The ‘time-limited trial’ for patients with critical illness is a collaborative plan made by clinicians, patients and families to use life-sustaining therapies for a defined duration. After this period, the patient’s response to therapy informs decisions about continuing recovery-focused care or transitioning to comfort-focused care. The promise of time-limited trials to help navigate the uncertain limits and benefits of life-sustaining therapies has been extensively discussed in the palliative and critical care literature, leading to their dissemination into clinical practice. However, we have little evidence to guide clinicians in how to conduct time-limited trials, leading to substantial variation in how and why they are currently used. The overall purpose of this study is to characterise the features of an optimal time-limited trial through a rich understanding of how they are currently shaping critical care delivery.

We are conducting an observational, multicentre, focused ethnography of time-limited trials in patients with acute respiratory failure receiving invasive mechanical ventilation in six intensive care units (ICUs) within five hospitals across the US. Study participants include patients, their surrogate decision makers and ICU clinicians. We are pursuing two complementary analyses of this rich data set using the open-ended, inductive approach of constructivist grounded theory and, in parallel, the structured, deductive methods of systems engineering. This cross-disciplinary, tailored approach intentionally preserves the tension between time-limited trials’ conceptual formulation and their heterogeneous, real-world use.

This study has been reviewed and approved by the University of Wisconsin Institutional Review Board (IRB) as the single IRB (ID: 2022-1681; initial approval date 23 January 2023). Our findings will be disseminated through peer-reviewed publication, conference presentations, and summaries for the public.

NCT06042621.

To explore why there is variation in implementation of multifactorial falls prevention practices that are recommended to reduce falls risks for older patients in hospital.

Mixed method, realist evaluation.

Three older persons and three orthopaedic wards in acute hospitals in England.

Healthcare professionals, including nurses, therapists and doctors (n=40), and patients aged 65 and over, and carers (n=31).

We examined mechanisms hypothesised to underpin the implementation of multifactorial falls risk assessment and multidomain, personalised prevention plans.

We developed an explanation detailing that how contextual factors supported or constrained implementation of recommended falls prevention practices.

Nurses led delivery of falls risk assessment and prevention planning using their organisation’s electronic health records (EHR) to guide and document these practices. Implementation of recommended practices was influenced by (1) organisational EHR systems that differed in falls risk assessment items they included, (2) competing priorities on nurse time that could reduce falls risk assessment to a tick box exercise, encourage ‘blanket’ rather than tailored interventions and that constrained nurse time with patients to personalise prevention plans and (3) established but not recommended falls prevention practices, such as risk screening, that focused multidisciplinary communication on patients screened as at high risk of falls and that emphasised nursing, rather than Multidisciplinary Team (MDT), responsibility for preventing falls through constant patient supervision.

To promote consistent delivery of multifactorial falls prevention practices, and to help ease the nursing burden, organisations should consider how electronic systems and established ward-based practices can be reconfigured to support greater multidisciplinary staff and patient and carer involvement in modification of individual falls risks.

Inside CKD aims to assess the burden of chronic kidney disease (CKD) and the cost-effectiveness of screening programmes in Belgium.

Microsimulation-based modelling.

Data derived from national statistics and key literature from Belgium.

Virtual populations of ≥10 million individuals, representative of Belgian populations of interest, were generated based on published data and cycled through the Inside CKD model. Baseline input data included age, estimated glomerular filtration rate (eGFR), urine albumin-creatinine ratio (UACR) and CKD status.

Outcomes included the clinical and economic burden of CKD during 2022–2027 and the cost-effectiveness of two different CKD screening programmes (one UACR measurement and two eGFR measurements or only two eGFR measurements, followed by renin-angiotensin-aldosterone system inhibitor treatment in newly diagnosed eligible patients). The economic burden estimation included patients diagnosed with CKD stages 3–5; the screening cost-effectiveness estimation included patients aged ≥45 years with no CKD diagnosis and high-risk subgroups (with cardiovascular disease, hypertension, type 2 diabetes or aged ≥65 years).

Between 2022 and 2027, CKD prevalence is estimated to remain stable and substantial at approximately 1.66 million, with 69.9% undiagnosed. The total healthcare cost of patients diagnosed with CKD is expected to remain stable at approximately 2.15 billion per year. The one UACR, two eGFR measurement screening programme was cost-effective in all populations, with an incremental cost-effectiveness ratio of 3623 per quality-adjusted life year (QALY) gained in those aged ≥45 years, well below the estimated willingness-to-pay threshold of 43 839 per QALY gained.

