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Objectives Identifying the barriers and facilitators for Chadian youth (aged 15–24 years) along the pathway of access to HIV information and health services.Study design Qualitative descriptive study.Study setting The study was conducted in N’Djamena, Chad, with 20 high schools purposefully selected based on participation in a Blue Cross Chad (BCC) peer-to-peer education programme.Participants A total of four focus groups, each consisting of 12 participants, stratified by gender and BCC programme participation (two each among participating and non-participating high schools), were conducted.Methods A descriptive qualitative study using thematic analysis of content was conducted. The qualitative software ATLAS.ti V.22 was used to organise and code the data.Results Five main categories of barriers and facilitators for HIV information and health services were identified, including (1) societal expectations and norms; (2) power dynamics; (3) social networks; (4) peer-education programmes; and (5) bypassing the system. Barriers and facilitators to information information-seeking and access to health services were observed at individual, community and system levels. High school students expressed that access to information and health services were important when it comes to HIV and AIDS prevention and treatment. Societal expectations and power dynamics were identified as key barriers, while trust through social networks and peer-education programmes were key facilitators to accessing information and health services.Conclusion This study allowed for the identification of both barriers and facilitators of HIV information and health-seeking in the context of N’Djamena, Chad. Our findings highlight the importance of comprehensive community- and youth-led approaches that are youth-friendly and youth-centric and are needed to effectively communicate HIV information.

Objective To understand the social support network of Amazonian women when making decisions about planned home births.Method Descriptive, exploratory, qualitative research.Setting Planned home birth care, accompanied by obstetric nurses, in the state of Pará, Brazil.Participants 20 women who had a planned home birth in the metropolitan region of the state of Pará, Brazil. These women were surveyed by a team of obstetric nurses working in home birth care. In-depth semistructured interviews were conducted at the women’s homes between August 2021 and February 2022, with the audio captured on an mp3 device. The data were analysed at the same time as the data collection. Each interview was transcribed and content analysis was used to process the data.Results The social support network shares experiences and knowledge between women in order to guarantee knowledge and not perpetuate traumatic episodes during childbirth. This network is a link to women’s power of choice in relation to their own birth, which culminates in successful experiences in the birth process.Final considerations Understanding the social support network for women’s decision-making during planned home births is central to guaranteeing rights and expectations regarding the place of birth. Social support networks need to be expanded by non-governmental groups and by the Unified Health System itself, especially in primary healthcare.Descriptors Women; home childbirth; social support; access to information and nursing.

Objective The Person Empowered Asthma Relief (PREPARE) study found that as-needed inhaled corticosteroid (ICS) supplementation combined with participants’ usual controller and rescue therapy reduced asthma exacerbations for Black and Hispanic/Latinx individuals. We aimed to determine whether treatment assignment to the intervention group (Patient Activated Reliever-Triggered ICS (PARTICS)) versus the control group (usual care) influenced controller therapy based on clinicians’ written prescriptions.Design Secondary data analysis of electronic health record data of a pragmatic, open-label, patient-level randomised trial.Setting Practices treating asthma.Participants PREPARE study participants— Black and Hispanic/Latinx individuals with asthma.Interventions Effects of adding ICS to rescue therapy among black and Hispanic adults with moderate-to-severe asthma.Outcome measures For PARTICS therapy impact on patients, each month is the 28-month period (12 months prior to enrolment, the month of enrolment and 15 months after enrolment), a patient was assigned to a controller step based on a six-step classification scheme. A linear mixed effect spline model was completed for before and after enrolment data to determine controller changes over a 28-month period between the two study arms.Results This analysis included 713 participants. Of these, 49.1% were usual care patients and 50.9% were PARTICS patients. Throughout the study, the majority of patients changed asthma controller medications in both arms. By the end of the study, the usual care patients were at a significantly higher asthma controller medication step (0.20 step higher) than the PARTICS patients.Conclusions Clinicians’ prescribing patterns showed significant changes over time. Compared with usual care patients, PARTICS patients were on lower doses of asthma controller medications by the end of the study.Trial registration number NCT02995733.

Introduction Thyroid surgery with intraoperative nerve monitoring under total intravenous anaesthesia often requires deeper sedation due to limitations or lack of neuromuscular blocking agents, usually resulting in haemodynamic instability. Remimazolam, a newly developed sedative, is being studied for its effect on the haemodynamic profile of patients undergoing this procedure and compared with propofol.Methods and analysis This will be a single-centre, single-blind, randomised, controlled trial in American Society of Anesthesiologists I-III patients between the ages of 18 and 65 who require recurrent laryngeal nerve monitoring for thyroid surgery. Patients will be randomised 1:1 to either remimazolam besylate or propofol, with 142 cases in each group according to a randomised, computer-generated cohort. The primary outcome is the occurrence of hypotension from induction of anaesthesia to full recovery. Secondary outcomes include the administration of vasoactive agents, the number of hypotension or hypertension episodes, the cumulative duration of hypotension or hypertension, the dose of intraoperative rescue sedation and analgesia, the time to extubation and awakening and the incidence of adverse events.Ethics and dissemination Ethical approval for this study was obtained from the Medical Ethics Committee of the Affiliated Cancer Hospital and Institute of Guangzhou Medical University (2023–2024). The study protocol was modified according to the reviewers’ comments, and the revised version was approved by the Ethics Committee (2024 Research Ethics Amendment No. 3). On completion of the study, we will commit to ensuring that the results are made available to the public, regardless of the outcome. This will include either publication in an appropriate journal or oral presentation at academic conferences.Trial registration number ChiCTR2300076583.

Objectives This study evaluated the association between serum albumin levels and coronary artery calcification (CAC) progression in asymptomatic adults without hypoalbuminaemia at baseline.Design Observational cohort study.Setting Data from the Korea Initiatives on Coronary Artery Calcification (KOICA) which is a retrospective, single ethnicity, multicentre and observational registry were analysed.Participants A total of 12 344 Korean adults with baseline albumin level of ≥3.5 g/dL (51.7±8.5 years; 84.3% male) were included. The median interscan period was 3.0 (2.0–4.8) years. All participants were stratified into three groups based on serum albumin tertile.Primary and secondary outcome measures Association of serum albumin with the risk of CAC progression was analysed using multivariate logistic regression models with adjustment of interscan period. CAC progression was defined as a square root (√) transformed difference between the baseline and follow-up coronary artery calcium score (CACS) (Δ√transformed CACS) of ≥2.5. Annualised Δ√transformed CACS was defined as Δ√transformed CACS divided by interscan period.Results With increasing serum albumin tertiles, the annualised Δ√transformed CACS (I (lowest): 0.16 (0–1.24) vs II: 0 (0–1.09) vs III (highest): 0 (0–1.01)) and the incidence of CAC progression (I: 36.6% vs II: 31.3% vs III: 25.0%) were decreased despite higher prevalence of hypertension, diabetes and hyperlipidaemia (all p

Introduction Burnout, a disorder caused by chronic stress at work, involves emotional exhaustion, depersonalisation and reduced professional efficacy. The prevalence of burnout appears to be high among physicians worldwide. Burnout may affect different dimensions of healthcare, such as patient safety. Several systematic reviews and meta-analyses have examined the relationship between physician burnout and quality of care, although with some controversial results. To our knowledge, no overview of systematic reviews and meta-analyses has been conducted, specifically evaluating physician burnout, patient safety and other relevant aspects of quality of care. The main objective of this study will be to evaluate the available evidence of the association between physician burnout and patient safety.Methods and analysis An overview of systematic reviews and meta-analyses will be carried out. Systematic reviews with or without meta-analyses assessing the relationship between burnout in physicians and quality of care will be included. The primary outcome will be patient safety (ie, the occurrence of any adverse event related to healthcare which could have resulted, or did result, in unnecessary harm to patients). Secondary outcomes will be patient satisfaction and professionalism. Literature searches will be conducted (from their inception onwards) in PubMed/MEDLINE, EMBASE and Cochrane Database of Systematic Reviews. Two researchers will select studies that meet the predefined eligibility criteria and proceed to extract information from each included study. The methodological characteristics, measures of association and qualitative conclusions of the reviews will be assessed. The methodological quality of each review will also be analysed using the AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews) tool. A descriptive synthesis will be carried out using evidence tables and graphs.Ethics and dissemination The proposed research mainly involves the analysis of existing studies, approval from a research ethics committee is not required. This overview of systematic reviews will help to gain a better understanding of the association between physician burnout and patient safety. Our findings could support future research, recommendations and policies in this area. We plan to publish the full study in a peer-reviewed journal.Registration of the protocol Open Science Framework: https://osf.io/wr73u/

Objectives Our primary objective was to assess the association between symptoms at the time of surgery and postoperative pulmonary complications and mortality in patients with COVID-19. Our secondary objective was to compare postoperative outcomes between patients who had recovered from COVID-19 and asymptomatic patients and explore the effect of the time elapsed between infection and surgery in the former. Our hypotheses were that symptomatic patients had a higher risk of pulmonary complications, whereas patients who had recovered from the infection would exhibit outcomes similar to those of asymptomatic patients.Background Managing COVID-19-positive patients requiring surgery is complex due to perceived heightened perioperative risks. However, Canadian data in this context remains scarce.Design To address this gap, we conducted a multicentre observational cohort study.Setting Across seven hospitals in the province of Québec, the Canadian province was most affected during the initial waves of the pandemic.Participants We included adult surgical patients with either active COVID-19 at the time of surgery or those who had recovered from the disease, from March 22, 2020 to April 30, 2021.Outcomes We evaluated the association between symptoms or recovery time and postoperative pulmonary complications and hospital mortality using multivariable logistic regression and Cox models. The primary outcome was a composite of any postoperative pulmonary complication (atelectasis, pneumonia, acute respiratory distress syndrome and pneumothorax). Our secondary outcome was hospital mortality, assessed from the date of surgery up to hospital discharge.Results We included 105 patients with an active infection (47 were symptomatic and 58 were asymptomatic) at the time of surgery and 206 who had recovered from COVID-19 prior to surgery in seven hospitals. Among patients with an active infection, those who were symptomatic had a higher risk of pulmonary complications (OR 3.19, 95% CI 1.12 to 9.68, p=0.03) and hospital mortality (HR 3.67, 95% CI 1.19 to 11.32, p=0.02). We did not observe any significant effect of the duration of recovery prior to surgery on patients who had recovered from their infection. Their postoperative outcomes were also similar to those observed in asymptomatic patients.Interpretation Symptomatic status should be considered in the decision to proceed with surgery in COVID-19-positive patients. Our results may help optimise surgical care in this patient population.Study registration ClinicalTrials.gov Identifier: NCT04458337 registration date: 7 July 2020.

