Practice Priorities Research Articles

Palliative Care Research and Clinical Practice Priorities in the United States as Identified by an Interdisciplinary Modified Delphi Approach.

Background: Palliative care demands in the United States are growing amid a comparatively small workforce of palliative care clinicians and researchers. Therefore, determining research and clinical practice priorities is essential for streamlining initiatives to advance palliative care science and practice. Objectives: To identify and rank palliative care research and clinical practice priority areas through expert consensus. Design: Using a modified Delphi method, U.S. palliative care experts identified and ranked priority areas in palliative care research and clinical practice. Priorities were thematically grouped and analyzed for topic content and frequency; univariate analysis used the median of each priority item ranking, with a cutoff median of ≤8 indicating >76% agreement for an item's ranking. Results: In total, 27 interdisciplinary pediatric and adult palliative care experts representing 19 different academic institutions and medical centers participated in the preliminary survey and the first Delphi round, and 22 participated in the second Delphi round. The preliminary survey generated 78 initial topics, which were developed into 22 priority areas during the consensus meeting. The top five priorities were (1) access to palliative care, (2) equity in palliative care, (3) adequate financing of palliative care, (4) provision of palliative care in primary care settings, and (5) palliative care workforce challenges. Conclusions: These expert-identified priority areas provide guidance for researchers and practitioners to develop innovative models, policies, and interventions, thereby enriching the quality of life for those requiring palliative care services.

Abstract PO1-01-04: The optimal neoadjuvant treatment regimen for HR+/HER2+ breast cancer: a network meta-analysis

Abstract Background In patients with the HR+/HER2+ breast cancer (BC) subtype, it can be more challenging to achieve pathological complete response (pCR) after neoadjuvant therapy compared with the HR-/HER2+ subtype. The importance of neoadjuvant therapy and the association of pCR with long-term clinical benefits have been widely demonstrated in HER2+ BC. This network meta-analysis aimed to identify the optimal anti-HER2 regimen, the role of endocrine therapy, and the better chemotherapy choice for the neoadjuvant treatment of HR+/HER2+ BC patients. Methods Literature for neoadjuvant clinical trials in HR+/HER2+ breast cancer was searched in Medline, EMBASE, Cochrane Library, and Web of Science for publications released before June 2023. Single-arm trials, retrospective studies, and observational studies were excluded, as well as studies containing no neoadjuvant phase and/or no anti-HER2 drugs. A network meta-analysis with the fixed-effect model in a Bayesian framework was performed. Odds ratios (ORs) with 95% confidence intervals (CI) for pathological complete response (pCR) analysis and hazard ratios (HRs) with 95% CI for event-free survival (EFS) were calculated. A ranking of treatment patterns was performed using SUCRA. (Registered in PROSPERO: CRD42023385644 Results 2,844 records were identified by the literature search, 60 trials were included after the screening, and valid data were extracted. 19 trials and 2,883 patients were included in the primary analysis of pCR. Compared with trastuzumab + chemotherapy (CT), three treatment regimens showed significantly higher pCR rates, T-DM1 based treatment (T-DM1, OR: 2.83, 95% CI: 1.90, 4.27; which includes T-DM1 alone, T-DM1 + pertuzumab or T-DM1 + endocrine therapy), trastuzumab + pertuzumab + CT (PH, OR: 2.57, 95% CI: 1.70, 3.94), and trastuzumab + tyrosine kinase inhibitor (TKI)+ CT (H+TKI, OR: 1.60, 95% CI: 1.22, 2.09; TKI includes lapatinib, neratinib and pyrotinib). The SUCRA ranking of pCR showed that T-DM1 was ranked first (SUCRA: 0.94), followed by PH (SUCRA: 0.85) and H+TKI (SUCRA: 0.60). PH came first in the SUCRA ranking of EFS (SUCRA: 0.74) as well as cumulative SUCRA combining pCR and EFS (SUCRA: 0.79). For chemotherapy strategies, platinum-containing regimens showed no significant increase in pCR rate compared to no platinum regimens (OR: 1.27, 95% CI: 0.95, 1.69), regimens with anthracycline also had no statistical difference from those without anthracycline (OR: 0.74, 95% CI: 0.51, 1.07). When assessing the impact of endocrine therapy, no significant difference in pCR rate was observed with or without endocrine therapy (OR: 1.18, 95% CI: 0.80, 1.73). Conclusions The PH regimen remains the best neoadjuvant treatment choice for HR+/HER2+ early BC patients considering pCR and EFS outcomes simultaneously. H+TKI did not show significant benefits, so it is not recommended to be given priority in clinical practice. The platinum-containing regimen’s potential benefit compared to the non-platinum regimen is uncertain and needs more clinical investigation. The necessity of adding endocrine therapy is not proven due to limited data availability. Funding: This study was sponsored by Shanghai Roche Pharmaceuticals Ltd. Disclosure: Hao Tang, Shanghai Roche Pharmaceuticals Ltd.: Employee (Ongoing), Salary (Ongoing) Yajing Feng, Shanghai Roche Pharmaceuticals Ltd.: Employee (Ongoing), Salary (Ongoing) Xin Yu, Shanghai Roche Pharmaceuticals Ltd.: Employee (Ongoing), Salary (Ongoing) Citation Format: Hao Wang, Shiwei Liu, Miao Yu, Kun Mi, Exian Mou, Li Xia, Weimin Xie, Hao Tang, Yajing Feng, Xin Yu. The optimal neoadjuvant treatment regimen for HR+/HER2+ breast cancer: a network meta-analysis [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-01-04.

