BMJ Open最新文献

Introduction: Immediate dental implant placement has been proposed as a strategy to reduce treatment time and improve patient satisfaction. However, systematic reviews addressing immediate versus delayed implant placement have reported inconsistent findings, limiting clinical interpretability. An umbrella review is warranted to synthesise, appraise and contextualise the existing evidence.

Methods and analysis: This umbrella review will include systematic reviews with or without meta-analysis comparing immediate implant placement after tooth extraction with delayed placement in healed sites. Comprehensive searches will be conducted in September 2026, in PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, Scopus, Web of Science, LILACS, the Cochrane Database of Systematic Reviews. Methodological quality will be assessed using A Measurement Tool to Assess Systematic Reviews (AMSTAR 2). Overlap of primary studies will be quantified using the corrected covered area. Outcomes of interest include implant survival, success and failure rates, biological and technical complications, patient-reported outcomes and surgical time. A structured narrative synthesis will be performed.

Ethics and dissemination: This overview does not require ethics approval, as it uses secondary data from previously published studies. The results will be disseminated through the publication in a high-impact journal. OSF REGISTRATION NUMBER: https://doi.org/10.17605/OSF.IO/GZ3DR.

Introduction and objectives: After the loss of a parent, families with minor children face psychosocial stressors. The bereaved parent has to deal with their own grief and at the same time support the children. Providing professional support to the parents can improve well-being of parents, children and the family as a whole. However, such manualised interventions are missing for the German context. This study aims to translate and culturally adapt the parent group 'Resilient Parenting for Bereaved Families' (RPBF) of the Family Bereavement Program for the German context specifically for loss due to cancer, and to pilot evaluate its feasibility and potential effects.

Methods and analysis: In this mixed-methods pilot study, six to eight group leaders, who are experienced in working in bereavement support, will be trained to conduct the parent group and afterwards lead parent groups. We aim to conduct three to four parent groups with 6-8 parents each (total target sample size n=24-32). Parents participate in 10 biweekly parent group sessions on-site or online. We will assess feasibility, acceptability, satisfaction and preliminary effects on parental well-being, family coping and communication (baseline (t₀), post-intervention (t₁) and 12-week post-intervention follow-up (t₂)). Semistructured interviews with 10-12 parents will further explore experience and suggestions for refinement. Quantitative data will be analysed using descriptive and exploratory analyses and qualitative data will be analysed using qualitative content analysis.

Ethics and dissemination: The study was approved by the Local Psychological Ethics Committee of the Center for Psychosocial Medicine of the University Medical Center Hamburg-Eppendorf (LPEK-0919). Upon completion, a German version of the Resilient Parenting for Bereaved Families (RPBF) parent group and the group leader training will be available. Findings will be disseminated through peer-reviewed publications and conference presentations. To make the results available to affected families, a lay summary will be written and disseminated in several ways.

Trial registration number: The study was registered with the German Clinical Trials Register (DRKS00039060 (date of registration: 19 February 2026)).

Background: Low- and middle-income countries (LMICs) experience recurrent public health emergencies, including infectious disease outbreaks, climate-related shocks and humanitarian crises, which expose persistent weaknesses in health system preparedness and response. Although resilience-defined as the capacity of health systems to anticipate, absorb, adapt to and recover from shocks-has gained increasing attention, there is no comprehensive synthesis of tools specifically designed to evaluate the resilience of public health emergency preparedness and response (PHEPR), particularly in LMICs contexts.

Objective: To identify, describe and critically appraise existing tools and frameworks used to evaluate PHEPR resilience, and to assess their methodological robustness, availability and applicability to LMICs health systems.

