Risultati per: Nuovi farmaci per il danno renale acuto (Acute kidney injury – AKI)

Introduction
Each year in the UK, 140 000 patients are discharged from intensive care units (ICUs) to general hospital wards, almost all with complex rehabilitation needs. 84% of patients still require nutritional support and 98% are not physically independent. Despite this, many are discharged from ICU without a nutrition plan, and failure to recognise malnutrition is common. Consequently, malnutrition persists in the ward environment, leading to poor outcomes and acting as a barrier to successful physical rehabilitation. This transition from intensive care to the ward represents a key stage in the recovery journey, and a window for optimising physical independence prior to hospital discharge, decreasing the need for support in the community. However, uncertainty as to how best to provide ongoing rehabilitation which combines adequate nutrition and exercise on the general ward has driven widespread variation in practice.
We have previously shown the benefits of delivering a structured rehabilitation strategy in the ICU. However, the ward environment poses different challenges to the development of an integrated rehabilitation pathway. There is a need to evaluate the clinical and cost-effectiveness of structured rehabilitation strategies when delivered outside the ICU.

Methods and analysis
Physiotherapy and Optimised Enteral Nutrition In the post-acute phase of critical illness is a bi-centre, mixed methods feasibility randomised controlled trial (RCT). 60 patients will be recruited from ICUs at two acute National Health Service Trusts and randomised on a 1:1 basis to receive either individualised physiotherapy and optimised nutrition post discharge from ICU (intervention) or standard care. The primary objective is to assess the acceptability of the intervention and feasibility of a future, multicentre RCT. The primary outcome measures, which will determine feasibility, are recruitment and retention rates, and intervention fidelity. Acceptability of the intervention will be evaluated through semistructured interviews of participants and staff. Secondary outcome measures include collecting baseline, clinical and outcome data to inform the power calculations of a future definitive trial.

Ethics and dissemination
Ethical approval has been obtained through the Wales Research and Ethics Committee 2 (24/WA/0050). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media.

Trial registration number
NCT06159868. Prospectively registered on 28 November 2023.

Objectives
Early evaluation and treatment of patients with acute chest pain pose a massive challenge to the emergency care system worldwide. This study aims to determine the current burden and early management of acute chest pain presenting to the emergency departments (EDs) in China.

Design
The Evaluation and Management of Patients with Acute ChesT pain study is a prospective, multicentre and provincially representative registry of acute chest pain patients in Chinese EDs.

Setting
A stratified random sampling design generated the province representative sample of 21 public hospitals with independent EDs in Shandong, China. Each participating site consecutively enrolled patients for at least 12 months from August 2015 to September 2017.

Participants
A total of 8349 adult patients presenting with acute chest pain or suspected acute coronary syndrome (ACS) were included.

Primary outcome measures
The annual incidence of ED-assessed acute chest pain was estimated. The aetiology, process of care and 30-day major adverse cardiac events (MACE) of included patients were analysed.

Results
The estimated annual incidence of ED-assessed acute chest pain was 96.6 (95% CI 95.9 to 97.3) per 100 000 adults, significantly increasing with age. The mean age of included patients was 63.8 years, with 57.9% males. Prehospital delay was a median of 2.8 (IQR, 1.2–10.3) hours, with 17.9% transported by ambulance. About 75.6% of patients received their first ECG within 10 min. Cardiac troponin was tested in 54.2%, with high-sensitivity cardiac troponin in 24.5% and serial troponins in 5.1% during the ED stay. Most (74.0%) were admitted to the inpatient ward, with a median ED stay of 65.0 (IQR, 27.0–385.0) min. Within 30 days, 6.8% experienced MACE. Among included patients, 62.9% were diagnosed with ACS, with specific management varying by ST-segment elevation status.

Conclusions
China’s first regionally representative registry of acute chest pain revealed a lower incidence of ED-assessed cases but a higher proportion of high-risk patients compared with other countries. Gaps persist in aligning emergency management with guidelines. More programmes and policies are needed to enhance the quality of acute chest pain care in China.

Trial registration number
This study was registered at URL: https://www.clinicaltrials.gov (NCT02536677).

