Portiuncula Hospital

In 2023, the VAS international working group on Buerger's Disease (BD) recommended two diagnostic criteria based on a prior Delphi study: "definitive" and "suspected". The "definitive" criteria are history of smoking, typical angiography, and typical histopathological features. All three features are mandatory to confirm a "definitive" diagnosis of BD. The conundrum is-what features should be considered typical of BD angiography? According to this review, segmental occlusion of infrapopliteal arteries, corkscrew collaterals that appear to continue the occluded arterial segment (Martorell's sign) or bypass the segmental occlusion, absence of atherosclerotic plaque or aneurysm could differentiate BD from ASO. Hence, for "typical" BD angiography, these manifestations should certainly be considered. However, data for differentiating angiography patterns of BD from the small- and medium-sized vasculitis including Behcet's disease, scleroderma, hepatitis associated vasculitis, and anti-phospholipid syndrome are limited. Further studies for investigating the angiography pattern in BD patients in early and late presentation of BD, particularly in the patients with long-term follow up, are highly recommended.

Este estudio explora las experiencias de los estudiantes de último ãno de enfer-mería con la venopunción y la canulación intravenosa periférica, centrándose tanto en entornoseducativos como de práctica clínica. Este estudio es de disẽno descriptivo cualitativo. Los datos se recopilaron a partirde tres sesiones de grupos focales utilizando un enfoque de entrevista semiestructurada. Lasentrevistas se transcribieron palabra por palabra y el análisis de los datos se guió por el modelode seis pasos para el análisis temático de Braun y Clarke. Participaron ocho estudiantes de último ãno de enfermería y cada estudiante asistióa una sesión de grupo focal. El análisis de datos dio como resultado cuatro temas principales1) Práctica, práctica, práctica 2) No como se hace aquí 3) Suerte en el sorteo y 4) Aprendizajeexperiencial. Los resultados resaltan lo que obstaculizó y ayudó a los estudiantes a aprenderestas habilidades tanto en el entorno educativo como en el clínico Se recomiendan mejoras que se pueden realizar en la enseñanza de estas habilidades a los estudiantes de enfermería. Los hallazgos de este estudio pueden informar sobre programas educativos que incorporen este tipo de habilidades. This study explores final-year nursing students’ experiences with venepuncture and peripheral intravenous cannulation, focusing on both educational and clinical practice settings. This study is qualitative descriptive design. Data were collected from three focus group sessions using a semi-structured interview approach. Interviews were transcribed verbatim, and data analysis was guided by Braun and Clarke's six-step model for thematic analysis. Eight final-year nursing students participated, with each student attending one focus group session. Data analysis resulted in four main themes 1) Practice, practice, practice 2) Not the way it's done here 3) Luck of the draw and 4) Experiential learning. The results highlight what hindered and helped students learn these skills in both the educational and clinical environment. Improvements are recommended which can be made to the teaching of nursing students on these skills. The findings of this study can inform educational programmes which incorporate these types of skills.