Introduction Anti-retroviral therapy (ART) simplification strategies are needed for treatment-experienced people with HIV (PWH) and multidrug-resistant viruses. These individuals are commonly treated with boosted ART regimens and are thereby at risk for harmful drug-drug interactions (DDI). In this trial, we aim to assess the efficacy of the combination doravirine, dolutegravir and lamivudine (DOR/DTG/3TC) among people with a history of virological failure who receive boosted ART.Methods and analysis B-Free is a multistage, randomised, multicentre, open-label, non-inferiority trial, embedded within the Swiss HIV Cohort Study and conducted in collaboration with cohorts of PWH in the Netherlands and France. Cohort participants with a history of ART change due to virologic failure and who maintain HIV virologic suppression with an ART regimen consisting of a pharmacological booster and at least two drugs from classes other than nucleoside reverse transcriptase inhibitors are included. Patients with major drug resistance mutations against DTG or DOR and individuals with chronic hepatitis B virus infection are not eligible for the study. Individuals are randomised 1:1 to either receiving co-formulated DTG/3TC and DOR once daily or continuing their boosted ART regimen. The primary outcome is the proportion of individuals lacking virologic control (HIV-RNA ≥50 cp/mL) at 48 weeks, according to the Food and Drug Administration snapshot algorithm. Changes in DDI burden (assessed using a DDI score), treatment satisfaction (assessed using the HIV Treatment Satisfaction Questionnaire), quality of life and mental health represent key secondary outcomes. Additional secondary outcomes include the proportion of individuals developing new resistance-associated mutations and changes in quality of life and mental health. In a qualitative substudy, we will conduct semistructured interviews with a subset of participants to assess their expectations and experiences towards HIV treatment and clinical research in general. Enrolling 210 individuals will provide 80% power to demonstrate non-inferiority, defined as less than 8% absolute increase in loss of viral suppression in individuals randomised to DOR/DTG/3TC (one-sided type I error rate of 0.025).Ethics and dissemination The study was approved by the competent ethics committees (reference number BASEC 2023–01060) and the regulatory authority Swissmedic (reference number 701655) in Switzerland before the enrolment of the first participant. Approval by the European Medicines Agency and local ethical committees in the Netherlands and France will be obtained prior to including participants in these countries. Participant’s written informed consent is obtained by the investigators before enrolment. The results of all major B-Free study outcomes will be submitted to peer-reviewed journals that enable Open Access publication.Trial registration number Swiss National Clinical Trials Portal (SNCTP000005686, registered on 06 November 2023) and Clinicaltrials.gov (NCT06037564, registered on 07 September 2023).

Objectives To evaluate the cost of delivering childhood respiratory syncytial virus (RSV) prevention interventions to the health system in Kenya.Design A prospective (cost projection) activity-based costing study.Setting Kenya, national introduction of interventions.Participants Not applicable.Interventions A single-dose RSV maternal vaccine and a single-dose, long-acting monoclonal antibody (mAb).Primary and secondary outcome measures Cost per eligible target population; cost per dose administered; non-commodity cost of delivery. Costs are reported in 2023 USD.Results RSV interventions are expected to be delivered using existing systems: maternal vaccine using the antenatal care platform and the mAb delivered similar to existing birth dose vaccines. Assuming a price of US$3 per dose (for both interventions) and baseline coverage rates averaging 50% for the maternal vaccine and 86% for the mAb, the estimated cost of delivering maternal vaccine was US$1.74 (financial) and US$6.60 (economic) per vaccinated woman, and the cost of delivering mAbs was US$1.56 (financial) and US$6.27 (economic) per vaccinated child. Excluding commodity cost, the cost of delivering maternal vaccine was US$1.32 (financial) and US$2.72 (economic) and that for mAb was US$1.23 (financial) and US$2.48 (economic). Cost differences between the two interventions are driven by the anticipated baseline coverage. Health worker training, service delivery and programme planning and coordination were major cost drivers.Conclusion This study presents the prospective cost of new RSV intervention introduction and delivery in low-income and middle-income country settings, which is largely unknown. Cost estimates incorporate anticipated health system strengthening activities needed to deliver the future RSV interventions. These cost estimates support country-level and global-level decision-makers evaluating implementation feasibility and intervention affordability.

Introduction Financial protection (FP) is a central function of health systems to enhance access to essential care and improve health equity. We aim to characterise evidence on the distribution of FP in high-income countries as well as how equity of FP is conceptualised and measured in these settings. Findings from this review can advance methodological and conceptual knowledge about equity in FP, guide the evaluation of health systems and inform policy on eliminating inequitable barriers to care to achieve universal health coverage.Methods and analysis We will undertake a scoping review following guidance from Colquhoun et al and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. We will search four academic databases covering health sciences and economic literature as well as four grey literature sources for relevant publications. Screening for eligibility will be performed independently by two reviewers after calibration of screening criteria. Data will be charted using a standardised form and summarised by thematic analysis.Ethics and dissemination Institutional research ethics review was not required; however, research ethics will be considered iteratively throughout the research process. Research findings will be disseminated to scientific and policy meetings, summarised for lay audiences and submitted for publication in a peer-reviewed journal.

Objectives To quantify the association between Gestational Diabetes Mellitus (GDM) and adverse pregnancy outcomes and primarily compare the associations between diagnostic criteria following the International Association of Diabetes and Pregnancy Study Groups (IADPSG) recommendations and non-IADPSG criteria, which use higher blood glucose cut-offs.Design Systematic review and meta-analysis of observational studies using contemporary GDM diagnostic criteria.Data sources PubMed, Scopus, Google Scholar, Cochrane Database of Systematic Reviews and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched for articles published between 2010 and 2023. The search was carried out on 15 May 2023.Eligibility criteria Studies were included if they were observational studies that reported adjusted effect sizes for GDM-related adverse outcomes and compared outcomes between women with and without GDM, used contemporary diagnostic criteria and were conducted after 2010.Data extraction and synthesis Two reviewers independently extracted data and assessed study quality using the MethodologicAl STandards for Epidemiological Research (MASTER) scale. Bias-adjusted inverse variance heterogeneity meta-analysis models were used to synthesise adjusted effect sizes. The same meta-analytic models were used to synthesise the overall OR and their 95% CIs for comparisons of the criteria which followed the IADPSG recommendations to other criteria, mostly with higher blood glucose cut-offs (non-IADPSG).Results We included 30 studies involving 642 355 participants. GDM was associated with higher odds of maternal outcomes, namely; caesarean section (adjusted OR (aOR) 1.24, 95% CI 1.01 to 1.51) and pregnancy-induced hypertension (aOR 1.55, 95% CI 1.03 to 2.34). GDM was associated with higher odds of neonatal outcomes, specifically; macrosomia (aOR 1.38, 95% CI 1.13 to 1.69), large for gestational age (aOR 1.42, 95% CI 1.23 to 1.63), preterm birth (aOR 1.41, 95% CI 1.21 to 1.64), neonatal intensive care unit admission (aOR 1.42, 95% CI 1.12 to 1.78), neonatal hypoglycaemia (aOR 3.08, 95% CI 1.80 to 5.26) and jaundice (aOR 1.47, 95% CI 1.12 to 1.91). Further analyses showed no major differences in adverse pregnancy outcomes between IADPSG and non-IADPSG criteria.Conclusions GDM is consistently associated with adverse pregnancy, maternal and foetal outcomes, regardless of the diagnostic criteria used. These findings suggest no significant difference in risk between lower and higher blood glucose cut-offs used in GDM diagnosis.

