BMJ Open Quality

Background Regulatory inconsistency across African countries contributes to duplicative scientific assessments, prolonged approval timelines, and delayed access to essential medical products. To inform the operationalisation of the African Medicines Agency (AMA), the African Medicines Regulatory Harmonisation (AMRH) programme implemented Africa's first continental pilot study for the scientific evaluation and listing of human medicinal products. This study evaluates the pilot's procedural performance and examines how continental scientific opinions were translated into national regulatory decisions through reliance mechanisms. Methods and Findings A mixed-methods programme evaluation was conducted using regulatory datasets generated during the pilot study. Quantitative data included assessment timelines, GMP inspection outcomes and national post-listing regulatory actions. Retrospective qualitative thematic analysis was applied to governance documents and National Regulatory Authority (NRA) feedback to identify legal, institutional and procedural determinants influencing uptake. Of 64 expressions of interest, 24 products progressed to full evaluation and 12 received positive continental scientific opinions. Ten met the predefined performance target of [≤]210 working days. Twenty-four GMP inspections identified no critical deficiencies and aligned with global regulatory benchmarks. National uptake demonstrated active reliance: full reliance (continental opinion as primary basis for national approval) for 7 products (58%); sequential reliance (continental assessment supplemented with targeted national queries) for 3 products (25%); and supplemented national review (separate national assessment undertaken) for 2 products (17%). Products with broader market strategies achieved registration in up to 23 African countries within a median of 77 working days post-listing. Variability in uptake reflected national legal authority, administrative requirements, and applicant submission strategies Conclusions The pilot study demonstrates the feasibility of a continent-wide regulatory assessment mechanism capable of producing trusted scientific outputs and enabling reliance-based national decision-making in Africa. While reliance was widely applied, heterogeneity in national procedures and administrative sequencing affected time to national registration. Findings provide empirical evidence to inform the AMA scale-up, highlighting the need for harmonised reliance pathways, streamlined administrative processes, and coordinated digital regulatory infrastructure.

Introduction Large language models are increasingly being used in healthcare. In interventional pain medicine, clinical reasoning is essential for procedural planning. Prior studies show that simplified prompts reduce clinical detail in AI-generated responses. It remains unclear whether this reflects knowledge loss or simply prompt-driven suppression of information. Methods We performed a controlled comparative study using 15 standardized low back pain questions representing common interventional pain questions. Each question was submitted to ChatGPT under three conditions, professional-level prompt (DP), fourth-grade reading-level prompt (D4), and clinician-directed rewriting of the D4 response to a medical level (U4[->]MD). No follow-up prompting was allowed. Three physicians independently rated responses for accuracy using a 0-2 ordinal scale. Clinical completeness was determined by consensus. Word count and Flesch-Kincaid Grade Level (FKGL) were also measured. Paired t-tests compared conditions. Results Accuracy was highest with professional prompting (1.76). Accuracy declined with the fourth-grade prompt (1.33; p = 0.00086). When simplified responses were rewritten for clinicians, accuracy returned to baseline (1.76; p {approx} 1.00 vs DP). Clinical completeness followed the same pattern showing DP 80.0%, D4 6.7%, U4[->]MD 73.3%. Fourth-grade responses were shorter and less complex. Upscaled responses were more complex and similar in length to professional responses. Inter-rater reliability was low (Fleiss {kappa} = 0.17), but trends were consistent across conditions. Conclusions Reduced clinical detail under simplified prompts appears to reflect constrained output rather than loss of knowledge. Clinician-directed reframing restores omitted content. LLM performance in interventional pain depends strongly on prompt design and intended audience.

ABSTRACT Background Before obtaining professional medical care, many people in peri-urban and rural Pakistan contact herbalists, spiritual healers, and unlicensed caregivers. This study examined the social, economic, and cultural factors influencing the use of informal care by analysing the health-seeking behaviours of individuals in the Faisalabad District. Methods An exploratory mixed-methods study was conducted in Makkuana and the surrounding villages of Faisalabad District, Punjab. The quantitative component involved a cross-sectional survey of 69 adults using a structured questionnaire adapted from the I-CAM-Q. The qualitative component comprised twelve in-depth interviews and two focus group discussions. Descriptive statistics and chi-square analysis were used for quantitative data. Thematic analysis, guided by the Health Belief Model and Andersen's Behavioural Model, was applied to qualitative data. Results The mean age of participants was 40.4 years; 62.3% were female, and 79.7% had monthly household incomes below PKR 60,000. Of the 69 participants, 68 (98.6%) sought care from an informal provider first, most commonly an unqualified practitioner (50.7%), herbal practitioner (29.0%), or homeopath (17.4%). Trust was the leading reason for provider choice (43.5%), followed by proximity (24.6%) and low cost (15.9%). Complications were reported by 21.7% of participants, and 39.1% later required formal care for the same illness. Eight qualitative themes emerged: structural and economic barriers to formal care; proximity and convenience as determinants of informal care; trust, familiarity, and social networks; cultural and religious normalisation of traditional practices; poor doctor-patient communication in formal settings; perceived safety and naturalness of alternative remedies; awareness deficits about provider qualifications; and treatment-related harm and delayed escalation to formal care. Conclusion Informal health care seeking is nearly universal in this community, driven by intersecting economic, structural, cultural, and interpersonal factors. Enhancing primary care affordability, accessibility, and the quality of provider-patient communication together with culturally sensitive health literacy programs, is essential to redirect care seeking toward qualified providers.