Without changes to current practice, the disease burden of CKD in Belgium is predicted to remain substantial over the next few years. This highlights the need for timely diagnosis of CKD and demonstrates that, in line with guideline recommendations, implementing a CKD screening programme involving UACR and eGFR measurements followed by treatment would be cost-effective.

Adenotonsillectomy is the primary treatment for type 1 obstructive sleep apnoea (OSA1). Although polysomnography (PSG) remains the gold standard for measuring Apnoea-Hypopnoea Index, it is a labour-intensive procedure and does not correlate with improvements in quality of life postadenotonsillectomy. Mouth breathing is associated with poorer quality of life in children. Mandibular movement (MM), which measures mouth opening, is a validated measure of respiratory effort that can be easily and safely assessed in children using the JAWAC technology. This study aims to evaluate the relationship between changes in quality of life and changes in mouth opening in children with OSA1 after undergoing adenotonsillectomy. Secondary objectives include evaluating changes in quality of life, clinical symptoms and other MM and PSG metrics in the same population.

This exploratory, non-randomised, monocentric, prospective cohort study with a non-blinded single arm will include 50 children aged 3–7 years, undergoing adenotonsillectomy at the Clinique Saint Jean, Montpellier, France. Quality of life will be measured using the parent version of the Paediatric Quality of Life Inventory and MM metrics will be measured during PSG using the JAWAC system during the inclusion visit and 3 months after adenotonsillectomy. The primary outcome will be the correlation between the changes in quality of life and mouth opening (1/10 mm) postadenotonsillectomy. Secondary analyses will evaluate changes in clinical symptoms, PSG measures and other MM metrics including respiratory effort, as well as the associations between these measures.

This study was approved by an independent ethics committee (Comité de Protection des Personnes Est) on 24 March 2025 (2024-A02761-46) and will be conducted in accordance with French law, good clinical practice and the guidelines of the Declaration of Helsinki. Study findings will be disseminated through international peer-reviewed journal articles as well as public, academic presentations at national and international conferences.

NCT06973928.

To identify the barriers and facilitators towards deceased organ donation among Pakistanis living globally.

Systematic review using narrative synthesis.

CINAHL, Medline with Full Text, Global Health and PsycINFO via EBSCO; Scopus via Elsevier; Web of Science via Clarivate; and PubMed through the US National Library of Medicine and the National Institutes of Health were searched between 1 January 1995 and 31 July 2024 and limited to English.

We included qualitative and cross-sectional studies involving Pakistani participants aged 18 years and above, conducted both within Pakistan and internationally across settings such as universities, religious venues, hospitals and workplaces.

Four independent reviewers were involved in screening, quality assessment and data extraction. A narrative synthesis method was employed to synthesise and integrate the data from qualitative and cross-sectional studies. The Joanna Briggs Institute tool was used to assess the quality of the included studies.

Out of 11 944 studies retrieved, 26 studies were included in the current review. Based on the narrative synthesis, the findings are presented under the following five themes: (1) knowledge of deceased organ donation, (2) willingness towards deceased organ donation, (3) collective decision-making overriding individual’s preferences, (4) religious uncertainty and its impact on deceased organ donation and (5) trust and the healthcare systems.

This review shows that decisions about deceased organ donation are shaped by family dynamics, religious beliefs and trust in healthcare. More diverse research is needed to uncover new gaps and improve donor registration and consent rates in Pakistan. A whole-systems approach, considering families, religion and trust, is essential for effective strategies.

CRD42022346343.

The sustainable employability of healthcare workers is associated with quality of care and vice versa, but how both interact remains largely unknown. This study aims to better understand the underlying mechanisms that explain the interconnectedness between healthcare workers’ sustainable employability and quality of care by examining organisational practices in two hospital teams that work on improving specific clinical processes.

A qualitative study was conducted, where team leaders, department managers and healthcare teams were observed and interviewed about their experiences with, and perspectives on, the (organisation of the) respective clinical process and daily (quality improvement) work. Transcripts and field notes were analysed in accordance with reflexive thematic analysis.

The emergency room and operating room of a recently merged Dutch hospital.

