Conectar
Hyperkalaemia (HK) is common in the emergency department (ED) and can cause life-threatening arrhythmias. Patiromer is a potassium binder whose role in acute HK management is uncertain; therefore, we investigated the efficacy and safety of patiromer as an adjunct to the standard of care treatment of HK in the ED.
A prospective, randomised, double-blind, placebo-controlled study.
16 ED sites across the USA.
Patients aged ≥18 years treated at a participating ED who were found to have serum potassium ≥5.8 mEq/L.
Participants were randomised 1:1 to standard combination therapy (25 g intravenous dextrose, 5 units intravenous insulin and 10 mg albuterol) with either patiromer or placebo. The initial dose was given within 1 hour of the potassium result, and the second dose 24 hours later.
The primary endpoint was net clinical benefit (NCB) at 6 hours, defined as the change in number of potassium-lowering interventions minus change in serum potassium. Adverse events (AEs) were also recorded.
The study was terminated early and did not reach the prespecified sample size. Overall, 111 patients (53 patiromer and 58 placebo) were analysed. Mean (SD) age was 61.34 (15.21) years, 34% were female, 48% white and 22.5% received chronic haemodialysis. Mean baseline potassium was 6.5 mmol/L. NCB at 6 hours was similar between patiromer and placebo (–0.6 vs –0.4; p=0.44). Potassium levels at 2, 4 and 6 hours were similar between the groups (5.50 vs 5.70, 5.45 vs 5.65, 5.50 vs 5.60; patiromer and placebo (all p>0.05)). The number of interventions per patient was similar (p>0.05) between groups at each time point. The proportion of patients experiencing AEs was not significant between the patiromer and placebo groups (16.98% vs 32.76%; p=0.08).
No differences in efficacy were reported in this study, which was underpowered to detect statistical efficacy of patiromer over placebo.
This systematic review explored the barriers and facilitators to the implementation of clinical practice guidelines (CPGs) among nurses in emergency departments (EDs) and critical care units (CCUs).
Systematic review.
A systematic review was performed using both qualitative and quantitative studies from five databases (CINAHL, Web of Science, Embase, Scopus and PubMed). The literature search was conducted in May 2024. The PRISMA framework was used to guide the review process. Findings were subject to a narrative, thematic analysis and critical appraisal.
Eighteen studies were identified that met the inclusion criteria, yielding three themes related to barriers and facilitators of guideline implementation: individual-level, guideline-level and organisational-level. Key barriers included lack of awareness of guidelines, lack of knowledge and skills, attitudes towards guidelines, resource limitations, lack of perceived support, complexity of guidelines and lack of training. Facilitators to guideline use included colleague support, adequate training, effective leadership and refinement of guidelines to ensure relevance, local adaptation and user-friendly content.
Numerous barriers to nurse implementation of CPGs exist in ED and CCU settings, reflecting a complex interplay of individual, CPG-related and organisational factors. To facilitate CPG implementation, it is important for staff to be educated and trained in their use, supported to implement (including resource allocation) and that CPGs are designed to be easily implemented in practice.
This systematic review highlights risk factors for poor CPG implementation and highlights the importance of addressing awareness, knowledge, resources and support for CPG use through targeted training, leadership and CPG design.
An analysis of barriers and facilitators to CPG implementation among nurses in ED and CCU settings provides an important opportunity to address a gap in the literature, facilitating the development of strategies to promote CPG use and enhance care quality among nurses in these specific contexts.
Over 777 million COVID-19 infections have occurred globally, with data suggesting that 10%–20% of those infected develop Long COVID. Fatigue is one of the most common and disabling symptoms of Long COVID. We aim to assess the feasibility and safety of a new, remotely delivered, multimodal rehabilitation intervention, paced to prevent post-exertional malaise (PEM), to support the conduct of a future, definitive randomised trial.
We will conduct a randomised, two-arm feasibility trial (COVIDEx intervention vs usual care). Sixty participants with Long COVID will be recruited and randomised prior to giving informed consent under a modified Zelen design using 1:1 allocation with random permuted blocks via central randomisation to receive either the COVIDEx intervention or usual care. The 50-minute, remotely delivered, COVIDEx intervention will occur twice weekly for 8 weeks. All participants will wear a non-invasive device throughout their entire study participation, to track heart rate, blood oxygen saturation, steps, sleep and monitor PEM. The primary feasibility objectives will be recruitment rates, intervention fidelity, adherence, acceptability (intervention and design), retention, blinding success and outcome completeness. Secondary objectives will include refined estimates for the standard deviation and correlation between baseline and follow-up measurements of fatigue. Feasibility and clinical outcomes will be collected at baseline, 4, 8, 12 and 24 weeks. Qualitative interviews with participants and physiotherapists will explore intervention acceptability and barriers/facilitators.
Ethical approval for this study was obtained by the Western University Health Sciences Research Ethics Board (REB# 123902). Dissemination plans include sharing of trial findings at conferences and through open access publications and patient/community channels.
