Conectar
This study aimed to explore perceptions of the Paediatric Improvement Collaborative’s (PIC’s) Clinical Practice Guidelines (CPGs) among clinicians, with a focus on awareness, frequency of use, applicability and areas for improvement.
Cross-sectional online survey and semi-structured interviews.
Clinicians working in all Australian states and territories. Recruitment was via non-probability convenience sampling. Invitations to participate in the online survey were posted on national- and state-level paediatric organisations, networks and groups. Survey participants could express interest in taking part in a follow-up online interview.
A total of 466 clinicians, including consultants/specialists (46.1%), specialists in training (residents/registrars: 20.4%), nurses (17.8%), allied health professionals (4.7%) and general practitioners (3.6%) participated in the survey. Findings indicated a high level of usage, with two-thirds of participants (63.9%) using the guidelines weekly. Most participants (91.8%) deemed the CPGs highly applicable to their practice settings, and over half (57.9%) had referred to more than 10 different PIC CPGs in the past month. Patterns of use reflected experience, seniority and scope of practice, with utilisation significantly higher among specialists in training, those working in emergency settings and those with less practising experience. Ten clinicians were interviewed to gain deeper insights, reinforcing that PIC CPGs serve multiple purposes, such as to check practice and for self-learning, for teaching more junior staff, and to reinforce treatment decisions with parents and patients. The guidelines were noted as being useful for all members of the multidisciplinary team in providing consistent language and uniform care. Key areas for improvement included enhancing accessibility in time-pressured environments, such as incorporating human factors-based navigation features and standardised layouts, and integrating additional tools and localised referral information.
PIC CPGs are viewed as a source of credible, evidence-based information that was valued across medical, nursing and allied health professionals.
Patient mental state deterioration presents significant challenges in acute hospital settings, affecting outcomes, increasing reliance on restrictive interventions, and placing additional strain on healthcare staff. Despite its prevalence, consensus on best practice remains limited. The De-escalation, Intervention, Early Response Team (DIvERT) is a pilot rapid response system introduced to improve early identification, enable timely interventions, reduce crisis incidents, and support ward staff in caring for patients with mental state deterioration.
A realist evaluation approach was used to test, validate, and refine program theories explaining DIvERT's mechanisms. Data collection included a cross-sectional survey, semi-structured interviews, field observations, a medical record audit, and incident report analysis. Analysis was guided by the Context-Mechanism-Outcome framework to explain DIvERT's effective functioning in responding to patient deterioration.
DIvERT facilitated early intervention through multidisciplinary collaboration, though organisational factors such as staffing constraints, workload pressures, and inconsistent assessment practices influenced effectiveness. Key mechanisms included structured escalation pathways, clinical skills, staff training, and interprofessional collaboration. Challenges included limited after-hours availability, reflecting the constraints of a pilot initiative, underreporting of incidents, and hierarchical decision-making. While causation cannot be directly established, trends indicate DIvERT was associated with fewer Code Grey responses, particularly during initial episodes of mental state deterioration.
This realist evaluation highlights the value of structured escalation pathways, multidisciplinary collaboration, organisational support, and tailored training in managing mental state deterioration. Preliminary trends suggest DIvERT may enable more proactive and timely early intervention, whereas traditional reactive hospital emergency response for aggression (Code Grey) was more often linked to repeat incidents. Workforce constraints and inconsistent assessment limited effective functioning, underscoring the need for strengthened training, integration into workflows, and improved after-hours coverage to support scalability and long-term success.
This study demonstrates that a proactive rapid response model (DIvERT) can strengthen the recognition and management of mental state deterioration in acute hospital settings. By formalising escalation pathways, improving interdisciplinary collaboration, and tailoring training to staff needs, the model supports safer and more timely responses to patient deterioration. Embedding such approaches into organisational workflows has implications for patient safety, staff confidence, and system efficiency.
The study addressed the challenge of inconsistent and reactive responses to patient mental state deterioration, which are often reliant on crisis interventions such as Code Grey. DIvERT facilitated early intervention through structured escalation processes, improved interdisciplinary collaboration, and enhanced staff skills. However, organisational barriers such as workforce constraints, after-hours gaps, and inconsistent use of mental state deterioration assessment tools limited its effective functioning. Findings are directly relevant to clinicians in acute hospital settings (particularly nursing and allied health staff), hospital administrators responsible for patient safety and workforce planning, and policymakers overseeing standards for recognising and responding to acute deterioration. The results highlight where investment in training, structured escalation systems, and organisational support can reduce reliance on restrictive interventions and improve both patient and staff safety.
This evaluation adhered to the Realist And Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) II reporting standards for realist evaluations, as outlined in the EQUATOR Network guidelines.
This study did not include patient or public involvement in its design, conduct, or reporting.
