Accurate comparable prevalence proportions are required to better understand the epidemiology of frailty. Estimates in many countries are missing or incomparable. The Global Burden of Disease Frailty Index (GBD-FI) applies the deficit accumulation model to generate frailty scores from items available in the Global Burden of Disease study. To externally validate the GBD-FI. Data were obtained from the Survey of Health Ageing and Retirement in Europe (SHARE). A 20-item modified GBD-FI was compared with established frailty measures: a 70-item frailty index (FI-70), the Clinical Frailty Scale (CFS), Frailty Phenotype (FP) and SHARE-FI. Area under receiver operating characteristic curves (AUC) were fitted to examine diagnostic accuracy for frailty and predictive validity for 2-year mortality. In total, 31,624 participants aged ≥50years from 15 countries were included. Frailty prevalence was 22% using the GBD-FI (ranging from 8% in Switzerland to 41% in Poland). The GBD-FI had good to excellent diagnostic accuracy for frailty, irrespective of approach; the AUC ranged from 0.86 (95% confidence interval: 0.85-0.87) measuring frailty using the CFS to 0.94 (0.93-0.94) with the FI-70. The GBD-FI had similar accuracy for 2-year mortality (AUC 0.71, 0.69-0.74) compared with the CFS (0.73; P = 0.186), FP (0.73; P = 0.392) and SHARE-FI (0.70; P = 0.255) but lower than the FI-70 (0.76; P < 0.001). The GBD-FI demonstrated concurrent and predictive validity, suggesting it is a valid measure of frailty. It has the potential to be an efficient, replicable and consistent approach to comparing frailty between countries and regions across time using GBD data.

Buerger's disease (BD) remains a debilitating condition and early diagnosis is paramount for its effective management. Despite many published diagnostic criteria for BD, selective criteria have been utilized in different vascular centers to manage patients with BD worldwide. A recent international Delphi Consensus Study on the diagnostic criteria of BD showed that none of these published diagnostic criteria have been universally accepted as a gold standard. Apart from the presence of smoking, these published diagnostic criteria have distinct differences between them, rendering the direct comparison of patient outcomes difficult. Hence, the expert committees from the Working Group of the VAS-European Independent Foundation in Angiology/Vascular Medicine critically reviewed the findings from the Delphi study and provided practical recommendations on the diagnostic criteria for BD, facilitating its universal use. We recommend that the 'definitive' diagnosis of BD must require the presence of three features (history of smoking, typical angiographic features and typical histopathological features) and the use of a combination of major and minor criteria for the 'suspected' diagnosis of BD. The major criterion is the history of active tobacco smoking. The five minor criteria are disease onset at age less than 45 years, ischemic involvement of the lower limbs, ischemic involvement of one or both of the upper limbs, thrombophlebitis migrans and red-blue shade of purple discoloration on edematous toes or fingers. We recommend that a 'suspected' diagnosis of BD is confirmed in the presence of a major criterion plus four or more minor criteria. In the absence of the major criterion or in cases of fewer than four minor criteria, imaging and laboratory data could facilitate the diagnosis. Validation studies on the use of these major and minor criteria are underway.

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 Dysphagia prevalence in the acute setting is 30%. Managing dysphagia can reduce mortality, length of stay and increase overall quality of life. Use of thickener for patients with dysphagia should be the last alternative. However, in the acute setting due the patient’s respiratory or cognitive status, thickener use is required to manage the risk of aspiration and ensure patients improve clinically. The goal is for discharge prescriptions to contain all the necessary information for patients. The aim of this audit is to investigate the rate of prescription of thickener on patient’s discharge. Methods Two retrospective chart audits of discharge prescriptions were completed (December 2022 and May 2023); pre and post implementation of a new communication strategy for thickener being prescribed. All patients discharged from hospital on thickened fluids were included as identified via Speech and Language Therapy database. The audit investigated the rate of thickener on discharge prescription and documentation in the Kardex. Results Initial audit was completed in December 2022. 20 patients were included. 0% of patients had thickener prescribed on discharge with no (0%) documentation in the Kardex. Re-audit was completed in May 2023, following the implementation of a new communication strategy involving SLTs place a sticker on the Kardex, included 13 patients 77% (10 patients) had thickener prescribed on discharge with the same number (77%; 10 patients) having documentation in the Kardex. Conclusion Improved communication between healthcare professionals results in better patient outcomes and reduces the risk of re-admission. The use of instrumental assessment has enabled SLTs to truly identify those who require thickener, particularly during an acute admission. The SLT department is striving to reduce the use of thickener for patients, however, in those who do require this management option, it is imperative that it is included on their discharge prescription.