Introduction Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a diverse clinical presentation that involves multiple organ systems and may lead to organ damage and increased risk of mortality. SLE is associated with a high burden of disease that can include loss of productivity and employment and reduced health-related quality of life. The current standard of care for SLE is primarily based on immunosuppression and glucocorticoids and is associated with risk of toxicities and poor tolerability. Anifrolumab, a human monoclonal antibody to type I interferon receptor subunit 1, was recently approved as a new treatment for patients with moderate-to-severe SLE.Methods and analysis Here, we report the study design of the ongoing, multinational Anifrolumab Study for Treatment Effectiveness in the Real World (ASTER) that includes 3-years of follow-up beginning with the first infusion of anifrolumab and 1 year of retrospective baseline data. ASTER aims to enrol 500 adult patients receiving anifrolumab for SLE in Europe and Canada. The key study objective is to describe the real-world effectiveness of anifrolumab in routine clinical practice, including clinician-reported disease activity and patient-reported outcomes collected via mobile application. This mobile application also includes a medication diary, where patients report their prescription and non-prescription medication use for SLE on a weekly basis; these data will lend insights on treatment patterns for the study population.Ethics and dissemination The design of the ASTER study was informed through consultations with patients with SLE who provided important insights to help maximise patient engagement, retention and the collection of key, patient-relevant endpoints. ASTER enrolment began in February 2023 and the study is expected to finish in 2029.Trial registration number NCT05637112.

Objective To investigate the association between the triglyceride-glucose (TyG) index, a surrogate marker of insulin resistance and the risk of kidney stones (KSs) in a Chinese population.Design Case–control study.Setting Three Physical Examination Centers in Shanghai, China, between January 2020 and December 2022.Participants A total of 117 757 Chinese adults underwent health check-ups during the study period.Primary and secondary outcome measures The association between the TyG index and the risk of KS was assessed using multivariable logistic regression analysis. The dose–response relationship between the TyG index and KS risk was evaluated with a restricted cubic spline (RCS) analysis. Stratified analyses were conducted to explore whether factors such as age, sex, obesity, hypertension and diabetes modify the association between the TyG index and KS risk.Results Out Of the 117 757 participants, 11 645 (9.9%) were diagnosed with KS using ultrasound. Individuals with KS had significantly higher TyG values than controls (p

Objectives The objectives are to explore the relationship between study stress and anxiety in high school students and the mediating role of physical activity and mobile phone addiction.Design A cross-sectional study.Setting 129 high schools were randomly selected in 13 cities of Jiangsu province, China.Participants High school students aged 16–19 years, age and gender balance. A total of 40 000 questionnaires were distributed, with 32 974 effectively recovered.Primary and secondary outcome measures Questionnaires were administered offline, covering four parts: General Demographics, Learning Stress Scale, International Physical Activity Questionnaire, Mobile Phone Addiction Scale and Generalized Anxiety Scale-7. Data analysis included path analysis and correlation analysis, along with descriptive statistics, independent sample t-test, correlation analysis and structural equation model.Results In this study, the proportions of anxiety, high academic pressure, low physical activity level and high mobile phone addiction were 58.18%, 46.48%, 36.40% and 39.26%, respectively. Study stress was positively correlated with anxiety (r=0.130, p

Introduction Amid the COVID-19 pandemic, outpatients’ concerns about infection risk have increased. It is crucial to understand the factors that contribute to this fear of infection to promote patient safety and encourage outpatients to seek proper follow-up treatment without fear. This study aims to understand the relationship between outpatients’ experiences of patient safety and their fear of infection.Design This was a secondary analysis of national data from the Healthcare Service Experience Survey in 2020.Setting and participants A total of 4416 patients with experience using outpatient services in the past year were included in South Korea.Primary and secondary outcome measures Demographic characteristics, fear of infection and safety experiences were assessed in the original survey. Fear of infection served as the dependent variable, with safety experiences—specifically, patient identification, preinjection explanations, hand hygiene, proper use of injection supplies, skin disinfection and adverse drug reactions—as the independent variables.Results Approximately 14% of outpatients had a fear of infection when receiving medical care. The unadjusted model showed that all patient safety categories were determinants of fear of infection, and the multivariate logistic model identified hand hygiene and medication safety experiences as significant factors associated with fear of infection.Conclusions This study revealed that patient safety experiences are associated with fear of infection in outpatient settings. Improving healthcare professionals’ hand hygiene and managing adverse drug reactions are crucial for enhancing patient safety.

Objectives The objective of this study is to examine the trends in geographical inequality of opportunity in maternal health services in India considering the Every Newborn Action Plan (ENAP) 2025 coverage targets.Setting India.Participants Women in the National Family Health Survey (NFHS)—NFHS-4 (2014–2015) and NFHS-5 (2019–2021).Primary and secondary measures District-level coverages of 4+antenatal care (ANC) visits, institutional delivery with skilled birth attendant, postnatal care (PNC) services within 48 hours of delivery, continuum of care (CoC) services for women with most recent live births were considered. Human Opportunity Index (HOI) documented the opportunities for equitable access to these services, ranging from 0 (high inequality) to 100 (universal access). HOI was compared between the survey rounds and wealth index (WI) quintiles that the women belonged to.Results Coverages of 4+ANC visits, institutional delivery, PNC and CoC in India increased by 22.8% (95% CI 22.1% to 23.5%), 12.6% (95% CI 12.2% to 12.9%), 28.5% (95% CI 28.0% to 29.0%) and 38.6% (95% CI 37.6% to 39.6%) between NFHS-4 and NFHS-5, respectively. The HOI for 4+ANC visits was 48.4 in NFHS-5, ranging from 11.3 to 92.4 in states and from 31.1 to 70.5 for WI I–V. The HOI for institutional delivery was 80.4 in NFHS-5, ranging from 37.4 to 99.7 in the states and from 21.0 to 100 for WI I–V. The HOI for PNC services was 73.5 in NFHS-5, ranging from 37.5 to 95.6 in the states and from 61.2 to 88.3 for WI I–V. The HOI for CoC was 37.1, ranging from 6.5 to 88.8 in the states and from 19.8 to 62.7 for WI I–V for CoC in NFHS-5.Conclusion Though significant improvements in the geographical inequity of maternal health services have been made in India, the geographical inequity for 4+ANC visits coverage lags significantly behind resulting in CoC coverage inequity to achieve the ENAP targets for these services.

Introduction The gut microbiome plays an important role in maintaining both cognitive and physical functions in older adults, and gut dysbiosis is an important pathophysiological mechanism of mild cognitive impairment (MCI) in older adults. As a typical traditional Chinese mind-body exercise, regular Baduanjin training has been shown to improve cognitive function and modulate the gut microbiome in community-dwelling older adults. However, the potential role of the gut microbiome in the benefits of Baduanjin on cognitive function remains unclear. The aim of this study is to investigate the mediating effect of gut microbiome between regular Baduanjin training and improvement in cognitive function in community-dwelling older adults with MCI.Methods and analysis This is a two-arm, randomised, parallel-controlled, single-blinded trial. Four residential communities (clusters) with a total of 64 eligible participants (16 participants in each residential community) will be randomised 1:1 to either the 24-week Baduanjin exercise intervention group (60 min per session, four sessions per week) or the no specific exercise intervention control group. Global cognitive function and the subdimensions of cognition including executive function, visuospatial function, language function and memory function will be assessed using the Montreal Cognitive Assessment Scale, Trail Making Test, Auditory Verbal Learning Test, Boston Naming Test-30 and Clock-Drawing Test, while the gut microbiome and its metabolomics will be detected using 16S rRNA and ultra-high-performance liquid chromatography–tandem mass spectrometry at baseline and at the end of 24-week intervention. The intervention effect of Baduanjin exercise and mediating role of gut microbiota will be analysed using linear mixed models and the bootstrapping method in the Hayes process.Ethics and dissemination This study conforms to Declaration of Helsinki principles and relevant ethical guidelines. Ethical approval has been obtained from the Ethics Committee of the Shanghai University of Medicine and Health Sciences (approval number: 2023-GZR-011). Written informed consent will be obtained from all participants. Results will be disseminated to relevant groups in peer-reviewed journal(s), and at relevant international or national scientific conferences. Key findings will also be shared with social media, healthcare providers, participants or community-dwelling older adults to support access for non-research audiences.Trial registration number ChiCTR2300078147.

Introduction Efforts to improve access to essential medicines globally include the implementation and assessment of national medicine policies. Although existing assessment tools may identify gaps, they do not link these to health system functions and policy priority areas in a way that facilitates decision-making. This systematic review aims to identify and map out existing indicators assessing essential medicines policies; assess their strengths and limitations and understand the parameters required to develop a new instrument for assessing access to medicines in a way that better supports decision makers in identifying and addressing the gaps in their national medicine policies.Methods and analysis This systematic review is guided by the updated Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol. Eligible studies will be identified across scholarly databases (MEDLINE, Embase and Scopus) and grey literature using relevant subject headings and text words. Title, abstract screening and full-text screening will be conducted by two independent reviewers. Indicators or assessment tools focused on the performance of national medicine policies with respect to improving access to essential medicines will be eligible. Data will be extracted using a pretested data abstraction form. Findings will be reported in the form of a descriptive narrative. This study will provide insights into the relevance of existing indicators and tools for assessing access to essential medicines policies. This review will also discuss the opportunities for the development of a new instrument for the assessment of national medicines policies in a way that better supports decision makers to improve access to essential medicines.Ethics and dissemination This systematic review does not require ethics approval as it only aims to synthesise evidence from the literature. Findings will be disseminated to key health stakeholders including researchers and global and public health organisations and published in a peer-review journal. This protocol has been registered on PROSPERO (CRD42023493052).

