Global urbanisation is intensifying alongside steadily expanding older adult populations. The resulting air pollution profoundly impacts human health by exacerbating diseases, particularly among vulnerable elderly groups. Evidence demonstrates that green spaces mitigate air pollutant effects on health. Recent studies indicate green space exposure benefits older adults physiologically, psychologically and socially. However, existing systematic reviews have not synthesised the health impacts on this demographic. Consequently, this protocol outlines a systematic review and meta-analysis to evaluate how green space exposure affects health outcomes in older adults.

This systematic review protocol adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. A comprehensive search strategy will be applied across: (1) electronic databases (eg, PubMed, Web of Science), (2) the National Institute for Health and Care Excellence and (3) the Guidelines International Network database. Grey literature will be searched via GreyNet International, covering records from each database’s inception to November 2024. The study will analyse associations between green space exposure and health outcomes in older adults. Two researchers will independently screen literature, extract data and assess risk of bias. Heterogeneity will be assessed with a focus on study design, exposure variables and outcome measures. If sufficient homogeneity exists, a meta-analysis will be undertaken; otherwise, a narrative synthesis will be performed.

This study requires no ethics approval because it uses publicly available data from published studies. The completed review will be published in a peer-reviewed journal and disseminated at relevant conferences.

PROSPERO (CRD42024619700).

The incidence of acute pain subsequent to modified radical mastectomy (MRM) for breast cancer approximates 40%, with more than half of these cases evolving into chronic pain. Currently, the commonly employed analgesic schemes in clinical practice still have inadequacies. Liposomal bupivacaine (LB) is bupivacaine encapsulated in liposomes, and it is reported that its duration of action can extend up to 72 hours. This study will investigate the analgesic efficacy of LB in combination with bupivacaine hydrochloride (BHCl) for transversus thoracic muscle plane (TTP) block and pectoral nerves (PECS) block after MRM for breast cancer.

In this prospective, randomised, controlled trial, we will enrol 80 female patients aged 30 to 65 years who are scheduled to undergo MRM under general anaesthesia in combination with nerve block. They will be randomly assigned in a 1:1 ratio to the LB+BHCl group (Group A) and the BHCl group (Group B). All patients will undergo ultrasound-guided TTP+PECS block prior to surgery. The primary outcomes are the cumulative pain visual analogue scale (VAS) scores from 6 to 72 hours post-surgery and the quality of recovery, assessed using the QoR-40 score at 72 hours post-surgery. The secondary outcomes include the time to first analgesic rescue, the consumption of analgesic drugs within 72 hours postoperatively, the occurrence of adverse events and the VAS scores at 6 and 12 months postoperatively.

Ethical approval was obtained from the Ethics Committee of the Affiliated Hospital of Yangzhou University (2024 Ke Lun Shen (2024-07-01)). All patients will provide written informed consent. The results of this study will be published in a peer-reviewed journal.

Chinese Clinical Trial Registry (ChiCTR2400089933).

The prevention of treatment discontinuation is crucial in mitigating the adverse consequences of diabetes. This study aimed to identify the psychosocial factors and patient experiences associated with the discontinuation of diabetes treatment.

A cross-sectional study was conducted.

A nationwide online survey with convenience sampling.

Participants, aged 40–79 years, who reported living with diabetes, were included.

Treatment continuation status was the outcome variable. Participants who previously received regular treatment but were not currently under medical care were classified as the treatment discontinuation group. Psychological factors (mood and anxiety disorders, self-esteem, procrastination), social factors (loneliness, economic difficulties, adverse childhood experiences) and patient experiences and opinions regarding diabetes were assessed.

A total of 4715 individuals were included in the analysis. After adjusting for confounders, psychological distress (adjusted OR (AOR)=1.87, 95% CI (1.06 to 3.30), p=0.032) and higher procrastination (AOR=2.64, 95% CI (1.25 to 5.56), p=0.011) were significantly associated with treatment discontinuation. Overall, 9.7% of participants reported financial hardship, and 12.1% reported diabetes burnout during their course of treatment. Financial hardships (p=0.002), difficulty with child or older adult care (p

Psychological distress and higher procrastination levels were significantly associated with diabetes treatment discontinuation, after adjusting for potential confounders. The treatment discontinuation group reported significantly more psychosocial challenges than the continuation group. Healthcare providers and systems should prioritise addressing the psychosocial characteristics, experiences and challenges faced by individuals with diabetes.

This study analysed the clinical outcomes and healthcare costs associated with diabetic foot ulcer (DFU) within a tertiary healthcare centre in Singapore.