Introduction
Each year in the UK, 140 000 patients are discharged from intensive care units (ICUs) to general hospital wards, almost all with complex rehabilitation needs. 84% of patients still require nutritional support and 98% are not physically independent. Despite this, many are discharged from ICU without a nutrition plan, and failure to recognise malnutrition is common. Consequently, malnutrition persists in the ward environment, leading to poor outcomes and acting as a barrier to successful physical rehabilitation. This transition from intensive care to the ward represents a key stage in the recovery journey, and a window for optimising physical independence prior to hospital discharge, decreasing the need for support in the community. However, uncertainty as to how best to provide ongoing rehabilitation which combines adequate nutrition and exercise on the general ward has driven widespread variation in practice.
We have previously shown the benefits of delivering a structured rehabilitation strategy in the ICU. However, the ward environment poses different challenges to the development of an integrated rehabilitation pathway. There is a need to evaluate the clinical and cost-effectiveness of structured rehabilitation strategies when delivered outside the ICU.

Methods and analysis
Physiotherapy and Optimised Enteral Nutrition In the post-acute phase of critical illness is a bi-centre, mixed methods feasibility randomised controlled trial (RCT). 60 patients will be recruited from ICUs at two acute National Health Service Trusts and randomised on a 1:1 basis to receive either individualised physiotherapy and optimised nutrition post discharge from ICU (intervention) or standard care. The primary objective is to assess the acceptability of the intervention and feasibility of a future, multicentre RCT. The primary outcome measures, which will determine feasibility, are recruitment and retention rates, and intervention fidelity. Acceptability of the intervention will be evaluated through semistructured interviews of participants and staff. Secondary outcome measures include collecting baseline, clinical and outcome data to inform the power calculations of a future definitive trial.

Ethics and dissemination
Ethical approval has been obtained through the Wales Research and Ethics Committee 2 (24/WA/0050). We aim to disseminate the findings through international conferences, international peer-reviewed journals and social media.

Trial registration number
NCT06159868. Prospectively registered on 28 November 2023.

Farmindustria: ‘Scenario da evitare, fiducia nell’Ue e nel Governo’

New England Journal of Medicine, Volume 392, Issue 12, Page 1234-1236, March 27, 2025.

Background
ST-segment elevation myocardial infarction (STEMI) remains a major cause of morbidity and mortality. Primary percutaneous coronary intervention (PPCI) is the preferred treatment, yet some patients experience major adverse cardiac events (MACE) within a year despite successful recanalisation. Identifying predictors of futile recanalisation—defined as achieving thrombolysis in myocardial infarction grade III flow after PPCI but still developing MACE—is essential for improving outcomes.

Research design and methods
This single-centre, retrospective study included patients with STEMI treated with PPCI from January 2019 to January 2023. The primary outcome was futile recanalisation. Least absolute shrinkage and selection operator (LASSO) regression and logistic regression were used to identify independent predictors of futile recanalisation.

Results
Of the 489 consecutive patients who achieved successful recanalisation, 20.9% met the criteria for futile recanalisation within 1 year. Multivariable analysis identified several independent predictors: heart rate at admission (OR 1.32, 95% CI 1.02 to 1.71), reduced left ventricular ejection fraction (LVEF; OR 0.30, 95% CI 0.22 to 0.41), advanced left ventricular diastolic dysfunction (OR 1.44, 95% CI 1.02 to 2.15), elevated cardiac troponin I (CTnI) levels (OR 1.42, 95% CI 1.08 to 1.90), high Selvester QRS scores (OR 1.59, 95% CI 1.20 to 2.13) and increased homocysteine (HCY) levels (OR 1.37, 95% CI 1.07 to 1.77).

Conclusion
Despite successful recanalisation, certain factors—high admission heart rate, low LVEF, advanced left ventricular diastolic dysfunction, elevated CTnI levels, high Selvester QRS scores, and increased HCY levels—are associated with futile recanalisation in patients with STEMI. These findings highlight the need for targeted monitoring and management strategies to reduce long-term MACE risks in this population.