Background Low-income and middle-income countries, including Kenya, are pursuing universal health coverage (UHC) through the establishment of Social Health Insurance programmes. As Kenya rolls out the recently unveiled UHC strategy that includes a national indigent cover programme, the goal of this study is to evaluate the impact of health insurance subsidy on poor households’ healthcare costs and utilisation. We will also assess the effectiveness and equity in the beneficiary identification approach employed.Methodology and analysis Using a quantitative design with quasi-experimental and cross-sectional methods, our matched cohort study will recruit 1350 households across three purposively selected counties. The ‘exposure’ arm, enrolled in the UHC indigent programme, will be compared with a control arm of eligible but unenrolled households over 12 months. Coarsened exact matching will be used to pair households based on baseline characteristics, analysing differences in expenses and catastrophic health expenditure. A cross-sectional design will be employed to evaluate the effectiveness and equity in beneficiary identification, estimating inclusion errors associated with the subsidy programme while assessing gender equity.Ethics and dissemination Ethical approval has been obtained from the Scientific and Ethics Review Unit at Kenya Medical Research Institute, with additional permissions sought from County Health Departments. Participants will provide written informed consent. Dissemination strategies include peer-reviewed publications, conference presentations and policy-maker engagement for broad accessibility and impact.

Introduction Coughing during extubation can lead to several postoperative complications, including surgical site bleeding, intracranial hypertension and high intraocular pressure. Currently, various pharmacological and non-pharmacological interventions are employed in clinical practice to reduce coughing during extubation. However, it is unclear which of these interventions has the best preventive effect and the fewest adverse events. Therefore, we plan to conduct a systematic review and network meta-analysis to compare the effects of all interventions.Methods and analysis We will search MEDLINE, Embase, Web of Science, Cochrane Central Register of Controlled Trials, CNKI and Wanfang databases, as well as reference lists from previously published papers, from the date of their inception to April 2024. We will only include randomised controlled trials, regardless of publication in any language. The primary outcome is the incidence of cough during extubation, using the modified Minogue scales. The secondary outcomes are as follows: (1) the incidence of severe coughing (grade 4); (2) the incidence of other types of postoperative airway complications, such as laryngospasm, apnoea, hypoxaemia and sore throat, which will be evaluated within 24 hours after surgery; (3) the side effects related to the interventions, such as bradycardia (heart rate less than 60 beats per minute), hypotension or allergic reactions, which will be evaluated within 24 hours from the start of the drug to the postoperative period and (4) the time from the end of the surgery to the extubation of the endotracheal tube. The articles meeting the criteria will be independently evaluated by two researchers based on the established screening criteria. The data will then be extracted. Bias will be assessed for all included studies using the Cochrane Risk of Bias Risk Assessment Tool Version 2. We will use the Netmeta package of the R software with a random-effects model to make direct and indirect comparisons through the frequency framework. We will assess the quality of evidence using Confidence in Network Meta-Analysis.Ethics and dissemination Ethical approval is not required for this protocol, as we will only pool published data. We plan to submit our manuscript for publication in a peer-reviewed academic journal.PROSPERO registration number CRD42023401609.

Objective The objective of the study was to determine the magnitude of and the factors associated with late presentation for induced abortion care services at hospitals in the South Gondar district of Ethiopia.Design This study employed an institution-based, cross-sectional design.Setting The study was conducted at five hospitals in the South Gondar district of Ethiopia.Participants A total of 381 women recruited through systematic random sampling techniques from October 2022 to February 2023 participated in the study. All women presenting for safe abortion care services at selected hospitals during the data collection period were included, whereas induced abortion care service due to the pregnancy being a high risk to maternal health or at high risk for fetal anomaly were excluded from the study. Data were collected at the abortion clinic at the time of presentation through face-to-face interviews using a pretested and structured questionnaire.Outcome measures The magnitude of and the factors associated with late presentation for induced abortion care service were assessed in the study.Statistical analysis The collected data were entered and coded using EpiData V.4.6, and SPSS V.25 was used for analysis. Binary logistic regression analyses were undertaken to identify the factors associated with the outcome variable. The level of significance was declared at a p value of

Objectives This study aims to evaluate and compare health outcomes and costs between home hospitalisation and traditional hospitalisation for three common diagnoses—cellulitis, urinary tract infection (UTI) and pneumonia.Design A retrospective cohort study.Setting Primary care, nationwide.Participants 1311 patients in home hospitalisation and 992 in traditional hospitalisation.Interventions The primary intervention is home hospitalisation, compared with traditional hospitalisation. The intervention was performed according to medical considerations by a specialised team, and this study was done retrospectively to evaluate it.Primary and secondary outcome measures Primary measures included healthcare costs, length of hospitalisation, referrals for further medical services and mortality.Results Costs of home hospitalisation were lower compared with traditional hospitalisation (6056 vs 9619 NIS for pneumonia, 6011 vs 9767 NIS for cellulitis, 6466 vs 8552 NIS for UTI and p value

Introduction The allostatic load (AL) is a framework for conceptualising the physiological multisystemic impact of prolonged exposure to stress and its related side effects on mental health.Stress due to AL can influence the development and outcomes of cardiovascular diseases. AL increases the risk of coronary and peripherical artery diseases. AL emerges from the detection of emotional dimensions related to the disease, low psychosocial functioning and high rates of psychopathological signs in patients with hypertension or coronary heart disease.Method and analysis The primary endpoint of the PLAY-UP protocol is the implementation of a multidimensional model underlying the clinical treatment of patients with cardiovascular disease through the integration of medical and psychological clinical variables.PLAY-UP is a cohort study that will last for 24 months. 200 participants will be recruited and divided into three groups: early disease, midterm disease and long disease. All patients will undergo a clinical evaluation based on the detection of biological, medical and psychological indicators and variables. The evaluation battery will comprise three types of measurements: medical, psychological and pharmacological treatments. Clinical and psychological measurements will be processed in an integrated manner through the combination of all variables examined, elaborating the Allostatic Load Index from a longitudinal time perspective. The Allostatic Load Index will be calculated by measuring the z-score.Ethics and dissemination Ethical Committee Approval was obtained from CEtRA Abruzzo Region (IT) (ID 0461499/23). The results of the present project will be published in peer-reviewed journals, disseminated electronically and in print, and presented as abstracts and/or personal communications during national and international conferences.

Objective This qualitative study aimed to analyse rectal cancer survivors’ lived experiences to identify facilitators and barriers to support access.Design We conducted one-on-one semi-structured interviews and employed thematic analysis to identify key themes and insights.Setting/participants Participants included eight rectal cancer survivors and three caregivers recruited at Texas Colorectal Collaborative sites.Results Results showed that adequate hospital resources, high health literacy and close connections with clinicians and peers who share similar experiences facilitate survivors’ access to social support. Conversely, ineffective healthcare team communication, financial challenges and low self-motivation hindered access.Conclusion Survivorship experiences were shaped by varying degrees of social support access, influenced by internal and external factors. We aim to establish a cross-institutional survivorship support network to address these factors, ensuring equitable access to support services and enhancing survivorship experiences.

Objective This study was conducted to assess knowledge of stroke risk factors and prevention among hypertensive patients on follow-up at Addis Ababa University Tertiary Hospital, Addis Ababa, Ethiopia.Design Cross-sectional study design.Setting This study was conducted at Addis Ababa University Tertiary Hospital in Addis Ababa, Ethiopia.Participants The sample size was determined using the single population proportion calculation. A list of all patients with hypertension on follow-up was framed from the appointment book of the cardiovascular clinic. Then, 316 participants were recruited by simple random sampling procedure from 18 April 2022 to 19 May 2022. The study included all patients with hypertension >18 years of age who were on follow-up during the data-collecting period. In contrast, patients with memory loss or cognitive impairment and who are unable to communicate were excluded from the study.Result With a response rate of 96.8%, 306 respondents in total were questioned. The average age of the participants was 53.6 years (SD±13.4). More than half of participants (52.9%) were female. The average score for understanding stroke risk factors and prevention is 44.1% and 49.7%, respectively. Knowledge of stroke risk factors was substantially correlated with residency and educational level, while knowledge of stroke prevention was significantly associated with sex, income and educational level.Conclusion This study indicates that patients with hypertension who participated in the study had poor knowledge of stroke risk factors and prevention. The mean score of knowledge on risk factors and prevention strategies of stroke is 44.1% and 49.7%, respectively, and needs improvement.

Objective To estimate the herd effects of anti-microbial-based decontamination (ABD) interventions on bloodstream infections (BSIs) among groups of intensive care unit (ICU) patients in relation to group mean length of stay (LOS). To deduce which of three competing hypotheses of ABD effect mediation best accounts for the observed effects.Design Arms-based meta-regression of ICU-acquired BSI incidence against group mean LOS for control and interventions arms of ABD and non-ABD controlled trials each versus that in arms of observational studies.Exposures Within controlled trials of ABD, intervention, concurrent control (CC) and non-concurrent (NCC) groups are directly, indirectly and non-exposed, respectively.Main outcomes and measures BSI incidence, both overall and for BSI subtypes.Results In the arms-based meta-regression, the predicted BSI incidence per 100 patients in the ABD intervention arms increased from 4.6 (95% CI 3.8 to 5.5) at mean LOS 7 days to 13.0 (10.4–16.0) at mean LOS 20 days (n=60 arms) and CC arms 8.5 (6.7–11.0) increasing to 19.3 (14.8–24.8; n=52). These increases were double those in the observational (7.2; 6.1–8.5 increasing to 12.9; 10.4–16.7; n=99) and NCC arms and non-ABD arms. These results triangulate with the notional effect size observed in contrast-based meta-analyses.Conclusions The increased tempo of BSI acquisition, both overall and for various BSI subtypes, within intervention and CC groups of ABD randomised concurrent controlled trials versus other groups implicate rebound and spillover, respectively. Mechanisms other than colonisation resistance mediate ABD effects.