This is a retrospective, single-centre study. Patient data were extracted from the hospital’s electronic health system, including demographic, clinical and hospitalisation information. Hospitalisation costs were categorised into DFU-related and other hospitalisation costs. A one-way sensitivity analysis was performed to estimate the total healthcare costs associated with DFU.

Tertiary centre within a population suffering from a diabetic epidemic.

All patients aged 18 years or older who received DFU treatment between January 2019 and December 2023 at the Singapore General Hospital were included.

A total of 2857 DFU patients were included in the study. In-hospital mortality remained stable at 5%–6% annually. Among the cohort, 39.1% underwent minor amputations, 19.6% had major amputations and 9.0% experienced both minor and major amputations. The median length of stay for surgical patients ranged from 10 (IQR 4–24) to 13 days (IQR 6–31), compared with 4 (IQR 2–8) to 5 (IQR 3–9.5) days for non-surgical patients. Total costs per admission for patients with DFU-related surgery ranged from US$28 588.96 to US$34 204.77, while for those without surgery, costs ranged from US$6637.59 to US$7955.23. Total hospitalisation costs for DFU during the study period ranged from US$65.87 million to US$72.16 million. All figures were inflation adjusted to 2023 US dollars.

DFU poses a significant clinical and economic burden in Singapore. Understanding the costs associated with DFU is essential for resource allocation and planning in DFU management.

Sepsis and antibiotic resistance constitute a deadly synergy, causing the loss of millions of lives across the world, with their economic and developmental consequences posing a threat to global prosperity. Their impact is disproportionately felt in resource-limited settings and among vulnerable populations, especially children. A key challenge is prompt diagnosis and timely commencement of appropriate antibiotic therapies. These challenges are compounded in low-income and middle-income countries by a lack of comprehensive epidemiological data, with Nigeria being one such country for which it is lacking. Kaduna is the third largest state in Nigeria, with over 10 million inhabitants, of whom more than half are children under 14 years old. While bacterial sepsis and antimicrobial resistance (AMR) are recognised as a growing problem in the state, there are huge gaps in the current understanding of their aetiology. This project employs a cross-sectional design to investigate the clinical and haematological markers of paediatric sepsis, alongside determining the bacterial cause and prevalence of AMR at four high-turnover hospitals in Kaduna State, Nigeria. Further, whole-genome sequencing of isolated bacterial pathogens will be performed to determine the genetic features of resistance. This project represents the largest surveillance study of paediatric sepsis in Kaduna to date. Additionally, we aim to use the clinical, haematological, microbiological and genomic data to derive predictive models for sepsis causes, treatment strategies and patient outcomes.

This is a hospital-based, cross-sectional study that will recruit up to 461 children with bacterial sepsis who were admitted at the two teaching and two general hospitals in Kaduna State, Nigeria. Children presenting with features of fever, subnormal temperature and body weakness would be recruited into the study and have their blood samples collected. The blood samples will be used for culture, complete blood count, HIV and malaria testing. Accordingly, we will capture clinical presentation, haematological characteristics, causative pathogen from blood culture and patient outcomes. Nutritional status, known congenital immunosuppressive diseases, HIV infection and malaria infection will also be determined and documented. The bacterial isolates will be phenotypically characterised for AMR and genotypically following whole genome sequencing. Known and potential confounders to the outcomes of bacterial sepsis would be assessed in all participants, and adjustment for confounding would be performed using logistic regression and/or stratification±Mantel-Haenszel estimator where applicable.

Ethical approvals were granted by the University of Birmingham (ERN_2115-Jun2024), the Ahmadu Bello University Teaching Hospital (ABUTHZ/HREC/H45/2023), Barau Dikko Teaching Hospital, Kaduna (NHREC/30/11/21A) and the Kaduna State Ministry of Health (MOH/AD M/744/VOL.1/1110018). The study will be conducted using the international guidelines for good clinical practice and based on the principles of the Declaration of Helsinki. The results will be disseminated via oral and poster presentations in scientific conferences and published in peer-reviewed journal articles.

We will recruit 478 paediatric patients with newly diagnosed IgAV across multiple centres. Participants will undergo prospective longitudinal assessment at disease onset and at 1, 3, 6 and 12 months postdiagnosis. Standardised evaluations will include clinical manifestations, physical examinations, laboratory parameters and patient-reported outcomes. The data will be analysed statistically with SPSS software (V.27.0), adopting a significance threshold of p

This study has been approved by the Medical Ethics Committee of the First Affiliated Hospital of Guangxi Medical University (2024-K0480), the Ethics Committee of the First People’s Hospital of Yulin (YLSY-IRB-SR-2025060), the Medical Research Ethics Committee of the Liuzhou Workers’ Hospital (KY2024356) and the Ethics Committee of the Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region (No. (2025–1)003) and written informed consent was obtained from all the parents or guardians of the patients involved. It will be disseminated by publication of peer-reviewed manuscripts and presentation in abstract form at national and international scientific meetings.

