Systematic Reviews

AbstractsO_ST_ABSBackgroundC_ST_ABSSelf-management is essential for stroke survivors to maintain a healthy lifestyle and reduce recurrence risk. Although theory-based self-management interventions are widely recommended, the theoretical frameworks underpinning them and their comparative effectiveness remain unclear. AimsTo systematically identify the theories, models, and frameworks (TMFs) used in self-management interventions for stroke survivors, to explore how they guide interventions, and evaluate their effectiveness on self-management behaviors and self-efficacy. MethodsPubMed, Embase, Web of Science, ProQuest Health & Medical Collection and the Cochrane Library were searched from inception to July 15, 2025. Randomized controlled trials or quasi-experimental studies evaluating theory-based self-management interventions for stroke survivors were included. Two reviewers independently screened studies, extracted data, and assessed risk of bias (Cochrane RoB 2.0). Meta-analyses were performed using random-effects models. ResultsFrom 11,495 records, 32 studies with 3,212 participants were included. Sixteen distinct TMFs were identified; self-efficacy theory was most frequent (13/32), followed by social cognitive theory (6/32). All TMFs were middle-range theories. Meta-analysis showed TMFs-based interventions significantly improved self-management behaviors (SMD = 4.26, 95%CI: 0.20-8.31, I{superscript 2} = 98.2%) and self-efficacy (SMD = 0.60, 95%CI: 0.32-0.88, I{superscript 2} = 72.8%). However, the effect for behaviors is likely inflated due to extreme heterogeneity and theoretical diversity. Theory-specific analysis of self-efficacy theory (k = 8) confirmed significant effects on self-efficacy (SMD = 0.64, 95%CI: 0.21-1.08). ConclusionsThis review identified 16 distinct theoretical models; self-efficacy theory was most frequently applied, followed by social cognitive theory. Theory-based interventions significantly improved self-management behaviours and self-efficacy.

This study aimed to systematically review and critically evaluate the risk of bias and applicability of surgical site infection (SSI) risk prediction models after spinal surgery. China National Knowledge Infrastructure, Wanfang Database, China Science and Technology Journal Database (VIP), SinoMed, PubMed, Web of Science, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Embase were searched from inception to April 10, 2025. The prediction model risk of bias assessment tool-artificial intelligence (AI) and transparent reporting of a multivariable prediction model for individual prognosis or diagnosis-AI were used to assess the quality of the included studies, and RevMan software was used to perform a meta-analysis of the odds ratio values for certain model predictors. A total of 37 studies were included, identifying 43 predictive models. The incidence of SSI after spinal surgery ranged from 1.5% to 50%. Among these, 11 studies focused solely on model development, 4 studies included external validation, 22 studies were only internally validated, and 1 study was both internally and externally validated. The area under the curve values ranged from 0.610 to 0.991. The meta-analysis of high-frequency predictors identified statistically significant factors, including diabetes, age, surgery duration, albumin, body mass index, drainage time, smoking history, and American Society of Anesthesiologists score. All studies were rated as having a high risk of bias, primarily due to poor reporting related to study participants and the analysis domain. The evaluation using the prediction model risk of bias assessment tool indicated a considerable risk of bias in current predictive models for postoperative SSI after spinal surgery. Although the predictive model for SSI after spinal surgery is generally acceptable, most studies have methodological flaws. Moreover, studies with larger sample sizes and multicenter external validation are necessary to enhance the robustness of predictive models.

IntroductionVentriculoperitoneal (VP) and Lumboperitoneal (LP) shunts are the most common treatments for Idiopathic Normal Pressure Hydrocephalus (iNPH). Shunt procedure choice is generally based on surgeon on preference rather than evidence. We performed a systematic review and meta-analysis to address this gap for evidence-based shunt selection in iNPH treatment. MethodsPublications on post-operative outcomes for LP and VP shunts in iNPH were identified in MEDLINE and EMBASE. Papers were selected based on pre-specified inclusion and exclusion criteria and meta-analysis was conducted for outcome measures after shunt procedure. Results17 papers were included. LP Shunt patients showed greater cognitive improvement with an average increase of 2.00 points (95% CI: 1.08; 2.93, p < 0.0001) on their MMSE score post-operatively compared to VP shunt patients who improved on average by 1.30 points (95% CI: 0.81; 1.79, p < 0.0001). The LP group had considerable heterogeneity (I2 = 66.42%, p = 0.0003) whereas the VP shunt group had minimal heterogeneity (I2 = 0.00%, p = 0.8447) reflecting more uniformity across its included studies. For overall symptomatic improvement measured by the iNPHGS, VP shunts patients demonstrated a larger reduction in overall symptom scores with an average decrease of 2.91 points (95% CI: -3.78; -2.05, p < 0.0001) but with a high heterogeneity (I2 = 79.12%, p = 0.0012) compared to LP shunt patients with an average reduction of 1.91 points (95% CI: -2.31; -1.51, p < 0.0001) with no detected heterogeneity (I2 = 0.00%, p = 0.8454). ConclusionsOur findings demonstrate that LP and VP shunts show differing patterns of improvement across the cognitive domain and the broader iNPH triad, with LP shunting showing greater cognitive improvement and VP shunting showing greater overall symptomatic improvement. These differences represent a signal warranting further investigation, specifically whether symptom profiles should inform shunt selection.

