Cardiogenic shock (CS) is a complex syndrome characterised by primary cardiac dysfunction. Despite advances in therapeutic options such as mechanical cardiac support, it remains associated with high mortality. Although previous registries have described heterogeneous populations and outcomes across different centres, contemporary real-world data on management practices remain limited. This gap is particularly evident in low- and middle-income countries, where there is no robust registry that clearly defines the current state of CS management. Therefore, a multicentre registry is needed to better characterise current practices and outcomes. Our study aims to gain insight into current therapeutic trends in Mexico, a low- to middle-income country with a significant cardiovascular disease burden.

The Mexican Registry of Cardiogenic Shock is a quality initiative that aims to identify therapeutic trends, demographic characteristics and clinical presentations. It also aims to evaluate outcomes, including mortality and cognitive function at in-hospital and 1-year follow-ups, and to identify areas for improvement in the care process across the broad spectrum of CS.

Ethical approval for this multicentre study was obtained from the local research ethics committees of all participating institutions. The study results will be disseminated to all participating institutions in the form of summary reports and presentations on completion of the analysis.

While health services leaders rely heavily on information gathered via environmental scans (ESs) to guide strategic decision-making, formal guidance on how to conduct these scans is notably absent. The purpose of this study was to determine the level of agreement on essential components of a definition and a methodological framework for ESs. The goals were to (1) advance our working definition to a concept definition for ESs and (2) develop a methodological framework to guide health service researchers conducting ESs.

We used a real-time, modified Delphi survey in a virtual platform setting to seek perspectives on statements related to ESs from individuals who were recruited based on having verifiable experience designing or conducting ESs in health services delivery research. Surveylet, an online software, was used to facilitate asynchronous data collection and to determine the level of agreement on the statements with an a priori threshold of 75% set for agreement on each statement.

21 panellists provided opinions on 59 statements related to a proposed ES definition and on 69 statements specific to components of a methodological framework for ESs.

Panellists from four countries participated in the survey representing 2 to ≥11 years of experience with ESs and having completed 1 to ≥7 ESs. Agreement was achieved in 28 of the 59 statements related to the ES definition and for 51 of 69 statements related to a methodological framework.

The agreement on many elements deemed essential for a definition of ES support development of a proposed concept definition of ES in health service delivery research. As well, the agreement on components deemed necessary for a methodological framework will help in future development of such a framework to guide stakeholders in the planning and implementation of ESs. These results provide a starting point for a common understanding of ESs in the field of health services delivery research.

Musculoskeletal (MSK) conditions account for up to one-third of general practice consultations and over one-fifth of emergency department attendances in the UK. Postpandemic, the elective orthopaedic surgery backlog remains one of the most substantial across surgical specialties. Despite this burden, undergraduate exposure to trauma and orthopaedics (T&O) remains limited and inconsistent. Most UK medical students receive only 2–3 weeks of T&O teaching, with up to 40% of foundation doctors feeling underprepared to manage MSK conditions. The Evaluation of Trauma and Orthopaedic Teaching in Medical Schools Nationally (TENDON Study) aims to evaluate the current state of undergraduate T&O education in UK medical schools from both student and educator perspectives.

This national, prospective, cross-sectional survey will be conducted between 25 July and 27 October 2025. A dual-instrument electronic survey was developed through Qualtrics, informed by the British Orthopaedic Association (BOA) Undergraduate Curriculum and UK Medical Licensing Assessment content map. Participants will include medical students (Years 1–6), foundation doctors and orthopaedic educators recruited through British Orthopaedic Medical Students Association and BOA networks, and designated school representatives. Survey domains include curriculum coverage, teaching methods, clinical exposure and self-reported competence. Quantitative data will be analysed using descriptive and inferential statistics; qualitative data will undergo thematic analysis. Reporting will follow the Checklist for Reporting Of Survey Studies framework, with relevant elements drawn from the Checklist for Reporting Results of Internet E-Surveys checklist.

Ethical approval was obtained from the Human Biology Research Ethics Committee, University of Cambridge. Findings will be disseminated via peer-reviewed publication, conference presentations and summary reports to curriculum leads and relevant educational bodies.

The Shoulder Instability Registry (SIR) was established in 2019 to systematically capture and monitor outcomes following surgical treatment of shoulder instability (SI). The aim of this cohort profile is to describe the purpose, design, data structure and baseline characteristics of the SIR, and to outline how the registry supports longitudinal assessment of safety, functional recovery, quality of life and patient-reported outcomes after surgical treatment of SI.

