To assess the level of alarm fatigue among intensive care unit (ICU), cardiac care unit (CCU) and emergency room (ER) nurses, identify associated demographic and occupational factors, determine the most frequent sources of alarms and evaluate nurses’ psychological reactions to alarms.

A cross-sectional, descriptive–analytical study.

ICUs, CCUs and ERs of six public teaching hospitals affiliated with Tehran and Kashan Universities of Medical Sciences in Iran.

Using a multistage stratified random sampling method, 285 nurses were approached, of whom 260 completed and returned the questionnaires (response rate: 91%). Participants were registered nurses with at least a bachelor’s degree or higher and 3 months of experience in ICUs, CCUs or ERs.

The primary outcome was the level of alarm fatigue measured using the validated Nurses’ Alarm Fatigue Questionnaire. Secondary outcomes included factors associated with alarm fatigue and nurses’ reported psychological responses to frequent alarms.

The mean score of alarm fatigue was 26.4±7.9, indicating a moderate level. After adjusting for confounders and hospital-level clustering using multivariable mixed-effects regression, higher monthly income was significantly associated with lower alarm fatigue (β=–0.15, p=0.03), and nurses working rotational shifts reported significantly higher fatigue compared with those with fixed shifts (β=0.18, p=0.02). Other demographic and occupational factors were not significant. Reported psychological reactions to alarms included indifference (14%), irritability (18%) and anxiety/stress (15%).

ICU, CCU and ER nurses experience a moderate level of alarm fatigue, with income and shift type as independent associated factors. The association between income and alarm fatigue may reflect the role of financial stress as an additional job demand that compounds the burden of frequent alarms, particularly in contexts where low base salaries lead nurses to rely on overtime and multiple shifts. These findings underscore the need for targeted managerial and educational interventions, including shift schedule optimisation and attention to workload-related stressors, alongside alarm prioritisation strategies. Due to the cross-sectional design, causal inferences cannot be drawn.

This study aimed to address the spatial distribution and multilevel analysis of healthcare access barriers among women of reproductive age in Somalia.

The study was conducted across Somalia, an East African country facing significant spatial disparities in healthcare access. A cross-sectional study design was employed, using data from the 2020 Somali Demographic and Health Survey (SDHS). The data were analysed using both multilevel logistic regression and spatial analysis. To pinpoint barriers and identify statistically significant spatial clusters, the data were analysed using multilevel logistic regression in Stata V.17 and spatial analysis in R Studio (V.4.4.1), respectively.

The study population consisted of a weighted sample of 5118 women of reproductive age (15–49 years) from the SDHS.

Spatial analysis revealed significant regional heterogeneity, with high-prevalence areas concentrated in the northern region of Togdheer and a south-central cluster encompassing Galguduud, Hiiraan and Bakool. Multilevel analysis presented that women in the Bay region had nearly 10 times (AOR: 9.62) the risk of facing healthcare access barriers. While women in the highest quintile of wealth (AOR 0.21), those in higher education (AOR 0.30), those aged 45–49 (AOR 0.49) and not currently working (AOR 0.46) were significantly less likely to report access barriers.

Healthcare access barriers in Somalia are driven by a complex interplay of socioeconomic factors, specifically maternal age, education, employment and household wealth, and profound geographical disparities. Access barriers are not uniform but are geographically clustered in the south-central regions (Bay, Bakool, Hiiraan) and Togdheer in the northern region. Policy efforts must prioritise infrastructure investment in these identified high-burden hotspots while simultaneously dismantling systemic inequalities through the expansion of female education and financial protection schemes. This data-driven approach offers a definitive roadmap for decision-makers to equitably allocate resources and ensure that the most vulnerable populations are not left behind.

The timing of a woman’s first birth is significantly associated with maternal and child health outcomes and socioeconomic opportunities. Delaying the first birth is associated with reduced risks of adolescent pregnancy complications, improved birth outcomes and enhanced interpregnancy intervals, all of which contribute to better maternal and child health. In Somaliland, early childbearing is prevalent, necessitating an understanding of its associated factors. Early childbearing, defined as a first birth before age 20, is prevalent in Somaliland, with 47.02% of women having their first birth by this age, significantly higher than the average for sub-Saharan Africa (approximately 30%) and global figures.

