Urgent and emergency care (UEC) systems in England face unprecedented pressures, with record accident and emergency attendances, persistent breaches of ambulance response targets and poorer outcomes for time-sensitive conditions. National UEC recovery plans have introduced multiple innovations—such as same-day emergency care, virtual wards and specialty hubs—to manage these pressures and improve patient flow. Rural coastal areas are particularly vulnerable to excessive demand due to higher levels of deprivation, older populations with complex health needs, seasonal surges that generate unpredictable demand and challenges in attracting and retaining staff. Following the Chief Medical Officer’s 2021 Annual Report, funding research and developing bespoke solutions to manage UEC demand and address geographical disparities has been recognised as a national priority. The Elevate study responds to this priority by identifying and evaluating innovative models of UEC in rural coastal communities in England.

The Elevate study is a 30-month, mixed-methods evaluation that comprises three interlinked work packages: (1) National service mapping—outlining provision of innovative models of UEC in rural coastal areas of England. This will be developed through document review and interviews with regional and national service leaders. (2) Quantitative analysis—quasiexperimental and longitudinal approaches will use National Health Service (NHS) England’s Emergency Care Data Set and linked routine NHS datasets to evaluate the impact of UEC models on health and process outcomes. Standard and bespoke metrics will be developed and used to assess performance. (3) Qualitative case studies—up to 12 case studies of UEC models in rural coastal communities. Interviews with patients and staff and non-participant observation will explore how and why different UEC models influence patient experience, clinical outcomes, resource use and the workforce. Findings will be integrated using the Consolidated Framework for Implementation Research to identify components of UEC models that are effective, scalable and sensitive to local context,

Ethical approval for qualitative components was granted by the North of Scotland Research Ethics Committee (25/NS/0099). Dissemination will include peer-reviewed publications, policy briefs, creative media and community engagement activities to ensure findings are communicated inclusively and effectively to policymakers, health and social care practitioners and the public.

Research Registry (researchregistry11126).

Therapy-associated thrombosis remains a challenge in the management of patients with acute lymphoblastic leukaemia (ALL). Thrombosis associated with asparaginase-containing chemotherapy complicates patient management strategies, prompting the need for effective prophylaxis. Assessing the relationship between chemotherapy-induced thrombosis and patient outcomes is crucial for optimising ALL management strategies. The aim of this systematic review is to provide a synthesis on whether the development of thrombosis during asparaginase-containing chemotherapy regimens impacts the overall and event-free survival of patients with ALL.

Data sources: to identify relevant studies, a comprehensive search will be conducted on the major electronic databases, including MEDLINE (PubMed), Web of Science (Clarivate), Academic Search Complete (EBSCOhost), clinicaltrial.gov and the Cochrane Central Register of Controlled Trials from inception to 30 January 2026.

Inclusion criteria for selecting studies: randomised and non-randomised clinical studies evaluating the impact of asparaginase-containing chemotherapy-associated thrombosis on survival outcomes in patients with ALL will be included. Two reviewers will independently screen the retrieved studies, extract data and assess study quality using a predefined criteria. A narrative synthesis will be undertaken, and if feasible, meta-analyses will be conducted. A subgroup and sensitivity analysis will be performed to explain the sources of heterogeneity. The quality of cumulative evidence will be assessed using the grading of recommendations assessment, development and evaluation tool. The findings from this systematic review will inform evidence-based clinical guidelines for thrombosis risk assessment and management in patients with ALL, potentially improving treatment outcomes and reducing thrombosis-related morbidity.

No ethical approval will be required and the findings of this meta-analysis will be published in a peer-reviewed journal.

CRD42024532665.

To assess health-related quality of life (HRQoL), treatment satisfaction and associated factors among older adults with acute heart failure in Northwest Ethiopia.

Prospective, multicentre observational study.

Three tertiary hospitals in Northwest Ethiopia provide secondary and tertiary care services.

A total of 422 patients aged ≥60 years with a confirmed diagnosis of acute heart failure were consecutively enrolled between December 2024 and April 2025. Patients with unstable psychiatric conditions or advanced kidney disease were excluded.