ChiCTR2500099716.

To explore whether vaccine confidence and vaccine delay intention mediated the effect of the pay-it-forward intervention on human papillomavirus (HPV) vaccine uptake.

This secondary mediation analysis of a two-arm randomised controlled trial was conducted among female adolescents aged 15–18 years in Chengdu, China, from July 2022 to June 2023.

This study was conducted in four residential areas representing diverse economic backgrounds in Chengdu.

A total of 321 parents of girls aged 15–18 years who had not received the HPV vaccine participated in the study.

Participants were randomly allocated into two arms. Pay-it-forward participants received a community-contributed subsidy (47.7 USD) to support the HPV vaccination, along with educational postcards and an opportunity to donate to support others. In the standard-of-care arm, participants paid for their vaccination.

Primary outcome was the receipt of the first HPV vaccine dose within a 3-month period following an intervention. Based on previous literature, we hypothesised that vaccine confidence and vaccine delay intention were potential mediators. Vaccine confidence was measured using the vaccine confidence index. Vaccine delay intention refers to the caregiver’s preference to postpone HPV vaccination for their daughter until the preferred vaccine type becomes available, rather than accepting the immediately accessible HPV vaccine. Data on these mediators were collected via a self-administered online questionnaire conducted after the intervention but before vaccination.

Among urban participants, when compared with the standard-of-care arm, about 39% of the effect of the pay-it-forward intervention on vaccine uptake was mediated by a reduction in vaccine delay intention. Notably, vaccine confidence did not appear to mediate the effect of the intervention on vaccine uptake. Among suburban participants, no mediation effects were observed. In the suburban setting, caregivers who vaccinated their daughters showed poorer prior awareness of the HPV vaccine before participating in the trial compared with those who did not vaccinate their daughters (41.5% vs 21.1%; p=0.011).

Our findings indicate that among urban participants, the pay-it-forward may have effectively reduced vaccine delay intention, which was associated with an increased uptake of the HPV vaccine. However, in suburban areas, enhanced awareness might be a potential contributing factor to improved vaccine uptake, but further research is necessary to affirm this.

Chinese Clinical Trial Registry: ChiCTR2200055542.

In order to prevent chronic kidney disease (CKD), it is crucial to identify temporal trends in CKD incidence at the global level, both past and future.

An observational cross-sectional study.

We retrieved data on annual cases of CKD from the Global Burden of Disease (GBD) online database for the period between 1990 and 2021. To assess the trends in age-standardised incidence rates (ASRs) of CKD, we applied the average annual percentage change (AAPC) for both observed data (1990–2021) and projected data (2022–2030). Bayesian age-period-cohort models were employed to predict CKD ASRs and case numbers through 2030.

From 1990 to 2021, the number of newly diagnosed CKD cases worldwide rose from 7 758 599 (95% CI: 7 721 790 to 7 795 410) to 19 950 853 (95% CI: 19 914 040 to 19 987 670). During that same period, the CKD ASR increased from 145.66 to 252.93 per 100 000 people, with an AAPC of 0.74% (95% CI: 0.73 to 0.75). By 2030, the number of CKD cases is projected to reach 25 057 700 (95% credible interval (CrI: 23 389 630 to 26 725 770), and the ASR is expected to increase to 297.62 per 100 000 (AAPC: 0.15%, 95% CrI: 0.14 to 0.16). The most significant ASR increases are expected among individuals with type two diabetes mellitus (AAPC: 0.17%, 95% CI: 0.01 to 0.34), hypertension (AAPC: 0.17%, 95% CI: 0.05 to 0.28%), older adults (aged ≥60) (AAPC: 0.21%, 95% CI: 0.20 to 0.22) and individuals in middle- (AAPC: 0.19%, 95% CI: 0.11 to 0.27) and high-middle socio-demographic index (SDI) countries (AAPC: 0.18%, 95% CI: 0.09 to 0.27). Of the six WHO regions, the largest increase is predicted to occur in the Western Pacific region by 2030 (AAPC: 0.21%, 95% CrI: 0.11 to 0.32), followed by Eastern Mediterranean (AAPC: 0.18%, 95% CrI: 0.06 to 0.31). Of the 204 countries and territories examined, 201 showed an increasing trend between 1990 and 2030, while only three experienced a decrease.

