Objective To explore healthcare professionals’ experiences of the development and delivery of Early Supported Discharge for people after stroke, including experiences of the COVID-19 pandemic. Design Qualitative descriptive study using one-to-one semi-structured interviews. Data were analysed using reflexive thematic analysis. Setting Nine Early Supported Discharge service sites in Ireland. Participants Purposive sampling identified 16 healthcare professionals. Results Five key themes were identified (1) Un-coordinated development of services, (2) Staff shortages limit the potential of Early Supported Discharge, (3) Limited utilisation of telerehabilitation post COVID-19 pandemic, (4) Families need information and support, and (5) Early Supported Discharge involves collaboration with people after stroke and their families. Conclusions Findings highlight how Early Supported Discharge services adapted during the COVID-19 pandemic and how gaps in the service impacts on service delivery. Practice implications include the need to address staff recruitment and retention issues to prevent service shortages and ensure consistent access to psychology services. Early Supported Discharge services should continue to work closely with families and address their information and support needs. Future research on how telerehabilitation can optimally be deployed and the impact of therapy assistants in Early Supported Discharge is needed.

The Oxford Carotid Stenosis tool (OCST) and Essen Stroke Risk Score (ESRS) are validated to predict recurrent stroke in patients with and without carotid stenosis. The Symptomatic Carotid Atheroma Inflammation Lumen stenosis (SCAIL) score combines stenosis and plaque inflammation on fluorodeoxyglucose positron-emission tomography (18FDG-PET). We compared SCAIL with OCST and ESRS to predict ipsilateral stroke recurrence in symptomatic carotid stenosis. We pooled three prospective cohort studies of patients with recent (<30 days) non-severe ischaemic stroke/TIA and internal carotid artery stenosis (>50%). All patients had carotid 18FDG-PET/CT angiography and late follow-up, with censoring at carotid revascularisation. Of 212 included patients, 16 post-PET ipsilateral recurrent strokes occurred in 343 patient-years follow-up (median 42 days (IQR 13-815)).Baseline SCAIL predicted recurrent stroke (unadjusted hazard ratio [HR] 1.96, CI 1.20-3.22, p = 0.007, adjusted HR 2.37, CI 1.31-4.29, p = 0.004). The HR for OCST was 0.996 (CI 0.987-1.006, p = 0.49) and for ESRS was 1.26 (CI 0.87-1.82, p = 0.23) (all per 1-point score increase). C-statistics were: SCAIL 0.66 (CI 0.51-0.80), OCST 0.52 (CI 0.40-0.64), ESRS 0.61 (CI 0.48-0.74). Compared with ESRS, addition of plaque inflammation (SUVmax) to ESRS improved risk prediction when analysed continuously (HR 1.51, CI 1.05-2.16, p = 0.03) and categorically (ptrend = 0.005 for risk increase across groups; HR 3.31, CI 1.42-7.72, p = 0.006; net reclassification improvement 10%). Findings were unchanged by further addition of carotid stenosis. SCAIL predicted recurrent stroke, had discrimination better than chance, and improved the prognostic utility of ESRS, suggesting that measuring plaque inflammation may improve risk stratification in carotid stenosis.

Background Early Supported Discharge (ESD) after stroke has demonstrated cost savings, reducing hospital length of stay (LOS) and long-term dependency. ESD discharges people after stroke from hospital earlier than conventional care with rehabilitation continuing at home. The Irish National Stroke Strategy 2022–2027 aims for ESD to be available to 92% of the stroke inpatient population. This study aims to profile the clinical characteristics and rehabilitation needs of those referred to ESD on discharge versus those discharged home without it in Ireland. Methods This study represents secondary analysis of an anonymised nationally representative prospective cohort study; the Irish National Audit of Stroke (INAS). Data were retrieved for 2018–2020 inclusive. A subset of 20 variables were used to profile the clinical characteristics and rehabilitation needs of those referred to ESD on discharge versus those discharged home without it. Data were analysed descriptively. Results In 2018, 139 people were discharged home with ESD, representing 3.8% of all people after stroke discharged home. This increased to 207 (4.9%) in 2019 and to 325 (6.6%) in 2020. More men were discharged home with and without ESD. Those aged 65–79 years represented the largest proportion of those discharged home with and without ESD. For those discharged with ESD, the mean LOS reduced each year from 17 days (SD=20) in 2018, 16 days (SD=16) in 2019 to 13 days (SD=13) in 2020. Those with a modified Rankin Scale score of 1, 2 at discharge represented the highest proportion of those returning home with ESD (59.3%) and without ESD (40.8%). Of those returning home with ESD, 10.8% were seen by a psychologist. Conclusions There is a need for significant scale-up of ESD to meet National Stroke Strategy targets. Consensus on ESD eligibility criteria nationally needs to be established and access to psychology services for people after stroke needs expansion.