BackgroundMiddle meningeal artery embolization (MMAE) has emerged as an adjunct or alternative strategy for the management of chronic subdural hematoma (cSDH). Although accumulating studies suggest potential benefit, uncertainty remains regarding its safety profile, recurrence-prevention effect, and the reliability of adverse event reporting. This systematic review and meta-analysis re-evaluate contemporary evidence, incorporating new randomized trials and large observational cohorts. MethodsThis systematic review was conducted in accordance with PRISMA 2020 guidelines and prospectively registered in PROSPERO. PubMed, Scopus, Web of Science Core Collection, Embase, and CENTRAL were searched from inception to 12 September 2025 without language restrictions. Randomized controlled trials, prospective or retrospective cohort studies, and non-randomized clinical studies evaluating middle meningeal artery embolization (MMAE) for chronic subdural hematoma were eligible. Data extraction and risk-of-bias assessment were performed independently using Joanna Briggs Institute appraisal tools. Where outcomes were sufficiently comparable, quantitative synthesis was undertaken using random-effects single-arm proportion meta-analysis with logit transformation. Recurrence after MMAE was pooled across observational studies and MMAE arms of randomized trials with available event-level data, with prespecified subgroup analyses by study design. Mortality was synthesized from randomized trials reporting event-level data within a [&le;]90-day follow-up window. Complication rates and technical success were analyzed descriptively due to heterogeneity in definitions and follow-up durations. ResultsNineteen studies met eligibility criteria, including seven randomized controlled trials, sixteen retrospective cohorts, and one prospective cohort, comprising an elderly and medically complex population (mean ages 61-89 years). Common comorbidities included hypertension, diabetes, cardiovascular and cerebrovascular disease, renal dysfunction, and antithrombotic use. Technical success of middle meningeal artery embolization (MMAE) was consistently high, with a pooled success rate of 100% (95% CI 0.99-1.00; I2 = 0%). Recurrence after MMAE was consistently low across randomized and observational studies, including high-risk populations, and was uniformly lower than in comparator groups. Radiographic outcomes showed substantial hematoma volume reduction and high rates of complete or near-complete resolution, with favorable functional recovery. Complications were uncommon but heterogeneous; the pooled overall complication rate was 14% (95% CI 0.08-0.21). Pooled 90-day all-cause mortality from randomized trials was 8% (95% CI 0.07-0.10; I2 = 0%). ConclusionMMAE is a safe and effective adjunctive or alternative treatment for chronic subdural hematoma, demonstrating a reproducible and clinically meaningful reduction in recurrence across randomized and observational datasets with homogeneous outcome definitions. However, variability in adverse event reporting, insufficient documentation of rare complications, and inconsistent definitions of radiographic versus clinical recurrence highlight the need for standardized outcome frameworks and harmonized follow-up protocols. Future well-designed trials with robust adverse event adjudication are essential to define the long-term safety profile of MMAE and to guide its optimal integration into cSDH management pathways.

BackgroundWhile veterinary surgeons are known to have particularly high rates of injury compared to other sectors, little is known about rates of injury among veterinary students. This study aims to understand animal-related injury rates, injury context and mechanisms, attitudes to reporting injuries, and behaviour change among UK and Irish veterinary students. MethodsA survey was distributed to students across all veterinary schools operating in the UK and Ireland in 2021. Questions explored participants experience of injury through asking about their most recent and most severe injuries via quantitative and free-text questions. Data were analysed using descriptive statistics, logistic regression, and qualitative content analysis. Results533 responses were included in the analyses. Overall, 47.5% of students reported having been injured by an animal during the veterinary degree, 35.5% of students reported being injured within the last 12 months. Most recent injuries were caused by companion animals (38.0%), livestock (37.6%), and equids (23.5%). For their most severe injuries, 48.7% involved livestock, 28.7% companion animals, and 22.1% equids. The content analysis highlighted that students normalised injuries and infrequently reported injuries to the university. It was very rare for students to take time off from their studies or placements, due to course pressures. ConclusionsThese findings reflect concerningly high levels of injury, which are being under-reported and reflect a culture of injury acceptance and expectation among students. Veterinary schools should consider lessons learnt in other work environments which have been successful in changing safety culture.