Introduction Despite recommendations, non-surgical treatment modalities in knee and/or hip osteoarthritis (KHOA) are underused. An information campaign was developed targeting patients with early stage KHOA and healthcare professionals (HCPs) to optimise timing of referral to secondary care. This protocol describes the development and design of this information campaign and a randomised controlled trial (RCT) on its effectiveness in impacting healthcare utilisation.Methods and analysis The behaviour change wheel was used as a theoretical framework for the campaign design. After an inventory of the literature, a selection was made of factors influencing healthcare use. Effectiveness will be evaluated with a cluster RCT. The study aims to recruit 300 patients in 24 general practices, randomly allocated to intervention or usual care (ratio 1:1). General practitioners and affiliated HCPs are invited to participate in the trial and recruit patients. Patients are eligible to participate if they are Dutch speaking, aged 50–75 years, registered with KHOA at the general practice, without joint replacement nor having considerable walking impairment. The main end point is the difference in rate of referral to hospital care as reported by patients over a period of 18 months. Secondary parameters include quality of care, beliefs about KHOA treatment modalities, physical activity, self-management behaviour and referral rates to secondary care. Patients receive online questionnaires at baseline, 6, 12 and 18 months. Online questionnaires are sent to HCPs at baseline and after 12 months to assess (changes in) beliefs about KHOA treatment modalities.Ethics and dissemination All methods are carried out in accordance with relevant guidelines and regulations and ethical approval was waived by the Dutch medical research ethical committee of Arnhem-Nijmegen (file number 2020-7246). Trial results will be communicated to participants and patient representatives via news letters, the public via the Sint Maartenskliniek website and journals of patient organisations and HCPs via congresses and international scientific journals.Trial registration number NL9140.

Introduction Adults with congenital heart disease (ACHD) are a heterogeneous group with a large variation in the severity of lesions and symptoms. This population has rapidly grown in recent years due to improved surgical and medical treatments. Sedentary time and physical activity (PA) and health among individuals classified with single lesions, for example, shunt defects such as atrial and ventricular septal defects, and patent foramen ovale (PFO) with stroke are less studied. The present study describes the study protocol and examines associations between sedentary time, PA, circulating biomarkers in the blood (heart and muscles) and heart failure. Results have the potential to supply the healthcare system with information if further action to promote cardiovascular health in ACHD is needed.Methods and analysis A cross-sectional design will be used with data from the local heart register, Swedish Registry for Congenital Heart Disease in Uppsala, Sweden. Individuals ≥18 years of age with simple congenital heart disease, according to the definition atrial septal defect, ventricle septal defect or PFO as the cause of stroke, will be included.Outcome measures: Self-reported questionnaire: demographic characteristics, education, the prevalence of diabetes, smoking, ethnicity, self-reported level of sitting time and leisure-time PA/exercise, everyday activities, commuting and degree of symptoms associated with exertion. Blood analyses: blood lipids (total cholesterol, high-density lipoprotein and low-density lipoprotein cholesterol, apolipoprotein A1 and B), creatinine, cystatin-C (eGFR), creatine kinase, myoglobin, high-sensitivity troponin, brain natriuretic peptide, C-reactive protein and glycated haemoglobin. Quantitative methods will be used for statistical analyses.Ethics and dissemination The Swedish Ethical Review Authority has approved the study (registration numbers 2022-06525-01 and 2023-02082-02). Results will be disseminated in peer-reviewed journals, research meetings, conferences and possibly patient organisations.

Objectives The aim of this study is to assess cost-effectiveness of robotic radical hysterectomy (RRH) vs laparoscopic radical hysterectomy (LRH) in early-stage cervical cancer (ECC).Design Model-based cost-effectiveness analysis.Setting Based on long-term survival data, a three-state Markov model was constructed using TreeAge Pro 2022 to simulate the possible recurrence of ECC. Data on clinical efficacy and costs were derived from published literature and local databases.Participants A hypothetical cohort of 1000 individuals diagnosed with early-stage cervical cancer (FIGO 2009 stages

Objectives This goal of this research is to present a comprehensive method for evaluating stress and the factors that contribute to it in mothers of premature babies.Design Analytical cross-sectional study.Setting Data were collected from inpatient service for preterm infants including neonatal intensive care unit, and neonatal step-down units of the Aga Khan University Hospital—a private tertiary care hospital in Karachi, Pakistan.Participants Mothers aged 18 years and above who delivered preterm infants (gestational age of preterm below 37 weeks) in a private tertiary care hospital in Karachi, Pakistan.Primary outcome Stress in mothers of preterm infants.Results 200 participants with a mean age of 30.12 years (SD ±5.21) were assessed. The level of stress identified using the perceived stress scale (PSS) among mothers who had delivered preterm infants was significantly higher as compared with other countries around the world. Based on the criteria of PSS scoring, the majority of the participants (92%, n=184) were categorised as having high perceived stress and 8% (n=16) of the mothers fell into the category of moderate stress.Conclusions The study findings suggest high levels of perceived stress among mothers of preterm infants. The factors associated with the stress among mothers of preterm infants included immunisation of newborn, education and occupation status of mothers, substance abuse by mother, gender preference from family, planning for further children, consumption of balance diet, education status of husband, mode of socialisation, years of marriage and hours of sleep.

Introduction Adolescence represents a critical developmental period, with changes in emotional regulation capacities influencing physical and mental health. With less than 6% of Canadian youth currently meeting the 24-hour movement guidelines for physical activity, sleep and sedentary behaviour, there is an urgent need to understand the potential association between movement behaviours, physical literacy, emotional regulation and mental health during adolescence. Additionally, there is a need to better understand these associations among equity-deserving groups. We developed the Adolescents’ Daily Lives (ADL) project to identify how, when, under what contexts and to whom to promote healthy engagement in movement behaviours to optimise youth mental health.Methods and analysis For the ADL project, we will employ a 14-day intensive longitudinal design to investigate the associations between physical literacy, movement behaviours, emotion regulation and mental health among a diverse sample of 120 adolescents (ages 13–17 years) living in the Greater Victoria Area, British Columbia, Canada. A comprehensive baseline survey and movement competence test, assessing physical and mental well-being, 24-hour movement behaviours (ie, physical activity, sleep and sedentary behaviours) and physical literacy, will be accompanied by daily diary surveys and accelerometer-based movement tracking (ie, Fitbit Inspire 3) to assess daily fluctuations in movement behaviour, emotional regulation and mood. Multivariate analyses, including multilevel modelling, multilevel structural equation modelling and Bayesian hierarchical continuous-time SEM, will be used to model the repeated measures data and understand the simultaneous variations in daily movement behaviours, emotion regulation and mental health.Ethics and dissemination The ADL project received ethical approval from the University of Victoria Behavioural Research Ethics Board (protocol #22-0262). Study participation is voluntary, and data collection will be anonymised to protect participant privacy and confidentiality. Research findings will be shared through academic publications and conference proceedings. Through knowledge mobilisation resources, cocreated with the youth community advisory board, relevant findings will be shared directly with the wider community of adolescents.

Objective To understand what leads to the non-adherence to the cervical cancer screening (CCS) recommendations during a consultation.Design For this qualitative study, in-depth semistructured interviews were carried out with French healthcare professionals. An interview guide was developed and tested. It included the following themes: CCS recommendations, patients’ profiles, relationship with patients, emotional work, over-screening and under-screening. Interviews were carried out until data saturation (no new data, theoretical diversity reached). The grounded theory was used for data analysis.Participants Gynaecologists, midwives and general practitioners (GPs). The sample diversity was achieved using the following criteria: place of work, type of healthcare profession, type of patients, private-sector or hospital professional.Setting Interviews were conducted between July and December 2022 in six regions in France.Results In-depth semistructured interviews were carried out with 15 midwives, 24 GPs and 11 gynaecologists from six French regions. Their analysis highlighted that the following factors contributed to the non-adherence to the CCS recommendation: burden of caring for family members for some women, adhesion to the principle of yearly screening by healthcare professionals and patients, need of negotiating the respect of the CCS recommendations, use of emotions, and arbitration to prioritise what is needed for good health maintenance. The search for mutual emotional comfort led some healthcare professionals to adopt attitudes towards the CCS that avoid positioning conflicts, even if this means departing from the recommendations.Conclusion CCS can be correctly performed if healthcare professionals and patients agree on the need of actively taking care of their health, which is difficult for women from lower sociocultural backgrounds. During the one-to-one meeting with their patients, healthcare professionals may find difficult to apply the CCS recommendations, although they know and agree with them.