Injury is a major cause of death in Rwanda, with many deaths occurring before hospital admission. Timely transport of injured patients to appropriate hospitals is crucial, ideally within an hour for severely injured patients. However, delays in reaching treatment facilities are common, with ambulance services using inefficient mobile phone communication. This project aims to evaluate the effectiveness and implementation of an innovative electronic communication platform (912Rwanda).
The study will be conducted through the public ambulance service, Service d’Aide Médicale d’Urgence (SAMU), and receiving health facilities in Kigali city and Musanze district in Rwanda. The 912Rwanda intervention will be rolled out in the two locations at different times. The primary effectiveness outcome is the time from ambulance deployment to patient arrival at the health facility. Secondary effectiveness outcomes include disaggregated times of the primary outcome and clinical outcomes, such as length of stay and requirement for intensive care. These outcomes will be evaluated using an interrupted time series analysis, accounting for non-homogeneous variances, auto-regressive errors and non-linear trends where appropriate. Implementation outcomes will be evaluated using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Qualitative Evaluation for Systematic Translation (QuEST) framework. Cost-effectiveness will be evaluated using a cost-consequence analysis with consequences as determined by the interrupted time series analysis.
Ethical approval was obtained from the Rwanda National Research Ethics Committee (Ref No: 99/RNEC/2023). Dissemination will occur through open-access peer-reviewed publications, relevant national and international conferences.
While survival rates following neonatal surgery for congenital heart disease (CHD) have improved over the years, neurodevelopmental delays are still highly prevalent in these patients. After correcting for the CHD subtype, the severity of developmental impairment is dependent on multiple factors, including intraoperative brain injury, which is more frequent and more severe in those undergoing aortic arch repair with deep hypothermic circulatory arrest (DHCA). It is proposed that brain injury may be reduced if cooling is stopped at the point of electrocerebral inactivity (ECI) on electroencephalogram (EEG), but there is limited evidence to support this as few centres perform perioperative EEG routinely. This study aims to assess the feasibility of EEG monitoring during neonatal aortic arch repair and investigate the relationship between temperature and EEG to inform the design of a future clinical trial.
Single-centre prospective observational cohort study in a UK specialist children’s hospital, aiming to recruit 74 neonates (≤4 weeks corrected age) undergoing aortic arch repair with DHCA. EEG will be acquired at least 1–3 hours before surgery, and brain activity will be monitored continuously until 24 hours following admission to intensive care. Demographic, clinical, surgical and outcome variables will be collected. Feasibility will be measured by the number of patients recruited, data collection procedures, technically successful EEG recordings and adverse events. The main outcomes are the temperature at which ECI is achieved and its duration, EEG patterns at key perioperative steps and neurodevelopmental outcomes at 24 months postsurgery.
The study was approved by the Yorkshire and The Humber Sheffield National Health Service Research Ethics Committee (20/YH/0192) on 18 June 2020. Written informed consent will be obtained from the participant’s parent/guardian prior to surgery. Findings will be disseminated to the academic community through peer-reviewed publications and presentations at conferences. Parents/guardians will be informed of the results through a newsletter in conjunction with local charities.
Background
Chronic pain is a major cause of distress and disability, and biomarkers may aid in the assessment and treatment of it. Urine metabolites may be valuable bioindicators that can provide biological insight regarding chronic pain.
Objectives
To investigate the relationship between a multimarker composite measure of metabolites and patient-reported outcomes scores in adults with chronic pain, using data from a pragmatic clinical trial with a sequential, multiple-assignment randomized trial design.
Methods
Self-reported measures and urine samples from 169 active-duty service members with chronic pain were collected. Urine was analyzed using a preestablished panel of metabolites, including four previously identified biomarkers of pain: kynurenic acid, pyroglutamic acid, ethylmalonic acid, and methylmalonate. Multivariable linear regression models—adjusted for participant characteristics such as age and sex—were used to cross-sectionally examine the relationship between 11 patient-reported outcomes (fatigue, sleep-related impairment, anxiety, depression, anger, pain catastrophizing, physical function, pain interference, satisfaction with participation with social roles, pain intensity, and pain impact score) and the four urine metabolites both individually and as a composite (urine metabolite pain indicator, or UMPI). Given the study’s small sample size and exploratory nature, a significance threshold of p ≤ .10 was used for all analyses.
Results
The UMPI showed statistically significant associations with five self-reported measures (fatigue, anxiety, depression, physical functioning, and pain impact score); adjusted Pearson correlations ranged from .18 to .25. Individual metabolite analyses supported these findings, with all relationships between individual metabolites and self-reported measures showing positive associations. Kynurenic acid and ethylmalonic acid showed the strongest associations, each having statistically significant relationships with four individual self-reported measures, while pyroglutamic acid had statistically significant relationships with three self-reported measures and methylmalonate with none. The UMPI demonstrated feasible reliability.
Discussion
Our finding of associations between the UMPI and components of the self-reported measures supports the development of the UMPI and these four urine metabolites as biomarkers for chronic pain outcomes. Further research is planned and will be essential for establishing mechanistic insight and guiding biomarker development within the context of pain management. 
FreshRSS 