This paper examines the impact of India’s National Publicly Funded Health Assurance Scheme, Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY), in Haryana on out-of-pocket (OOP) expenses and catastrophic health expenditure (CHE).

We conducted a case-control study using a stratified random sampling approach.

Six districts in Haryana, based on utilisation, were selected: Mewat, Faridabad, Sonipat, Ambala, Kurukshetra and Karnal.

A total sample size of 772 individuals, that is, 386 PM-JAY beneficiaries (cases) and non-beneficiaries (controls) each.

Data were collected using a semistructured questionnaire covering household demographics and expenditure details. The interview gathered information on hospitalisation within the past year, types of ailments, the type of empanelled facility visited, expenditure details and borrowing/selling of assets for treatment.

Mean OOP expenditure was calculated for beneficiaries and non-beneficiaries based on the type of healthcare provider. The impact of PM-JAY on OOP expenditure was analysed using a generalised linear model controlling for religion, caste, type of house, type of family, morbidity patterns, type of disease, type of health facility, hospital stay duration, average distance to the facility and travel time. CHE was defined as OOP payments ≥30% of household income. Logistic regression was used to assess the determinants of CHE.

We found that direct medical expenses incurred for hospitalisations were 65% lower for beneficiaries (11 131 rupees) compared with non-beneficiaries (31 675 rupees). While OOP expenditures are similar for both groups in public empanelled hospitals, non-beneficiaries incur OOP costs three times higher than PM-JAY beneficiaries in private empanelled hospitals. Factors, including the disease type, average distance from home to the facility, average travel time and type of hospital, significantly influence these expenses. Furthermore, the prevalence of CHE is significantly lower among PM-JAY beneficiaries (13.3%) compared with non-beneficiaries (45.9%), with an OR of 7.15 (95% CI: 4.74 to 10.80; p

Our analysis shows the scheme’s impact on decreasing OOP expenditure and CHE. To enhance the scheme’s effectiveness, the study highlights the necessity of addressing non-medical expenses and expanding coverage for indirect costs, such as food, accommodation and transportation. Additionally, strengthening the supply side through improved drug availability at healthcare facilities is crucial for enhancing financial protection and access to care.

There is an absence of real-world evidence, especially from low- and middle-income countries (LMICs), on the implementation successes and challenges of COVID-19 Test and Treat (T&T) programmes. In 2022, nirmatrelvir/ritonavir was provided as standard of care for mild to moderate COVID-19 treatment in eight LMICs (Ghana, Kenya, Laos, Malawi, Nigeria, Rwanda, Uganda and Zambia). This manuscript describes a research protocol to study novel drug introduction during the COVID-19 health emergency, with implications and learnings for future pandemic preparedness. The goal of the study is to provide simultaneous programme learnings and improvements with programme rollout, to fill a gap in real-world implementation data on T&T programmes of oral antiviral treatment for COVID-19 and inform programme implementation and scale-up in other LMICs.

This multiple methods implementation research study is divided into three components to address key operational research objectives: (1) programme learnings, monitoring and evaluation; (2) patient-level programme impact; and (3) key stakeholder perspectives. Data collection will occur for a minimum of 6 months in each country up to the end of grant. Quantitative data will be analysed using descriptive statistics for each country and then aggregated across the programme countries. Stakeholder perspectives will be examined using the Consolidated Framework for Implementation Research implementation science framework and semistructured interviews.

This study was approved by the Duke University Institutional Review Board (Pro00111388). The study was also approved by the local institutional review boards in each country participating in individual-level data collection (objectives 2 and 3): Ghana, Malawi, Rwanda, Nigeria and Zambia. The study’s findings will be published in peer-reviewed journals and disseminated through dialogue events, national and international conferences and through social media.

NCT06360783.

In deprived urban areas of South America, young people face heightened risks of mental disorders. Research suggests an association exists between social media engagement (SME), depression and anxiety.

This study explored the associations of SME with symptoms of depression, anxiety and subjective quality of life among young people from South American deprived urban areas.

Our cross-sectional survey study used an adapted version of the Multidimensional Facebook Intensity Scale to categorise 2399 participants into four SME groups: low, moderate, high and very high. Symptoms of depression (Patient Health Questionnaire-8), anxiety (Generalised Anxiety Disorder-7) and quality of life (Manchester Short Assessment) were assessed and compared using F and Tukey tests.

