Digital health competences and AI beliefs as conditions for the practice of evidence-based medicine: a study of prospective physicians in Canada

BACKGROUND

The practice of evidence-based medicine (EBM) has become pivotal in enhancing medical care and patient outcomes. With the diffusion of innovation in healthcare organizations, EBM can be expected to depend on medical professionals' competences with digital health (dHealth) and artificial intelligence (AI) technologies.

OBJECTIVE

We aim to investigate the effect of dHealth competences and perceptions of AI on the adoption of EBM among prospective physicians. By focusing on dHealth and AI technologies, the study seeks to inform the redesign of medical curricula to better prepare students for the demands of evidence-based medical practice.

METHODS

A cross-sectional survey was administered online to students at the University of Montreal's medical school, which has approximately 1,400 enrolled students. The survey included questions on students' dHealth competences, perceptions of AI, and their practice of EBM. Using structural equation modeling (SEM), we analyzed data from 177 respondents to test our research model.

RESULTS

Our analysis indicates that medical students possess foundational knowledge competences of dHealth technologies and perceive AI to play an important role in the future of medicine. Yet, their experiential competences with dHealth technologies are limited. Our findings reveal that experiential dHealth competences are significantly related to the practice of EBM (β = 0.42, p < 0.001), as well as students' perceptions of the role of AI in the future of medicine (β = 0.39, p < 0.001), which, in turn, also affect EBM (β = 0.19, p < 0.05).

CONCLUSIONS

The study underscores the necessity of enhancing students' competences related to dHealth and considering their perceptions of the role of AI in the medical profession. In particular, the low levels of experiential dHealth competences highlight a promising starting point for training future physicians while simultaneously strengthening their practice of EBM. Accordingly, we suggest revising medical curricula to focus on providing students with practical experiences with dHealth and AI technologies.

Artificial intelligence in kidney transplantation: a 30-year bibliometric analysis of research trends, innovations, and future directions

Kidney transplantation is the definitive treatment for end-stage renal disease (ESRD), yet challenges persist in optimizing donor-recipient matching, postoperative care, and immunosuppressive strategies. This study employs bibliometric analysis to evaluate 890 publications from 1993 to 2023, using tools such as CiteSpace and VOSviewer, to identify global trends, research hotspots, and future opportunities in applying artificial intelligence (AI) to kidney transplantation. Our analysis highlights the United States as the leading contributor to the field, with significant outputs from Mayo Clinic and leading authors like Cheungpasitporn W. Key research themes include AI-driven advancements in donor matching, deep learning for post-transplant monitoring, and machine learning algorithms for personalized immunosuppressive therapies. The findings underscore a rapid expansion in AI applications since 2017, with emerging trends in personalized medicine, multimodal data fusion, and telehealth. This bibliometric review provides a comprehensive resource for researchers and clinicians, offering insights into the evolution of AI in kidney transplantation and guiding future studies toward transformative applications in transplantation science.

Gut virome and its emerging role in inflammatory bowel disease

Inflammatory bowel disease (IBD) is a progressive multifactorial inflammatory disease of the gut. The cause of IBD is yet unknown. Some researchers have shown that genetic factors, environmental factors, and the gut microbiome are significant considerations. Our gut contains gut virome and gut bacteria, which vary among individuals due to some factors. The gut virome is a substantial component of the microbiome. This editorial explores the emerging role of gut virome in IBD.

Interaction between gut virome and microbiota on inflammatory bowel disease

Inflammatory bowel disease (IBD), encompassing Crohn's disease and ulcerative colitis, is a chronic condition marked by recurring gastrointestinal inflammation. While immune, genetic, and environmental factors are well-studied, the gut virome has received less attention. This editorial highlights the work which investigates the gut virome’s role in IBD and its interactions with the bacterial microbiome and host immune system. The gut virome consists of bacteriophages, eukaryotic viruses, and endogenous retroviruses. Among these, Caudovirales bacteriophages are predominant and influence bacterial communities via lysogenic and lytic cycles. Eukaryotic viruses infect host cells directly, while endogenous retroviruses impact gene regulation and immune responses. In IBD, the virome shows distinct alterations, including an increased abundance of Caudovirales phages and reduced Microviridae diversity, suggesting a pro-inflammatory viral environment. Dysbiosis, chronic inflammation, and aberrant immune responses contribute to these changes by disrupting microbial communities and modifying virome composition. Phages affect bacterial dynamics through lysis, lysogeny, and horizontal gene transfer, shaping microbial adaptability and resilience. Understanding these interactions is crucial for identifying novel therapeutic targets and restoring microbial balance in IBD.

