Magnetic Resonance-Guided Focused Ultrasound without Anesthesiologist Support.

INTRODUCTION: Magnetic resonance-guided focused ultrasound (MRgFUS) is an effective treatment option for essential tremor (ET) and tremor dominant Parkinson's disease (TDPD), which is often performed with sedation or in the presence of an anesthesiologist in an effort to minimize adverse events and maximize patient comfort. This study explores the safety, feasibility, and tolerability of performing MRgFUS without an anesthesiologist. METHODS: This is a single academic center, retrospective review of 180 ET and TDPD patients who underwent MRgFUS treatment without anesthesiologist support. Patient demographics, intra-procedural treatment parameters, peri-procedural adverse events, and 3-month Clinical Rating Scale for Tremor Part B (CRST-B) scores were compared to MRgFUS studies that utilized varying degrees of anesthesia. RESULTS: There were no anesthesia related adverse events or unsuccessful treatments. There were no early treatment terminations due to patient discomfort, regardless of skull density ratio. 94.6% of patients would repeat the procedure again. The most common side effects during treatment were facial/tongue paresthesia (26.3%), followed by nausea (22.3%), dysarthria (8.6%), and scalp pain (8.0%). No anxiolytic, pain, or antihypertensive medications were administered. The most common early adverse event after MRgFUS procedure was gait imbalance (58.3%). There was a significant reduction of 83.1% (83.4% ET and 80.5% TDPD) of the mean CRST-B scores of the treated hand when comparing 3-month and baseline scores (1.8 vs. 10.9, n = 109, p < 0.0001). CONCLUSION: MRgFUS without intra-procedural anesthesiologist support is a safe, feasible, and well-tolerated option, without an increase in peri-procedural adverse events.

Integrated palliative care in oncology: a protocol for a realist synthesis.

INTRODUCTION: Emerging evidence suggests improved quality of life, reduced symptom burden and lower health services costs when integrated palliative care and cancer care are implemented. Integrated palliative care aims to achieve care continuity by integrating organisational, administrative and clinical services involved in patient care networks. However, integrated palliative care for cancer is not common practice. This project, therefore, aims to understand how integrated palliative care and cancer care works in different healthcare settings (inpatient/outpatient), and for which groups of people (at what stage of the cancer journey), so we can develop guidance for optimal delivery. METHODS AND ANALYSIS: We will conduct a realist synthesis to develop a programme theory of how integrated palliative care in cancer works, for whom and in what contexts to achieve improved symptom management and quality of life for patients and their families.This realist synthesis will follow the five stages outlined by Pawson: (1) locating existing theories, (2) searching for evidence, (3) article selection, (4) extracting and organising data and (5) synthesising the evidence and drawing conclusions. We will work closely with our expert stakeholder group, which includes health and social care professionals providing palliative care and oncology; management and policy groups and members of the public and patients. We will adhere to RAMESES quality standards for undertaking a realist synthesis. ETHICS AND DISSEMINATION: Ethics approval for this project is not required.The realist synthesis will develop a programme theory that provides clarity on the optimal delivery of palliative care for adults with cancer. We will use the programme theory to coproduce guidance and user-friendly outputs, working with stakeholders to inform delivery of best practice. Findings will inform further research in integrated palliative care and cancer. Stakeholder engagement will assist in the dissemination of our findings. PROSPERO REGISTRATION NUMBER: CRD42023389791.

Applying clinical decision aids for the assessment and management of febrile infants presenting to emergency care in the UK and Ireland: Febrile Infant Diagnostic Assessment and Outcome (FIDO) Study protocol.

INTRODUCTION: Febrile infants 90 days and younger are at risk of invasive bacterial infections (bacteraemia and meningitis) and urinary tract infections. Together this is previously termed serious bacterial infection with an incidence of approximately 10-20%. The National Institute for Health and Care Excellence guidance advocates a cautious approach with most infants requiring septic screening, parenteral broad-spectrum antibiotics and hospital admission. Internationally, variations exist in the approach to febrile infants, with European and North American guidance advocating a tailored approach based on clinical features and biomarker testing. None of the available international clinical decision aids (CDAs) has been validated in the UK and Irish cohorts. The aim of the Febrile Infant Diagnostic Assessment and Outcome (FIDO) Study is to prospectively validate a range of CDAs in a UK and Irish population including CDAs that use procalcitonin testing. METHODS AND ANALYSIS: The FIDO Study is a prospective multicentre mixed-methods cohort study conducted in UK and Irish hospitals. All infants aged 90 days and younger presenting with fever or history of fever (≥38°C) are eligible for inclusion. Infants will receive standard emergency clinical care without delay. Clinical data and blood samples will be collected, and consent will be obtained at the earliest appropriate opportunity using research without prior consent methodology. The performance and cost-effectiveness of CDAs will be assessed. An embedded qualitative study will explore clinician and caregiver views on different approaches to care and perceptions of risk. ETHICS AND DISSEMINATION: This study was reviewed and approved by the Office for Research Ethics Committees Northern Ireland-Health and Social Care Research Ethics Committee B, Public Benefit and Privacy Panel for Health and Social Care Scotland, and Children's Health Ireland Research and Ethics Committee Ireland. The results of this study will be presented at academic conferences and in peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT05259683.

