BMJ Open最新文献

Objectives: Acute type A aortic dissection is a life-threatening cardiovascular disease commonly seen in emergency department, resulting in substantial mortality and morbidity. We aimed to investigate the prognostic value of N-terminal pro-B type natriuretic peptide (NT-proBNP) among this critically ill population.

Design: The design of this study was a retrospective cohort study.

Setting: The study population was recruited in the Emergency Department of Fuwai hospital in China from 2018 to 2020.

Participants: We consecutively enrolled 829 patients with acute type A aortic dissection and measurable baseline NT-proBNP.

Primary outcome: The primary endpoint was 1-year all-cause death.

Results: Based on tertiles of NT-proBNP (pg/mL), patients were stratified into low (≤150.3, n=276), intermediate (150.3-667.6, n=277) and high (>667.6, n=276) NT-proBNP groups. Compared with patients with low NT-proBNP, the Kaplan-Meier estimates for primary 1-year mortality were higher in intermediate (32.5% vs 18.1%; HR 1.91, 95% CI 1.35 to 2.69) and high (42.0% vs 18.1%; HR 2.56, 95% CI 1.84 to 3.57) NT-proBNP groups, respectively. After multivariable regression adjusted for confounders, NT-proBNP tertiles were independent predictors for 1-year mortality (adjusted HR for intermediate group 1.52, 95% CI 1.02 to 2.27; adjusted HR for high group 2.17, 95% CI 1.41 to 3.32). Notably, the predictive performance of NT-proBNP for 1-year mortality was greater in patients receiving surgery than conservative treatment (between-cohorts difference in area under the curve 0.13, Delong's test p=0.04).

Conclusion: NT-proBNP provides incremental prognostic information for mortality in patients with acute type A aortic dissection who underwent surgical repairment, which could aid in risk stratification as a pragmatic and versatile biomarker in this critically ill population while having limited prognostic value for those receiving conservative treatment.

Introduction: This review aims to synthesise research evidence regarding biomarkers in the synovial fluid that may predict the risk of post-traumatic osteoarthritis (PTOA) in young adults. Considering the high prevalence of knee joint injuries, particularly among youth sports athletes, this review will focus on anterior cruciate ligament and/or meniscal ruptures. These injuries are highly associated with PTOA, with studies indicating that even with surgical reconstruction, 50%-80% of affected individuals develop knee PTOA within a 10-year follow-up.

Methods and analysis: The results of this systematic review will be reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Diagnostic Test Accuracy guidelines. Comprehensive electronic searches will be conducted across five platforms: four bibliographic databases (PubMed, Cochrane Central Register of Controlled Trials, Web of Science Core Collection and Embase) and ClinicalTrials.gov registry. These searches will use combinations of predefined keywords, such as "knee", "synovial fluid", "post-traumatic osteoarthritis", "anterior cruciate ligament", "meniscus", "trauma", "inflammation" and "biomarker". We will include randomised clinical trials, non-randomised prospective or retrospective clinical studies, case controls, cohort studies and case series, ranging from database inception to 30 June 2024 and published in English. Two independent reviewers will screen and evaluate the retrieved studies to determine their eligibility. Any reviewer disagreements will be resolved through discussion and consensus or, if necessary, by consultation with a third reviewer. The data will be extracted from the included studies and analysed, with the risk of bias assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. A narrative synthesis will be performed to evaluate the strength and consistency of the findings, considering both the methodological quality of the included studies and the reliability of the results.

Ethics and dissemination: Ethical approval is not required for this review as it is a secondary study based on public and published data. The findings from this work will be submitted for publication in a peer-reviewed journal and presented at relevant academic conferences. Any amendments to the protocol arising from deviations during the study's execution will be documented and reported in the final publication.

Prospero registration number: CRD42024534272.

Objective: Delayed neurocognitive recovery, previously known as postoperative cognitive dysfunction, is a common complication affecting older adults after surgery. This study aims to address the knowledge gap in postoperative neurocognitive recovery by exploring the relationship between subjective experiences, performance-based measurements, and blood biomarkers.

Design: Mixed-methods study with a convergent parallel (QUAL+quan) design.