Introduction We present a case study of a 19-year old Ukrainian refugee presenting with delirious mania, with no personal or family psychiatric history. Delirious mania is a complex and severe neuropsychiatric condition that remains under-recognised in diagnostic manuals. Delirious mania describes a neuropsychiatric state where a patient is exhibits signs and symptoms of mania, delirium and often catatonia. Most of the patients described in past case reports are older in age than our patient and have a personal or family history of a mood disorder. Objectives Our objectives were to investigate the signs and symptoms of delirious mania in this this 19 year-old patient. We sought to compare his presentation to the existing diagnoses in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition and International Classification of Diseases 11th Revision. These include delirium, mania and catatonia. In addition, we aimed to study existing literature on delirious mania as well as cross-cultural factors in formulation of this complex case. Methods We assessed this patient daily as part of the Liaison Psychiatry team and compared his presentation to existing diagnostic criteria of delirium, mania and catatonia. We performed a literature review of delirious mania to identify suggested diagnostic criteria, management strategies and cultural considerations. Results Our patient presented to the Emergency Department with a four-day history of bizarre behaviour and poor sleep. He had no past psychiatric history. He was admitted to the general medical ward for a medical work-up, which ultimately yielded no organic pathology. During this time, our patient fulfilled separate diagnostic criteria for delirium, manic episode and catatonia. We found that there was no overarching diagnosis within international diagnostic manuals that encompassed this patient’s presentation. However, delirious mania has been described in the literature since 1849. There are various suggested diagnostic criteria for delirious mania suggested in the literature, such as those by Bond (1980) and Fink (1999). This patient was successfully treated with intramuscular lorazepam. In our discussion, we considered various unique factors in the formulation. These included the cultural considerations given that the patient had recently entered the country as a Ukrainian refugee, difficulties in assessment and treatment due to language and cultural barriers and the limitations of psychiatric treatment on a general medical ward. Conclusions Delirious mania continues to be unrepresented in diagnostic manuals, which in turn leads to confusion over diagnosis and treatment. Given the complexity of this neuropsychiatric condition, early recognition is key in providing effective treatment before progression into a malignant state. This would be aided by having delirious mania recognised in international classifications. Disclosure of Interest None Declared

This descriptive, cross-sectional study aimed to identify whether having a chronic leg ulcer (CLU), in addition to diabetes, contributed to frailty in individuals ≥65 years old. It also explored the associations between frailty, pre-frailty and other factors. 125 participants aged ≥65 attending outpatient clinics in Ireland were categorised into three groups: (1) diabetes-only and no CLU, (2) CLU-only and no diabetes, and (3) diabetes and CLU. Frailty status was identified using the Groningen Frailty Indicator (GFI) and the Physical Frailty Phenotype (PFP). The mean age was 76.09 ± 7.31. Overall, 90 (72%) had diabetes, and 89 (71.2%) had CLU in the past 6 months. While 124 (99.2%) were frail according to the GFI, 122 (97.6%) were either physically frail (n = 40, 32%) or pre-frail (n = 82, 65.6%) based on the PFP. There was no difference between the three groups regarding general frailty status (p > 0.05). However, being aged ≥75, having CLU and having CLU in addition to diabetes were associated with frailty severity (p < 0.05). Slow gait, inability to go to the toilet and dress/undress independently were the common factors contributing to frailty. Age, comorbidities and CLU were associated with frailty severity. Incorporating multidimensional frailty screening into regular clinic visits for older adults with CLU is recommended.

Abstract Background The processing of blood cultures is technically difficult and time consuming. Nucleic acid amplification tests (NAATs) can supplement this process, with some commercial systems offering NAAT for multiple pathogens simultaneously. These platforms also present distinct challenges, including managing false positive identifications. The use of broad multiplex NAAT in cases of low pre-test probability carries an inherent risk of low positive predictive value. We describe a series of detections of Candida tropicalis targets from positive blood cultures where C. tropicalis was not present and subsequent management. Incident Biofire Filmarray BCID2 was introduced in May 2022 in a General Hospital to aid laboratory workflow. The BCID2 panel is used 5–10 times weekly on positive blood cultures. BC specimens are then sent to an associated hospital for sub-culture, identification and antimicrobial susceptibility testing. In August 2023 a blood culture with Gram-positive cocci on Gram stain was positive for C. tropicalis and Staphylococcus spp. targets on BFBCID2. The consultant microbiologist did not advise antifungal treatment based on Gram stain and assessment of patient clinical features. Only Staphylococcus spp. was identified on culture. bioMérieux UK Ltd subsequently released a Field Safety Notice in August 2023 highlighting the risk of false positive identification of C. tropicalis and other organisms using BCID and BCID2 panels. This may be related to yeast DNA in the culture media. C. tropicalis has been detected from 18 additional blood cultures up to March 2024 from multiple batches of blood culture bottles and multiple BCID and BCID2 panels. Risk management Laboratory practices were reviewed to address the possibility of sample contamination. Of note, C. tropicalis was not cultured from blood in the laboratory in the year prior August 2023. All scientific and medical staff in the laboratory were alerted to the issue. Use of the BCID and BCID2 panels was continued because of the clinical value of rapid on-site identification of key pathogens such as S. aureus and differentiation from CoNS. In each case of C. tropicalis identification, the Gram stain and clinical features were reviewed. No patients received inappropriate antifungal treatment. Lessons for trainees (i) The combination of two technologies (blood culture and multiplex NAAT) can generate unanticipated challenges. (ii) Use of NAATs in samples with a low pre-test probability is associated with the risk of low positive predictive value. (iii) Potential risk can be mitigated by correlation of results of molecular testing with Gram stain and assessment of clinical features. Conclusions Learning for microbiology trainees relates to the need for caution in interpretation of new technologies and the importance of pre-test probability in interpreting a positive result in any assay.