A Wearable Monitoring System (WMS), comprising a chest patch, wrist-worn pulse oximeter, and arm-worn blood pressure device, was developed in preparation for a pilot Randomised Controlled Trial (RCT) on a UK surgical ward. The system was designed to support continuous physiological monitoring and early detection of deterioration. An initial prototype user interface was developed by the research team based on prior clinical experience and engineering knowledge. To ensure suitability for clinical practice, iterative user-centred refinement was undertaken through a series of clinician focus groups and wearability assessments. Six focus groups were conducted between November 2019 and May 2021 involving multidisciplinary healthcare professionals. Feedback from these sessions informed successive interface and system modifications. System development spanned the COVID-19 pandemic, during which the WMS was rapidly adapted and deployed to support clinical care on isolation wards. Feedback obtained during this period was incorporated into later versions of the system and provided a unique opportunity to examine changes in clinician priorities under pandemic conditions. Clinicians consistently prioritised alert visibility, alarm fatigue mitigation, parameter flexibility, and centralised monitoring. Notably, preferences regarding alert modality and access mechanisms evolved over time: early enthusiasm for mobile or smartphone-type devices shifted towards a preference for fixed, ward-based displays and audible alerts at the nurses station following pandemic deployment. Building on previous wearability testing in healthy volunteers, wearability testing using a validated questionnaire was completed by 169 patient participants during the RCT. The chest patch and pulse oximeter demonstrated high tolerability, whereas the blood pressure cuff showed poor wearability and was removed from the final system. These findings demonstrate the importance of iterative, clinician-led design for wearable WMS and highlight how extreme clinical contexts such as the COVID-19 pandemic can significantly reshape perceived requirements for safety-critical monitoring technologies.

Background Individuals experiencing or at risk of homelessness face substantial barriers to preventive eye care that are poorly addressed by standard service models. Interdisciplinary optometry-social work collaboration offers a rights-based approach to improving engagement and continuity of care. Methods A convergent mixed-methods study was conducted between February and August 2024 at a multidisciplinary community centre. Clients experiencing or at risk of homelessness received integrated optometry and social work assessment and were prioritised as high, medium, or low based on combined clinical and social risk. Social work follow-up was guided by the Triple Mandate and W-Questions framework. Quantitative data were summarised using mean (SD), median [IQR], or n (%). Qualitative case notes were analysed using content analysis with inductive coding and secondary review for consistency. Results A total of 165 clients had priority categories coded (high: 68; medium: 47; low: 154). Demographic data were available for 132 clients (60% male; mean age 49.5 years [SD 16]); 27% had not completed high school, 89% reported weekly income below AUD 1000, and 28% had vision impairment. Two hundred forty-five case-note entries were consolidated into 146 unique records. SMS (46%) and phone calls (38%) were the most documented contact methods, although only 21% of calls were answered; missed calls (13%) and disconnected numbers (7%) were common. Multi-modal contact was more frequently documented for higher-priority clients. Appointment assistance was the most recorded facilitator (71%), while rights-based supports, including interpreter and transport assistance, were infrequently documented (<=5%). Qualitative analysis identified unstable communication, reliance on informal supports, and service fragmentation as key influences on recall outcomes. Conclusion This study supports an interdisciplinary, rights-based optometry-social work model to address barriers to preventive eye care among people experiencing or at risk of homelessness. Embedding structured handovers and tiered recall processes within community-based services may strengthen continuity and accountability for high-priority clients. Future implementation should evaluate outcomes related to equity of reach, service integration, and sustained engagement in care.