Down syndrome: Parental experiences of a postnatal diagnosis.

Globally it is estimated that Down syndrome occurs in 1 in 800 live births (Bull 2020). It has also been estimated that the incidence of Down syndrome occurs in 1/444 live births in the Republic of Ireland. Given the prevalence of Down syndrome births in Ireland and the fact that care is provided by the majority of parents at home, this qualitative study aimed to explore the experiences of Irish parents receiving a postnatal diagnosis of Down syndrome. A qualitative research approach was used through semi structured interviews. Eight parents of a baby diagnosed postnatally with Down syndrome participated in this study sharing their stories of their postnatal diagnosis experiences. Five overarching themes emerged using a descriptive thematic analysis; 1. prenatal screening, pregnancy and delivery; 2. how the diagnosis was delivered; 3. setting and emotional experiences; 4. moving on with the postnatal diagnosis and 5. Future recommendations from parents' perspectives. This study highlighted the importance of the need for clinicians to ensure that partners are present at the time of the disclosure, that ample time is allocated and that verbal and written communications are provided to parents using less medical jargon when delivering the postnatal diagnosis of Down syndrome. These reasonable adjustments could alleviate parental anxiety at this critical juncture in their lives. Online resources and support forums were also identified as an integral support for families on discharge from the maternity centres and in the early months and years.

The effect of mother-infant group music classes on postnatal depression-A systematic review protocol.

BACKGROUND: Postnatal mental health problems affect 10-15% of women and can adversely impact on mother-infant interactions and bonding, the mother's mood, and feelings of competence. There is evidence that attending performing arts activities, such as singing, dancing, and listening to music, may improve maternal mental health with potential for an effect on postnatal depression. METHODS: A systematic review will be conducted to assess the effect of mother-infant group music classes on postnatal depression compared to standard care, no control or wait list control. Studies will be included that report on postnatal depression. Further outcomes of interest include anxiety, stress, parenting competence, confidence and self-efficacy, perceived social support and mother-infant bonding. Infant and child outcomes measuring cognitive development, behaviour and social and emotional development will be included. Search databases to be used will be Medline, EMBASE, CINAHL, PsycINFO, Scopus, CENTRAL, Web of Science, Maternity and Infant Care and discipline-specific journals for music. The Cochrane's Template for Intervention description and replication (TIDieR) checklist and guide will be utilised to aid a detailed description, standardised assessment and quality assurance. Risk of bias will be assessed by the authors using the Cochrane Handbook for Systematic Reviews of Interventions risk of bias tool. If sufficient studies are available, meta-analyses will be conducted to combine, compare and summarise the results of the studies for more precise estimates of effects. Where meta-analysis is not possible, results for each individual study will be reported through qualitative narrative data synthesis. DISCUSSION: This systematic review will identify and synthesise evidence of the measured effect of postnatal mother-infant interventions involving music on maternal psychological and psychosocial outcomes and infant/child outcomes. SYSTEMATIC REVIEW REGISTRATION: This protocol was registered with Prospero on 18 October 2021 (registration number CRD42021283691). https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021283691.

Support for healthy breastfeeding mothers with healthy term babies.

