Environmental enrichment for stroke and other non-progressive brain injury.

BACKGROUND: Rehabilitation is effective for recovery after stroke and other non-progressive brain injuries but it is unclear if the rehabilitation environment itself, outside of limited therapy hours, is maximally conducive to recovery. Environmental enrichment is a relatively new concept within rehabilitation for humans. In this review, this is defined as an intervention designed to facilitate physical (motor and sensory), cognitive and social activity by the provision of equipment and organisation of a structured, stimulating environment. The environment should be designed to encourage (but not force) activities without additional specialised rehabilitation input. OBJECTIVES: To assess the effects of environmental enrichment on well-being, functional recovery, activity levels and quality of life in people who have stroke or non-progressive brain injury. SEARCH METHODS: We conducted the search on 26 October 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE (from 1950); Embase (from 1980); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982); the Allied and Complementary Medicine Database (AMED; from 1985); PsycINFO (from 1806); the Physiotherapy Evidence Database (PEDro; from 1999); and 10 additional bibliographic databases and ongoing trial registers. SELECTION CRITERIA: We planned to include randomised controlled trials (RCTs) that compared environmental enrichment with standard services. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed eligible studies, extracted data, and assessed study quality. Any disagreements were resolved through discussion with a third review author. We determined the risk of bias for the included study and performed a 'best evidence' synthesis using the GRADE approach. MAIN RESULTS: We identified one RCT, involving 53 participants with stroke, comparing environmental enrichment (which included physical, cognitive and social activities such as reading material, board and card games, gaming technology, music, artwork, and computer with Internet) with standard services in an inpatient rehabilitation setting. We excluded five studies, found two studies awaiting classification and one ongoing study which described environmental enrichment in their interventions. Of the excluded studies, three were non-RCTs and two described co-interventions with a significant component of rehabilitation. Based on the single small included RCT at high risk of bias, data are insufficient to provide any reliable indication of benefit or risk to guide clinical practice in terms of the provision of environmental enrichment. AUTHORS' CONCLUSIONS: The gap in current research should not, however, be interpreted as proof that environmental enrichment is ineffective. Further research is needed with robust study designs, such as cluster RCTs, and consistent outcome measurement evaluating the effectiveness of environmental enrichment in different settings (inpatient versus outpatient), the relative effectiveness of various components of environmental enrichment, cost-effectiveness, and safety of the intervention in people following stroke or other non-progressive brain injuries. It should be noted, however, that it is challenging to randomise or double-blind trials of environmental enrichment given the nature of the intervention.

Interventions for sexual dysfunction following stroke.

BACKGROUND: Sexual dysfunction following stroke is common but often is poorly managed. As awareness of sexual dysfunction following stroke increases as an important issue, a clearer evidence base for interventions for sexual dysfunction is needed to optimise management. OBJECTIVES: To evaluate the effectiveness of interventions to reduce sexual dysfunction following stroke, and to assess adverse events associated with interventions for sexual dysfunction following stroke. SEARCH METHODS: We conducted the search on 27 November 2019. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; from June 2014), in the Cochrane Library; MEDLINE (from 1950); Embase (from 1980); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982); the Allied and Complementary Medicine Database (AMED; from 1985); PsycINFO (from 1806); the Physiotherapy Evidence Database (PEDro; from 1999); and 10 additional bibliographic databases and ongoing trial registers. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared pharmacological treatments, mechanical devices, or complementary medicine interventions versus placebo. We also included other non-pharmacological interventions (such as education or therapy), which were compared against usual care or different forms of intervention (such as different intensities) for treating sexual dysfunction in stroke survivors. DATA COLLECTION AND ANALYSIS: Two review authors independently selected eligible studies, extracted data, and assessed study quality. We determined the risk of bias for each study and performed a 'best evidence' synthesis using the GRADE approach. MAIN RESULTS: We identified three RCTs with a total of 212 participants. We noted significant heterogeneity in interventions (one pharmacological, one physiotherapy-based, and one psycho-educational), and all RCTs were small and of 'low' or 'very low' quality. Based on these RCTs, data are insufficient to provide any reliable indication of benefit or risk to guide clinical practice in terms of the use of sertraline, specific pelvic floor muscle training, or individualised sexual rehabilitation. AUTHORS' CONCLUSIONS: Use of sertraline to treat premature ejaculation needs to be tested in further RCTs. The lack of benefit with structured sexual rehabilitation and pelvic floor physiotherapy should not be interpreted as proof of ineffectiveness. Well-designed, randomised, double-blinded, placebo-controlled trials of long-term duration are needed to determine the effectiveness of various types of interventions for sexual dysfunction. It should be noted, however, that it may not be possible to double-blind trials of complex interventions.

Symptomatic treatments for amyotrophic lateral sclerosis/motor neuron disease.