HRQoL was assessed using the WHO Quality of Life – Brief Version questionnaire, and treatment satisfaction was measured using the Treatment Satisfaction Questionnaire for Medication (TSQM). Multiple linear regression identified factors associated with HRQoL and treatment satisfaction.

95% of participants reported moderate HRQoL, and 3% reported poor HRQoL. Weight loss was positively associated with HRQoL (β=1.52; 95% CI 0.04 to 3.07; p=0.021), whereas asthma was negatively associated with HRQoL (β = –3.28; 95% CI 6.94 to 0.37; p=0.001). Regarding treatment satisfaction, 65% of patients were moderately satisfied, with notable concerns regarding medication safety and overall experience. Rural residents reported lower satisfaction than urban residents (β = –0.20; 95% CI 0.34 to 0.05; p=0.007). Patients with New York Heart Association (NYHA) class III had higher satisfaction (β=0.25; 95% CI 0.05 to 0.45; p=0.016). Effective hypertension management was linked to increased satisfaction (β=0.20; 95% CI 0.02 to 0.37; p=0.026), whereas coronary heart disease was associated with lower satisfaction (β = –0.40; 95% CI 0.64 to 0.88; p=0.012).

Among older adults with heart failure in Northwest Ethiopia, 98% reported moderate to low HRQoL. Asthma and polypharmacy negatively affected HRQoL, whereas weight loss was positively associated with HRQoL. An NYHA class III status and well-managed hypertension improved treatment satisfaction, whereas rural residency and coronary heart disease were associated with lower satisfaction. These findings underscore the need for targeted interventions to enhance outcomes and QoL in this vulnerable population.

The WHO Safe Childbirth Checklist (SCC) has been implemented in diverse settings to improve the quality and safety of intrapartum care, but implementation strategies and their relationship with adoption and fidelity remain heterogeneous and incompletely described.

To describe the landscape of SCC implementation, map the implementation strategies used and explore how these strategies were reported in relation to adoption and fidelity.

We included primary studies reporting SCC implementation in healthcare settings that described at least one implementation strategy, with no restrictions on country or language. Studies that did not report implementation strategies or did not involve SCC use in real-world care settings were excluded.

We searched PubMed, Embase, CINAHL, Global Health and Global Index Medicus (June 2024), screened reference lists and consulted grey literature for the period 2009–2024.

This scoping review followed JBI methodology (Peters et al) and was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. We extracted study characteristics and implementation findings, coded strategies using the Expert Recommendations for Implementing Change (ERIC) taxonomy and grouped them by clusters. Adoption (initial uptake) and fidelity (adherence to core components) were categorised following Proctor’s implementation outcomes. We created a descriptive implementation intensity score and conducted exploratory analyses (tertiles, boxplot).

34 studies described 19 SCC implementation projects across 16 countries. We identified 24 distinct ERIC strategies, with most projects using 5–11 strategies. Frequently reported strategies included educational meetings, audit and feedback, supervision, contextual adaptation and leadership or champions. Exploratory analyses did not show consistent associations between implementation intensity and adoption or fidelity. ‘Change infrastructure’ strategies (such as record system or equipment changes) were variably defined and warrant cautious interpretation. Adaptations (eg, translation and alignment with national guidelines) were common and aimed at improving local fit, but heterogeneous reporting limited cross-study comparability.

SCC implementation has relied on diverse, multicomponent strategies, yet reporting—especially of strategy content and adaptations—remains insufficient, constraining comparison and synthesis across settings. As a pragmatic bundle, implementers may prioritise brief team training, unit-level champions and leadership signals, point-of-care audit and feedback, light-touch SCC adaptation that preserves core content and structured supervision or peer coaching, combined with systematic inclusion of women and families through codesign and companion-mediated prompting. Using theory-informed frameworks (such as Exploration, Preparation, Implementation, and Sustainment and Consolidated Framework for Implementation Research [CFIR]) and standardised reporting tools (eg, Proctor’s outcomes; Template for Intervention Description and Replication / Standards for Reporting Implementation Studies [TIDieR/StaRI]) can make SCC implementation strategies more transparent, comparable and scalable.