Patellofemoral positioning CT protocol has diagnostic ability to differentiate patellar maltracking phenotype

Introduction

Traditional radiographs often fail to capture the dynamic nature of patellar maltracking in patellofemoral pain syndrome (PFPS) and patellar instability, necessitating improved diagnostic protocols. This study aimed to: (1) introduce a CT protocol with scans at three knee positions (45° flexion, extension, and extension with quadriceps contraction), (2) assess how positioning influences patellofemoral indices measured from radiographs and CT, and (3) to evaluate the protocol's ability to classify maltracking phenotypes: dislocator, subluxator, or symptomatic without dislocation/subluxation (Neither).

Methods

Patients who underwent surgery for PFPS from April to December 2022 were retrospectively reviewed. Patellofemoral indices from the three scans within the CT protocol were compared among themselves and with standard radiographs. Patients were grouped by maltracking phenotype, and their patellofemoral indices on radiographs and CT were compared to determine which imaging modality best distinguished the phenotypes. Statistical analyses included bivariate and multivariate logistic regression.

Results

The study included 65 patients (51 females, 14 males) with mean age of 27. Patellofemoral indices measured on CT-45° versus CT-Extended differed significantly (p < 0.05), indicated the influence of knee position. Quadriceps contraction further worsened most indices, highlighting the importance of load-bearing conditions. Radiographs and CT-45° had limited capability to differentiate Dislocator, Subluxator, and Neither, but CT-Extended and CT-Quad showed significant differences among these groups. Multivariate analysis identified four independent predictors of patellar maltracking severity (p < 0.05): (1) Lateral Offset and (2) Insall-Salvati Ratio measured on CT-Extended, as changes in (3) Lateral Offset and (4) Lateral patellofemoral angle (LPFA) between extension and quadriceps contraction.

Conclusions

Radiographs alone cannot reliably distinguish Dislocator, Subluxator, and Neither. A dedicated CT protocol featuring scans in neutral extension and with quadriceps contraction better delineates patellofemoral maltracking phenotypes and offers improved diagnostic accuracy in PFPS. This approach may guide tailored interventions to address distinct underlying mechanics of each phenotype.

Level of evidence

III.

Adult ileo cecal intussusception as a manifestation of colon carcinoma: A case report

BACKGROUND

Intussusception is the invagination of a segment of the bowel into an adjacent segment. It is the most common cause of intestinal obstruction in children, but in adults, it is rare, accounting for 1% of all intestinal obstructions and 5% of all intussusceptions, with malignancy being the most common cause. In the past, it was typically diagnosed intraoperatively. However, with the availability of computed tomography for abdominal imaging, recognizing the condition's signs has become crucial. Surgical intervention is essential for managing neoplastic cases and their complications.

CASE SUMMARY

A 45-year-old female presented with severe abdominal pain encompassing her entire abdomen, abdominal distension, vomiting, and persistent constipation. Over the past two months, she has also experienced considerable weight loss. After an initial history review, examination, and imaging investigations, the patient was diagnosed with ileo cecal intussusception resulting from a colo rectal mass located in the cecum and ascending colon. This condition was surgically managed through an extended right hemi colectomy.

CONCLUSION

Intussusception is uncommon in adults, but it should be considered in patients with intestinal obstruction. Surgical intervention is essential.

