Mayo General Hospital

Introduction: Student absenteeism in undergraduate Medical and Health Sciences programs is a growing concern, affecting academic performance and professional preparedness. Faculty perspectives though essential for understanding and addressing this issue, remain underexplored in quantitative research. Objectives: To quantify faculty perceptions of the causes of student absenteeism, preferred interventions, and their associations with faculty demographics. Materials and Methods: A cross-sectional online survey was conducted among 150 faculty members at Liaquat University of Medical and Health Sciences, Hyderabad, Pakistan from September to November 2024. A structured questionnaire gathered data on demographics, perceived attendance trends, contributing factors, and suggested strategies. Data were analyzed using SPSS. Descriptive, and inferential statistics were applied; p < 0.05 was considered statistically significant. Results: Most participants were female (80%) and had over five years of teaching experience (83%). A decline in student attendance was reported by 67.5%, and 80% agreed that attendance affects academic performance. Major causes included exam pressure (73%), repetitive content (62%), and internet distractions (57%). Over half recommended interactive teaching, attendance-based incentives, and mental health support. Female faculty more often reported declining attendance (χ² = 7.78, p = 0.005). Teaching experience positively correlated with attributing absenteeism to internet use (r = 0.32, p = 0.001). Logistic regression showed that female gender (OR = 1.8) and greater experience (OR = 1.5) predicted the likelihood of recommending solutions. Conclusion: Faculty perceive absenteeism as a multifactorial issue requiring pedagogical, psychosocial and institutional reforms to foster engagement.

Nephrotic syndrome is a common glomerular disorder in childhood, often complicated by oedema, which contributes to morbidity, discomfort and prolonged hospitalisation. Intravenous (IV) albumin is frequently used with diuretics in children with resistant oedema, but its effectiveness and safety remain uncertain. Previous reviews are limited by adult populations, small sample sizes or a lack of quantitative synthesis. Our aim was to systematically evaluate the effectiveness and safety of IV albumin, with or without diuretics, versus no albumin in hospitalised children with nephrotic syndrome and oedema, and to map excluded-but-relevant studies to identify evidence gaps. We searched PubMed, Cochrane CENTRAL, Google Scholar and Europe PMC from January 1, 1990, to June 30, 2025, using MeSH terms and free-text keywords for nephrotic syndrome, albumin and paediatric populations. Reference lists of eligible studies and prior reviews were hand-searched. We included randomised controlled trials (RCTs), quasi-RCTs and comparative observational studies in children aged 1-18 years hospitalised with nephrotic syndrome and oedema. Studies without a comparator, non-paediatric populations, non-English publications or single-arm case series were excluded. Two reviewers independently screened records, extracted data and assessed risk of bias using the Cochrane Risk of Bias 2.0 tool (ROB 2) for RCTs. Due to the paucity of eligible studies and heterogeneity, outcomes were narratively synthesised. Excluded-but-relevant studies were mapped to identify evidence gaps. Out of 784 screened records, only one RCT met the inclusion criteria. Albumin plus furosemide significantly increased short-term urine output and weight reduction compared to furosemide alone, but effects were transient, and patient-centred outcomes were largely unassessed. Evidence mapping revealed multiple excluded studies with methodological limitations, inappropriate comparators or adult/mixed populations. Previous reviews corroborated the transient physiological effects but lacked paediatric-specific conclusions. We concluded that evidence supporting IV albumin use in hospitalised children with nephrotic syndrome is extremely limited. Albumin may provide short-term physiological benefit in select cases, but routine use is not justified. High-quality, adequately powered paediatric RCTs with standardised outcomes and systematic safety reporting are urgently needed to guide clinical practice.