BACKGROUND: Motor neuron disease (MND), which is also known as amyotrophic lateral sclerosis (ALS), causes a wide range of symptoms but the evidence base for the effectiveness of the symptomatic treatment therapies is limited. OBJECTIVES: To summarise the evidence from Cochrane Systematic Reviews of all symptomatic treatments for MND. METHODS: We searched the Cochrane Database of Systematic Reviews (CDSR) on 15 November 2016 for systematic reviews of symptomatic treatments for MND. We assessed the methodological quality of the included reviews using the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the GRADE approach. We followed standard Cochrane study (review) selection and data extraction procedures. We reported findings narratively and in tables. MAIN RESULTS: We included nine Cochrane Systematic Reviews of interventions to treat symptoms in people with MND. Three were empty reviews with no included randomised controlled trials (RCTs); however, all three reported on non-RCT evidence and the remaining six included mostly one or two studies. We deemed all of the included reviews of high methodological quality. Drug therapy for painThere is no RCT evidence in a Cochrane Systematic Review exploring the efficacy of drug therapy for pain in MND. Treatment for crampsThere is evidence (13 RCTs, N = 4012) that for the treatment of cramps in MND, compared to placebo:- memantine and tetrahydrocannabinol (THC) are probably ineffective (moderate-quality evidence);- vitamin E may have little or no effect (low-quality evidence); and- the effects of L-threonine, gabapentin, xaliproden, riluzole, and baclofen are uncertain as the evidence is either very low quality or the trial specified the outcome but did not report numerical data.The review reported adverse effects of riluzole, but it is not clear whether other interventions had adverse effects. Treatment for spasticityIt is uncertain whether an endurance-based exercise programme improved spasticity or quality of life, measured at three months after the programme, as the quality of evidence is very low (1 RCT, comparison "usual activities", N = 25). The review did not evaluate other approaches, such as use of baclofen as no RCTs were available. Mechanical ventilation for supporting respiratory functionNon-invasive ventilation (NIV) probably improves median survival and quality of life in people with respiratory insufficiency and normal to moderately impaired bulbar function compared to standard care, and improves quality of life but not survival for people with poor bulbar function (1 RCT, N = 41, moderate-quality evidence; a second RCT did not provide data). The review did not evaluate other approaches such as tracheostomy-assisted ('invasive') ventilation, or assess timing of NIV initiation. Treatment for sialorrhoeaA single session of botulinum toxin type B injections to parotid and submandibular glands probably improves sialorrhoea and quality of life at up to 4 weeks compared to placebo injections, but not at 8 or 12 weeks after the injections (moderate-quality evidence from 1 placebo-controlled RCT, N = 20). The review authors found no trials of other approaches. Enteral tube feeding for supporting nutritionThere is no RCT evidence in a Cochrane Systematic Review to support benefit or harms of enteral tube feeding in supporting nutrition in MND. Repetitive transcranial magnetic stimulationIt is uncertain whether repetitive transcranial magnetic stimulation (rTMS) improves disability or limitation in activity in MND in comparison with sham rTMS (3 RCTs, very low quality evidence, N = 50). Therapeutic exerciseThere is evidence that exercise may improve disability in MND at three months after the exercise programme, but not quality of life, in comparison with "usual activities" or "usual care" including stretching (2 RCTs, low-quality evidence, N = 43). Multidisciplinary careThere is no RCT evidence in a Cochrane Systematic Review to demonstrate any benefit or harm for multidisciplinary care in MND.None of the reviews, other than the review of treatment for cramps, reported that adverse events occurred. However, the trials were too small for reliable adverse event reporting. AUTHORS' CONCLUSIONS: This overview has highlighted the lack of robust evidence in Cochrane Systematic Reviews on interventions to manage symptoms resulting from MND. It is important to recognise that clinical trials may fail to demonstrate efficacy of an intervention for reasons other than a true lack of efficacy, for example because of insufficient statistical power, the wrong choice of dose, insensitive outcome measures or inappropriate participant eligibility. The trials were mostly too small to reliably assess adverse effects of the treatments. The nature of MND makes it difficult to research clinically accepted or recommended practice, regardless of the level of evidence supporting the practice. It would not be ethical, for example, to design a placebo-controlled trial for treatment of pain in MND or to withhold multidisciplinary care where such care is available. It is therefore highly unlikely that there will ever be classically designed placebo-controlled RCTs in these areas.We need more research with appropriate study designs, robust methodology, and of sufficient duration to address the changing needs-of people with MND and their caregivers-associated with MND disease progression and mortality. There is a significant gap in studies assessing the effectiveness of interventions for symptoms relating to MND, such as pseudobulbar emotional lability and cognitive and behavioural difficulties. Future studies should use appropriate outcome measures that are reliable, have internal and external validity, and are sensitive to change in what is being measured (such as quality of life).

Multidisciplinary rehabilitation after primary brain tumour treatment.