ObjectiveTo define contemporary medium and long term survival and durability outcomes after elective fenestrated and branched endovascular aortic repair (F/BEVAR) for complex abdominal and thoracoabdominal aneurysms and to assess the certainty of the available evidence. Data SourcesMEDLINE, Embase and the Cochrane Library were searched from January 2000 to February 2026, supplemented by citation screening. Review MethodsPublished Kaplan Meier time-to-event data were digitised and reconstructed into individual patient datasets. Pooled survival probabilities were generated using validated methods for meta-analytic methods for survival curves. Certainty of evidence was assessed using the GRADE framework. ResultsTwenty-four studies comprising 8,886 patients were included. Pooled overall survival was 91.3% (95% CI: 90.7, 91.9) at 1 year, 73.0% (95%CI: 71.9, 74.0) at 3 years and 55.4% (95% CI: 53.9, 56.8) at 5 years. Estimated median overall survival was 6.36 years. At 5 years, freedom from aneurysm-related mortality was 96.4% (95%CI: 95.3, 97.2), freedom from reintervention was 66.5% (95%CI: 64.6, 68.2), and target vessel patency (TVP) was 94.8% (95%CI: 93.3, 96.0). Certainty of evidence was low for overall survival, aneurysm related mortality and reintervention, and very low for TVP. ConclusionElective F/BEVAR provides durable aneurysm exclusion with low aneurysm related mortality; however, long term survival declines substantially. There is a need for more robust survival data and improved tools to support patient selection, shared decision making, and assessment of anticipated benefit when considering prophylactic complex endovascular repair. What this paper addsThis study provides a time-to-event synthesis of medium and long term outcomes after elective F/BEVAR for complex abdominal and thoracoabdominal aortic aneurysms, analysing reconstructed survival data from 8,886 patients across 24 studies published between 2000 and 2025. This analysis provides empirical survival data to inform recent European Society for Vascular Surgery guidance, demonstrating a median survival of 6.36 years and showing that most late deaths are not aneurysm related. These findings quantify the divergence between procedural durability and long term survival, supporting an individualised treatment strategy grounded in assessment of life expectancy, competing risk and shared decision making.

ObjectivesTo quantify the amount and certainty of evidence in Cochrane systematic reviews of interventions, and to describe how this evidence has evolved over time. DesignLarge-scale meta-research study Data sourceCochrane Database of Systematic Reviews (search date April 8, 2025) Eligibility criteriaCochrane systematic reviews assessing interventions reporting "Summary of findings" tables. Data extractionData were automatically extracted using web scraping and a large language model, with quality control performed by humans on a random sample. AnalysisWe describe the certainty of evidence for each population-intervention-comparison-outcome (PICO) question reported in all Cochrane "Summary of findings" tables. When available, we compared the certainty of evidence between the initial version and the latest update. ResultsWe identified 5,116 reviews that reported a "Summary of findings" table, containing 64,849 PICO questions. Overall, 24% (n = 15,768) of PICOs had no study included, 31% (n = 20,390) included only 1 study, 14% (n = 8,796) 2 studies, and 31% (n = 19,895) more than 2 studies. Nearly all PICOs (97%) only included randomized trials. The median [Q1-Q3] number of included participants was 123 [0-557]. The certainty of evidence was rated as high for 4% (n = 2,852), moderate for 16% (n = 10,574), low for 27% (n = 17,409), very low for 26% (n = 17,012), and not assessed for 26% (n = 17,002). Of the 7,461 PICO questions with an update (median time to update of 4.3 years [Q1-Q3: 2.6-6.4]), the number of included studies in the latest update remained the same for 63%; the certainty of evidence was unchanged for 71%; upgraded for 13% and downgraded for 15%. ConclusionThe amount and certainty of evidence is low and has not improved over time with review updates. These results question the efficiency of the research ecosystem. SummaryO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIHigh quality up-to-date evidence synthesis is essential for decision-makers. C_LIO_LIConfidence in the evidence informing decision-making can be limited by the amount and quality of primary research on a specific research question C_LI What this study addsO_LIThis large-scale meta-research study analyzed all Cochrane "Summary of findings" tables (i.e., 64,849 population-intervention-comparison-outcome - PICO - questions), and found that about two thirds of the PICO questions were informed by two or fewer studies, with a median [Q1-Q3] of 123 [0-557] participants per PICO; the associated certainty of evidence was rated as high in only 4% of the cases. C_LIO_LIAfter an update of the review (i.e., 7,461 PICOs), 63% PICOs did not include additional studies, and 71% showed no change in certainty of evidence; upgrades and downgrades of certainty occurred at similar frequencies. C_LIO_LIThese results question the efficiency of the research ecosystem. C_LI

BackgroundPostoperative delirium (POD) is a common complication of surgery. It is associated with a number of detrimental effects, including mortality and healthcare costs. We sought to determine whether common comorbidity indices are predictors of POD. MethodsUsing the Medical Information Mart for Intensive Care (MIMIC)-IV database, we identified 8022 abdominal surgery procedures across 7212 adult patients. We calculated both the Charlson comorbidity index (CCI) and the Elixhauser comorbidity index (ECI) for each procedure and used logistic regression to predict postoperative delirium, which was defined as delirium within 30 days following the procedure. ResultsModels based on either the CCI and ECI were predictive of postoperative delirium (area under the receiver-operator characteristic curve (AUC-ROC) of 0.622 and 0.652, respectively). However, the addition of other factors known to be associated with delirium improved model performance (AUC-ROC of 0.680). ConclusionsBoth the CCI and ECI are predictors of postoperative delirium in patients undergoing abdominal surgery. Addition of factors known to be associated with delirium renders additional predictive value and should be included in models that predict postoperative delirium.

