Chronic obstructive pulmonary disease (COPD) affects approximately 480 million individuals globally and is projected to reach 600 million by 2050, representing a substantial burden on healthcare systems and patient quality of life. Pulmonary rehabilitation is a cornerstone intervention for COPD management, delivering clinically meaningful improvements in exercise capacity, health-related quality of life and dyspnoea. Despite strong guideline recommendations and established efficacy, only 2%–4% of eligible patients with COPD access traditional centre-based pulmonary rehabilitation due to geographical barriers, transportation difficulties, scheduling conflicts and limited healthcare resources. Digital health technologies offer promising alternatives to overcome these access barriers while potentially maintaining therapeutic benefits. Various digital delivery models have emerged, including video-based telerehabilitation, virtual reality platforms, mobile health applications and web-based programmes. However, their comparative effectiveness remains unclear, limiting evidence-based clinical decision making. This systematic review and network meta-analysis will aim to compare and rank the effectiveness and safety of different digital health delivery models for pulmonary rehabilitation in patients with COPD, providing evidence to inform optimal intervention selection in clinical practice.

We will conduct a systematic review and Bayesian network meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Network Meta-Analyses guidelines. Comprehensive searches will be performed across five electronic databases (PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL) from inception to January 2026, without language restrictions. Eligible studies will include randomised controlled trials comparing digital health delivery models for pulmonary rehabilitation in adults with COPD. Digital health interventions will be categorised into four distinct delivery models: video-based telerehabilitation, virtual reality rehabilitation, mobile health rehabilitation and web-based platform rehabilitation. Interventions combining multiple modalities will be categorised according to the predominant component based on intervention frequency, duration and primary therapeutic mechanism. Two independent reviewers will perform study selection, data extraction and risk of bias assessment using the Cochrane Risk of Bias 2 tool. The primary outcome will be change in 6 min walk distance. Key secondary outcomes will include disease-specific quality of life measures, dyspnoea severity, hospitalisation rates, exacerbation frequency, intervention adherence and adverse events. A Bayesian random-effects network meta-analysis will be conducted, calculating mean differences or ORs with 95% credible intervals. Treatment rankings will be estimated using surface under the cumulative ranking curve probabilities. Evidence certainty will be assessed using the Confidence in Network Meta-Analysis framework. Planned subgroup analyses will explore potential effect modifiers including disease severity, intervention duration, supervision mode and technological features.

As this systematic review will use data from previously published studies, formal ethical approval is not required. Findings will be disseminated through peer-reviewed publication, presentations at relevant scientific conferences and communication to healthcare providers, policymakers and patient advocacy organisations.

CRD420251268701.

Immune checkpoint inhibitors (ICIs) have revolutionised cancer treatment through targeted disruption of the physiological pathways that maintain tissue tolerance, but which are co-opted by cancers to evade immunosurveillance. Thus, the resultant T-cell activity often causes immune-related adverse events including immune checkpoint inhibitor-induced inflammatory arthritis (ICI-IA). ICI-IA results in functional impairment that frequently persists, even after ICI discontinuation, with substantial quality-of-life impacts for cancer survivors.

A high-quality body of evidence to guide ICI-IA management remains an unmet need. Pharmacological treatment may be prolonged, typically begins with non-specific immunosuppression, including systemic steroids, and is usually only rationalised to more targeted therapy in resistant cases. Moreover, retrospective data suggest the high dose glucocorticoids sometimes used in new-onset ICI-IA may be associated with worse cancer outcomes.

Tumour necrosis factor (TNF) inhibition strategies are well established with excellent efficacy and safety profiles in ‘spontaneous’ inflammatory arthritides including rheumatoid and psoriatic arthritis. Mechanistic evidence from ex vivo and murine studies also supports the utility of anti-TNF therapy for steroid-refractory cases of ICI-IA. Although good clinical responses have been reported in this setting, the REACT trial (REmission induction of Arthritis caused by Cancer ImmunoTherapy) aims to provide randomised and robust clinical evidence for deploying targeted therapy earlier in ICI-IA management. It will test whether up-front anti-TNF therapy can more effectively and quickly control symptoms, reduce glucocorticoid exposure, prevent early ICI discontinuation and increase the frequency of drug-free ICI-IA remission.