Objectives Ramadan fasting is an Islamic religious practice involving abstinence from food and drink from dawn to sunset. Its consequences on kidney-relevant outcomes in patients with chronic kidney disease (CKD) and kidney transplant recipients remain unclear.Design Systematic review and meta-analysis.Data sources MEDLINE, Embase, Global Health, CINAHL (EBSCOhost), Scopus, Web of Science and Google Scholar were searched up to 18 September 2023.Eligibility criteria We included observational studies among non-dialysis CKD and kidney transplant recipients who fasted during Ramadan and examined changes in kidney function.Data extraction and synthesis Standardised methods were used by two independent reviewers to screen, select and extract data. Outcomes included changes in serum creatinine (SCr), estimated glomerular filtration rate (eGFR), proteinuria, blood pressure, electrolytes and adverse events—all pre- and post-Ramadan. Results were pooled using random effects modelling.Results We included 32 observational studies with a total of 2592 participants. 21 studies reported on participants with CKD and 11 studies reported on kidney transplant recipients (studies variably including non-fasting control arms). Meta-analysis of 25 studies revealed that Ramadan fasting was not associated with changes to SCr for the following groups according to study design: CKD with a non-fasting arm (mean difference (MD)=0.82 µmol/L; 95% CI −7.22, 8.86; I2=38%); transplant with a non-fasting arm (MD=−0.17 µmol/L; 95% CI −2.50, 2.15; I2=0%) and CKD without a non-fasting arm (post–pre MD=13.84 µmol/L; 95% CI −3.78, 31.47; I2=88%). For transplant studies without a non-fasting arm, lower SCr was associated with the post-Ramadan period (post–pre MD=−5.40 µmol/L; 95% CI –10.78, –0.02; I2=0%). In the 18 studies that reported on eGFR, fasting during Ramadan was not associated with an effect on eGFR for any of the groups.Conclusion We report inconsistent effects of Ramadan fasting on kidney function in CKD or kidney transplantation. Results should be interpreted with caution due to the significant limitations of the underlying studies.

Objectives Effective, real-time surveillance of dengue may provide early warning of outbreaks and support targeted disease-control intervention but requires widespread accurate diagnosis and timely case reporting. Research directing innovation in diagnostics for dengue surveillance is lacking. This study aimed to describe experience and requirements of relevant prospective users.Design A qualitative, focus group study was conducted.Participants Data were collected from 19 users of diagnostic technology who work across the Thai dengue surveillance system.Data collection and analysis Contextual knowledge, experience and needs were explored in focus groups. Discussions were translated, transcribed, analysed thematically and mapped to Consolidated Framework for Implementation Research domains.Results Participants expressed a need for rapid, accurate, serotype-specific tests which can be operated easily by non-expert users without laboratory equipment. They supported integration of diagnostics with surveillance systems and felt this would increase the quantity and speed of case reporting as well as provide healthcare professionals with up-to-date information about the number of cases locally, thereby aiding interpretation of test results. Concerns included those relating to data security and the cost of tests.Conclusions Engagement to understand prospective user experience and requirements can improve relevance and uptake of new technology, leading to system efficiencies. The present study highlights specific needs for accurate, serotype-specific, remote-connected diagnostics which are integrated with surveillance systems and support dengue case reporting at the point-of-care.

Introduction The presence of cognitive dysfunction notably affects the quality of life in individuals diagnosed with Parkinson’s disease (PD) and is often recognised as a non-motor symptom. Comprehensive studies have shown the possible advantages of hyperbaric oxygen therapy (HBOT) in alleviating cognitive deficits in these individuals. This systematic review aims to investigate the practicality of incorporating HBOT within a more extensive therapeutic framework for PD, with a specific focus on cognitive symptoms.Methods and analysis A comprehensive literature review will be conducted utilising various databases such as PubMed and Cochrane Library and so on. The duration of the search will encompass the entire timeline from the initiation of each database up to 1 April 2024. This investigation seeks to uncover randomised controlled trials that explore the efficacy and safety of HBOT in patients with PD who are facing cognitive impairments. The authors' autonomous screening and extraction of data will facilitate the attainment of impartial results. The assessment of possible biases will be conducted using the Cochrane risk-of-bias tool, while statistical analyses will be executed with RevMan V.5.3 and Stata V.15.0.Ethics and dissemination As this review synthesises and evaluates previously conducted studies, the requirement for ethical approval is not applicable. The findings from this review will be shared via academic publications, comprehensive reports and presentations at pertinent conferences.PROSPERO registration number CRD42024504763

Introduction The only treatment for non-resectable colorectal liver metastasis (CRLM) is medical therapy, and the overall survival (OS) rate at 3 and 5 years is approximately 30%–40% and less than 10%, respectively. In 2020, a group in Norway reported that liver transplantation for non-resectable CRLM improved the 5-year OS rate to up to 83%. Clinical trials have been launched since that report was published, but most have involved deceased-donor liver transplantation rather than living-donor liver transplantation. Our study will assess the efficacy and safety of living-donor liver transplantation for patients with non-resectable CRLM.Methods and analysis This is an investigator-driven, multicentre, prospective, single-arm study involving 11 university hospitals in Japan. Patients with non-resectable CRLM and resected primary cancers will be enrolled in the study. Any patients with histopathological or genetic mutations, such as those of RAS and BRAF, are eligible. Furthermore, patients who underwent lung treatment for three or fewer pulmonary metastases and experienced no recurrence for more than 6 months are eligible. The eligibility of the candidates will be reviewed by the Central Eligibility Review Committee. The primary endpoint is the 3-year OS rate. Assuming an OS rate of 70% and a threshold of 45%, the number of required patients is 23, with an alpha error of 5% (one-sided), power of 80% and a 10% dropout rate.Ethics and dissemination Ethical approval was obtained from the ethical review board of Kyoto University (R-1591). All participants are required to provide written informed consent. The results will be submitted for publication in a peer-reviewed journal.Trial registration number jRCT1050230053 and UMIN000049785.

Introduction A literature review provides a synthesis on a selection of papers about a specific topic. This is used by health practitioners in critical care as in other specialities when making clinical practice decisions. The task of knowledge transfer through the review process of scientific papers involves a variety of methodologies with differing expectations on the quality and rigour that is applied. Exploration on the types of review methodologies selected by the authors of critical care literature may reveal the extent that choice of methodology has on how papers are selected and appraised may influence evidence-based practice recommendations. This scoping review aims to systematically map the breadth of current literature with the objective of identifying the types of review methodologies used by interdisciplinary authors synthesising the literature in adult critical care.Methods and analysis Arksey and O’Malley’s approach in conducting a scoping review will be followed and use of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review guidelines in the reporting of findings. Papers with diverse review methodologies will be identified by searching four electronic databases (CINAHL/EBSCO, MEDLINE/PubMed, Scopus and Embase). Grey literature will be excluded due to the clinical nature of the review question. Search results will be reviewed independently by two researchers based on title and abstract followed by full-text papers that meet inclusion criteria. Characteristics of review methodologies will be collected and analysed using a tool developed by the interdisciplinary research team.Ethics and dissemination This scoping review will provide an overview of the types of review methodologies most often undertaken with the interdisciplinary research team synthesising the quality of critical care literature. Scrutiny will be applied to the review methodologies selected, the challenges faced and current trends in the transfer of knowledge towards evidence-based practice. The results will be disseminated by publication through a peer-reviewed journal and by presentation as a part of conference proceedings. Ethics approval is not applicable for this scoping review.

Introduction Routine collection of patient-reported outcome measures (PROMs) has the potential to inform and improve cancer care. It is now feasible for patients to complete PROMs electronically (ePROMs) providing information about their current levels of symptoms, side effects of treatment and other concerns. PROM scores can be tracked over time allowing more timely identification of problems and more appropriate intervention. Studies have reported clear benefits in patient–clinician communication when PROMs are used and trials in the USA and France found patients randomised to complete regular ePROMs reported better health-related quality of life, had fewer unplanned hospital visits and, importantly, significantly better survival than those randomised to usual care. However, information about the effects on health outcomes and, particularly, the cost-effectiveness of incorporating this information into practice is limited.Methods and analysis PROMISE (Patient Reported Outcome Measures in cancer care: a hybrid effectiveness-Implementation trial to optimise Symptom control and health service Experience) is a multicentre, randomised hybrid effectiveness/implementation trial to evaluate the clinical and cost-effectiveness of using ePROMs in routine cancer care to improve patient outcomes. Participants (target sample=572; randomised 1:1 to intervention and control) are adults aged 18 years or older diagnosed with a solid cancer and starting treatment at one of the four study hospitals. The primary outcomes are unplanned hospital presentations and physical/functional well-being at 6 months. We hypothesise that, compared with usual care, patients randomised to use an ePROM tool will have fewer unplanned hospital presentations, report better health-related quality of life and greater satisfaction with their care and that the ePROM tool will be cost-effective. We will also assess implementation and process outcomes consistent with the RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) Framework.Ethics and dissemination This trial has been approved by the Metro South Human Research Ethics Committee (HREC/2020/QMS/67441). Participants provide written informed consent, including consent for record linkage, prior to completing the baseline questionnaire. Study results will be disseminated via peer-reviewed journals and presentations at scientific conferences and clinical meetings.Trial registration number ACTRN12620001290987.