ObjectivesTo evaluate the effect of surgical hubs on the volume of surgeries, patient waiting times, and length of hospital stay for elective hip and knee replacements in the English NHS. DesignA retrospective longitudinal study using a difference-in-differences approach to compare changes in outcomes at NHS trusts that opened surgical hubs with those that did not. SettingThe study was set in the English NHS, using administrative data from NHS acute trusts providing elective hip and knee replacements between April 2014 and September 2024. ParticipantsThe study included 76 NHS trusts. The treatment group consisted of 29 trusts that opened a surgical hub for trauma and orthopaedic surgery during the study period. The control group consisted of 47 trusts that did not. 48 trusts that performed fewer than 1,000 relevant procedures over the ten-year period or that reported data for fewer than 41 of the 42 quarters in the sample period were excluded. InterventionThe phased introduction of surgical hubs dedicated to elective procedures at 29 NHS trusts between Q1 2020 and Q3 2024. Main outcome measuresThe three main outcomes were, measured at the trust-quarter level: the total number of elective primary hip and knee replacements (surgical volume), the average length of stay in hospital, and the average waiting time from being added to the waiting list to hospital admission. ResultsThe opening of a surgical hub was associated with an increase of 43.75 hip and knee replacement surgeries per quarter (95% CI: 22.22 to 65.28), which represents a 19.1% increase compared to the pre-hub mean. Length of stay was reduced by 0.32 days (95% CI: - 0.48 to -0.16), a 7.8% reduction. There was no statistically significant effect on average waiting times (-14.96 days, 95% CI: -33.11 to 3.19). ConclusionsSurgical hubs appear to be effective at increasing the number of hip and knee replacements and reducing the time patients spend in hospital. However, in this study, they did not lead to a statistically significant reduction in waiting times overall.

BackgroundSouth Africas public healthcare system serves most of the population through approximately 3,900 primary healthcare clinics characterised by long waiting times and high volumes of repeat-prescription visits. No published pre-arrival digital triage system operates across all 11 official South African languages while aligning with the South African Triage Scale (SATS). This paper reports the design and preliminary safety validation of BIZUSIZO, a hybrid deterministic-AI WhatsApp triage system. MethodsBIZUSIZO delivers SATS-aligned triage via WhatsApp, combining AI-assisted free-text classification (Claude Haiku 4.5) with a Deterministic Clinical Safety Layer (DCSL) that overrides AI output for 53 clinical discriminator categories (14 RED, 19 ORANGE, 20 YELLOW) coded in all 11 official languages and independent of AI availability. A five-domain risk factor assessment can only upgrade triage level. One hundred and twenty clinical vignettes in patient language (English, isiZulu, isiXhosa, Afrikaans; 30 per language) were scored against a developer-assigned gold standard with independent blinded nurse review. A 121-vignette multilingual DCSL safety consistency check across all 11 languages and a 220-call post-hoc framing sensitivity evaluation (110 paired vignettes) were also conducted. ResultsUnder-triage was 3.3% (4/120; 95% CI: 0.9%-8.3%) with no RED under-triage; exact concordance was 80.0% (96/120) and quadratic weighted kappa 0.891 (95% CI: 0.827-0.932). One two-level under-triage was observed on a non-RED presentation (V072, isiXhosa burns vignette, ORANGEGREEN); one two-level over-triage was observed (V054, isiZulu deep laceration, YELLOWRED). In the framing sensitivity evaluation, AI-only classification achieved 50.9% RED invariance under adversarial framing; full-pipeline classification achieved 95.0% in four validated languages, with the DCSL rescuing 18 of 23 AI drift cases. ConclusionsA hybrid deterministic-AI triage system with DCSL-based emergency detection achieved zero RED under-triage and consistent RED detection across all 11 official languages. The 16.7% over-triage rate falls within published South African SATS ranges (13.1-49%). A single two-level under-triage event was observed on an isiXhosa burns vignette (ORANGEGREEN) and is discussed in Limitations. Findings are preliminary; prospective validation against independent nurse triage is the necessary next step.

Background: China has implemented policies to strengthen its pharmacist workforce since the 2009 healthcare reform, yet a comprehensive evaluation of their long-term systemic effects is lacking. Objective: To systematically analyze the evolution of Chinas pharmacist workforce in healthcare institutions from 2007 to 2023 across four dimensions: quantity, quality, structure, and distribution, providing an empirical foundation for policy optimization. Methods: A retrospective analysis was conducted using longitudinal data from the China Health Statistics Yearbooks. Trends were delineated via descriptive statistics. Equity and spatial evolution were assessed using the Gini coefficient, Theil index decomposition, and spatial autocorrelation analyses (Global Morans I and hotspot analysis). Results: From 2007 to 2023, the total number of pharmacists increased from 357,700 to 569,500 (average annual growth: 2.2%). This growth lagged behind physicians (4.6%) and nurses (7.4%), causing the pharmacist-to-physician ratio to decline from 1:5.15 to 1:8.39. The workforce showed trends of feminization (female proportion rose from 59.7% to 70.8%) and aging. While quality improved, 51.1% still held an associate degree or below, and only 6.6% held senior titles. Equity analysis revealed the provincial Gini coefficient improved from 0.145 to 0.093. Theil index decomposition confirmed intra-provincial disparities as the primary inequality driver. Spatial analysis showed a non-significant global Morans I by 2023 (0.154, P*>0.05), down from 0.254 (P<0.01) in 2007. Hotspot analysis confirmed this transition, revealing a contraction of high-confidence clusters and a trend toward balanced distribution. Conclusions: China has made measurable progress in expanding pharmacist workforce size and improving inter-provincial equity since 2007. However, persistent structural challenges remain: relative workforce contraction compared to other health professions, an aging demographic, a shortage of senior talent, and significant intra-provincial inequity. Future policies must prioritize optimizing workforce structure and enhancing clinical service capabilities to catalyze a shift toward patient-centered pharmaceutical care.