BACKGROUND: There is extensive evidence of important health risks for infants and mothers related to not breastfeeding. In 2003, the World Health Organization recommended that infants be breastfed exclusively until six months of age, with breastfeeding continuing as an important part of the infant's diet until at least two years of age. However, current breastfeeding rates in many countries do not reflect this recommendation. OBJECTIVES: 1. To describe types of breastfeeding support for healthy breastfeeding mothers with healthy term babies. 2. To examine the effectiveness of different types of breastfeeding support interventions in terms of whether they offered only breastfeeding support or breastfeeding support in combination with a wider maternal and child health intervention ('breastfeeding plus' support).  3. To examine the effectiveness of the following intervention characteristics on breastfeeding support:      a. type of support (e.g. face-to-face, telephone, digital technologies, group or individual support, proactive or reactive);      b. intensity of support (i.e. number of postnatal contacts);      c. person delivering the intervention (e.g. healthcare professional, lay person);     d. to examine whether the impact of support varied between high- and low-and middle-income countries. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes results of searches of CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP)) (11 May 2021) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing extra support for healthy breastfeeding mothers of healthy term babies with usual maternity care. Support could be provided face-to-face, over the phone or via digital technologies. All studies had to meet the trustworthiness criteria.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane Pregnancy and Childbirth methods. Two review authors independently selected trials, extracted data, and assessed risk of bias and study trustworthiness.  The certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS: This updated review includes 116 trials of which 103 contribute data to the analyses. In total more than 98,816 mother-infant pairs were included.  Moderate-certainty evidence indicated that 'breastfeeding only' support probably reduced the number of women stopping breastfeeding for all primary outcomes: stopping any breastfeeding at six months (Risk Ratio (RR) 0.93, 95% Confidence Interval (CI) 0.89 to 0.97); stopping exclusive breastfeeding at six months (RR 0.90, 95% CI 0.88 to 0.93); stopping any breastfeeding at 4-6 weeks (RR 0.88, 95% CI 0.79 to 0.97); and stopping exclusive breastfeeding at 4-6 (RR 0.83 95% CI 0.76 to 0.90). Similar findings were reported for the secondary breastfeeding outcomes except for any breastfeeding at two months and 12 months when the evidence was uncertain if 'breastfeeding only' support helped reduce the number of women stopping breastfeeding.  The evidence for 'breastfeeding plus' was less consistent. For primary outcomes there was some evidence that 'breastfeeding plus' support probably reduced the number of women stopping any breastfeeding (RR 0.94, 95% CI 0.91 to 0.97, moderate-certainty evidence) or exclusive breastfeeding at six months (RR 0.79, 95% CI 0.70 to 0.90).  'Breastfeeding plus' interventions may have a beneficial effect on reducing the number of women stopping exclusive breastfeeding at 4-6 weeks, but the evidence is very uncertain (RR 0.73, 95% CI 0.57 to 0.95). The evidence suggests that 'breastfeeding plus' support probably results in little to no difference in the number of women stopping any breastfeeding at 4-6 weeks (RR 0.94, 95% CI 0.82 to 1.08, moderate-certainty evidence). For the secondary outcomes, it was uncertain if 'breastfeeding plus' support helped reduce the number of women stopping any or exclusive breastfeeding at any time points.  There were no consistent findings emerging from the narrative synthesis of the non-breastfeeding outcomes (maternal satisfaction with care, maternal satisfaction with feeding method, infant morbidity, and maternal mental health), except for a possible reduction of diarrhoea in intervention infants.  We considered the overall risk of bias of trials included in the review was mixed. Blinding of participants and personnel is not feasible in such interventions and as studies utilised self-report breastfeeding data, there is also a risk of bias in outcome assessment.   We conducted meta-regression to explore substantial heterogeneity for the primary outcomes using the following categories: person providing care; mode of delivery; intensity of support; and income status of country.  It is possible that moderate levels (defined as 4-8 visits) of 'breastfeeding only' support may be associated with a more beneficial effect on exclusive breastfeeding at 4-6 weeks and six months. 'Breastfeeding only' support may also be more effective in reducing women in low- and middle-income countries (LMICs) stopping exclusive breastfeeding at six months compared to women in high-income countries (HICs). However, no other differential effects were found and thus heterogeneity remains largely unexplained. The meta-regression suggested that there were no differential effects regarding person providing support or mode of delivery, however, power was limited.  AUTHORS' CONCLUSIONS: When 'breastfeeding only' support is offered to women, the duration and in particular, the exclusivity of breastfeeding is likely to be increased. Support may also be more effective in reducing the number of women stopping breastfeeding at three to four months compared to later time points.  For 'breastfeeding plus' interventions the evidence is less certain. Support may be offered either by professional or lay/peer supporters, or a combination of both. Support can also be offered face-to-face, via telephone or digital technologies, or a combination and may be more effective when delivered on a schedule of four to eight visits. Further work is needed to identify components of the effective interventions and to deliver interventions on a larger scale.

Cortisol levels versus self-report stress measures during pregnancy as predictors of adverse infant outcomes: a systematic review.

Systematically review existing evidence to (1) identify the association between self-report stress and cortisol levels measured during pregnancy; and, (2) assess their association with adverse infant outcomes to determine which is the better predictor. A systematic review was conducted in accordance with PRISMA guidelines. Search terms focused on pregnancy, psychological stress and cortisol. Nine electronic databases were searched, in addition to reference lists of relevant papers. Eligibility criteria consisted of studies that included measurement of self-reported psychological stress, cortisol and assessed their associations with any infant-related outcome. Further limits included studies published in English or Spanish with human female participants. A meta-regression was not feasible due to differences in study samples, measurement tools employed, types of cortisol assessed and outcomes reported. A narrative synthesis was provided. 28 studies were eligible for inclusion. Convergent validity between self-report measures and cortisol was reported by three studies (range r = 0.12-0.41). Higher levels of self-report stress were significantly associated with intrauterine growth restriction (fetal biparietal diameter, low fetal head circumference, abdominal circumference), low gestational age at birth, low anthropometric measures (birth length, head circumference, length of the neonate), poor infant neurodevelopment (cognitive development) and potentially pathogenic gut microbiota (Clostridiaceae Clostridium, Haemophilus) in six studies. Higher cortisol levels were significantly associated with intrauterine growth restriction (fetal biparietal diameter, low fetal head circumference, abdominal circumference), low gestational age at birth, low infant birth weight, poor infant neurodevelopment (attention scores on the Network Neurobehavioral Scale) and low levels of potentially protective gut microbiota (Lactobacillus, Slackia and Actinobaculum) in 13 studies. Of the studies that assessed which type of measure was a better predictor of infant outcomes (n = 6), there was agreement that cortisol levels were statistically better at predicting adverse outcomes than self-reported stress. Self-report stress measures appear to be modest predictors of adverse infant outcomes in comparison to cortisol. A number of methodological limitations need to be addressed in future studies to help understand the relationship between cortisol and self-reported stress and how they are related to adverse infant outcomes.

Identifying postnatal anxiety: comparison of self-identified and self-reported anxiety using the Edinburgh Postnatal Depression Scale.