Open Science Framework: https://doi.org/10.17605/OSF.IO/RWY27.

The impact of poor nutritional health on maternal and infant morbidity and mortality remains high in low- and middle-income countries (LMICs), exacerbated by climate change-linked disasters. Maternal nutritional health, as a modifiable factor, is influenced by various social, political, economic and environmental factors, as well as cultural practices. Identifying climate change-related interventions, adaptive strategies and best practices targeting maternal nutritional health and well-being in LMICs within a cultural context helps inform the co-production of sustainable, culturally sensitive interventions to improve health outcomes for mothers and babies.

We will undertake a systematic review of the literature employing the six steps of the Protocol, Search, Appraisal, Synthesis, Analysis and Report (PSALSAR) framework, including both peer-reviewed and grey literature. The Population, Concept and Context approach will be used to formulate the review question and the inclusion and exclusion criteria. We will include primary research comprising all study designs published in English from 2007 onwards. We will conduct searches in online academic databases, including CINAHL, MEDLINE, Global Health (CABI), AGRIS (FAO) and SCOPUS, as well as defined grey literature sources (ie, Google Scholar). Titles, abstracts and later full-text articles will be independently accessed and screened for eligibility criteria by four researchers. Following the integrative review methodology, we will present findings narratively, organised around the components of the PSALSAR framework to provide a comprehensive synthesis of the available evidence.

As no primary data will be collected, the systematic review does not require formal ethics approval. However, we will give attention to ethical considerations within the identified studies. Findings will be published in a peer-reviewed journal and presented at relevant conferences. The findings of our systematic review and the ethnographic component of our research project will inform the development of appropriate maternal nutritional health interventions using co-production methodology in Pakistan.

CRD420251080897.

To assess the association between the maternal continuum of healthcare and child immunisation in East Africa using propensity score matching (PSM).

Cross-sectional study using Demographic and Health Survey data.

This study was conducted in East African countries.

This study included a weighted sample of 13 488 women with children aged 12–23 months.

Child immunisation was the outcome variable of this study.

The PSM estimates indicate that the average treatment effect on the treated for complete child immunisation was 0.0583, meaning that children of mothers who received a complete maternal continuum of care had a 5.83% higher probability of being fully immunised compared with children of mothers with incomplete care. Expressed relative to the treated group’s mean, this corresponds to a 7.48% increase. Additionally, our results indicated that the population average treatment effect was 0.0629. This means that, on average, a complete continuum of maternal healthcare increases the probability of full child immunisation by approximately 6.29% across the entire population.

The study highlights that children whose mothers receive comprehensive maternal healthcare are more likely to complete their childhood immunisations. This finding underscores the need to integrate immunisation services into maternal healthcare programmes to enhance vaccination coverage and promote better child health. To maximise this connection, improving access to maternal healthcare, especially in underserved regions, is crucial, along with ensuring that immunisation is a regular part of maternal care.

South Asia carries the burden of a rapidly changing climate with floods and extreme heat. These disasters further translate into mental health distress, financial stress and detrimental effects on well-being, with women being the most vulnerable. This study aims to demonstrate that mental health screening, referral and resilience-building group sessions can be successfully administered by community health workers and primary health facility staff in a flood-affected rural population of women in Pakistan and provide evidence on the effectiveness of this approach for improving their mental health status.

A quasi-experimental design with a comparison group will be used for the study, preceded by a formative phase. The formative phase evaluated the feasibility of mental health screening by Lady Health Workers (LHWs) in flood-affected areas using a qualitative approach such as focus group discussions and in-depth interviews. Manuals developed by the study team of mPareshan will be used to train LHWs, Lady Health Supervisors (LHS) and health facility staff. Following this, LHWs will briefly screen women aged 18 to 49 years, administer awareness-raising and resilience-building sessions and refer women who screen positive for depression or anxiety to a primary health facility. Physicians at the health facility will confirm the diagnosis and provide counselling to mild-moderate cases, while severe cases would be referred to specialists. Statistical evaluation of quantitative data and thematic content analysis of qualitative data will be conducted to assess the feasibility and impact of the intervention. This trial is registered at clinicaltrials.gov with number NCT06756165.