The registry includes all patients treated surgically for SI. Data collection includes medical history of instability, surgical techniques and intraoperative findings. Clinical assessments include range of motion, instability-specific tests, hyperlaxity signs, Constant Score, subjective shoulder value and SI-specific scores such as the ROWE Score and the Western Ontario Shoulder Instability Index. Radiological evaluations included initial and follow-up imaging via X-rays and CT to assess bony lesions and SI-related arthropathy, as well as MRI for soft tissue injuries. Data are documented preoperatively, at 6 months and at 24 months postoperatively. Although the SIR is an observational cohort rather than a randomised clinical trial, treatment effectiveness is evaluated through longitudinal changes in validated patient-reported outcomes, clinical performance measures and imaging findings.

Between January 2019 and December 2024, 668 patients have been registered (mean age 31 years, 82% men, mean body mass index of 25). According to the American Association of Anesthesiology (ASA) Classification, 66% of patients were classified as ASA I, 33% as ASA II and only 1% as ASA III. 69% of admissions were due to accidents and 31% due to illness. Mean surgery duration was 75 min, and the median hospital stay was 2 days. 38% of patients were insured privately and had general insurance in 62%. 85% of cases were treated arthroscopically, and 15% were treated openly. Baseline clinical scores showed a mean Constant Score of 77 points, mean subjective shoulder value of 49%, mean ROWE Score of 46 points and mean Western Ontario Shoulder Instability Index of 53. Based on Gerber’s classification, 68% of cases were type B2, 29% B3, 2% B5 and fewer than 2% were classified as B4 or B1. 85% of cases suffered from anterior instability, while only 13% experienced posterior instability, the remaining 2% showed multidirectional instability. Among posterior cases, Moroder’s classification identified 58% as type B2, 19% as A2, 7% as A1, 6% as B1, 6% as C1 and 4% as C2. Regarding osteochondral lesions, 20% showed none, 31% showed a glenoid defect, 54% showed a Hill-Sachs lesion and 13% showed a cartilage defect. Scheibel’s classification identified glenoid defects as type 3a in 38% of cases, type 2 in 24%, type 1a in 13% of cases, type 3b in 11%, type 1b in 8% and type 1c in 5% of cases. Positive Gagey and Walch signs were observed in 29% and 27% of cases, respectively. Dislocations presented as primary events in 24% of cases, while 76% were recurrent. Surgical interventions included 459 (70%) Bankart repairs, 6 Bankart plus repairs (

We will continue prospectively enrolling and monitoring patients that receive surgical treatment of SI. There are no current plans to halt the data collection in the near future, thereby consistently increasing the number of patients in the registry. A larger availability of data will additionally allow us to apply machine learning modelling and develop risk-prediction tools with the goal of aiding surgical decision making.

Prolonged glucocorticoid (GC) use is associated with significant morbidity and mortality, including the development of GC induced adrenal insufficiency. Recent guidance from the European Society of Endocrinology and Endocrine Society provides a framework for tapering GCs. However, there is limited understanding of current practice across endocrine and other medical specialties, including barriers and challenges to GC weaning. This study aimed to establish how GCs are weaned in patients across endocrine and non-endocrine specialists.

Anonymous online surveys were disseminated to all members of the Society for Endocrinology and all members of the Association of Southeast Asian Nations Federation of Endocrine Societies and the Endocrine and Metabolic Society of Singapore. Non-endocrine specialists were surveyed in the UK and in Singapore.

A total of 306 (258 endocrine specialists and 48 non-endocrine specialists) responded to the survey. Approaches to discontinuing prednisolone were heterogeneous. Among endocrine respondents, only 78% would fully wean the prednisolone, with 50.4% switching to hydrocortisone to wean and 12.6% favouring long-term GC replacement without further investigations. Among the non-endocrine respondents, 16.7% would stop prednisolone abruptly and 10.4% would refer to endocrinology to supervise weaning. The most common barrier to weaning GCs reported by both endocrine and non-endocrine specialists was relapse of the underlying condition (55.9% and 70.8%, respectively).

Relapse of the underlying condition is common, and endocrinology input may not be appropriate when this occurs. There remains a need to develop an evidence-based approach for safe and effective GC weaning and hypothalamic–pituitary–adrenal axis assessment.