CKD incidence rates and case numbers are predicted to increase globally through 2030. Women; people with type two diabetes mellitus and hypertension; people over 60 years of age; people living in high, middle and high-middle-SDI countries, as well as those from the region of the USA, Europe and the Western Pacific, are projected to have the highest ASR of CKD in 2030. This highlights the need to consider these subgroups in future plans for global control of CKD.

Providing care management, treatment and support to patients with Alzheimer’s Disease and Related Dementias (ADRD) is a difficult task for health systems. Over the past 20 years, interventions designed to improve outcomes for patients living in the community with dementia and their care partners have moved progressively, but separately, from large scale trials and pragmatic models of collaborative care. Given the projected increase in the number of people living with dementia coupled with the realignment of payment for services to be value-based and provided in the community, system-level approaches are needed to address the complex needs of patients with a dementia diagnosis and their care partners. We designed a statewide, pragmatic trial to evaluate virtual delivery of an evidence-based dementia collaborative care program on patient healthcare utilization and medication use.

The Aging Brain Care Virtual (ABCV) program is a 12-month embedded, cluster randomized, usual care controlled trial designed to test the effectiveness of a virtual dementia collaborative care program in 24 Indiana University Health primary care clinics (12 intervention, 12 control) across the state of Indiana, enrolling 860 persons living with dementia (430 intervention, 430 control) and their care partners. ABCV relies on a tailored approach in which dyad needs are identified during virtual visits and addressed with standardized protocols previously tested in a randomized controlled trial delivered in person. The ABCV trial will measure emergency department utilization (primary outcome) and appropriate medication use (secondary outcome) at 12 months using electronic medical record data. Additionally, this study will use semi-structured interviews with care partners and clinicians to explore the implementation context, process and outcomes of the ABCV program.

Ethics approval was obtained from the Indiana University Institutional Review Board (20249). Research findings will be published in peer-reviewed journals and presented at scientific conferences.

NCT06245499.

Current guideline-recommended antibiotic treatment durations for ventilator-associated pneumonia (VAP) are largely standardised, with limited consideration of individual patient characteristics, pathogens or clinical context. This one-size-fits-all approach risks both overtreatment—promoting antimicrobial resistance and adverse drug events—as well as undertreatment, increasing the likelihood of pneumonia recurrence and sepsis-related complications. There is a critical need for VAP-specific biomarkers to enable individualised treatment strategies. The Ventilator-associated pneumonia Biomarker Evaluation (VIBE) study aims to identify a dynamic alveolar biomarker signature associated with treatment response, with the goal of informing personalised antibiotic duration in future clinical trials.

VIBE is a prospective, observational, case-cohort study of 125 adult patients with VAP in Michigan Medicine University Hospital intensive care units. Study subjects will undergo non-bronchoscopic bronchoalveolar lavage on the day of VAP diagnosis (Day 1) and then on Days 3 and 5. Alveolar biomarkers (quantitative respiratory culture bioburden, alveolar neutrophil percentage and pathogen genomic load assessed via BioFire FilmArray polymerase chain reaction) will be assessed. An expert panel of intensivists, blinded to biomarker data, will adjudicate each patient’s Day 10 outcome as VAP clinical cure (control) or treatment failure (case). Absolute biomarker levels and mean-fold changes in biomarker levels will be compared between groups. Data will be used to derive a composite temporal alveolar biomarker signature predictive of VAP treatment failure.

Ethical approval was obtained from the University of Michigan Institutional Review Board (IRB #HUM00251780). Informed consent will be obtained from all study participants or their legally authorised representatives. Findings will be disseminated through peer-reviewed publications, conferences and feedback into clinical guidelines committees.

Mental health issues such as depression and anxiety are highly and disproportionally prevalent among university students. Beyond the academic rigour, stressors imposed by a new environment result in them being vulnerable to the onset and manifestation of mental health symptomatology. Leveraging smartphones and wearables for digital phenotyping capabilities is an innovative approach for monitoring and intervening in the mental health conditions of university students. This provides a unique opportunity to collect and identify digital and behavioural biomarkers, subsequently enabling the development of predictive models to identify university students at risk.

This study—Brightline—will employ an observational study design over a 6-month period, recruiting 500 students from a major public university in Singapore. Passive data collection will occur continuously throughout the monitoring period through a wearable device (Fitbit Charge 6) and smartphone sensors via the Brightline app, which uses a digital phenotyping data collection platform. Active data collection will consist of self-report questionnaires to be completed at the beginning of the study and follow-up assessments at 1, 3 and 6 months after. The passive and active data collected will be analysed to identify the digital biomarkers associated with depression, anxiety, stress, loneliness and affect among university students. Predictive models of these mental health issues will also be developed.