Managing patients' mental state deterioration in acute hospital settings is a critical challenge, requiring prompt specialised intervention to mitigate adverse outcomes. Current responses vary widely across health systems. Integrating rapid response systems that incorporate mental health expertise offers a promising approach to reduce risks and adverse outcomes.
To evaluate how a response system manages patient mental state deterioration in acute hospital settings, focusing on the mechanisms driving system effectiveness, for whom it works and under what circumstances, using a realist-informed theory-testing approach with field observation.
We conducted non-participant field observations in one trauma and one surgical unit over 4 months to examine the contexts, mechanisms and outcomes shaping a mental state deterioration response system. Observations captured multidisciplinary interactions, escalation processes and decision-making. Structured field notes were thematically coded using a realist framework to refine program theories and identify key factors influencing timely intervention.
Twenty responses were observed, most in the trauma unit. The system worked best when bedside nurses escalated early signs of deterioration, prompting timely intervention. Multidisciplinary collaboration involving nurse unit managers, liaison psychiatry, doctors and allied health professionals activated mechanisms of integrated assessment and coordinated care, enabling both medical and mental health needs to be addressed. Competing medical acuity demands at times reduced system availability. Teleconferencing supported specialist input when in-person attendance was not possible, ensuring person-centred care.
System functioning depended on early risk communication by bedside nurses and proactive multidisciplinary collaboration. Organisational support and staff training are essential to address operational challenges. Findings provide evidence for strengthening response systems to deliver timely, comprehensive interventions that improve physical and mental health outcomes.
DIvERT (De-escalation, Intervention, Early, Response, Team) is a proactive rapid response model of care piloted to improve the management and outcomes of patients experiencing mental state deterioration in acute hospital settings. The model achieves this through structured escalation pathways, proactive interventions and coordinated multidisciplinary collaboration to integrate medical and mental health care. Strengthening organisational support and staff training further reduces reliance on restrictive practices and promotes safer, person-centred care.
What problem did the study address? Acute hospitals face persistent challenges in responding to patient mental state deterioration alongside medical acuity, with existing rapid response systems often insufficiently integrated with mental health expertise. What were the main findings? Field observations of the DIvERT model demonstrated that proactive integration of mental health expertise, supported by organisational investment in training, clear escalation protocols and multidisciplinary collaboration, enabled earlier intervention and more coordinated responses. Where and on whom will the research have an impact? These findings have implications for acute hospital services, informing system-level improvements to rapid response models that support patient safety, reduce adverse events and improve staff wellbeing.
This study adhered to the relevant EQUATOR guidelines. Specifically, reporting followed the RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards II) reporting standards, which provide criteria for transparent and rigorous reporting of realist evaluation methodology.
No patient or public contribution.
Dual immune checkpoint inhibitor (ICI) therapy might improve the outcome of adult patients with untreated metastatic BRAF-mutant melanoma. We synthesised the evidence of its effect on overall survival (OS) and adverse events.
Systematic review and meta-analysis using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
MEDLINE and the Cochrane Library were searched through 15 May 2025.
We included randomised controlled trials (RCTs) assessing the effects of first-line dual ICI therapy compared with first-line dual targeted therapy (TT) on adult patients with metastatic BRAF-mutant melanoma. We considered articles in English or German language.
Two independent reviewers extracted data and assessed risk of bias. Time-to-event data were pooled using the generic inverse-variance method and expressed as HRs with 95% CIs. Dichotomous data were pooled using the Mantel-Haenszel method and expressed as risk ratios (RRs). Heterogeneity was assessed (Cochran Q statistic) and quantified (I2 statistic). GRADE assessed the certainty of the evidence.
We identified two RCTs (305 participants) with parallel assignment and intention-to-treat analyses. The primary beneficial outcome was overall survival (OS), and OS favoured the first-line ICI group: HR 0.66 (95% CI 0.49 to 0.90) I2=0%. In contrast, the primary adverse outcome was treatment-related adverse events of grade 3 or higher (TRAEs), and TRAE favoured the first-line TT group: RR 1.18 (95% CI 1.01 to 1.39) I2=0%. The certainty of the evidence was graded as moderate.
The evidence base is compatible with a favourable effect of first-line nivolumab plus ipilimumab for adults with untreated metastatic BRAF-mutant melanoma on survival and an unfavourable effect on toxicity when compared with first-line TT. Future RCTs could provide more data on therapy failure and quality of life.
CRD420251006128.
by Oumarou I. Wone Adama, Iman Frédéric Youa, Alexandra Bitty-Anderson, Arnold Junior Sadio, Rogatien Comlan Atoun, Yao Rodion Konu, Hezouwe Tchade, Martin Kouame Tchankoni, Kokou Herbert Gounon, Kparakate Bouboune Kota-Mamah, Abissouwessim Egbare Tchade, Godonou Amivi Mawussi, Fiali Ayawa Lack, Fifonsi Adjidossi Gbeasor-Komlavi, Anoumou Claver Dagnra, Didier Koumavi Ekouevi
IntroductionIn Togo, the syndromic approach is used for the diagnosis and management of sexually transmitted infections (STIs). The aim of this study was to evaluate the syndromic approach for diagnosis of STIs among female sex workers (FSW) in Lomé, Togo.