To explore barriers and facilitators to a good death in patients with respiratory disease when advanced respiratory support, including non-invasive ventilation (NIV) and continuous positive airway pressure (CPAP), is used. Specifically, we examined healthcare professionals’ perspectives on what constitutes a good death in this context, how treatment failure is recognised, how decisions to continue or withdraw therapy are made, and the impact of providing this care on staff.

Qualitative study using semistructured interviews and reflexive thematic analysis.

Secondary care services in a large UK National Health Service Trust, including acute medicine, general medicine, respiratory medicine and palliative care.

25 healthcare professionals (19 female, 6 male) from multidisciplinary backgrounds, including doctors, nurses and physiotherapists. Participants self-identified as experienced in the provision of NIV/CPAP at the end of life. Staff working primarily in intensive care units were excluded.

None.

Not applicable.

Healthcare professionals described the complexity of caring for patients dying while receiving or recently withdrawn from NIV/CPAP. Five interrelated themes were identified: beliefs around dying well, symptom management during active treatment, recognition of treatment failure, negotiated decision-making and the process of withdrawal. Staff reported tensions between providing active treatment and ensuring comfort, inconsistent practices regarding symptom control and withdrawal, and conflicts within multidisciplinary teams. Nurses highlighted hidden psychological and relational labour in supporting patients, while doctors often described delays in decision-making to align families with treatment withdrawal.

Caring for patients using NIV/CPAP at the end of life presents ethical, clinical and emotional challenges for staff, patients and families. Variation in practices and perspectives highlights the need for structured training, interdisciplinary approaches and greater recognition of the often hidden relational and emotional labour involved in this work, particularly among nursing colleagues. Further research should evaluate strategies to support consistent and compassionate withdrawal practices.

To develop a context-specific health technology assessment (HTA) framework tailored to the healthcare needs and system of Iran, to improve evidence-based decision-making, optimise resource allocation and support progress towards universal health coverage.

A mixed-methods Delphi consensus study conducted using a three-phase, sequential approach: document review, qualitative focus group discussions and Delphi consensus rounds. The study reporting follows the Accurate Consensus Reporting Document guideline to ensure transparent reporting of consensus methods.

A national-level study conducted in Iran’s healthcare system between January 2023 and March 2024, including perspectives from public and academic institutions, policy bodies and patient organisations.

The study involved 18 purposively selected stakeholders in three focus group discussions, including policymakers, healthcare professionals, researchers and patient representatives. Subsequently, 20 HTA experts participated in three iterative Delphi rounds to refine and reach consensus on the framework components.

Identification of core components and operational steps required to develop and implement a comprehensive HTA framework in Iran.

The final HTA framework includes nine core components: (1) establishing a national HTA body; (2) engaging stakeholders; (3) building capacity through training and research; (4) developing standard HTA methodologies; (5) implementing prioritisation and evaluation processes; (6) ensuring sustainable funding; (7) enhancing transparency and accountability; (8) promoting continuous improvement and (9) fostering innovation. Detailed operational steps and micro-activities were developed for each component. The framework achieved an 84% consensus among Delphi panellists, indicating strong agreement on its content and applicability.

This tailored HTA framework provides a structured roadmap to institutionalise evidence-based decision-making in Iran’s healthcare system. Its implementation can strengthen the efficiency, equity and sustainability of healthcare planning and policy. Pilot testing is recommended to assess feasibility and scalability, with potential to serve as a model for other low-income and middle-income countries.

To estimate the treatment outcomes among individuals treated for hypertension in the public sector in 89 districts across 15 states in India and to identify the risk factors for uncontrolled blood pressure (BP).

An analysis of a cohort of people with hypertension from 2018 to 2022 from public sector health facilities.

All India Hypertension Control Initiative (IHCI) implementing districts using digital information systems across 15 states of India, namely Andhra Pradesh, Bihar, Goa, Gujarat, Jharkhand, Karnataka, Maharashtra, Nagaland, Puducherry, Punjab, Rajasthan, Sikkim, Tamil Nadu, Uttar Pradesh and West Bengal.

Individuals aged 30 years or older, who were diagnosed with hypertension or on medication at the time of registration between 1 January 2018 and 31 December 2021 were included in the study.

Treatment outcomes were controlled BP, uncontrolled BP and missed visits in the reporting quarter (1 January 2022–31 March 2022). We analysed the risk factors for uncontrolled BP.