DEVELOPMENT OF THE NEXT ESSA RESEARCH STRATEGY

INTRODUCTION The generation and use of research is a function within ESSA and the first research strategy was developed for the period 2018 - 2021. Research program activities are diverse. ESSA has hosted the Research Committee and the Publications Committee for 5 years. ESSA has facilitated the development of member-driven Guidelines, Consensus and Position Statements for use by professionals in practice. ESSA has hosted an annual Research Grant Program and a biannual scientific conference. This paper outlines the research strategy development project. METHODS The previous strategy delivered research grants and ESSA publications. Investments were made into administration and research governance including release of the ESSA Research Publications Development Guideline. Consultation on the development of the next Research Strategy included presentations and surveys to engage members, key stakeholders and staff about: the program; the key strategy pillars; principles; and actions. Actions were assessed for feasibility and priority. RESULTS The outcomes of the consultation on the ESSA Research Strategy 2023-2026 identified four pillars of capacity building, engagement, translation and data, and research for policy and practice priorities. The use of research publications by ESSA accredited professionals and industry will be guided by a translation framework, aligning with the objectives of the National Health and Medical Research Council (NHMRC) Translation Strategy 2022-2025, the resources of the National Centre of Implementation Science and the ESSA Strategic Plan. This will support members to leverage research findings, to encourage researchers to develop translation collateral and to implement new research results. The strategy will have actions, references and tools to help accredited professionals to engage in research translation. CONCLUSIONS The Research Strategy and translation framework will be outlined. The paper will include examples relating to physical activity. ESSA’s next Research Strategy is to further support research generation and use by ESSA accredited professionals, staff and the industry.

Palliative psychiatry: research, clinical, and educational priorities.

Palliative psychiatry has been proposed as a new clinical construct within mental health care and aims to improve quality of life (QoL) for individuals experiencing severe and persistent mental illness (SPMI). To date, explorations of palliative psychiatry have been largely theoretical, and more work is needed to develop its approaches into tangible clinical practice. In this paper, we synthesize existing literature with discussions held at a one-day knowledge user meeting titled "A Community of Practice for Palliative Psychiatry" to generate priorities for research, clinical practice, and education that will help advance the development of palliative psychiatry. Palliative psychiatry will benefit from research that is co-produced by people with lived experience (PWLE) of mental illness, that clarifies contested concepts within mental health care and wider medicine, and that adapts existing interventions that have the potential to improve the QoL of individuals experiencing SPMI into the mental health care context. Specific methods and tools might be developed for use in clinical spaces taking a palliative psychiatry approach. More work must be done to understand the populations that might benefit from palliative psychiatry, and to mitigate mental health care providers' (MHCPs') anxieties about using these approaches in their work. As palliative psychiatry is developed, current MHCPs, trainees, individuals experiencing SPMI, and their loved ones will all require education about and orientation to this novel approach within mental health care. There are several priorities in research, clinical practice, and education that can help advance the development of palliative psychiatry. All future work must be considered through a human rights-based, anti-oppressive lens. Research projects, clinical models, and educational initiatives should all be developed in co-production with PWLE to mitigate the epistemic injustices common in mental health care.