Abstract: Background: Vascular access is essential in treating patients undergoing prolonged endovenous therapy such as chemotherapy, antibiotics, and parenteral nutrition. Since the 1990s, when PICCs (peripherally inserted central catheters) appeared, vascular access options have expanded significantly, revolutionizing the treatment landscape for all types of patients. Objective: To analyze and describe the profile of the use of PICCs in a Brazilian quaternary hospital over 10 years with data collected by the infusion therapy team. Evaluating the number of PICCs implanted over the years, patients epidemiology and clinical characteristics, insertion details, associated complications, and the reason for removal. Methods: A retrospective cohort study that employs a quantitative, non-experimental approach to classify and statistically analyze past events associated with 21,652 PICCs implanted from January 2012 to December 2021 in a quaternary hospital at Sao Paulo - Brazil. All the catheters were implanted, and the data was collected by a team of nurses specializing in infusion therapy. We analyzed the number of catheters implanted over the years, insertion characteristics, patients epidemiology and clinical data, possible associated complications, and the reason for removal. Statistical analyses were conducted using R software (version 4.4.1) and SPSS (version 29) for Windows (IBM Corp, Armonk, NY). Results: During the specified period, 21,652 catheters were analyzed. The patients gender distribution was nearly balanced (48.2% versus 51.8%), and the average age was 66 years. Cardiovascular and metabolic issues were the most common comorbidities, and between 2020 and 2021, 29.3% of the sample tested positive for COVID-19. The most common location of hospitalization and implantation was the medical-surgical clinic (31.6% - 41.4%), and the most used type of catheter was the Power Picc (83.9%). The estimated complication incidence density is 2.94 complications per 1,000 catheter-days. Almost all the PICCs (98,2%) were adequately located at the cavo-atrial junction after the first attempt, 82.2% of catheters were removed after therapy, and the median duration of catheter use was 12 days. Conclusion: PICCs are widely employed for drug infusion, with their use growing progressively due to specialized teams greater availability and training. The high efficiency of these devices with a relatively low risk of complications already observed in previous studies was reinforced by the findings of this study of more than 20,000 catheters.

PurposeTo characterize maternal transport patterns in Iowa, a state with levels of maternal care and without formal perinatal regions, and assess whether transport decisions reflect efficient, risk-appropriate coordination. MethodsWe analyzed 2010-2023 Iowa birth records, which included 2,251 maternal transports between obstetric facilities across 106 unique routes. We characterized transport patterns and applied a community detection algorithm to identify "communities" of obstetric facilities that disproportionately transport among themselves. FindingsSuburban and rural counties have elevated transport rates compared to urban counties. 2,189 transports (97%) were from lower-to higher-level facilities. Among these, 2,037 (93%) were to Level III tertiary care centers. 567 transports (25.2%) bypassed a closer facility offering an equivalent or higher level of care than its destination facility. Health system affiliation was associated with bypassing transport, indicating potential organizational rather than purely geographic drivers of transport decisions. Three "communities" of obstetric facilities largely shaped by geographic proximity were identified. ConclusionsAlthough Iowa does not have formal perinatal regions, patterns of maternal transport are mostly in line with three de facto regions. Some potential inefficiencies were identified, such as obstetric facilities transporting to a farther facility when a closer facility offered the same level of care or higher. These findings may help identify opportunities to enhance care coordination among obstetric facilities, optimize maternal transport networks, and improve regionalization of maternal care.

Patients with amyotrophic lateral sclerosis (ALS) face critical decisions regarding life-sustaining treatments, such as invasive mechanical ventilation and percutaneous endoscopic gastrostomy. Advance care planning and shared decision-making are standard supportive frameworks but they often fail to account for structural pressures like progressive decline, shifting patient values, and fear of becoming a burden that may influence decision-making. This study explores how patients with ALS interpret ventilator and care options amid progressive physical decline, thereby reconsidering approaches to decision support. Using a qualitative descriptive design, the researcher (a nurse/sociologist) conducted 2-3 hour home interviews with five purposively sampled patients with ALS. Data, including eye-tracking-aided responses, were analysed via Sandelowskis framework. Rigour was ensured through team-based triangulation, independent coding by two researchers, and a reflexive audit trail. Subjective narratives were prioritised without medical record cross-referencing to capture patients experiences. Four categories emerged: (1) Rewriting clinical prognosis into a narrative of exploration via peer models, where meeting active ventilator users transformed future perceptions; (2) The conflict between securing care infrastructure and the burden on family, which greatly influenced the will to survive; (3) Existential fluctuation, where patients intentions shifted with daily fulfilment and family events; and (4) Governance of the body via pre-emptive technology use and training carers as physical extensions. Findings showed decision-making was a multi-layered process redefining lifes meaning within social resources. This necessitate shifting from independent to relational autonomy, where agency relies on care infrastructure, not physical ability. Treatment choice is a dynamic exploration requiring narrative companions to support existential fluctuations. Professionals must coordinate environments to reduce patient indebtedness. Limitations include the small, resource-advantaged sample (N = 5) and reliance on subjective narratives without medical record verification. Living with ALS means governing a new self through relational support and continuous dialogue.