This study aimed to identify the sociodemographic factors associated with age at first birth among married women in Somaliland.

The median duration from marriage to first birth was 3 years, with a median age at first birth of 21 years. Women residing in the Sool (adjusted HR: 1.318, 95% CI 1.138 to 1.527) and Sanaag (adjusted HR: 1.265, 95% CI 1.095 to 1.462) regions had a significantly higher hazard of first birth compared with those in Awdal (reference). Conversely, women in the middle (adjusted HR: 0.821, 95% CI 0.685 to 0.985) and highest (Adjusted HR: 0.799, 95% CI 0.663 to 0.964) wealth quintiles had a significantly lower hazard of first birth compared with the lowest wealth quintile. Age at first marriage was a strong factor associated with the outcome; marrying at age 20 or older (adjusted HR: 0.699, 95% CI 0.644 to 0.759) was associated with a significantly lower hazard of first birth compared with those who married before age 20. After adjustment, other factors including residence, media exposure and husband’s employment status were not significantly associated with the timing of first birth.

Region, wealth quintile and age at first marriage are critical factors associated with first birth timing in Somaliland. Interventions should focus on addressing regional disparities and promoting delayed marriage to improve maternal and child health outcomes. Further research is needed to explore the complex social and cultural drivers of these findings.

Visual Patient Predictive (VPP) is an AI-based extension of the Visual Patient Avatar (VPA) that integrates deep learning models to predict upcoming vital sign deviations and display them as dashed visual elements. By explicitly showing anticipated changes, the system aims to support level 3 situation awareness—the projection of future patient states. This multicentre simulation study will evaluate whether predictive algorithms and visualisations integrated into the VPA (resulting in VPP) improve clinicians’ ability to anticipate critical vital sign changes compared with conventional number-based and waveform-based monitoring and examine its effects on decision-making, confidence, workload and user acceptance.

This investigator-initiated, randomised, within-subjects crossover, computer-based simulation trial will be conducted at five academic centres in Switzerland, Germany and the United States. Medical professionals from anaesthesiology departments will complete scenario-based prediction tasks using both VPP (as the index test) and conventional monitoring (as the reference standard) in randomised order, with the same participant evaluating both modalities and the identical underlying clinical scenario used in each condition, following video-based training and a learnability test. The primary outcome is recall (true positive rate) of vital sign deviation predictions. Secondary outcomes include average lead time, precision, prediction confidence, number and correctness of proposed interventions, perceived workload (NASA-TLX) and qualitative usability feedback. Quantitative data will be analysed using a logistic generalised linear mixed model with random intercepts for centre and participant, and a random slope for the intervention effect. Qualitative interviews will undergo thematic analysis.

The leading ethics committee (Zurich, Switzerland; BASEC-Req-2023–00465) reviewed and approved the study protocol. Ethics committees at the other participating centres have obtained their respective approvals or waivers. Bonn: 2025–144-BO, Boston: 2025P000501, Heidelberg: S-376/2025, Munich: 2025–357 W-CB. As this simulation study involves only healthcare professionals performing prediction tasks based on simulated vital sign scenarios—without collection of patient data or any medically relevant personal data—it does not constitute human subjects research under applicable regulations. Study results will be disseminated through peer-reviewed publications and presentations at scientific conferences.

Self-care plays a pivotal role in the management of heart failure (HF). Health literacy and empowerment are considered the prerequisites of effective self-care. This project aims to improve self-management in people with HF by describing, analysing and enhancing the communication practices of clinicians and patients to support people with HF to increase their health literacy skills and participate in shared decision-making.