Background: Barrett’s oesophagus (BO) is a pre-malignant condition whereby the normal stratified squamous epithelium of the distal oesophagus is replaced by metaplastic columnar epithelium. The British Society of Gastroenterology (BSG) 2014 guidelines recommend specific surveillance intervals and a standardised reporting approach to BO using a minimum dataset during oesophagogastroduodenoscopy (OGD). The objective of this study was to the assess the adherence of endoscopists to these guidelines and promote a standardised approach to BO reporting and surveillance. Methods: To assess adherence, a retrospective closed-loop audit was carried out. Audit cycle 1 included patients who had undergone surveillance OGD for BO during 2021. An educational intervention for endoscopists and a proforma for reference during OGD were implemented thereafter. Cycle 2 audited the same parameters post-intervention, from January to July 2023. Results from both were analysed and compared. Results: A total of 50 patients were included in cycle 1, and 44 patients in cycle 2. Both cycles demonstrated high levels of adherence the recommended surveillance intervals (89% and 88.9% respectively). Adherence to the Seattle protocol and measurement of hiatus hernia size increased in cycle 2, while adherence to the Prague criteria remained low (20% versus 22.7%). Paris classification was not reported during either cycle. Conclusions: There is a need for further intervention to increase the standard of BO reporting, namely the Prague criteria for reporting BO extent and Paris classification for classifying visual lesions. Future plans may comprise of focused local proforma development including expansion to include the computer-based platform on which OGD reports are generated.

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.

Background Spontaneous preterm birth is the leading global cause of neonatal death, and countless efforts have failed to establish a single effective treatment for preterm labor, partly because the mechanisms that regulate the uterus and the cervix during pregnancy are not well understood. When a post-term pregnancy truly exists, its cause is mostly unknown. Objective To support the hypothesis. Study Design: This study investigated the current evidence-based literature and research that may support the hypothesis, accompanied by 40-second 3D animations. Results Light-dark cycle modulation of interactive inhibitory and stimulatory systems divides gestation into five clinical phases: growth, maturation, transition, parturition, and involution. During the maturation phase (30–40 weeks), nocturnal synchronisation and synergy of the inhibitory and stimulatory systems, secondary to light-dark cycle modulation, make the cervix progressively transform into the lower uterine segment and lose its strength, eventually causing EUWT failure. The clock that measures the duration of pregnancy consists of two interacting timers, an interval timer measuring the overall length of gestation and a circadian timer that defines when a 24-hour cycle birth occurs. Pregnancy intervals and circadian timers are achieved by a single mechanism, namely EUWT failure, secondary to the complete loss of cervical strength nocturnally. Inhibitory system malfunction causes preterm labor, and most of the current therapeutic modalities for preterm labor focus on delaying or preventing EUWT failure. Stimulatory system malfunctions cause post-term pregnancy. Conclusion The creation, autonomic maintenance, and eventually autonomic EUWT termination make pregnancy an autonomic cycle with constant intervals and circadian timers where its malfunctions change the timing of birth and pregnancy duration. Laplace’s law measures EUWT, which might be the law of physics that controls pregnancy duration.