BACKGROUND: Identifying women with perinatal anxiety is important in order to provide timely support and prevent adverse outcomes. Self-report instruments are commonly used in maternity settings. An alternative is to ask women directly whether they self-identify as having anxiety. We examine the agreement between self-reported and self-identified anxiety at 3 months postpartum and compare the characteristics of women with self-reported and self-identified anxiety. METHODS: A secondary analysis of national maternity surveys conducted in 2014 in England and Northern Ireland was conducted. Self-reported anxiety was assessed using the Edinburgh Postnatal Depression Scale anxiety subscale (EPDS-3A). Agreement between self-reported and self-identified anxiety was measured using Cohen's kappa. Logistic regression was used to identify characteristics of women in each group. RESULTS: In our sample of 6752 women, 14.2% had self-reported anxiety, 5.9% had self-identified anxiety and 3.5% were positive on both measures. Among those with self-identified anxiety, 58.1% also had self-reported anxiety. Of those with self-reported anxiety, 24.4% also had self-identified anxiety. Statistical agreement between the two measures was minimal with Cohen's kappa 0.283 at an EPDS-3A threshold of ≥6. Among both self-identified and self-reported anxiety groups, psychological factors were the strongest associated factors. Women with self-reported anxiety had higher odds of being from Northern Ireland (OR 1.81); having a mixed or unhappy reaction to the pregnancy (OR 1.65); living without a partner (aOR 1.37); and antenatal depression (aOR 1.32). Women with self-identified anxiety had higher odds of physical problems (OR 1.84); and being of Black or minority ethnicity (OR 0.39). CONCLUSIONS: Asking postnatal women directly whether they self-identify as having anxiety identifies a different group of women from those who score highly on self-report measures. Women with self-identified anxiety may benefit from further follow-up and support.

Mental health of mothers after natural childbirth and cesarean section: a comparative study in kohat, khyber pakhtunkhwa, pakistan / Saúde mental de mães após parto normal e cesariana: um estudo comparativo em kohat, khyber pakhtunkhwa, paquistão / Salud mental de madres después del parto normal y cesárea: un estudio comparativo en kohat, khyber pakhtunkhwa, pakistán

ABSTRACT Objective: to compare the quality of life of women after natural childbirth and cesarean section from a mental health perspective. Method: this is a causal-comparative study that included 104 women, 52 of whom underwent natural childbirth: and 52 cesarean sections. It was conducted in the gynecology ward of Liaqat Memorial Hospital in Kohat Khyber Pakhtunkhwa, Pakistan using the Quality-of-Life Questionnaire. Pakistani Nurses made direct translation of it in to Urdu language, interview by interview (read in English and told in Urdu). The results related to Emotional Health Problems, Energy, Emotions and Social Activities were analyzed. Results: women after cesarean section reported more problems regarding emotional health variables than women after natural childbirth. The mean quality of life score among the natural childbirth group was 89.94 and 66.02 among the cesarean section group (p<0.001). Conclusion: women who undergo natural childbirth have better quality of life than women who undergo cesarean section (average versus poor quality of life). Mental health is also affected, especially for those who undergo cesarean section. Thus, natural childbirth demonstrates benefits in the puerperium in terms of emotional indicators.

RESUMO Objetivo: comparar a qualidade de vida de mulheres após parto normal e cesariana na perspectiva da saúde mental. Método: estudo causal-comparativo que incluiu 104 mulheres, das quais 52 tiveram parto normal e 52 cesarianas. O estudo foi realizado na enfermaria de ginecologia do Liaqat Memorial Hospital em Kohat Khyber Pakhtunkhwa, Paquistão, usando o Questionário de Qualidade de Vida. As enfermeiras paquistanesas fizeram a tradução direta para o idioma Urdu, entrevista por entrevista (lida em inglês e falada em urdu). Foram analisados os resultados relacionados aos Problemas de Saúde Emocional, Energia, Emoções e Atividades Sociais. Resultados: as mulheres após cesariana relataram mais problemas em relação às variáveis de saúde emocional do que as mulheres após o parto normal. O escore médio de qualidade de vida no grupo de mulheres após parto normal foi de 89,94 e 66,02 no grupo de mulheres após cesariana (p<0,001). Conclusão: as mulheres que realizaram parto normal apresentaram melhor qualidade de vida do que as mulheres após cesariana (média versus má qualidade de vida). A saúde mental também é afetada, principalmente para aquelas que são submetidas a cesariana. Assim, o parto normal demonstra benefícios no puerpério em termos de indicadores emocionais.

RESUMEN Objetivo: comparar la calidad de vida de las mujeres después del parto natural y cesárea desde la perspectiva de la salud mental. Método: estudio causal-comparativo que incluyó 104 mujeres, de las cuales 52 tuvieron parto natural y 52 cesáreas. El estudio se realizó en la enfermería de ginecología del Liaqat Memorial Hospital en Kohat Khyber Pakhtunkhwa, Pakistán, utilizando el Cuestionario de Calidad de Vida. Las enfermeras paquistaníes hicieron la traducción directa al idioma Urdu, entrevista por entrevista (leída en inglés y hablada en urdu). Los resultados relacionados con los Problemas de Salud Emocional, Energía, Emociones y Actividades Sociales fueron analizados. Resultados: Las mujeres después de la cesárea reportaron más problemas en relación a las variables de salud emocional que las mujeres después del parto natural. El puntaje medio de calidad de vida en el grupo de parto natural fue de 89,94 y 66,02 en el grupo de cesárea (p<0,001). Conclusión: las mujeres que tuvo parto natural tienen mejor calidad de vida que las mujeres después de la cesárea (media versus mala calidad de vida). La salud mental también se ve afectada, especialmente para aquellos que se someten a cesárea. Por lo tanto, el parto natural muestra beneficios en el período posparto en términos de indicadores emocionales.