REACT is a prospective, multicentre, open-label, superiority, two-arm, randomised controlled clinical trial to guide initial therapy for patients with ICI-IA. The trial will compare the current standard of care (initial prednisolone; Arm A) with the anti-TNF drug, adalimumab without glucocorticoids (Arm B).

The primary outcome is glucocorticoid-free arthritis remission rate at 24 weeks where remission is defined as: (i) No use of systemic or intra-articular glucocorticoids (except when used for adrenal insufficiency) within 4 weeks prior to assessment at 24 weeks; and (ii) absence of synovitis on clinical examination.

The protocol was approved by East Midlands—Leicester South Research Ethics Committee on 31-Oct-2024 (Ref: 24/EM/0202). Participants are required to provide written informed consent. The results of this trial will be disseminated through national and international presentations and peer-reviewed publications.

ISRCTN18217497.

Healthcare utilisation (HU) is key to improving the health of residents in urban informal settlements. This study aimed to explore household-level factors influencing HU among informal settlement households in Freetown, Sierra Leone.

Cross-sectional survey.

Three informal settlements (Cockle Bay, Dwarzark and Moyiba) in Freetown, Sierra Leone.

Primary data from 4871 households were collected during the Health and Wellbeing survey conducted between April and May 2023, targeting households with adults aged 18 years and older.

The primary outcomes were households HU both within and outside informal settlements. Household-level predisposing and enabling explanatory variables were derived from Andersen’s Behavioural Model of HU.

Disability in households increases HU within settlements (especially in Dwarzark, 13% and Moyiba, 10%) but is less likely outside. Households engaged in income-generating activities are more likely to seek healthcare within settlements, but 12% less likely outside in Cockle Bay and Dwarzark. Food insecurity decreases HU within Dwarzark (9%) and increases HU outside by 174% in Moyiba. Longer water fetching times and water shortages were associated with higher HU (between 6% and 16%) within settlements, especially in Cockle Bay and Dwarzark. Clean water sources (eg, piped dwelling, bowser, surface, bottled) were consistently associated with higher HU both within and outside settlements. Shared sanitation facilities (such as shared toilets) were positively associated with HU both within and outside settlements, particularly in Dwarzark and Moyiba. Households with income from fishing, informal salaried work and bike riding showed higher HU both within and outside settlements, especially in Dwarzark and Moyiba.

We identified strong settlement-specific patterns of household-level factors that influence HU both within and outside Freetown’s informal settlements. These findings provide a foundation for developing targeted policies such as strengthening local services, addressing affordability and accessibility barriers and supporting vulnerable occupation groups.

Osteoporosis (OP) is a systemic skeletal disorder that increases fragility and susceptibility to fractures. Despite the availability of teriparatide for the treatment of patients with acute fractures with better efficacy, its long-term daily injection and high cost limit its broader use among a wider patient population, especially for those living in low- and middle-income countries. This study aims to evaluate the efficacy of a novel sequential treatment with teriparatide daily for 6 months followed by denosumab every 6 months for another 18 months, in comparison with denosumab monotherapy every 6 months for 24 months, in reducing the risk of fractures in patients with newly diagnosed osteoporotic fractures. The study will also explore the possible difference between two sequential treatments (shifting to denosumab treatment at 6 or 12 months) in their effect on increasing bone mineral density (BMD).

This study is designed as a multicentre, open-label, randomised controlled trial among 2478 patients with newly diagnosed osteoporotic fractures from 58 hospitals across China. Participants will be randomly assigned in a 10:10:1 ratio to three treatment groups: 24 months of denosumab monotherapy, early sequential treatment (teriparatide for 6 months followed by denosumab for 18 months) and late sequential treatment (teriparatide for 12 months followed by denosumab for 12 months). The primary outcome is the incidence of vertebral fractures over 24 months of treatment. Secondary outcomes include changes in BMD at the lumbar spine, total hip and femoral neck, changes in bone turnover markers (β-carboxy-terminal telopeptide of type 1 collagen and procollagen type 1 N-terminal propeptide), treatment adherence and cost-effectiveness. Follow-up assessments are scheduled at 3, 6, 9, 12, 18 and 24 months post-randomisation for primary and secondary outcomes, and biannually afterwards for the primary outcome.