Research and practice priorities in pilonidal sinus disease: a consensus from the PITSTOP study.

Pilonidal sinus disease is a common condition treated by colorectal surgeons. There is a lack of literature in the field to guide optimal management of this condition. As part of the PITSTOP study, we aimed to identify policy and research priorities to provide direction to the field. Patients and surgeons were invited to participate. A 'So what, now what' exercise was conducted, informed by data from PITSTOP. This generated statements for research and practice priorities. A three-round online Delphi study was conducted, ranking statements based on policy and research separately. Statements were rated 1 (not important) to 9 (important). Statements that were rated 7-9 by more than 70% of participants were entered into the consensus meeting. Personalized voting feedback was shown between rounds. A face-to-face meeting was held to discuss statements, and participants were asked to rank statements using a weighted choice vote. Twenty-two people participated in the focus group, generating 14 research and 19 policy statements. Statements were voted on by 56 participants in round 1, 53 in round 2 and 51 in round 3. A total of 15 policy statements and 19 research statements were discussed in the consensus round. Key policy statements addressed treatment strategies and intensity, surgeon training opportunities, need for classification and the impact of treatment on return to work. Research recommendations included design of future trials, methodology considerations and research questions. This study has identified research and policy priorities in pilonidal sinus disease which are relevant to patients and clinicians. These should inform practice and future research.

The International Performance, Resilience and Efficiency Program Protocol for the Application of HRV Biofeedback in Applied Law Enforcement Settings

Law enforcement officers are routinely exposed to high-threat encounters that elicit physiological stress responses that impact health, performance, and safety. Therefore, self-regulation using evidence-based approaches is a priority in police research and practice. This paper describes a five-module heart rate variability biofeedback (HRVB) protocol that is part of a larger resilience program (the International Performance Resilience and Efficiency Program – iPREP) established in 2014. Supported by 10 years of user-informed research and development, our methods are tailored to address occupational stressors and the practical realities of training and resource availability in operational settings. Building on existing clinical methods that comprise five to six weekly sessions and up to 40-min of daily practice, our iPREP HRVB protocol is typically delivered in a condensed format across 2–3 days and is seamlessly integrated with reality-based training scenarios commonly employed in policing. By combining best practices in clinical HRVB with police-specific pedagogical frameworks, officers receive accelerated and job-relevant training to adaptively modulate autonomic responses to acute and chronic stress. Efficacy of the iPREP HRVB protocol is supported by several research studies of various methodological designs (i.e., randomized control trial, longitudinal cohort) that demonstrate immediate and sustained improvements in police performance and physiological health outcomes. We conclude with a critical appraisal of the available empirical evidence contrasting common and emerging breathing techniques proposed for use in operational policing contexts. The critical appraisal guide is intended to serve as a resource for law enforcement agencies, governing bodies, and operators when choosing appropriate and effective self-regulation training approaches.

American Board of Internal Medicine Nephrology Procedure Requirements for Initial Certification: Time for a Change and Pursuing Consensus in the Nephrology Community

In 1988, the American Board of Internal Medicine (ABIM) defined essential procedural skills in nephrology, and candidates for ABIM certification were required to present evidence of possessing the skills necessary for placement of temporary dialysis vascular access, hemodialysis, peritoneal dialysis, and percutaneous renal biopsy. In 1996, continuous renal replacement therapy was added to the list of nephrology requirements. These procedure requirements have not been modified since 1996 while the practice of nephrology has changed dramatically. In March 2021, the ABIM Nephrology Board embarked on a policy journey to revise the procedure requirements for nephrology certification. With the guidance of nephrology diplomates, training program directors, professional and patient organizations, and other stakeholders, the ABIM Nephrology Board revised the procedure requirements to reflect current practice and national priorities. The approved changes include the Opportunity to Train standard for placement of temporary dialysis catheters, percutaneous kidney biopsies, and home hemodialysis which better reflects the current state of training in most training programs, and the new requirements for home dialysis therapies training will align with the national priority to address the underuse of home dialysis therapies. This perspective details the ABIM process for considering changes to the certification procedure requirements and how ABIM collaborated with the larger nephrology community in considering revisions and additions to these requirements.

