Nenagh Hospital

Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) are inflammatory disorders predominantly affecting older adults. PMR is primarily characterized by proximal muscle pain and systemic inflammation, while GCA involves large-vessel inflammation, posing risks of vision loss and stroke. Due to overlapping clinical features and age-related prevalence, diagnosing these conditions remains challenging. While PMR is largely diagnosed based on clinical symptoms and laboratory markers, GCA often requires histopathological confirmation via temporal artery biopsy (TAB). This study aims to assess the clinical presentation, diagnostic approaches, and treatment outcomes of PMR and GCA in geriatric patients, emphasizing the role of clinical versus laboratory and histopathological diagnosis. A cross-sectional study was conducted at Khyber Teaching Hospital, Peshawar, Pakistan, from September 2023 to September 2024, involving 118 patients aged 50 years or older diagnosed with PMR and/or GCA. Data were collected through patient interviews, medical records, and diagnostic reports. Statistical analyses were performed to evaluate clinical characteristics, laboratory markers, and treatment responses. The mean age of participants was 68.5 ± 7.4 years, with 65% female. PMR diagnosis was based on clinical symptoms, supported by laboratory markers such as elevated CRP (85%) and ESR (90%). GCA was clinically suspected in 38 patients, with 76% confirmed through TAB. Additionally, 67% of GCA patients exhibited the "halo sign" on vascular ultrasound, while 12% required magnetic resonance angiography for further evaluation. Glucocorticoid therapy was initiated in all cases, leading to clinical remission in 84% of patients. However, 28% developed hyperglycemia, and 14% experienced osteoporosis as treatment-related complications. Delayed glucocorticoid initiation caused a significantly higher relapse rate (p = 0.04). Glucocorticoid therapy remains effective in most cases, though adverse effects necessitate careful monitoring. Tocilizumab was required in 18% of patients due to glucocorticoid resistance or intolerance, but it causedhigher relapse rates and metabolic complications. The findings emphasize the need for steroid-sparing therapies and personalized treatment approaches to improve long-term disease control. Future research should explore newer biologic treatments, optimize imaging strategies, and address resource limitations to enhance early detection and management outcomes in elderly patients.

Abstract Background Urinary tract infection (UTI) is the most common reason for antibiotic use in older persons in residential care. Dipstick urinalysis for UTI is an ingrained practice. Inappropriate use of dipstick urinalysis can lead to inappropriate antibiotic prescribing, contributing to adverse effects and antimicrobial resistance. The ‘Skip the Dip for UTI in over 65s’ quality improvement initiative (QI) aims to raise awareness of best practice for diagnosis and management of suspected UTI to reduce unnecessary antibiotic use. It supports implementation of national guidance stating dipstick urinalysis is not recommended for assessment of evidence of UTI in people 65 years and over. Methods Focus groups with nursing staff in older persons residential care facilities (OPRCFs) identified barriers and facilitators for implementing national guidance on dipstick urinalysis for UTI. Supporting resources developed included a resident leaflet on UTI, staff handbook and webinar recording, hosted on www.antibioticprescribing.ie. Antimicrobial pharmacists delivered workshops on improving assessment of suspected UTI in the HSE OPRCFs from September 2023 to March 2024. Monthly monitoring of antibiotic use for UTI was established in all 119 HSE OPRCFs. Surveys to establish dipstick urinalysis practice in the OPRCFs were administered in March 2023 and March 2024. Results A baseline survey in 2020/21 indicated 98% HSE OPRCFs (133/135) performed dipstick urinalysis for residents with symptoms of UTI, reducing to 53% (57/107) in March 2023, and 24% (25/103) in March 2024 following this QI. Prevalence of antibiotics for treatment of UTI in the HSE OPRCFs decreased by 38%, from a baseline of 2.6% (114/4,446 residents) in 2020/21, to 1.6% (66/4,222 residents) in March 2024. Conclusion The ‘Skip the Dip for UTI in over 65s’ QI has resulted in a change in practice, with the majority of HSE OPRCFs now reporting dipstick urinalysis is not performed for UTI assessment, with a considerable reduction in antibiotics prescribed for UTIs.