BACKGROUND: Brain tumours can cause significant disability, which may be amenable to multidisciplinary rehabilitation. However, the evidence base for this is unclear. This review is an update of a previously published review in the Cochrane Database of Systematic Reviews [2013, Issue 1, Art. No. CD009509] on 'Multidisciplinary rehabilitation after primary brain tumour treatment'. OBJECTIVES: To assess the effectiveness of multidisciplinary rehabilitation in people after primary brain tumour treatment, especially the types of approaches that are effective (settings, intensity). SEARCH METHODS: For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library up to Issue 12 of 12, 2014), MEDLINE (1950 to January week 2, 2015), EMBASE (1980 to January week 2, 2015), PEDro (1985 to January week 2 2015), and LILACS (1982 to January week 2, 2015). We checked the bibliographies of papers we identified and contacted the authors and known experts in the field to seek published and unpublished trials. SELECTION CRITERIA: Controlled clinical trials (randomised and non-randomised clinical trials) that compared multidisciplinary rehabilitation in primary brain tumour with either routinely available local services or lower levels of intervention, or studies that compared multidisciplinary rehabilitation in different settings or at different levels of intensity. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed study quality, extracted data, and performed a 'best evidence ' synthesis based on methodological quality. MAIN RESULTS: We did not identify any studies for inclusion in the previous version of this review. For this update, the literature search identified one low-quality controlled clinical trial involving 106 participants. The findings from this study suggest 'low-level' evidence to support high-intensity ambulatory (outpatient) multidisciplinary rehabilitation in reducing short- and long-term motor disability (continence, mobility and locomotion, cognition), when compared with standard outpatient care. We found improvement in some domains of disability (continence, communication) and psychosocial gains were maintained at six months follow-up. We found no evidence for improvement in overall participation (quality of life and societal relationship). No adverse events were reported as a result of multidisciplinary rehabilitation. We found no evidence for improvement in quality of life or cost-effectiveness of rehabilitation. It was also not possible to suggest best 'dose' of therapy. AUTHORS' CONCLUSIONS: Since the last version of this review, one new study has been identified for inclusion. The best evidence to date comes from this CCT, which provides low quality evidence that higher intensity ambulatory (outpatient) multidisciplinary rehabilitation reduces short- and long-term disability in people with brain tumour compared with standard outpatient care. Our conclusions are tentative at best, given gaps in current research in this area. Although the strength of evidence has increased with the identification of a new controlled clinical trial in this updated review, further research is needed into appropriate and robust study designs; outcome measurement; caregiver needs; evaluation of optimal settings; type, intensity, duration of therapy; and cost-effectiveness of multidisciplinary rehabilitation in the brain tumour population.

Evaluation of hazardous airborne carbonyls on a university campus in southern China.

A comprehensive assessment of indoor carbonyl compounds for the academic staff workers, and students was conducted on a university campus in Xiamen, China. A total of 15 representative environment categories, including 12 indoor workplaces and three residential units, were selected. The potential indoor pollution sources were identified based on the variability in the molar compositions and correlation analyses for the target carbonyls. Furnishing materials, cooking emissions, and electronic equipment, such as photocopiers, can generate various carbonyls in the workplace. Comparison studies were conducted in the clerical offices, demonstrating that off-gases from wooden furniture and lacquer coatings, environmental tobacco smoke (ETS), and the use of cleaning reagents elevated the indoor carbonyl levels. The measured concentrations of formaldehyde and acetaldehyde in most locations surpassed the exposure limit levels. The lifetime cancer hazard risk (R) associated with formaldehyde was above the concern risk level (1 x 10(-6)) in all of the workplaces. The results indicate that formaldehyde exposure is a valid occupational health and safety concern. Wooden furniture and refurbishing materials can pose serious health threats to occupants. The information in this study could act as a basis for future indoor air quality monitoring in Mainland China. Implications: A university campus represents a microscale city environment consisting of all the working, living, and commercial needs of staff and students. The scope of this investigation covers 21 hazardous carbonyl species based on samples collected from 15 categories of workplaces and residential building in a university campus in southern China. Findings of the study provide a comprehensive assessment of indoor air quality with regards to workers' health and safety. No similar study has been carried out in China.

Multidisciplinary rehabilitation after primary brain tumour treatment.

BACKGROUND: Brain tumours can cause significant disability, which may be amenable to multidisciplinary rehabilitation. However, the evidence base for this is unclear. OBJECTIVES: To assess the effectiveness of multidisciplinary rehabilitation in adults after primary brain tumour treatment, especially the types of approaches that are effective (settings, intensity) and the outcomes that are affected. SEARCH METHODS: We searched the Cochrane Neuromuscular Disease Group Specialized Register (March week 2, 2012), The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 3, 2012), MEDLINE (1966 to March week 2, 2012), EMBASE (1980 to March week 2, 2012), PEDro (1982 to March 2012) and LILACS (1982 to March week 2, 2012). We checked the bibliographies of papers identified and contacted the authors and known experts in the field to seek published and unpublished trials. SELECTION CRITERIA: Controlled clinical trials (randomised and non-randomised clinical trials) that compared multidisciplinary rehabilitation in primary brain tumour with either routinely available local services or lower levels of intervention, or studies that compared multidisciplinary rehabilitation in different settings or at different levels of intensity. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed study quality, extracted data and performed a 'best evidence' synthesis based on methodological quality. MAIN RESULTS: No randomised controlled trials (RCTs) or controlled clinical trials (CCTs) were identified. AUTHORS' CONCLUSIONS: No RCTs or CCTs were available for synthesis of 'best evidence' for multidisciplinary rehabilitation after treatment for brain tumour patients. However, this does not suggest the ineffectiveness of multidisciplinary rehabilitation but rather highlights the challenges in trial design and rigour, outcome measurement and complexities of care in this population. For completeness of literature, 12 observational studies (with high risk of bias) involving patients with brain tumours were included. These studies provided 'very low level' evidence suggesting that multidisciplinary rehabilitation (inpatient, home-based) may improve functional outcomes, and ambulatory programmes (outpatient and home-based) may improve vocation and quality of life. These conclusions are tentative at best, given gaps in current research in this area. Further research is needed into appropriate and robust study designs, outcome measurement, caregiver needs, evaluation of optimal settings, type, intensity, duration of therapy, and cost-effectiveness of multidisciplinary rehabilitation in the brain tumour population.