Each step of increased SME was associated with more symptoms of depression and anxiety and poorer quality of life. Statistically significant differences were observed across all groups (p

The findings suggest an association exists between SME, increased mental distress and lower quality of life in young people from deprived South American urban areas. This influence seems to apply across the spectrum of engagement levels, not only to extremes. However, due to the cross-sectional nature of the study, causal relationships cannot be established.

SME should be explored in clinical settings, as lower levels are associated with lower symptom levels and better quality of life. Policies addressing youth SME should be developed and evaluated in the challenging contexts of deprived urban areas.

Perioperative adverse events increase morbidity and mortality. The rate and severity of complications and the risk for subsequent mortality are increased after high-risk procedures and in elevated-risk patients. Over the past decades, a multitude of prognostic studies identified perioperative risk factors at the population level. However, to allow for the advancement of precision surgery strategies, improved risk prediction on the individual patient level is warranted. Comprehensive, consecutive, multisource, structured, high-quality patient-related and procedure-related data sets, together with thorough follow-up and combined with state-of-the-art machine-learning analyses, are needed to facilitate precise prediction of perioperative complications. Therefore, we designed and currently conduct the Heidelberg Perioperative Deep Data study (HeiPoDD). Here, we report the rationale and design of the HeiPoDD study.

HeiPoDD is a prospective, single-centre, exploratory cohort study aiming to build up a large-scale deep-data base and corresponding biomaterial collection. 1040 adult patients planned for elective high-risk, non-cardiac surgery for any indication at Heidelberg University Hospital, Germany will be included. The obtained study-specific data set includes clinical data, lab values, genome- and proteome analysis as well as plasma, serum and peripheral blood mononuclear cells (PBMC) collected before and at days 1, 3 and 7 postsurgery. Urine samples are collected before and at day 1 postsurgery. Structured follow-up for perioperative complications such as redo-surgery, length of intensive care stay or length of hospital stay is conducted at days 30, 90 and 1 year postsurgery and for disease progression and survival after 3 and 5 years postsurgery. All study data will be transferred to the HeiPoDD registry to allow merging with all available routine clinical data from the hospital information system including imaging studies as well as haemodynamic and respiratory biosignals. Biomaterials will be stored in the HeiPoDD biomaterial bank to allow further analyses.

The trial protocol and amendments were approved by the ethics committee of the University of Heidelberg (S-758/2021). The protocol is registered with the German Clinical Trial Register (DRKS00024625). Participating patients’ data will be recorded only in pseudonymised form. After completion of the study, data collected during the study will be kept on file for up to 30 years. Biomedical samples collected during the study and entered into the biobank will be held for the same amount of time. The findings will be disseminated in peer-reviewed academic journals.

Outcome after surgery depends on both patient-related as well as procedure-related risks. Complications after surgery are a significant burden to patients and to the health system. A vast amount of often unstructured data from different sources are generated during surgery, which contain valuable information associated with outcome. Advances in computer hardware and machine learning now increasingly facilitate the development of prediction models in standardised, parametric, information-rich areas such as the perioperative setting. For the development and validation of risk scores and prediction models, high-fidelity data sources are required to arrive at meaningful and reliable predictions. However, data quality standards in retrospective studies are rarely met. Therefore, the prospective Heidelberg Perioperative Deep Data Registry and Biomaterial Bank (HeiPoDD - Registry and Bio Bank) was started to implement a clinical data base and a corresponding biobank merging the entirety of available clinical records.

The HeiPoDD - Registry and Bio Bank is a study-driven, prospective, single-centre observational registry data base and biomaterial bank. It contains data and material from eligible patients who give informed consent and undergo elective non-cardiac high-risk surgery at the surgical centre of the Heidelberg University Hospital. The screening for eligibility started in January 2022, with no maximum sample size specified in advance. Routine data are recorded and stored during hospital stay and potential readmissions within 90 days after index surgery. The data are merged with the potentially available genome, proteome, flow cytometry, and bio signal data. Endpoints are obtained from routine observations, stored data in the hospital information system and follow-up visits. Further, data and biological specimens from separate perioperative studies with the patients’ consent can be transferred into the HeiPoDD - Registry and Bio Bank as well. This large-scale data collection will allow the calculation of endpoint-specific prediction models using logistic regression models as well as machine learning models. The first 1040 patients included in the HeiPoDD - Registry and Bio Bank are also included in the HeiPoDD study.