Background Breast cancer is emerging as a leading cause of mortality among women and adolescent girls in Sub-Saharan Africa (SSA). However, there is a lack of clarity on the enablers and barriers associated with the implementation of preventive strategies, such as breast self-examination (BSE), particularly among adolescent girls.Objective This paper presents a protocol for conducting a systematic review aiming to synthesise studies on the enablers and barriers to implementing BSE education programmes among adolescent girls in SSA.Methods and analysis The systematic review will be conducted from December 2024 to August 2025, following the predefined methodological framework outlined in the PRISMA guidelines. To gather relevant studies, a comprehensive search will be conducted across four main online databases, namely PubMed, Scopus, Cochrane Library and EMBASE, along with other relevant grey literature sources, such as Google Scholar, to identify pertinent literature on this topic. The screening process will involve an initial review of titles and abstracts to quickly identify relevant studies, followed by a thorough assessment of the full-text versions of selected studies. Two reviewers, working independently, will extract data and evaluate the risk of bias in the included studies using either the Joana Briggs Institute’s Critical Appraisal tool or Cochrane’s Risk of Bias tool V.2 (RoB 2). The focus of the included studies will be on BSE among adolescents aged 10 to 19 years of age. Depending on the results of the literature search and the characteristics of the findings in the selected studies, we will conduct a meta-analysis if possible. Alternatively, a narrative synthesis will be conducted. The review will provide empirical evidence to inform health promoters and policymakers in advocating for BSE, particularly, among adolescent girls in SSA, with the ultimate goal of mitigating the risk of breast cancer.Ethics and dissemination Since this study is based on the analysis of already published research articles, ethical approval is not required. The results will be disseminated through peer-reviewed academic publications and presentations, informing further research and practice regarding BSE education programmes.

Introduction Evidence shows that resistance training (RT) reduces lymphoedema in patients with breast cancer–related lymphoedema (BRCL), making it a safe and efficient intervention. However, it is uncertain if RT is safe and effective in patients at risk of developing BRCL. This systematic review (SR) protocol aims to describe all methodological aspects in order to evaluate the short-, medium- and long-term effects of RT on the prevention of BCRL.Materials and methods Throughout 2024, randomised clinical trials (RCTs) will be identified in electronic databases MEDLINE/PubMed, Embase, Cochrane Central Register of Controlled Trials, PEDro and LILACS. Only studies in English, Spanish and Portuguese will be included. Grey literature and clinical trial registration will also be reviewed. The primary outcome will be the occurrence of lymphoedema and quality of life. Second, pain intensity, upper limb function, range of movement, grip strength and adverse events will be considered. The individual studies’ risk of bias will be evaluated using the Cochrane Risk of Bias 2.0 tool. Pairwise meta-analyses using a frequentist approach and random effects model will be conducted. The Grading of Recommendations Assessment, Development and Evaluation system will be used to evaluate the certainty of the evidence.Ethics and dissemination This protocol does not require the approval of an ethics committee, as it is a secondary study. The results will be disseminated through peer-reviewed publications.PROSPERO registration number CRD42023455720.

Objectives There is limited information about the stability and predictability of Bayley Scales of Infant and Toddler Development (BSID) assessing child development in low- and middle-income settings. The objective of the present study was to analyse stability and predictive validity of BSID using an existing birth cohort.Design Prospective birth cohort follow-up study.Setting and participants A community-based birth cohort of 251 newborns was recruited and followed-up in urban Vellore, South India, until 9 years of age. Using BSID-III, child development was measured at 6, 15, 24 and 36 months. Cognition was assessed using the Wechsler Preschool Primary Scales of Intelligence at 5 years, and the Malin’s Intelligence Scale for Indian Children scale at 7 and 9 years of age. The stability of BSID measurements across time points was expressed by intraclass correlation (ICC) and concordance correlation coefficients. Linear regression was used to describe the predictability of BSID-III of cognition at 5, 7 and 9 years.Results The ICC for domain-wise BSID scores between time points of measurement suggested a weak correlation. The BSID scores at 36 months correlated best with Full-Scale Intelligence Quotient (FSIQ) at 5 years (r: 0.40–0.49), 7 years (r: 0.35–0.48) and 9 years (r: 0.36–0.38). BSID scores at 36 months predicted FSIQ better at 5, 7 and 9 years with R2 ranging from 23.3% to 28.6%, when compared with 24 months BSID scores (R2 - 16.0% to 25.9%).Conclusion Poor stability and predictability of BSID warrant caution in the predictive projection of early childhood assessments. Better predictability of future cognition of 36 months’ BSID scores highlights its advantage over the 24 months’ assessment.

Objective We evaluate change in low back pain (LBP) intensity and interference as the mechanism by which chiropractic care affects other biopsychosocial factors in US active-duty military members.Design We conducted secondary, exploratory mediation analysis of pragmatic, multisite, clinical trial (NCT01692275) post results using natural effect modeling. Mediators were the 6-week values of Patient-Reported Outcomes Measurement Information System (PROMIS)-29 pain interference and intensity. Outcomes were 12-week values of other PROMIS-29 biopsychosocial subdomains. Models evaluated overall and individual factor contribution and were adjusted for baseline age, sex, LBP duration, LBP intensity and mediator and outcome values.Setting Three US military treatment facilities.Participants 750 US active-duty military members with LBP.Interventions Trial participants received 6 weeks of treatment with chiropractic care plus usual medical care or usual medical care alone.Results In multiple mediator models, pain interference and pain intensity explained much of the effect of chiropractic care on physical function (proportion mediated=0.77, 95% CI 0.43 to 2.0), fatigue (0.62, 95% CI 0.30 to 1.0), sleep disturbance (0.49, 95% CI 0.31 to 1.5) and social roles (0.81, 95% CI 0.50 to 2.0). Mental health was not evaluable due to the low prevalence of symptoms reported. The combined models of pain interference and pain intensity did not have a higher proportion mediated than the individual pain intensity models except for fatigue outcome models.Conclusion Pain intensity appeared to be the mechanism by which much of the change in biopsychosocial factors occurred and should be considered a key clinical indicator for improvement in biopsychosocial health when chiropractic care is added to usual medical care for US active-duty military members.

Objectives To investigate the prevalence, associated factors, treatment status and burden of constipation in workers with depression or anxiety.Study design This was a retrospective observational study using a pre-existing database.Setting Claims data from October to November 2022 and data from the survey conducted in November 2022 were extracted from the database.Participants This study included self-reported workers who completed the survey, after excluding those with major mental disorders diagnosed as distinct from depression or anxiety and constipation due to organic diseases identified by International Classification of Diseases (ICD-10) codes.Outcome measures The subjects were divided into three groups: treated depression/anxiety, untreated depression/anxiety and no depression/anxiety. The prevalence of constipation, factors associated with constipation and medications prescribed for constipation were analysed. Work productivity and quality of life (QOL) were compared between three subgroups based on constipation status: treated constipation, untreated constipation and no constipation subgroup.Results Of the 18 585 respondents in the analysis population, 950 respondents (5.1%) were classified into the treated depression/anxiety group, 6035 respondents (32.5%) into the untreated depression/anxiety group and the remaining respondents into the no depression/anxiety group (11 600 (62.4%)). The prevalence of constipation was 22.5% in the treated group, 22.3% in the untreated group and 10.4% in the no depression/anxiety group, respectively. Depression and anxiety severity were independently associated with an increased risk of constipation. In all groups, the most commonly prescribed drug class was osmotic laxatives. Work productivity and QOL tended to indicate a greater burden in the untreated constipation subgroup than in the treated or no constipation subgroups.Conclusions The prevalence of constipation was twice as high if workers had depression/anxiety. Considering that the comorbidity of constipation with mental disorders may increase multiple burdens, appropriate medical interventions are required to treat both mental (depression/anxiety) and physical (constipation) conditions. This should be widely recognised by physicians and employers.

Objectives To investigate the details of disaster-related deaths due to the indirect health effects of the Fukushima Daiichi Nuclear Power Plant (FDNPP) accident following the Great East-Japan Earthquake in 2011 and serve as a source of reference in the event of similar circumstances in the future.Design A retrospective observational study.Setting Minamisoma City, Fukushima Prefecture, Japan, which is located 13–38 km north of the FDNPP.Participants 520 residents of Minamisoma City, Fukushima Prefecture, who were certified as having died from disaster-related causes between September 2011 and February 2021.Results The most common cause of death was circulatory system diseases (27.7%), followed by respiratory system diseases (25.0%) and neoplasms (15.4%). The prevalence of circulatory and respiratory diseases is higher in older people, suggesting that they are more susceptible to indirect health effects due to the environmental changes related to evacuation. Malignant neoplasms accounted for the third and leading cause of death overall and for people in their 50s, respectively, implying the potential impact of evacuation on cancer diagnosis and treatment. Suicide is the leading cause of death among younger people and can occur even long after a disaster, which shows the psychological impact of environmental changes.Conclusion To prevent indirect disaster-related deaths in the future, it is important to consider appropriate intervention methods by age group and period since disaster occurrence. It is especially important to improve the environment of evacuation shelters and establish a healthcare system for evacuees, create a system for cancer screening and treatment during evacuation and expand long-term suicide prevention measures.