Methods: This systematic review protocol is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) 2015 statement and will follow the PRISMA 2020 reporting guideline. A comprehensive search will be conducted in PubMed, Scopus, Web of Science, WHO Institutional Repository for Information Sharing (IRIS), Africa Centres for Disease Control and Prevention repositories and relevant governmental and organisational platforms. Eligible sources will include peer-reviewed and grey literature published in English between 2005 and 2025 that describe, develop, validate or apply PHEPR resilience assessment tools. Two reviewers will independently undertake screening, full-text review and data extraction using a piloted 24-item extraction form. Methodological quality of empirical studies will be appraised using appropriate Joanna Briggs Institute critical appraisal tools, while resilience assessment instruments will be evaluated using structured qualitative criteria examining their conceptual foundations, development methods, validation evidence and implementation characteristics ETHICS AND DISSEMINATION: Ethical approval was not required because this review will use publicly available literature. Findings will be disseminated through peer-reviewed publication, conference presentations and policy briefs to inform future development and implementation of resilience assessment tools for public health emergency preparedness and response in LMICs.

Prospero registration number: CRD420251243633.

Objective: To investigate the effect of terrorism-related attacks on modern contraceptive uptake and to assess the effects of recent family planning (FP) interventions in Burkina Faso.

Design: Nationwide longitudinal study using a multiple interrupted time-series analysis.

Setting: Public primary healthcare centres and district hospitals in Burkina Faso, from January 2013 to December 2023.

Data sources: Monthly data on new FP users were drawn from Burkina Faso's National Health Information System, covering 132 months. Data on terrorist attacks were extracted from the Armed Conflict Location and Event Data Project.

Exposures: The main exposure was the occurrence of terrorist attacks at the commune-month level. Secondary exposures were the 2020 FP user-fee exemption policy and national family planning weeks (NFPWs).

Primary and secondary outcome measures: The primary outcome was the monthly count of new FP users used as an indicator of modern contraceptive uptake. Secondary measures were predicted gains and losses in visits by new FP users associated with terrorist attacks, user-fee removal and NFPWs.

Results: The monthly number of visits by new FP users decreased by 13% (95% CI 11% to 15%) in the month of and following a terrorist attack. NFPWs were associated with a 152% increase in new users (95% CI 147% to 156%), while the 2020 FP fee exemption policy was associated with a 22% immediate increase (95% CI 18% to 25%). Predicted gains were greater for NFPWs (+4 31 846 new users) than for the free FP policy (+3 52 006). Terrorist attacks were associated with a predicted loss of 133 688 new users since January 2013.

Conclusion: Terrorist attacks were associated with reduced modern contraceptive uptake in Burkina Faso, likely through disruptions in both service supply and access. Combining user-fee removal with active outreach strategies such as NFPWs may help sustain reproductive health service coverage in settings affected by protracted insecurity.

Background: Diabetes has reached epidemic proportions in Pakistan. This study applied machine learning (ML) techniques to identify comorbidity-based and diabetic complications-based clusters in hospitalised patients with diabetes and examine their association with in-hospital mortality.

Design: Retrospective cross-sectional study.

Setting: Aga Khan University Hospital, Pakistan.

Participants: Adult patients (≥18 years) with diabetes admitted between 2008 and 2021.

Methods: Diagnoses were extracted using International Classification of Diseases (ICD-9 and ICD-10) codes. Data was integrated from the Hospital Information Management Systems (HIMS). The K-Modes clustering algorithm was applied to categorical diagnostic data, with the optimal number of clusters determined using elbow curve and silhouette score analysis. Latent-Dirichlet Allocation and Term Frequency-Inverse Document Frequency were applied to identify frequent terms from each cluster followed by expert validation. Logistic regression was performed to assess the association between cluster membership and in-hospital mortality.