Setting and participants: The study reports results from 40 older adult patients (52.5% women; mean age 73, SD 6.7) scheduled for total hip arthroplasty at a hospital in Sweden.

Outcome measures: Neurocognitive performance was assessed using a standardised test battery, neuroinflammation through blood biomarker analysis and postoperative neurocognitive recovery via semistructured interviews and the Swedish Quality of Recovery questionnaire.

Results: Five patients were classified as having delayed neurocognitive recovery based on performance tests. Qualitative data revealed that most patients reported cognitive symptoms, particularly related to executive functions and fatigue. Psychological factors, including a sense of agency and low mood, significantly influenced cognitive recovery and daily functioning. Elevated inflammatory blood biomarkers were not detected pre- or postoperatively in patients with delayed neurocognitive recovery. The global postoperative recovery score was 40.9, indicating a low quality of recovery.

Conclusion: Many patients reported subjective cognitive decline that was not corroborated by delayed neurocognitive recovery in the performance-based tests. Psychological factors were influential for neurocognitive recovery and should be routinely assessed. Future research should incorporate longitudinal follow-ups with performance-based measurements, fatigue assessment, evaluations of instrumental activities of daily living and subjective reporting, supported by a multidisciplinary team approach.

Trial registration number: NCT05361460.

Objectives: To study the effect of implementing a Trial of Labour After Caesarean (TOLAC) delivery bundle with respect to decreasing caesarean delivery rates across five hospitals.

Design: Prospective quality improvement study.

Setting: Five Canadian hospital sites participated, two academic centres and three community hospitals, with annual delivery rates ranging from 2500 to 7500 per site.

Participants: All obstetrical patients with a singleton gestation in cephalic presentation and only one previous caesarean delivery were included.

Interventions: A TOLAC bundle was introduced at each hospital site, consisting of three main interventions: (1) education for healthcare providers, (2) a TOLAC discussion sheet and (3) patient educational tools.

Primary and secondary outcome measures: The primary outcome was the caesarean delivery rate in eligible patients. Secondary outcomes included rates of trial of labour after caesarean delivery, vaginal birth after caesarean delivery and induction of labour. Balance measures included rates of uterine rupture and neonatal intensive care unit admission. Process measures included attendance at educational rounds, elements of the interventions identified in chart review and view counts for educational videos.

Results: The baseline caesarean delivery rate was 77% (1730 out of 2244 eligible patients). Following the introduction of the bundle, the caesarean delivery rate decreased to 71% (1497 out of 2097 eligible patients; 6% decrease, p<0.001). A significant increase in induction rate was noted from 5% preintervention to 9% postintervention (p<0.001). There was no increase in the uterine rupture or neonatal intensive care admission rates.

Conclusion: This TOLAC bundle can decrease caesarean delivery rates without negatively impacting uterine rupture or neonatal intensive care admission rates. The interventions can be easily adapted for use in different hospitals and practice environments.

Introduction: The infrapatellar fat pad and synovium are the sites of immune cell infiltration and the origin of proinflammation. Studies have shown that Hoffa's synovitis may be a sign of early-stage osteoarthritis (OA). However, there have been no effective interventions specifically for Hoffa's synovitis.

Methods and analysis: We will conduct a multicentre, multi-blind (participant, physician, outcome assessor and data analyst blinded) randomised controlled trial to compare the effectiveness of an intra-infrapatellar fat glucocorticoid versus an intra-articular injection for Hoffa's synovitis in patients with knee OA. We will recruit 236 knee OA patients with Hoffa's synovitis at outpatient clinics in three centres. We will randomly allocate them to two groups in a 1:1 ratio. One group will receive ultrasound-guided injection of 40 mg (1 mL) triamcinolone acetonide into the infrapatellar fat pad; the other group will receive ultrasound-guided injection of 40 mg (1 mL) triamcinolone acetonide into the knee joint cavity. All patients will be followed up at 2, 4, 8, 12 and 24 weeks after the injection. Primary outcomes are (1) Hoffa's synovitis improvement rate, measured with the MRI Osteoarthritis Knee Score system (superiority outcome) at 24 weeks and (2) pain intensity, measured with the Western Ontario and McMasters University Osteoarthritis Index (WOMAC) at 2 weeks post-injection. Secondary outcomes include Hoffa's synovitis score at 2 weeks post-injection, pain intensity with the numerical rating scale, WOMAC questionnaire score improvements (function, joint stiffness and total score), improvement rates in effusion synovitis at 2 and 24 weeks, articular cartilage thickness changes at 2 and 24 weeks, Intermittent and Constant Osteoarthritis Pain score, quality of life measured with the EuroQol-5D, OARSI-OMERACT response indicators, co-interventions and side effects at 2, 4, 8, 12 and 24 weeks.