This effect is more pronounced in people with lower levels of kidney function at the time of stopping.

Introduction
Multidisciplinary advanced kidney care (AKC) services provide care to patients with advanced chronic kidney disease (CKD) (typically estimated glomerular filtration rate (eGFR) ≤20 mls/min/1.73m2), as symptoms and complications become more common, also in preparation for kidney failure treatments. Despite their prominence in UK renal services, there is no consensus around the best practice for AKC services in terms of care delivery models or interventions to optimise patient care, and there is widespread geographical variation in practice. The UK Kidney Association Kidney Quality Improvement Partnership has launched a 3-year ‘Transform AKC’ quality improvement project to address unmet needs in AKC services and work towards improvement. This scoping review is part of the Transform AKC project and aims to identify existing evidence for the current and best practice in AKC. The aim of this review is to establish any evidence that demonstrates best practice models of care and interventions to optimise care for adult patients with advanced CKD.

Methods and analysis
We will undertake a scoping review seeking to identify and evaluate evidence that demonstrated best practice for care of adults with advanced CKD. Databases (Medline and Embase) will be searched systematically (search dates from 1 January 2014 to 8 August 2024), and a final list of included studies will be analysed and synthesised.

Ethics and dissemination
We will use robust methodology to identify the existing literature describing the best practices in care of adults with advanced CKD. These findings will directly inform the ‘Transform AKC’ national quality improvement project, in which this scoping review is embedded. Findings will also be disseminated through national conferences and will be published in a relevant journal.

Yang X, He X, Pan D, et al. Intra-arterial alteplase for acute ischaemic stroke after mechanical thrombectomy (PEARL): rationale and design of a multicentre, prospective, open-label, blinded-endpoint, randomised controlled trial. BMJ Open 2024;14:e091059. doi: 10.1136/bmjopen-2024091059
This article was previously published with an error.
Figure 1 has been updated. During the trial, some participating centres underwent official name changes. The figure now reflects the revised names while maintaining the original study site distribution. These changes neither affect the centres themselves or the conduct of the trial nor the study’s data and conclusions.

Stroke, Ahead of Print. BACKGROUND:Modifiable risk factors play a central role in the development and course of neurodegenerative disorders of later life, including dementias. Although past research has focused on independent associations of modifiable risk factors, including cardiovascular disease risk factors using Framingham cardiovascular risk score, physical activity, dietary quality, body mass index, and sleep, on neurodegeneration, the impact of all 5 factors simultaneously in a multimodal model has not been studied. We examined independent associations and an overall combined model with 5 modifiable risk factors with white matter injury, a recognized risk factor for dementia, ≈10 years later in a diverse Hispanic/Latino population.METHODS:Participants were from the HCHS/SOL (Hispanic Community Health Study/Study of Latinos)-Magnetic Resonance Imaging longitudinal study (n=2667; clinical visit 1 mean age, 52.01 [8.90] years). We conducted path and mediation analyses across 5 modifiable risk factors obtained at clinical visit 1 (2008–2011) and 2 measures of white matter injury (free water and white matter hyperintensity volume) obtained at the magnetic resonance imaging visit (2018–2022; mean age, 62.37 [9.23] years). We controlled for age at the time of the dependent variable was measured, sex, education, Hispanic/Latino heritage, overall cognitive status, and b-value when free water was included.RESULTS:We observed 11 significant independent associations across modifiable risk factors and white matter injury measures. The association of Framingham cardiovascular risk score to white matter hyperintensity volume was mediated by free water (indirect mediation: β=2.473; SE=0.207;P