The trial protocol and subsequent amendments were approved by the ethics committee of the University of Heidelberg (S-745/2021). Participating patients’ data will be entered only in pseudonymised form. Data and biomaterials will be kept for up to 30 years. The findings will be disseminated in peer-reviewed academic journals.

DRKS00025924, registered on 2021-11-12.

The rising burden of non-communicable diseases (NCDs), including mental health disorders (MHDs) such as anxiety and depression, poses a significant public health challenge globally. Evidence suggests that both diabetes and hypertension, the two most prevalent NCDs, are linked to a higher prevalence of MHDs. However, there is a lack of evidence on prevalence of generalised anxiety disorder (GAD) and depression among adults living with both diabetes and hypertension in Bangladesh. We aimed to assess the prevalence of GAD and depression and explore the associated factors among adults living with diabetes and hypertension comorbidity in rural Bangladesh.

We implemented a cross-sectional study.

The study was conducted in Chirirbandar, a sub-district of Dinajpur, Bangladesh.

We interviewed a total of 387 adults living with diabetes and hypertension comorbidity.

We had two primary outcome measures: GAD and depression. Individuals scoring ≥10 on the General Anxiety Disorder-7 scale were considered as having GAD and individuals scoring ≥10 on the Patient Health Questionnaire-9 scale were considered as having depression. The outcome variables were dichotomised based on these scores.

The prevalence of GAD was 7.24% (95% CI 5.04 to 10.29). Education level (grades 5–9) (adjusted OR (AOR): 3.40, 95% CI 1.26 to 9.19) and household wealth status (highest wealth tertile) (AOR: 0.12, 95% CI 0.02 to 0.62) were associated with GAD. The prevalence of depression was 17.83% (95% CI 14.32 to 21.98). Socioeconomic factors associated with depression included unemployment (AOR: 3.26, 95% CI 1.05 to 10.10) and household wealth status (highest wealth tertile) (AOR: 0.45, 95% CI 0.21 to 0.98). Higher odds of depression were also observed among participants with controlled hypertension (AOR: 3.88, 95% CI 1.81 to 8.35). Other factors, such as tobacco use, dietary diversity and physical activity, were not associated with GAD or depression.

A high prevalence of GAD and depression was observed among adults living with diabetes and hypertension comorbidity. The findings from the study emphasise the need for integration of mental health services into the existing non-communicable disease care. The identified factors associated with GAD or depression should be considered to develop targeted interventions for people with hypertension and diabetes comorbidity in Bangladesh.

Coronary artery bypass grafting (CABG) remains one of the most commonly performed cardiac surgeries worldwide. Despite surgical advancements, a significant proportion of patients experience psychological distress following surgery, with depression being particularly common. Current evidence regarding the effectiveness of preoperative psychological interventions in improving postoperative mental health outcomes remains inconclusive. There is a critical need for predictive models that can identify patients at risk of developing clinically significant depressive symptoms (CSDSs) and related psychological conditions after CABG. This multicentre observational study aims to develop and validate prognostic models for predicting CSDSs and other psychological outcomes, including anxiety, post-traumatic stress symptoms and quality of life, 6 weeks after elective CABG surgery.

The study will recruit 300 adult patients undergoing elective CABG (with or without valve intervention) across two Swiss hospitals. Data collected will include demographic, clinical, psychometric, inflammation-related and interoceptive variables. A training set (n=200) will be used to develop predictive models using machine learning, while a held-out test set (n=100) will be used for model validation. The primary outcome prediction will focus on CSDSs, assessed using the Patient Health Questionnaire-9 (PHQ-9), with analyses conducted both categorically (PHQ-9 total score ≥10) and continuously as complementary approaches. Secondary models will address anxiety, using the General Anxiety Disorder Scale-7, post-traumatic stress, using the post-traumatic stress disorder checklist for Diagnostic and Statistical Manual of Mental Disorders-5 and health-related quality of life, using the 12-item Short Form Survey. A simplified ‘light solution’ model with fewer predictors will also be developed for broader applicability. This study will address an important gap in perioperative mental healthcare by identifying key predictors of psychological morbidity following CABG, particularly CSDSs. The resulting models may inform future screening and preventive strategies and improve postsurgical outcomes through early identification and intervention in high-risk individuals.

