From the literature

INTRODUCTION: Despite being recognised as a critical component of high-quality care, shared decision-making is still not consistently achieved during childbirth. TeamBirth is a care process developed to promote intrapartum teamwork and shared decision-making, adapted to the Swedish context and implemented in two labour wards. This study aims to explore how care providers engage women and their partners in intrapartum decision-making during the implementation of the adapted Swedish version of TeamBirth. METHODS: A qualitative design, based on 23 observations comprising 79 huddles, and 65 interviews with the care providers involved, was used. Data were collected April 2022 - June 2023, and analysed deductively using directed content analysis, guided by the Conceptual Framework for Patient and Family Engagement in Healthcare. RESULTS: Four levels of engagement were found. No Engagement involved care providers giving instructions without explanations. Providing Information entailed brief updates followed by instructions, with limited opportunities for questions. Involvement, the most common level, included discussions and planning with women and their partners, although final decisions were made by care providers. Partnership and Shared Leadership, the least observed level, was characterised by dialogue and joint decisions. Barriers for engagement included limited Swedish proficiency, high workload, and critical situations, whereas continuous support, effective pain management, and use of the TeamBirth care process were enabling factors. CONCLUSIONS: Engagement in decision-making occurred on a continuum, with modifiable factors including workload, continuous support, and use of TeamBirth. Although conducted during the implementation of a care process designed to improve engagement, Partnership and Shared Leadership remained the least observed level.

IntroductionScreening for lung, breast, and cervical cancer can reduce morbidity and mortality by enabling earlier detection and treatment. However, participation remains below target levels, particularly among individuals experiencing marginalization. While primary care providers (PCPs) can play a key role in improving screening uptake, few reviews have focused on interventions targeting individuals experiencing marginalization that are aimed at PCPs, delivered by PCPs, or that occurred in a primary care setting.MethodsThe aim of this scoping review was to examine the extent and types of PCP interventions implemented to increase lung, breast, and cervical cancer screening uptake among individuals experiencing marginalization and identify gaps to inform future practice and research. We searched for studies of PCP interventions aimed at increasing lung, cervical, and/or breast cancer screening among marginalized populations in Ovid MEDLINE, Ovid Embase, Scopus, EBSCO CINAHL Complete and Ovid EBM Reviews - Cochrane Central Register of Controlled Trials from 2000 to March 31, 2022. Title, abstract, and full-text articles were screened, and data extraction was performed by three independent reviewers. The charted data were summarized using narrative synthesis.ResultsForty-two studies were included: 13 for cervical cancer, 15 for breast cancer, one for lung cancer, and 13 on multiple cancer sites. Interventions included education (for both patients and PCPs), self-collected human papillomavirus (HPV) testing, patient navigation, clinic system tools, event-based, and multicomponent. Increases in screening rates were observed across various intervention types for breast and cervical cancer, with multi-site interventions evaluated based on their reported effects on breast and cervical cancer screening independently.ConclusionsEducational interventions demonstrated the greatest effectiveness for breast cancer screening, and self-collected HPV testing demonstrated the greatest effectiveness for cervical cancer screening. There is a clear gap in the literature regarding interventions aimed at increasing lung cancer screening participation, and further research is needed to evaluate the effectiveness of such interventions. Screening programs and PCPs should consider targeted strategies to support greater participation among individuals experiencing marginalization.