Ethics and dissemination: Ethical approval has been granted by the Medical Ethics Committee of the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (2023-178). Written informed consent will be obtained from all patients prior to data collection. The findings of this research will be shared through presentations at academic conferences and publications in peer-reviewed journals.

Trial registration number: ChiCTR2400080474.

Introduction: Surgical site infections (SSIs) are the second leading cause of healthcare-associated infections in Europe with the highest rates being reported in colorectal surgery (ranging from 9% to 30%). Surgical antibiotic prophylaxis (SAP) is one of the most efficient measures for SSI prevention and should be started before surgical incision. Cefoxitin is an antibiotic widely used as SAP for colorectal surgery, but its continuous administration is currently the subject of debate due to its potential pharmacokinetic advantages. Therefore, the aim of the PROPHYLOXITIN study is to demonstrate that a loading dose followed by continuous infusion of cefoxitin during colorectal surgery (intervention group) decreases the rate of SSI compared to an intermittent bolus administration (control group).

Methods and analysis: The PROPHYLOXITIN study is a superiority, prospective, double-blind, randomised and multicentre study of 2000 patients undergoing colorectal surgery. The primary objective is to demonstrate the superiority of a loading dose of cefoxitin followed by continuous infusion over intermittent bolus administration in reducing the proportion of SSIs within 30 days after colorectal surgery. Subjects will be randomised 1:1 using a secure web-based random-number generator to one of two study groups. Randomised allocation of treatment will be done by minimisation and stratified according to the centre, the localisation of surgery (colon or rectum) and the type of surgical procedure (laparoscopy or laparotomy).

Ethics and dissemination: This research has been approved by an independent ethics committee and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.

Trial registration number: EudraCT 2022-003262-20 and Clinical trial NCT05755789.

Objective: To assess the prevalence and trends of chronic kidney disease (CKD) in Western Australia (WA) from 2010 to 2020 using linked pathology data.

Design: A retrospective observational cohort study using linked de-identified data from WA pathology providers, hospital morbidity records and mortality records.

Setting: A Western Australian population-based study.

Participants: All individuals aged 18 years and older with at least one serum creatinine test.

Primary outcome measure: CKD status as determined by estimated glomerular filtration rate and urine albumin-creatinine ratio.

Results: Analysing data from 2 501 188 individuals, there was a significant increase in age-sex standardised CKD prevalence from 4.7% in 2010 to 6.0% in 2020, with annual average percentage change of 3.0% (95% CI: 2.3% to 3.7%). Prevalence of CKD stages 3 and above was 4.8% in 2020. Higher CKD prevalence was observed in regional and remote areas compared with major cities, and among individuals in the most socioeconomically disadvantaged quintiles. Sensitivity analysis indicated minor impacts from data exclusions and methodological choices.

Conclusions: CKD prevalence in WA has been steadily increasing, reflecting broader Australian trends. The study highlights significant disparities in CKD prevalence based on age, socioeconomic status and geographic remoteness.

Objective: To investigate how various morbidities affect older patients' performance on the Timed Up and Go (TUG) test.

Design: Cross-sectional study.

Setting: The seven government hospitals of Lahore, Pakistan, included are major tertiary care centres, representing an older patient population of Punjab, Pakistan.

Method: 160 elderly participants completed the TUG test, frailty evaluations and Charlson Comorbidity Index (CCI) scoring to assess mobility, frailty and comorbidity burden. The Student's t-test analysed differences between TUG groups (<10 vs ≥10 s). Multivariate linear regression pinpointed key predictors of CCI scores. All analyses were performed using SPSS software.