The responsible ethics committee has reviewed and approved this project (Kantonale Ethikkommission Zürich, BASEC number: 2023-02040). The study minimises participant burden by integrating brief validated instruments and limiting psychiatric interviews to relevant outcomes, while ensuring ethical safeguards and respect for participant rights (including written consent). Results will be shared through peer-reviewed publications, conference presentations and stakeholder meetings involving clinicians and mental health professionals. Findings will also be communicated to participating centres and patient communities in accessible formats.

Recent studies have demonstrated a beneficial role of steroids in severe community-acquired pneumonia, severe COVID-19 infection and acute respiratory distress syndrome (ARDS) of diverse aetiology. This multicentre randomised controlled trial in severe scrub typhus pneumonitis and ARDS will compare the effects of 6 mg of dexamethasone once per day with placebo, in addition to standard treatment, on ventilator-free days (VFD), mortality and ventilatory requirement.

The study, involving six sites, will recruit 440 patients with severe scrub typhus pneumonitis or ARDS to concealed, block-randomised, site-specific assignment of dexamethasone or placebo for 4–7 days. The primary outcome will be VFD, defined as days alive and free of ventilation at 28 days. Secondary outcomes will include 28-day mortality, need and duration of ventilation, and treatment failure, defined as death, or escalation of respiratory support from simple devices (nasal cannula, mask) to non-invasive or invasive ventilation, or the use of open-labelled steroids for worsening shock. The study will also ascertain if antinuclear antibody (ANA) expression during the acute phase of illness will predict steroid responsiveness. Subgroup analyses will be conducted a priori on ANA expression and the need for ventilation. All analyses will be conducted on an intention-to-treat basis. The trial, which commenced in April 2025, would clarify the role of corticosteroids in scrub typhus pneumonitis.

The Institutional Review Board and Ethics Committee of the lead site, Christian Medical College, Vellore, India, has approved the study (IRB Min No 15920 (INTERVE) dated 22 November 2023). The remaining five sites have obtained approval from their respective ethics committees. Study results will be published in an international peer-reviewed journal.

CTRI/2024/12/077709. Registered 5 December 2024.

To investigate the relationship between demographic characteristics and extracurricular achievements among UK medical students.

National, cross-sectional survey.

All 44 UK medical schools recognised by the General Medical Council.

8,395 medical students.

Binary indicators of extracurricular engagement, including PubMed-indexed authorship, academic presentations, quality improvement projects, leadership roles and academic prizes. Logistic regression models were used to explore associations with demographic and extracurricular achievement predictors.

Logistic regression analysis showed that students from private schools (OR 1.35, CI 1.20 to 1.53, p

Significant disparities in extracurricular achievement exist among UK medical students, principally associated with gender, private schooling and familial links to medicine. Apparent ethnic differences were largely attenuated after adjustment for other variables, indicating socioeconomic factors as stronger predictors of engagement. Given the role of these achievements in postgraduate selection, targeted interventions by medical schools and professional bodies to widen access to funding, mentorship and structured guidance for all students, regardless of perceived advantage, may support equitable opportunity without undermining merit-based standards.

To explore factors influencing UK medical students’ specialty choices and examine variations in these influences across demographic groups and stages of training.

National, cross-sectional online survey.

All 44 UK medical schools recognised by the General Medical Council.

8,395 medical students.

The primary outcome was the specialty preferences of UK medical students. The secondary outcomes were factors behind these preferences and how these factors vary across demographic groups and different stages of training.

General Practice (15.3%), Paediatrics (10.6%) and Anaesthetics (9.9%) were the most preferred specialties among final-year students. Work-life balance (84.1%), compatibility with family life (78.2%), positive training experiences (85.2%) and future specialty outlook (74.9%) were key factors influencing specialty choice. Only 23.1% of students felt confident about securing a specialty training post, with confidence higher among males (OR 1.36, 95% CI 1.21 to 1.52, p

This study highlights disparities in specialty preferences and influencing factors among UK medical students. A focus on improving career guidance, exposure to various specialties and supporting equitable access to training opportunities is essential for fostering a motivated and sustainable medical workforce.