The study acquired ethical approval from the Ethical Review Committee at Aga Khan University (2024-10475-30776) and the National Bioethics Committee (4-87/NBC-1158/23/481) in Islamabad. Approval was obtained from relevant provincial authorities. The trial will adhere to the ethical principles of autonomy, anonymity, confidentiality, equity and respect. All eligible participants will be provided with informed consent, details regarding the purpose and procedure of the study, and the right to withdraw at any time. Data and information will be anonymised and stored securely. Dissemination of the results of the trial will occur after its completion to stakeholders, participants and the public.

NCT06756165.

Inappropriate medication use among surgical patients poses significant risks, including antibiotic resistance, complications, mortality, increased healthcare costs and challenges in pain management. This study aimed to assess the extent of inappropriate antibiotic and analgesic prescriptions, treatment adequacy and contributing factors.

A hospital-based cross-sectional study was conducted among patients admitted to surgical wards in three comprehensive specialised hospitals in northwest Ethiopia.

All eligible adult patients admitted to the surgical wards during the data collection period were included in the study.

The primary outcomes were the appropriateness of antibiotic and analgesic prescriptions. To assess patients’ pain perception and the effectiveness of pain management strategies, the American Pain Society Patient Outcome Questionnaire was used. The Pain Management Index was employed to evaluate the treatment adequacy. The RAND (Research and Development)-modified Delphi method was applied to reach expert consensus on best practices for antibiotic prescribing. Additionally, the national standard treatment guideline was used to benchmark prescribing practices. Binary logistic regression was used to identify factors associated with inappropriate prescriptions of antibiotics and analgesics.

The prevalence of inappropriate antibiotics use was 67.5% and 42.2% of patients received inappropriate analgesic prescriptions. Moreover, 51.6% of patients experienced inadequate pain management. Significant factors associated with inappropriate antibiotic prescription included the presence of comorbidities (adjsuted OR (AOR) 3.34, 95% CI 1.88 to 5.92), lack of laboratory tests (AOR 0.26, 95% CI 0.16 to 0.43, higher number of medications (AOR 2.71, 95% CI 1.62 to 4.52) and contaminated wound class (AOR 3.13, 95% CI 1.58 to 6.20). For inappropriate analgesic prescription, pain due to disease (AOR 8.69, 95% CI 1.73 to 4.62), mixed causes of pain (AOR 7.20, 95% CI 1.43 to 6.31), head and facial pain (AOR 0.14, 95% CI 0.05 to 0.39) and an increased number of medications (AOR 2.75, 95% CI 1.72 to 4.41) were significant factors.

The majority of the patients admitted to surgical wards were found to receive inappropriate antibiotic and analgesic medications. Prescribers should pay attention to patients with comorbid diseases, receiving multiple medications. Additionally, routine laboratory tests are essential for guiding antibiotic therapy and improving patient outcomes in surgical wards.

Early and balanced replacement of blood products appears to be the key factor in improving outcomes of major bleeding patients including acute trauma, cardiac, obstetric and transplant surgery patients. Definitive clinical guidance regarding the optimal ratio of blood products, including those containing fibrinogen, is still lacking. Therefore, we tested the hypothesis that increasing the fibrinogen content to erythrocyte suspension ratio improves the mortality and functional outcomes of patients undergoing surgeries with expected major bleeding.

The Approximate Dose-Equivalent of Fibrinogen-to-Erythrocyte Suspension (ADEFES) ratio is a multicentre, prospective, observational, cohort study of patients undergoing major surgical procedures with expected major perioperative bleeding (ie, requiring packed red blood cells (PRBC)>4U/24 hours). For 5U of cryoprecipitate and 1.5 U of fresh frozen plasma (FFP), the approximate dose-equivalent for fibrinogen is considered as 1 gram of fibrinogen. Association of the ADEFES ratio at 24 hours will be assessed on the primary objective, which will consist of the composite of 30-day all-cause mortality, 30-day bleeding-specific mortality and the ‘highly-dependent scores’ of Katz index of independence in activities of daily living.