Aims: To examine current monitoring practices for valproate users within Mayo Mental Health Services and analyse the conditions for which it is prescribed.Methods: Information on sodium valproate users was collected from clinical records using a data collection tool specifically developed to capture indicative parameters.Results: Data was collected from 6 community clinics and 4 inpatient units with a total of 69 patients on sodium valproate treatment within the service. Licensed indication was accounted for in 24.6% of patients with 63.8% prescribed valproate for unlicensed use and 11.6% for unknown indication. Amongst the prescribed users 33.3% were male and 66.7% were female with 27.5% of participants being under 55 years old and 72.5% over 55 years old. Out of 39 females using valproate 20.5% were on effective contraceptives and 79.5% were not using any. Regarding the annual physical health check, all participants in the approved inpatient units were compliant as it was part of the inpatient care requirement. 54.5% of patients in the community clinic on valproate had annual physical health reviews and 45.5% were not compliant.Conclusion: Our examination of Mayo Mental Health Service shows that most valproate use was for unlicensed indications with the majority of the users being female, most of whom were over 55 years of age. This reflects the high percentage of non-effective contraceptive users. There is also inadequate physical health monitoring for patients in the community.

A 51-year-old female, with no previous history of psychosis, presented to the Emergency Department with an acute psychotic episode in the context of excess caffeine consumption. Caffeine is an adenosine antagonist. An antagonist of adenosine can lead to the release of dopamine into the synaptic cleft, which can induce psychotic symptoms in vulnerable individuals. The patient had consumed caffeine in the form of up to eight energy drinks daily. She experienced persecutory delusions alongside auditory and visual hallucinations. She did not have a history of psychotic disorder but did have a history of generalized anxiety disorder. Upon cessation of caffeine, her symptoms resolved within five days. She remained caffeine-free and symptom-free 18 months later when reviewed in the community. This case highlights the potential psychiatric consequences of excessive caffeine consumption and identifies the need to screen for excessive consumption of caffeine in individuals presenting with new psychotic symptoms or worsening of pre-existing psychotic symptoms.

Abstract Background: Blood transfusion may be required in the management of patients undergoing emergency non-trauma laparotomy. However, several retrospective cohort studies involving patients undergoing laparotomy for benign and malignant indications have identified blood transfusion as a significant predictor of postoperative infections and mortality. Still, no study has explored such an association in our setting. We aimed to determine the effect of perioperative blood transfusion on the 30-day risk of surgical site infections and mortality among patients undergoing emergency non-trauma laparotomy in a large urban tertiary hospital in a low-resource setting. Methods: In this prospective cohort study, we recruited 160 adult patients admitted to the general surgery wards 48 hours after emergency non-trauma laparotomy. We grouped them based on transfusion exposure and non-exposure. Independent variables, including perioperative blood transfusion and confounders, were recorded on entry, while dependent variables, including the presence or absence of surgical site infection and mortality, were obtained over a 30-day follow-up period. Data were analysed using EPI INFO version 7, SPSS version 29 & Stata version 14. Results: All 160 participants recruited, 28 (17.5%) transfused (exposed) and 132 (82.5%) not transfused (non-exposed), were included in the final analysis. Transfusion exposure (RR, 7.81; 95% CI, 2.58 – 23.63; p=0.0003) and preoperative leucocytosis/leucopoenia (RR, 2.19; 95% CI, 1.04 – 4.65; p=0.040) were identified as independent risk factors for SSI after multivariate logistic regression analysis adjusted for confounders including preoperative anaemia, young-to-middle-aged adults, cloudy/purulent/feculent exudate, gut perforation diagnosis, female sex, and registrar-led surgical team. Furthermore, transfusion exposure (HR, 3.36; 95% CI, 1.11 – 10.25; p=0.033) and old age (HR, 5.50; 95% CI, 1.67 – 18.11; p=0.005) were identified as independent risk factors for 30-day mortality after multivariate Cox regression analysis adjusted for confounders including high ASA score, immunodeficiency, cloudy/purulent/feculent exudate, bowel obstruction and high-risk procedure for bowel leak. Conclusion: Among patients undergoing emergency non-trauma laparotomy, perioperative blood transfusion compared to no perioperative blood transfusion increased the risk of 30-day SSI by 7.81 and the 30-day mortality risk by 3.36. A restrictive transfusion strategy and a more extensive multicentre prospective cohort study are recommended.