To determine the independent predictors of full immunisation coverage (FIC) among children aged 12–23 months along with the parental awareness and attitudes (of children aged ≤23 months) regarding routine childhood vaccinations in Perambalur district of Tamil Nadu, South India.

A community-based cross-sectional analysis.

Perambalur district situated in the central region of Tamil Nadu state, South India.

Parents of children aged ≤23 months.

The primary outcome measured was the FIC and FIC plus in the district along with the parental awareness and attitudes regarding routine childhood vaccinations. The independent predictors of FIC and FIC plus were determined using multivariable logistic regression models.

The study included 652 children, with a mean (±SD) age of 16.47 (±6.37) months and a male-to-female ratio of 60:40. The FIC and FIC plus of children aged 12–23 months were 91.3% (95% CI 88.64 to 93.33) and 79.7% (95% CI 76.15 to 82.80), respectively. The immunisation card retention was 97.9% among the parents of children aged 12–23 months. The independent predictors of FIC included below poverty line families (adjusted OR (AOR) 0.11; 95% CI 0.02 to 0.64), illiteracy among mothers (AOR 0.67; 95% CI 0.32 to 0.87), lack of immunisation card (AOR 0.14; 95% CI 0.03 to 0.55), lack of frequent home visits by healthcare worker (AOR 0.38; 95% CI 0.18 to 0.79) and hesitancy of parents towards vaccination (AOR 0.26; 95% CI 0.12 to 0.87).

This study revealed a high FIC in this specific district. However, achieving full coverage is influenced by factors like socioeconomic status, maternal education and parental attitudes. Understanding these factors is essential for improving immunisation rates and ensuring all children are protected.

Using the community-based participatory research (CBPR) methodology, sustained peer group treatment has effectively improved medication adherence. Although many studies investigate the effectiveness of peer group therapy, there is a lack of evidence addressing the cost-effectiveness of CBPR models in low- and middle-income countries. This protocol outlines the methods for the economic evaluation of the PArticipatory Research model for medicaTIon adherenCe In People with diAbetes and hyperTEnsion (PARTICIPATE) trial to determine whether the CBPR approach to enhance medication adherence among patients with diabetes and/or hypertension is cost-effective in India.

A within-trial cost-effectiveness analysis (CEA) from a societal perspective will be conducted alongside a multicentre cluster randomised controlled trial to identify, measure and evaluate the key resource and outcome impacts of a CBPR model compared with usual care aimed at improving medication adherence in adult rural Indian patients with diabetes and/or hypertension. The CEA will provide results in terms of the cost per improvement in medication adherence score, and a cost-utility analysis (CUA) will express the findings as the cost per disability-adjusted life year (DALY) or quality-adjusted life year (QALY) gained. Intervention costs and effects will be projected for the population of Indian adults with diabetes and/or hypertension who are on medication, analysed over the cohort’s lifetime. Results from the modelled CUA will detail incremental costs, costs per death averted and costs per DALY averted/QALY gained for the interventions relative to the comparator. Incremental cost-effectiveness ratios will be computed by dividing the cost difference between the intervention and comparator by the difference in benefits. Health economic evaluation methods, including a lifetime horizon, a 3% discount rate for costs and benefits and a societal perspective, will be followed. The effects of sampling uncertainty on estimated incremental costs and effectiveness parameters, as well as the influence of methodological assumptions (such as the discount rate and study perspective), will be examined through both deterministic and probabilistic sensitivity analyses. Relevant differences in costs, outcomes or cost-effectiveness disparities among subgroups of patients with varying baseline characteristics will also be reported. Results will be illustrated using cost-effectiveness acceptability curves across a range of willingness-to-pay thresholds. Modelled CUA will broaden the target population and time frame to offer decision-makers insights into the cost-effectiveness of the CBPR approach for enhancing medication adherence. Furthermore, a return on investment analysis will be performed to express benefits in monetary terms relative to investments made, allowing for a comprehensive expression of both costs and the full spectrum of intervention benefits in monetary units.

The Institutional Ethics Committee of Sri Aurobindo Medical College and PGI, Indore, provided ethics approval. The results of the main trial and economic evaluation will be submitted for publication in a peer-reviewed journal and disseminated through reports to Indian Council of Medical Research and conference presentations.

Clinical Trial Registry of India (CTRI) CTRI/2024/01/061939.