Stroke, Volume 56, Issue 4, Page 1026-1035, April 1, 2025. BACKGROUND:In ischemic stroke due to large vessel occlusion, cerebral blood flow is impaired by thromboemboli, which can originate from various sources in the body. A better understanding of thromboembolus composition can improve our understanding of the underlying pathophysiology and potentially guide improvement of prevention strategies. The aim of this study therefore was to perform a large-sample multi-parameter quantitative histological analysis of retrieved thromboemboli from stroke patients.METHODS:Thromboemboli (n=501) were collected from thrombectomy-treated ischemic stroke patients at AZ Groeninge Hospital (Kortrijk, Belgium) and CHU Lille (Lille, France). Stroke etiology was determined by the treating stroke specialist using the TOAST classification system (Trial of ORG 10172 in Acute Stroke Treatment). Extensive histological analysis, blinded to stroke etiology, was performed for key thrombus constituents including red blood cells (RBCs), platelets, fibrin, von Willebrand Factor, leukocytes, citrullinated histone H3 (as a marker for neutrophil extracellular traps), and extracellular (ex)DNA. Quantitative histology results were linked to etiology.RESULTS:Compared with large-artery atherosclerotic thromboemboli, cardioembolic thromboemboli contained significantly fewer RBCs and significantly more platelets, fibrin, leukocytes, and exDNA. Interestingly, cryptogenic thromboemboli contained relatively low amounts of RBCs and high amounts of platelets, similar to cardioembolic thromboemboli. A multivariable logistic regression model indicated that it is difficult to predict stroke etiology based on the individual thrombus composition.CONCLUSIONS:Based on a large sample cohort of stroke thromboemboli, we found that cardiac thromboemboli contained fewer RBCs and more platelets than atherosclerotic thromboemboli and that cryptogenic thromboemboli have a similar composition to cardiac thromboemboli in terms of RBCs and platelets.

Stroke, Volume 56, Issue 4, Page 915-925, April 1, 2025. BACKGROUND:Diffusion-weighted magnetic resonance imaging is essential for diagnosing ischemic stroke and identifying targets for emergency revascularization. Apparent diffusion coefficient (ADC) maps derived from diffusion-weighted magnetic resonance imaging are commonly used to locate the infarct core, but they are not strictly quantitative and can vary across platforms and sites due to technical factors. This retrospective study was conducted to examine how differences in ADC map generation, resulting from varied protocols across platforms and sites, affect the determination of infarct core size, location, and related clinical outcomes in acute stroke.METHODS:In this retrospective study, 726 patients with acute anterior circulation stroke from a cohort of 1210 unique visits to the Lausanne University Hospital between May 2018 and January 2021 were selected, excluding patients with poor quality imaging or no magnetic resonance imaging or clinical information available. Diffusion-weighted magnetic resonance imaging data were used to generate ADC maps as they would appear from different protocols: 2 simulated with low- and medium-angular resolution (4 and 12 diffusion gradient directions) and 1 with high-angular resolution (20 directions). Using DEFUSE criteria and image postprocessing, ischemic cores were localized; core volume, location, and associations to the National Institutes of Health Stroke Scale and modified Rankin Scale scores were compared between the 2 imaging sequences.RESULTS:Significant differences were observed in the ADC distribution within white matter, particularly in the kurtosis and skewness, with the segmented infarct core volume being higher in protocols with reduced angular resolution compared with the 20-directions data (7.63 mL versus 3.78 mL). The volumetric differences persisted after correcting for age, sex, and type of intervention. Infarcted voxel’s locations varied significantly between the 2 protocols. This variability affected associations between infarct core volume and clinical scores, with lower associations observed for 4-direction data compared with 20-direction data for the National Institutes of Health Stroke Scale at admission and after 24 hours, and modified Rankin Scale after 3 months, further confirmed by multivariate regression.CONCLUSIONS:Imaging protocol heterogeneity leads to significant changes in the ADC distribution, ischemic core location, size, and association with clinical scores. Work is needed in standardizing imaging protocols to improve the reliability of ADC as an imaging biomarker in stroke management protocols to improve the reliability of ADC as an imaging biomarker in stroke management.

Circulation, Volume 151, Issue 12, Page 884-886, March 25, 2025.

Objectives
To investigate the knowledge, attitudes and practices (KAP) among patients with end-stage kidney disease (ESKD) towards hyperkalaemia.

Design
A cross-sectional study.

Setting
This study was conducted between September and November 2023 at the Department of Nephrology, Shenzhen Third People’s Hospital and the Second Affiliated Hospital of Southern University of Science and Technology.

Participants
The study included 568 patients with ESKD who were undergoing haemodialysis, peritoneal dialysis or both, recruited through convenience sampling.