Background In out-of-hospital cardiac arrest (OHCA), decisions to terminate resuscitation or transport the patient to hospital are ethically fraught. However, little is known about paramedics’ ethical concerns in these decision-making processes.Objective To develop an understanding of how paramedics experience ethical concerns in OHCA decision-making processes, and how this relates to the ethical concerns of patients’ relatives.Design A qualitative study using semi-structured interviews with paramedics and relatives of OHCA non-survivors.Setting Two ambulance trusts in England.Participants Thirty-one paramedics, identified as decision-makers in adult OHCA events in which cardiopulmonary resuscitation (CPR) had been initiated, were interviewed. Fourteen interviews with relatives of OHCA non-survivors were also conducted.Analysis The interviews were analysed thematically, using a coding framework and following an empirical ethics approach.Results Four themes were developed: preventing harm to patients, best interests, caring for the patient’s family and moral distress. Paramedics conceptualised preventing harm both as saving lives and as preventing an undignified death or a life with severe brain damage. Paramedics’ and relatives’ views of best interests were influenced by values such as patient dignity and assumptions about age and quality of life. Paramedics expressed a duty of care towards the patient’s family. Relatives conveyed the importance of clear communication and acts of care performed by the ambulance crew, underscoring the ethical commitment that paramedics had towards patients’ families. Paramedics described decision-making processes that relied on clinical guidelines, rather than personal values and beliefs; this sometimes led to moral distress.Conclusion Non-protocolised ethical considerations are important in paramedic decision-making about terminating CPR in OHCA events. While paramedics use established guidelines and processes to reach decisions that prevent patient harm, they experience moral distress when personal convictions clash with guidelines. Training around ethical reasoning and decision making may help paramedics reduce their moral distress and provide consistent and transparent decisions for patients and their families.

Objectives Osteoporosis is a condition characterised by decreased bone strength and an increased risk of fragility fractures. Its prevalence is increasing in developed countries, highlighting the need for appropriate diagnosis and intervention. However, in practice, adequate testing and treatment are not often provided. Therefore, in this study, we investigated the status of osteoporosis management in a rural community hospital in Japan.Design Cross-sectional retrospective study.Setting Department of General Medicine from a rural community hospital in Japan.Participants A total of 984 women aged≥65 years who were recommended to undergo osteoporosis screening were included.Primary and secondary outcome measures Bone mineral density (BMD) testing rates and characteristics of patients who underwent these tests, including diagnosis and treatment rates for osteoporosis.Results The BMD testing rate was 14%. Despite being at risk of osteoporosis, older patients and those requiring nursing care had a lower rate of testing. The proportion of patients diagnosed with osteoporosis was 41%, and the treatment rate was 19%.Conclusions The management of osteoporosis in a rural Japanese community hospital was found to be inadequate. The rate of BMD testing was low, particularly among older adults and those requiring nursing care. This finding suggests that osteoporosis may be underdiagnosed in many cases in this population or diagnosed but not appropriately followed up. Further cohort studies and intervention strategies are needed to fully investigate these issues.

Introduction Orofacial clefts (OFCs), including cleft lip, cleft palate and combined cleft lip and palate, are among the most common craniofacial malformations in newborns and present significant healthcare challenges. Emerging evidence has raised concerns regarding the potential impact of prenatal exposure to antibiotics on fetal development. Antibiotics prescribed during pregnancy—particularly those that cross the placental barrier—may pose teratogenic risks. Previous studies investigating the association between prenatal antibiotic exposure and the risk of OFCs have yielded inconsistent results. However, no studies have yet attempted to summarise this evidence, highlighting the need for a comprehensive evaluation. This report describes a systematic review and meta-analysis protocol to retrospectively analyse the relationship between prenatal antibiotic exposure and the risk of developing OFCs, focusing on the role of antibiotic type and timing of exposure. The results of such a review will hopefully provide a comprehensive synthesis of the available evidence, helping to inform clinical practice and guide patient counselling regarding the use of antibiotics during pregnancy.Methods and analysis The planned systematic review and meta-analysis will adhere to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines to ensure a comprehensive and systematic approach to summarising the available evidence on the topic. This study will include longitudinal cohort studies, case–control studies, and interventional trials that investigate the association between prenatal antibiotic exposure and OFCs. The search strategy will cover major databases, including CINAHL, Cochrane Library, ClinicalTrials.gov, EMBASE, PubMed, Scopus and Web of Science, using tailored search terms. A team of independent assessors will screen article titles, abstracts and full texts. Any discrepancies will be resolved through discussions. Quality assessment will use the Newcastle-Ottawa Scale and Grading of Recommendations Assessment, Development and Evaluation criteria. Data extraction will focus on the study characteristics, participant details, exposure specifics and outcome measures. A random-effects meta-analysis will aggregate summary effect sizes, and heterogeneity will be assessed using I2 and Q statistics.Ethics and dissemination Ethical approval is not required for this systematic review, as it relies on already published data. The findings will be disseminated through peer-reviewed journals and conference presentations, providing critical insights into clinical practice and public health policies regarding antibiotic use during pregnancy.PROSPERO registration number CRD42024565064

Introduction People with cancer and other chronic illnesses, their families and caregivers report financial burden as a problem that affects multiple aspects of daily life. While cancer research has coined the term ‘financial toxicity’ to describe the financial consequences, the understanding, development and operationalisation of the concept of financial burden are still incomplete, particularly regarding subjective financial burden and its relationship with well-being. The overall aim is to investigate financial burden and its implications for the well-being of people living with chronic illness, their families, and caregivers in Switzerland.Methods and analysis Transdisciplinary discussion groups and a participatory action design element frame: (1) a conceptualisation using a hybrid concept analysis approach and (2) an assessment of financial burden of chronic illness in relation to well-being. The hybrid concept analysis combines the results of a scoping review with a secondary analysis of existing interviews using computational linguistics and qualitative analysis. The assessment phase will investigate the extent and nature of financial burden through a nationwide survey. Results from mobile diaries/interviews will contribute to both—the conceptualisation and assessment phases.Ethics and dissemination The Ethics Committee of the Canton Zurich, Switzerland, did not consider the research project to fall under the Swiss Law on Human Subjects research and issued a waiver (Req-2O23-01496). The project respects all the rules and regulations in the Swiss Federal Act on Data Protection and those by the Swiss Federal Official Responsible for Data Protection and Transparency. Results will be disseminated through presentations at conferences and publications in peer-reviewed journals and through the established multi-stakeholder network.

Objectives The increasing burden of cardiovascular diseases (CVDs) in Kenya threatens its healthcare system. There is a need for innovative models that improve equitable access to CVD prevention services. Community markets are social establishments with untapped potential to promote public health. This is a multiphased feasibility study that explores the potential of Health Kiosks in Markets (HEKIMA) to improve access to CVD prevention services. In this formative phase, the aim was to assess the readiness of primary healthcare centres (HCs) and community markets to jointly deliver CVD prevention services.Design Mixed methods using concept mapping and readiness surveys. Concept mapping with 35 stakeholders from different sectors (health and non-health) to identify feasible priorities for HEKIMA. The readiness questionnaire contained 193 items which were based on the guidance of the WHO Handbook for Monitoring the Building Blocks of Health Systems and adapted to suit the context of a single HC.Setting Vihiga County is located in western Kenya and has a population of 590 013. A total of 18 HCs and 19 markets were assessed, with 10 HCs and 15 markets included in the evaluation.Results 91 statements were generated from concept mapping and distilled into 8 clusters, namely equipment and supplies, access and referral, communication, manpower, networks and linkages, practice, service delivery and health promotion. Agreed actions for HEKIMA were provision of efficient quality services, health promotion and partnerships sensitive to the local context. HCs and markets had established governance systems and basic infrastructure. The majority of the HCs lacked essential CVD medications. No HC–market interface existed but there was willingness for a partnership.Conclusion There was strong consensus that an HC–market interface via community health worker manned kiosks could have a positive impact on health systems, markets and CVD prevention in vulnerable communities. However, significant infrastructural, technical and resource gaps were observed that need to be addressed.

Objective The objective is to externally validate and assess the opportunity to update the Canadian COVID-19 Mortality Score (CCMS) to predict in-hospital mortality among consecutive non-palliative COVID-19 patients infected with Omicron subvariants at a time when vaccinations were widespread.Design This observational study validated the CCMS in an external cohort at a time when Omicron variants were dominant. We assessed the potential to update the rule and improve its performance by recalibrating and adding vaccination status in a subset of patients from provinces with access to vaccination data and created the adjusted CCMS (CCMSadj). We followed discharged patients for 30 days after their index emergency department visit or for their entire hospital stay if admitted.Setting External validation cohort for CCMS: 36 hospitals participating in the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN). Update cohort for CCMSadj: 14 hospitals in CCEDRRN in provinces with vaccination data.Participants Consecutive non-palliative COVID-19 patients presenting to emergency departments.Main outcome measures In-hospital mortality.Results Of 39 682 eligible patients, 1654 (4.2%) patients died. The CCMS included age, sex, residence type, arrival mode, chest pain, severe liver disease, respiratory rate and level of respiratory support and predicted in-hospital mortality with an area under the curve (AUC) of 0.88 (95% CI 0.87 to 0.88) in external validation. Updating the rule by recalibrating and adding vaccination status to create the CCMSadj changed the weights for age, respiratory status and homelessness, but only marginally improved its performance, while vaccination status did not. The CCMSadj had an AUC of 0.91 (95% CI 0.89 to 0.92) in validation. CCMSadj scores of 15 had observed mortality of >56.8%.Conclusions The CCMS remained highly accurate in predicting mortality from Omicron and improved marginally through recalibration. Adding vaccination status did not improve the performance. The CCMS can be used to inform patient prognosis, goals of care conversations and guide clinical decision-making for emergency department patients with COVID-19.