BMJ Open最新文献

Objective: To explore the association between COVID-19 bed utilisation and changes in rehabilitation service provision in Japan, focusing on cerebrovascular, musculoskeletal and respiratory rehabilitation in the pre-COVID-19, during-COVID-19 and post-COVID-19 periods.

Design: Retrospective study using seasonal autoregressive integrated moving average model to predict expected values, which were compared with actual values to calculate observed-to-expected (OE) ratios.

Setting: Acute care hospitals in Kanagawa Prefecture, which has the second largest population in Japan after Tokyo, covering April 2014 to March 2024.

Participants: Patients aged 0-74 years who were enrolled in the National Health Insurance of Kanagawa Prefecture and underwent the studied types of rehabilitation.

Exposure: COVID-19 pandemic waves and associated bed utilisation rates, with multiple distinct peaks.

Outcome measures: The difference between the predicted and actual values of the volume of rehabilitation services provided and the number of patients per insured person calculated as OE ratios during periods of peak bed utilisation for COVID-19.

Results: The OE ratio of inpatient rehabilitation services for cerebrovascular showed a significant decrease after five waves at -14.3%, and musculoskeletal conditions showed a similar decline during periods of high COVID-19 bed utilisation. Outpatient services experienced sharp declines initially but showed differential recovery patterns. Respiratory rehabilitation displayed unique patterns, with inpatient services increasing up to 62.4% above expected levels until September 2021, before sharply declining. By March 2024, musculoskeletal rehabilitation demonstrated complete recovery, cerebrovascular rehabilitation showed partial recovery, while respiratory rehabilitation exhibited mixed patterns with persistent outpatient deficits.

Conclusions: Rehabilitation services in Japan showed substantial changes associated with the COVID-19 pandemic, with inpatient services for cerebrovascular and musculoskeletal conditions being particularly vulnerable to disruptions during high COVID-19 bed utilisation periods. The differential recovery patterns across rehabilitation types, with some structural changes persisting beyond the acute pandemic phase, indicate the need for flexible healthcare systems to deal with future healthcare crises. These findings underscore the importance of developing strategies to maintain essential rehabilitation services during public health emergencies, especially considering the ageing global population and rising demand for rehabilitation.

Objectives: To identify multifactorial contributors to treatment-seeking delays among Chinese young and middle-aged stroke patients using socioecological model.

Design: Descriptive phenomenological interview study.

Setting: A tertiary hospital in China.

Participants: Twenty acute stroke patients with treatment-seeking delays and 16 family members were recruited for dyadic semistructured interviews.

Primary and secondary outcome measures: Barriers influencing treatment-seeking delays across individual, interpersonal and systemic levels. And how do interlevel interactions shape decision-making trajectories?

Results: Data analysis revealed 5 overarching themes encompassing 12 subthemes: (1) limited stroke-specific health literacy; (2) psychological barriers at symptom onset; (3) inadequate interpersonal support systems; (4) structural impediments to timely care; (5) decision-making dynamics across levels. Delay was characterised as a sequential cascade mediated by cognitive misattribution, emotional paralysis, relational dependency, institutional constraints and cross-level feedback loops. Two dominant pathways, silent progression and diverted seeking, were identified.

Conclusion: Treatment-seeking delay among young and middle-aged stroke patients arises through dynamic interactions across socioecological strata rather than isolated factors. Integrated interventions targeting public awareness, familial preparedness, workplace policies and healthcare accessibility are required to disrupt this cascade.

Introduction: Dietary recommendations should be based on scientific evidence, and ideally, systematic reviews (SRs) are conducted as part of the guideline development process. The usability of SRs for decision-making is primarily determined by the quality of the evidence from available primary studies, as well as the quality of the SRs themselves. A comprehensive SR protocol ensures high-quality implementation and minimises bias, while making these protocols publicly accessible, promotes transparency and prevents redundancy. The PROSPERO database offers valuable insights into planned methodologies. The aim of this study is to investigate the completeness of reporting in SR protocols for diet- or nutrition-related trials, determine how this has changed over time, and examine the publication of completed SRs by comparing their content with those described in the corresponding protocols.

