Javier Zamora

Background: Portal vein thrombosis (PVT) in cirrhosis has a quite unpredictable natural history. Spontaneous recanalization may occur, but predictors and prognostic impact remain uncertain. We performed an individual patient data (IPD) meta-analysis to evaluate survival according to spontaneous recanalization and to identify predictors of recanalization. Methods: We included cohort studies of patients with cirrhosis and PVT not receiving anticoagulation and obtained de-identified IPD. All-cause mortality was analyzed using a competing-risk model (competing event: liver transplantation) adjusted for prespecified baseline covariates. Predictors of recanalization were assessed with mixed-effects ordinal logistic regression including a random study intercept. Results: Eight studies contributed 586 patients. Spontaneous recanalization occurred in 264 (47.7%). Overall recanalization was independently associated with lower mortality (aSHR 0.51; 95% CI 0.28–0.90), with the benefit driven by complete recanalization (aSHR 0.45; 95% CI 0.21–0.94). Recanalization of PVT localized in the main portal vein trunk was linked to a strong survival benefit (interaction SHR 0.39; 95% CI 0.16–0.91; p =0.02), whereas no benefit was observed after recanalization of isolated intrahepatic branch thrombosis. PVT recanalization was more likely to occur in Child–Pugh A (aOR 2.63; 95% CI 1.18–5.88), partial thrombosis (aOR 1.69; 95% CI 1.09–2.56), and isolated intrahepatic location (aOR 2.04; 95% CI 1.23–3.33). Conclusions: Spontaneous recanalization occurs in approximately half of patients with cirrhosis and PVT and is associated with improved survival, particularly when complete and involving the main portal vein trunk. These findings underscore its prognostic relevance and indirectly support anticoagulation to promote recanalization.

Background: Nurse turnover intention is a multifactorial construct shaped by individual, occupational, organizational, and policy‐level factors. Although widely studied in some regions, evidence from Southern Europe, particularly Spain, remains scarce. Understanding these factors in diverse healthcare contexts is essential for designing effective retention strategies that are both locally relevant and internationally informative. Objective: This study aims to explore turnover intention prevalence and associated factors among nurses across different care settings in Spain. Design: A cross‐sectional study. Settings: Primary care, hospitals, emergency services, or social healthcare settings. Participants: A total of 20,316 actively employed nurses. Methods: An online survey was disseminated by the Spanish Ministry of Health and other institutional channels. Turnover intention was the primary outcome and was measured with a single item asking whether nurses intended to leave the profession within the next 10 years (yes/no). Work‐related variables and perceptions of care quality and patient safety were also collected. Multivariable logistic regression was used to identify key predictors across care settings. Results: Of the 20,316 participants, most were women (84.8%) and 50.3% were under 35 years. Overall, 39.58% reported an intention to leave the nursing profession within 10 years. Turnover intention was significantly associated with perceptions of care quality (OR = 1.706, p < 0.001) and patient safety (OR = 1.809, p < 0.001), regional disparities, and temporary employment contracts (OR = 1.333, p < 0.001). In primary care, working as a generalist and on afternoon shifts increased turnover risk, while in hospitals, long shifts (> 7.5 h) were influential. Conclusions: This study provides novel insights into nurse turnover intention in Spain, highlighting the interplay of modifiable institutional factors and regional disparities in a decentralized health system. Turnover intention was strongly associated with organizational conditions, reinforcing the urgent need for tailored, context‐sensitive retention strategies. Standardizing definitions, measurements, and temporal frameworks remains critical for advancing comparative research and developing effective, evidence‐based interventions to strengthen the nursing workforce.

Introduction: Time-lapse imaging (TLI) systems for embryo incubation and assessment are hypothesised to improve the success rates of in vitro fertilisation (IVF) treatment by providing undisturbed culture conditions for embryos and/or providing more information on embryo development (morphokinetic parameters) to improve predictive accuracy for embryo selection. Despite numerous aggregate meta-analyses showing uncertainty of benefit, IVF clinics globally continue to invest significant resources into this technology with little translation of evidence into guidelines or policy frameworks. This may be attributed to heterogeneity in participant populations and/or variations in the use of TLI, as highlighted in the aggregate meta-analyses. Methods and analysis: Our research proposal for evidence synthesis using individual participant data meta-analysis will provide greater power than aggregate meta-analysis to detect differential treatment effects for effectiveness (live birth, clinical pregnancy) and safety (pregnancy loss, multiple births, congenital malformations) outcomes across three comparisons (overall effect, undisturbed culture and morphokinetic parameters). We will also analyse if there are specific subgroups of women who may benefit from the intervention and if variations in use of the intervention show any benefits. We have incorporated the results of the literature search used for the latest Cochrane review (7 January 2019) into this review and will include all the trials included therein. We will further update the literature search to include new evidence by searching the electronic databases MEDLINE, EMBASE, CINAHL and CENTRAL from 07/01/2019 to date, outcomes for all ongoing trials reported in the 2019 Cochrane review, trial registers for newer ongoing/completed trials and the citation lists of all the newly identified trials for any relevant references. The search strategy will include a combination of subject headings and text words relating to or describing the participants and the intervention, with no language restrictions. Two authors will independently screen the titles and abstracts, and full text of articles retrieved from the search, to finalise a list of trials suitable for inclusion in the review. We will include randomised controlled trials that assess TLI systems for either undisturbed culture and/or use of morphokinetic parameters for embryo selection in women having IVF/ICSI treatment using their own oocytes. Ethics and dissemination: Ethical approval is not required for this study. We plan to disseminate the findings of the research to all stakeholders, including the National Institute for Health and Care Excellence and other international guideline development groups, through publication in peer-reviewed journals, presentation at conferences, newsletters, meetings and websites of the funders, fertility charities and patient support groups. PROSPERO registration number: CRD42024564332.

