José Erivelton de Souza Maciel Ferreira

The selection of patient‐reported outcome measures for kidney replacement therapy requires more than achieving an overall numerical majority among stakeholders. This editorial examines methodological issues arising from a modified Delphi study that selected the EQ‐5D‐5L and IPOS‐Renal for implementation in a kidney registry. Although the final combination exceeded the predefined consensus threshold among participants who voted, it did not receive support from most consumers with lived experience, who predominantly preferred combinations including the KDQOL‐36. This divergence illustrates how pooled voting can understate stakeholder‐specific differences when one stakeholder group numerically predominates. Additional considerations include the treatment of abstentions and missing votes, the use of open voting after anonymous Delphi rounds, changes in panel participation across rounds, and the distinction between selecting outcome domains and selecting measurement instruments. Replication in other settings should therefore include transparent denominator rules, stakeholder‐specific consensus reporting, meaningful patient participation, anonymous final voting, and local assessment of linguistic validity, cultural relevance, accessibility, respondent burden, and clinical actionability. Patient‐centered measurement requires patients to meaningfully influence what is measured, how it is assessed, and how results inform care.

Objetivo: evaluar la contribución del Programa Nacional para la Mejora del Acceso y la Calidad de la Atención Primaria en sus diferentes fases de actuación. Métodos: revisión integrativa de la literatura en la base de datos LILACS; Biblioteca electrónica SciELO y Google Scholar. Resultados: muestra de 14 artículos que abordan los componentes de sus fases de actuación, que son adhesión y contratación, desarrollo, evaluación externa y recontratación. Conclusión: la mayoría de los estudios científicos abordaron la evaluación externa, que es la tercera fase del Programa Nacional para Mejorar el Acceso y la Calidad en la Atención Primaria. Es necesario profundizar en este tema con el fin de que el profesional de la salud mejore sus conocimientos para realizar un trabajo de calidad a la población usuaria.

Introduction: Scoping reviews are widely used to map the extent of the available literature and to organize the main concepts that structure a given topic. However, their results are usually presented as descriptive categories, with limited emphasis on how these dimensions appear together and how these combinations are distributed across the evidence base. Objective: The objective of this study is to develop and evaluate the feasibility of the SCoRE-Layer, a structured analytical method designed to represent the relational architecture of evidence in scoping reviews through co-occurrence matrices and descriptive structural metrics. Methods: This methodological study focused on the conceptual development, mathematical formalization, and operational structuring of SCoRE-Layer. To avoid conflating development and implementation, method development followed four analytical movements, whereas method implementation was organized into five interdependent operational stages: construction of a structured categorical system; independent coding allowing multiple categories per study; development of co-occurrence matrices between analytical dimensions; application of descriptive structural metrics associated with classification based on predefined cut-off points; and systematic identification of structural gaps based on the comparison between expectation and observation. The internal coherence and operational feasibility of the proposed method were examined through demonstrative application in three illustrative datasets. Results: The SCoRE-Layer made explicit the combinations between categories, quantified the connectivity of the investigated field, differentiated recurrence from relational specificity, classified structural patterns, and systematically identified gaps, while preserving the inherently descriptive nature of scoping reviews. The method also supported a more structured interpretation of how evidence is distributed across analytical dimensions, including in implementation-oriented readings of the literature. Conclusion: The method enhances the analytical capacity of scoping reviews by explicitly modeling the relational organization of evidence without exceeding their interpretative boundaries. In addition, it broadens the practical interpretability of mapped evidence by supporting clearer identification of central patterns, peripheral configurations, and underexplored gaps, including in implementation-oriented evidence syntheses. Spanish https://links.lww.com/IJEBH/A709

Clinical protocols are commonly framed as technical instruments for standardizing care and improving patient safety. Their implementation in practice, however, depends not only on the strength of the evidence that underpins them, but also on the organizational and political conditions that enable their continuity over time. In health-care settings characterized by administrative instability, political interference, patronage-based appointments, and high workforce turnover, adherence to protocols becomes especially fragile. This practice-based analysis examines how such conditions affect clinical governance and argues that nursing leadership plays a pivotal operational role in safeguarding the technical coherence of care. Drawing on frontline managerial experience and recent literature, the paper explores how politically volatile institutional environments can undermine protocol continuity, weaken safety culture, erode team trust, and generate tensions between formal authority and technical authority. It also considers the practical implications for nurse leaders and health-care managers working in systems where nontechnical pressures may reshape priorities, disrupt implementation, and compromise the sustainability of evidence-based practices. In these contexts, sustaining protocols requires more than technical design; it demands leadership capable of protecting standards, reinforcing accountability, and preserving continuity amid recurrent political and organizational disruption. The analysis further proposes that nurse leaders engage upstream through nonpartisan policy advocacy, participation in governance structures, and coalition-building when political and social conditions repeatedly threaten care continuity.

To map evidence on climate-related exposures and mental health outcomes among older adults, and to characterise how social determinants of health are framed as vulnerability, protective, and recovery-related factors. A scoping review was conducted in accordance with the Joanna Briggs Institute Manual for Evidence Synthesis and reported according to the PRISMA-ScR guidelines. The protocol was registered in the Open Science Framework. Searches were performed in PubMed/MEDLINE, Scopus, Web of Science, LILACS, SciELO, PsycINFO, the Cochrane Library, and Google Scholar, without language or date restrictions. Older adults were defined as individuals aged 60 years or older, consistent with the World Health Organization operational threshold. Study selection was conducted by two independent reviewers. Data extraction was followed by descriptive and thematic synthesis. Co-occurrence matrices were calculated only for empirical sources to reduce double counting from reviews and commentaries. A total of 740 records were identified; and 27 sources were included in the final synthesis. The principal exposure types mapped were heatwaves/extreme heat, floods, hurricanes/storms, wildfires, smoke exposure, and air pollution, including fine particulate matter with an aerodynamic diameter of 2.5 μm or less (PM2.5). Anxiety, stress, depression, and post-traumatic stress disorder were the most recurrent mental health outcomes. The mapped evidence suggests that income, social support, social isolation, education, chronic disease/functional limitation, housing/geography, gender, and access to services or information frequently co-occurred with adverse outcome profiles. The available literature suggests that climate-related mental health risks among older adults are heterogeneous and socially patterned. The mapped evidence is consistent with a socioecological and cumulative vulnerability interpretation, although causal mediation cannot be established by this scoping review. Integrating mental health into climate adaptation strategies requires psychosocial risk stratification, continuity of care, and strengthening of community and service networks.

