The WHO's Framework Convention on Tobacco Control (FCTC) obligates Parties to reduce tobacco use among Indigenous populations, who suffer disproportionate harm from historical and ongoing colonisation. These obligations must be upheld despite challenges like COVID and the tobacco industry's influence. This review updates an earlier analysis of the FCTC reports from Australia, Canada and Aotearoa New Zealand, evaluating their progress in fulfilling obligations to Indigenous peoples between 2018 and 2023. This study employed a qualitative content analysis to review the FCTC progress reports from Australia, Canada and New Zealand, covering the period from 2018 to 2023. The analysis was based on three Global progress reports and nine country-specific reports. Using consistent search terms aligned with a previous review, we systematically identified relevant activities, achievements and practices reported in the FCTC documents. Two independent reviewers conducted the coding and analysis, and after initial coding, the findings were cross-checked by the research team. Across the three countries, there was a focus on increasing Indigenous leadership in the development and implementation of tobacco control programmes. For example, in Australia, the Tackling Indigenous Smoking programme focuses on codesigning culturally tailored interventions to address high smoking rates and overcome challenges, particularly in remote communities, while addressing gaps in providing culturally safe supports. Indigenous leadership in tobacco control was also indicated in New Zealand's Smokefree Aotearoa 2025 Action Plan and in Canada's Tobacco Strategy. However, despite the encouraging progress, absence of Indigenous-specific data and inconsistent reporting is challenging, and more work is required.

Rationale: The Undiagnosed COPD and Asthma Population trial showed that early diagnosis and treatment of asthma and chronic obstructive pulmonary disease (COPD) by pulmonologists improved healthcare use, respiratory symptoms, and quality of life. Objectives: To determine if the benefits of early diagnosis and treatment were greater in individuals with more advanced disease or in individuals with asthma as opposed to COPD. We also assessed whether pulmonologist-directed care benefited asthma and COPD subgroups equally. Methods: Case finding was used to identify adults with undiagnosed chronic respiratory symptoms in the community. A total of 508 newly diagnosed participants with COPD or asthma were randomized to receive pulmonologist-care intervention or usual care. Low and high disease burden categories for the St. George's Respiratory Questionnaire (SGRQ) and COPD Assessment Test were defined using a median-split of baseline scores, and minimal clinically important difference thresholds were used to define significant responses. Benefits of pulmonologist care were assessed by evaluating treatment effects within subgroups and by assessing treatment-by-subgroup interactions. Measurements and Main Results: Patients with higher disease burden at diagnosis were more likely to benefit from early diagnosis and treatment compared with those with lower disease burden. A total of 71% of those with high disease burden showed an improvement in COPD Assessment Test score by ⩾2 points over 12 months compared with 47% with low disease burden (odds ratio, 2.78; 95% confidence interval, 1.90-4.07; P < 0.001). Similar results were seen for SGRQ and FEV1 improvements. In contrast, responses to early diagnosis and treatment were similar for those with asthma versus COPD. Individuals with asthma randomized to undergo pulmonologist-directed care showed greater 1-year improvements in COPD Assessment Test score, SGRQ score, 36-item Short Form score, and FEV1 compared with individuals randomized to receive primary care. However, individuals with COPD experienced similar improvements regardless of whether their treatment was managed by a pulmonologist or primary care provider. Treatment-by-disease interaction terms were not statistically significant. Conclusions: Patients with greater disease burden who exhibited more advanced and symptomatic asthma and COPD at the time of diagnosis benefited more from earlier diagnosis and treatment. Patients with asthma tended to derive greater benefit from pulmonologist-directed care than patients with COPD.