Results: Among 78 271 patients, four clusters were identified with varying mortality risks: (1) cardio, tumour and tobacco (CTT), (2) renal complication cluster (RCC), (3) cardiovascular cluster (CVC) and (4) uncontrolled diabetes mellitus, hypertension, stroke and kidney (HSK). The within cluster mortality was highest in the RCC cluster (682; 18.1%), followed by CVC (543; 4.4%), HSK (1,379; 4%) and CTT (603; 2.2%). Compared with CTT, the unadjusted odds of in-hospital mortality were significantly higher in RCC (OR=9.9, 95% CI 8.9 to 11.2, p<0.001), CVC (OR=2.1, 95% CI 1.9 to 2.3, p<0.001) and HSK (OR=1.9, 95% CI 1.7 to 2.1, p<0.001).

Conclusion: Among hospitalised patients with diabetes, the RCC cluster demonstrated the highest mortality risk, comprising predominantly older patients with severe complications. These findings highlight the utility of unsupervised ML approaches for identifying high-risk clinical phenotypes and informing risk stratification in resource-constrained settings. Longitudinal studies are warranted to evaluate progression and long-term outcomes across clusters.

Introduction: Pakistan is one of the countries most affected by climate change, where peak temperatures in certain areas frequently exceed 40°C. Despite evidence that vernacular designs and behavioural adjustments can reduce indoor temperatures, heat-adaptation efforts remain concentrated in urban or high-resource settings, with limited evidence for vulnerable rural populations in low- and middle-income countries, including Pakistan.

Methods and analysis: This trial aims to evaluate the effectiveness of a comprehensive Resilience and Heat Adaptation Bundle (ReHAB) that integrates behavioural and structural interventions to reduce heat-related morbidity and mortality and improve internal ambient conditions in rural settings of Pakistan. This study is a prospective, cluster-randomised trial, comprising 22 clusters allocated to intervention and control arms in a 1:1 ratio. The ReHAB intervention combines community education and awareness with targeted structural improvements, including roof and wall treatments, enhanced shading, improved ventilation, sustainable energy installations and communal outdoor shelters. Health and behavioural data will be collected through household surveys, while wearable devices and environmental sensors will measure individual heat exposure and record indoor and outdoor thermal conditions.

Ethics and dissemination: The study has received ethical approval from the Aga Khan University (AKU) (ref: 2025-11559-35625) and National Bioethics Committee (ref: 4-87/NBCR-1065/23/1736). Written informed consent will be obtained from all participants before enrolment. Referral pathways to healthcare facilities will be established to ensure timely management of complications. Findings will be disseminated through peer-reviewed publications, scientific conferences and engagement with policymakers and public health stakeholders. Results will also be shared with participants and communities through meetings and informal sessions to raise awareness and support evidence-based heat adaptation.

Trial registration number: NCT06983483.

Objective: Emergency care departments often navigate the dual imperatives of providing timely medical care and cooperating with police as law enforcement officers (LEOs) involved in injury-related cases. Using Strauss' negotiated order theory, we examined the engagements between clinicians and the police at the Upper West Regional Hospital in Ghana, analysing the structural and negotiation contexts shaping their interactions.

Design: We used a qualitative case study design.

Setting: The study was conducted at the Upper West Regional Hospital in Ghana.

Participants: Participants included clinicians (n=11; 7 nurses and 4 doctors) and police officers (n=10; 6 Criminal Investigation Department and 4 Motor Traffic and Transport Department) with experience engaging with each other during patients' visits at the emergency department of the Upper West Regional Hospital.

Methods: Participants were recruited through snowball sampling. We first conducted semi-structured interviews (April 2024 and February 2025) with the 21 participants. We then conducted a validation workshop with clinicians, healthcare managers and police in April 2025, incorporating key insights from the workshop into the thematic analysis to strengthen the study's credibility and contextual relevance.

Results: We found that interactions between clinicians and police were shaped by three key structural factors: (1) organisational structures like role boundaries and decision-making authority; (2) the policy environment, particularly legal and ethical obligations; and (3) wider cultural contexts, such as societal norms. Within these contexts, negotiations centred on how clinicians and police balanced autonomy with collaboration, shared information, resolved disputes and built interprofessional trust. Informal networks and feedback were particularly important mechanisms for building smoother engagements.