A total of 49 hours of observations and 10 interviews were conducted with team leaders, department managers, (scrub) nurses, physicians and other allied health professionals. Interviewees were purposively recruited when they were involved in, or considered knowledgeable about, the clinical processes.

This study identified three mechanisms as a result of different organisational practices that affected healthcare workers’ sustainable employability and quality of care separately and set in motion their interconnectedness: routinely overburdened staff, prolonged perceived distance between staff and regular disregard of raised concerns by staff. Over time, as these mechanisms remained unaddressed, undertows of slumbering sentiments—discontent, distrust and inertia—emerged. These sentiments proved hard to bring to the surface and to resolve and, in turn, may further compromise sustainable employability of healthcare workers and quality of care.

In this study, we show how the relationship between the sustainable employability of healthcare workers and quality of care is set in motion by seemingly unrelated organisational practices. To benefit both healthcare workers and patients, leadership and healthcare teams are urged to prevent (undertows of) slumbering sentiments by recognising sentiments as important signals of dysfunctional circumstances and by effectively organising participatory practices that enable healthcare workers’ voice and input.

Countries face challenges in maternal and newborn care (MNC) regarding costs, workforce and sustainability. Organising integrated care is increasingly seen as a way to address these challenges. The evidence on the optimal organisation of integrated MNC in order to improve outcomes is limited.

(1) To study associations between organisational elements of integrated care and maternal and neonatal health outcomes, experiences of women and professionals, healthcare costs and care processes and (2) to examine how the different dimensions of integrated care, as defined by the Rainbow Model of Integrated Care, are reflected in the literature addressing these organisational elements.

We included 288 papers and identified 23 organisational elements, grouped into 6 categories: personal continuity of care; interventions to improve interdisciplinary collaboration and coordination; care by a midwife; alternative payment models (non-fee-for-service); place of birth outside the obstetric unit and woman-centred care. Personal continuity, care by a midwife and births outside obstetric units were most consistently associated with improved maternal and newborn outcomes, positive experiences for women and professionals and potential cost savings, particularly where well-coordinated multidisciplinary care was established. Positive professional experiences of collaboration depended on clear roles, mutual trust and respectful interdisciplinary behaviour. Evidence on collaboration interventions and alternative payment models was inconclusive. Most studies emphasised clinical and professional aspects rather than organisational integration, with implementation barriers linked to prevailing biomedical system orientations.

Although the literature provides substantial evidence of organisational elements that contribute to improved outcomes, a significant gap remains in understanding how to overcome the barriers in sustainable implementation of these elements within healthcare systems. Interpreted through a systems and transition science lens, these findings suggest that strengthening integrated maternity care requires system-level changes aligning with WHO policy directions towards midwifery models of person-centred care.

To determine the risk perception, health-related adaptive behaviours and associated factors related to climate change among high school students in Thiruvananthapuram district, Kerala, India.

A cross-sectional study with multistage cluster sampling was conducted among high school students from Neyyatinkara Taluk in the Thiruvananthapuram district of Kerala, India. After identifying the taluk, 10 schools were chosen using probability proportionate to size to ensure adequate representation.

The study was conducted among 600 high school students (mean age 14 years, SD 0.75) from Neyyatinkara Taluk in the Thiruvananthapuram district of Kerala.

Neyyattinkara taluk was randomly selected from the six taluks in Thiruvananthapuram district. From each of the 10 selected schools, students from classes 8 to 10, section A, formed the study clusters, with cluster sizes ranging from 45 to 60 students. All students from classes 8 to 10 (section A) who were present on the day of the survey and had obtained informed consent from their parents or guardian were considered eligible to participate in the study. Risk perception and health-related adaptive behaviour scores for children were calculated using a pretested structured questionnaire with 8 and 17 questions, respectively. All questions were designed on a 5-point scale. For positively worded questions, scores ranged from 5 to 1 (strongly agree to strongly disagree), and for negatively worded questions, the scoring was reversed. Binary logistic regression analysis was used to determine the independent factors associated with risk perception and health-related adaptive behaviour.