Hazardous airborne carbonyls emissions in industrial workplaces in China.

UNLABELLED: A pilot hazardous airborne carbonyls study was carried out in Hong Kong and the Mainland of China. Workplace air samples in 14 factories of various types of manufacturing and industrial operations were collected and analyzed for a panel of 21 carbonyl compounds. The factories can be classified into five general categories, including food processing, electroplating, textile dyeing, chemical manufacturer, and petroleum refinery. Formaldehyde was invariably the most abundant carbonyl compound among all the workplace air samples, accounting for 22.0-44.0% of the total measured amount of carbonyls on a molar basis. Acetone was also found to be an abundant carbonyl in workplace settings; among the selected industrial sectors, chemical manufacturers' workplaces had the highest percentage (an average of 42.6%) of acetone in the total amount of carbonyls measured in air. Benzaldehyde accounted for an average of 20.5% of the total amount of detected carbonyls in electroplating factories, but its contribution was minor in other industrial workplaces. Long-chain aliphatic carbonyls (C6-C10) accounted for a large portion (37.2%) of the total carbonyls in food-processing factories. Glyoxal and methylglyoxal existed at variable levels in the selected workplaces, ranging from 0.2% to 5.5%. The mixing ratio of formaldehyde ranged from 8.6 to 101.2 ppbv in the sampled workplaces. The observed amount of formaldehyde in two paint and wax manufacturers and food-processing factories exceeded the World Health Organization (WHO) air quality guideline of 81.8 ppbv. Carcinogenic risks of chronic exposure to formaldehyde and acetaldehyde by the workers were evaluated. The lifetime cancer hazard risks associated with formaldehyde exposure to male and female workers ranged from 2.01 x 10(-5) to 2.37 x 10(-4) and 2.68 x 10(-5) to 3.16 x 10(-4), respectively. Such elevated risk values suggest that the negative health impact of formaldehyde exposure represents a valid concern, and proper actions should be taken to protect workers from such risks. IMPLICATIONS: Many carbonyl species (e.g., formaldehyde, acetaldehyde, and acrolein) are air toxins and they pose public healt risks. The scope of this investigation covers 21 types of carbonyls based on samples collected from 14 different workplaces. Findings of the study will not only provide a comprehensive assessment of indoor air quality with regard to workers' healthy and safety, but also establish a theoretical foundation for future formulation of intervention strategies to reduce occupational carbonyl exposures. No similar study has been carried out either in Hong Kong or the Mainland of China.

Outcomes of medical students training schoolchildren of ages 13-18 in cardiopulmonary resuscitation: A systematic review.

Background: Training schoolchildren in cardiopulmonary resuscitation (CPR) can increase the number of qualified people in the community, which in turn can improve survival rates of out-of-hospital cardiac arrests (OHCA). Medical students could be a valuable resource for providing the training. This systematic review aims to determine the outcomes of medical students providing CPR training to schoolchildren, aged 13-18 (who are thought to have the strength for effective chest compression), specifically CPR skills for both and non-technical skills such as communication and leadership for medical students. Methods: A literature search of academic databases was conducted on 5 July 2023 using the following keywords: cardiopulmonary resuscitation, basic life support, medical students and high/middle/secondary school students. For the purpose of this review, "schoolchildren" refer to those aged 13-18. Studies were included where the primary focus was medical students teaching CPR to schoolchildren. The studies were critically appraised using the Medical Education Research Study Quality Instrument (MERSQI) tool and outcomes categorised by Kirkpatrick's Levels. Results: Eleven studies were included, six randomised controlled trials and five cohort studies, with 1670 schoolchildren and 355 medical students as participants. Eight studies examined outcomes targeting schoolchildren, two examined outcomes for medical students and one examined both. Four of the eleven studies used validated outcome measures. Only outcomes at Kirkpatrick Level 1 and 2 were found, and all outcomes for both schoolchildren and medical students were positive. Schoolchildren showed improvements in theoretical and practical elements of CPR post-training, while medical students demonstrated improved professional practice skills such as leadership and mentorship as well as improvements in their own CPR skills post-teaching. Conclusions: Schoolchildren can effectively acquire CPR skills through being trained by medical students, who themselves also benefit from improved CPR and professional practice skills after teaching. Further studies with robust methodology such as multi-site randomised controlled trials, the use of consistent and validated outcome measures, and the measurement of outcomes at higher Kirkpatrick levels to determine the impact on bystander CPR rates and community OHCA survival rates, are needed.

Educational Interventions for Medical Students to Improve Pharmacological Knowledge and Prescribing Skills: A Scoping Review.