Background: Platform trials are an efficient trial design which enable testing of multiple interventions simultaneously. They could advance knowledge of treatments for intracerebral haemorrhage (ICH). We aimed to investigate the views of clinicians involved in stroke research on recruitment to a future platform trial for ICH. Methods: Between April and July 2025, we conducted a UK-wide online survey of clinicians actively involved in stroke research using convenience sampling through professional organisations. Participants considered factors related to the consent process and research environment and could provide optional free text responses about additional barriers or facilitators to recruitment. We used descriptive statistics for quantitative data and content analysis for qualitative data. Results: Among 73 respondents, 46 (63%) were female, 36 (50%) were stroke physicians, 24 (34%) nurses, 6 (8%) allied health professionals, and 7 (10%) were in other roles. 36 (49%) had >20 years of clinical experience, 45 (61%) reported spending <10% of their role in research. 66 (91%) thought that a platform trial would be a good option for testing interventions for patients with stroke due to ICH. Across 11 modifiable factors, clinicians most frequently rated perceived importance of the research question as a facilitator of recruitment (94%), while clinician preference for specific treatments was most frequently rated as a barrier (48%). Two themes emerged from free text responses: study design and infrastructure. Regarding study design respondents perceived consent procedures (n=9), study materials (n=8), study procedures (n=8), eligibility assessment (n=6), the research question (n=3) and randomization (n=3) as important for a future platform trial. Regarding infrastructure, emergent factors were staffing (n=17), local research culture and capacity (n=9), research governance and delivery (n=6), and training (n=6). Conclusion: The overwhelming majority of respondents from the UK clinical stroke community supported a platform trial for ICH, although the influence of survey responder bias is unknown.

IntroductionStroke disproportionately affects minoritised ethnicities. While quantitative evidence has shown a difference in stroke risk and type of care received between UK ethnicity groups, qualitative data is sparse. We sought to explore experiences of in-hospital and community-based care from stroke survivors and caregivers from minoritised ethnicities.DD MethodsAudio recorded semi-structured interviews were conducted with stroke survivors and caregivers who self-identified as a minoritised ethnicity (e.g., Black, South Asian). Interviews covered experiences of incorporating cultural, religious, and/or dietary needs into stroke care, whether they perceived care was affected by ethnicity or cultural background, and ways to make care more culturally inclusive. Interviews were transcribed verbatim and analysed using reflexive thematic analysis. ResultsTwenty-four participants (n=16 stroke survivors, n=8 caregivers) took part. Themes included feeling different from a "typical" stroke survivor and affinity with British cultural norms ("I Feel Different in Stroke Care"); valuing culturally inclusive care but not always receiving it ("Culturally Inclusive Stroke Care is Important but Inconsistent"); individual perceptions of whether ethnicity affected care ("Personal Interpretations of the Role of Ethnicity in Stroke Care"); and tensions between caregivers advocating for cultural needs versus community perspectives of stroke ("Families Champion Stroke Survivors Cultural Needs, What about the Community?"). ConclusionsStroke survivors from UK minoritised ethnicity groups may feel "out of place" in care and may not receive sufficient cultural support. Individual interpretations of ethnicity, and affinity to British culture, affected perspectives on stroke care. Further efforts should be made to include culture and religion within person-centred stroke care.DD

IntroductionDespite the ubiquity of diverticular disease, the options for reducing the risk of recurrent diverticulitis remain limited and the pathogenesis remains incompletely understood. While high intraluminal pressures within the distal colon and rectum have been proposed as a possible association with diverticular disease, studies on this relationship have been few, inconsistent and not generalisable. The investigators of this pilot study propose that the repeated transient high intraluminal pressures generated within the distal colon and rectum due to ineffective defecatory technique may predispose some patients to an increased risk of diverticulosis and diverticulitis. Therefore, by correcting defecatory technique through the implementation of pelvic floor physiotherapy (PFPT), the investigators hypothesise that there would be a reduction in the risk of recurrent diverticulitis. Methods and analysisThis pilot multi-centre open-label randomised controlled trial will be conducted at Queen Elizabeth II Jubilee Hospital (QEII) and Logan Hospital (LGH) in Brisbane, Queensland, Australia. Eligible adult patients admitted with acute diverticulitis will be considered for enrolment and randomised into two groups in a 1:1 allocation ratio. The aim is to recruit 40 patients with 20 patients per group. The control group will receive standard of care dietary advice. The intervention group will receive PFPT as an outpatient within 4 weeks of discharge. The primary endpoint will be the risk of readmission with recurrent diverticulitis within a 12-month follow-up period. Secondary endpoints will be the risk of surgical intervention and/or interventional radiology (IR) procedure in the subgroup of patients readmitted with recurrent diverticulitis. Feasibility outcomes will review patient compliance and completeness of data collection. Results of this trial will inform study design and sample size required in a larger prospective study. Ethics and disseminationApproval was obtained from the Human Research Ethics Committee at the participating centre. Results will be submitted for publication in a peer-reviewed journal. Trial registration numberACTRN126250009274426. STRENGTHS AND LIMITATIONS OF THIS STUDYO_LIThis pilot RCT is the first prospective study to assess the correction of defecatory dysfunction as a method for reducing the risk of recurrent diverticulitis C_LIO_LIA practical design with ease of reproducibility that will inform a larger study adequately powered for hypothesis testing C_LIO_LIOpen-label design poses risk of performance bias C_LIO_LILack of standardisation for pelvic floor physiotherapy interventions may impact generalisability outside of facilities with dedicated pelvic floor units C_LI