To explore neonatal survival by type of neonatal complications at birth and referral pattern for these complications by place of delivery.

Bihar, India.

Women aged 15–49 years who had given live birth between July 2020 and June 2021.

Prevalence of neonatal complications at birth, referral pattern by complication and neonatal deaths by type of complication.

Data were available for 6767 (81.8%) newborns including 717 neonatal deaths. The prevalence of at least one neonatal complication at birth was reported for 32.9% (95% CI 32.4 to 33.4) newborns, with the most common complications including difficulty in breathing (21.9%), high fever (20.7%), low birth weight (12.5%) and jaundice (13.2%). A total of 578 (26.6%; 95% CI 25.8 to 27.4) neonates with complications at birth were referred to another health provider, predominantly to private sector (68.1%, 93% and 78.7% from public facility, private facility and home). The complications with high referrals included meconium aspiration syndrome (64.1%; 95% CI: 61.1 to 67.1), inability to pass urine (54.7%; 95% CI: 42.1 to 67.2), difficulty in suckling (49.7%; 95% CI: 46.9 to 52.5), cold to touch (48.5%; 95% CI: 43.5 to 53.6), inability to cry (47.2%; 95% CI: 44.2 to 50.1), pneumonia (45.6%; 95% CI: 42.0 to 49.1), difficulty in breathing (44.0%; 95% CI: 42.5 to 45.6) and lethargy (43.5%; 95% CI: 38.4 to 48.6). Referrals were linked to higher neonatal deaths, in particular, among neonates born at home and referred for complications (84.7%; p

With one-third of the neonates reported to have complications at birth and those referred more likely to die, critical gaps in addressing neonatal complications at birth and improvement in the referral services are urgently needed to reduce neonatal mortality.

Liver cirrhosis accounts for over 10 000 deaths in the UK each year with a total loss of 60 000 quality-adjusted life-years. There is a substantial cost to the NHS of £4.5 billion, with new liver-related decompensation events accounting for the majority of this. Following an acute cirrhosis decompensating event, there is a significant risk of hospital readmission with 90-day readmission rates as high as 53%. Current care in the UK is reactive and patients are often only readmitted when they have presented acutely as an emergency with significant decompensation.

CirrhoCare is a prospective, multicentre, randomised controlled trial comparing the CirrhoCare management system with standard-of-care for high-risk cirrhosis patients who have been discharged following an admission with acute decompensation. The CirrhoCare management system comprises a novel digital platform for use in a patient’s home, designed to proactively detect the first signs of new decompensation in patients with established cirrhosis, discharged to the community. This enables a clinician to instigate early community-based care or, if needed, to triage the patient for hospital interventions.

214 patients will be recruited to the CirrhoCare trial from at least 12 UK centres. Patients will be randomised on a 1:1 ratio allocation to the CirrhoCare Management System or standard of care. Participants who are randomised to CirrhoCare will receive a CirrhoCare health kit comprising a smart watch, smart phone with enabled SIM (Subscriber Identity Module) network card, blood pressure monitor, weighing scales and thermometer. Participants will take measurements every morning Monday to Friday and will be followed up for 90 days postdischarge.

The primary objective of this study is to assess the clinical effectiveness of the CirrhoCare digital management system. We hypothesise that its early community-based intervention will reduce the number of unplanned hospital interventions and admissions and prevent liver-related complications when compared with standard-of-care management.

CirrhoCare is a National Institute for Health and Care Research-funded study (NCT06223893). The study has UK Research Ethics Committee and Health Research Authority (HRA) approvals, with approval granted by the HRA and Health and Care Research Wales committee. The results of this study will be published in peer review journals, disseminated at international conferences as well as established Patient and Public Involvement and Engagement networks.

ISRCTN11380842.

Perinatal complications involving conflicts between maternal and fetal health interests present a unique challenge to health economic evaluations. No comprehensive synthesis exists of how such studies account for dual-patient outcomes. We aim to develop a scoping review protocol to map and critically examine the methodologies in this understudied area.