A multimethod research design incorporating an interview component, a concurrent mixed-methods component and a pilot intervention study is used. The study is currently being conducted at two Australian hospitals in metropolitan areas (one public and one private). The interview component involves semistructured interviews with healthcare providers and hospital executives and managers at the participating sites to explore perceived barriers and facilitators to HF self-management and understand the institutional context of HF care. The concurrent mixed-methods components include: (a) tracking and audio recording the clinical interactions of patients with HF (n=30) during their hospitalisation and up to 6 months after discharge and semistructured interviews with the patient (and the carer) and the participating clinician after each clinical interaction and (b) collecting longitudinal survey data (n=180, patients) to track patients’ health literacy, empowerment and self-management over 6 months. The pilot feasibility study includes developing a complex intervention for clinicians and patients and evaluating its acceptability and potential in improving health literacy and reducing readmissions, length of stay and costs.

This study was approved by the Australian Capital Territory Health (2023.ETH.00007) and Edith Cowan University (023–04314-SAUNDERS) Human Research Ethics Committees. Informed consent was obtained and will continue to be sought from all participants. Study results will be disseminated in peer-reviewed journals.

To examine demographic, behavioural and clinical determinants of self-rated health (SRH) among Iranian adults with hypertension (HTN), with a particular focus on the association between blood pressure (BP) control and perceived health.

National cross-sectional analysis of 15 predictors spanning demographic, lifestyle and clinical domains.

2021 Iranian STEPwise Approach to Non-communicable Disease Risk Factor Surveillance, a nationally representative survey.

A total of 8812 adults with HTN (mean age 56.97 years; 57% female). Controlled HTN was defined as systolic blood pressure

The primary outcome was SRH, measured on a standard EuroQol-Visual Analogue Scale (0–100).

Controlled HTN was independently associated with higher SRH scores (β=1.31, 95% CI 0.07 to 2.54). Positive predictors of SRH included male gender (β=4.34, 95% CI 3.38 to 5.31), higher wealth (richest vs poorest: β=5.52, 95% CI 4.06 to 6.97), sufficient physical activity (β=4.38, 95% CI 3.48 to 5.28), healthier diet (β=3.06, 95% CI 1.99 to 4.14) and complementary insurance coverage (β=2.50, 95% CI 0.63 to 4.37). Significant negative predictors included diabetes mellitus (β=–4.23, 95% CI –5.59 to –3.26), dyslipidaemia (β=–3.61, 95% CI –4.62 to –2.59), people who smoke (β=–4.21, 95% CI –5.64 to –2.78) and older age. Notably, antihypertensive medication use showed one of the strongest negative associations with SRH (monotherapy: β=–4.83; combination therapy: β=–5.28), likely reflecting underlying disease severity and treatment burden.

Better SRH among hypertensive adults was associated with controlled BP, healthier lifestyle patterns and higher socioeconomic status. Conversely, comorbidities, smoking, older age and antihypertensive treatment were linked to poorer perceived health. Integrating SRH screening into HTN management may help identify vulnerable individuals and inform targeted interventions addressing behavioural and socioeconomic determinants of health.

Systematic reviews (SRs) on the management of temporomandibular disorders (TMDs) have predominantly focused on evaluating the effectiveness of various treatments, identifying those that provide the greatest benefits. However, the economic evaluation of these treatments has not been systematically explored. This SR aims to address this gap by evaluating the economic outcomes of the most common treatment modalities for TMDs, including cost-effectiveness, cost-utility, cost-benefit, cost-minimisation and the burden of illness.

This SR will be conducted using the following electronic databases Business Source Complete, CINAHL, EconLit (ProQuest), Embase (Ovid), MEDLINE (PubMed), MEDLINE (Ovid) and Scopus to identify studies evaluating the economic outcomes of treatments for TMDs. The eligibility criteria are as follows: (1) studies examining the costs and/or impact of treatments for TMDs and (2) articles published between 2000 and 2025. The primary outcomes of interest are the economic findings outlined earlier. Data extraction will include the following: author(s), year of publication, country, study objectives, study design, eligibility criteria, TMD diagnosis and screening, study groups, randomisation, blinding, sample size, number of participants invited, enrolled and completed, duration of treatment, follow-up, study duration, settings, assessment instruments, study outcomes, statistical analyses, results, limitations, strengths and funding sources. The quality of studies will be evaluated using the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist, with risk of bias assessed using the Cochrane Effective Practice and Organization of Care’s risk-of-bias tool; where applicable, the Outcome Reporting Bias in Trials will be used to detect reporting biases. A narrative synthesis and summary tables will outline study characteristics, economic outcomes and the overall quality of evidence. We will conduct qualitative secondary and sensitivity analyses.