BackgroundLung cancer compensation systems for occupational exposure to asbestos commonly apply Helsinki criteria, which assume 4% excess lung cancer risk per fibre-year of asbestos exposure. The Probability of Causation (PoC) is [&ge;]50% at 25 fibre-years (risk doubling threshold). Large case-control studies have suggested steeper exposure-response relations at lower exposures. We aimed to estimate PoC of asbestos-related lung cancer to evaluate exposure thresholds for compensation of lung cancer cases occupationally exposed to asbestos. MethodsRelative risk of asbestos-related lung cancer was estimated using two approaches: O_LIA meta-regression of 22 occupational studies forming the core evidence on cumulative asbestos exposure and lung cancer since the 1980s (130,341 participants). C_LIO_LIA meta-analysis of the recently conducted SYNERGY pooled case-control study (14 studies, 37,866 participants), adjusted for age, sex, smoking, and study. C_LI The likelihood that lung cancer was caused by asbestos was estimated as the PoC with 95% prediction intervals (95%PI). ResultsOccupational cohort studies produced a shallow exposure-response relation with substantial heterogeneity (I{superscript 2} = 92.7%). SYNERGY showed a steeper relation with 6.8% (95%PI: 0%-17.7%) lung cancer risk increase per fibre-year and lower heterogeneity (I{superscript 2} = 63.4%). PoC [&ge;]50% occurred at 62.93 (point estimate) and 18.2 fibre-years (upper 95%PI) for occupational asbestos studies, compared to 10.5 and 4.3, respectively, in SYNERGY. ConclusionsThe SYNERGY pooled case-control study provided exposure-response estimates that are more representative of current exposure to lower mixed asbestos fibres in the Netherlands, supporting lower exposure thresholds than the existing Helsinki criteria when estimating PoC in compensation contexts.

BackgroundPeripheral Artery Disease (PAD) is a progressive condition that can lead to major amputation if not properly managed. Geographic barriers may influence access to vascular care and outcomes. ObjectiveTo assess the impact of geographic distance on amputation rates and to evaluate mortality and hospitalization length among PAD patients treated in Brazils public healthcare system. MethodsA nationwide, retrospective, population-based analysis was conducted using DATASUS data from 2015-2024, including 335,716 PAD hospitalizations and 70,602 amputations. Logistic regression models evaluated factors associated with amputation and death. ResultsAmputation risk increased among patients treated outside their municipality and in state-managed hospitals. Male sex and older age were associated with higher odds of amputation, whereas women, though less frequently amputated, had greater mortality and longer hospital stays when amputation occurred. Mortality following amputation remained elevated nationwide. Regional variations reflected disparities in access to specialized vascular services. ConclusionGeographic and structural inequalities increased PAD-related amputations and mortality in Brazils public system. Greater distance to care and treatment outside the municipality were key predictors of poor outcomes.

BackgroundAntimicrobial resistance (AMR) is a global public health threat driven significantly by antimicrobial misuse in agriculture, particularly in poultry farming. This study assessed the awareness, knowledge, practices, and associated factors related to antimicrobial resistance among poultry farmers in Osun State, Nigeria. MethodsA cross-sectional study was conducted among 289 poultry farmers selected through stratified random sampling across Osun State. The study included actively practicing poultry farmers aged 18 years and above who used antimicrobials in their operations. Farmers not using antimicrobials were excluded. Data were collected using a pre-tested, structured, interviewer-administered questionnaire and analyzed with SPSS version 27. Descriptive statistics, chi-square tests, and inferential analyses were used to examine relationships between variables. ResultsThe majority of respondents (89.6%) had heard of AMR, the majority 239 (92.3%) of the respondents heard it from veterinary doctors. The majority (77.2%) also demonstrated good knowledge. Most farmers (89.6%) used antibiotics, with 52.9% using them occasionally. Personal experience (57.8%) was the primary basis for antibiotic selection. About 71.6% implemented biosecurity measures, and 57.8% had received training on AMR. Significant associations were found between knowledge and practice (p<0.001) and between attitude and practice (p<0.001). ConclusionDespite high awareness, antibiotic misuse persists, driven by factors such as reliance on personal experience and limited veterinary consultation. There is a need for enhanced farmer education, stricter regulatory enforcement, and the implementation of targeted antimicrobial stewardship programs to mitigate AMR risks in poultry farming.