The study protocol has been registered on ClinicalTrials.gov and has received ethical approval from the Peking Union Medical College Hospital Medical Science Research Ethics Committee (1-22PJ939). The findings will be disseminated through peer-reviewed scientific journals.

NCT05866029.

To evaluate the prognostic significance of tumour deposit (TD) across different N stages in patients with stage III colon cancer and to develop and validate a novel N staging system that incorporates TD count to improve prediction of cancer-specific survival (CSS).

Retrospective cohort study based on population-based data and external validation.

Secondary and tertiary care settings; data from the SEER database, a population-based cancer registry capturing cancer incidence and survival information (USA, 2010–2017); and a single-centre validation cohort from South China (2015–2019).

A total of 8739 stage III colon cancer patients from the SEER database who underwent curative surgery were included; 1335 (15.3%) had TD. Patients with

The outcome was cancer-specific survival (CSS). The prognostic impact of tumour deposit (TD) and the comparative performance of the novel N staging system versus the AJCC system were evaluated using the Fine-Gray competing risks model, time-dependent area under the curve (AUC) and Brier score.

TD was independently associated with poorer CSS: 1 TD (SHR=1.23, 95% CI 1.04 to 1.47, p=0.017), 2–3 TDs (SHR=1.36, 95% CI 1.17 to 1.58, p3 TDs (SHR=2.02, 95% CI 1.73 to 2.35, pet al, TDs were converted to metastatic lymph nodes (mLNs) using the following weighting: 1 TD=3 mLNs (N1c), 1 TD=2 mLNs (N1) and 1 TD=1 mLN (N2). The novel N staging system stratified patients as nN1a (1 nLN), nN1b (2–3 nLNs), nN2a (4–6 nLNs) and nN2b (≥7 nLNs). This approach showed improved prognostic accuracy compared with AJCC N staging: 3-year AUC (0.623 vs 0.614) and Brier score (0.151 vs 0.157, p

TD significantly worsens prognosis in stage III colon cancer, particularly in lower N stages. Incorporating TD counts into the N staging system with different weightings based on N stage enhances prognostic accuracy and risk stratification within stage III disease, particularly for the heterogeneous AJC N1c category. This novel staging system provides better prognostic value and more accurate treatment guidance and should be considered for broader clinical use, subject to further (eg, prospective) validation.

To estimate tuberculosis (TB) incidence trends in the high-altitude Xizang, China, and to explore the key intervention strategies on achieving the WHO 2030 TB control target.

We developed a susceptible–exposed–infectious–recovered transmission model using routinely reported TB surveillance data from 2004 to 2022. Scenario-based simulations were conducted to project future TB incidence under alternative intervention strategies. Model assumptions are as follows: (1) a stable population, (2) lifelong vaccine-induced immunity, (3) infectiousness of active TB cases, (4) relapse risk after recovery and (5) homogeneous mixing within the population.

Seven prefectures of Xizang Autonomous Region on the Tibetan Plateau, China.

An estimated population of approximately 3 million individuals residing in Xizang.

We assessed the epidemiological impact of four interventions implemented independently: increasing vaccine efficacy rate, reducing transmission rates of susceptible individuals, decreasing progression rate from latent TB infection to active disease and reducing relapse rate among successfully treated patients, compared with continuation of current control measures.

The estimated basic reproduction number (R₀ ) for TB in Xizang was 0.39 (95% CI 0.21 to 0.71) in the absence of additional interventions, which was the highest among all regions of China. Model simulations indicated that all four evaluated interventions were each likely to reduce TB incidence, but only reducing the latent-to-active TB progression had a substantial effect. A 50% reduction in the progression rate was predicted to lower TB incidence from 66.56 (62.00–70.11) to 40.54 (37.15–43.77) cases per 100 000 population, meeting the WHO 2030 TB control target.