INTRODUCTION: Rabies remains a persistent public health threat in India, while gaps in surveillance and coordination of control measures undermine progress towards ending human rabies deaths. The WHO advocates a One Health approach, combining mass dog vaccination, postexposure prophylaxis (PEP) and Integrated Bite Case Management (IBCM). IBCM is not yet incorporated into India's national rabies action plan for rabies elimination. This study seeks to generate robust evidence on the effectiveness, cost-effectiveness, feasibility, facilitators and barriers of IBCM implemented within Kerala's Rabies Control Programme. METHODS AND ANALYSIS: This implementation research adopts a stepped-wedge cluster randomised controlled trial (RCT) design. IBCM will be implemented across six administrative blocks in Thiruvananthapuram District, Kerala, across diverse rural and urban settings and including tribal population representation. The IBCM intervention includes stakeholder training and support and active animal surveillance aligned with WHO guidance. Suspect or probable rabies exposures presenting at selected health facilities will be identified via a community-based hotline. This will trigger investigations and responses including dog vaccination and sensitisation. Prior to IBCM implementation, baseline data will be collected on management of dog bites, bite patient incidence and healthcare seeking behaviours. Hospital-based event tracking of bite cases will be conducted at enrolled public health facilities before and during IBCM implementation. The resulting RCT data will be used to model the impacts and cost-effectiveness of IBCM, including the potential for cost savings through judicious PEP if scaled across Kerala. To understand the barriers and facilitators to IBCM implementation, we will use in-depth interviews and focus group discussions with stakeholders.There is an urgent need to strengthen rabies surveillance, including coordination across health and animal health sectors and outbreak responses to accelerate rabies elimination. IBCM is expected to lead to improved PEP completion, increased detection and laboratory confirmation of rabid dogs, strengthened dog vaccination coverage and targeted outbreak responses in high-risk areas. This RCT will provide critical evidence to inform policy, support scale-up, generate insights into contextual barriers and facilitators for IBCM implementation, and guide India's One Health rabies elimination strategy. This study will evaluate a health-sector-initiated IBCM approach that identifies cases through dog-bite patients presenting to health facilities, supporting comprehensive One Health integration and improved patient care. ETHICS AND DISSEMINATION: The study was approved by WHO Ethics Committee (2024.9.Ind), Kerala University of Health Sciences (AX04/SOP07A/V2) and the ethics committee of Government Medical College, Thiruvananthapuram (HEC No.12/06/2024/MCT); informed written consent will be obtained from all participants, analysis will be limited to de-identified data, and findings will be disseminated through peer-reviewed publications and policy-relevant platforms. TRIAL REGISTRATION NUMBER: CTRI/2024/08/073117.

BACKGROUND: One in 4 young adults has prediabetes, and improving diet is a key step to lowering the risk of diabetes. Existing standard-of-care diet approaches show short-term efficacy but lack long-term effectiveness, including in young adults. Greater fiber intake is associated with a reduced risk of diabetes; however, fiber is not well targeted using existing interventions. Many young adults may be reluctant to consume fiber given the coexistence with digestible carbohydrates and concerns over gastrointestinal effects. Targeting these factors more explicitly may improve uptake and lower diabetes risk, and doing so via a mobile health (mHealth) intervention may be particularly responsive to young adult demands. OBJECTIVE: This study aims to establish and preliminarily test the feasibility of a highly innovative and scalable mHealth-based intervention to improve fiber intake among young adults with prediabetes. METHODS: This single-arm feasibility study includes 2 phases to preliminarily test an mHealth-based fiber intervention (phase 1) and elucidate factors that impact sustained behavior change and fiber intake after intervention end using ecological momentary assessment (EMA; phase 2). The intervention is 3 months in length and features daily EMAs with responsive text-based coping messages to target key predictors of fiber intake. EMAs will also be paired with brief (ie, <1 minute) educational videos on fiber delivered once per day. Participants will also receive weekly home-delivered high-fiber food packages and wear a continuous glucose monitor at 2 time points during the intervention as a form of biofeedback. At the baseline and postintervention time points, fasting blood glucose, hemoglobin A, and insulin resistance (Homeostatic Model Assessment of Insulin Resistance) will be assessed. After the postintervention time point, participants will continue with daily EMAs to assess factors associated with sustained fiber intake. Diet will be assessed using Automated Self-Administered 24-hour dietary recalls at the baseline and postintervention time point and after the phase 2 EMA. RESULTS: This study was initiated in July 2025. As of March 2026, the mHealth intervention content is being built, with app completion and trial enrollment both slated to begin in April 2026. CONCLUSIONS: The results of this study will provide pivotal evidence on the utility of a fiber-focused intervention delivered via mHealth with biofeedback and home-delivered foods to lower the risk of diabetes in young adults with prediabetes.