Results: A total of 160 participants (mean age: 67.2±6.9 years and body mass index (BMI): 28.7±4.9 kg/m²) were included. Those with TUG test times under 10 s had lower CCI scores (5.06±1.8) and frailty index (0.15±0.07), compared with those with longer times (CCI: 8.6±4.3 and frailty index: 0.42±0.1). Multivariate regression analysis revealed that TUG time (β=0.342, p=0.001), frailty index (β=0.680, p=0.003), age (β=0.128, p=0.002) and BMI (β=0.098, p=0.027) were significant predictors of CCI. Additionally, higher Mini-Mental State Examination scores (β=-0.092, p=0.017) were associated with lower comorbidity burden. These results highlight mobility, frailty and cognitive function as a predictors of comorbidities in the elderly.

Conclusion: Our study highlights a significant relationship between mobility, frailty and cognitive function with the comorbidity burden in older adults. Incorporating these metrics into routine care can guide targeted interventions, promoting healthier ageing and improved quality of life.

Objective: Glyphosate is widely used in Malaysian agriculture but poses a significant under-reported public health concern due to poisoning. This paper aims to study the epidemiology of glyphosate poisoning in Malaysia, assessing severity, identifying risk factors, and high-risk groups.

Setting: All glyphosate-related data of the Malaysia National Poison Centre from 2006 to 2023.

Participants: Telephone inquiries of incidents involving glyphosate made by healthcare professionals across Malaysia. Information received was recorded according to WHO guidelines.

Outcomes: The outcome is to provide an overview of national glyphosate poisoning epidemiology, including identifying risk factors and high-risk groups to strategise appropriate measures.

Results: A total of 4548 glyphosate poisoning cases were reported, with males comprising 67.3% of cases. The most affected age groups were 21-30 years (25.5%) and 31-40 years (23.5%). Ingestion was the primary exposure route (93.0%). Intentional poisonings, mainly suicides, accounted for 68.4% (n=3078) of cases. Among the 1420 unintentional cases, 78.2% resulted from ingestion exposures. The incidence rate declined from 1.17 per 100 000 in 2011 to 0.61 in 2023. Significant associations were found between intentional ingestion and sociodemographic factors. From 2013 to 2023, 73.7% of cases were minor, 11.5% moderate, 0.8% severe and 0.1% fatal.

Conclusions: In Malaysia, the reported intentional glyphosate poisoning most commonly affects young adults, resulting in generally minor to moderate symptoms. The study highlights the need for stricter regulations on glyphosate use and improved mental health support, to mitigate poisoning risks. Continued surveillance and public education are essential to address this public health issue.

Background: Older adult care homes in England are required to develop care plans on behalf of each of their residents and to make these documents available to those who provide care. However, there is a lack of formal agreement around the key principles that should inform the development of care plans in care homes for older adults. Using a modified Delphi survey, we intend to generate consensus on a set of key principles that should inform the care planning process.

Methods and analysis: A two-stage modified Delphi survey will be used to try to reach a consensus on a set of key principles to inform care planning within older adult care homes in England. An interdisciplinary panel of approximately 50 people with experience in care planning will be convened and invited to provide feedback on a set of key principles. We will use an iterative, quasi-anonymous, multistage approach with controlled feedback. In the first round, panellists will be asked to provide feedback on a draft document whose contents have been informed by a systematic scoping review and consultations with care home staff. The first round will be administered and subsequently analysed. The results from the first round will be fed back to the panel members and panellists will be asked to complete a second survey. In each round, panel members will use a 5-point unipolar scale to rate their agreement with the item. Consensus will be considered if ≥75% of participants rate an item as 4-5.

Ethics and dissemination: This study to which this protocol relates has been granted ethical approval by the University of Kent's Division for the Study of Law, Society and Social Justice Research Committee Ethics Panel (reference: 1006) on 9 April 2024. The results of this project will be disseminated through conferences and one or more peer-reviewed journals. In a subsequent research phase, the research team plans to share the key principles document developed through this modified Delphi survey with care home residents and their families and friends. We plan to invite their feedback through a series of focus groups with a view to developing a related document for the family and friends of care home residents.