Introduction Clinical trials evaluating the effectiveness of falls prevention interventions for people with Multiple Sclerosis (MS), Parkinson’s Disease (PD) and stroke measure heterogeneous outcomes, often omitting those meaningful to patients. A core outcome set (COS) is a standardised set of outcomes that should be assessed in all trials within a research area. The aim of this study was to develop a COS for evaluating mixed-diagnosis falls prevention interventions for people with MS, PD and stroke in non-acute and community settings, with input from relevant stakeholder groups. Methods Previously published research undertaken by the team, including a qualitative study with 20 patients and a review of the literature, were used to derive a longlist of potential outcomes. Outcomes were prioritised for inclusion in the COS using a three-round online Delphi survey. A multi-stakeholder, consensus meeting was conducted to agree upon the final COS and to provide a recommendation for a single outcome measure for each outcome in the COS. Results Forty-eight participants were recruited across four stakeholder groups (researchers, patients, clinicians, and service-planners/policymakers). A total of 42 participants (87.5%) completed all three rounds of the surveys. Sixty-two outcomes were considered for inclusion in the COS throughout the Delphi process. A total of 15 participants attended the consensus meeting where they agreed upon the final COS and accompanying measurement instruments: fall incidence, injurious fall incidence, quality of life, falls self-efficacy, fear of falling, activity curtailment due to fear of falling, and cost-effectiveness. Attendees at the consensus meeting recommended that the proposed mechanism of impact of an intervention is considered when selecting additional outcomes outside of those in the COS to assess. Conclusions This study identified a COS for evaluating the effectiveness of mixed-diagnosis falls prevention interventions for people with MS, PD and stroke. It is recommended that this COS and accompanying measurement instruments be used in all future trials in this research area so that findings can be combined and compared.

ABSTRACT Background: Relational aspects of self-awareness following Acquired Brain Injury (ABI) are increasingly being recognized. However, research underpinning the nature of the association between self-awareness and quality of relationships has yet to be synthesized. Method: Searches, which were completed between February 2022 and February 2023, consisted of combining terms related to ABI, self-awareness, and quality of relationships. Data were analyzed using the Synthesis Without Meta-Analysis (SWiM) approach. Results: Associations between self-awareness and relationship quality across eight studies identified for this review differed in direction and significance. A more consistent pattern emerged, however, when studies assessing the quality of specific types of relationships i.e., spousal (N = 1) and therapeutic (N = 3), were compared to studies assessing the quality of a person’s broader network of relationships (N = 4). In particular, good awareness was positively associated with the quality of specific relationships (r = 0.66) whereas it was negatively associated with the quality of a person’s broader network of relationships (r = −0.35). Conclusion: Results are discussed with consideration given to measures assessing the quality of specific relationships. In particular, such measures may tap into important patterns of interaction between two individuals, such as those related to attunement or communication, which may be valuable preconditions for improving awareness.