Service Users’ and Providers’ Experiences and Perceptions of Mental Health Accommodation Services: A Rapid Qualitative Synthesis of International Evidence

Background. There is a high prevalence of homeless people with psychotic disorders and supported housing is often required. However, there is little evidence about supported housing services, especially in low-middle income countries. This rapid review synthesizes evidence about the experiences of users and providers of community-based accommodation services for people living with serious mental illness internationally to understand priorities for policy and practice. Methods. PubMed, PsycINFO, Google Scholar, and reference lists were searched to identify 1344 studies. The inclusion criteria specified qualitative studies about users’ and/or providers’ views of the accommodation services for adults aged 18+ years with serious mental illness. Title, abstract, and full-text screening were conducted in duplicate, and quality appraisal was conducted using the standard for reporting qualitative research tool. Data extraction was conducted using both Excel and Word documents, and we used thematic analysis to report findings. Results. Only 43 studies were identified for inclusion. Service users’ and providers’ experiences of accommodation services from high income countries and low-middle income countries were similar. Both the service providers and users appreciated housing, and service providers mentioned it was not a sufficient step towards independent living. Shortage of resources in low-middle income countries made it challenging for some service providers to provide care because they had to choose between buying medicine or food. While service users needed greater availability of service providers, providers were at risk of burnout. Although some service providers were trained to respond to stigmatizing events, some users continued to experience stigma from their family members, society, and service providers. Conclusions. People living with serious mental illness and service providers value the housing provision but globally their experience of this provision is relatively poor compared to mainstream society, suggesting people living with serious mental illness remain disadvantaged. Further research should explore low-cost housing options that will provide quality person-centered care for people living with serious mental illness.

Atypical anorexia nervosa: A scoping review to determine priorities in research and clinical practice.

There is currently a limited understanding of the identification, nature, and treatment of Atypical Anorexia Nervosa (AAN). Recent systematic reviews have identified only small numbers of candidate papers, and some areas lack any meaningful review so far - particularly treatment outcomes. A key issue is the lack of clarity in the literature regarding the definition of weight loss criteria. This scoping review aimed to determine the nature and extent of our knowledge of AAN, in order to assist in the development of future systematic reviews and meta-analyses, as well as indicating what further research is needed. Following the identification of 6747 records, 317 records using the term AAN or a defined equivalent were identified from six databases, including the 'grey' literature. Of the 317 studies, 111 provided participant characteristics, and only 10 provided discrete treatment outcomes. Each of these subsets of the data are tabulated and supported with supplementary material, so that future systematic reviewers can access this resource. The pattern and content of the existing studies allows recommendations to be made regarding future reviews, research and clinical practice. There is a particular need for clear weight/weight loss criteria and adequate interventions.

The Right to Equal Health: Best Practice Priorities for Māori with Bipolar Disorder from Staff Focus Groups.

Bipolar disorder (BD) is a serious mental health condition that is clinically complex to monitor and manage. While best practice guidelines exist, they vary internationally lacking consensus. Indigenous peoples, including Māori in New Zealand, experience higher community rates of BD. While New Zealand practice guidelines recommend providing culturally responsive care to Māori, studies show that Māori do not receive best practice. This qualitative study aimed to share the evidence about patterns of health service use and Māori patient experiences with focus group participants involved in the design and delivery of BD services, to discuss and develop guidelines for best practice for Māori with BD and address areas of unmet need. Three focus groups were conducted with 22 participants involved in the delivery of services to Māori with BD across three sites. Willing participants were sent background information and three focus group questions framed to elicit priority solutions to improve clinical, structural and organisational features of mental health service delivery for Māori patients with BD and their whānau (family). The nominal group technique was used to synthesise responses, and then develop a prioritised list of proposed solutions. Results identified system-level changes required at the clinical, structural and organisational levels of healthcare. Findings further evidence the need for healthcare reform in New Zealand, to be responsive to Māori with BD.