Abstract Background Delirium is a common feature in admission of older adults to inpatient wards. The diagnosis of delirium is often over-looked by healthcare professionals. This leads to lack of early intervention; associated with negative outcomes including prolonged Length of Stay (LoS), avoidable complications, and use of psychotropic medications. We assessed whether a Quality Improvement Program (QIP) should be implemented for frail older patients focused on identification and intervention of delirium. Methods The pre-intervention retrospective audit included patients aged 75 or older, assessed by the Frailty at the Front Door team in a four-month period (2022). All patients had 4AT score of 4 or greater, indicating a delirium syndrome. Data was collected on discharge destination, Clinical Frailty Score (CFS), LoS, and number of bed-moves. A selection of patients had in-depth medical record reviews to identify whether delirium was documented, and what interventions occurred, including pharmacological. Results Data was collected on 40 patients, age range 77–97 years, median age 86 years. 57.5% were aged 85 or older (23/40). Median CFS was 5, Median 4AT score was 5. 30% had a 4AT score ≥ 7 (12/40). 57.6% (19/33) were discharged home to their usual residence, 30.3%(10) went to inpatient ‘respite’. 4 patients were not admitted. Longest LOS was 42 days, average LOS 8 days. One patient experienced 13 bed moves during their inpatient stay (average = 8). 19 patients had in-depth chart review: 2/19 had appropriate documentation of delirium in the ED, 6/19 as an inpatient. 1 patient had non-pharmacological interventions recommended. 2 patients were discharged on a new psychotropic medication. Conclusion In an older, frail population presenting to ED, delirium is under-recognised despite routine use of 4AT score. Non-pharmacological interventions are under-utilised. Patients experience prolonged inpatient stays and frequent bed moves, and are likely to be discharged to a different inpatient unit for ‘respite’. A QIP will be developed aiming to improve patient experiences.

Abstract Background Stroke Unit Nurses require multifaceted competencies to manage the complex needs of the stroke patient. The National Clinical Programme for Stroke (NSP) set out to develop a competency toolkit for stroke nurses. A modified-Delphi format was used, the questionnaire was developed by an Irish expert advisory group. The development was informed by the group experience and review of existing stroke unit nurse competency toolkits In Ireland and abroad. Methods Round one of the Survey was conducted using a semantic differential question, with a 3 point score scale. The survey was sent to a subject matter expert group (32 Clinical Nurse Specialists &amp; Advanced Nurse Practitioners). In round two, the participants were given controlled structured feedback based on the overall feedback from round one, which allowed for adjusted responses. The advisory group looked at themes that emerged in the answers in round one. This formed the basis for the questions in round two, a multiple-choice format, with one answer. Results Response rates for round one was 66%, Individual opinions were combined into a group consensus, which lead to the completion of the questionnaire for round two. A consensus definition of at least 80% agreement for each item was decided a priori, in round one, 75% of items reached consensus. Round two response rate was 71%, with 49% of items reaching consensus. Conclusion Development of a standardised competency toolkit for stroke unit nursing is a strategic goal of the NSP. While round one lead to considerable consensus, it is clear that what is not agreed initially can be difficult to reach a consensus on, with only 49% consensus in round two. A third round will be required, but if consensus remains elusive, additional methodology techniques such as a focus group may be used. Challenges are response exhaustion and availability of busy ‘experts’ in their fields.