BackgroundHeart failure with reduced ejection fraction (HFrEF) is a complex disease, with multiple comorbidities, making management with guideline-directed medical therapy (GDMT) a challenging feat. Nurse-led outpatient HF clinics play a pivotal role in the optimisation of GDMT in HFrEF patients, with established benefits in reducing hospitalization and mortality. The recent addition of sodium-glucose transport protein 2 inhibitors (SGLT2i) to the backbone of HFrEF disease-modifying therapy has further increased the complexities of HF management. Prescriber hesitancy of SGLT2i in nurse-prescribers is compounded by concerns of treatment side effects, comorbidities, polypharmacy, and patient hesitancy. The lack of SGLT2i initiation in nurse-led clinics is under-investigated and may result in lower rates of patients receiving appropriate GDMT. Considering the widespread use of nurse-led outpatient HF clinics in Ireland, this trend could have widespread implications depending on the rate of SGLT2i initiation by nurse-prescribers.PurposeTo describe the rate of SGLT2i use in a nurse-led outpatient HF clinic (HFSU) and the impact of developing local nurse-prescriber guidelines on improving SGLT2i initiation rates.MethodsA retrospective closed-loop clinical audit was performed on HFrEF patients actively attending the HFSU. HFrEF was defined as left ventricular ejection fraction (LVEF) ≤40% and active attendance was defined as a single HFSU engagement within one year, and patients who have not died, been transferred to another service, or lost to follow-up. Patients who attended the HFSU during the respective phases had information on patient demographic, comorbidities, baseline investigations, and pharmacotherapy patterns collected and compared: Pre-intervention (January 2021 to December 2021), and Post-intervention (January 2022 to April 2022). Nurse-prescriber guidelines and patient information leaflets were developed and initiated as an intervention in January 2022.ResultsA total of 320 HFrEF patients were actively attending the HFSU during the Pre- and Post-intervention phases (160 Pre-intervention vs 160 Post-intervention) (table 1). During the Pre-intervention phase, SGLT2i was used in 9 patients (5.6%) who were all comorbid with type 2 diabetes mellites (T2DM). After intervention, SGLT2i use was significantly higher in the Post-intervention group when compared to the Pre-intervention group (9 (5.6%) vs 34 (21.3%), P <0.0001) (table 1). 16 of the 34 patients on SGLT2i in the Post-intervention group were comorbid with T2DM. 58 Table 1Comparison of patient characteristicsConclusionsPrescriber hesitancy of SGLT2i is an ongoing issue in nurse-led outpatient HF clinics. Auditing pharmacotherapy patterns can identify current rates of SGLT2i initiation, alerting clinicians to inadequate GDMT rates. Local nurse-prescriber guidelines and patient information leaflets can effectively increase the rate of SGLT2i initiation by non-physician prescribers and extend its licensed use beyond the diabetic cohort.

Abstract Background Stroke is a leading cause of death and disability. Thrombolysis with intravenous (IV) alteplase is the mainstay management of ischaemic stroke. It has a narrow therapeutic window with a high potential for adverse outcomes such as intracranial haemorrhage. The efficacy of alteplase is time and dose dependent with weight-based dosing. National clinical guidelines recommend a dose of 0.9 mg/kg, up to a maximum of 90 mg. (Irish Heart Foundation Council for Stroke 2015). In most hospitals in Ireland however, patients are not weighed prior to thrombolysis. Time pressure and lack of available suitable equipment are factors. Methods This retrospective clinical audit evaluated the dosing of alteplase, estimated and actual weight for a convenience sample of stroke thrombolysis patients treated between 2016–2020 at an Irish University Teaching Hospital. Results 107 patients were audited (62 males, 45 females). Actual and estimated weights were available in 92/107. Weight was not documented (n = 15) due to severe stroke/palliative management (n = 6) or omission (n = 9). 21% (19/92) received the correct dose of 0.9 mg/kg. A further 54% (50/92) received a dose within the range of 0.81–0.99 mg/kg (±10%). 25% received a dose outside this range (&amp;gt; ± 10%). 11% (10/92) were under-thrombolysed and 14% (13/92) over-thrombolysed. 17/92 patients had an intracranial haemorrhage. 35% (n = 6/17) of patients who had an intracranial haemorrhage received a higher dose of thrombolysis (&amp;gt;10%). Conclusion A quarter of patients received inappropriate dosing of alteplase that was outside the range of ±10% of 0.9 mg/kg. While stroke thrombolysis must be completed urgently, an accurate weight should be determined to avoid errors in dosing. A process evaluation of stroke thrombolysis would provide information on how best to incorporate an objective means of weight measurement without delaying treatment.