OBJECTIVE: To compare the risk of renal deterioration under treatment with glucagon-like peptide-1 (GLP-1) receptor agonists or sodium-glucose contransporter-2 (SGLT-2) inhibitors versus other second line treatments in people with type 2 diabetes with and without albuminuria (albumin to creatinine ratio ≥30 mg/g). DESIGN: Target trial emulation. SETTINGS: Linkage of electronic health records and claims data from 10 health systems and two national health insurance plans-data from BESTMED (observational evaluation of second line therapy medications in diabetes) study. PARTICIPANTS: People with type 2 diabetes and moderate cardiovascular risk and estimated glomerular filtration rate ≥45 mL/min/1.73 m on metformin monotherapy who started treatment with a GLP-1 receptor agonist or SGLT-2 inhibitor, a sulfonylurea, or a dipeptidyl peptidase-4 (DPP-4) inhibitor after metformin between 2014 and 2022. MAIN OUTCOME MEASURE: Deterioration of kidney function defined as doubling of serum creatinine or estimated glomerular filtration rate <15 mL/min/1.73 m. RESULTS: Among 75 455 eligible people (61 583 (81.76%) without albuminuria), median age was 60 years (interquartile range 51-68), 36 231 (48%) were women, median haemoglobin A was 7.8% (interquartile range 7.3-8.5%), and median estimated glomerular filtration rate was 92 mL/min/1.73 m (interquartile range 77-102). People were followed for a median of 32 months (interquartile range 18-57). The estimated five year risk of the renal outcome was 2.4% (95% confidence interval 2.1% to 2.7%) for people taking GLP-1 receptor agonists or SGLT-2 inhibitors versus 2.1% (1.8% to 2.6%) for people taking DPP-4 inhibitors among those without albuminuria; and 3.2% (2.3% to 4.1%) versus 5.4% (4.2% to 6.7%), respectively, among people with albuminuria. The estimated five year risk ratio comparing the GLP-1 receptor agonist or SGLT-2 inhibitor group with the DPP-4 inhibitor group was 1.10 (95% confidence interval 0.90 to 1.38) among people without albuminuria and 0.60 (0.42 to 0.82) among people with albuminuria. CONCLUSIONS: Compared with DPP-4 inhibitors, GLP-1 receptor agonists and SGLT-2 inhibitors reduce the risk of deterioration of renal function in people with albuminuria. Little evidence of renal benefit among people without albuminuria was observed over the study follow-up period.

BACKGROUND: Islet xenotransplantation is a strategy for treatment of Type 1 Diabetes, but immune-mediated rejection limits graft survival. This study investigated a strategy with flow cytometry-based immune monitoring to evaluate immunosuppressive therapy and provide indicators of graft rejection. METHODS: Porcine neonatal islet cell clusters (NICC) from GTKO-hCD55-hCD59 transgenic pigs were transplanted into streptozotocin-induced diabetic baboons (n = 10). Recipients received anti-CD2 induction with anti-CD154, Belatacept, and full-dose (n = 7) or reduced/no dose Tacrolimus (n = 3). Leukocyte subsets and activation status were monitored using multiplex flow cytometry. Graft function was assessed by blood glucose measurements, porcine C-peptide ELISA, and histological analysis. RESULTS: Porcine C-peptide was detected in all recipients. Seven animals receiving full-dose Tacrolimus maintained NICC function for up to 675 days, whereas three experienced acute rejection within two months. Flow cytometry generated absolute leukocyte counts equivalent to standard full blood counts (Deming regression slope 0.91-1.03, p<0.001), while requiring less blood (50 µl vs ∼500 µl) and processing time (50±15 vs 150±30 min). Anti-CD2 treatment significantly reduced unoccupied surface CD2 on circulating T cells (mean 73.21%, range 55.26-91.16%, p<0.001). Long-term graft survival was associated with greater first-month T-cell suppression (36.47%, 13.35-50.75%) than acute rejection (176.28%, 171.26-181.31%). Following immunosuppression withdrawal, lymphocyte counts increased by 40%-142% in all recipients. Multiplex immunofluorescence of endpoint grafts from these IS-free animals revealed cell-mediated destruction with increased lymphocyte infiltration and activated cytotoxic CD8 T cells. CONCLUSION: Multiplex flow cytometry provides a reliable method for immune monitoring in islet xenotransplantation and may help predict graft rejection.