Cancer in general practice research priorities in Australia.

The Primary Care Collaborative Cancer Clinical Trials Group (PC4) is funded by Cancer Australia to support the development of new cancer in primary care research. We undertook a research prioritisation exercise to identify cancer research priorities in Australian general practice. We adapted the nominal group technique, including a literature search and stakeholder survey. An expert group from the Primary Care Collaborative Cancer Clinical Trials Group consolidated and ranked priorities. A second stakeholder survey reviewing the top 50 priorities informed a final prioritisation workshop. Overall, 311 priorities were identified across the cancer continuum. Nearly one-third of priorities were related to cancer survivorship and included strategies to detect recurrence, behavioural interventions and tools to assess physical and psychosocial aspects of survivorship. Prevention/early detection comprised 43.4% of priorities. Palliative care produced the least priorities (9.6%). Cross cutting research priorities (15.1%) included quality and models of care. This is the first study to identify cancer research priorities for general practice in Australia. It could be used to inform the development of targeted research and funding to improve the care and outcomes for Australians affected by cancer.

‘Patience, persistence and proportionality’: Probation officer's perspectives of desistance in practice

Desistance from crime is a priority for criminal justice policy and practice yet the term carries varying definitions across research literature. Contemporary discourses promote a refocusing from desistance's representation as an individual's personal journey, to understanding desistance more akin to a social movement. Research has predominantly focused on the lived experience of those striving to achieve desistance, with practitioner perspectives remaining under researched. This study, conducted post COVID-19, aimed to explore and evaluate how probation officers operationalise desistance in practice. Outcomes evidence that whilst practitioners acknowledge the diverse conceptualisations of desistance, it remains a priority in practice, even where the focus is predominantly risk management. Key practice features emerging as essential to promoting desistance include identifying and cultivating a motivation to change, approaches to forming the supervisory relationship and how practitioner's respond when risks increase. A supporting organisational ethos is critical but challenged in the complex post COVID-19 context.

An insight into healthcare professionals' perspectives on discussing implantable cardioverter defibrillator deactivation.

International studies have examined patients' views concerning the discussion of deactivating an implantable cardioverter defibrillator (ICD). Findings reported that many patients were either not informed about the subject or were informed late in their illness trajectory. This study aimed to explore healthcare professionals' perspectives on discussing ICD deactivation and identify priorities for clinical practice and future research. Eleven interviews were conducted, involving heart failure nurses, physicians, and an allied professional. All were responsible for the care of patients with an ICD, from the UK or Sweden. A semi-structured guide was used. All interviews were audio-recorded, transcribed, translated (as applicable), and analysed independently by experienced researchers, using framework analysis. Findings were presented, along with published work at a stakeholder meeting, and a consensus agreement was reached on priorities for clinical practice and future research. Four themes emerged from the exploratory interviews. Healthcare professionals described the discussion about deactivation as challenging, requiring compassion and involvement of family members. They agreed that the topic should be initiated prior to, or shortly after, device implantation. This was reflected in the priorities to improve communication, through the increased availability and implementation of prompts and tools, as well as the provision of tailored information to patients and family members. Stakeholders recognized the future potential of digital technology in device education. Discussing deactivation remains challenging. Healthcare professionals recognized the need to initiate the discussion early, with compassion and involvement of family members. Priorities were agreed by stakeholders, which require clinical implementation and further research.

Premature mortality projections to inform clinical practice and public health priorities

Premature mortality projections to inform clinical practice and public health priorities

Assessing urban livability in Shanghai through an open source data-driven approach

Urban livability has become a major policy and practice priority in many parts of the world. However, its attainment remains challenging in many cities of developing and emerging economies. The lack of data with appropriate quality, coverage, and spatial and temporal resolution often complicates both the assessment of livability in such cities and the identification of priority areas for improvement. Here we develop a framework to mobilize and synthesize open-source data to analyze spatially urban livability patterns in Shanghai. The framework brings together diverse types of open-source data including housing characteristics, population distribution, transportation networks, and points of interest to identify city areas with low livability, and thus priority areas for improvement. Such findings can provide a comprehensive overview of the residential living conditions in Shanghai, as well as useful information to urban planners and decision-makers. Furthermore, subject to data availability, the proposed method has the potential for application in other cities.