Purpose of review Home dialysis remains variable and underused globally despite clinical and quality of life benefits for patients. Due to low patient volumes in many centers, it is challenging for nephrology trainees to gain adequate clinical exposure to achieve competency and comfort in patient management. In this review, we highlight the University of Toronto-affiliated University Health Network (UHN) and St. Michael's Hospital (SMH) Home Dialysis Fellowship as an educational model to improve competency and comfort in home dialysis. Recent findings The UHN/SMH Home Dialysis Fellowship offers diverse clinical exposure with over 300 patients on peritoneal dialysis and home hemodialysis. Trainees achieve competency through repetitive exposure to a large volume of patients. The fellowship leverages continuity and longitudinal follow-up across all stages of a patient's chronic kidney disease journey. The program fosters interprofessional collaboration to develop comprehensive patient management plans. The attending physicians are leading world experts and support the varied trainee academic and career goals through mentorship and sponsorship. Summary The UHN/SMH Home Dialysis Fellowship program combines evidence-based medical education principles with high volume, diverse, and complex patient populations to offer trainees an exceptional learning experience and the foundations to become the next generation of home dialysis experts.

Background & objectivesLength of Stay (LoS) is a critical quality metric and focus of improvement efforts in healthcare. Successfully managing LoS depends on understanding the drivers of variation amenable to change. This study aims to (1) characterize physician-level variation in LoS; (2) identify physician actions associated with LoS; and (3) explore the individual-, team-, and hospital-level factors influencing this variation to generate hypotheses for further study.MethodsThis mixed-methods comparative case study approach examined six General Internal Medicine (GIM) departments in Toronto, Ontario. Physician-level variation in LoS was calculated using a random-intercept negative binomial regression model and sensitivity analysis. Semi-structured interviews and ethnographic observations were conducted and analyzed using the AACTT Framework (Action-Actor-Context-Target-Time), the Consolidated Framework for Implementation Research (CFIR), and the Theoretical Domains Frameworks (TDF). Hospitals with the lowest and highest physician-level variation in LoS were compared.ResultsPhysician-level variation in LoS ranged from 1.7 to 7.0%, which—though modest numerically—represents meaningful differences in physician decision-making not explained by patient complexity, and no significant hospital-level effect was observed. Qualitative analysis from 12 observations and 67 interviews (32 GIM physicians and residents, 35 nurses and other health professionals) identified eight discrete physician actions influencing LoS, along with five individual-level factors and five team- and hospital-level factors. The nature of these factors was different when comparing hospitals with the lowest and highest variation. Organizational culture and perceptions of the patient population shaped physician perceptions of their professional role, while GIM departmental culture, structural characteristics, and communication networks informed physician beliefs about team capabilities and consequences of action (or inaction).ConclusionThis study highlights the complex interplay between physician actions and factors influencing physician-level variation in LoS. Interventions that target physicians but do not attend to team and hospital factors are likely insufficient to achieve sustained improvements in LoS. Aligning individual-level feedback and environmental restructuring with organizational values and needs of the patient population may offer a more promising approach to sustained improvement.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12913-025-13304-5.