Targeted management of individuals with latent TB infection should be strengthened to substantially reduce TB transmission in high-altitude areas.

Generative artificial intelligence (GAI), including large language models and multimodal generative systems, is rapidly emerging in healthcare with growing interest in its potential applications for dementia care. These technologies offer new possibilities for communication support, cognitive engagement and personalised interaction, yet they also introduce complex ethical, relational and practical challenges. Nurses—who hold central, sustained roles across dementia care settings—are key mediators of technology adoption and are positioned to assess the appropriateness, safety and ethical implications of GAI use. However, existing literature remains fragmented and largely focused on technological development or patient-facing outcomes, with limited synthesis of nurses’ roles, experiences and ethical perspectives. This scoping review aims to map the current evidence regarding how nurses engage with GAI in dementia care and to identify gaps that may inform practice, policy and future research.

This review will follow the methodological framework of Arksey and O’Malley, refined by Levac et al and guided by the Joanna Briggs Institute Manual for Evidence Synthesis. Reporting will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. The review will be conducted between March 2026 and October 2026, encompassing database searching, screening, data charting, synthesis and reporting. A comprehensive search will be conducted across MEDLINE (Ovid), CINAHL, PsycINFO, Scopus and Web of Science using controlled vocabulary and keywords related to nursing, generative artificial intelligence and dementia. Eligible sources will include empirical studies, reviews, conceptual papers and policy analyses that report nursing roles, experiences or ethical considerations related to GAI in dementia care. Two reviewers will independently screen titles/abstracts and full texts and extract data using a structured charting form. Findings will be synthesised through descriptive statistics and inductive thematic analysis, supported by conceptual mapping to illustrate relationships among GAI types, nursing roles, ethical concerns and care settings. Critical appraisal will not be undertaken, as it is optional in scoping reviews and is not aligned with the primary mapping objectives of this review.

Ethical approval is not required as the review synthesises publicly available literature. Should the optional interest-holders consultation be undertaken, ethical clearance will be obtained from an appropriate institutional review board prior to participant engagement. Findings will be disseminated through peer-reviewed publication, conference presentations and knowledge-translation outputs targeted at clinicians, educators, policymakers and AI developers. The review will support informed, ethically grounded integration of GAI in dementia care.

The diversity of treatment options for diabetic retinopathy (DR) and the high uncertainty about the benefits and risks of different treatment modalities necessitate shared decision-making between patients and healthcare professionals. However, little is known about the involvement of individuals with DR in treatment decision-making in China. This study aims to gain insight into the current status and factors associated with involvement in treatment decision-making in patients with DR. Furthermore, we will explore the experiences and perceptions of patients with DR regarding their involvement in treatment decision-making.

We will conduct a mixed-method study using an explanatory sequential design. In the quantitative research (n=350), participants’ actual decision-making roles, sociodemographic data, disease-related data, health literacy, need for involvement in decision-making, decision-making self-efficacy, social support and ophthalmologist facilitation of patient involvement will be investigated to analyse the current state of patient involvement in treatment decision-making and the factors influencing it. Descriptive statistics, one-way analysis of variance and multinomial logistic regression will be performed. During this period, individual semistructured interviews will be conducted with a subset of these participants to understand the perceptions and experiences of people with DR regarding their involvement in treatment decision-making, and thematic analysis will be used to analyse the interview data. Finally, the joint display will be used to integrate quantitative and qualitative data.

Ethical approval for this study has been obtained from the Ethical Review Committee for Human Trials of Shanghai General Hospital, China (number: 2024–098). Written informed consent will be obtained from all participants after they have been fully informed about the study, prior to any data collection. The study’s findings will be disseminated through peer-reviewed publications and conference reports.

ChiCTR2400087906.