Abstract Background Dysphagia post stroke has a significant impact on patient’s outcomes including mortality due to stroke associated pneumonia, length of stay, rehabilitation potential and overall quality of life. Evidence derived from both experimental and observational studies demonstrates that swallow screening following stroke has a significant protective health benefit against pneumonia, mortality, dependency and length of stay. Stroke Swallow Screening (SSS) should be completed within 4 hours of patients presenting with stroke. In 2022, 70% of patients presenting with stroke received a SSS with only 43% receiving SSS within the recommended 4 hours. The aim of this audit is to investigate how PUH compares to the international standard and the national audit of stroke findings. Methods Retrospective audit using the 2022 HIPE Stroke data for PUH. Audit reviewed data from January to December 2022. Sample size was the entire cohort of strokes in 2022 (88 patients). Data was analysed quantitatively using an excel spreadsheet. Results 88 patients presented to PUH with stroke in 2022. 44% (39 patients) had a SSS completed, while only 13% (11 patients) had the screen completed within 4 hours. Conclusion PUH will use this patient-centred data to improve our stroke care, specifically the SSS standard as per the National Stroke Guidelines (2022). The SLT department is currently collaborating with our stroke colleagues to provide training to relevant staff. A SSS Programme is a priority quality improvement project for 2023, striving to make significant improvements to our standard of stroke care. Our goal is to become champions locally and nationally in SSS, an area that has consistently lagged behind the national and international standards for too long.

Background Despite a considerable body of literature gathered from the few species that have been studied, the mechanisms responsible for the maintenance of pregnancy and the initiation of parturition have not been fully elucidated. Failure to understand uterine function during pregnancy is a major shortcoming in healthcare. 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 The isthmus of the cervix does not seem to exist embryologically, anatomically, histologically, or functionally. The isthmus of the cervix may be a flaw in the concept of human parturition, which creates a block barrier that prevents understanding of uterine function. Mechanotransduction is the process by which cells sense physical forces and translate them into biochemical and biological responses. Uterine mechanotransduction has functional and molecular components, wherein intrinsic myometrial cell character (IMCC) is the molecular component and Exponential uterine wall tension (EUWT) is the functional component. IMCC enables the uterus to control its functions autonomically and intrinsically, secondary to changes in tension, where high tension induces relaxation and low tension induces contraction. EUWT is created and maintained by a complex interaction between the gestational sac, uterus, and cervix, for which the primary function is to maintain EUWT. EUWT mechano-transduction and progesterone/estrogen induce the stretch-dependent inhibitory system, and indirectly, they also induce the stimulatory system by inducing myometrial hyperplasia and hypertrophy. Pregnancy is mainly maintained through a stretch-dependent inhibitory system, in addition to direct myometrial relaxants. Contractions of the stimulatory system in the presence of the foetus create direct and indirect uterine-cervical interactions (DIDUCI). DIDUCI transforms the cervix into the lower uterine segment through TYVU pattern formation and causes EUWT failure. So, the functional components of the stimulatory system (DIDUCI) are the uterus corpus, fetus, cervix, and bony pelvic inlet. Conclusion Pregnancy is a state of balance between the two opposing and interactive inhibitory and stimulatory systems secondary to EUWT mechanotransduction and progesterone/estrogen stimulation. EUWT is measured using Laplace’s law, which might be the law of physics that controls uterine function during pregnancy.

Background Our hypothesis suggests another view regarding the following: Labor physiology. Labor progress. Labor dystocia. Objective To support the hypothesis. Study Design This study investigated the current evidence-based literature and research that may support the hypothesis. Results Intrinsic myometrial cell character ensures that parturition is an autonomic, intrinsic, and interactive repetitive contraction and relaxation cycle, secondary to myometrial tension changes that cause labor progression and protect the foetus against hypoxia. The progress during the first stage of labor and what is called cervical dilatation is the complete transformation of the cervix into the LUS, which has a clinical and radiological presentation. The clinical presentation is effacement, and dilatation. Radiologically, the cervix transforms into the LUS through an inverted inside-out TYVU and an inverted U pattern formation. In the second stage of labor, the cervix has completely transformed into the LUS which is a wedge-shaped birth canal that extends from the vaginal vault (cervicovaginal junction) into the physiologic retraction ring. All these changes reverse instantly after foetal delivery, and the cervix returns to its anatomical site and regains its full anatomical shape. Concomitant malfunctions of the inhibitory and stimulatory systems cause labor dystocia. Conclusion Labor dystocia is the failure of the complete transformation of the cervix into the lower uterine segment secondary to combined inhibitory and stimulatory system malfunction. Most of the cervical transformation into the LUS takes place during the third trimester and is completed during the first stage of labor. So, the treatment of labor dystocia should focus on the causes of the stimulatory system’s malfunction before the onset of labor. There is evidence to support the hypothesis, and it should be in the interest of obstetricians, physiologists, midwives, neonatologists, and those with a research interest in maternal and family welfare.

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.