Patterns of Chlamydia trachomatis and Neisseria gonorrhoeae in different anatomical sites among Pre-Exposure Prophylaxis (PrEP) users in Brazil

BackgroundThe presence of untreated sexually transmitted infections (STIs) significantly increases the chance of acquiring HIV. In Brazil, testing for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) among Pre-Exposure Prophylaxis (PrEP) users is insufficient, and syndromic treatment is a priority in clinical practice. Multi-site testing for CT/NG improves thescreening of asymptomatic cases and ensures timely treatment. Therefore, it is essential for HIV prevention. This study aims to test the importance of two-site testing for better screening of these pathogens and to determine whether the presence of symptoms is an indicator of CT/NG infection.MethodsThis is a cross-sectional study carried out in four public infectious diseases clinics in São Paulo State, Brazil between January of 2022 and March of 2023. All participants had an anal swab and a first-pass or mid-stream urine collected for CT/NG analysis by Polymerase chain reaction (PCR). Data about sociodemographic, sexual behavioural and clinical aspects were collected. Pathway analysis was used to examine the direct and indirect relationships between variables according to the theoretical model.ResultsWe screened 171 PrEP users which had two samples collected, resulting in 342 samples. Comparing the anatomic sites, the urine samples showed lower sensitivity for CT and NG than anal samples. Gonorrhoea was directly linked to lower age (β= -0.161, p = 0.001). Time of PrEP use was directly associated with CT infection (β = 0.202; p = 0.042) and inversely associated with dysuria (β= -0.121, p = 0.009). Lower occurrence of yellow-green secretion was linked to detection of CT (β= -0.089, p = 0.005) and NG (β= -0.048, p = 0.002) infections. Foul-smelling discharge was directly associated with CT (β = 0.275, p = 0.004) and NG (β = 0.295, p = 0.037) infection.ConclusionThe symptoms are a bad indicator of CT and NG infection, and the screening must be done in more than one site since most of the positive results would be missed if only urines were tested. In the case of testing only one anatomical site, specifically the urethra, the CT/NG incidence and prevalence would be underestimated. The two-sites testing improves detection rates of CT/NG, and PrEP follow-up benefits people offering STI testing.

Reengagement with Physiology in Neonatal Heart and Lung Care: A Priority for Training and Practice

Reengagement with Physiology in Neonatal Heart and Lung Care: A Priority for Training and Practice

A national survey of sedation practice and clinicians’ attitudes regarding sedation-related research in the UK paediatric intensive care units

AimsResearch involving analgo-sedation is a priority for parents and professionals in paediatric intensive care, and current guidelines are based on low-quality evidence. Future research will require an understanding of current practice and research priorities of healthcare professionals. This survey aimed to identify perceived barriers to research, describe the current UK analgo-sedation practice and assess outcome priorities for future research.MethodsA 26-question web-based survey was emailed to all Paediatric Critical Care Society members (n=1000) in April/May 2021. Responses were analysed either by ‘unit’ or at the individual respondent level. Questions related to four patient categories: ‘infant (< 3 months of age) ‘paediatric’ > 3 months of age, ‘cardiac’ and ‘non-cardiac’.ResultsTwo hundred sixteen healthcare professionals responded and responses were available from 100% of the UK paediatric intensive care units (n=29) for all questions. Most units (96%, 28/29) routinely use scoring systems for sedation adequacy but few routinely screen for delirium (24%, 7/29). The most highly prioritised outcome measure was the duration of mechanical ventilation. Respondents were most likely to agree to randomise paediatric general intensive care patients to trials comparing two different alpha agonists and least likely to randomise neonatal cardiac patients to trials comparing benzodiazepines with alpha agonists. The most common perceived barrier to research was unit familiarity with a particular regimen, followed by the perception that parents would not provide consent.ConclusionsThis study provides a snapshot of the UK analgo-sedation practice and highlights the importance of public involvement in planning future trials, as well as consultation work across the spectrum of stakeholder clinicians to maximise the acceptability of study design.

