Aortic dissection (AD) is a life-threatening cardiovascular emergency with a high mortality rate, and acute Stanford Type A AD is the most dangerous form, often requiring surgical intervention. Factors contributing to the progression of AD include increased heart rate, blood pressure and the rate of ventricular contraction (dP/dt). While heart rate control is a cornerstone of preoperative management for AD per existing guidelines, the recommended target (eg, ≤60 bpm in American Heart Association 2010) is consensus-driven (Level C) and thus not grounded in high-level evidence. The ESCORT (Efficacy and Safety of preoperative Controlling heart Rate in patients with acute Type A aortic dissection) trial is designed to address this critical gap by providing high-level evidence from a randomised controlled trial to define the optimal preoperative heart rate target. The study is a multicentre, single-blind, RCT involving adult patients diagnosed with acute (Stanford Type A) AD, scheduled for aortic arch prosthetic vascular replacement and elephant trunk stent implantation surgery. 680 patients will be randomised into two groups: low heart rate target group (55-65 beats per minute) and standard heart rate target group (75-85 beats per minute). The intervention involves protocol-directed medication to achieve the target heart rates, with esmolol as the primary recommended agent. The primary outcome measure is the rate of major adverse cardiovascular event within 30 days after surgery, and secondary outcomes include various clinical, economic and biochemical measures. The ESCORT study is the large-scale RCT to investigate the optimal preoperative heart rate control in patients with acute type A AD. The results of this study have the potential to fill the evidence gap in current clinical guidelines and provide evidence-based support for clinical management. The findings may influence the standard of care by either endorsing lower heart rate targets or providing alternative guidance for managing heart rate in this high-risk patient population. The study's results will be disseminated through publications and presentations at both national and international conferences, ensuring that the results are accessible to the medical community and relevant patient organisations. This study, including the study protocol (version 1.3, 3 December 2022), was approved by the Ethics Committee of Fuwai Hospital, CAMS and PUMC (approval number: 2022-1886). Additional approvals were obtained from the ethics committees of participating subcentres (approval numbers are listed in the main text). The findings will be disseminated through publications in peer-reviewed journals and presentations at scientific conferences. ChiCTR2300067811.

The Trauma Recovery Center (TRC) is an evidence-based model of care designed to meet the needs of underserved survivors of violent crime through the provision of comprehensive mental health and psychosocial services. Originally developed in the USA, the TRC model has been adopted by 53 hospitals and outpatient settings nationwide. Its demonstrated effectiveness supports its potential for international scale-up, particularly in countries seeking to improve their responses to interpersonal violence and trauma. While the core principles of the model remain universally consistent, there is a striking paucity of synthesised evidence on implementation barriers and enablers, necessary to guide effective scale-up and adaptation across diverse systems of care. The objective of this scoping review is to identify and map barriers and facilitators that influence implementation of the TRC model of care. The scoping review was initiated in May 2025 and is expected to be completed in May 2026. The review will be conducted following the Joanna Briggs Institute methodology for scoping reviews. Results will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The initial PubMed search was conducted in June 2025. The finalised search strategy will subsequently be applied to PubMed, Embase, PsycINFO, CINAHL and Scopus databases. A two-stage screening process using Covidence software will be used to determine study eligibility. To be included, studies will be required to have examined implementation-related barriers or facilitators associated with at least one core element of the TRC model or analogous psychosocial support programmes within the context of comprehensive, trauma-informed care for survivors of violent crime. Studies conducted within the USA and published in English between 2001 and 2026 will be included.All studies will be independently assessed for eligibility. Data will be extracted and mapped using the Consolidated Framework for Implementation Research (CFIR). Extracted data will be analysed and synthesised narratively across the five CFIR domains, accompanied by summary tables that describe how the findings relate to the review objective. Existing knowledge gaps will be identified and discussed. Ethics approval is not required for this scoping review. Experts from the National Alliance of Trauma Recovery Centers (NATRC) will be engaged to provide feedback on the study findings and support the dissemination of results. Dissemination activities will include peer-reviewed publications and presentations at academic conferences and professional events, such as NATRC's technical assistance and learning community training sessions.