MethodsA cross-sectional study was carried out from September to October 2023 among FSW in Lomé (Togo). FSW aged 18 years and above were included. A gynecological examination was performed for syndromic diagnosis, and the Xpert® CT/NG were used to screen vaginal swabs for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). The performance (predictive values) of the syndromic approach to STI diagnosis was evaluated using the Xpert® CT/NG test as the gold standard.
ResultsA total of 357 FSW were recruited. The median age of FSW was 32 years (IQR: [26–40 years]) and 8.2% had attained a higher level of education. The prevalence of syndromic STI among FSW was 33.3%. Vaginal swabs were positive for CT (8.4%) and NG (8.7%), with a prevalence of bacterial STIs (CT and/or NG) of 14.3%. The syndromic approach to STI diagnosis demonstrated a positive predictive value of 24.3%.
ConclusionThe prevalence of STIs is relatively high among FSW in Lomé. According to this study, the diagnosis of STIs using the syndromic approach has limited relevance. National STI screening and management policies urgently need to be rethought, incorporating recent technological advances.
Cellulitis is a common bacterial skin infection causing significant pain, swelling and impact on daily activities, frequently leading to emergency department presentations and hospital admissions. While antibiotics are the mainstay of treatment, they do not directly address inflammation, often resulting in persisting or worsening symptoms in the initial days. Corticosteroids, with their potent anti-inflammatory effects, have shown benefit in other acute infections but are not currently standard care for patients with cellulitis. This trial aims to determine if adjunctive oral dexamethasone can reduce pain and improve outcomes in adults with cellulitis presenting to UK urgent secondary care settings.
This is a pragmatic, multicentre, double-blind, placebo-controlled, randomised, parallel group, phase 3 superiority trial, with an internal pilot and parallel health economic evaluation. Adult patients (≥16 years) with a clinical diagnosis of cellulitis (at any body site except the orbit) presenting to urgent secondary care will be screened for eligibility. 450 participants will be randomised (1:1) to receive either two 8 mg doses of oral dexamethasone or matched placebo, administered approximately 24 hours apart, in addition to standard antibiotic therapy. The primary outcome is total pain experienced over the first 3 days postrandomisation, calculated using the standardised area under the curve from pain scores (Numerical Rating Scale 0–10) across up to seven timepoints. Secondary outcomes include health-related quality of life (EuroQol 5 Dimension 5 Level), patient global impression of improvement, analgesia and antibiotic usage, hospital (re)admissions, complications, unscheduled healthcare use, cellulitis recurrence and cost-effectiveness at 90 days. The primary estimand will apply a treatment policy approach to intercurrent events.
The trial has received ethical approval from South Central—Oxford B Research Ethics Committee (reference: 24/SC/0289) and will be conducted in compliance with Good Clinical Practice and applicable regulations. Informed consent will be obtained from all participants. A model consent form can be seen in . Findings will be disseminated through peer-reviewed publications and conference presentations, and to patient groups and relevant clinical guideline committees.
To identify and understand the different approaches to local consensus discussions that have been used to implement perioperative pathways for common elective surgeries.
Systematic review.
Five databases (MEDLINE, CINAHL, EMBASE, Web of Science and the Cochrane Library) were searched electronically for literature published between 1 January 2000 and 6 April 2023.
Two reviewers independently screened studies for inclusion and assessed quality. Data were extracted using a structured extraction tool. A narrative synthesis was undertaken to identify and categorise the core elements of local consensus discussions reported. Data were synthesised into process models for undertaking local consensus discussions.
The initial search returned 1159 articles after duplicates were removed. Following title and abstract screening, 135 articles underwent full-text review. A total of 63 articles met the inclusion criteria. Reporting of local consensus discussions varied substantially across the included studies. Four elements were consistently reported, which together define a structured process for undertaking local consensus discussions.
Local consensus discussions are a common implementation strategy used to reduce unwarranted clinical variation in surgical care. Several models for undertaking local consensus discussions and their implementation are presented.
Advancing our understanding of consensus building processes in perioperative pathway development could be significantly improved by refining reporting standards to include criteria for achieving consensus and assessing implementation fidelity, alongside advocating for a systematic approach to employing consensus discussions in hospitals.
These findings contribute to recognised gaps in the literature, including how decisions are commonly made in the design and implementation of perioperative pathways, furthering our understanding of the meaning of consensus processes that can be used by clinicians undertaking improvement initiatives.
This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.