Conclusion: Clinician-LEO interactions are dynamic and require continuous negotiation to align healthcare priorities with law enforcement mandates. Clear policies on engagements, interprofessional training programmes and culturally responsive frameworks are needed to enhance emergency care.

Introduction: Adolescent-onset type 2 diabetes (T2D) has increased in prevalence in recent decades. However, the efficacy of preventative interventions targeting health behaviours is limited, and key developmental factors that may influence effectiveness, such as executive functioning (EF) and stress, are often overlooked. Within-person fluctuations in EF and stress are linked to the adoption and maintenance of physical activity, a critical component of T2D prevention, yet little is known about the between- and within-person temporal variability of these constructs or their relationship with physical activity in adolescents at risk for T2D. Ecological momentary assessment (EMA) is ideal to capture these processes in real-time to inform intervention development and personalisation.

Methods and analyses: We will enrol a subset of participants from a larger intervention study involving assigned-female-at-birth adolescents aged 12-17 years, with elevated depression symptoms (CES-D≥21) and T2D risk (BMI≥85th percentile) and diabetes family history. Prior to the intervention, a minimum of 50 participants will complete a 7-day EMA protocol consisting of repeated daily gamified EF assessments and brief surveys about EF, stress and physical activity. Participants will simultaneously wear an activity monitor to provide objective measures of physical activity. Recruitment began in Spring 2024 and is ongoing. Multilevel models will be used to separate between- and within-person variability and to estimate short-term lagged within-person associations between EF/stress and subsequent physical activity across 15-60 min windows. Primary analyses are planned for Winter 2026.

Ethics and dissemination: The Colorado Multiple Institutional Review Board approved this study (COMIRB#22-0180). Findings will be disseminated in peer-reviewed journals and conference presentations.

Trial registration number: NCT05543083.

Background: Patient engagement within healthcare institutions is growing, with studies outlining its relevance and impact on clinical care, education and research. Literature exists on the engagement of patients in specific contexts; however, articles on engagement models, which centralise these practices at the institutional level, are limited. This article addresses that gap by describing the development and implementation of the SickKids Model of Advisor-Centred Engagement, an institution-wide approach to integrating the voices of patients, families and communities across clinical care, education and research at The Hospital for Sick Children (SickKids). Historically, engagement practices at SickKids were siloed and inconsistent, thus limiting the potential for meaningful partnerships. To address these challenges and drawing on existing frameworks and extensive stakeholder consultations, the SickKids Model of Advisor-Centred Engagement and a centralised Office of Patient, Family and Community Engagement were established.

Main body: The SickKids Model prioritises advisor-centredness, efficiency, sustainability and scalability to foster meaningful collaborations across the institution. Core elements include the Engagement Incubator, a space for training, knowledge sharing and capacity building, along with centralised resources to streamline advisor onboarding, honourarium processes and engagement practices. During its first year of operations, the Office has supported numerous engagement activities, developed inclusive policies and offered training to staff and advisors. Metrics to assess implementation and impact are being developed, including measures of engagement reach, satisfaction, capacity building and methodological contributions to patient-oriented research practice. Learnings to date highlight the importance of institutional commitment, dedicated resources and cross-departmental collaboration in embedding engagement at a systemic level. Challenges remain, including managing increasing demands for engagement support and developing robust evaluation metrics.

Conclusion: The SickKids Model of Advisor-Centred Engagement moves engagement beyond project-level approaches to the implementation of an institution-wide framework for coordinated, scalable and sustainable engagement across clinical care, education and research. Initial findings suggest that implementation of a centralised infrastructure can support cross-domain learning, reduce fragmentation and strengthen organisational capacity for meaningful engagement. This model may serve as a blueprint for healthcare institutions looking to embed engagement practices at the organisational level, thereby ensuring that lived experiences inform clinical care, education and research.