Ethnic disparities in reproductive, maternal, neonatal and child health (RMNCH) persist in Latin America, rooted in structural racism and colonial legacies. Evidence on the temporal evolution of these disparities and the impact of policies targeting Indigenous populations remains limited. Following the 2000 economic crisis, Ecuador showed the region's largest ethnic gaps in intervention coverage and social determinants. Since 2008, inclusion policies have advanced. This study analysed trends in RMNCH coverage, social determinants and their potential association with policies and strategies over 14 years. Using a mixed-methods design, we analysed three nationally representative surveys (2004, 2012 and 2018) to assess changes in social determinants and the coverage of six RMNCH services; defined as the proportion of women and children receiving essential health services across the continuum of care, including family planning, antenatal care, skilled birth attendance and child immunisation, stratified by ethnicity (Indigenous women and children, Afro-Ecuadorian populations and Mestizo and White populations). We estimated absolute inequality measures and adjusted coverage ratios using Poisson regression models. Through a literature review and temporal graphs, we analysed plans, policies and strategies in health, education and ethnic inclusion during the same period to estimate potential impact. By 2018, Indigenous populations doubled their representation in the highest wealth quintiles (10% to 20%) and increased secondary education attainment (25% to 45%), with slower progress in rural areas. RMNCH coverage, including prenatal care, institutional deliveries and professional-assisted births, rose significantly (27% to 75%) among Indigenous populations. Afro-Ecuadorians also experienced improvements in RMNCH coverage and social determinants, though progress was less pronounced compared with Indigenous groups. Although ethnic gaps persisted, inequalities declined over the study period. These reductions coincided with increased social investment in rural health and education, constitutional recognition of plurinationality, and policies promoting intercultural health practices. However, gaps in monitoring and impact evaluation were evident. Ecuador demonstrates that inclusive and integrated policies, leadership, social participation and sustained social investment can reduce ethnic inequalities, promote the integral development of society and strategies that should be maintained. Temporal studies based on routine surveys are crucial for monitoring the impact of such policies. These findings provide a pre-pandemic benchmark and serve as a reference for countries aiming to improve health outcomes among Indigenous and Afro-descendant populations and advance the Sustainable Development Goals.

Breastfeeding provides well-documented benefits for both mothers and infants, yet global exclusive breastfeeding rates remain below target levels. Current research on lactation outcomes and challenges tends to focus on isolated factors, creating a fragmented evidence base. This scoping review aims to systematically map the existing literature on factors affecting lactation during the first 6 months post partum. We will develop and apply a Bio-Psycho-Social-Ecological (BPSE) integrative framework to organise the findings and identify gaps for future research. We will conduct this scoping review following the updated Joanna Briggs Institute (JBI) methodology and report findings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Systematic searches will be performed in PubMed, Cochrane Library, Scopus, Web of Science, CNKI, Wanfang and VIP databases. We will include systematic reviews, meta-analyses and randomised controlled trials published between January 2020 and October 2025. Two reviewers will independently screen articles and extract data. The extracted data will include study characteristics, trial registration status, examined factors or interventions and relevant lactation outcomes. Findings will be synthesised narratively and mapped within the BPSE framework. Ethical approval is not required as this scoping review will synthesise data from publicly available publications. The findings will be disseminated through publication in a peer-reviewed journal and presentations at relevant academic conferences. Open Science Framework https://doi.org/10.17605/OSF.IO/NXCRF.

Antimicrobial resistance (AMR) and plastic pollution are converging global crises that threaten both human health and environmental sustainability. Despite the growing recognition of these challenges, few legislative and policy frameworks acknowledge the complex interplay between antibiotic misuse and environmental plastic contamination. This protocol seeks to bridge that gap by critically examining policies in Europe and the Philippines, focusing on those that target antibiotic misuse and plastic pollution in human and animal health. Document analysis will be employed to systematically review relevant legislative and policy frameworks. We will retrieve laws, regulations and policy documents from official databases, government websites and other sources using broad inclusion criteria. The extraction process and analysis will be guided by the READ (Ready, Extract, Analyse, Distill) approach which will ensure a thorough examination of how these documents address the dual challenges of AMR and plastic pollution. Particular attention will be paid to identifying policy gaps, overlaps and synergies that may affect the overall effectiveness and coherence of current governmental responses. This policy review has been granted exemption from ethical review by the Research Institute for Tropical Medicine (RITM-IRB No. 2024-35), Philippines. The results are expected to provide a robust evidence base to inform the development of integrated policies at the nexus of global public health and environmental sustainability. Findings will be disseminated at academic conferences and peer-reviewed publications and to key stakeholders within European, Philippine, and international organisations. The detailed protocol is pre-registered and openly available on the Open Science Framework (https://osf.io/3tkn2/overview).