The scoping review will be conducted under the Joanna Briggs Institute (JBI) framework. It will include health economic studies, such as cost-effectiveness, cost utility and decision analysis studies, focusing on clinical conditions during pregnancy where maternal and fetal interests conflict. Cost analysis without effectiveness assessment will be excluded. Using comprehensive search strategies in Medline (Ovid), EMBASE (Elsevier) and Cochrane Library (Wiley), two independent reviewers will screen and identify relevant studies via abstract and full-text review. We will perform data extraction following an adapted form from the Consolidated Health Economic Evaluation Reporting Standards checklist, which includes the content details, such as the type of study, population, intervention, comparator, probability, utility, duration, cost, model types and uncertainty measurements. As we try to explore the impact of the health economic studies in clinical practice, we will include citation metrics of each study and whether the study was cited by practice guidelines and clinical trials in the data extraction. We will also apply the JBI Checklist for Economic Evaluations to assess the reporting completeness in each article. Results will be tabulated by clinical theme and synthesised narratively to highlight patterns in valuation approaches, gaps in current methods and impact on clinical guidelines.

This study does not require ethical approval as it involves secondary analysis of published data. Findings will be disseminated through peer-reviewed publications, conference presentations and stakeholder engagement activities.

CRD42024557324

Perinatal care continuity across the full continuum is essential for optimising maternal and infant health; however, a stark gap occurs post partum, with less than one half of Indian mothers receiving postpartum care due to significant logistical and sociocultural barriers, particularly for periurban and rural residents. To overcome these barriers and reduce women’s postpartum isolation, our international team of maternal and infant health clinicians and researchers developed and pilot-tested a culturally-tailored mobile interactive education and support group intervention, Kushal Maa (‘informed-mother’), confirming feasibility and acceptability and preliminary effectiveness. The current study seeks to estimate the effectiveness of the Kushal Maa intervention compared with standard care on maternal and neonatal health-related behaviours and health, characterise the mechanisms of intervention impact and evaluate the cost-effectiveness of the Kushal Maa intervention in improving postpartum maternal and neonatal health compared with the standard of care.

We will conduct a prospective, parallel block-randomised controlled trial with a 1:1 allocation ratio among 2100 pregnant women across three geographically diverse Indian states. Inclusion criteria for women: aged 18+years of age at enrolment, in the last trimester of pregnancy (30–33 weeks of gestation), with any parity, carrying single or multiple gestation (1-2), with knowledge of site-specific local language and had access to a mobile phone. Participants will be block-randomised in groups of 15. Intervention participants will receive 28 tailored education and support sessions weekly via audio/video conference facilitated by trained moderators (four prenatal and 24 weekly postpartum sessions through 6 months) and will be engaged in WhatsApp groups for health education videos and peer discussion via text chat. Control participants receive the standard of care. Data will be collected at four points: 30–33 weeks of pregnancy (enrolment), 6 weeks, 3 months and 6 months postpartum (endline). Investigators, outcome assessors and data analysts will be blinded to group allocation. Primary outcomes will be measured at 6 weeks, 3 months and 6 months post partum and include: postpartum depression (using Edinburgh Postnatal Depression Scale), exclusive breastfeeding and met need for postpartum family planning. Secondary outcomes include other maternal and child health knowledge, outcomes and maternal and newborn healthcare use indicators. We will use intention-to-treat analysis. Mixed-effects models will account for clustering due to the group-oriented delivery of the intervention and repeated measures.

This study has been approved by the Health Ministry Screening Committee, Government of India and approved by ethics boards at the Post-Graduate Institute for Medical Education and Research, Chandigarh (Ref:001208, IEC-06/2022–2471), Maharashtra University of Health Sciences (Ref: MUHS/EC/06/2024), Sangath (Ref: AB_2022_81) and the University of California, San Francisco (Ref: 21–35730). All research activities will be performed in accordance with the Declaration of Helsinki. On completion, findings will be disseminated to stakeholders through diverse strategies. Results will be published in academic journals and presented at conferences.

ClinicalTrials.gov: NCT05268588 Clinical Trials Registry – India: CTRI/2022/07/043889.

To assess the association between educational level and cardiovascular age acceleration metric derived from ECG, and to determine whether this association is mediated by established cardiovascular disease (CVD) risk factors.

Prospective population-based cohort study (the Tromsø Study).

General population of the Tromsø municipality, Norway.

The study sample consisted of 4367 participants of the Tromsø Study, who took part in both Tromsø6 (2007–2008) and Tromsø7 (2015–2016), had a 12-lead ECG obtained at Tromsø7 and did not report a history of heart attack, stroke or atrial fibrillation.