Introduction: Medication-related errors place a heavy financial burden on healthcare systems worldwide, and mistakes are most likely to occur at the stage of prescribing. Junior doctors are more likely to make prescribing errors, and medical graduates also lack confidence and preparedness towards prescribing. Thus, this review aimed to evaluate the existing educational approaches to improve pharmacological knowledge and prescribing skills among medical students. Methods: CENTRAL, CINAHL, ERIC, Ovid Embase, Ovid MEDLINE, Ovid PsycINFO, and Scopus were searched with keywords related to "pharmacological knowledge", "prescribing skills", "educational interventions" for articles published since 2016. Results: 3595 records were identified, and 115 full-text articles were assessed for eligibility. Eighty full-text articles were eligible and included in this review. Thirty-seven studies focused on improving prescribing skills, whilst 43 targeted pharmacological knowledge. A broad range of interventions was implemented, including e-learning, case-based, interprofessional, and experiential learning. Pharmacological knowledge and prescribing skills were measured in various ways, and all studies reported one or more positive findings at Kirkpatrick level 1 or 2. No study reported outcomes at Kirkpatrick levels 3 and 4. Discussion: The World Health Organisation's Good Guide to Prescribing was the foundation of the development of prescribing educational interventions. Emerging interventions such as experiential and interprofessional learning should be incorporated into the prescribing curriculum. Innovative approaches such as game-based learning can be considered for clinical pharmacology teaching. However, there was a lack of outcomes at Kirkpatrick levels 3 and 4. Robust methodology and reliable outcome measures are also needed in future studies.

Quality of life and swallowing outcomes after early proactive swallowing rehabilitation by either transcutaneous neuromuscular electrical stimulation or exercise-based swallowing training in patients with nasopharyngeal carcinoma after radiotherapy.

Background: Exercise-based swallowing training (EBST) and transcutaneous neuromuscular electrical stimulation (TNMES) are common modalities used to treat late dysphagia after radiotherapy for nasopharyngeal carcinoma (NPC). We aimed to investigate and compare the efficacies of EBST and TNMES as proactive treatments administered early after radiotherapy. Methods: Patients with early post-radiotherapy NPC (n = 120) underwent either TNMES or EBST. Flexible endoscopic evaluation of swallowing (FEES), quality of life (QOL), and swallowing function questionnaires were completed before the intervention as well as immediately, 6, and 12 months after the intervention. Outcome measures included the scores for the swallowing function score (SFS), penetration and aspiration scale (PAS), dynamic imaging grade of swallowing toxicity (DIGEST), functional oral intake scale (FOIS), swallowing performance status scale (SPSS), pharyngeal motor impairment (PMI), pharyngeal function impairment (PFI), and functional assessment after cancer therapy-nasopharyngeal (FACT-NP) questionnaire. Results: Three months after radiotherapy, 31 and 34 patients underwent TNMES and EBST, respectively, and completed swallowing assessments at all four assessment timepoints. All patients showed post-radiotherapy impairments in the SFS, PAS, DIGEST, PMI, and PFI. Compared with the EBST group, the TNMES group showed significant improvements in the PFI and PMI scores, with small-to-medium effect sizes. Additionally, compared with the EBST group, the TNMES group demonstrated a trend toward slightly better improvements in the PAS, DIGEST, FOIS, and SPSS scores immediately and 6 months after the intervention. The SFS scores improved from baseline in both groups; however, the TNMES group showed an earlier improvement. Finally, the TNMES group showed better QOL according to the FACT-NP than the EBST group. Conclusion: Proactive TMNES and EBST are safe and feasible modalities for improving swallowing in patients with NPC when administered early after radiotherapy. Although TNMES showed better results than EBST, these results should be interpreted with caution given the study limitations. Level of evidence: 1B.

Multidisciplinary rehabilitation for follow-up of women treated for breast cancer.

BACKGROUND: Breast cancer is the most common malignancy in women worldwide. Multidisciplinary rehabilitation aims to improve outcomes for women but the evidence base for its effectiveness is yet to be established. OBJECTIVES: To assess the effects of organised multidisciplinary rehabilitation during follow-up in women treated for breast cancer. SEARCH METHODS: We searched the Cochrane Breast Cancer Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, CINAHL, AMED, PEDro and LILACS in December 2011. SELECTION CRITERIA: Randomised and controlled clinical trials (RCTs, CCTs, respectively) that compared multidisciplinary rehabilitation with some form of control intervention (such as a lower level or different type of intervention, minimal intervention, waiting list controls or no treatment, interventions given in different settings). DATA COLLECTION AND ANALYSIS: The type of data retrieved did not allow for quantitative synthesis and therefore a narrative synthesis was provided. The methodological quality of the included studies was evaluated by three authors using the risk of bias tool. MAIN RESULTS: Two RCTs, including 262 participants, met the inclusion criteria. Both trials scored poorly for methodological quality. There was 'low level' evidence that multidisciplinary rehabilitation produced short-term gains at the levels of impairment (that is range of shoulder movement), psychosocial adjustment and quality of life after breast cancer treatment (up to 12 months). No evidence was available for the longer-term functional outcomes for caregivers or the cost effectiveness of these programmes. It was not possible to suggest the most appropriate frequency and duration of therapy or choice of one type of intervention over another. AUTHORS' CONCLUSIONS: There was 'low level' evidence that multidisciplinary rehabilitation can improve the outcomes of people with breast cancer in terms of functional ability, psychosocial adjustment and participation in social activities. There was no evidence available on functional gain at the level of activity. This review highlights the limitations of RCTs in rehabilitation settings and the need for high-quality trial-based research in this area. Regular evaluation and assessment of breast cancer survivors for rehabilitation is recommended.

