Invasive arterial blood pressure monitoring is critical for perioperative and critically ill patients, yet traditional radial artery cannulation near the wrist joint is prone to catheter dysfunction (eg, kinking, occlusion) due to positional changes, compromising accuracy and patient safety. This trial hypothesises that modifying the cannulation site to 1.5–2.5 cm proximal to the radial styloid process may enhance catheter stability.

This is a prospective, parallel-group, randomised, controlled, analyst-blinded trial. A total of 486 participants (243 per group) will be enrolled at the Sixth Affiliated Hospital, Sun Yat-sen University. Eligible patients (18–75 years, American Society of Anesthesiologists physical status I–III, requiring elective surgery with radial artery cannulation) will be randomised 1:1 to the modified group (1.5–2.5 cm proximal to the radial styloid process) or the conventional group (traditional site). The primary outcome is the incidence of arterial catheter dysfunction (defined by criteria such as blood sampling difficulty, position-dependent waveform or improved waveform post-square wave test). Secondary outcomes include frequency of catheter dysfunction, damping abnormality rate, first-puncture success rate, number of arterial punctures, arterial cannulation time, complication incidence and blood pressure measurement differences.

This study protocol (V.4.0) was approved by the Ethics Committee of the Sixth Affiliated Hospital of Sun Yat-sen University in Guangzhou, China on 2 September 2025. The first participant was recruited on 15 September 2025, with an estimated completion date of 31 December 2025. Informed consent will be obtained from all participants. Findings will be published in peer-reviewed journals.

NCT06566456.

To describe prescription patterns, dosing and persistence of guideline-directed medical therapy (GDMT) among patients with heart failure with reduced ejection fraction in Singapore, and to identify factors associated with the use of quadruple therapy (ACE inhibitor (ACEi)/angiotensin II receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI), β-blocker, mineralocorticoid receptor antagonist (MRA) and sodium-glucose cotransporter-2 (SGLT2) inhibitor).

Retrospective, observational cohort study.

Secondary and tertiary care settings across seven public hospitals in Singapore.

3999 adults hospitalised from 2020 to 2022 with a first heart failure-related admission and left ventricular ejection fraction ≤40%. Patients with absolute contraindications to specific GDMT classes were excluded from eligibility calculations.

Primary outcomes were the proportions of eligible patients prescribed each GDMT class and quadruple therapy at discharge. Secondary outcomes were 6-month prescription patterns, dose attainment and predictors of quadruple therapy use.

Among eligible patients, 80%–99% met criteria for each GDMT drug class, yet only 29% received quadruple therapy at discharge in 2022. Prescription rates for ACEi/ARB/ARNI (67%), beta-blockers (89%), MRAs (40%), and SGLT2 inhibitors (46%) remained suboptimal despite high eligibility. At discharge, over 90% of patients on ACEi/ARB/ARNI and beta-blockers received ≤50% of target doses. By 6 months, prescription rates declined by 16% for ACEi/ARB/ARNI, 26% for beta-blockers and 7% for MRAs, while SGLT2 inhibitor use increased. Older age (OR 0.97, 95% CI 0.96 to 0.98) and chronic kidney disease stage 3a–4 (OR 0.65 to 0.04) were associated with lower odds of receiving quadruple therapy, while significant institutional variation was observed.

Despite high eligibility, uptake and optimisation of GDMT remain poor in Singapore, with substantial treatment gaps driven by underprescription, inadequate dosing and discontinuation. Interventions targeting clinician awareness, postdischarge support and institutional practice variation may improve adherence to guideline-recommended therapy.

To systematically compare the effects of various antithrombotic strategies on prespecified outcomes including 28-day all-cause mortality (primary outcome), major thrombotic events and major bleeding events (secondary outcomes) in adult COVID-19 patients.

Systematic review and Bayesian network meta-analysis (NMA).

PubMed, Web of Science, Embase, Cochrane Library and ClinicalTrials.gov up to February 2024.

We included randomised controlled trials (RCTs; published in English) comparing different antithrombotic strategies (eg, anticoagulants, antiplatelet (AP) agents, fibrinolytics or combinations) in adults (aged≥18 years) with laboratory-confirmed SARS-CoV-2 infection. Eligible trials had at least one active antithrombotic arm versus another strategy or standard care.

Two reviewers independently extracted data using a standardised form; disagreements were resolved by consensus or third-party adjudication. Bayesian NMA was performed using Markov chain Monte Carlo methods with random/fixed effects models selected by the deviance information criterion. The risk of bias (RoB) was assessed using the Cochrane Collaboration’s tool. The confidence in NMA framework was used to assess the quality of evidence.

35 RCTs that randomly assigned 39 949 participants were included in the main analysis. Primary outcome: evidence of low to moderate certainty suggested that, compared with standard of care (SoC), both prophylactic-dose anticoagulation (PA) (risk ratio (RR) 0.71, 95% credible interval (CrI) 0.44 to 0.99) and therapeutic-dose anticoagulation (TA; RR 0.65, 95% CrI 0.38 to 0.94) reduced the 28-day all-cause mortality. Secondary outcomes: TA (RR 0.19, 95% CrI 0.09 to 0.31), TA+AP (RR 0.27, 95% CrI 0.05 to 0.95), PA (RR 0.33, 95% CrI 0.18 to 0.53) and AP+PA (RR 0.52, 95% CrI 0.25 to 0.94) were effective in reducing major thrombotic events. AP was associated with an increased risk of major bleeding events (RR 2.27, 95% CrI 1.01 to 5.07). Subgroup analyses by hospitalisation status showed that PA significantly reduced 28-day mortality versus SoC (RR 0.52, 95% CrI 0.26 to 0.90) for non-hospitalised patients, whereas no strategies showed significant benefit in hospitalised patients. Subgroup analysis based on severity of hospitalised patients indicated that TA was more favourable than PA in decreasing the 28-day mortality in non-critically ill patients (fixed-effect model: RR 0.75, 95% CI 0.61 to 0.91; random-effect model: RR 0.71, 95% CI 0.48 to 1.05), but for critically ill patients, all antithrombotic strategies showed no significant difference.

Our NMA indicates that both PA and TA reduced the 28-day all-cause mortality of adult COVID-19 patients. However, subgroup analyses revealed substantial heterogeneity, and the benefit may differ across hospitalisation status and disease severity.

CRD42022355213.