A protocol for a systematic review and meta-analysis of tuberculosis care around the time of pregnancy.

Tuberculosis is estimated to cause 1.5 million deaths annually and is most common during the reproductive years. Despite that fact, we found that tuberculosis screening, prevention or care recommendations for people around the time of pregnancy were absent from some national policy recommendations and varied in others. To address the apparent gaps and inconsistencies in policy, we aim to design a systematic review and meta-analysis of the original research evidence informing tuberculosis care around the time of pregnancy. With assistance from librarians at the Biomedical library of the University of Gothenburg, Pubmed, CINAHL and Scopus databases will be searched. Search terms will aim to identify studies generating original research evidence informing care for tuberculosis around the time of pregnancy. Evidence may include: the outcome of TB and/or of pregnancy; the cost-effectiveness or acceptability of any intervention; the sensitivity and specificity of any assessment, selection, diagnostic or test criterion. The output from these literature searches will be screened by two independent reviewers to select the eligible studies for inclusion. Discrepancies will be resolved with a third reviewer. Firstly, publications that provide contextual data will be tabulated, summarising their main contributions. Secondly, studies that provide evidence directly guiding patient care will be our focus and will be considered to be key. The key studies will be subject to quality assessment, data extraction and when possible, meta-analysis. This systematic review and meta-analysis aims to guide policy, practice and future research priorities concerning tuberculosis care around the time of pregnancy.

An Environmental Scan of Canadian Kidney Transplant Programs for the Management of Patients With Graft Failure: A Research Letter.

Kidney transplant recipients with graft failure (KTR-GF) and those with a failing graft are an increasingly prevalent group of patients. Their clinical management is complex, and outcomes are worse than transplant naïve patients on dialysis. In 2023, the Kidney Disease: Improving Global Outcomes (KDIGO) organization reported findings from a controversies conference and identified several clinical practice priorities for KTR-GF. As an exercise in needs assessment, we aimed to collate and summarize current practices in adult Canadian kidney transplant programs around these KDIGO-identified clinical practice priorities. Environmental scan followed by content analysis. Canadian adult kidney transplant programs. We categorized the themes of our content analysis around 7 clinical practice priorities: (1) determining prognosis and kidney failure trajectory; (2) immunosuppression management; (3) management of medical complications; (4) preparing for return to dialysis; (5) evaluation and listing for re-transplantation; (6) management of psychological effects; and (7) transition to supportive care. We solicited documents that identified each program's current care practices for KTR-GF or patients with a failing graft, including policies, procedures, pathways, and protocols. A content analysis of documents and informal correspondence (email or telephone conversations) was done to extract information surrounding the 7 practice priorities. Of the 18 programs contacted, 12 transplant programs participated in this study and a document from a provincial organization (where 2 non-responding programs are located) was procured and included in this analysis. Overall, practice gaps and discrepancies were noted. Many participants highlighted the lack of evidence or consensus to guide the management of KTR-GF as the key reason. Immunosuppression management was the most frequently addressed priority. Six programs and the provincial document recommended a nuanced approach to immunosuppressant management based on clinical factors and re-transplant candidacy. Two programs used the Kidney Failure Risk Equation and eGFR to determine referral trajectories and prepare patients for return to dialysis. Exact processes outlining medical management during the transition were not found except for nephrectomy indications and in 1 program that has a specific transition clinic for KTR-GF. All programs have a formal or informal policy that KTR-GF should be assessed for re-transplantation. Referrals for psychological support and transition to supportive care were made on a case-by-case basis. Our environmental scan was at risk of non-response bias and restricted to transplant programs. Kidney clinics and dialysis units may have relevant policies and procedures that were not examined. The findings from our environmental scan suggest gaps in care and potential areas for quality improvement, including a lack of multidisciplinary care, structured dialysis preparation and psychological support. There is also a need to prioritize research that generates evidence to guide the management of KTR-GF and contributes to the aim of developing clinical practice guidelines.