Understanding the Causes of Work-Related Stress among Registered Nurses Working with Children at Home: An Integrative Literature Review.

Work-related stress in nursing is widely acknowledged. This integrative review was undertaken to systematically identify and appraise the causes of work-related stress experienced by registered nurses working with children at home. Ten studies were included, eight of which focused solely on the experiences of nurses providing palliative and end of life care at home for children. One study focused on the experiences of newly qualified nurses and one on the experiences of nurses caring for sick children at home at different stages within their care trajectory. Stress was experienced by nurses caring for children at home and identified and acknowledged within all included studies. Recurrent themes reported in the literature that contributed to work-related stress were, provision of out of hours care, challenge of developing and maintaining skills (clinical and non-clinical), ambiguity of roles and relationships (professional team and child and family), lack of resources, emotional toll, and lack of staff support. The causes of work-related stress highlighted in this review need to be proactively addressed; thus, providing an opportunity to improve the working experiences of nurses improve job satisfaction and overall wellbeing. A recommendation from this integrative review is for workplaces to identify and invest in effective strategies to prevent or reduce work-related stress.

Responsive Neurostimulation of the Mesial Temporal White Matter in Bilateral Temporal Lobe Epilepsy.

BACKGROUND: Responsive neuromodulation (RNS) is a treatment option for patients with medically refractory bilateral mesial temporal lobe epilepsy (MTLE). A paucity of data exists on the feasibility and clinical outcome of hippocampal-sparing bilateral RNS depth lead placements within the parahippocampal white matter or temporal stem. OBJECTIVE: To evaluate seizure reduction outcomes with at least a 1-yr follow-up in individuals with bilateral MTLE undergoing hippocampus-sparing implantation of RNS depth leads. METHODS: A retrospective analysis of prospectively collected data was performed on patients at our institution with bilateral MTLE who were implanted with RNS depth leads along the longitudinal extent of bitemporal parahippocampal white matter or temporal stem. Baseline and postoperative seizure frequency, previous surgical interventions, and postimplantation electrocorticography and stimulation data were analyzed. RESULTS: Ten patients were included in the study (7 male, 3 female). Overall seizure frequency declined by a median 44.25% at 3.13 yr (standard deviation 3.31) postimplantation. Four patients (40%) achieved 50% responder rate at latest follow-up. Two of four patients with focal onset bilateral tonic-clonic seizures became completely seizure-free. Forty percent of patients were previously implanted with a vagus nerve stimulator, and 20% underwent a prior temporal lobectomy. All depth lead placements were confirmed as radiographically located in the parahippocampal white matter or temporal stem without hippocampus violation. There were no cases of lead malposition. CONCLUSION: Extrahippocampal or temporal stem white matter targeting during RNS surgery for bitemporal MTLE is feasible and allows for electrographic seizure detection. Larger controlled studies with longer follow-up are needed to validate these preliminary findings.

Validating clinical practice guidelines for the management of children with non-blanching rashes in the UK (PiC): a prospective, multicentre cohort study.

BACKGROUND: No previous studies have validated current clinical practice guidelines for the management of non-blanching rashes in children who have received meningococcal B and C vaccinations. The aim of this study was to evaluate the performance of existing clinical practice guidelines in the diagnosis of invasive meningococcal disease in children presenting with a fever and non-blanching rash in the UK. METHODS: The Petechiae in Children (PiC) study was a prospective, multicentre cohort study involving children (aged <18 years) presenting to 37 paediatric emergency departments in the UK with a fever (≥38°C) and a new-onset non-blanching rash or features suggestive of meningococcal infection. Children with pre-existing haematological conditions (ie, haematological malignancy, idiopathic thrombocytopenic purpura, or coagulopathy) or an existing diagnosis of Henoch-Schonlein purpura were excluded. Invasive meningococcal disease was confirmed by positive culture or a quantitative PCR test for Neisseria meningitidis from either blood or cerebrospinal fluid samples. The primary outcome was the performance of six tailored clinical practice guidelines from participating centres (London, Nottingham, Newcastle-Birmingham-Liverpool, Glasgow, Chester, and Bristol) and two clinical practice guidelines from the National Institutes for Health and Care Excellence (NICE; CG102 and NG51) in identifying children with invasive meningococcal disease, assessed by the sensitivity and specificity of each clinical practice guideline. This study is registered with ClinicalTrials.gov, NCT03378258. FINDINGS: Between Nov 9, 2017, and June 30, 2019, 1513 patients were screened, of whom 1329 were eligible and were included in the analysis. The median age of patients was 24 months (IQR 12-48). 1137 (86%) of 1329 patients had a blood test and 596 (45%) received parenteral antibiotics. 19 (1%) patients had confirmed meningococcal disease. All eight clinical practice guidelines had a sensitivity of 1·00 (95% CI 0·82-1·00) for identifying meningococcal disease. The specificities of NICE guidelines CG102 (0·01 [95% CI 0·01-0·02]) and NG51 (0·00 [0·00-0·00]) for identifying meningococcal disease were significantly lower than that of tailored clinical practice guidelines (p<0·0001). The best performing clinical practice guidelines for identifying meningococcal disease were the London (specificity 0·36 [0·34-0·39]) and Nottingham (0·34 [0·32-0·37]) clinical practice guidelines. INTERPRETATION: Invasive meningococcal disease is a rare cause of non-blanching rashes in children presenting to the emergency department in the UK. Current NICE guidelines perform poorly when compared with tailored clinical practice guidelines. These findings suggest that UK national guidance could be improved by shifting towards a tailored approach. FUNDING: Public Health Agency.