Out of 1, 235, 453 hypertensive individuals enrolled in the IHCI project across 15 states, 1, 046, 512 remained under care, with 44% BP control. The control varied from 26% to 57% in various types of facilities. The states of Maharashtra, Punjab and Rajasthan had above 50% control, while Nagaland, Jharkhand and Bihar had below 25%. BP control declined from 68% when defined using a single recent reading to 52% when defined using the two-visit readings. Younger individuals (

We documented the implementation of IHCI strategies at scale and measured treatment outcomes in a large cohort. Overall, BP control improved with variations across states. We need focused strategies to improve control in higher-level facilities, among males and people with diabetes. Using two BP readings may support consistent treatment adherence.

Military personnel are a unique population with heightened vulnerability to sexually transmitted infections (STIs), often exhibiting higher prevalence rates than civilians due to demographic, environmental and occupational factors. These vulnerabilities underscore the need for global prevalence estimates to guide effective, evidence-based interventions. This study aims to quantify the global burden of STIs among military personnel, providing a comprehensive and up-to-date assessment.

This systematic review will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Guidelines (2020). Using the CoCoPop (Condition, Context, and Population) framework, a comprehensive search strategy will be conducted in MEDLINE, Embase, Global Health and Scopus to retrieve peer-reviewed records published between January 2010 and June 2025. Eligible studies will report numerical STI prevalence data among military personnel. Studies with insufficient information to calculate prevalence or those relying on self-reported STI data will be excluded. Data extraction will include study details, military descriptors, STI prevalence and diagnostic methods. Risk of bias will be assessed using the Joanna Briggs Institute critical assessment tool for prevalence and incidence studies. Prevalence estimates with 95% CIs will be reported for each STI and, where appropriate, pooled for curable STIs. Subgroup analyses will stratify prevalence by geographic region, service status, deployment status and socioeconomic factors. Heterogeneity will be evaluated within predefined subgroups using the I² statistic. Data will be presented in comprehensive tables and visualised with graphical tools, including forest plots for subgroup analyses and pooled estimates.

Ethical approval is not required for this review. The results will be disseminated through a peer-reviewed publication and conference presentations.

CRD42023472113.

Genitourinary syndrome of menopause (GSM) is a prevalent condition among breast cancer survivors, often exacerbated by oncological treatments. Hormonal therapies are typically contraindicated in this population, necessitating effective non-hormonal interventions.

This randomised controlled trial aims to compare the effectiveness and cost-effectiveness of multimodal pelvic floor physiotherapy—comprising pelvic floor muscle training, non-ablative radiofrequency, therapeutic pelvic health education and the use of vaginal moisturisers—versus fractional CO₂ laser therapy combined with vaginal moisturisers in alleviating GSM symptoms in breast cancer survivors. Participants will be randomly assigned to one of the two intervention groups. Primary outcomes include measures of sexual function (assessed by the Female Sexual Function Index), subjective pelvic perineal pain intensity (measured with a 100 mm Visual Analogue Scale) and health-related quality of life (assessed by the Functional Assessment of Cancer Therapy-Breast), assessed at baseline, post-intervention and at 3, 6 and 12 months of follow-up. Statistical analyses will be conducted to evaluate the clinical efficacy and cost-effectiveness of the interventions.

The study protocol has been approved by the Ethics and Health Research Committee of the University of Alcalá (Reference: CEIP/2024/1/012). All participants will provide informed consent prior to inclusion in the study. Findings will be disseminated through peer-reviewed journals and conference presentations, and by engaging with patient associations and survivor groups through tailored materials.

NCT06721936.

The aim of this work was to understand carer involvement in transitions of care from hospital to home in relation to medicines management. Specifically, via a realist review, to describe how carers provide support, to what extent do they support patients and under what circumstances are carers able to provide support towards patient care in relation to medicines management.

A realist review was conducted in line with a published protocol and as registered via PROSPERO (CRD42021262827). An initial programme theory (PT) was developed before searches of three databases, PubMed, CINHAL and EMBASE, were conducted in accordance with eligibility criteria. Data were extracted from eligible studies and synthesised into realist causal explanations in the form of Context-Mechanism-Outcome-Configurations (CMOCs) and the PT was refined. Throughout the review, a patient and PPIE group (n≥5) was involved, meeting five times, to inform the research focus and develop CMOCs and the PT by providing feedback and ensuring they capture the carer experience.

Following title and abstract screening of 4835 papers, the final number of included articles was 208. The evidence synthesis identified 31 CMOCs which were categorised into three themes: (1) continuum of support; (2) understanding the carers’ priorities, role and responsibilities through shared decision-making (SDM) and (3) access to appropriate materials, resources and support information. These themes were formed into an updated PT with accompanying narrative that explained the transition from hospital to home involving carers in medicines management and identified possible areas for future intervention development.