The study protocol was approved by the Ethics Committee of Ankara Bilkent City Hospital (approval no. E2-23-4265, dated 07 June 2023; Chair: Prof. Dr. F.E. Canpolat) and by the institutional review boards of all participating centres. The study will be conducted in accordance with the principles of the Declaration of Helsinki and the Strengthening the Reporting of Observational Studies in Epidemiology guidelines, as well as in compliance with national regulations on data protection and Good Clinical Practice standards. Written informed consent will be obtained from all participants prior to inclusion in the study.

The results of this study will be disseminated through peer-reviewed scientific journals, presentations at national and international conferences, and communication with relevant stakeholders including clinical practitioners and healthcare institutions. If applicable, study outcomes will also be shared via institutional newsletters and digital platforms to reach a broader audience in the medical community.

NCT06021184.

This study aimed to assess the proportion of nutrition-related information-seeking behaviour and its associated factors among pregnant women attending antenatal care at public hospitals in Bahir Dar City, northwest Ethiopia, 2023.

A cross-sectional quantitative supplemented with qualitative study design was conducted from March to April 2023 among 406 pregnant women. Pre-tested structured interviewer-administered and semistructured open-ended questionnaires were used to collect quantitative and qualitative data, respectively. Data were collected using the Kobo toolbox, and SPSS V.25 was used for analysis. Descriptive statistics were used to describe study subjects, and multivariate logistic regression analysis was employed to investigate the associated factors. The strength of associations was described using the OR with the corresponding 95% CI.

The study included 406 pregnant mothers with a median age of 28 with an IQR of 8 and 212 (52.2%) from rural settings. Of the total respondents, 173 (42.6%; 95% CI 37.7 to 47.6) of pregnant mothers were nutrition-related information seekers. Educational status, residence, monthly income and nutrition information literacy were significantly associated with nutrition-related information-seeking behaviour.

The proportion of nutrition information seeking among pregnant mothers in Bahir Dar City public hospitals was low. Lower educational status, low nutrition information literacy level, being from a rural residence and low monthly income are significantly associated factors.

Awareness creation for pregnant mothers from rural areas and with low educational status and improving nutrition information literacy of pregnant mothers are important activities to improve their nutrition information-seeking behaviour.

This study aims to assess the level of cardiovascular disease (CVD) risk and its associated determinants among hypertensive patients in Jigjiga, Somali Region, Ethiopia using the WHO 10-year CVD risk score.

An institution-based cross-sectional study design was employed.

Hypertensive patients aged 40–74 years in two public hospitals in Jigjiga, Somali Region, Ethiopia, from 20 December 2023 to 20 February 2024.

Randomly selected 344 hypertensive patients aged 40–74 years with a duration of 1 year or more from the time of diagnosis and at least having 6-month follow-up.

10-year CVD risk level was assessed by using WHO 10-year CVD risk score. Risk levels were categorised as low (

Associated factors influencing CVD risk.

The study included 341 hypertensive individuals, with a 99.1% response rate. Of the respondents, 58.9% were men. The overall prevalence of CVD risk within the coming 10 years was 134 (39.3%; 95% CI: 34.1% to 44.5%). Multivariable logistic regression analysis identified age, khat chewing, smoking and comorbid conditions as significant independent predictors of CVD risk. Specifically, individuals aged 60–69 years had an adjusted OR (AOR) of 3.97 (95% CI: 1.94 to 8.16) and those aged 70–74 years had an AOR of 2.99 (95% CI: 1.57 to 5.71). Khat chewers had an AOR of 2.58 (95% CI: 1.22 to 5.46), smokers an AOR of 3.44 (95% CI: 1.59 to 7.48) and individuals with comorbidities an AOR of 2.42 (95% CI: 1.47 to 3.99).

There is a significant increase in 10-year CVD risk among hypertensive patients in the study area. Age, khat chewing, smoking and comorbidities were independent predictors. Regular CVD risk screening for older patients, focused health education to reduce khat and tobacco use and integrated management of comorbidities are essential to lower future cardiovascular risk.