies born before 28 weeks gestation in the North East
of England, over a 12-month period between July
2015 and June 2016, recorded in the Badger database.
Phase two was a qualitative study of parents’ and health
professionals’ (HPs) views, perceptions, and experience
of the follow up of extremely preterm babies. Parents
were recruited to the study during their attendance for
their baby’s follow up appointments and were
interviewed using a topic guide. Seventeen semistructured
interviews were carried out with 23 parents of
babies born before 28 weeks completed gestation,
between January and December 2018. Thematic
analysis based on the Braun and Clarke model was used.
Twenty one-to-one, semi-structured interviews were
carried out with HPs involved in the follow up care of
preterm babies, between October and December 2018.
Data were analysed using thematic analysis.4. Results
The recruitment rate for phase one was 61%
of the eligible babies; 86.2% of the babies included were
born after 24 weeks gestation, with a mean gestation age
(GA) of 25+3 weeks and a mean birth weight (BW) of 805
grams. More than three quarters of babies were
discharged home on oxygen. Of the cases where
information was available, half of the babies showed
developmental delay, with half of these cases showing
moderate to severe delay. There was no formal diagnosis
of cerebral palsy recorded in the Badger database.
The analysis of the parents’ interviews identified two key
themes: ‘Emotions’ and ‘Here and now’.
The first theme, ‘Emotions’, included three subthemes:
‘The emotions related to the preterm birth - a
rollercoaster’, ‘The post-traumatic stress syndrome’ and
‘The overprotective parent’. Following the birth of their
preterm baby, parents experienced mixed and
contradictory emotions, compared to a rollercoaster,
which may contribute to developing symptoms
suggestive of post-traumatic stress syndrome. Parent
participants developed an overprotective type of
parenting, as previously described in literature.
4. Results
The recruitment rate for phase one was 61%
of the eligible babies; 86.2% of the babies included were
born after 24 weeks gestation, with a mean gestation age
(GA) of 25+3 weeks and a mean birth weight (BW) of 805
grams. More than three quarters of babies were
discharged home on oxygen. Of the cases where
information was available, half of the babies showed
developmental delay, with half of these cases showing
moderate to severe delay. There was no formal diagnosis
of cerebral palsy recorded in the Badger database.
The analysis of the parents’ interviews identified two key
themes: ‘Emotions’ and ‘Here and now’.
The first theme, ‘Emotions’, included three subthemes:
‘The emotions related to the preterm birth - a
rollercoaster’, ‘The post-traumatic stress syndrome’ and
‘The overprotective parent’. Following the birth of their
preterm baby, parents experienced mixed and
contradictory emotions, compared to a rollercoaster,
which may contribute to developing symptoms
suggestive of post-traumatic stress syndrome. Parent
participants developed an overprotective type of
parenting, as previously described in literature.
The second theme, ‘Here and now’, included four
subthemes: ‘The storytelling’, ‘The coping mechanism’,
‘The impact of being born early’ and ‘The value of the
follow up’. Future parents expected a normal term
pregnancy, followed by a normal birth; the
normality was interrupted by the onset of
preterm labour. This interruption marked the beginning
of a different experience, the quality of
which impacted on the bonding and relationship
between baby and parents, and the relationships
between parents and HPs. Parents reported that follow
up offered reassurance.
The analysis of the HPs’ interviews identified two key
themes: ‘Communication’ and ‘The Child Not
Brought’. The first theme, ‘Communication’, included
two subthemes: ‘The Journey’ and ‘The multi-disciplinary
team post discharge’.
The HPs described the experience of the birth and the
follow up of a preterm baby as a journey and continuity
of care was a marker of quality. HPs understood that the
follow up offers reassurance and support to
parents. There was a diversity of job roles of HPs involved
in the care and follow up of preterm babies, leading to
the formation of a multi-disciplinary team
(MDT). Communication occurred in every direction
between the members of the MDT, in many
ways (written/verbal, formal/informal,
paper/electronic).
The second theme, ‘The Child Not Brought’ included
three subthemes: ‘The impact on the baby’, ‘The NHS
point of view’ and ‘Why do parents not attend?’.
HPs suggested several potential reasons why
parents may not bring their child(ren) to the follow up
appointments: parents may not understand the role
of the follow up, especially if the child is well; parents
fear bad news; families may have a busy life, have too
many appointments or have
just seen another HP; communication breakdown
(related to system or human factors); neglect; distance
and travel; psychological issues (fear to leave the house,
bad memories linked to the hospital environment).