Multi-response optimization and validation analysis in the detection of acetochlor and butachlor by HPLC based on D-optimal design methodology

Acetochlor and butachlor, widely used herbicides, pose environmental and health risks through water contamination. This study developed a high-performance liquid chromatography (HPLC) method for analyzing these compounds, employing a multi-response approach and D-optimal design. The D-optimal design reduced the number of required experiments from 36 to 14. The response model was analyzed by variance and residual diagnosis, and a multi-response optimization process was implemented to minimize the retention time and maximize the peak area of the two analytes. The optimal conditions were determined: a column temperature of 30 °C, a mobile phase composition of 80:0:20 (CH3OH:CH3CN:H2O) by volume, a flow rate of 0.9 mL min-1, an injection volume of 25 μL, and a detection wavelength of 215 nm. The method achieved complete separation of acetochlor and butachlor within 10 min. The detection limits were 0.0018 mg L-1 for acetochlor and 0.01 mg L-1 for butachlor, with quantitation limits of 0.009 mg L-1 and 0.06 mg L-1, respectively. The linear ranges extended from 0.009 to 9 mg L-1 for acetochlor and 0.06 to 15 mg L-1 for butachlor, with a correlation coefficient (R2) of 0.9998, indicating excellent linearity. The recoveries ranged from 98.36 % to 103.13 % for acetochlor and 80.30 % to 107.74 % for butachlor, with the relative standard deviations both below 2 % (n = 6). This accurate, rapid, and sensitive method is well-suited for quantitative detection of these herbicides in water. It also serves as an invaluable reference for analyzing structurally similar chloroacetamide herbicides using HPLC.

Predicting hospital admissions, ICU utilization, and prolonged length of stay among febrile pediatric emergency department patients using incomplete and imbalanced electronic health record (EHR) data strategies

OBJECTIVE

Determine the efficacy of commonly used approaches to handling missing and/or imbalanced Electronic Health Record (EHR) data on the performance of predictive models targeting risk of admission, intensive care unit (ICU) use, or prolonged length of stay (PLOS) among presenting febrile pediatric emergency department (ED) patients.

MATERIALS AND METHODS

Historical ED EHR data was used to train a series of XGBoost (XGB) and logistic regression (LR) classifiers. Data handling strategies included imputation methods (multiple imputation (MI), median imputation, complete case (CC) analysis), and imbalanced data corrections (minority oversampling, stratified sub-group analysis). Model performance was evaluated using discriminative (AUC, AUPRC) and calibration metrics (Brier score, Z-scores, p-values).

RESULTS

Among the study population, 34 % were admitted, 2 % utilized the ICU, and 7 % had a PLOS. Significant data missingness was observed and determined to be not at random (MNAR). In predicting admissions using data recorded within the first two hours of presentation, LR trained using full cohort with median imputation was comparable to MI yielding well-calibrated admissions models with an AUC/AUPRC of 0.82/0.73 while CC analysis yielded an AUC/AUPRC of 0.76/0.78. XGB, trained with unimputed data, produced a well-calibrated admissions classifier with an AUC/AUPRC of 0.85/0.78. In contrast, imbalanced data correction techniques, including synthetic minority oversampling (SMOTE), risk stratification, or the use of XGB did not significantly improve the poor AUPRC and calibration performance of LR models predicting ICU and PLOS.

CONCLUSION

Both XGB and LR with median imputation demonstrated robust performance in predicting admissions in the presence of missing data. However, deriving clinically useful models for rare outcomes, such as ICU use or PLOS, remains a challenge due to poor precision/recall and calibration performance. Further research is needed to improve the prediction of rare outcomes in this population.

Novel cytochrome c-oxidase deficiency and mitochondrial myopathy in non-syndromic cleft lip with or without palate