Peer teaching and Pecha Kucha for pharmacology.

BACKGROUND: Peer teaching involves learners at the same level in their academic career aiding each other's education. In medical education, it has had success in clinical and procedural skills; we set out to design a pharmacology peer teaching initiative and evaluate its acceptability and value as a learning tool. APPROACH: Second-year medical students (n = 62) were invited to participate in a peer-led pharmacology educational initiative over 2 months. Students created PowerPoint presentations on medications using Pecha Kucha principles (automatic slide advancement that emphasises concision through time and content limitations to sustain the audience's attention). Presentations occurred over eight, 1-hour sessions, facilitated by senior academics. EVALUATION: The evaluation consisted of an anonymous questionnaire with 10 Likert-scale questions and two open-ended questions on the learners' perceptions of feasibility, acceptability and effectiveness in improving knowledge, teaching and independent learning skills. Fifty-three students presented at well-attended sessions. Twenty-nine students completed the Kirkpatrick Level 1 evaluation with largely positive perceptions, including improved pharmacology knowledge (n = 21, 72%), teaching skills (n = 23, 79%) and independent learning skills (n = 22, 76%). Satisfaction with both the quality of peer teaching (n = 21, 72%) and presence of expert facilitators (97%, n = 28) was high. Three found the initiative burdensome, and 23 reported information overload. Nevertheless, 23 deemed the experience valuable. Facilitator reflections were also positive. IMPLICATIONS: Our peer teaching initiative appeared useful to our learners, but in this process, we gained valuable information to improve the next iteration. We plan to use this format either for revision material or reduce session length and increase interval time between sessions to address the perceived information overload.

Geriatric Educational Interventions for Physicians Training in Non-Geriatric Specialties: A Scoping Review.

BACKGROUND: Physicians require the expertise to care for an increasingly aging population. A robust understanding of geriatric educational interventions is needed to improve geriatric training for physicians. OBJECTIVE: To map the breadth of geriatric educational interventions for residents (in non-geriatric specialties). METHODS: We used a scoping review methodology. We searched MEDLINE, Embase, EMCare, CENTRAL, ERIC, and Scopus from 2004 to September 2019 for search terms related to "educational approaches" AND "geriatric" AND "residents." Two authors independently selected eligible studies, extracted data (categorized by educational approaches and Kirkpatrick level outcomes), and critically appraised studies using the Mixed Methods Appraisal Tool. RESULTS: There were 63 included studies, with a total of 6976 participants. Twelve studies had comparators, including 5 randomized controlled trials. Fifty-three studies (84%) described multicomponent interventions, incorporating combinations of didactic or self-directed approaches with interactive, simulation, experiential, and/or group-based learning. Use of curricular process was explicitly reported in 34 studies (59%). Most studies met at least 4 of 5 Mixed Methods Appraisal Tool criteria. Studies commonly measured outcomes at Kirkpatrick levels 1 and 2 (reaction and learning), with 15 studies measuring performance outcomes (Kirkpatrick levels 3 and 4b). All included studies had at least one positive result. CONCLUSIONS: All educational interventions had positive outcomes; however, curriculum-informed multicomponent interventions were the most common. This scoping review demonstrates that robust methodology with comparators, longer-term designs, and use of higher-level Kirkpatrick outcome measures is possible but not commonly used. Clear direction for future research is provided.

Multidisciplinary care for Guillain-Barré syndrome.

BACKGROUND: Guillain-Barré syndrome is a significant cause of new long-term disability, which is thought to be amenable to multidisciplinary care, but the evidence base for its effectiveness is unclear. OBJECTIVES: To assess the effectiveness of multidisciplinary care in adults with Guillain-Barré syndrome, especially the types of approaches that are effective (settings, intensity) and the outcomes that are affected. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Specialized Register (20 May 2010), The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2010, Issue 2), MEDLINE (1966 to May 2010), EMBASE (1980 to May 2010), CINAHL (1982 to May 2010), AMED (1985 to May 2010), PEDro (1982 to May 2010) and LILACS (1982 to May 2010). We checked the bibliographies of papers identified and contacted their authors and known experts in the field seeking published and unpublished trials. SELECTION CRITERIA: Randomised and controlled clinical trials that compared multidisciplinary care in Guillain-Barré syndrome with either routinely available local services or lower levels of intervention, or studies that compared multidisciplinary care in different settings or at different levels of intensity.Studies of 'other designs' (such as observational studies) were included only in the Discussion since such studies could only be of limited contribution to the best evidence synthesis. DATA COLLECTION AND ANALYSIS: We performed a 'best evidence' synthesis based on methodological quality. MAIN RESULTS: No randomised controlled trials or controlled clinical trials were identified. We summarised the results of three observational studies in the Discussion section of this review. AUTHORS' CONCLUSIONS: In the absence of randomised controlled trials or controlled clinical trials, the 'best' evidence to date comes from three 'very low quality' observational studies. These provide some support for improved disability in the short term (less than 6 months) with high intensity inpatient multidisciplinary rehabilitation; and for improved quality of life, as measured by a reduction in handicap (participation). These conclusions are tentative and the gap in current research should not be interpreted as proof that multidisciplinary care is ineffective. Further research is needed into appropriate study designs; outcome measurement; caregiver needs; and the evaluation of optimal settings, type, intensity or frequency and cost-effectiveness of multidisciplinary care in the Guillain-Barré syndrome population.