Our understanding of the complex pathophysiology of Heart failure with preserved ejection fraction (HFpEF) is limited by the lack of a robust in vivo model. Existing in-vivo models attempt to reproduce the four main phenotypes of HFpEF; ageing, obesity, diabetes mellitus and hypertension. To date, there is no in vivo model that represents all the haemodynamic characteristics of HFpEF, and only a few have proven to be reliable for the preclinical evaluation of potentially new therapeutic targets. HFpEF accounts for 50% of all the heart failure cases and its incidence is on the rise, posing a huge economic burden on the health system. Patients with HFpEF have limited therapeutic options available. The inadequate effectiveness of current pharmaceutical therapeutics for HFpEF has prompted the development of device-based treatments that target the hemodynamic changes to reduce the symptoms of HFpEF. However, despite the potential of device-based solutions to treat HFpEF, most of these therapies are still in the developmental stage and a relevant HFpEF in vivo model will surely expedite their development process. This review article outlines the major limitations of the current large in-vivo models in use while discussing how these designs have helped in the development of therapy devices for the treatment of HFpEF.

Colon capsule endoscopy (CCE) has been demonstrated to be comparable to traditional colonoscopy and better than CT colonography (CTC) for the detection of colonic pathology. It has been shown to have a high incremental yield after incomplete colonoscopy. It is a safe test with good patient acceptability. Challenges currently include great variability in completion rates and high rates of re-investigation. In this review, we will discuss the evidence to date regarding CCE in symptomatic and surveillance populations, and in those post incomplete colonoscopy. We will discuss current challenges faced by CCE and areas for further research.

Abstract Introduction The potential of guideline-directed heart failure therapy to reduce mortality and morbidity in HF patients is tremendous however real-world data indicates sub-optimal up-titration to target doses. Challenges to optimisation include patient-related factors, treatment related factors and service-related factors. The observational QUALIFY Study reported a prescription rate of 87.8% for ACEI's/ARB's, 86.9% for Beta-blockers and 70.3% for MRA's. Purpose To examine the real-world pattern of up-titration and maximisation of four pillars of HF therapy to maximum doses in Irish Nurse-led HF Clinics in comparison to recent observational/registry studies and to highlight the main treatment related factors limiting optimisation. Methods A cross sectional prospective audit over a 3-month period was carried out in 18 HF centres in Ireland. Ethical approval was sought and granted in all centres. Patients included in the audit were those with HFrEF that achieved optimal tolerated dose of betablocker, ARNI/ACE-I, MRA and SGLT2I during the period of the audit. Results The audit included 648 participants, 499 (77%) male and 147 (23%) female (2 unknown). Average age of male was 68.5 years old and female was 68.7 years old. The rate of prescription for ARNI and ACEi/ARB was 93.8% (n=608), 65% (n=420) of patients were prescribed ARNI, ACEi were prescribed for 147 (22.6%) and ARB’s for 41 (6.3%) patients respectively. Hypotension was a limiting factor in 22.4% (n=146) of cases. Over 608 (93.6%) patients received a beta-blocker to maximum tolerated dose and 6% (n=40) did not receive a beta-blocker. Hypotension was a limiting factor for 77 (11.8%) patients, followed by fatigue in 15 (2.3%) of patients. 84% of patients received an MRA and 97 (14.9%) patients did not received an MRA. Hyperkalaemia was a limiting factor in 51 cases (7.8%), followed by chronic kidney disease in 32 cases (4.9%) and hyponatraemia in 6 cases (0.9%). Only 13.2% (n=86) of patients did not receive an SGLT2 and 86.8% were prescribed an SGLT2. Urinary tract infection was reported in 13 cases (2%), CKD preluded prescription in 7 patients (1%) and fungal infection occurred in 3 cases (0.4%). Conclusion A strong commitment to optimising heart failure therapy is evident in Irish nurse-led clinics. Prescription rates for patients optimised were 93.8% for ARNI/ACE/ARB, 93.6% for BB, 84% for MRA and 86.8% for SGLT2. This has surpassed target doses seen in observation studies. Future audits will examine the impact of nurse prescribing on the achievement of optimal target doses.

Klinefelter syndrome (KS) is the most common cause of primary hypogonadism in male patients; however, the diagnosis of KS is frequently delayed or missed. This delay can lead to undesirable outcomes for patients, especially considering that individuals with KS have a higher risk of developing specific malignancies, including breast cancer, non-Hodgkin’s lymphoma and mediastinal germ cell tumours. We present a case of a male patient in his 60s, where the established diagnosis of metastatic bilateral breast cancer prompted us to investigate and subsequently confirm a diagnosis of KS. This case highlights the diagnostic challenges of KS and emphasises the unfavourable consequences of a delayed diagnosis. We aim to raise awareness and enhance physicians’ understanding of KS and its non-reproductive manifestations, with a view to promote early recognition and improve patient outcomes.

