Mater Dei Hospital

This update and revision of the international guideline for urticaria was developed in accordance with the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. It is an initiative of the Global Allergy and Asthma Excellence Network (GA2LEN) and its Urticaria and Angioedema Centers of Reference and Excellence (UCAREs and ACAREs), with the participation of 210 delegates from 107 national and international societies, from 59 countries. The consensus conference was held on December 6th, 2024. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell-driven disease, defined by a rapid appearance of wheals, angioedema, or both. The lifetime prevalence of acute urticaria is estimated to be approximately 20%. Chronic urticaria, categorized as either chronic spontaneous urticaria or chronic inducible urticaria, is disabling, impairs quality of life, and affects performance at work and school, however, novel therapies are available. This updated version of the international guideline for urticaria covers the definition and classification of urticaria and outlines expert-guided and evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria.

Type 2 diabetes mellitus is characterized by obesity and insulin resistance. Macrovascular (cardiovascular) disease (CVD) encompasses myocardial infarction, stroke and peripheral arterial disease. It is caused by atherosclerosis, a complex pathological process that is accelerated in people with diabetes and therefore causes premature morbidity and mortality. Risk is modified by established factors including hypertension and dyslipidaemia (which are linked to underlying insulin resistance), and microalbuminuria/renal impairment as well as cigarette smoking. Hyperglycaemia is a relatively weak risk factor for CVD once diabetes is established but is the key driver of microvascular complications. Other ‘novel’ predictors include elevated B-type natriuretic peptide, obstructive sleep apnoea, non-alcoholic fatty liver disease, hypoadiponectinaemia and testosterone deficiency, as well as chronic periodontitis and collagen vascular disorders. Early identification of cases and prompt management of risk factors is important in improving long-term outcome. Smoking cessation is a neglected area that requires urgent attention. Relative cardiovascular risk is similarly high in type 1 diabetes, even in younger individuals, and is also an important area for research.

Optic neuritis is a rare immune-related adverse event of immune checkpoint inhibitor use and may result in poor visual outcomes. We describe an elderly woman with metastatic malignant melanoma treated with nivolumab, a programmed cell death protein 1 immune checkpoint inhibitor. After 2 months, she developed bilateral painless loss of vision due to optic neuritis. Although there is limited evidence, expert opinion favours early corticosteroid use and/or plasma exchange, as recommended for neuromyelitis optica spectrum disorders. Optic neuritis is increasingly recognised as an immune-related adverse event, likely to occur more frequently with greater use of immune checkpoint inhibitors. Its early recognition is important as prompt treatment can improve outcomes.

INTRODUCTION:Evidence suggests that existing pre-operative fasting guidelines are associated with prolonged fasting times. Prolonged fasting, particularly from clear liquids, has the potential to harm patients through reduced peri-operative wellbeing; impaired glucose metabolism and peri-operative inflammatory response; delayed return of bowel function; and reduced muscle strength. Liberalisation of fasting practices has, therefore, become increasingly common. Such a change in practice dictates the need for updated practice guidance. We aimed to develop recommendations on peri-operative fasting that reflect increasing global awareness of the adverse effects of prolonged fasting. METHODS:Following a systematic literature review, 13 draft recommendations related to peri-operative fasting were developed iteratively. These were modified during a three-round Delphi process by an international, multidisciplinary stakeholder panel, which included: patients; anaesthetists; surgeons; physicians; nurses; and members of relevant international organisations from five continents. RESULTS:Sixty-eight stakeholders participated in the Delphi consensus process. The panel subsequently agreed on eight recommendations. We recommend continuing current practices on pre-operative fasting for solid food and non-clear liquids. We recommend encouraging clear liquids until 2 h before the start of anaesthesia or sedation, unless institutional protocols allow for more liberal liquid intake. We further recommend implementation of institutional protocols that allow more liberal clear liquid intake < 2 h before the start of anaesthesia or sedation. Salivation stimulants can be used until transfer for the procedure. Oral intake should be resumed as soon as clinically feasible. Preprocedural gastric ultrasound performed by a trained provider may be used to guide clinical decisions when additional information is required. DISCUSSION:This international, multidisciplinary consensus statement aims to improve the quality of patient care by minimising periprocedural fasting times, within safe margins. To achieve this, liberalised pre-operative clear liquid intake regimens may be implemented with institutional protocols.

Home parenteral nutrition (HPN) is life-sustaining for patients with chronic intestinal failure (IF), yet access remains inconsistent worldwide. HPN has evolved into a complex, multidisciplinary service that requires coordinated planning, durable investment, and strong governance to deliver safe, equitable care from hospital to home. This narrative review integrates clinical, organisational, and policy evidence and translates it into a pragmatic implementation roadmap for adult chronic IF health systems at different stages of maturity. We synthesise the volume-outcome signal linking higher-centre caseloads and structured nutrition support teams (NSTs) with lower mortality and complications; consolidate contemporary quality standards (minimum volumes, team composition, governance); and appraise health-economic analyses pertinent to HPN. International exemplars translating guidance into implementable actions enable the development of a four-domain framework to develop cohesive and practical chronic IF services globally: (1) identify and connect the network - map expertise, align professional societies and patient organisations, and establish referral communications; (2) develop the structure - formal centre designation, referral criteria, core infrastructural elements; (3) operationalise care - standardised shared-care/remote-discharge protocols, defined escalation to accredited centres with requisite governance and NST expertise and telehealth-enabled regional support (4) measure and improve - registry participation, routine audit, patient-reported outcomes, and transparent feedback loops. Cross-cutting enablers include robust governance, diagnosis-adjusted reimbursement aligned to NST resourcing, and policy mechanisms (designation, commissioning, funding) that secure access and consistent performance across geographies. Applied iteratively, this framework supports phased, resource-conscious scale-up of safe, high-quality, and equitable chronic IF/HPN services, aiming to reduce complications and mortality while strengthening patient experience, system resilience, and accountability.