This SR does not require an ethics approval. The results will be disseminated through international and national conferences and peer-reviewed journals.

CRD42024613553.

The introduction of fentanyl and its analogues in the illicit drug supply has prompted greater emphasis on refining clinical treatment protocols to ensure sustained retention in opioid agonist treatment (OAT). Take-home dosing may lessen the treatment burden on clients and thus reduce the risk of treatment discontinuation. The evidence base supporting the use of take-home dosing, including the optimal duration of dispensations, is, however, limited. The objective of this study is to determine the comparative effectiveness of alternative take-home dosing schedules, as observed in clinical practice in British Columbia, Canada from 2010 to 2022.

We propose to emulate a target trial with a population-level retrospective study of individuals initiating methadone or buprenorphine/naloxone between 1 January 2010 and 31 December 2022 who are 18 years of age or older and not currently incarcerated or pregnant with no history of cancer or palliative care. Our study will draw on nine linked health administrative databases from British Columbia and will evaluate take-home doses of 2–5 days, 6 days or >6 days compared with continuous daily dosing. The primary outcomes include OAT discontinuation and all-cause mortality on treatment. A causal per-protocol analysis is proposed with longitudinal matching and inverse probability of censoring weighting approaches to adjust for time-fixed and time-varying confounding. A range of sensitivity analyses will be executed to determine the robustness of results.

The protocol, cohort creation and analysis plan have been classified and approved as a quality improvement initiative by Providence Health Care Research Ethics Board and the Simon Fraser University Office of Research Ethics. Results will be disseminated and shared with local advocacy groups and decision-makers, developers of national and international clinical guidelines, presented at national and international conferences and published in peer-reviewed journals electronically and in print.

(1) Examine the associations between imprisonment history and mortality among adults with neurodevelopmental disabilities and (2) examine the associations between receipt of disability services and post-release mortality among adults with neurodevelopmental disabilities released from prison.

Population-based data-linkage cohort study using historical administrative data.

New South Wales (NSW), Australia.

67 217 adults aged ≥18 years (59.1% male) with one or more neurodevelopmental disabilities in NSW, Australia, from July 2001 to June 2015.

The main outcome measure was all-cause mortality. In the full cohort, we used Cox regression to examine the associations between release from imprisonment and all-cause mortality. In a subcohort of those released from prison, we used Poisson regression to examine the associations between receipt of disability services and post-release all-cause mortality.

3.3% of participants (n=2214) were imprisoned and released at least once during follow-up. In all age groups

Among adults with neurodevelopmental disabilities, mortality was increased among those released from prison compared with their peers who had not been imprisoned, although this was largely explained by health-related factors, including mental illness, substance use and physical comorbidity. Comprehensive policy and service system responses are required to meet the health and safety needs of people with neurodevelopmental disabilities who have complex needs, including criminal legal system involvement, mental illness and substance use.

Vaccination has been an effective public health intervention for immunising individuals against many common communicable and non-communicable diseases. However, there is limited information on the efficacy of vaccination among patients undergoing dialysis or patients with chronic kidney disease (CKD). The objective of this review is to assess the effectiveness of vaccination within dialysis and CKD patient populations.

This will be a systematic review of studies assessing the effectiveness of vaccination among CKD and dialysis patients. Relevant studies will be identified using MEDLINE, Embase, Scopus and Cochrane Library. All searches will be conducted from database inception to October 2025. Only observational studies such as cohort, prospective, retrospective and cross-sectional studies will be included. Data pertaining to patient outcomes and study design will be extracted. A narrative synthesis will be conducted as well as a meta-analysis if data permitting this analysis is extracted from included studies.

Since data collection will be conducted by examining existing studies, no ethical approval or consent will be required. The results of this review will be published in a peer-reviewed journal as well as presented at seminars, conferences and symposiums.