Little is known about the long-term costs and outcomes related to strategies for timing of initiation of kidney replacement therapy (KRT) in critically ill patients with severe acute kidney injury (AKI). To estimate the cost-utility and cost-effectiveness of accelerated KRT initiation compared with standard KRT initiation in critically ill patients with AKI. In this economic evaluation, a state-transition model was developed using data from the Standard vs Accelerated Initiation of Renal Replacement Therapy in AKI (STARRT-AKI) trial, a multicenter, multinational randomized clinical trial of critically ill patients with severe AKI conducted between October 2015 and September 2019. Trial data were linked to administrative health databases in Alberta, Canada, to estimate costs and long-term clinical outcomes. The model included 4 health states: no chronic kidney disease, severe chronic kidney disease, KRT dependent, and dead. Costs are reported in 2024 Canadian dollars. Data were analyzed from February 2022 to November 2024. Initiation of KRT. The primary outcome for the economic evaluation was cost per quality-adjusted life-year (QALY) gained. The QALY is a combined measure of patient quality of life and length of life. Expected costs, QALYs, incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INMB) were estimated on the basis of 5000 Monte Carlo simulations. A total of 146 patients from the STARRT-AKI trial were included in the analysis, with 73 patients (mean [SD] age, 59.67 [14.5] years; 52 men [71.3%]) randomized to receive accelerated initiation and 73 patients (mean [SD] age, 61.88 [12.9] years; 48 men [65.8%]) randomized to receive standard initiation. Standard initiation was more costly per patient than accelerated initiation (mean [SD], $251 370 [$155 801] vs $231 518 [$183 302]) but generated more QALYs (mean [SD] 7.49 [2.03] QALYs vs 6.64 [1.76] QALYs). The ICER of standard initiation compared with accelerated initiation was $23 208, with an INMB of $22 648 (95% credible interval, $15 980-$29 316) when assuming a willingness to pay per QALY of $50 000. The findings of this economic evaluation suggest that standard KRT initiation may be cost-effective in a Canadian setting, but this finding was sensitive to postdischarge cost trajectories and regional variation in KRT dependence.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has substantially affected daily life. Sustainable testing practices are essential to balance the resource demands of widespread testing with the need to reduce the health impacts of COVID-19. However, the effectiveness of specific testing strategies for symptomatic and asymptomatic individuals in reducing COVID-19 cases, hospitalisations, and deaths remains uncertain. To evaluate the effectiveness of different SARS-CoV-2 testing strategies in reducing COVID-19 cases, hospitalisations, and deaths amongst suspected cases and asymptomatic individuals. We searched CENTRAL, MEDLINE (Ovid), Embase (Elsevier), Europe PMC, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform. We also conducted reference checks, citation searches, and contacted study authors to identify eligible studies. The most recent search was conducted on 07 October 2024. We included randomised controlled trials (RCTs), non-randomised studies of interventions (NRSIs), controlled before-and-after studies (CBA), matched cohort studies, and observational studies with a comparison group involving suspected or asymptomatic individuals. Eligible studies compared testing strategy versus no testing or standard care or usual practice; one testing strategy with another, such as antigen-detecting rapid diagnostic tests (RDTs) versus nucleic acid amplification testing (NAAT), including reverse transcription polymerase chain reaction (RT-PCR); home-based versus provider-administered testing; one-time testing versus repeated testing at different frequencies; and targeted testing versus widespread testing. Combinations of these components were also considered. In this review, we define 'SARS-CoV-2 testing strategy' as a complex intervention comprising multiple varying components, including test type (e.g. NAAT, antigen-detecting RDT), sample type (e.g. nasopharyngeal swab, saliva), target population (e.g. symptomatic, contacts), setting (e.g. home, clinic, congregate), frequency of testing (e.g. one-time, weekly, daily), and response protocol (e.g. isolation, confirmatory testing, treatment). We excluded single-arm studies, reviews, theses, editorials, letters, commentaries, studies reported solely in abstract form, laboratory or animal studies, mathematical modelling studies, and diagnostic test accuracy studies. Our critical outcomes were: COVID-19 cases avoided (reduction in new cases); COVID-19-related hospitalisations avoided (reduction in hospital admissions); COVID-19-related deaths avoided (reduction in mortality); and serious adverse events related to testing, including unnecessary