Hypertension represents a major public health challenge globally, with a rising prevalence in China. This study aims to explore the factors shaping blood pressure (BP) control among hypertensive patients managed in community health centres (CHCs), with a particular emphasis on the association with age.

This was a population-based, observational study that used healthcare records from CHC in Shenzhen, covering the period from 1 January 2000 to 8 October 2024. Univariate and multivariate logistic regression analyses were employed to assess the independent associations of various factors with BP control rate. Additionally, the study evaluated the relationship between age and BP control across six distinct age subgroups.

The study included 1 073 914 participants who met the eligibility criteria, with 955 415 (88.97%) patients achieving BP control. The median baseline age was 55.9 (IQR 18–109) years. Individuals aged 45 years and above demonstrated better BP control rates (46–55, OR 1.053, 95% CI 1.020 to 1.087; 56–65, OR 1.246, 95% CI 1.205 to 1.289; 66–75, OR 2.183, 95% CI 2.103 to 2.265; >75, OR 2.159, 95% CI 2.060 to 2.262). Among young adults aged 18–35 years, increasing age was consistently associated with poorer BP control across most subgroups. For the middle-aged groups (36–45 and 46–65 years), age had little impact on BP control. In the 66–75 years age range, older age was linked to better BP control in some groups.

The association between age and BP control varied across age groups. Hypertension management strategies should be tailored to address the unique needs of different age groups, geographical regions and targeted populations.

Deep vein thrombosis (DVT) of the lower limbs has a significantly higher incidence among elderly populations than that observed in other types of fractures, prolonged immobilisation and the systemic inflammatory response triggered by preoperative pain are the main risk factors. Liposomal bupivacaine (LB) single-injection pericapsular nerve group (PENG) block has demonstrated effective analgesia both before and after surgery, while preserving motor function in patients with hip fracture. Although regional nerve block is a well-established component of preoperative multimodal analgesia, its potential role and underlying mechanisms in the prevention of DVT in elderly patients with hip fracture remain largely unexplored.

This study will be conducted as a double-blind, randomised, sham-controlled, prospective clinical trial. On admission, a total of 132 participants will be randomly assigned using block randomisation to receive either treatment group (LB single-injection PENG block) or sham group (saline solution single-injection PENG block). The primary outcome was the incidence of DVT, while secondary outcomes included perioperative inflammatory and immune-related stress levels and functional-based pain scores.

This study protocol complies with the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 guidelines and has been approved by the Ethics Committee of Shunde Hospital, Guangzhou University of Traditional Chinese Medicine (Approval No KY-2025005). The raw data are planned to be made publicly available on the ResMan raw data–sharing platform (IPD sharing platform) of the Chinese Clinical Trial Registry in December 2027 and can be accessed at http://www.medresman.org.cn.

ChiCTR2500100799.

The WHO Package of Essential Non-communicable Diseases Interventions (WHO PEN) provides a core set of measures to prevent, detect and manage non-communicable diseases (NCDs) in low-resource settings. Many countries have adopted WHO PEN to strengthen primary healthcare, yet there is limited consolidated evidence on what components have been implemented and how WHO PEN has been implemented across different contexts. Understanding both the ‘what’ (disease modules, intervention activities, tools) and the ‘how’ (strategies, approaches, target populations and contextual factors) is crucial to assess the short-term to medium-term effects on health system readiness, provider performance, patient outcomes and long-term population health impact.

This protocol outlines a systematic review that will be updated as new evidence emerges and additional countries adopt or adapt WHO PEN. It represents the first systematic review focused on the implementation of the multifaceted interventions under WHO PEN. Findings will support efforts to sustain and scale up NCD interventions at the primary healthcare level and inform future updates of WHO PEN and related WHO guidance.

We will search PubMed, Web of Science, Cochrane Library and Google Scholar for studies published up to June 2025, supplemented by grey literature and reference checking.

The review will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. Given the complexity, the review will be conducted in two stages. Stage 1 consists of an overview of review, mapping of existing review and evidence and guiding deeper inquiry of stage 2. Stage 2 will conduct a mixed-methods systematic review of the primary studies, forming the main output of this protocol.