Methods and analysis: We developed a systematic search strategy for PROSPERO to identify nutrition- or diet-related SR protocols registered at two different time points (2019 and 2024). Following a screening process to identify eligible protocols, relevant predefined data will be extracted. Subsequently, a structured search will be conducted to identify potential journal publications of the selected protocols, as well as publications describing the results of the SRs, from which relevant predefined data will be also extracted. The methodology of the published articles will be compared with the corresponding a priori protocols registered in PROSPERO. The PROSPERO records registered in 2019 will be compared with those registered in 2024. The results will be evaluated by descriptive statistics, the reporting completeness of PROSPERO records will be assessed based on Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P), the planned use of any approaches to assess certainty of evidence will be investigated, and the adherence of published SRs to the methodological details outlined in their corresponding PROSPERO entries will be examined.

Ethics and dissemination: Since both databases and publications used in this study are publicly available, ethical approval is not required. Results of the study will be submitted for publication in an international, peer-reviewed journal.

Prospero registration number: The present study has previously been registered with the Open Science Framework (https://osf.io/8fsx7).

Introduction: Adverse neurological complications, including postoperative delirium (POD) and stroke, remain one of the major risks after cardiac surgery. A lack of comprehensive knowledge about their causes and neuroprotective strategies has hindered the development of effective interventions to reduce these events. Personalised cerebral autoregulation (CA)-oriented blood pressure monitoring aims to identify blood pressure targets tailored to each individual patient, thereby reducing brain injury. The PRECISION study aims to assess whether perioperative duration and magnitude of mean arterial pressure (MAP) deviation from an individual's CA limits are associated with adverse neurological complications.

Methods and analysis: This international, multicentre, prospective cohort study is conducted at two Swiss and one British hospital. Patients aged 65 years or older undergoing elective primary or re-operative coronary artery bypass graft and/or valvular and/or ascending aorta surgery requiring cardiopulmonary bypass are included. Preoperatively, the patient's baseline of physical, cognitive and mental status is established. Intraoperatively, near-infrared spectroscopy (NIRS) and transcranial Doppler (TCD) are recorded in real-time to generate NIRS-derived and TCD-derived CA indices. The primary endpoint is POD, assessed daily on postoperative days 0 to 7 or up to discharge, whichever occurs earlier with the 3D-Confusion Assessment Method (3D-CAM) or CAM-Intensive Care Unit. Secondary endpoints include a composite neurological outcome of POD and overt stroke, postoperative neurocognitive disorders, major morbidity and mortality. Associations between neurologic outcomes, neurobiomarkers and genetic variation will be explored.A total of 500 participants is required to achieve 90% power to find a statistically significant effect of the area under the curve MAP

Ethics and dissemination: Ethical approval has been obtained from all responsible ethics committees (Swiss lead ethics committee EKNZ 2022-01457 and Health Research Authority and Health and Care Research Wales, UK, REC 23/SW/0076). Results will be disseminated at national and international conferences and published in peer-reviewed journals.

Trial registration number: NCT05595954.

Objectives: To improve social determinants of health, healthcare organisations can support societal and economic goals in their role as anchor institutions (large organisations with an important presence and ties to a place). In England, the National Health Service (NHS) Long Term Plan highlighted the role of the NHS as an Anchor. Despite a clear policy mandate on this, less is known about specific indicators to measure and benchmark anchor performance. A set of metrics was developed to quantify anchor activity using the Greater Manchester (GM) region in England as a case study.

Design: Descriptive cross-sectional study.

Setting: Data were received on employment and procurement for the financial year 2022/2023 from NHS trusts located in GM.

Primary and secondary outcome measures: Performance against two anchor metrics, local spending and employment, was assessed. 'Local' was defined as the Integrated Care Board (ICB) footprint in which the trusts are located. The proportion of procurement spend to the local economy was derived from procurement data. Employment data was aggregated by ethnicity codes and deprivation levels and compared with ICB-level ethnicity and deprivation profiles using the Index of Multiple Deprivation based on 2021 Census data.