IntroductionMusculoskeletal injuries (MSKIs) are ubiquitous in the U.S. military, especially among high-performing service members such as Marines. Given that female service members only started to be assigned to ground combat roles since December 2015, evaluation of sex on MSKI risk in ground combat occupations has not been possible until there was an ample population to study. The purpose of this population-level epidemiological study was to assess (1) if female sex was a salient risk factor for MSKI in Marines serving in different military occupations, including combat arms, and (2) the effects of integration period on MSKI risk among female Marines. Materials and MethodsA population-based epidemiological retrospective cohort study of all U.S. Marines was performed assessing female sex, occupation, and integration period on the prevalence of MSKI from 2011 through 2020. The Military Health System Data Repository was utilized to identify initial healthcare encounters for diagnosed ankle-foot, knee, lumbopelvic-hip, thoracocostal, cervicothoracic, shoulder, elbow, or wrist-hand complex injuries. Prevalence was calculated for female and male Marines in each occupational category (combat, combat support, aviators, aviation support, services) during the pre-integration (2011-2015) and post-integration (2016-2020) periods. ResultsDuring the pre-integration period, 520/1,000 female Marines (n=13,985) and 299/1,000 male Marines (n=142,158) incurred MSKIs. In the post-integration period, the prevalence increased to 565/1,000 female Marines (n=17,608) and 348/1,000 male Marines (n=161,429). In the multivariable evaluation of sex, occupation, integration period, and the interaction of sex and occupation on combined MSKIs, only female sex was a significant factor for injury (prevalence ratio [PR]=1.99), with service in ground combat and aviation occupations identified as protective factors when compared with services occupations (PR=0.69). When these same factors were evaluated for specific MSKI outcomes, female sex remained a robust factor in all lower quarter (PR=1.75-2.63) and upper quarter (PR=1.38-2.36) injuries except for shoulder injuries. Service in ground combat and aviation occupations was protective for all lower quarter injuries (PR=0.46-0.71). In the upper quarter, ground combat was protective for all injuries except for elbow injuries (PR=0.67-0.77). Serving as an aviator was a risk factor for cervicothoracic (PR=1.57) and thoracocostal (PR=1.22) injuries and a protective factor for shoulder (PR = 0.73) and wrist-hand (PR = 0.46) injuries. Adjusted risk for lumbopelvic-hip (PR=1.13), ankle-foot (PR=1.53), cervicothoracic (PR=1.19), thoracocostal (PR=1.14), and elbow (PR=1.48) injuries significantly increased during the post-integration period. There was a significant sex-by-period interaction for shoulder injuries alone, with female sex in the post-integration epoch found to be salient (PR=1.26). ConclusionsFemale sex was a salient factor for MSKI, with service in ground combat and aviation occupations identified as protective factors when compared with services occupations. In the evaluation of specific MSKIs, female sex remained a robust and significant factor in all lower quarter injuries and upper quarter injuries except for shoulder injuries. There was only a significant sex-by-period interaction for shoulder conditions, with an increased risk of these injuries in female Marines in the post-integration period.

ImportanceBariatric surgery is an established treatment for obesity and its associated comorbidities, including diabetes, hypertension, sleep apnea, and hypercholesterolemia. Despite the widespread adoption of various bariatric procedures, rigorous causal comparisons of their differential effects on treatment outcomes and adverse events remain scarce. ObjectiveThis large-scale observational study aimed to rigorously compare the effects of commonly performed bariatric surgery procedures on both weight loss (effevtiveness) and the risk of postoperative complications. Evidence ReviewThis study utilized data from the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MB-SAQIP) database, encompassing 729,482 cases from 2015 to 2020. With Sleeve Gastrectomy serving as the reference procedure, we assessed the effect of alternative procedures on changes in body mass index (BMI) and the risk of reoperation, readmission, and subsequent interventions. State-of-the-art machine learning-based causal inference techniques, including Causal Forest, Dragonnet, and Double Machine Learning, were employed to conduct robust causal comparisons. FindingsBiliopancreatic Diversion with Duodenal Switch (BPD/DS) demonstrated superior BMI reduction compared with Sleeve Gastrectomy. Roux-en-Y Gastric Bypass (RYGB), Adjustable Gastric Band (AGB, or Band), and Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) were associated with less pronounced BMI decreases relative to Sleeve Gastrectomy. The risk of complications was similar or higher for all other surgical procedures compared with Sleeve Gastrectomy. Importantly, these represent causal effect estimates rather than mere associations, providing clinically actionable evidence for treatment selection. Detailed effect estimates and risk ratios, along with their confidence intervals, are presented in the full text. All our implementations are available at GitHub. Conclusions and RelevanceOur causal estimates-derived from state-of-the-art machine learning methods applied to the largest bariatric surgery registry-provide the first rigorous quantitative evidence supporting current clinical practice guidelines, issued by the American Society for Metabolic and Bariatric Surgery (ASMBS), and enable evidence-based surgical decision-making. Key PointsO_ST_ABSQuestionC_ST_ABSWhat are the causal effects of the five widely adopted bariatric surgery procedures on weight loss efficacy and postoperative complication risks? FindingsOur causal analysis reveals that Biliopancreatic Diversion with Duodenal Switch (BPD/DS) achieves significantly greater BMI reduction compared with the most widely conducted Sleeve Gastrectomy, but at the cost of substantially elevated complication risks. Our causal analysis results of all five bariatric surgery procedures align with mechanistic understanding and provide quantitative causal estimates rather than associations. MeaningThis represents the first large-scale and comprehensive causal analysis comparing weight loss and adverse event risks across the five most important bariatric surgery procedures, providing rigorous evidence to inform surgical decision-making.

Policing is one of the most rewarding occupations; however, it is stressful and demanding. This study was designed to explore stress, stress management, and coping mechanisms among Nigerian Police Officers working across four geopolitical zones in Nigeria. Using an exploratory design, forty in-depth interviews (IDIs) were conducted with police officers. Data was collected using an interview guide. The interviews were conducted in English and the participants indigenous languages (by preference), audio-recorded, and transcribed verbatim. Data were analyzed using the thematic approach. A range of contextual stressors were identified as barriers to the health and well-being of police officers in Nigeria. The police often lack the tools and equipment needed to perform their official duties effectively. This includes items like uniforms, bulletproof vests, and even operational vehicles. Shortage of manpower, lack of operational tools, poor welfare for police officers, and poor remuneration were also among their concerns. The participants were able to identify signs of stress that are common among police officers, which are majorly weaknesses, lack of sleep, dizziness, headache, anxiety, exhaustion, and anger. The common coping mechanisms include regular exercise, adequate rest, and relaxation through recreational activities, regular medical checkups, and seeking support from colleagues, among others. Nigerian police officers face many challenges that affect their health and daily routines. This analysis identifies potential opportunities to improve officers welfare in these contexts.