Ethics approval is not required. The protocol and findings will be disseminated through peer-reviewed publications, webinars and conferences.

CRD420251064835.

Parenting a preterm infant in the neonatal intensive care units (NICUs) is a profoundly stressful experience, shaped by clinical uncertainty, physical separation and emotional vulnerability. Although stress management strategies—such as counselling, peer support and psychoeducation—are commonly available in NICU settings, little is known about how parents experience these forms of support when they are intended to be culturally sensitive or delivered within diverse cultural contexts. Cultural values, beliefs and practices shape how parents interpret stress and engage with support, highlighting the need to synthesise qualitative evidence on parents’ lived experiences of culturally sensitive stress management strategies during NICU hospitalisation.

This systematic review of qualitative evidence will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology. A comprehensive search will be undertaken across six databases: MEDLINE, CINAHL, Scopus, Web of Science, PsycINFO and Airiti Library. This review will include qualitative studies that examine parents’ experiences, perceptions and meaning-making in relation to stress management strategies that are explicitly culturally sensitive or situated within identifiable cultural contexts in NICU settings. Studies published in English or Chinese between 2014 and 2024 will be eligible. Two reviewers will independently screen studies, assess methodological quality using the JBI critical appraisal checklist and extract data using the standardised JBI data extraction tool. Meta-aggregation will be used to synthesise findings, and the ConQual approach will be applied to assess confidence in the synthesised outputs.

This systematic review of qualitative evidence will synthesise data from previously published studies and does not require formal ethical approval. The review will be conducted and reported in accordance with the JBI methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines for systematic reviews. Findings will be disseminated through publication in a peer-reviewed journal and presentations at national and international conferences on neonatal care, nursing and family-centred healthcare. Target audiences include NICU clinicians, hospital administrators, educators and policymakers interested in integrating culturally responsive approaches into stress management and family support practices.

CRD42022357472.

Antimicrobial resistance (AMR) is one of the most urgent global health threats, responsible for an estimated 4.95 million deaths annually, including 1.27 million directly linked to drug-resistant infections. Nigeria is particularly affected, ranking 19th globally in AMR-related mortality, with an estimated 64 500 attributable and 263 400 associated deaths in 2019. These estimates are likely conservative due to limited surveillance. Economically, AMR could cost Nigeria 5%–7% of its GDP by 2050.

Despite this burden, antibiotic misuse remains widespread, with 42% of adults and over 46% of children under 5 receiving antibiotics without prescriptions. At the primary healthcare (PHC) level, where most antibiotics are prescribed, challenges such as limited diagnostics, inconsistent prescription and poor access to digital tools hinder effective antimicrobial stewardship (AMS).

The primary objective of this study is to assess the knowledge, attitudes and practices regarding antimicrobial resistance (AMR) among PHC prescribers in Imo State, Nigeria. A secondary objective is to explore preliminary indicators of their digital readiness to inform future technological interventions for AMS.

A cross-sectional study using an online questionnaire.

PHC facilities across all 27 local government areas of Imo State, Nigeria.

A purposive sample of 547 facility-based public PHC prescribers included 84% of all facility Officers-in-Charge of health facilities in the state and 16% of other PHC workers who were involved in prescription.

The primary outcome measures were composite scores for knowledge (adequate/inadequate), attitude (positive/negative) and prescribing practice (good/poor), derived from a validated questionnaire. Secondary measures included sources of AMR information and indicators of digital readiness.

While 77.1% demonstrated adequate knowledge, only 32.7% exhibited positive attitudes and 88.5% reported poor prescribing practices. Attitude was the strongest predictor of good practice (OR=17.585, p

These findings underscore a critical gap between knowledge and practice, driven in part by limited access to digital decision-support tools. To address the documented gaps in tool access and training, strengthening digital inclusion through context-adapted e-learning, offline-compatible AMS tools and simplified digital antibiograms is a necessary implication for improving antibiotic stewardship and clinical outcomes at the PHC level.