Background: Maternal and perinatal mortality remain critical indicators of global health inequity. In 2020, an estimated 287 000 women died from preventable causes related to pregnancy, and in 2021, approximately 2.3 million neonatal deaths occurred within the first 28 days of life. A recently defined risk group, small vulnerable newborns (SVNs, including preterm, low birth weight, and small‐for‐gestational‐age infants), highlights the compounded vulnerability of certain newborns. Maternal education is a key social determinant of health, yet its effect on maternal and perinatal outcomes across global settings remains insufficiently quantified. Aims: The primary aim of this study was to quantify the association between maternal education level and adverse maternal and perinatal outcomes. The secondary aim was to evaluate whether these associations vary by country income level. Methods: We conducted an individual participant data (IPD) meta‐analysis using data from the International Prediction of Pregnancy Complications (IPPIC) Network. Eligible studies included those reporting maternal and perinatal outcomes stratified by at least two levels of maternal education (informal/primary, secondary, tertiary). Primary outcomes were maternal mortality, preeclampsia, stillbirth, and SVNs. Associations were estimated using a two‐step random‐effects IPD meta‐analysis adjusted for maternal age and ethnicity. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported. Results: Compared to tertiary education, women with secondary education had a 27% higher risk of maternal death (OR 1.27, 95% CI 0.38; 4.30), and those with informal or primary education had approximately double the risk (OR 2.51, 95% CI 0.23; 26.95). Risk of stillbirth was also twofold higher in lower education groups. These association remained significant in analyses restricted to high‐income countries. Discussion: Women with lower levels of education are at substantially greater risk of adverse maternal and perinatal outcomes. These findings reinforce the need for education‐focused policy and health system strategies to reduce maternal and neonatal mortality, particularly in settings with high educational inequality.

Objective A synthesis and appraisal of the recommendations for biomarkers in practice guidelines concerning sepsis is required to consolidate evidence-based practice. We generated an evidence gap map (EGM) on the use of biomarkers for managing adults with sepsis. Design Scoping review. Data sources MEDLINE, Guidelines International Network, Pan American Health Organization, Trip Database and UpToDate were searched from 2016 to March 2025. Eligibility criteria Guidance documents (GD) that searched at least one literature source and provided clinical recommendations for the use of biomarkers for the management (diagnosis and prognosis, including treatment response) of adults with sepsis. Data extraction and synthesis Two reviewers independently applied the eligibility criteria and extracted data. We used the AGREE-II (Appraisal of Guidelines for Research and Evaluation) tool to assess the GD quality. GDs that scored ≥50% on the AGREE-II 'Rigour of development' domain were considered robust. We also applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to evaluate if the recommendations were strong or conditional. Results We found 10 GDs, with only half (4/8) having a robust methodology. There were 31 recommendations concerning biomarkers. Among these, 24 (77.4%) recommendations were about single biomarkers, with lactate (23; 74.2%) and procalcitonin (8; 25.8%) most frequently recommended. Biomarker testing focused on prognosis in 28 (90.3%) recommendations. Overall, 16 (51.6%) recommendations were graded strong and 13 (42.0%) were conditional, which we displayed in an EGM. Conclusions The methodology of GDs concerning adult sepsis was poor. Our review calls for more prudent use of biomarkers in specific prognostic scenarios and in combination with standard clinical assessments. Enhancing the methodological quality of future GDs is essential to generate more valid and robust recommendations for optimising patient care.