Primary and secondary outcome measures
This study was conducted using a self-administered questionnaire, which assessed participants’ KAP towards hyperkalaemia management. The questionnaire comprised four sections: demographic information, knowledge (13 items), attitudes (9 items) and practices (9 items), with responses evaluated using a 5-point Likert scale. A cut-off value of 70% of the total score was applied, with thresholds for sufficient knowledge, favourable attitudes and proactive practices set at 6.3, 31.5 and 31.5 points, respectively. The higher the KAP scores, the better the levels of knowledge, attitude and practice. A structural equation model (SEM) was constructed to analyse the effects of demographic characteristics on KAP dimensions. Path coefficients (standardised estimates) were used to assess the strength of relationships between variables, with coefficients >0.2 generally considered moderate effects and >0.5 strong effects.

Results
A total of 568 participants were enrolled in this study, including 369 (64.69%) males, and 249 (43.84%) have been diagnosed with ESKD for more than 5 years. The median (IQR) KAP scores of the participants were 9 (3–9) (possible range: 0–9), 34 (24–45) (possible range: 9–45) and 32 (10–45) (possible range: 9–45), respectively. SEM demonstrated that the frequency of dialysis had direct effects on knowledge (coefficient=0.113, p=0.039), education had direct effects on attitudes (coefficient=0.257, p

Background
Delayed graft function (DGF) continues to represent one of the most frequently encountered early complications following kidney transplantation. Despite notable progress in donor and recipient pretreatment protocols, diagnostic techniques and therapeutic approaches, the incidence of DGF, along with its associated short- and long-term sequelae, has not demonstrated a significant reduction. DGF is influenced by a multitude of factors, and individuals with exposure to these risk factors exhibit a markedly increased probability of developing DGF.

Objectives
To systematically identify and evaluate risk factors associated with DGF in kidney transplant recipients.

Design
A systematic review and meta-analysis

Data sources
A comprehensive search was performed across multiple databases, including PubMed, Embase, The Cochrane Library, Web of Science, CNKI, Wanfang, VIP and SinoMed, from the inception of each database until 1 March 2024.

Primary outcome measures
OR and OR 95% CI of risk factors for DGF.

Results
The meta-analysis included 19 studies involving a total of 153 008 patients, of whom 96 596 (63.1%) developed DGF. The following risk factors for DGF were identified: prolonged cold ischaemia time (CIT) (OR=1.05, 95% CI=1.03 to 1.07, p

Objective
A multidisciplinary team is essential to providing high-quality, patient-centred care. However, its effectiveness can be either hindered or facilitated by various factors, such as the need for rapid decision-making, which may compromise patient outcomes despite individual efforts. The aim of this study is to synthesise the factors that may act as barriers and facilitators to the work of multidisciplinary teams in managing labour within acute care settings.

Design
A systematic qualitative review and meta-synthesis was conducted following the five-step methodology proposed by Sandelowski et al.

Data source
Three databases (Medline, Embase and Scopus) were systematically searched without time restrictions up to 25 May 2024.

Eligibility criteria for selecting studies
Qualitative studies exploring perspectives, experiences and other similar factors were included. These studies were assessed for methodological quality using the Critical Appraisal Skills Programme.

Data extraction and synthesis
The reviewers independently searched, screened and coded the results of the included studies. Data were synthesised using the method proposed by Thomas and Harden.

Results
Seventeen studies were included in the meta-synthesis. Four key dimensions emerged, reflecting both the barriers and the facilitators of multidisciplinary team performances: (1) organisational variables, (2) individual variables, (3) collaborative variables and (4) role variables. A total of 36 variables were identified, which could function as barriers (n=6; eg, high staff turnover), facilitators (n=6; eg, strong listening skills) or both (n=24; eg, team climate), depending on the context.

Conclusions
This meta-synthesis identifies specific barriers and facilitators and variables that can act as both. Understanding these factors enables targeted interventions to enhance the performance of multidisciplinary teams in clinical practice, particularly in acute care settings.

PROSPERO registration number
CRD42022297395.