-age, a biomarker of cardiovascular ageing, is defined as the difference (in years) between an individual’s ECG-predicted heart age and their chronological age. ECG-predicted heart age was estimated using a previously validated deep neural network.

Our findings indicate an inverse association between education and -age, with a regression coefficient per increment increase in education of –0.24 (95% CI –0.41 to –0.07) in the overall sample, –0.38 (95% CI –0.59 to –0.16) for women and –0.04 (95% CI –0.31 to 0.23) for men. Participants with the highest level of education (university/college for 4 or more years) had the lowest estimated -age with a regression coefficient of –0.69 years (95% CI –1.23 to –0.16) compared with the group with primary education for the overall sample, –1.05 years (95% CI –1.73 to –0.37) for women and –0.15 years (95% CI –1.03 to 0.73) for men. CVD risk factors mediated up to 75% of the association between overall education and -age, and 80% of the association among those with the highest education level (university/college for 4 or more years). Among women, 50% of the effect of overall education on -age was mediated by CVD risk factors, rising to 53% in the category with the highest level of education. However, in the subsample of men, there was no significant association between education and -age, and the mediation analysis produced natural direct and indirect effects pointing in opposite directions.

Cardiovascular ageing is inversely associated with educational level, an effect that appears to be largely mediated through established risk factors.

Delirium is common in the older hospital population and is often precipitated by acute illness. Delirium is associated with poor outcomes including subsequent cognitive decline and dementia and may therefore be a modifiable risk factor for dementia. However, the mechanisms underpinning the delirium–dementia relationship and the role of coexisting acute illness factors remain uncertain. Current biomarker studies of delirium have limitations including lack of detailed delirium characterisation with few studies on neurodegenerative or neuroimaging biomarkers especially in the acute setting. The Oxford and Reading Cognitive Health After Recovery from acute illness and Delirium—Prospective Study (ORCHARD-PS) aims to elucidate the pathophysiology of delirium and subsequent cognitive decline after acute illness in older adults, through acquisition of multimodal biomarkers for deep phenotyping of delirium and acute illness, and follow-up for incident dementia.

ORCHARD-PS is a bi-centre, prospective cohort study. Consecutive eligible patients requiring acute hospital admission or assessment are identified by the relevant acute clinical care team. All patients age >65 years without advanced dementia, nursing home residence, end-stage frailty or terminal illness are eligible. Details of potential participants are communicated to the research team and written informed consent or consultee agreement is obtained. Participants are interviewed as soon as possible after admission/assessment using a structured proforma.

Data are collected on demographics, diagnosis and comorbidities, social and functional background. Delirium is assessed using the 4A’s test, Confusion Assessment Method (long-form), Observational Scale of Level of Arousal, Richmond Agitation-Sedation Scale and Memorial Delirium Assessment Scale and diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. Delirium is categorised by time of onset (prevalent vs incident), dementia status, motoric subtype, severity and duration. Cognitive tests include the 10-point Abbreviated Mental Test and Montreal Cognitive Assessment. Participants are reassessed every 48–72 hours if remaining in hospital. Informant questionnaire data and interview are supplemented by hand searching of medical records and linkage to electronic patient records for nursing risk assessments, vital observations, laboratory results and International Classification of Diseases, Tenth Revision diagnostic and procedure codes.

In-person follow-up with more detailed cognitive testing and informant interview is undertaken at 3 months, and 1 and 3 years supplemented with indirect follow-up using medical records. Blood banking is performed at baseline and all follow-ups for future biomarker analyses. CT-brain and MRI-brain imaging acquired as part of standard care is obtained for quantification of brain atrophy and white matter disease/stroke supplemented by research CT-brain imaging. Outcomes include length of hospitalisation, change in care needs, institutionalisation, mortality, readmission, longitudinal changes in cognitive and functional status and incident dementia. Biomarker associations with delirium, and with incident dementia on follow-up, will be determined using logistic or Cox regression as appropriate, unadjusted and adjusted for covariates including demographics, baseline cognition, frailty, comorbidity and apolipoprotein E genotype.

ORCHARD-PS is approved by the South Central—Berkshire Research Ethics Committee (REC Reference: 23/SC/0199). Results will be disseminated through peer-reviewed publications and conference presentations.

ISRCTN24171810.