5. Discussion
Findings from this research
provide important insights into the views and
experiences of parents of preterm babies with
regards to their baby’s follow up appointments. The birth
of a preterm baby is a stressful event; parents develop a
different pattern of parenting, stemming from the
concept of the increased vulnerability of the preterm
baby.
HPs described the birth and follow up of an extremely
preterm baby as a journey. The continuity of care and
good communication contribute to improving this
journey. Due to the complexity of the team involved in
the follow up of the extremely preterm baby, there were
challenges in communication, at different levels.
Relatively small changes in practice,
such as allowing for normality by encouraging the
parents to read to their baby at night-time, and ensuring
adequate communication and appropriate
reassurance, could improve the parents’ experience,
their engagement with follow up appointments, and
therefore their baby’s outcomes.
NICE recommends follow up of babies born extremely
preterm to school age, however there is
no established referral pathway into the paediatric
services. Parents value continuity of care, which may
be challenging if there is no clear transition process
between neonates and paediatrics. Ensuring a smooth
transition at every level by designing a clear pathway for
the neonatal follow up of extremely preterm babies and
the transition to paediatric services may improve the
follow up process, parents’ engagement with the
system and their baby’s outcomes.
Description: M.D Thesis2021-01-01T00:00:00ZDietary nitrate in vascular and brain health
http://theses.ncl.ac.uk/jspui/handle/10443/5238
Title: Dietary nitrate in vascular and brain health
Authors: Babateen, Abrar Mohammad
Abstract: Nitric oxide (NO) is a highly reactive molecule that is essential for several biological processes,
including the regulation of vascular resistance, neurotransmission and muscular energetics.
Sufficient NO production is crucial for the maintenance of a healthy vascular system. With
ageing, NO synthesis from arginine, catalysed by NO synthase (NOS), is reduced, which may
contribute to increased blood pressure (BP), endothelial dysfunction (ED) and impaired brain
function. Dietary nitrate (NO3-) is an important source of NO production via a non-enzymatic
pathway involving the progressive conversion of NO3- into nitrite (NO2-) by the action of oral
bacteria, and then to NO in low pH and hypoxic environments (i.e., stomach and arterial-tocapillary
circulation). Whilst several clinical studies have assessed the effect of supplemental
dietary NO3- intake (often supplied as beetroot juice (BJ)) on vascular and cognitive functions,
there is a significant gap in the literature concerning the effects of longer-term intervention,
especially in older people. This PhD investigated the effects of BJ supplementation in adult
population, including healthy younger and older overweight and obese adult population who is
at a higher risk of physiological dysfunctions, including cardiovascular disease and cognitive
impairment.
I conducted a systematic review of observational studies to assess NO3- intake by adults. The
review included 55 articles and found that the median daily NO3- intakes were similar in both
healthy and patient populations and below the safe upper intake of daily NO3- intake (3.7 mg/kg
body weight). Then, I performed a meta-analysis of 18 randomised control trials (RCT) to
examine the effect of NO3- or NO2- supplementation on cognitive function and cerebral blood
flow (CBF). This meta-analysis revealed no overall effect of NO3- or NO2- supplementation on
cognitive function or CBF. This meta-analysis helped to inform the design of the subsequent
feasibility study.
Next, I conducted a small pilot study to examine the validity and reliability of NO2- salivary
strips (against reference standard laboratory measures) with and without the use of mouthwash.
This study showed that these strips have a high level of reproducibility and repeatability in
detecting changes in salivary NO2-. The study also indicated that the strips can be used to
monitor NO3- intake in long-term dietary NO3- interventions.
The final phase of this project provided evidence of the acceptability and feasibility of an
intervention testing the effects of prolonged consumption of incremental doses of NO3- in
overweight and obese older participants. The findings of this study showed that cognitive
function and CBF were not affected by long-term BJ supplementation. However, there was a
non-significant trend towards on systolic BP (SBP) reduction with lower BJ doses.