Effectiveness of a Novel Sleep Clinical Pathway in an Inpatient Musculoskeletal Rehabilitation Cohort: A Pilot Randomized Controlled Trial.

OBJECTIVE: Sleep disturbance in hospital is common. This pilot randomized controlled trial assessed a sleep clinical pathway compared with standard care in improving sleep quality, engagement in therapy and length of stay in musculoskeletal inpatient rehabilitation. METHODS: Participants (n = 51) were randomized to standard care ("control", n =29) or sleep clinical pathway ("intervention", n = 22). Outcome measures included: Pittsburgh Sleep Quality Index (PSQI), Hopkins Rehabilitation Engagement Rating Scale (HRERS), Fatigue Severity Scale (FSS), Patient Satisfaction with Sleep Scale, and actigraphy. Assessment time-points were at admission and before discharge from rehabilitation. RESULTS: No significant differences were found between groups for any outcome measure. As a cohort (n = 51), there were significant improvements from admission to discharge in sleep quality (PSQI (-2.31; 95% confidence interval (95% CI) -3.33 to -1.30; p <0.001)], fatigue (FSS (-8.75; 95% CI -13.15 to -4.34; p <0.001)], engagement with therapy (HRERS-Physiotherapists (+1.37; 95% CI 0.51-3.17; p =0.037), HRERS-Occupational Therapists (+1.84; 95% CI 0.089-2.65; p = 0.008)), and satisfaction with sleep (+0.824; 95% CI 0.35-1.30; p = 0.001). Actigraphy findings were equivocal. CONCLUSION: The sleep clinical pathway did not improve sleep quality compared with standard care. Larger studies and studies with alternate methodology such as "cluster randomization" are needed.

Effectiveness of vocational rehabilitation intervention on the return to work and employment of persons with multiple sclerosis.

BACKGROUND: Multiple sclerosis is a neurological disease that frequently affects adults of working age, resulting in a range of physical, cognitive and psychosocial deficits that impact on workforce participation. Although, the literature supports vocational rehabilitation (VR) approaches in persons with multiple sclerosis (pwMS), the evidence for its effectiveness is yet to be established. OBJECTIVES: To evaluate the effectiveness of VR programs compared to alternative programs or care as usual on return to work, workability and employment in pwMS; to evaluate the cost effectiveness of these programs. SEARCH STRATEGY: Electronic searches included: Cochrane Central Register of Controlled Trials "CENTRAL" 2008 issue 3, MEDLINE (PubMed) (1966- 2008), EMBASE (1988- 2008), CINAHL (1982- 2008), PEDro (1990- 2008), the Cochrane Rehabilitation and Related Therapies Field trials Register and the National Health Service National Research Register. SELECTION CRITERIA: Randomized and controlled clinical trials, including before - after controlled trials, that compare VR rehabilitation with alternative intervention such as standard or a lesser form of intervention or waitlist controls. DATA COLLECTION AND ANALYSIS: Two reviewers selected trials and rated their methodological quality independently. A 'best evidence' synthesis was performed, based on methodological quality. Trials were grouped in terms of type and setting of VR programs. MAIN RESULTS: Two trials (one RCT and one CCT) (total 80 participants) met the review criteria. Both trials scored poorly on the methodological quality assessment. There was 'insufficient evidence' for VR programs for (a)'competitive employment', in altering rates of job retention, changes in employment, improvement in rates of re-entry into the labour force; (b) for altering 'work ability' by improving participants' confidence in the accommodation request process, or employability maturity or job seeking activity. No evidence could be assimilated for changes in proportions of persons in supported employment or on disability pensions, nor for cost-effectiveness. AUTHORS' CONCLUSIONS: There was inconclusive evidence to support VR for pwMS. However, the review highlights some of the challenges in providing VR for pwMS. Clinicians need to be aware of vocational issues, and to understand and manage barriers for maintaining employment. Proactive and timely VR programs should incorporate practical solutions to deal with work disability, workplace accommodation and educate employers, and the wider community. Liaison with policy makers is imperative for government initiatives that encourage work focused VR programs. Future research in VR should focus on improving methodological and scientific rigour of clinical trials; on the development of appropriate and valid outcome measures; and on cost effectiveness of VR programs.

Multidisciplinary care for adults with amyotrophic lateral sclerosis or motor neuron disease.