interventions, employment impacts, isolation effects, and psychological harms. We used the Risk of bias 2 (RoB 2) tool to assess the risk of bias in RCTs and the ROBINS-I tool to assess the risk of bias in NRSIs, CBA studies, and matched cohort studies. As a meta-analysis was not feasible due to the nature of the data, we applied Synthesis Without Meta-analysis (SWiM) methods. We assessed the certainty of the evidence for each outcome using the GRADE approach. We included 21 studies (10 RCTs and 11 NRSIs) with 13,312,327 participants. Among these, 13 studies-comprising eight RCTs and five NRSIs-either reported one or more prespecified outcomes (four studies), provided relevant information through proxy measurements (five studies), or supplied information following author correspondence (four studies). We present the prioritised comparisons and critical outcomes. For the comparison testing strategy versus no testing or standard care or usual practice, one included study measured two critical outcomes. The study did not measure the other critical outcomes: COVID-19 cases avoided, and serious adverse events related to testing. No studies measured any critical outcomes for the other prioritised comparison: antigen-detecting RDT versus NAAT testing. Benefits and harms of testing strategy versus no testing or standard care or usual practice One observational study with a comparison group, conducted in a long-term care facility in Israel, compared weekly SARS-CoV-2 RT-PCR testing with no testing and measured two of our critical outcomes. Based on the analysis, the evidence is very uncertain about the effect of SARS-CoV-2 RT-PCR testing on reducing hospitalisation (decrease in the hospitalisation rate from 13.59% to 11.41%; 1 study, 162,205 participants, very low-certainty evidence) and mortality (33.8% decrease in expected mortality; 1 study, 162,205 participants, very low-certainty evidence) compared to no testing. We downgraded the certainty of the evidence because of methodological limitations, indirectness, and imprecision. The available data are of very low-certainty. Only one of the 21 included studies reported hospitalisations or deaths; therefore, we cannot draw conclusions about the effects of testing strategy versus no testing on reducing hospitalisation and mortality. No studies evaluated other critical outcomes i.e. COVID-19 cases avoided, and serious adverse events related to testing. Future research should aim for consistency and relevance by using clearly defined outcomes, preferably based on a standardised core outcome set. A qualitative evidence synthesis (QES) would help identify barriers and facilitators to routine SARS-CoV-2 testing in healthcare settings, which could help inform intervention development. The QES would explore factors affecting the implementation of routine testing, drawing on the perspectives of healthcare providers, patients, and other interest holders. This Cochrane review was partially funded by the World Health Organization (WHO) and the Health Research Board of Ireland. Protocol (2025) DOI: 10.1002/14651858.CD016192.

Background: Choroid plexus (ChP) enlargement correlates with neuroinflammation, brain atrophy, and disability in multiple sclerosis (MS); its relevance in people with radiologically isolated syndrome (pwRIS) is unclear. Objective: To investigate ChP volume (ChPvol) differences across age-/sex-matched pwRIS, people with MS (pwMS), and healthy controls (HCs), and to examine associations between ChPvol, brain volumetric measures, and development of clinically definite MS (CDMS). Methods: 3 Tesla magnetic resonance imagings (3T-MRIs) from 59 pwRIS, 59 pwMS, and 59 HCs were analyzed. ChPvol, white matter lesion volume (WMLvol), central vein sign (CVS), paramagnetic rim lesions (PRLs), and brain volumes were assessed. pwRIS were prospectively monitored for CDMS. Results: ChPvol was larger in pwRIS (p < 0.0001) and pwMS (p = 0.042) compared to HCs. Multivariable regression showed that higher ChPvol (odds ratio (OR) = 7.21, 95% confidence interval (CI) = 1.44–36.03, p = 0.016) and lower thalamic volume (OR = 0.23, 95% CI = 0.10–0.52, p < 0.001) independently distinguished RIS from HCs. In pwRIS, ChP enlargement correlated with higher WMLvol (rs = 0.495, p < 0.0001), higher proportion of CVS-positive lesions (rs = 0.28, p = 0.042), and lower thalamic volume (rs = −0.451, p < 0.0001). Of 35 pwRIS with longitudinal follow-up, 10 (28.6%) developed CDMS; however, baseline ChPvol did not differ between those who developed CDMS and those who did not (p = 0.77). Conclusions: ChP enlargement is evident at the earliest stage of MS, is associated with demyelination and neurodegeneration, highlighting ChP volume as a potential diagnostic biomarker. Although baseline ChPvol alone did not predict progression to CDMS, its similarity in RIS and MS cohorts supports the forthcoming 2024 revised McDonald criteria suggesting that RIS can be considered MS in specific situations.