This review protocol has been registered in International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42025648534.

Self-harm and suicide are common among prison inmates, but less is known about these phenomena in those with psychosis.

The aim of this study was to examine self-harm behaviour in New South Wales (NSW) prisons in Australia among inmates diagnosed with psychosis. This study also examined self-harm-related alerts applied by Corrective Services to assist staff with the management of the security and well-being of inmates.

A retrospective case-control data-linkage study was conducted using administrative data collections in NSW, Australia.

The study included all individuals diagnosed with psychosis and incarcerated between 2001 and 2020 in NSW as cases and an age and sex matched control group with no such diagnosis with a record of incarceration in the same time period.

The primary outcome measure was self-harm among the cases and controls. The secondary outcome measure was the application of alerts by Corrective Services in relation to self-harm incidents.

Multivariate regression analysis was used to examine predictors of self-harm in prison. Prisoners with psychosis (n=14 900) were more likely to self-harm than controls (n=2713), with 15.0% versus 3.6% engaging in self-harm (highest odds of self-harm observed in those with schizophrenia and related psychoses, aOR=4.84, 95% CI: 3.93 to 5.98). Those of Aboriginal heritage had an increased risk of self-harm (aOR=1.58, 95% CI: 1.43 to 1.75). Factors associated with a lower risk of self-harm were male sex and older age (≥25 years) at the time of their first incarceration. 35.6% of those released from prison with a prior psychosis diagnosis had at least one alert applied during incarceration compared with 10.1% of prisoners without a diagnosis of psychosis. Overall, 35 individuals with psychosis and 1 individual from the control group died while in prison between 2001 and 2020. 17 prison suicides were recorded from the study population; all occurred in the psychosis group.

Given the heightened risk of self-harm in those with histories of psychosis, consideration should be given to sharing mental health information between agencies to improve the care and management of this group during incarceration. Prison alerts may be a useful tool to help staff manage inmates’ well-being if used appropriately.

Selecting an optimal initial dosage of opioid agonist treatment (OAT) balances effectiveness and safety, as initial doses that are too low may be insufficient, potentially prompting clients to seek unregulated drugs to alleviate withdrawal symptoms, which may increase the likelihood of treatment discontinuation. Conversely, initial doses that are too high carry a risk of overdose. As opioid tolerance levels have risen in the fentanyl era, linked population-level data capturing initial doses in the real world provide a valuable opportunity to refine existing guidance on optimal OAT dosing at treatment initiation. Our objective is to determine the comparative effectiveness of alternative initial doses of methadone, buprenorphine-naloxone and slow-release oral morphine at OAT initiation, as observed in clinical practice in British Columbia (BC), Canada.

We propose a population-level retrospective observational study with a linkage of nine provincial health administrative databases in BC, Canada (1 January 2010 to 31 December 2022). Our study includes two time-to-event primary outcomes: OAT discontinuation and all-cause mortality during follow-up. We propose ‘initiator’ target trial analyses for each medication using both propensity score weighting and instrumental variable analyses to compare the effect of different initial OAT doses on the hazard of time-to-OAT discontinuation and all-cause mortality. A range of sensitivity analyses will be used to assess the robustness of the results.

The protocol, cohort creation and analysis plan have been classified and approved as a quality improvement initiative by Providence Health Care Research Ethics Board and the Simon Fraser University Office of Research Ethics. Results will be disseminated to local advocacy groups and decision-makers, national and international clinical guideline developers, presented at international conferences and published in peer-reviewed journals electronically and in print.

Opioid agonist treatment (OAT) prescribing patterns have shifted in recent years in British Columbia (BC), Canada due to the increasingly toxic unregulated drug supply. Experimental evidence to support guidelines on the effectiveness of maintaining clients at different maintenance dosage levels is incomplete and outdated for the fentanyl era. Our objective is to assess the risk of treatment discontinuation and mortality among individuals receiving different maintenance dosage strategies for OAT with methadone, buprenorphine/naloxone or slow-release oral morphine (SROM) at the population level in BC, Canada.

