Targeted temperature management in patients with intracerebral haemorrhage, subarachnoid haemorrhage, or acute ischaemic stroke: updated consensus guideline recommendations by the Neuroprotective Therapy Consensus Review (NTCR) group.

BACKGROUND: There is a lack of consistent, evidence-based guidelines for the management of patients with fever after brain injury. The aim was to update previously published consensus recommendations on targeted temperature management after intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and acute ischaemic stroke in patients who require admission to critical care. METHODS: A modified Delphi consensus, the Neuroprotective Therapy Consensus Review (NTCR), included 19 international neuro-intensive care experts with a subspecialty interest in the acute management of intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and acute ischaemic stroke. An online, anonymised survey was completed ahead of the meeting before the group came together to consolidate consensus and finalise recommendations on targeted temperature management. A threshold of ≥80% for consensus was set for all statements. RESULTS: Recommendations were formulated based on existing evidence, literature review, and consensus. After intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and acute ischaemic stroke in patients who require critical care admission, core temperature should ideally be monitored continuously and maintained between 36.0°C and 37.5°C using automated feedback-controlled devices, where possible. Targeted temperature management should be commenced within 1 h of first fever identification with appropriate diagnosis and treatment of infection, maintained for as long as the brain remains at risk of secondary injury, and rewarming should be controlled. Shivering should be monitored and managed to limit risk of secondary injury. Following a single protocol for targeted temperature management across intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and acute ischaemic stroke is desirable. CONCLUSIONS: Based on a modified Delphi expert consensus process, these guidelines aim to improve the quality of targeted temperature management for patients after intracerebral haemorrhage, aneurysmal subarachnoid haemorrhage, and acute ischaemic stroke in critical care, highlighting the need for further research to improve clinical guidelines in this setting.

Women's fertility decision-making with a diagnosis of breast cancer: A qualitative evidence synthesis.

AIM: To synthesize qualitative evidence of premenopausal women's experiences of fertility decision-making with a diagnosis of breast cancer. BACKGROUND: Breast cancer is increasingly more common in premenopausal women who may have not yet considered starting a family or have completed their families. DESIGN: Qualitative evidence synthesis guided by Thomas and Harden's three-stage approach to thematic analysis. DATA SOURCES: Twelve electronic databases were searched: CINAHL, Embase, Pubmed, Proquest, PsychINFO, Lenus, Scopus, Web of Science, Rian.ie, Medline, EThOS e-theses online and DART Europe. No year limit was set. REVIEW METHODS: The 'Enhancing transparency in reporting the synthesis of qualitative research guidelines' (ENTREQ) statement was followed. RESULTS: Fifteen qualitative studies were included in the synthesis. Seven review findings under four major themes were identified: (1) first comes survival, (2) making decisions 'under the gun', (3) health-care professionals should not make assumptions and (4) we want accurate, detailed information and we want it early. High confidence in six of the review findings was agreed. CONCLUSION: Most women experienced rushed fertility preservation decision-making at a time when they also faced cancer treatment decisions. Women want detailed, clear information on fertility preservation early after their diagnosis.

All hands on deck during the COVID-19 pandemic. Maintaining face-to-face medical education and clinical placements.

Medical students must have robust educational experiences, graduate and commence timely employment. Here, we describe how the Royal College of Surgeons in Ireland (RCSI) delivered clinical placements in medical programmes over the first three waves of the COVID-19 pandemic in Ireland, including a student-centred, holistic approach to students' educational, social and health needs with strong student involvement, re-organising the university's primary care team, developing COVID-19 PCR testing on site and re-focusing communications and student services. This resulted in re-arranging the students into learning communities, and students and staff electronically recorded their COVID-19 symptom status daily. In-person observed structured clinical examination and other clinical exams progressed. No lockdown of any campus occurred. Over the two senior years, 693 students completed 15,000 weeks of clinical and experiential learning across 104 sites, similar to previous years, including anatomy practicals, procedural skills training, simulated ward rounds and patient encounters, case-based presentations and small group tutorials. The compliance rate with the daily symptom tracker was 91%. The percentage response rate and the number of students providing feedback from October 2020 to April 2021 was as high as 50%. The overall response rate was 33%. By mid-May, 93-95% of students in the two senior years had had at least one dose of the SARS-CoV-2 vaccine, with 99% fully vaccinated by the start of the next academic year in autumn 2021. Over the period of testing for SARS-CoV-2, just over 22,000 samples were processed, of which 0.79% were positive; no medical student acquired COVID-19 or was associated with nosocomial transmission. The total investment by the RCSI in Dublin, was €9.3m (€1.2 in capital expenditure and €8.1 in operational expenses). Continuing face-to-face clinical placements during a pandemic was possible through a multi-model approach that prioritised two-way communication, compliance with national public health advice and student screening.

The short-term effects of selective dorsal rhizotomy on gait compared to matched cerebral palsy control groups.

OBJECTIVES: To examine the short-term effects of selective dorsal rhizotomy (SDR) ± soft-tissue surgery on gait in cerebral palsy (CP) compared to matched controls with no surgical intervention. METHODS: Participants had gait analysis before and one year after SDR. Non SDR participants were retrospectively matched for age and all significant gait parameters. The SDR group was further subdivided into those who had concomitant orthopaedic surgery and those who had SDR only. RESULTS: The SDR group consisted of 29 participants (mean age 5.8 years at baseline, 7.7 years at follow-up). Of these, 13 had concomitant orthopaedic surgery. The non SDR group consisted of 18 participants (mean age at baseline 6.1 years, 8.1 years at follow-up). SDR ± soft-tissue surgery significantly improved step-lengths, knee flexion at initial contact and mid-stance, ankle dorsiflexion, foot progression and timing of peak knee flexion. None of these improvements in gait were seen without surgical intervention. While more improvements were seen in those who had SDR and orthopaedic surgery, SDR only resulted in improved step-lengths, knee extension, foot progression and timing of peak knee flexion. CONCLUSIONS: SDR ± soft-tissue surgery results in short-term improvements in gait which are not seen without surgical intervention. While those who had SDR and soft-tissue surgery demonstrated more changes in gait, many improvements were attributable to SDR only.

Psychometric evaluation of the functional walking test for children with cerebral palsy.

PURPOSE: This study examined the psychometric properties of the functional walking test (FWT). METHOD: Fifty-six subjects with cerebral palsy (CP) (21 females and 35 males, mean age 9 years 6 months, SD 3 years 9 months, range 4-17 years) were assessed on two occasions, 6 months apart, using both the FWT and the gross motor function measure (GMFM). RESULTS: Generalisability correlation coefficients (GCC) for all 11 items were high (0.91-0.99). Inter-rater reliability was also high with excellent consensus in the scores given by the eight raters (intra-class correlation coefficient and GCC 0.99). Intra-rater reliability was equally high (GCC 0.99). The internal consistency of the FWT was estimated using Cronbach's α as 0.95 and 0.94 at Time 1 and 2, respectively. The FWT had a high degree of correlation with the GMFM, when total scores were compared at Time 1 and 2 (Pearson's r = 0.86 and 0.87, n = 56, p < 0.01). The FWT also found statistically significant differences in total scores between the three Gross Motor Function Classification System (GMFCS) levels. The correlation between the FWT scores and GMFCS was -0.70 at Time 1 and -0.76 Time 2 (p < 0.01) indicating the construct validity of the FWT. CONCLUSIONS: This study has demonstrated that the FWT has sound psychometric properties and is valid and reliable in a sample population of ambulant children with CP.