Results: The included trusts employed 65 597 residents of GM and spent £389 million on local procurement, demonstrating their importance as anchor organisations. Considerable variation was observed between trusts in local spending, ranging from 6.4% (95% CI 6.4% to 6.41%) to 52.7% (95% CI 52.69% to 52.72%) (with the mean at 21%). The percentage of locally employed staff ranged from 82.7% (95% CI 81.45% to 83.90%) to 89.5% (95% CI 89.12% to 89.95%). All trusts demonstrate strong workforce representation from minoritised ethnic groups, but most employed a lower proportion of staff from the most deprived areas than expected based on the local population profile.

Conclusions: It is feasible to quantify aspects of anchor activity using routine NHS data, and meaningful variation exists across trusts, even within a single health system. GM provides a useful case study, but further work is needed to embed anchor metrics in routine reporting and to extend measurement to other domains such as estates and sustainability.

Introduction: Each year, an estimated 1700 children should be diagnosed with cancer in western Kenya, with leukaemia making up nearly one-third of cases. However, far fewer are actually diagnosed, highlighting significant delays or errors in diagnosis. Flow cytometry, which the WHO considers essential for leukaemia diagnosis, remains underused across sub-Saharan Africa due to high costs, outdated equipment and a lack of trained personnel. In Kenya, decades-old cytometers have been adapted for leukaemia detection, but these systems are now outdated. Newer platforms, such as simplified single-tube multiparametric assays, provide a scalable and sustainable alternative. This study presents a protocol to evaluate the accuracy of diagnosis and the potential for implementing a streamlined flow cytometry assay using peripheral blood, supported by a regional educational initiative.

Methods and analysis: This prospective, mixed-methods implementation study has three aims: (1) to assess the concordance between the Beckman Coulter ClearLLab 10C gold standard 4-tube assay and the streamlined ClearLLab LS 1-tube assay using paired bone marrow and peripheral blood samples; (2) to evaluate the feasibility of peripheral facility referrals and transport logistics with couriered peripheral blood samples from referring sites across western Kenya; and (3) to measure training effectiveness and knowledge gain through a multimodal educational programme using the Project ECHO (Extension for Community Healthcare Outcomes) model. Up to 300 patients at Moi Teaching and Referral Hospital in Eldoret, Kenya, will be enrolled in Aim 1. A separate sample of 100 patients from peripheral facilities will be included in Aim 2. Surveys, knowledge assessments and structured interviews will be used to evaluate training impact under Aim 3. Diagnostic concordance, sensitivity, specificity and knowledge gain will be measured through appropriate quantitative and qualitative methods.

Ethics and dissemination: The protocol has received approval from institutional ethics committees at Moi University, MTRH and Indiana University. De-identified data will be analysed and shared through peer-reviewed publications, stakeholder presentations and educational platforms.

Introduction: Chronic low back pain (CLBP) remains a leading cause of disability worldwide and imposes a substantial personal and socioeconomic burden. Despite exercise being the first-line recommended intervention in clinical guidelines, its efficacy on pain relief remains modest and the hypoalgesia induced by exercise seems to be limited in individuals with musculoskeletal pain. Previous transcranial direct current stimulation (tDCS) studies have mainly targeted the motor cortex, yielding heterogeneous results, underscoring the need to evaluate alternative brain areas. Recently, tDCS studies targeting the dorsolateral prefrontal cortex (DLPFC) may enhance endogenous pain modulation and thereby potentiate the response to exercise. This study aims to compare the effects of adjunctive anodal DLPFC tDCS combined with a standardised exercise programme versus sham tDCS combined with the same exercise programme on pain and function in adults with CLBP.

Methods and analysis: This is a single-centre, triple-blinded, parallel-group randomised controlled trial. 48 participants with CLBP will be randomly assigned to receive either anodal tDCS over the left PFC combined with exercises, or sham tDCS combined with the same exercise programme, over nine sessions during a 3-week period. The primary outcome is the change in the multidimensional impact of CLBP, assessed using the Core Outcome Measures Index, from baseline to postintervention (week 4). Secondary outcomes include pain intensity, disability, psychological factors (fear-avoidance beliefs, catastrophising, anxiety, depression), measured at baseline, postintervention and at 12- and 24-week follow-up. Functional brain connectivity via electroencephalography and neuromuscular function of the erector spinae (flexion-relaxation phenomenon) will be measured at baseline and postintervention.