Interventions addressing men, masculinities and gender equality in sexual and reproductive health and rights: an evidence and gap map and systematic review of reviews.

OBJECTIVES: Working with men/boys, in addition to women/girls, through gender-transformative programming that challenges gender inequalities is recognised as important for improving sexual and reproductive health and rights (SRHR) for all. The aim of this paper was to generate an interactive evidence and gap map (EGM) of the total review evidence on interventions engaging men/boys across the full range of WHO SRHR outcomes and report a systematic review of the quantity, quality and effect of gender-transformative interventions with men/boys to improve SRHR for all. METHODS: For this EGM and systematic review, academic and non-academic databases (CINAHL, Medline, PsycINFO, Social Science Citation Index-expanded, Cochrane Library, Campbell Collaboration, Embase, Global Health Library and Scopus) were searched using terms related to SRHR, males/masculinities, systematic reviews and trials (January 2007-July 2018) with no language restrictions for review articles of SRHR interventions engaging men/boys. Data were extracted from included reviews, and AMSTAR2 was used to assess quality. Outcomes were based on WHO reproductive health strategy. RESULTS: From the 3658 non-duplicate records screened, the total systematic reviews of interventions engaging men/boys in SRHR was mapped through an EGM (n=462 reviews) showing that such interventions were relatively evenly spread across low-income (24.5%), middle-income (37.8%) and high-income countries (37.8%). The proportion of reviews that included gender-transformative interventions engaging men/boys was low (8.4%, 39/462), the majority was in relation to violence against women/girls (n=18/39, 46.2%) and conducted in lower and middle-income countries (n=25/39, 64%). Reviews of gender-transformative interventions were generally low/critically low quality (n=34/39, 97.1%), and findings inconclusive (n=23/39, 59%), but 38.5% (n=15/39) found positive results. CONCLUSION: Research and programming must be strengthened in engagement of men/boys; it should be intentional in promoting a gender-transformative approach, explicit in the intervention logic models, with more robust experimental designs and measures, and supported with qualitative evaluations.

Care technologies to prevent and control hemorrhage in the third stage of labor: a systematic review. / Tecnologias de cuidado para prevenção e controle da hemorragia no terceiro estágio do parto: revisão sistemática.

OBJECTIVE: to identify evidence concerning the contribution of health technologies used to prevent and control hemorrhaging in the third stage of labor. METHOD: systematic review with database searches. First, two researchers independently selected the papers and, at a second point in time, held a reconciliation meeting. The Kappa coefficient was used to assess agreement, while the Grading of Recommendations, Assessment, Development and Evaluation was adopted to assess risk of bias and classify level of evidence. RESULTS: in this review, 42 papers were included, 34 of which addressed product technologies, most referred to pharmacological products, while two papers addressed the use of blood transparent plastic bags collector and the contribution of birth spacing and prenatal care. The eight papers addressing process technologies included the active management of the third stage of labor, controlled cord traction, uterine massage, and educational interventions. CONCLUSION: product and process technologies presented high and moderate evidence confirmed in 61.90% of the papers. The levels of evidence confirm the contribution of technologies to prevent and control hemorrhaging. Clinical nurses should provide scientific-based care and develop protocols addressing nursing care actions.

Identifying postnatal depression: Comparison of a self-reported depression item with Edinburgh Postnatal Depression Scale scores at three months postpartum.

BACKGROUND: Early identification of postnatal depression is important in order to minimize adverse outcomes. The Edinburgh Postnatal Depression Scale (EPDS) is commonly used as a screening tool but a single, direct question on depression may offer an alternative means of identifying women in need of support. This study examines the agreement between these methods and characteristics of women who self-identify as depressed and those with EPDS ≥ 13. METHODS: Secondary analysis of two national maternity surveys conducted in England and Northern Ireland. Agreement between the direct question and EPDS scores was assessed using Cohen's kappa. Logistic regression was used to identify characteristics of women in each group. RESULTS: 6752 women were included. At three months postpartum, 6.1% of women self-identified as having depression, 9.1% scored EPDS ≥ 13, 2.8% were positive on both. Agreement between the two methods was minimal (Cohen's kappa < 0.3). Women who self-identified as having depression had higher odds of being aged > 40 years (OR 1.8; 95% CI 1.2-2.8). EPDS ≥ 13 was associated with < 16 years of education (OR 1.4; 95% CI 1.1-1.8), minority ethnicity (OR 1.4; 95% CI 1.1-1.9), living without a partner (OR 1.7; 95% CI 1.3-2.2), and a less than happy reaction to the pregnancy (OR 1.7; 95% CI 1.4-2.1). LIMITATIONS: Low survey response limits the representativeness of findings. The absence of a diagnostic interview limits conclusions on accuracy or internal validity of the measures. CONCLUSIONS: A direct question about postnatal depression may offer a valuable addition to screening tools to identify women in need of support.