Nearly three in four study participants (72.1%) were aware of the term climate change. The median risk perception score and health-related adaptive behaviour scores were 28 (IQR 26–30) and 52 (IQR 47–57), respectively. Study participants from urban areas had significantly better risk perception compared with rural counterparts (AOR 2.42; 95% CI 1.54 to 3.78). Similarly, children from above poverty line (APL) households demonstrated markedly higher risk perception than those from below poverty line households (AOR 28.77; 95% CI 16.84 to 45). Participation in a climate change awareness programme was also associated with higher risk perception (AOR 1.98; 95% CI 1.23 to 3.19). Positive health-related adaptive behaviour was more likely among children aged 14–16 years compared with those younger than 14 (AOR 1.92; 95% CI 1.3 to 2.84). Urban residence (AOR 20.72; 95% CI 5.04 to 85.17), higher paternal education (AOR 1.91; 95% CI 1.15 to 3.13) and APL household status (AOR 2.50; 95% CI 1.57 to 3.93) were also significantly associated with better adaptive behaviour.

Climate change interventions and awareness programmes should prioritise rural, lower socioeconomic and younger populations and equip them with practical life skills for adaptive behaviour.

Frontotemporal dementia (FTD) remains challenging to diagnose owing to the marked clinical heterogeneity associated with the disease. This heterogeneity stems from the complex interplay of various clinical phenotypes, genetic mutations and underlying neuropathologies, such as TDP-43 and tau proteinopathies. Currently, there is no single confirmed biomarker that can reliably diagnose disease, specifically disease stage, disease subtype and underlying neuropathology. Recent research has indicated that neuroimaging techniques hold the most promise for the discovery of FTD biomarkers. We propose a protocol for a systematic review and meta-analysis to identify MRI and fluorodeoxyglucose positron emission tomography (FDG-PET) biomarkers associated with clinical, genetic and pathological subtypes of FTD. We aim to address the following research questions: can regional MRI volumetry and FDG-PET hypometabolism differentiate (1) FTD patients from healthy controls; (2) sporadic cases of FTD from healthy controls; (3) genetic cases of FTD (MAPT, GRN, and C9orf72 mutations); and (4) underlying neuropathology, specifically discriminating between tau- and TDP-43-based FTD?

Literature searches will be performed across three databases: Ovid Medline, Ovid Embase and Web of Science. Publications that have fewer than five participants, are non-human-based, not written in the English language or contain unpublished data will be excluded. Two independent investigators will screen and subsequently evaluate which publications to include. Should any disagreements arise, a third investigator will settle the discrepancy. After the random-effects meta-analysis has been used to extract and pool the data, I² analysis will be used to quantify heterogeneity.

Ethics approval will not be required for this research. On completion, the systematic review and meta-analysis will be published in a peer-reviewed journal.

CRD42024545302.

To examine how socioeconomic deprivation influences referral pathways to emergency departments (EDs) and to assess how these pathways affect subsequent hospital outcomes.

Retrospective observational study.

Emergency department of a large teaching hospital in the East of England, providing secondary and tertiary care.

482 787 ED attendances by patients aged 16 years and over, recorded between January 2019 and December 2023. Patients were assigned Index of Multiple Deprivation (IMD) deciles based on residential postcode.

Referral source (general practitioner (GP), National Health Service (NHS) 111, ambulance, self-referral, other), total ED time, 4-hour breach, hospital admission and unplanned return within 72 hours.

Substantial socioeconomic inequalities were observed in referral pathways. Patients from the most deprived areas were significantly less likely to be referred by a GP (4.7%) than those from the least deprived areas (14.7%) and more likely to arrive via ambulance (32% vs 24%). These differences persisted after adjusting for demographic, clinical and contextual variables. Ambulance referrals showed the longest ED stays, ranging from 347 to 351 min across IMD deciles (overall 95% CI 343 to 363) and the highest probability of 4-hour breaches (51%; 95% CI 50% to 53%). Self-referrals had the greatest rates of unplanned returns within 7 days (up to 7.1%; 95% CI 5.5% to 8.7%). In contrast, NHS 111 and GP referrals were associated with shorter stays, lower breach rates and fewer reattendances. Minimal variation in outcomes was observed across deprivation levels once referral source was accounted for.

Inequalities in how patients access emergency care, particularly reduced GP and NHS 111 referrals among more deprived groups, appear to underpin disparities in ED outcomes. Referral source captures important clinical and system-level factors that influence patient experience and resource use. Interventions to improve equitable access to structured referral pathways, particularly in more deprived areas, may enhance both the efficiency and fairness of emergency care delivery. Further research using national data is needed to assess broader policy implications and economic costs associated with differential access.