We propose a retrospective population-level study of BC residents initiating OAT on methadone, buprenorphine/naloxone or SROM between 1 January 2010 and 31 December 2022 who were ≥18 years of age with no known pregnancy, no history of cancer diagnosis or receiving palliative care and not currently incarcerated. Our study will employ health administrative databases linked at the individual level to emulate a target trial per OAT type where individuals will be assigned to discrete maintenance dosing strategies, according to the full range observed in BC during the study period. Primary outcomes include treatment discontinuation and all-cause mortality. To determine the effectiveness of alternative maintenance doses, we will emulate a ‘per-protocol’ trial using a clone-censor-weight approach to adjust for measured time-dependent confounding by indication.

The protocol, cohort creation and analysis plan have been classified and approved as a quality improvement initiative by Providence Health Care Research Ethics Board and the Simon Fraser University Office of Research Ethics. All data are deidentified, securely stored and accessed in accordance with provincial privacy regulations. Results will be disseminated and shared with local advocacy groups and decision-makers, developers of national and international clinical guidelines, presented at national and international conferences and published in peer-reviewed journals electronically and in print.

Methadone and buprenorphine/naloxone are effective medications for people with opioid use disorder; however, interruptions in daily dosing are common and diminish the benefits of these medications. While clinical guidelines in most North American jurisdictions, including British Columbia (BC), recommend dose adjustment after treatment interruptions to varying levels of specificity, the evidence to support these recommendations is limited. We aim to estimate the comparative effectiveness of alternative dose adjustment strategies on subsequent overdose-related acute care visits and discontinuation of opioid agonist treatment in BC, Canada.

Using a linkage of nine health administrative databases, we propose a population-level retrospective cohort study of adults aged 18 years or older in BC who initiated methadone or buprenorphine/naloxone between 1 January 2010 and 31 December 2022. We will specify parallel hypothetical trials, known as target trials, for methadone interruptions of 1–3 days, 4 days and 5–14 days, and buprenorphine/naloxone interruptions of 1–5 days and 6–14 days. Following the index interruption, the primary outcomes are the time to overdose-related acute care visits and treatment discontinuation (interruptions lasting >14 days), with time to all-cause acute care visits as a secondary outcome. The intention-to-treat effect will be estimated using both propensity score and instrumental variable approaches. A range of sensitivity analyses will assess the robustness of our results, including cohort and timeline restriction, alternative definitions of exposure and outcome and alternative estimation strategies.

The protocol, cohort creation and analysis plan have been classified and approved as a quality improvement initiative by Providence Health Care Research Institute and the Simon Fraser University Office of Research Ethics. All data are deidentified, securely stored and accessed in accordance with provincial privacy regulations. Results will be disseminated to local advocacy groups and decision-makers, national and international clinical guideline developers, presented at international conferences and published in peer-reviewed journals electronically and in print.

Predictive scoring systems support clinicians in decision-making by estimating the prognosis of patients in intensive care units (ICUs). However, there is limited evidence on the accuracy of these systems in predicting mortality and organ dysfunction in special populations. The aim of this review is to assess the performance of predictive scoring systems in forecasting mortality in adult ICU patients in relation to baseline kidney function. It is anticipated that the assessment of predictive scoring systems’ performance and patient outcomes in this review may reveal information that will contribute to improve the quality of care and outcomes for special or under-represented ICU patient populations. It might also inform future research and contribute to the development of novel risk prediction models to address identified gaps or unanswered questions.

This review will include only observational studies, as these allow us to assess the real-world performance of predictive scoring systems in ICU settings by examining the original validation studies. By excluding randomised trials, paediatric studies, case reports and machine learning-derived models, this review focuses on the direct practical use of the scoring systems in adult ICU patients. A comprehensive search of MEDLINE, Embase and Scopus was conducted from database inception to 10 October 2024. The data will be extracted on study characteristics, patient outcomes and performance metrics.

This review will analyse data from previously published studies; no ethical approval is required. All data that will be included in the analysis will be publicly available and will be included in the final manuscript. Results will be disseminated through publication in a peer-reviewed journal and will also be presented at seminars and conferences.

CRD42024611547.