Psychometric validation of the Prenatal Distress Questionnaire (PDQ) in pregnant women in Spain.

The Prenatal Distress Questionnaire (PDQ) was developed among English-speaking women in the United States to assess specific worries and concerns during pregnancy. Our aim was to analyze the factor structure of the PDQ, using confirmatory factor analysis, and assess its convergent validity in Spanish women. A sample of 233 pregnant women with ages ranging from 19 to 42 years in the south of Spain (Europe) (January 2015 - March 2016) completed the translated PDQ, the Perceived Stress Scale (PSS) and the Symptom Checklist-90-revised (SCL-90-R). Confirmatory factor analysis revealed a three-factor structure supporting the original PDQ factor structure (χ2 (31) = 55.43, p = 0.004; CFI = 0.96; RMSEA = 0.058; WRMR = 0.702). The Spanish PDQ significantly correlated with the PSS and SCL-90-R (r's 0.18-0.49, p's < 0.05), providing evidence of convergent validity. These results illustrate that the stress dimensions investigated by the PDQ adequately represent pregnant women's distress across a different cultural context and corroborate the psychometric properties of this instrument previously demonstrated in English-speaking women. The Spanish version of the PDQ can be used by clinical practitioners to evaluate specific worries and concerns women experience during pregnancy.

Abdominal Epilepsy Treated With Vagal Nerve Stimulation: A Case Report.

BACKGROUND AND IMPORTANCE: Abdominal epilepsy is a rare seizure disorder characterized by episodic gastrointestinal symptoms with electroencephalogram abnormalities. It is typically well treated with anti-epileptic medications; however, little is known about treatment of refractory cases. CLINICAL PRESENTATION: The patient is a 16-yr-old male who began experiencing episodic abdominal pain and distension at the age of 2. After undergoing an extensive negative gastrointestinal workup, he was referred for neurological examination. The patient's examination and brain magnetic resonance imaging were normal, but epileptiform discharges were noted on the electroencephalogram. He initially failed treatment with several anti-epileptic medications but achieved seizure control with lamotrigine for 10 yr. However, his seizure frequency increased at age 15 and vagal nerve stimulation (VNS) was proposed for treatment. He underwent VNS placement surgery and experienced significant seizure reduction. By 22 mo postsurgery, he had experienced 11 total seizures compared to his preoperative seizure frequency of 16 seizures per month. Additionally, the patient's neuropsychological testing postsurgery demonstrated improvements in verbal reasoning and reading comprehension in comparison to presurgical testing. CONCLUSION: VNS has been used to treat intractable, nonfocal epilepsy although the therapeutic mechanism remains poorly understood. This case demonstrates utility of VNS for the treatment of abdominal epilepsy that remains refractory to pharmacotherapy.

Exploring parents' reasons for attending the emergency department for children with minor illnesses: a mixed methods systematic review.

BACKGROUND: The number of EDs visit is on the increase, and the pressure on EDs is of significant concern worldwide. The usage of EDs by parents of children with minor illness is an important and still unresolved problem causing a burden to healthcare services. The aim of this study was to review the literature to summarise parental reasons for visiting ED for children with minor illness. METHOD: Seven electronic databases (Medline, Embase, PsycINFO, CINAHL, PubMed, Web of Science and Scopus) were comprehensively searched during a 2-week period in August 2016 and updated between 11 and 20 June 2018. The study selection process was undertaken independently by two authors. Qualitative and quantitative studies that focused on the reasons for parents of children with minor illness to attend an ED were included. Studies were assessed for quality and data were analysed by means of narrative synthesis. RESULTS: Twenty-four studies were included. Eleven studies employed quantitative methods, eleven studies used qualitative methods and two studies used mixed methods. Parental reasons for using ED included perceived urgency, ED advantages (eg, faster service, superior ED resources and efficiency), difficulties with getting a general practitioner appointment, lack of facilities in primary healthcare services, lack of health insurance, reassurance, convenience and access. CONCLUSION: This review identified some of the reasons why parents bring their children to the ED for minor illnesses highlighting the multifaceted nature of this problem. Understanding parental reasons behind their choice to use the ED may help us better design targeted interventions to reduce unnecessary ED visits and alleviate the burden on overstretched healthcare services. This review may help inform emergency care policy makers, researchers and healthcare staff to understand parents' reasons for visiting the ED, to better meet their healthcare needs.

Age is but a number when considering epilepsy surgery in older adults.