No patient or public contribution.
Trial Registration: CRD42023413817
Patients receiving haemodialysis are at very high risk of fragility fracture, yet there are no proven treatments for fracture prevention. We will advance a pilot study on the feasibility of a large, pragmatic, randomised controlled trial (RCT) of denosumab for fragility fracture prevention in haemodialysis.
PRevEnting FracturEs in REnal Disease-1 is a pragmatic, open-label, pilot study of an RCT of a denosumab care pathway embedded in routine care haemodialysis centres.
We will recruit at least 60 participants at high risk of fracture from at least 6 haemodialysis centres in Ontario, Canada. They must be aged 40 years or older, have access to provincial drug coverage, have appropriate baseline calcium and parathyroid hormone levels and be deemed suitable for denosumab by their kidney care provider. Participants will be randomised 1:1 to denosumab (with supports to mitigate hypocalcaemia) versus usual care using block randomisation by a central statistician (computer-generated sequence). Primary outcomes include recruitment feasibility and adherence. Secondary outcomes include safety (hypocalcaemia) and participant satisfaction with our protocol and processes. Study investigators and data analysts will be blind to treatment allocation.
We will present results descriptively. The trial was approved by Clinical Trials Ontario and local research ethics boards across study sites.
Primary and secondary outcomes will be published on trial completion.
This pilot will inform the feasibility of conducting a large-scale, efficiently run, pragmatic RCT to test whether a denosumab care pathway safely reduces the risk of fragility fracture in patients receiving haemodialysis. Results have the potential to transform fracture care in real-world patients with kidney and metabolic bone disease.
To explore experience and prevalence of vulval lichen sclerosus (VLS) diagnosis in general practice using an anonymous patient survey.
Quantitative descriptive cross-sectional survey informed by previous qualitative interviews and developed with patient representatives, sent to people recorded in general practice as having a VLS diagnosis.
General practices (n=24) in the UK (West Midlands).
n=177 respondents.
One in five respondents reported that they had been misdiagnosed, and about a third reported that it was a struggle to get treatment. Only one third said they received regular check-ups, recommended in clinical guidelines. One-fifth reported they were not being treated with topical corticosteroids, the main first-line treatment for VLS. Less than one in 10 were members of a support group, and around four in 10 felt they had to hide their condition and did not speak to anyone else about it. Survey respondents prioritised improving education and awareness among healthcare professionals (HCPs).
General practitioners and other primary care HCPs have a key role in recognising, diagnosing and managing VLS. Improving education and awareness among HCPs was a key priority for this patient group. Patients should be made aware of the need for ongoing treatment and yearly check-ups to prevent or manage disease progression. VLS is a highly stigmatised condition, and appointments with HCPs may be the only opportunity for people to talk about their experience.
Amoxicillin is recommended for children with uncomplicated severe acute malnutrition (SAM). However, some trials have shown no difference in amoxicillin for nutritional recovery in children with SAM compared with placebo. In addition, amoxicillin treatment requires two times per day dosing for 7 days, which may influence adherence. Azithromycin is a broad-spectrum antibiotic that can be provided as a single dose and has reduced mortality in children aged 1–59 months when provided by mass drug administration. The AMOUR trial is designed to assess amoxicillin, azithromycin and placebo as part of outpatient treatment of uncomplicated SAM.
This double-masked randomised controlled trial will enrol 3000 children over 3 years in an individually randomised 1:1:1 allocation to azithromycin, amoxicillin or placebo arms and follow them for 12 months. Children eligible to enrol in the study will be aged 6–59 months and have uncomplicated non-oedematous SAM as defined by weight-for-height Z-score
Ethical approval was obtained from the Institutional Review Board at the University of California, San Francisco (Protocol 23–39411) and the Comité d’Ethique pour la Recherche en Santé in Ouagadougou, Burkina Faso (Protocol 2024-01-08). The results of this study will be disseminated to the Ministry of Health, community stakeholders and via peer-reviewed publications and academic conferences.
Commentary on: Autism intervention meta-analysis of early childhood studies (Project AIM): updated systematic review and secondary analysis - Sandbank et al 2023
Implications for practice and research Nurses may consider advocating for autistic clients by recommending naturalistic developmental behavioural intervention and other early interventions when appropriate and providing multidisciplinary care in collaboration with interventionists. More robust research methods are needed, including randomised controlled trials of early interventions for autism that assess adverse effects to ensure benefits outweigh any risks.
Behaviourists pioneered early intervention for autism in the 1960s using operant learning principles. The intervention was dubbed applied behavioural analysis (ABA). In the 1990s, naturalistic developmental behavioural intervention (NDBI) expanded behaviour intervention to include children as active learners with an emphasis on developmentally appropriate implementation using natural contingencies. Currently, there is a plethora of early intervention options but it is unclear which interventions...
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