Description: PhD Thesis2021-01-01T00:00:00ZAnxiety in Autism Spectrum Disorder (ASD) : the influence of executive and sensory processing dysfunctions
http://theses.ncl.ac.uk/jspui/handle/10443/5235
Title: Anxiety in Autism Spectrum Disorder (ASD) : the influence of executive and sensory processing dysfunctions
Authors: Darus, Nooraini
Abstract: Introduction: Autism Spectrum Disorder (ASD) is a neurodevelopmental
disorder associated with difficulties with social communication and the presence
of restricted and repetitive behaviours. There is significant heterogeneity of
symptom profiles within the disorder. Anxiety is very common in individuals with
ASD. Previous research suggests associations between executive function
deficits and sensory processing atypicalities and anxiety in ASD, though neither
relationship has been explored in detail. Aims: To examine the putative
relationships between anxiety, executive function difficulties and sensory
processing atypicalities in children with ASD, taking into account potential
heterogeneity within the sample. Method: Thirty six families with a child with
ASD were recruited. The children completed an anxiety questionnaire and
standardised assessments of executive function. Parents completed
questionnaire about their child’s anxiety, sensory processing difficulties and
autism severity. 22 parents completed a follow-up study of their child’s anxiety,
everyday executive function and repetitive behaviours. Correlational analysis
and cluster analysis were used to examine the data.
Results: Anxiety scores were high and remained stable over a twenty month
period. No significant associations were found between objective measures of
executive function difficulties and anxiety, though parent reported child
executive difficulties were associated with heightened parent reported child
anxiety.High anxiety was associated with sensory processing atypicalities, and
higher levels of ASD severity. Importantly, cluster analysis revealed distinct
subgroups of children in relation to anxiety, sensory and executive profiles,
illustrating heterogeneity within the sample.
Conclusions: The findings supports previous research that anxiety is high in
children with ASD and remains high over time and is associated with sensory
processing atypicalities. The relationship between executive function and
anxiety varied as a function of the source of the data. Cluster analysis illustrates
the importance of considering heterogeneity in ASD. Implications for clinical
practice and future research are discussed.
Description: Ph. D. Thesis.2021-01-01T00:00:00ZThe role of residual beta-cell function on glycaemic and vascular outcomes at rest and post exercise in people with type 1 diabetes
http://theses.ncl.ac.uk/jspui/handle/10443/5226
Title: The role of residual beta-cell function on glycaemic and vascular outcomes at rest and post exercise in people with type 1 diabetes
Authors: Taylor, Guy Stuart
Abstract: Within patients with type 1 diabetes (T1D), residual ꞵ-cell function and endogenous insulin secretion occurs in a substantial number of individuals. The role this ꞵ-cell function plays in glycaemic control in individuals with T1D is currently not fully understood. This is especially true around exercise, where maintaining glycaemic control is challenging and a large inter-individual variation exists. Micro amounts of endogenous insulin secretion appears to offer some protection against vascular damage and diabetes complications. Endothelial progenitor cells (EPCs) are important for the repair and growth of blood vessels, with circulating numbers increased by exercise. However, the count of EPCs appear to be reduced in individuals with T1D. It is unknown whether residual ꞵ-cell function in individuals with T1D influences these circulating cells. Therefore, this thesis aimed to investigate the effects of residual ꞵ-cell function in individuals with T1D and its influence on glycaemic control under free-living conditions and after an acute bout of aerobic exercise, as well as on the count of circulating EPCs at rest and after exercise mobilisation.
Chapter 3 demonstrated that under free-living conditions, increased endogenous insulin secretion was associated with improved continuous glucose monitoring measures, including increased time spent in euglycaemia. The results of Chapter 4 revealed that within a cohort who had comparable glycaemic control under free-living conditions, individuals with higher residual ꞵ-cell function displayed a substantially greater amount of time spent in euglycaemia in the hours following a bout of moderate intensity exercise compared to those with undetectable or lower endogenous insulin secretion. Lastly, Chapter 5 assessed the number of circulating EPCs at rest and after mobilisation with a bout of moderate intensity exercise. In comparison to matched non-diabetes controls, all markers of EPCs were lower in the T1D group, with some markers having attenuated mobilisation with exercise. Despite comparable resting counts, only the high residual ꞵ-cell function group had mobilisation of these cells with exercise within the T1D participants.
In conclusion, the findings of this thesis demonstrate that residual ꞵ-cell function impacts upon individuals with longer duration T1D. Increased C-peptide secretion is associated with improved glycaemic control under free-living conditions and after an acute bout of exercise, as well as increasing the count of circulating EPCs that are mobilised with exercise.
Description: PhD Thesis2020-01-01T00:00:00Z