IntroductionIncreasing global prevalence of overweight and obesity underscores the need for context-specific evidence to guide preventive policy implementation. Previous modelling showed that promoting healthy indigenous foods, implementing a 20% tax on sugar-sweetened beverages (SSBs), and introducing mandatory kilojoule menu labelling in formal-sector restaurants in Kenya were health-promoting, cost-saving, and cost-effective. Cost-effectiveness evidence is strengthened when considered alongside broader policy implementation considerations. We engaged stakeholders to assess additional implementation considerations relevant to decision-makers and to evaluate the stakeholder engagement process used in the modelling study. MethodsUsing the Assessing Cost-Effectiveness approach, we conducted a stakeholder-engaged study with national-level Kenya stakeholders recruited through purposive and snowball sampling. Through deliberative dialogue at a hybrid workshop, stakeholders assessed implementation considerations such as equity, feasibility and sustainability using a colour-coded scoring tool. We evaluated the engagement process using an anonymous survey covering seven stakeholder-engaged research domains. We analysed responses thematically. ResultsAcross the three interventions, most implementation considerations for feasibility, reach and impact, affordability, acceptability, and sustainability were assessed as medium or high. Industry acceptability of kilojoule labelling and SSB tax and affordability of kilojoule labelling to industry were rated low. Equity scores varied. Stakeholders proposed complementary measures that could raise low ratings to favorable scores. Clarity on stakeholder roles was identified as a key strength of the engagement process, while competing time commitments limited participation. ConclusionStakeholder insights contextualise prior cost-effectiveness evidence within policy-relevant implementation considerations and inform current fiscal and regulatory debates. Evaluation of the stakeholder engagement process underscores its contribution to strengthening public health research.

Child undernutrition remains a major public health challenge in Kenya. Suboptimal feeding practices contribute significantly to persistent underweight and stunting. This study evaluated the effect of a community-based Positive Deviance Hearth (PDH) intervention on feeding practices among children aged 6-59 months in Sub County within a County of study. The study adopted a two-group pretest-posttest randomized experimental study design conducted for six months period, among 84 caregiver-child pairs in intervention and control groups. A multi-stage sampling was employed to identify study settings and participants. Structured and pretested questionnaires, 24-hour food recall questionnaires and meal diversity questionnaires were used for data collection at pre-intervention and post-intervention periods. Data was analyzed using R software v.4.5.2. The differences between intervention and control groups at baseline and endline were assessed using difference-in-difference analysis, relevantly summarized using adjusted DID estimates, 95% confidence intervals and p-values, with p<0.05 considered significant. The PDH intervention significantly improved feeding practices among children 6-59 months. Meal frequency increased for 9-23 months (DiD = +1.4; 95% CI: 1.2-1.7; p = 0.034) and 24 months and above (DiD = +1.2; 95% CI: 1.1-1.5; p = 0.017), and dietary diversity rose (DiD = +1.3; 95% CI: 1.1-1.9; p < 0.001). Nutrient-dense food consumption improved, including legumes (DiD = +32.6%; p < 0.001) and animal-source foods (DiD = +35.4%; p < 0.001). Energy and protein intake increased across all age groups (p < 0.05), and micronutrients iron, vitamin A, vitamin C also rose significantly (p < 0.05). The PDH intervention substantially improved caregiver feeding practices, increased dietary diversity, and enhanced macro- and micronutrient intake, demonstrating its effectiveness as a scalable, community-driven strategy for sustainably improving child nutrition in high-burden settings.

Culture plays a crucial role in health; family, community, culture, and social conventions all have a significant impact on how an infant with jaundice is treated. Written or unwritten rules govern what parents and the community are allowed to do, which may have a detrimental effect on the neonates care. ObjectivesThe study explored how social expectations affect midwives management of neonatal jaundice at the St Patricks hospital in Maase-Offinso, in the Ashanti region of Ghana. MethodA total of seventeen midwives were sampled purposively using an exploratory descriptive design. Participants were engaged in interviews and focus group discussion after ethical approval was obtained. A semi-structured focus group discussion guide and interview guide was used to collect data. ResultsThe study discovered that the treatment of neonatal jaundice was adversely affected by social pressures, misconceptions, maternal choices, and spiritual views. Mothers and midwives socially approved sunbathing, and there were indications that grandmothers disapproved hospital care for their grandchildren. ConclusionCulture, family and social norms cannot be separated from health especially for the neonate whose means of identification is to belong to a family. Consequently, it is essential to respond to social influences, cultural conventions, and the various cultures of families with a culturally sensitive approach.