With the acceleration of the global ageing trend, sarcopenia has become a major public health problem. Probable sarcopenia, characterised primarily by decreased muscle strength, represents an early, potentially reversible stage. However, epidemiological evidence on the prevalence and risk factors of probable sarcopenia in older populations remains limited, scattered, and methodologically inconsistent. Therefore, systematic reviews and meta-analyses are needed to synthesise current data, quantify global and regional prevalence, identify associated risk factors, and explore sources of heterogeneity. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols 2020 and Joanna Briggs Institute (JBI) methodologies, this review will include observational studies that define probable sarcopenia according to recognised consensus criteria (European Working Group on Sarcopenia in Older People 2 and Asian Working Group for Sarcopenia 2). Comprehensive searches of eleven English and Chinese databases (Web of Science, PubMed, MEDLINE, Embase, Scopus, CENTRAL, CINAHL, CBM, CNKI, WANFANG, and VIP) will be conducted from inception to January 2026. Two reviewers will independently screen, extract, and appraise studies using JBI tools. Random-effects meta-analyses will be used to estimate global and regional prevalence and to synthesise the available evidence on associated risk factors. Pre-specified subgroup and meta-regression analyses will be undertaken to explore potential sources of heterogeneity across diagnostic criteria, geographical regions, and population characteristics. Ethical approval was not required for this protocol. The results of the final review will be disseminated in a peer-reviewed journal. CRD420251153142.

Sanaag and Sool are two remote regions in Somaliland with limited access to health service and high burden of HIV/AIDS. The aim of this study was to identify the predictors of HIV/AIDS awareness among women of reproductive age in underserved regions of Somaliland using data from the 2020 Somaliland Demographic and Health Survey through a cross-sectional analysis. A cross-sectional study using Somaliland Demographic and Health Survey data. The study was conducted in the Sanaag and Sool regions of Somaliland. These areas are characterised by underserved communities and ongoing internal conflict, which has significantly undermined the delivery of health services. Consequently, there is a high HIV/AIDS burden in these regions. The study focused on women of reproductive age, using data from the 2020 Somaliland Demographic and Health Survey for the analysis. The outcome variable of the study was awareness about HIV/AIDS and independent variables including education, media exposure, place of residence and wealth index were considered. The proportion of poor HIV/AIDS awareness is high in Sool and Sanaag, with 38.8% and 26.6% of women respectively having no awareness about HIV/AIDS. Findings indicate that women who had primary and above level of education (adjusted OR, AOR=2.25; 95% CI 1.99 to 2.53) and media exposure including radio (AOR=2.31; 95% CI 1.99 to 2.68) and television (AOR=3.94; 95% CI 3.45 to 4.5) are strong predictors of HIV/AIDS awareness. Women in urban areas (AOR=2.83; 95% CI 2.25 to 3.57) were more likely to have HIV/AIDS awareness compared with women in rural and nomadic settings. Inadequate awareness about HIV/AIDS was associated with education, residence and mass media exposure. Targeted health education programmes, promoting women's education status and media campaigns could help improve HIV/AIDS awareness, which in turn enables reproductive age women to take protective measures against exposure.

Angina with no obstructive coronary artery disease (ANOCA) affects millions and is frequently under-recognised because diagnostic pathways and risk tools predominantly target obstructive coronary artery disease (CAD). This protocol describes shared methods for two machine-learning (ML) studies: (1) differentiating ANOCA from stable angina with obstructive CAD and (2) predicting long-term mortality among patients with ANOCA and obstructive CAD. We will develop and cross-site validate ML classification models using a multicentre retrospective cohort drawn from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry and institutional datasets from the University of Ottawa Heart Institute and the University Health Network. Eligible participants are adults (≥18 years) undergoing initial cardiac catheterisation for chest pain/anginal equivalents since 1995, excluding prior revascularisation, major structural heart disease and predefined non-anginal indications. Outcomes are (1) ANOCA (0% to <50% stenosis) versus obstructive CAD (≥50% stenosis) and (2) 1, 3 and 5-year mortality, modelled separately for ANOCA and obstructive CAD.Model development will use nested cross-validation with stratified k-fold inner-loop tuning and leave-one-site-out cross-validation for repeated external validation. Candidate predictors will be harmonised across sites, filtered for missingness and refined using expert/directed acyclic graph-guided selection plus Boruta and Least Absolute Shrinkage and Selection Operator. Preprocessing includes appropriate encoding, missing-data imputation (multivariate imputation by chained equations) and feature scaling. Algorithms will include elastic-net logistic regression, random forest, LightGBM and multilayer perceptron models; hyperparameters will be optimised via Bayesian optimisation. Performance and threshold tuning will be reported. Explainability and subgroup fairness will be assessed using SHapley Additive exPlanations. Final models will be deployed as a web-based clinical risk calculator. Ethics approval has been obtained from the University of Calgary and the University Health Network (#24-5916). Analyses will use deidentified data in secure environments; only aggregate results will be reported. Findings will be disseminated via peer-reviewed publications, conferences and a web-based calculator.