Background: Fetal growth restriction is associated with perinatal morbidity and mortality. Early identification of women having at-risk fetuses can reduce perinatal adverse outcomes. Objectives: To assess the predictive performance of existing models predicting fetal growth restriction and birthweight, and if needed, to develop and validate new multivariable models using individual participant data. Design: Individual participant data meta-analyses of cohorts in International Prediction of Pregnancy Complications network, decision curve analysis and health economics analysis. Participants: Pregnant women at booking. External validation of existing models (9 cohorts, 441,415 pregnancies); International Prediction of Pregnancy Complications model development and validation (4 cohorts, 237,228 pregnancies). Predictors: Maternal clinical characteristics, biochemical and ultrasound markers. Primary outcomes: fetal growth restriction defined as birthweight c-statistic, calibration slope, calibration-in-the-large) for each model and pooled using random-effects meta-analysis. Heterogeneity was quantified using τ² and 95% prediction intervals. We assessed the clinical utility of the fetal growth restriction model using decision curve analysis, and health economics analysis based on National Institute for Health and Care Excellence 2008 model. Results: Of the 119 published models, one birthweight model (Poon) could be validated. None reported fetal growth restriction using our definition. Across all cohorts, the Poon model had good summary calibration slope of 0.93 (95% confidence interval 0.90 to 0.96) with slight overfitting, and underpredicted birthweight by 90.4 g on average (95% confidence interval 37.9 g to 142.9 g). The newly developed International Prediction of Pregnancy Complications-fetal growth restriction model included maternal age, height, parity, smoking status, ethnicity, and any history of hypertension, pre-eclampsia, previous stillbirth or small for gestational age baby and gestational age at delivery. This allowed predictions conditional on a range of assumed gestational ages at delivery. The pooled apparent c-statistic and calibration were 0.96 (95% confidence interval 0.51 to 1.0), and 0.95 (95% confidence interval 0.67 to 1.23), respectively. The model showed positive net benefit for predicted probability thresholds between 1% and 90%. In addition to the predictors in the International Prediction of Pregnancy Complications-fetal growth restriction model, the International Prediction of Pregnancy Complications-birthweight model included maternal weight, history of diabetes and mode of conception. Average calibration slope across cohorts in the internal-external cross-validation was 1.00 (95% confidence interval 0.78 to 1.23) with no evidence of overfitting. Birthweight was underestimated by 9.7 g on average (95% confidence interval −154.3 g to 173.8 g). Limitations: We could not externally validate most of the published models due to variations in the definitions of outcomes. Internal-external cross-validation of our International Prediction of Pregnancy Complications-fetal growth restriction model was limited by the paucity of events in the included cohorts. The economic evaluation using the published National Institute for Health and Care Excellence 2008 model may not reflect current practice, and full economic evaluation was not possible due to paucity of data. Future work: International Prediction of Pregnancy Complications models’ performance needs to be assessed in routine practice, and their impact on decision-making and clinical outcomes needs evaluation. Conclusion: The International Prediction of Pregnancy Complications-fetal growth restriction and International Prediction of Pregnancy Complications-birthweight models accurately predict fetal growth restriction and birthweight for various assumed gestational ages at delivery. These can be used to stratify the risk status at booking, plan monitoring and management. Study registration: This study is registered as PROSPERO CRD42019135045. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/148/07) and is published in full in Health Technology Assessment; Vol. 28, No. 14. See the NIHR Funding and Awards website for further award information.

Background: Post‐publication handling of integrity concerns in randomized clinical trials (RCTs) is a contentious matter.Objectives: We undertook a scoping systematic review to map the literature regarding post‐publication integrity issues in RCTs.Search Strategy and Selection Criteria: Following prospective registration (https://osf.io/pgxd8) we initially searched PubMed and Scopus but subsequently extended it to include the Cochrane Library, and Google Scholar databases without language, article type or publication time restriction until November 2022. Reviewers independently selected published articles covering any aspect of post‐publication research integrity concerns in RCTs.Data Collection and Analysis: The study findings grouped within domains relating to issues concerning post‐publication integrity were extracted in duplicate, verified by a third reviewer, and then tabulated.Main Results: The initial search captured 3159 citations, of which 89 studies were included in the review. Cross‐sectional studies constituted the majority of included studies (n = 34, 38.2%), followed by systematic reviews (n = 10, 11.2%), methodology reviews/studies (n = 9, 10.1%) and other types of descriptive studies (n = 8, 9.0%). A total of 21 articles (23.6%) covered the domain on general issues, 25 (28.1%) in the journal's instructions and policies domain, eight (9.0%) in the editorial and peer review domain, one (1.1%) in the correspondence and complaints (post‐publication peer review) domain, 12 (13.5%) in the investigation for concerns domain, six (6.7%) in the post‐investigation decisions and sanctions domain, none in the critical appraisal guidance domain, five (5.6%) in the integrity assessment in systematic reviews domain, and 26 (29.2%) in the recommendations for future research domain. A total of 12 of the selected articles (13.5%) covered two (n = 9) or three (n = 3) different domains.Conclusions: Various research integrity domains and issues covering post‐publication aspects of RCT integrity were captured and gaps were identified, mostly related with the necessary implications for all stakeholders to improve research transparency. There is an urgent need for a multistakeholder consensus towards creating specific statements for addressing post‐publication integrity concerns in RCTs.