Abstract Disclosure: R. Campbell: None. S.J. Lawless: None. B. MacNeill: None. E. Brosnan: None. M.J. Bell: None. Background: Insulinomas are a rare functioning pancreatic neoplasm, causing hypoglycaemia, typically during the fasting state (1). The non-specific and varied presentations of this condition make it quite the elusive diagnosis. Clinical Case: A 32 year old female with multiple presentations to the hospital with loss of consciousness and fatigue was subsequently noted to have complete heart block with a 4.4 second pause due to ventricular standstill in the early morning on a holter monitor. She had a background history of temporal lobe epilepsy from the age of 17 and was on regular anti-epileptics. Following discussion with the electrophysiology team, a dual chamber pacemaker (PPM) was inserted. Two months following PPM insertion she was re-admitted with another collapse, however on this occasion a blood glucose level (BGL) was 1.7mmol/L, promoting investigation for a possible insulinoma. A 72hr fast provided biochemical evidence of same with a BGL of 1.6mmol/L within 24hrs, insulin level 72.7pmol/L and c-peptide 621pmol/L. She was commenced on Octreotide and Diazoxide while awaiting further work-up. A CT pancreas was normal, and she subsequently underwent an endoscopic ultrasound, which visualised an isoechoic lesion in the pancreatic mid-body. One year following her initial presentation she underwent enucleation of the pancreatic lesion and pathology confirmed an insulinoma. Her symptoms resolved and her pacemaker was subsequently removed after multidisciplinary discussion and a period of close observation with the device function turned off. Conclusion: To date there are no published case reports of an insulinoma presenting as complete heart block, however the phenomenon has been studied in animal models. Key learning points are the ambiguous nature of this diagnosis and the need to keep an open mind, particularly when other factors muddy the water, which in this case were cardiac arrhythmias and seizure disorder. Reference: (1) Okabayashi T, Shima Y, Sumiyoshi T, Kozuki A, Ito S, Ogawa Y, et al. Diagnosis and management of insulinoma. World journal of gastroenterology: WJG. 2013;19(6):829. Presentation: Friday, June 16, 2023

Gestational diabetes is a common complication of pregnancy and the optimal management is uncertain. To test whether early initiation of metformin reduces insulin initiation or improves fasting hyperglycemia at gestation weeks 32 or 38. Double-blind, placebo-controlled trial conducted in 2 centers in Ireland (one tertiary hospital and one smaller regional hospital). Participants were enrolled from June 2017 through September 2022 and followed up until 12 weeks' postpartum. Participants comprised 510 individuals (535 pregnancies) diagnosed with gestational diabetes based on World Health Organization 2013 criteria. Randomized 1:1 to either placebo or metformin (maximum dose, 2500 mg) in addition to usual care. The primary outcome was a composite of insulin initiation or a fasting glucose level of 5.1 mmol/L or greater at gestation weeks 32 or 38. Among 510 participants (mean age, 34.3 years), 535 pregnancies were randomized. The primary composite outcome was not significantly different between groups and occurred in 150 pregnancies (56.8%) in the metformin group and 167 pregnancies (63.7%) in the placebo group (between-group difference, -6.9% [95% CI, -15.1% to 1.4%]; relative risk, 0.89 [95% CI, 0.78-1.02]; P = .13). Of 6 prespecified secondary maternal outcomes, 3 favored the metformin group, including time to insulin initiation, self-reported capillary glycemic control, and gestational weight gain. Secondary neonatal outcomes differed by group, with smaller neonates (lower mean birth weights, a lower proportion weighing >4 kg, a lower proportion in the >90% percentile, and smaller crown-heel length) in the metformin group without differences in neonatal intensive care needs, respiratory distress requiring respiratory support, jaundice requiring phototherapy, major congenital anomalies, neonatal hypoglycemia, or proportion with 5-minute Apgar scores less than 7. Early treatment with metformin was not superior to placebo for the composite primary outcome. Prespecified secondary outcome data support further investigation of metformin in larger clinical trials. ClinicalTrials.gov Identifier: NCT02980276; EudraCT: 2016-001644-19.