Background: The instability-plasticity framework proposes that multimorbidity trajectories periodically enter instability phases that are vulnerable to escalation but also potentially modifiable through relational intervention. Whether such phases commonly resolve without acute care, or predominantly progress to hospitalisation, has not been quantified at scale. Objective: To quantify instability window outcomes across a longitudinal monitoring cohort; to test whether the characteristics distinguishing admitted from resolved windows reflect within-patient trajectory dynamics or between-patient severity; and to characterise which patient-reported and operator-rated signals reliably precede admission, using both a curated pilot sub-cohort and the full monitoring cohort with an explicit cross-cohort comparison. Methods: Two complementary analyses were conducted on data from the MonashWatch Patient Journey Record (PaJR) relational telehealth system. Instability windows were identified algorithmically (>=2 consecutive calls with Total_Alerts >=3) across the full longitudinal dataset (16,383 calls, 244 patients, 2.5 years) and classified by linkage to ED and hospital admission data. Window characteristics were compared at window, patient, and paired within-patient levels. Pre-admission signal cascades were analysed in two configurations: a curated pilot sub-cohort (64 patients, 280 calls, +/-10-day window, 103 admissions, December 2016-September 2017) and the full monitoring cohort (175 patients, 1,180 pre-admission calls, +/-14-day window, December 2016-July 2019). A three-way cross-cohort comparison decomposed differences between the two configurations into pipeline and population effects. Results: 621 instability windows were identified across 157 patients (64% of the monitored cohort). 67.3% resolved without hospital admission or ED attendance, a rate stable across alert thresholds 1-5. In paired within-patient analysis (n = 70), duration in days (p = 0.002) and multi-domain breadth (p < 0.001) distinguished admitted from resolved windows; alert intensity did not. In the pilot sub-cohort, patient-reported illness prognosis (Q21) was the dominant pre-admission signal (GEE beta = +0.058, AUC = 0.647, p-BH = 0.018). This finding did not replicate in the full cohort: Q21 was non-significant (GEE beta = -0.008, p = 0.154, AUC = 0.507). Cross-cohort analysis identified selective curation of the pilot sub-cohort as the primary explanation. In the full cohort, six signals escalated significantly before admission after Benjamini-Hochberg correction: total alerts, health impairment (Q26), red alerts, self-rated health (Q3), patient concerns (Q1), and operator concern (Q34). Health impairment achieved the highest individual AUC (0.605) and showed the longest pre-admission lead. No individual signal exceeded AUC 0.61. Conclusions: Two thirds of instability phases resolve without hospitalisation, providing direct empirical support for trajectory plasticity as a clinically frequent phenomenon. Within the same patient, persistence - in duration and in the consistency of high-severity multi-domain flagging across calls - distinguishes trajectories that tip into admission from those that resolve. The Q21 signal reversal between cohorts illustrates how selective curation can produce compelling but non-replicable findings in monitoring research. In the full population, objective alert signals and operator judgement, rather than patient illness prognosis, carry the pre-admission signal