BackgroundPostoperative delirium is a common complication in surgical patients, and is associated with a multitude of negative outcomes, including mortality, dementia, and increased healthcare costs. Therefore, a better understanding of what factors contribute to postoperative delirium, especially those that can be easily obtained, is important. MethodsWe conducted a retrospective cohort study using patients from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Adult patients undergoing procedures in abdominal surgery who did not have pre-existing delirium were included in the study. Overall, we included 8022 procedures across 7212 patients. For each admission, we extracted values obtained from common blood tests, the Charlson and Elixhauser comorbidity score, and patient demographic information. We used stepwise logistic regression to identify predictive factors of postoperative delirium in this cohort. ResultsThe model isolated factors well known to be associated with postoperative delirium, such as age, comorbidity (as represented by the Elixhauser comorbidity score), and Parkinsons disease. The model also selected variables that are less studied, such as minimum preoperative platelets and maximum preoperative sodium levels. We hypothesize that the former is associated with postoperative delirium as a surrogate marker for inflammation as an acute phase reactant, and the second due to it being a marker for cerebral edema and altered neurotransmission. ConclusionPreoperative blood tests contain valuable information that can be used alongside patient demographics and past medical history to better predict the risk of postoperative delirium.

BackgroundManual bag-valve ventilation during cardiopulmonary resuscitation (CPR) is prone to substantial variability in tidal volume and respiratory rate, frequently resulting in hyperventilation. The clinical effectiveness of mechanical ventilation as an alternative strategy remains uncertain. ObjectivesThis systematic review and meta-analysis compared mechanical versus manual ventilation during adult CPR to assess return of spontaneous circulation (ROSC), survival to hospital discharge, and neurological outcomes. MethodsWe searched PubMed, Embase, and Scopus (inception through October 2025) for randomized controlled trials and observational studies comparing mechanical and manual ventilation during adult CPR. We conducted separate meta-analyses for randomized trials and observational studies using random-effects models and assessed evidence certainty using GRADE methodology. Primary outcomes were ROSC, survival to discharge, and favorable neurological outcome (Cerebral Performance Category 1-2). ResultsEight studies (5,130 patients) met inclusion criteria. Mechanical ventilation was associated with higher ROSC (odds ratio [OR] 1.22; 95% confidence interval [CI] 1.07-1.38; p=0.002; I{superscript 2}=8%), survival to discharge (OR 1.39; 95% CI 1.08-1.77; p=0.009; I{superscript 2}=0%), and favorable neurological outcome (OR 1.61; 95% CI 1.04-2.48; p=0.03; I{superscript 2}=0%) compared with manual ventilation. In randomized trials (n=120), mechanical ventilation showed a trend toward improved ROSC (OR 1.49; 95% CI 0.73-3.07; p=0.27) but lacked statistical significance. Observational studies (n=7,081) demonstrated an association between mechanical ventilation and higher ROSC (OR 1.21; 95% CI 1.03-1.42; p=0.02; I{superscript 2}=34%). Post-ROSC arterial blood gases showed improved oxygenation (mean difference 13.01 mmHg higher pO2 ; p<0.0001) and lower pCO2 levels (mean difference 15.12 mmHg lower; p<0.00001) with mechanical ventilation. GRADE assessment indicated low-certainty evidence for clinical outcomes and moderate-certainty evidence for physiological outcomes. ConclusionsMechanical ventilation during CPR was associated with higher rates of ROSC, survival, and favourable neurological outcomes, along with more controlled post-ROSC physiological parameters. However, the certainty of evidence is low, driven largely by confounded observational data and limited randomized trial evidence. These findings are hypothesis-generating and should not be interpreted as causal. Confirmation in adequately powered randomized controlled trials is required before changes to practice or guidelines can be recommended. WHAT IS NEW?O_LIThis systematic review and meta-analysis, stratified by study design, synthesizes the available evidence comparing mechanical and manual ventilation during adult cardiopulmonary resuscitation across eight studies involving 5,130 patients. C_LIO_LIMechanical ventilation was associated with higher rates of return of spontaneous circulation, survival to hospital discharge, and favorable neurological outcome compared with manual ventilation; however, these associations are derived largely from observational data with low certainty of evidence. C_LIO_LIMechanical ventilation demonstrated more consistent post-resuscitation arterial blood gas parameters--higher oxygenation and lower carbon dioxide levels--suggesting physiologic benefits, although these findings also require confirmation in randomized trials. C_LI CLINICAL IMPLICATIONS?O_LIMechanical ventilation may offer a more standardized approach to delivering tidal volumes and respiratory rates during CPR, potentially mitigating the variability and risk of hyperventilation inherent to manual bag-valve ventilation. C_LIO_LIBecause the evidence supporting improved clinical outcomes is low certainty and primarily observational, the observed associations should not be interpreted as causal. These results are hypothesis-generating and highlight an important area for further investigation rather than indicating definitive clinical benefit. C_LIO_LIIf mechanical ventilation is used during CPR, implementation should prioritize protocolized ventilator settings (e.g., tidal volume 6-7 mL/kg and respiratory rate 10 breaths/min) and strict adherence to high-quality chest compressions. C_LIO_LIAdequately powered randomized controlled trials are needed to determine whether mechanical ventilation confers true clinical benefit and to inform future guideline recommendations. C_LI