Abstract Background Sporadic Creutzfeldt-Jakob Disease (sCJD) is a rare neurodegenerative prion disease that presents with symptoms of rapid neuropsychiatric decline including dementia, behavioural abnormalities and loss of higher cortical function. Patients commonly present with rapidly-progressive neuromotor symptoms such as ataxia and myoclonus. Very few cases of CJD have been reported in which the patient initially presents with stroke symptoms such as hemiparesis as their primary presenting symptom. We present a case of a 56 year old male who initially presented to the stroke unit with waxing and waning left sided weakness and a non-corresponding ipsilateral left-sided acute parietal infarct on diffusion-weighted MRI. Over four weeks, his condition progressively worsened with declining cognitive function, motor dysfunction, sphincter dysfunction and eventual death. Methods Methods used to confirm the suspected diagnosis included: (1) Periodic sharp wave complexes are the most classical EEG finding for CJD and are seen in two third of the patients diagnosed with sporadic CJD, (2) The presence of the 14–3-3 protein in CSF has been found to be a sensitive and specific marker for sporadic CJD, (3) Neuroimaging plays a vital role in the diagnosis of CJD including serial MRIs and EEG sufficient to exclude other differential diagnoses. Results MRI brain revealed an acute cortical infarct within left parietal lobe measuring 3 mm.A n EEG demonstrated periodic sharp wave complexes occurring maximally in the left centro-temporal region. EEG finding was suggestive of a diagnosis of a prion disease. CJD Surveillance Unit confirmed the cerebrospinal fluid analysis was positive for RT-QuIC indicating sporadic CJD. Conclusion In cases of patients presenting with clinical signs and symptoms of a stroke with subsequent ipsilateral neurological findings on MRI, CJD should be included as a differential diagnosis. Additionally, a lumbar puncture, not routinely recommended in stroke patients, should be performed early to aid in early detection of CJD in order to confirm diagnosis and optimise the ceiling of care.

Abstract Background Mobility training is a complex intervention and recovery post-stroke is multidimensional. AVERT DOSE aims to define optimal early intervention regimens for people with mild to moderate ischaemic stroke. Methods AVERT DOSE (ACTRN:12619000557134) is an international randomised trial that will recruit >2,500 patients. Randomisation is to two groups according to stroke severity. Patients are then randomised to one of four mobility training regimens in each strata and the intervention is delivered for up to 14-days. Primary Outcome: Identification of the intervention regimen that results in higher proportion of favourable outcome at 3-months post-stroke. Results In Ireland, 4 sites are actively recruiting (1,2,3 and 7), one completing training (4) and two finalising ethical approval and contracts (5,6). Eighteen patients have been recruited to date in Ireland, and over 400 internationally. Trial set-up has proven complex with processes and requirements differing significantly across Irish sites. Time to ethics approval has ranged from 10-months to over 3-years. The novel status of this trial as a non-drug/medical device trial, but rather rehabilitation trial, had led to discussion in relation to the need for a trial EU representative. Staff recruitment and retention challenges have proven to be a significant barrier to recruitment in recent months. The development of an Irish Avert Dose group to collaboratively address challenges and provide peer support has proven very successful in both supporting sites to reach recruitment stage and throughout the stages of screening, recruitment, intervention and blind assessment. Conclusion Undertaking rehabilitation research against the backdrop of a global pandemic and increasing staffing challenges requires a determined, problem-solving approach. Irish sites have embraced this opportunity to answer an important stroke research question. Health and social care professionals have displayed innovation and competence in steering clinical research and this should improve future rehabilitation trial readiness. Trial recruitment is expected to gain pace as more Irish and international sites are approved.