This review provides insights and recommendations on how carers can be better supported when managing medicines when patients are discharged from hospital. Carers need a continuum of support throughout and following the transition. Healthcare professionals can support this by understanding the carer’s priorities, role and responsibilities through SDM during the hospital stay. Consequently, carers can then be offered access to appropriate materials, resources and support information which allows them to provide better care relating to medicines in the long term.

Patients with fragility fractures are two times as likely to suffer future fractures as their peers who have not suffered a fracture. In addition, 40% of those who suffer fragility fractures do not recover their level of functioning in terms of activities of daily living after 1 year. The present study aims to verify the hypothesis that a semipersonalised home-based exercise intervention may improve patients’ independence and reduce the number of hospital admissions compared with usual care for a population that suffers fragility fractures.

This parallel-arm single-blinded randomised-controlled trial will take place at the University of Cordoba (Spain) between September 2022 and September 2024. Patients aged >50 years old who have undergone surgery for a fragility hip fracture and who were prefracture independent (Barthel index (BI)>60) will be invited to participate. Patients will be excluded if they present a different type of fracture, mild or greater cognitive impairment or contraindication to exercise training. Patients will then be randomised into exercise or usual care group. The former will receive a daily walking appointment (number of steps to be completed inside home, interspersed with sit-to-stand movements) with the total volume increasing weekly. The latter will receive the usual care. The outcomes, collected at baseline, at the end of training (3 months) and at follow-up (6 months) by blinded operators will include the BI and number of readmissions (primary outcomes) and quality of life, exercise capacity, strength, cognitive status, bone mineral density and laboratory biomarkers (secondary outcomes). Variables related to quality of life, cognitive status, laboratory markers and densitometry will also be analysed.

The research ethics committee of the province of Cordoba approved the project (number 326; date 28 July 2021). Patients who meet the eligibility criteria will receive a patient information document and the consent form and will be encouraged to ask any questions. The proposed research respects the fundamental principles of the Declaration of Helsinki, the Council of Europe Declaration on Human Rights and Biomedicine, the UNESCO Universal Declaration on the Human Genome and Human Rights, and the Oviedo Council on Human Rights and Biomedicine. The data obtained in this study will be confidential. They will be treated by the Organic Law 3/2018, of 5 December, on the Protection of Personal Data and Guarantee of Digital Rights, keeping it strictly confidential and not accessible to unauthorised third parties, and the Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on Data Protection (RGPD). Written informed consent will be obtained from all the participants. The study’s results will be published in peer-reviewed journals and presented at scientific congresses worldwide. The results will also be disseminated through patient advocacy group newsletters and social media platforms. Patient partners will help select the appropriate channels and develop plain-language summaries tailored to their communities’ needs.

ClinicalTrials.gov ID: NCT04934358 (registration date: 14 June 2021).

Observational data are increasingly used to study and draw causal inferences about the effects of treatments. Target trial emulation (TTE) is a framework for mitigating biases in causal investigations through specification of an observational study, targeting a specific causal research question, based on a real or hypothetical randomised controlled trial. Investigations into the effects of treatment discontinuation are of growing interest and particularly relevant in cystic fibrosis (CF), where treatment burden is high and new transformative therapies are becoming widespread. We aim to use the TTE framework to investigate the effect of discontinuation of inhaled corticosteroids (ICS) on clinical outcomes in people with CF. Our observational emulation will be based on the CF WISE (Withdrawal of Inhaled Steroids Evaluation) trial (PMID:16556691).

Two study designs proposed for investigating treatment effects using observational data are the prevalent new-user design and the sequential trials design. Each design uses different but related methods to address similar causal questions; however, the comparability between them remains uncertain. We will conduct a population-based cohort study using data from the UK CF Registry between January 2016 and June 2018 and apply these designs. We will specify the target trial protocol for each study design. Estimates for the causal effects of discontinuing ICS will be obtained and compared with those from the CF-WISE trial.

This study has received approval from the UK CF Registry Research Committee for both the research and access to data. Ethical approval has also been granted by the LSHTM Ethics Committee. The UK CF Registry has NHS Research Ethics Committee approval (REC reference: 24/EE/0012). The findings from this project will be submitted to peer-reviewed journals and presented at academic conferences.