STRUCTURED ABSTRACTO_ST_ABSImportanceC_ST_ABSSexual dysfunction can occur after midurethral sling (MUS) and transvaginal prolapse surgery. It remains unclear whether these procedures impact the clitoris, despite its role in sexual function and proximity to the MUS and vagina. ObjectivesTo compare postoperative sexual function and clitoral features by MUS and vaginal surgery approach after transvaginal prolapse repair with/without concomitant MUS. DesignCross-sectional ancillary study of magnetic resonance imaging (MRI) and sexual function data from the Defining Mechanisms of Anterior Vaginal Wall Descent study. SettingEight clinical sites in the US Pelvic Floor Disorders Network. Participants: 88 women with uterovaginal prolapse who underwent vaginal mesh hysteropexy or vaginal hysterectomy with uterosacral ligament suspension with/without MUS between 2013-2015. Data were analyzed between September 2021-June 2023. ExposuresBetween June 2014-May 2018, participants underwent pelvic MRI 30-42 months after surgery, or earlier if reoperation was desired. Sexual activity and function at baseline and 24-48-month follow-up were evaluated using the Pelvic Organ Prolapse/Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR). Clitoral features were obtained from postoperative MRI-based 3-dimensional models. Main Outcomes and MeasuresPISQ-IR scores and clitoral features (size, position). ResultsEighty-two women (median [range] age, 65 [47-79] years) were analyzed: 45 MUS (22 hysteropexy, 23 hysterectomy) and 37 No-MUS (19 hysteropexy, 18 hysterectomy). Postoperatively, 25 MUS, 12 No-MUS, 20 hysteropexy, and 17 hysterectomy patients were sexually active (SA). Overall, within the MUS and vaginal surgery groups, sexual function remained unchanged or improved (most PISQ-IR change from baseline scores were [&ge;]0) among SA and NSA women. Among SA women after surgery, the MUS group (vs No-MUS) had a poorer PISQ-IR arousal/orgasm (SA-AO) score (median, 3.5 vs 4.3; P=.02). The hysteropexy group (vs hysterectomy) had less improvement in PISQ-IR SA-AO score (median, 0.0 vs 0.3; P=.01). Women with MUS (vs without) had a smaller clitoral glans thickness (median, 9.0 mm vs 10.0 mm; P=.008) and clitoral body volume (median, 2783.5 mm3 vs 3587.4 mm3; P=.01). Conclusions and RelevanceSA women with MUS (vs without) or hysteropexy (vs hysterectomy) experienced poorer postoperative sexual function. MUS was linked to a smaller clitoris. Future studies should explore surgery-induced changes in clitoral anatomy and sexual function. KEY POINTSO_ST_ABSQuestionC_ST_ABSHow do sexual function and clitoral anatomy differ by midurethral sling placement and vaginal surgery approach? FindingsThis cross-sectional study compared patient-reported sexual function outcomes and 30-42-month postoperative magnetic resonance imaging-based 3-dimensional clitoral models of 82 women after vaginal prolapse surgery with or without concomitant midurethral sling. Midurethral sling (vs no sling) and vaginal mesh hysteropexy (vs vaginal hysterectomy) were associated with poorer postoperative sexual function outcomes. Additionally, midurethral sling was associated with a smaller clitoral glans and body. MeaningMidurethral sling and vaginal mesh hysteropexy were associated with, and may adversely alter, postoperative sexual function and/or clitoral anatomy. VISUAL ABSTRACT/PROMOTIONAL IMAGE O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=113 SRC="FIGDIR/small/26351291v1_ufig1.gif" ALT="Figure 1"> View larger version (33K): org.highwire.dtl.DTLVardef@904497org.highwire.dtl.DTLVardef@187514aorg.highwire.dtl.DTLVardef@e9e799org.highwire.dtl.DTLVardef@640f1a_HPS_FORMAT_FIGEXP M_FIG C_FIG

Background: Lung cancer screening can reduce lung cancer mortality through early detection, but uptake of the NHS Targeted Lung Health Check (TLHC) programme remains low. Behaviourally informed invitation messages have been proposed as a low-cost approach to increase attendance, but evidence of their effectiveness in lung cancer screening is mixed. Few intervention studies used evidence-based behaviour change frameworks, and rarely tailored invitation strategies to empirically identified barriers and enablers. Methods: In an online experiment, 3,274 adults aged 55-74 years and with a history of smoking were randomised to see one of four behaviourally informed invitation messages or a control message. Participants then rated their intention to attend a TLHC appointment, and selected barriers and enablers to attending from a pre-defined list, which were classified according to the Theoretical Domains Framework. Invitation messages were mapped to Behaviour Change Techniques using the Theory and Techniques Tool. Message conditions were compared on intention to attend TLHC using bootstrapped ANOVA followed by pairwise comparisons. Exploratory counterfactual mediation analyses examined the role of fear in intention to attend. Results: Behaviourally informed invitation messages did not meaningfully increase intention to attend TLHC compared with the control message. While a GP-endorsed message showed a small potential benefit relative to the other conditions, this finding was not robust after adjustment for multiple comparisons. Participants most frequently reported barriers related to Emotion (particularly fear), Social Influence, and Knowledge, while Beliefs about Consequences emerged as the primary enabler of attendance. Only around half of reported barriers and enablers were addressed by the invitation messages. Exploratory analyses found that fear was associated with lower intention to attend a TLHC appointment, yet none of the behaviourally informed messages appeared to reduce fear compared to the control message. Conclusions: Improving lung cancer screening uptake will likely require invitation messages that directly address emotional concerns, particularly fear, alongside credible recommendations. These findings highlight the importance of systematically aligning invitation message content with empirically identified behavioural influences when designing scalable interventions to improve lung cancer screening uptake.