This study was approved by the Nanyang Technological University Institutional Review Board (IRB-2023-894). Findings from this study will be published in peer-reviewed journals and presented at academic conferences.

NCT06770075.

Escape room (ER) methodology is recognised as an innovative pedagogical tool in nursing education, fostering an interactive environment that transforms students from passive observers into active participants. Current research on ER in educational contexts primarily emphasises their effectiveness and learner experiences, while neglecting the specific facilitators and barriers relevant to nursing education. This gap leads to a lack of essential frameworks for course design. Understanding these barriers and facilitators is crucial for the effective application of ERs in educational settings. Consequently, this review aims to identify factors associated with the implementation of ER in nursing education, using the Consolidated Framework for Implementation Research as a guiding framework.

The search will encompass six English databases and three Chinese databases from their inception to 1 October 2025: CINAHL, Embase, Education Resources Information Center, Scopus, Web of Science and MEDLINE, Wang Fang, China National Knowledge Infrastructure and the Chinese Biomedical Literature Database. Studies with qualitative, quantitative or mixed-methods designs will be included. Publications in English or Chinese will be considered from database inception. Two independent researchers will conduct screening and data extraction according to predefined criteria. A convergent integrated approach, including the transformation of quantitative results, will be employed, followed by thematic synthesis to analyse the findings. Discrepancies will be resolved through discussions with a third reviewer.

The ethical approval for this review is unnecessary due to the utilisation of secondary data. The outcomes are scheduled for publication in a peer-reviewed journal, with the aim of elucidating the facilitators and barriers linked to the integration of ER in nursing education.

CRD42024605953.

This study aimed to determine the association between diabetes mellitus (DM) medication use and glycaemic control.

This was a retrospective diabetes registry-based cohort study.

Singapore.

Patients aged 18 and above with incident DM in the SingHealth Diabetes Registry from 2013 to 2020 were included. The entire study period included a 1 year baseline period, a 1 year observation period and a 3 month outcome period.

Drug use was measured using the proportion of days covered (PDC), and the changes in glycated haemoglobin (HbA1c) between the outcome and baseline periods were assessed. The associations between baseline HbA1c and PDC ≥0.80 and between PDC and change in HbA1c were analysed using logistic regression and the Kruskal–Wallis test, respectively.

Of 184 646 unique patients in the registry from 2013 to 2020, 36 314 met the inclusion and exclusion criteria and were included in the analysis. The median PDC for any DM drug, oral DM drugs and insulin during the observation period was 20.3%, 16.8% and 0%, respectively. Those who had good glycaemic control at baseline were less likely to receive DM drugs and those with poor baseline glycaemic control or missing baseline HbA1c were more likely to be consistent users (PDC >80%) (px 10^-16).

The relationship between DM drug use and glycaemic control is complex and non-monotonic. Higher PDC for any DM drug and oral DM drugs during the observation period was significantly associated with clinically relevant HbA1c improvements.

Subjective cognitive decline (SCD) and mild cognitive impairment (MCI) are high-risk factors for dementia. We developed a cognitive measurement tool for screening SCD and MCI in community-dwelling elderly individuals.

This study investigated the feasibility of using the Brief Elderly Cognitive Screening Inventory (BECSI) as a screening measure for MCI and SCD in community elderly.

A cross-sectional validation study.

The study included 1642 community-dwelling older adults aged ≥60 years.

The Cronbach’s α and split-half coefficients were calculated to test its reliability. The BECSI scores of the normal control group, SCD group and MCI group were compared. The internal consistency analysis, correlation analysis with the neuropsychiatric inventory (NPI) and core neuropsychological test (CNT) were conducted. The screening efficacy of BECSI was verified by receiver operating characteristic curve.

BECSI was a self-report questionnaire. Its Cronbach’s α coefficient and split-half coefficient were respectively 0.923 and 0.888. The correlation coefficients between the total score and individual items ranged from 0.185 to 0.813, and were also significantly correlated with NPI and CNT. Statistically significant differences were observed among the three groups in the total scores. The areas under the curves for distinguishing SCD from normal cognitive and MCI from SCD are 0.835 and 0.889, respectively, with the optimal cut-off points of 12.5 and 16.5.

BECSI is quick and easy to administer, and can be used as a feasible and useful measure for screening SCD and MCI in community-dwelling older adults.