Purpose: This study aims to describe the challenges and adaptive strategies involved in implementing a manual chronoanalysis instrument at the entrance of a medium-sized public emergency department in a nondigital context, from a Lean in Emergency Care perspective. Design/methodology/approach: A descriptive observational study with a qualitative and operational focus was conducted using the Lean methodology in a medium-sized public hospital in Brazil. A manual chronoanalysis instrument, the Time and Length of Stay Card, was developed to standardize the measurement of patient flow times at the emergency department entrance. The instrument made temporal milestones along the care flow visible and functioned as a data sensitization and data literacy device for teams operating in a predominantly analog environment. The card followed patients throughout the care pathway, recording key milestones to estimate Lead Time (total length of stay) and identify Waiting points (waste due to waiting) between stages such as risk classification, medical assessment and diagnostic testing. Data collection was conducted through managerial rounds across reception, triage, medical care, laboratory, diagnostic imaging and observation areas, following the Gemba Walk principle. Nonconformities were discussed in real time using the five Whys methodology, and implementation barriers were addressed through nonpunitive communication, rapid feedback and incremental adjustments to the instrument and work routines. Findings: Implementation revealed operational, organizational and behavioral challenges associated with high cognitive workload, initial resistance to perceived bureaucratic demands, and dependence on leadership presence to ensure record completeness. Addressing these challenges promoted organizational learning and strengthened situational awareness, shared responsibility and flow governance across macro, meso and micro levels. Originality/value: The study demonstrates that Lean transformation in public emergency departments depends less on digitalization and more on real-time institutional learning. Manual chronoanalysis emerges as a feasible, low-cost and effective Lean management strategy to initiate data-driven flow governance and sustain continuous improvement in resource-constrained settings.

Introduction: Research suggests an association between cocaine use and an increased risk of ische­mic stroke, with a more pronounced impact among young adults. Despite strong biological plausi­bility and growing epidemiological documentation, the magnitude of the risk attributable to cocaine use in this population has not yet been fully established. Therefore, the objective of this study was to analyze the published evidence regarding the association between cocaine use and the occurrence of ischemic stroke in young adults. Materials and methods: An integrative review was conducted in accordance with PRISMA recom­mendations. The literature search was performed in August 2024 in the MEDLINE/PubMed, LI­LACS, Scopus, and Web of Science databases. Studies investigating the relationship between co­caine use and ischemic stroke in adolescents or young adults were included. Methodological quality was classified according to Melnyk and colleagues’ hierarchy of evidence levels, and thematic analy­sis followed Bardin’s framework. Results: Thirteen studies met the eligibility criteria. The findings indicate an association between cocaine use and an increased risk of ischemic stroke in young adults, particularly following acute exposure. Reported mechanisms include cerebral vasospasm, endothelial dysfunction, platelet acti­vation, and hemodynamic alterations. Discussion: The amplification of risk following acute exposure and the concomitant use of multiple substances corroborate findings from previous investigations. Conclusion: The available evidence suggests that cocaine use constitutes a risk factor for ischemic stroke in young adults. The predominance of observational studies underscores the need for more rigorous investigations to achieve more precise estimates of attributable risk.

Introdução: No centro cirúrgico, os determinantes sociais da saúde influenciam diretamente os desfechos cirúrgicos, da indicação ao pós-operatório, refletindo desigualdades sociais que exigem atenção crítica da enfermagem. Objetivo: Refletir à luz de uma revisão narrativa sobre a influência dos determinantes sociais da saúde nos desfechos cirúrgicos e suas implicações para a Enfermagem perioperatória. Síntese do Conteúdo: Trata- se de um ensaio teórico-reflexivo fundamentado em revisão narrativa estruturada realizada na base PubMed entre abril e junho de 2025. Foram incluídos 26 artigos. A análise ocorreu por síntese temática integradora, organizada a partir do modelo de Dahlgren e Whitehead. Evidenciou-se que a incorporação dos determinantes sociais amplia o escopo da prática de enfermagem em diferentes níveis. No plano macro, envolve engajamento político-institucional, participação na formulação de políticas e gestão equitativa de recursos. Nos mesodeterminantes, destaca- se a avaliação social ampliada, o planejamento assistencial individualizado, a articulação com redes comunitárias e a educação em saúde culturalmente sensível. Nos microdeterminantes, incluem-se avaliação clínica individualizada, suporte psicossocial, acolhimento humanizado, planejamento pós-operatório e uso de tecnologias para continuidade do cuidado. Essa abordagem fortalece a integralidade e a justiça social no contexto cirúrgico. Conclusões: A integração dos determinantes sociais da saúde à prática da Enfermagem no centro cirúrgico fortalece a segurança do paciente, aprimora a qualidade do cuidado e contribui para a redução de iniquidades em saúde. Palavras-Chave: Determinantes Sociais da Saúde; Enfermagem Perioperatória; Assistência Perioperatória; Equidade em Saúde.