BACKGROUND: Multidisciplinary care (MDC) is increasingly thought to be an important means of symptomatic and supportive management for motor neuron disease (MND) but the evidence base for its effectiveness is unclear. OBJECTIVES: To assess the effectiveness of MDC in adults with MND, especially the types of approaches that are effective (settings, intensity) and the outcomes that are affected. SEARCH STRATEGY: We searched The Cochrane Neuromuscular Disease Group Specialized Register (11 May 2009), and The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2009), MEDLINE (1966 to April 2009), EMBASE (1980 to April 2009), CINAHLPlus (1937 to April 2009), AMED (1985 to April 2009) and LILACS (1982 to April 2009). SELECTION CRITERIA: Randomised and controlled clinical trials that compared MDC in MND with either routinely available local services or lower levels of intervention; or studies that compared MDC in different settings or at different levels of intensity.Studies of 'other designs' (such as observational studies) were included only in the Discussion since such studies could only be of limited contribution to the best evidence synthesis. DATA COLLECTION AND ANALYSIS: We performed a 'best evidence' synthesis based on methodological quality. We grouped studies in terms of setting and intensity (high or low) of therapy. MAIN RESULTS: No randomised controlled trials or controlled clinical trials were identified. We summarised the results of five observational studies (including one with two reports) in the Discussion section of this review. AUTHORS' CONCLUSIONS: In the absence of randomised controlled trials or controlled clinical trials, the 'best' evidence to date is based on three 'low' and two 'very low quality' observational studies. These suggest 'very low quality evidence' for an advantage for mental health domains (only) of quality of life without increasing healthcare costs, and 'low level quality' evidence for reduced hospitalisation for MDC in low-intensity outpatient settings; and 'very low quality' evidence for improved disability in high-intensity settings. The evidence for survival is conflicting. These conclusions are tentative and the gap in current research should not be interpreted as proof that MDC is ineffective. Further research is needed into appropriate study designs; outcome measurement; caregiver needs; and the evaluation of optimal settings, type, intensity or frequency and cost-effectiveness of MDC in the MND population. Future research should focus on observational designs to assess care and outcomes in 'real-life' settings. The interface between neurology, rehabilitation and palliative care should be explored to provide long-term support for MND.

5-Lipoxygenase DNA methylation and mRNA content in the brain and heart of young and old mice.

The expression of 5-lipoxygenase (5-LOX) is affected by aging and regulated by epigenetic mechanisms including DNA methylation. We used methylation-sensitive restriction endonucleases (AciI, BstUI, HpaII, and HinP1I) to assess 5-LOX DNA methylation in brain and heart tissue samples from young (2 months) and old (22 months) mice. We also measured mRNA content for 5-LOX and the DNA methyltransferases DNMT1 and DNMT3a. In young mice, the 5-LOX mRNA content was significantly greater in the heart compared to the brain; 5-LOX DNA methylation was lower, except in the AciI assay in which it was higher in the heart. Aging decreased 5-LOX mRNA content in the heart and increased it in the brain. Aging also increased 5-LOX DNA methylation and this effect was site- (i.e., enzyme) and tissue-specific. Generally, DNMT1 and DNMT3a mRNA content was lower in the brain regions compared to the heart; the only effect of aging was observed in the mRNA content of DNMT3a, which was decreased in the heart of old mice. These results indicate a complex tissue-specific and aging-dependent interplay between the DNA methylation system and 5-LOX mRNA content. Interpretation of this data must take into account that the tissue samples contained a mixture of various cell types.

The effectiveness of a novel cable-driven gait trainer (Robowalk) combined with conventional physiotherapy compared to conventional physiotherapy alone following stroke: a randomised controlled trial.

There is increasing interest in gait training devices to improve walking ability in people following stroke. This randomised controlled trial aimed to compare the effectiveness of the Robowalk, a novel cable-driven gait trainer combined with conventional physiotherapy to conventional physiotherapy alone in improving walking speed, endurance, balance, functional outcomes, and quality of life in people following stroke. Rehabilitation inpatients within 3 months following stroke (n = 40) were randomised to standard care with conventional physiotherapy ('control,' n = 20) and cable-driven gait trainer combined with conventional physiotherapy ('intervention,' n = 20). All participants received 1 hour of physiotherapy a day, 5 days a week. The control group received conventional physiotherapy only; the intervention group received a combination of 30 minutes of conventional physiotherapy and 30 minutes of cable-driven gait trainer consecutively. Outcome measures were 10-metre walk test (primary outcome), 6-minute walk test, timed up and go, step test, Functional Independence Measure, and EuroQol five-dimension scale. Evaluation timepoints were on admission (T0), discharge (T1), and 4 weeks post discharge (T2). There were no differences between groups at T0, T1, and T2 in all outcome measures although there was a trend towards a larger and more sustained improvement in 10-metre walk test in favour of the intervention group and in Functional Independence Measure motor and self-care in favour of the control group, both at T2. The combination of cable-driven gait trainer with conventional physiotherapy appears as effective as conventional physiotherapy alone in improving gait outcomes in people following a recent stroke. Further studies are required to confirm these findings and determine optimal dosing regimens and long-term outcomes.