Introduction: Chylothorax is a rare cause of pleural effusion that results from damage of the thoracic duct and chyle leakage from the lymphatic system into the pleural space. Causes of chylothorax can be traumatic or non-traumatic. Chylothorax occurring due to damage to the thoracic duct by thoracic irradiation is rare, and infrequently described in the literature. Case Report: We present a case of a 74-year-old patient with a history of stage IV esophageal cancer who developed recurrent bilateral chylothoraces after palliative radiotherapy to her esophagus. She was treated conservatively with multiple modalities, including total parental nutrition leading to an oral low-fat medium-chain triglyceride diet, subcutaneous octreotide injection, and long-term insertions of bilateral chest drains. Conclusion: This case report and discussion highlight that chylothorax is a rare complication of radiotherapy. A suspicion of chylothorax should be raised in patients who present with recurrent pleural effusions after radiotherapy to the esophagus or mediastinum, as early intervention can improve outcomes in these patients.

BackgroundPatients served by Helicopter Emergency Medical Services (HEMS) tend to be acutely injured or unwell and in need of stabilisation followed by rapid and safe transport. It is therefore hypothesised that a particular clinical crew composition is required to provide appropriate HEMS patient care. A literature review was performed to test this hypothesis.MethodsMEDLINE, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews were systematically searched from 1 January 2009 to 30 August 2019 to identify peer-reviewed articles of relevance. All HEMS studies that mentioned ‘staffing’, ‘configuration’, ‘competencies’ or ‘qualifications’ in the title or abstract were selected for full-text review.ResultsFour hundred one studies were identified. Thirty-eight studies, including one systematic review and one randomised controlled trial, were included. All remaining studies were of an observational design. The vast majority of studies described clinical crews that were primarily doctor-staffed. Descriptions of non-doctor staff competencies were limited, with the exception of one paramedic-staffed model.ConclusionsHEMS clinical crews tended to have a wider range of competencies and experience than ground-based crews, and most studies suggested a patient outcome benefit to HEMS provision. The conclusions that can be drawn are limited due to study quality and the possibility that the literature reviewed was weighted towards particular crewing models (i.e. primarily doctor-staffed) and countries. There is a need for trial-based studies that directly compare patient outcomes between different HEMS crews with different competencies and qualifications.

BackgroundEvidence-based hospital design could significantly improve patient safety and make patient, staff and family environments healthier. This systematic review aims to determine which neonatal intensive care unit design features lead to improved neonatal, parental and staff outcomes.MethodsMedline, CINAHL, Web of Science Citation Index and Cochrane Central Register of Controlled Trials Registry, were searched in January 2017. Using combinations of the relevant key words, review was performed following the recommended guidelines for reporting systematic reviews. English language limitation was applied and term limited to 2006–2016. Pre-piloted forms were used by one reviewer and cross verified by second reviewer. Included studies were assigned a grade based upon their level of evidence and critically appraised using defined tools. Data were not synthesized for metanlysis due to nature of literature reviewed and heterogeneity.Results3,592 titles were screened with 43 full-texts assessed for eligibility. 30 studies were deemed eligible for inclusion. These included 19 cohort studies, two qualitative studies, seven cross-sectional studies, one systematic review (peer reviewed articles up to January 2011) and one randomised control trial. Grey literature search from guidelines, catalogues and repositories yielded additional 10 guidelines.ConclusionsOptimally designed neonatal unit has many possible health implications, including improved breastfeeding, infection and noise control, reduced length of stay, hospitalisation rates and potentially improved neonatal morbidity and mortality. ‘Single family room’ design for neonatal units is recommended. Consideration should be given to infection prevention and control, including sink frequency and positioning, and airborne isolation facilities. Support areas for families, staff and breastfeeding mothers are also recommended. High quality, family centred neonatal care could be assisted through well grounded, future proofed and technology enabled design concepts that have the potential to impact upon early life development. Nature of the topic poses inherent limitations for conduct of randomized trials; however observational studies using standardised methodologies could add further evidence.