BACKGROUND AND OBJECTIVES: Despite an overall decline in incidence rate, the burden of stroke may be rising in young adults. We aimed to characterize the incidence rates, 30-day case fatality rates (CFRs), and the burden of stroke risk factors over time in young adults in a representative population-based study of stroke. METHODS: Using validated methods, hospitalized stroke cases in a 5-county region were ascertained and adjudicated by stroke-trained physicians in 6 study periods: July 1993-June 1994 and calendar years 1999, 2005, 2010, 2015, and 2020. Stroke in the young was defined as those occurring among individuals who were aged 20-54 years. Incidence rates were generated using US Census data standardized to the 2010 population, and trends were tested with linear regression. Temporal trends in 30-day CFR were evaluated with logistic regression after adjusting for age, race, and sex. RESULTS: Across all study periods, there were 2,076 first-ever strokes in young adults. Hypertension, diabetes, atrial fibrillation, and substance use were more common over time ( < 0.001). The stroke incidence rate increased in young adults over time (33.90 cases/100,000 person-years in 1993/4 to 62.18 cases/100,000 person-years in 2020, trend = 0.04), while declining in older adults (618.78 cases/100,000 person-years in 1993/4 to 453.04 cases/100,000 person-years in 2020, trend = 0.02). The rise in stroke incidence appeared driven by ischemic stroke, with an almost doubled incidence rate of 23.8 cases/100,000 person-years in 1993/4 to 47.3 cases/100,000 person-years in 2020 (trend = 0.02). There was a modest decline in the 30-day CFR in young adults (11.7% in 1993/4 to 9.4% in 2020, trend = 0.002), driven by intracerebral hemorrhage (27.5% in 1993/4 to 21.2% in 2020, trend = 0.03) and subarachnoid hemorrhage (27.9% in 1993/4 to 18.6% in 2020, trend = 0.09). DISCUSSION: The incidence of stroke in young adults is rising over time, while the CFR simultaneously declines. This coincides with a rise in both traditional vascular risk factors and substance use.

ObjectivesThis study aimed to identify multidimensional factors associated with hypertension self-management and examine candidate self-care support domains to inform the development of a person-centered nursing-based self-care bundle.MethodsA cross-sectional study was conducted among 152 patients with hypertension aged 40-59 years in primary healthcare centers in Bali, Indonesia, using multistage random sampling. Data were collected using researcher-developed questionnaires informed by established instruments, theories, and previous studies, and preliminarily tested for validity and reliability, measuring patient, family, socio-cultural, healthcare service, candidate self-care support domains, and self-management ability. Partial least squares structural equation modeling was used to examine associations among constructs.ResultsPatient factors were associated with candidate self-care support domains (β=0.593, p<0.001) and self-management ability (β=0.379, p<0.001). Family, sociocultural, and healthcare-service factors were associated with candidate self-care support domains but not directly with self-management ability. Candidate self-care support domains were also associated with self-management ability (β=0.481, p<0.001).ConclusionsThe findings provide a cross-sectional needs-assessment foundation for developing a person-centered nursing-based integrated self-care bundle for hypertension self-management. Future studies should refine the bundle through expert validation and test its feasibility and effectiveness using intervention designs.

Pulmonary arterial hypertension (PAH) with features of venous and/or capillary involvement, formerly pulmonary veno-occlusive disease (PVOD), represents a rare and severe subset of pulmonary hypertension. While PVOD is typically idiopathic, heritable or drug/toxin-induced, "PVOD-like" features have long been recognised in PAH associated with connective tissue diseases (CTDs), especially systemic sclerosis (SSc). This review synthesises the available evidence on this phenotype, integrating published data with an unreported cohort of 25 patients. Venular remodelling is a frequent histological finding in SSc-PAH lung explants, but high-resolution computed tomography (HRCT) signs of PVOD are inconsistently observed at PAH presentation, reflecting a progression of the lung vasculopathy and/or an unmasking effect of pulmonary vasodilators. Patients often exhibit major functional limitation, profound impairment in gas transfer and severe haemodynamic compromise. Assessing venular involvement in SSc-PAH poses unique challenges, due to possible lung fibrosis on HRCT and differential diagnosis with an occult post-capillary component. Despite the lack of robust evidence, PAH-approved therapies are commonly used, although with caution due to a high risk of pulmonary oedema with pulmonary vasodilators. As these patients also display significant arteriolar involvement, which can benefit from these drugs, dedicated treatment strategies warrant further investigation. Prognosis remains dismal, with a 5-year survival around 45-50%. Similar PVOD-like patterns have also anecdotally been reported in systemic lupus erythematosus, rheumatoid arthritis, mixed connective tissue disease, Sjögren syndrome and inflammatory myopathies, with comparable features. Overall, PVOD-like disease in CTD-PAH constitutes a high-risk phenotype with unresolved pathogenic and management challenges, requiring refined patient stratification and improved therapeutic strategies.