BACKGROUND: A quarter of patients with newly diagnosed epilepsy are older, yet they are less likely to be offered resective surgery potentially because of clinical bias that they incur increased surgical risks. There are few peer-reviewed case series that address this cohort and their outcomes. OBJECTIVE: In the context of current literature, the objective of this study was to report on all epilepsy surgeries in patients aged 50 years or older from a tertiary care center over 15 years with an average follow-up period of 6 years. METHODS: Patients with epilepsy who underwent surgery between 2001 and 2016 were reviewed retrospectively. Inclusion criteria were age > 50 at surgery, availability of presurgical evaluation data, and minimum one year of follow-up data. We identified 34 patients. Seizure outcome was evaluated using the Engel classification system. RESULTS: Thirty-four patients aged 50 years and older out of 276 underwent epilepsy surgery. Average age at time of surgery was 55 years, and average duration of epilepsy was 30 years. Average length of follow-up was 6 years (1-15 years). Twenty-two out of 34 patients (64%) were seizure-free (Engel class I) at their last follow-up visit. Patients with lesional pathology on neuroimaging were more likely to achieve seizure freedom (p < 0.02). Parameters associated with poorer outcome included extratemporal epileptogenic focus (p = 0.07) and bitemporal interictal epileptiform activity (p = 0.003). CONCLUSION: Our study cohort is one of the largest and most representative outcome studies of this age group, following the cohort for 6 years. Our findings demonstrated that when considering epilepsy surgery in an older adult, their age should not play a determining role in the decision-a finding that is more common in modern literature.

Tecnologias de cuidado para prevenção e controle da hemorragia no terceiro estágio do parto: revisão sistemática / Care technologies to prevent and control hemorrhage in the third stage of labor: a systematic review / Tecnologías de cuidado para prevención y control de la hemorragia en la tercera etapa del parto: revisión sistemática

Objetivo identificar evidências acerca das contribuições das tecnologias de cuidado usadas para prevenção e controle da hemorragia no terceiro estágio do parto. Método revisão sistemática com busca em bases de dados. Dois investigadores selecionaram os textos de forma independente na primeira etapa e, na segunda, em reunião de conciliação. Para avaliação da concordância, aplicou-se o coeficiente Kappa; para avaliação do risco de viés e classificação dos níveis de evidência, adotou-se o Grading of Recommendations, Assessment, Development and Evaluation. Resultados incluíram-se 42 artigos; desses, 34 classificados como tecnologias de produto, sendo a maioria produtos farmacológicos; dois referentes ao uso do saco plástico transparente para a coleta de sangue e contribuição do intervalo de nascimento e dos cuidados pré-natais. Os oito artigos classificados como tecnologias de processo se referiam a manejo ativo do terceiro estágio do parto, tração controlada de cordão, massagem uterina e intervenções educacionais. Conclusão as tecnologias de produto e de processo apresentaram evidência alta e moderada confirmada em 61,90% dos artigos. Os níveis de evidência demonstram contribuições das tecnologias para prevenção e controle da hemorragia. Na prática clínica, o enfermeiro deve oferecer cuidados à mulher fundamentados em evidências científicas e construir protocolos sobre as ações de cuidado da enfermagem.

Objective to identify evidence concerning the contribution of health technologies used to prevent and control hemorrhaging in the third stage of labor. Method systematic review with database searches. First, two researchers independently selected the papers and, at a second point in time, held a reconciliation meeting. The Kappa coefficient was used to assess agreement, while the Grading of Recommendations, Assessment, Development and Evaluation was adopted to assess risk of bias and classify level of evidence. Results in this review, 42 papers were included, 34 of which addressed product technologies, most referred to pharmacological products, while two papers addressed the use of blood transparent plastic bags collector and the contribution of birth spacing and prenatal care. The eight papers addressing process technologies included the active management of the third stage of labor, controlled cord traction, uterine massage, and educational interventions. Conclusion product and process technologies presented high and moderate evidence confirmed in 61.90% of the papers. The levels of evidence confirm the contribution of technologies to prevent and control hemorrhaging. Clinical nurses should provide scientific-based care and develop protocols addressing nursing care actions.

Objetivo identificar las evidencias acerca de las contribuciones de las tecnologías de cuidado usadas para la prevención y el control de la hemorragia en la tercera etapa del parto. Método revisión sistemática con búsqueda en bases de datos. Dos investigadores seleccionaron los textos, de forma independiente, en la primera etapa; y, en la segunda en reunión de conciliación. Para evaluación de la concordancia fue aplicado el coeficiente Kappa; para evaluación del riesgo de sesgo y clasificación de los niveles de evidencia, se adoptó el Grading of Recommendations, Assessment, Development and Evaluation. Resultados fueron incluidos 42 artículos; de estos, 34 fueron clasificados como: tecnologías de producto (siendo la mayoría productos farmacológicos), dos referentes a la contribución del saco plástico transparente recolector de sangre y del intervalo de nacimiento y de los cuidados prenatales. Los ocho artículos clasificados como tecnologías de proceso se referían al manejo activo de la tercera etapa del parto, a la tracción controlada del cordón, al masaje uterino y a intervenciones educacionales. Conclusión las tecnologías de producto y de proceso presentaron evidencia alta y moderada, lo que fue confirmado en 61,90% de los artículos. Los niveles de evidencia demuestran las contribuciones de las tecnologías para la prevención y el control de la hemorragia. En la práctica clínica, el enfermero debe ofrecer cuidados a la mujer fundamentados en evidencias científicas y construir protocolos sobre las acciones de cuidado de la enfermería.