Abstract This protocol is reported in accordance with the SPIRIT 2025 guidelines for clinical trial protocols. Introduction: Young children, from birth to age 5 y are particularly vulnerable to indoor air pollutants and respiratory pathogens. Portable air purifiers (or filtration) and upper-room ultraviolet germicidal irradiation (UVGI) are two widely used interventions with the potential to improve indoor air quality (IAQ) and reduce sick-related absences. However, a review of the literature revealed no real-world randomized studies evaluating their effectiveness in reducing young children's sick-related absences in early care and education (ECE) classrooms. Methods and Analysis: The OK-AIR study is a longitudinal, cluster-randomized 2x2 factorial trial conducted in Head Start centers using two implementation cohorts: Cohort 1 (five Head Start centers and 20 classrooms from 2023 to 2024) and Cohort 2 (11 centers and 59 classrooms from 2025 to 2026), with expanded inclusion of rural areas. Cohort 1 enrolled 204 children, 48 teachers and 5 site directors, and Cohort 2 enrolled 462 children, 97 teachers and 11 site directors. Within each center, four classrooms are randomized to: (1) control; (2) portable filtration; (3) upper-room ultraviolet germicidal irradiation (UVGI); or (4) both interventions. Cohort 2 was initially planned as a second factorial trial but was amended to a purifier-only design due to funding changes; details are provided in the protocol amendments section. We collect continuous IAQ data, including particulate matter (PM) with aerodynamic diameters [&le;]1 m (PM1), [&le;]2.5 m (PM2.5), [&le;]4 m (PM4), and [&le;]10 m (PM10); total volatile organic compounds (TVOCs) index; nitrogen oxides (NOx) index; carbon monoxide (CO), noise; temperature; and relative humidity, alongside daily child absences. Seasonal environmental surface swabs (dining tables and toilet flooring) are tested by Reverse-Transcriptase quantitative Polymerase Chain Reaction (RT-qPCR) for Influenza A/B, Respiratory Syncytial Virus (RSV), Human Parainfluenza Virus Type 3 (HPIV3), Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), and Norovirus. IAQ monitoring is structured across Winter, Spring, Summer, and Fall, including designated baseline/off-period weeks to characterize temporal and seasonal variability in environmental measures across classrooms and centers. Multi-informant surveys (Director, Teacher, Parent) capture contextual factors, and children's social-emotional development is assessed using teacher ratings on the Devereux Early Childhood Assessment (DECA). The primary outcome is the sick-related absence rate, analyzed as cumulative absences over the attendance year while accounting for clustering by school and classroom using generalized mixed-effects models. Secondary outcomes include children's social-emotional ratings, IAQ metrics and pathogen detection rates; analyses of IAQ incorporate time/seasonal structure, and season-stratified absenteeism analyses will be treated as secondary/exploratory refinements. An economic evaluation will estimate incremental intervention costs and cost-effectiveness/cost-benefit (such as cost per sick-related absence day averted). Ethics and Dissemination: This study was approved by the Institutional Review Board (IRB) at the University of Oklahoma. Findings will be shared through peer-reviewed publications; presentations at local, state, and national conferences; research briefs developed for lay and policy audiences; and community briefings prioritizing the participating early childhood programs and communities. ISRCTN Trial Registration: ISRCTN78764448 Disclaimer: The views expressed are those of the authors and do not reflect the official views of the Uniformed Services University or the United States Department of War. Strengths and Limitations of This Study: {middle dot} Real-world longitudinal cluster RCT: The study uses a rigorous longitudinal cluster-randomized 2x2 factorial design in real-world ECE settings. {middle dot} Combined interventions: Interventions target both air filtration and disinfection, allowing for combined and comparative evaluation. {middle dot} Objective air quality monitoring: Continuous monitoring of IAQ metrics provides objective and reliable data on environmental change. {middle dot} Environmental pathogen surveillance: qPCR on surface swabs yields an objective biological outcome to triangulate with IAQ and absences. {middle dot} Comprehensive context and child measures: Multi-method and multi-reporter data collection includes Head Start attendance records, continuous air monitoring, pathogen detection, contextual surveys completed by center directors, teachers, and parents, and standardized social-emotional assessments (DECA) completed by classroom teachers. Head Start program records providing children's longer-term health data available through Health Insurance Portability and Accountability Act (HIPAA) authorization. {middle dot} Clustered/temporal complexity: Seasonal design accounts for variation over time but may introduce complexity in modeling temporal effects. {middle dot} Practical Implications: Study findings will have practical implications for Head Start and other ECE programs striving to maximize child attendance with cost effective strategies. Keywords: Early childhood; Head Start; indoor air quality (IAQ); air purifiers; filtration; ultraviolet germicidal irradiation; cluster randomized trial; absenteeism; environmental pathogens; DECA; cost-benefit analysis