A 63-year-old right-handed female was admitted to the acute general medical service following an episode of unwitnessed loss of consciousness. There was a preceding three-month history of progressively worsening confusion, word-finding difficulties and spatial disorientation. Magnetic resonance imaging (MRI) revealed a small area of restricted diffusion in the splenium of the corpus callosum with contrast enhancement. The cerebrospinal fluid analysis demonstrated mildly elevated protein, mild pleocytosis and no abnormal cells on cytology.Infective screen, connective tissue diseases workup, systemic vasculitis screen, cardiac investigations and occult malignancy screen were negative. EEG showed frontal intermittent rhythmic delta activity with no epileptiform discharges. Treatment with intravenous immunoglobulin and steroids was started due to the severity of symptoms. There was an excellent response to therapy but a relapse during the steroid taper. Repeat imaging demonstrated more high-signal lesions affecting the left frontal lobe. Suspicion for primary angiitis of the CNS led to digital subtraction angiography and brain biopsy. Both were negative for vasculitis. Clinical suspicion remained strong despite this. Cyclophosphamide, mycophenolate mofetil and rituximab were initiated with moderate brief response. The patient continued to decline clinically and radiologically and died 1.5 years after the initial presentation.An autopsy revealed cerebral vessels affected by intravascular large B-cell lymphoma, an exceptionally rare haematological condition. This was a post-mortem diagnosis despite extensive workup and falsely reassuring investigations including biopsy from a highly affected area in the brain.

IntroductionThere has been widespread international implementation of duration-hour restrictions to prevent surgical resident burnout and promote patient safety and wellbeing of doctors. A variety of Extended-Duration Work Shifts (EDWS) have been implemented, with a variety of studies examining the effect of shift systems on both surgical performance and the stress response unestablished in the literature. MethodsThis was a systematic review evaluating the impact of extended working hours on surgical performance, cognitive impairment, and physiological stress responses. The review used PubMed, Ovid Medline, Embase, and Google Scholar search engines between September and October 2021 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Filters including studies carried out after 2002 and published in the English language were applied. ResultsIn total, 30 studies were included for analysis. General surgery was the most commonly studied rotation, with Neurosurgical, Orthopedic, and ear, nose and throat specialties also included. The majority of studies found no difference or a significant improvement in post-EDWS on simulated performance. EDWS appeared to have the greatest impact on physiological stress markers in junior surgical trainees. ConclusionsExperience appears to confer a protective element in the postcall period, with preservation of skill demonstrated. More experienced clinicians yielded lower levels of physiological markers of stress, although variability in hierarchical workload should be considered. Heterogeneity of findings across physiological, cognitive, and psychomotor assessments highlights the need for robust research on the optimum shift pattern prevents worker burnout and promotes patient safety. Future research to evaluate correlation between stress, on-call workload, and performance in the postcall period is warranted.

Physicians endorse deprescribing of risky or unnecessary medications for older adults (aged ≥65 years) with dementia, but there is a lack of information on what influences decisions to deprescribe in this population. To understand how physicians make decisions to deprescribe for older adults with moderate dementia and ethical and pragmatic concerns influencing those decisions. A cross-sectional national mailed survey study of a random sample of 3000 primary care physicians from the American Medical Association Physician Masterfile who care for older adults was conducted from January 15 to December 31, 2021. The study randomized participants to consider 2 clinical scenarios in which a physician may decide to deprescribe a medication for older adults with moderate dementia: 1 in which the medication could cause an adverse drug event if continued and the other in which there is no evidence of benefit. Participants ranked 9 factors related to possible ethical and pragmatic concerns through best-worst scaling methods (from greatest barrier to smallest barrier to deprescribing). Conditional logit regression quantified the relative importance for each factor as a barrier to deprescribing. A total of 890 physicians (35.0%) returned surveys; 511 (57.4%) were male, and the mean (SD) years since graduation was 26.0 (11.7). Most physicians had a primary specialty in family practice (50.4% [449 of 890]) and internal medicine (43.5% [387 of 890]). A total of 689 surveys were sufficiently complete to analyze. In both clinical scenarios, the 2 greatest barriers to deprescribing were (1) the patient or family reporting symptomatic benefit from the medication (beneficence and autonomy) and (2) the medication having been prescribed by another physician (autonomy and nonmaleficence). The least influential factor was ease of paying for the medication (justice). Findings from this national survey study of primary care physicians suggests that understanding ethical aspects of physician decision-making can inform clinician education about medication management and deprescribing decisions for older adults with moderate dementia.