Ethics and dissemination: This study was approved by the Commission Cantonale d'Ethique de la Recherche sur l'être humain (CCER) in December 2022 (reference number: 2022-D0077). Written informed consent will be obtained from all participants. The results will be disseminated through peer-reviewed publications and presentations at national and international conferences.

Trial registration number: NCT05757609.

Objective: To determine individual and community-level predictors associated with timely initiation of breastfeeding among women in Tanzania.

Design: Analytical cross-sectional study.

Setting: This was an analytical cross-sectional study that used the 2022 Tanzania Demographic and Health Survey, which was conducted across all regions of Tanzania.

Participants: Data from 4308 women were included.

Primary outcome: The outcome variable was timely initiation of breastfeeding, defined as starting breastfeeding within the first hour after birth, coded as 1 if timely and 0 otherwise. Mixed-effects generalised linear model (family- Binomial and link-logit) approach was used to account for the hierarchical structure of the data. Four models were constructed to assess individual and community-level predictors. Adjusted prevalence ratios (APRs) with 95% CIs were reported.

Results: Women aged 25-34 years were significantly more likely to initiate breastfeeding within 1 hour (APR=1.40; 95% CI 1.18 to 1.65). Vaginal delivery was strongly associated with the timely initiation of breastfeeding (TIBF) (APR=10.13; 95% CI 7.84 to 13.09), whereas home delivery (APR=0.29; 95% CI 0.24 to 0.36) was negatively associated with TIBF. Multiparity (APR=1.22; 95% CI 1.04 to 1.43) increased the likelihood of TIBF. Women in the richest wealth category were less likely to practise TIBF (APR=0.70; 95% CI 0.51 to 0.96). Approximately 12.3% of the variation in TIBF was explained by cluster-level differences.

Conclusions: Both individual and community-level factors influence TIBF in Tanzania, highlighting the need for strong communication between mothers and healthcare providers to consistently promote its importance across all ages and wealth groups.

Objective: To compare the distribution, aetiology, treatment patterns and 2-year outcomes of moderate to severe valvular heart disease (VHD) between men and women in China.

Design: Nationwide, prospective, multicentre cohort study.

Setting: 46 tertiary hospitals across China, representing a mix of primary and secondary care settings.

Participants: A total of 13 917 adult patients with moderate-to-severe VHD were enrolled between April and June 2018. Of these, 6296 (45.24%) were women. Inclusion criteria included moderate or severe native valve disease, infective endocarditis or prior valve intervention.

Interventions: Patients received either conservative therapy or valve interventions, including surgical repair/replacement or transcatheter procedures. Intervention decisions were based on clinical assessment.

Main outcome measures: 2-year all-cause mortality, cardiovascular mortality, heart failure hospitalisation and major adverse cardiovascular events. Multivariable Cox and logistic regression analyses were conducted to identify outcome predictors.

Results: The overall intervention rate was 31.72%, with no gender difference (men: 31.26% vs women: 32.27%). Among the 5427 patients with severe symptomatic VHD, 49.11% received interventional therapy. The sex-specific pattern was particularly significant in severe symptomatic multiple valvular heart disease, where women had a higher propensity for intervention (p<0.001, OR: 1.19-1.66). In severe symptomatic aortic regurgitation patients, women were less likely to receive valve replacement (p=0.03, OR: 0.39-0.95).The 2-year survival rate was 90.85% with no gender difference (men: 90.41% vs women: 91.38%, p=0.086). Valve intervention improved survival to 97.0%, with no gender disparity (men: 96.92% vs women: 97.01%, p=0.87). Multivariate Cox regression confirmed no significant gender effect (p>0.05).

Conclusions: Significant gender differences exist in VHD aetiology and subtypes in China. Women had more rheumatic VHD, while men had more degenerative and functional VHD. Intervention improved survival, with no gender disparity. Age and VHD subtype influenced intervention rates and prognosis, supporting individualised, sex- and age-stratified management strategies.

Trial registration number: NCT03484806.