The Needs Assessment Tool-Cancer (NAT-C) is a consultation guide to identify, triage and reduce unmet patient needs. We aimed to assess NAT-C fidelity, mechanisms of action and implementation issues in UK primary care as part of a clinical and cost-effectiveness cluster randomised controlled trial of the NAT-C for people with cancer compared with usual care (registration: ISRCTN15497400). Design: a mixed-methods process evaluation informed by normalisation process theory (NPT). 21 participating general practices in England were randomised to be trained to conduct an NAT-C guided consultation with people with cancer (excluding those in remission). General practitioner fidelity of intervention and clinical action resulting from the NAT-C consultation was noted. Two Normalisation MeAsure Development Questionnaire surveys were distributed to trained clinicians before (Survey 1) and after delivery of ≥2 NAT-C consultations (Survey 2). Semi-structured interviews were conducted with clinicians (post delivery ≥2 NAT-C consultations) and key stakeholders in primary and cancer care. Fidelity, action and paired before/after survey data were analysed using descriptive statistics. Interview data were analysed using a deductive thematic framework approach (NPT-informed). Data were narratively synthesised with cross-tabulated key findings. Of the 360/376 (96%) NAT-C consultations delivered, 258/360 (72%) resulted in clinical action, including 50 (13%) external referrals. 14 paired before (Survey 1, n=53) and after (Survey 2, n=29) responses. Survey 1 showed positive responses across all NPT domains, but while continuing to see relevance, usefulness and legitimacy, Survey 2 highlighted concerns about insufficient resources and management support. 16 clinician participants (eight GPs, eight key stakeholders; 50% male) completed interviews. Following synthesis, we identified five themes: (1) the perceived value of the NAT-C; (2) 'champions' are important at all levels (practice, regionally and nationally); (3) research evidence is seen as important, but influences implementation indirectly through policy, clinical guidelines and resourced initiatives; (4) adequate resources are fundamental for implementation beyond practice level and (5) NAT-C practicalities; training is adequate, but robust functional information technology systems are needed. Implementation requires champions and clinicians 'buy-in' to the patient value to legitimise use. In the context of current primary care pressures, resources were seen as essential to embed the NAT-C, but financial incentives were viewed with mixed feelings. ISRCTN15497400.

Obstructive sleep apnoea syndrome (OSAS) is a prevalent sleep disorder caused by recurrent upper airway collapse during sleep. Continuous positive airway pressure (CPAP) therapy is the most commonly prescribed treatment; however, adherence remains suboptimal, with non-compliance rates reported between 46% and 83%. Exercise-based interventions have demonstrated beneficial effects on respiratory muscle strength, upper airway function and sleep quality. This study aims to develop an interactive, web-based, game exercise platform (ApneaTheraPlay (ATP)) integrating respiratory, aerobic, strengthening and oropharyngeal exercises as an adjunct to CPAP therapy for individuals with OSAS, and to evaluate its effectiveness compared with a structured presleep exercise programme and a control condition. This study is designed as a single-blinded, three-arm, parallel-group randomised controlled trial. Individuals diagnosed with OSAS who use CPAP will be randomly allocated to the ATP group, the structured presleep exercise group (SPEG) or the control group (CG). Participants in the ATP and SPEG groups will perform exercise sessions three times per week for 12 weeks (36 sessions in total). The ATP group will use a web-based, interactive, game-based exercise system, whereas the SPEG group will follow a conventional video-based exercise programme delivered in a non-interactive format. Participants in the CG will continue their usual activities and record daily physical activity using an activity diary. The primary outcome measures will be the Apnoea-Hypopnoea Index and nocturnal oxygen saturation parameters. Secondary outcomes will include sleep quality, daytime functioning, fatigue, muscle strength and function, CPAP adherence, psychological status and technology usability. This study was approved by the Istanbul Medipol University Non-Interventional Clinical Research Ethics Committee (E-10840098-202.3.02-6266; 17 September 2025). The study will comply with the guidelines established by the International Committee of Medical Journal Editors (ICMJE) for clinical trial registration and reporting. The results of this trial will be disseminated through publication in peer-reviewed scientific journals and presentation at national and international scientific meetings. No individual participant data will be shared publicly. This study is supported by The Scientific and Technological Research Council of Turkey (TÜBİTAK) under project number 225S257. NCT07214636.