Objective The aim of this study was to develop and validate an automated, scalable framework to harmonise fragmented UK primary care prescription records into a research-ready dataset by mapping four diverse medical ontologies to a unified, historically comprehensive reference standard. Materials and Methods We used raw prescription records for consented participants in the UK Biobank, in which participants are uniquely characterized by multiple data modalities. Primary care data were preprocessed by selecting one drug code if multiple were recorded, cleaning codes to match reference presentations, expanding code granularity based on drug descriptions, and updating outdated codes to a single reference version. Harmonisation entailed mapping British National Formulary (BNF) and Read2 codes to dm+d, the universal NHS standard vocabulary for uniquely identifying and prescribing medicines. Harmonised dm+d records were then homogenised to a single concept granularity, the Virtual Medicinal Product (VMP). We validated our methods by creating medication profiles mapping contemporary drug prescribing patterns in 312 physical and mental health conditions. Results We preprocessed 57,659,844 records (100%) from 221,868 participants (100%). Of those, 48,950 records were dropped due to lack of drug code. 7,357,572 records (13%) used multiple ontologies. Most (76%) records were encoded in BNF and most had the code granularity expanded via the drug description (N=28,034,282; 49%). 41,244,315 records (72%) were harmonised to dm+d and 99.98% of these were converted to VMP as a homogeneous dataset. Across 312 diseases, we identified 23,352 disease-drug associations with 237 medications (represented as BNF subparagraphs) that survived statistical correction of which most resembled drug - indication pairs. Conclusion Our methodology converts highly fragmented and raw prescription records with inconsistent data quality into a streamlined, enriched dataset at a single reference, version, and granularity of information. Harmonised prescription records can be easily utilised by researchers to perform large-scale analyses in research.

Objective To analyse sociodemographic determinants of maternal health indicators in Kenyas conflict-affected regions. Methods A cross-sectional secondary analysis of the 2022 Kenya Demographic and Health Survey (KDHS) was conducted. Conflict-affected counties were identified using ACLED (>25 fatalities). The sample included 1,060 women aged 15-49 years. Outcomes were adequate antenatal care (ANC 4+), facility delivery, and skilled birth attendance (SBA). Predictors included age, education, wealth, employment, residence, and county; intimate partner violence was adjusted for. Weighted descriptive statistics, chi-square tests, and multivariable logistic regression were applied (p<0.05). Results Six counties met conflict criteria. While 90.2% of women attended at least one ANC visit, only 53.5% achieved ANC 4+. Facility delivery and SBA were 68.2% and 72.2%, respectively. Adolescents (15-19) were least likely to attain adequate ANC; women aged 20-24 had higher odds (aOR=1.83; 95% CI: 1.01-3.34). Education strongly predicted outcomes: higher education increased ANC 4+ (aOR=2.74; 95% CI: 1.19-6.34) and facility delivery (aOR=2.72; 95% CI: 1.15-6.47). Wealth showed strong gradients: middle quintile increased facility delivery (aOR=5.50; 95% CI: 2.14-14.14), while richer quintile increased SBA (aOR=11.04; 95% CI: 2.06-59.25). Rural residence reduced facility delivery (aOR=0.32) and SBA (aOR=0.22). County disparities persisted. IPV was not independently associated. Conclusion Maternal health indicators in conflict-affected Kenya follow a marked inequity gradient. Adolescents, rural residents, and socioeconomically disadvantaged women are most excluded. Strengthening adolescent ANC continuity, reducing rural access barriers, and investing in education and economic empowerment are critical for improving outcomes.

Background: Mobile phone-based tools are increasingly used to collect data on non-communicable disease (NCD) risk factors, particularly in low-resource settings where traditional data collection systems face operational and infrastructural constraints. This study examined stakeholder perspectives on the use of enhanced mobile phone-based capabilities to support the collection of public health surveillance data on NCD risk factors in low-resource settings. Methods: An exploratory qualitative study was conducted between November 2022 and July 2023. Twenty in-depth interviews were conducted with public health specialists, ethicists, NCD researchers, health informaticians, and policy makers in Uganda. Thematic analysis was used to interpret the results. Results: Four themes emerged from the data, including benefits of using mobile phone capabilities for NCD risk factor data collection; ethical, legal, and social implications; perceived challenges of using such mobile phone capabilities; and proposed solutions to improve the utility of phone-based capabilities in data collection on NCD risk factors. Participants recognized the potential of mobile technologies to improve data collection efficiency and expand access to hard-to-reach populations. However, concerns emerged regarding inadequate informed consent, risks to privacy and confidentiality, unclear data ownership, and vulnerabilities created by inconsistent enforcement of data protection laws. Social concerns included low digital literacy, unequal access to mobile devices, and fear of stigmatization. Participants emphasized the need for transparent communication, robust data governance, and community engagement. Conclusion: Mobile phone-based systems can strengthen the collection of NCD risk factor data in low-resource settings; however, their benefits depend on addressing key ethical, legal, and social challenges. To ensure responsible deployment, digital health initiatives must prioritize participant autonomy, data protection, equity, and trust building. Integrating contextualized ethical, legal, and social considerations into design and policy frameworks will be essential to leveraging mobile technologies in ways that support inclusive and effective NCD prevention and control.