The role of mitochondria in regulating cells during the embryonic phase is crucial, yet their function in causing deformation to orbicularis oris muscle of cleft lip remains controversial. The study was performed to explore morphological abnormalities of orbicularis oris muscle and mitochondria in patients with cleft lip with or without palate. Seventeen cleft lip tissue samples were obtained from consented patients who underwent cleft lip repair. All tissue samples were processed according to the respective analyses: modified Gomori trichrome, cytochrome c-oxidase (COX), adenosine triphosphatase (ATP-ase), and transmission electron microscopy (TEM). Fiber types and the sizes of fibers and mitochondria were determined using ImageJ processing program. The pathological hallmark of mitochondrial myopathy, which was the presence of ragged red fibers, and the presence of novel COX-negative fibers were observed in cleft lip tissues. Muscle fiber type ratio for type II fibers was found to be predominant in orbicularis oris muscle of cleft lip tissues with 78.43 %, while type I fibers was 21.57 %. The diameters of the fibers were 6.37 µm for type I, and 6.87 µm for type II. By means of electron microscopy, minimal accumulation of mitochondria and excessive lipid droplets were noted within the myofibrils of cleft lip orbicularis oris muscle. This report on series of pathologic features of the orbicularis oris muscle and mitochondria provides insights into the possibility of impaired mitochondrial function in non-syndromic cleft lip.

Development of an instrument to measure the attitudes and skills of undergraduate nursing students in caring for family caregivers: An international multi-method study

BACKGROUND

The increasing demands on family caregivers due to the shortage of healthcare professionals and the rising prevalence of chronic conditions underscore the need for adequate nursing support to enhance family caregivers' abilities and reduce their burden. No instrument exists to measure undergraduate nursing students' attitudes and skills in involving family caregivers. This study aimed to develop a questionnaire to evaluate undergraduate nursing students' attitudes and skills in caring for family caregivers.

METHODS

A three-phase multi-method study was conducted involving a consortium of five universities in Italy, Denmark, India, Spain, and Sweden. Theoretical models and literature analysis and review informed initial item generation. Then, a Delphi process with purposefully selected international experts across three rounds refined the item list based on clarity, essentiality, and relevance, achieving consensus on a final set of items. Finally, pilot testing with purposefully selected 25 students assessed face validity and clarity.

RESULTS

The preliminary phase led to 130 items. Delphi rounds reduced the initial 130 items to a refined set of 39 (13 items on attitudes, 26 on skills). Content Validity Index (CVI) scores for clarity and relevance were high (S-CVI/Ave = 0.93 for clarity, 1.0 for relevance). From the pilot test among 25 students, items scored an average clarity of 0.84 (I-CVI). Two items were removed, resulting in a final 37-item questionnaire (12 attitudes, 25 skills).

DISCUSSION

The developed questionnaire bridges a gap in nursing education assessment. Emphasizing attitudes and skills, it addresses key areas such as understanding family dynamics, emotional support, and collaborative planning with caregivers, aligning with nursing education needs across diverse cultural contexts. The use of this instrument will support educational programs in enhancing family-centered care competencies of undergraduate nursing students, ultimately improving support for family caregivers in healthcare settings.

Defining Clinical Remission in Severe Asthma: Expert Opinion From the Gulf Region Using the Modified Delphi Method

The introduction of biologics into the asthma management landscape and the adoption of patient-centricity and outcomes principles drive the need to revise clinical goals and targets while treating asthma patients. This necessitates a deeper understanding of asthma phenotypes, endotypes, pathophysiology, and clinical cutoff points depicting an operational definition of clinical remission in asthma. This publication represents a step in this direction, through systemically gathering and analyzing insights from experts in pulmonology and immunology from the Gulf Countries. A pre-workshop survey, scientific workshop, and two rounds of Delphi surveys constituted the analysis process and resulted in agreed-upon comprehensive criteria defining clinical remission in severe asthma. While constructing the Delphi expert opinion addressing the concept of on treatment remission, the following factors were agreed to be the main defining criteria: The sustained absence of asthma symptoms, the sustained absence of asthma exacerbations, stable lung function, and zero systemic corticosteroids for the treatment of asthma for at least 12 months.

Precision oncolytic viral therapy in colorectal cancer: Genetic targeting and immune modulation for personalized treatment (Review)

Colorectal cancer (CRC) is a leading health issue and treatments to eradicate it, such as conventional chemotherapy, are non‑selective and come with a number of complications. The present review focuses on the relatively new area of precision oncolytic viral therapy (OVT), with genetic targeting and immune modifications that offer a new future for CRC treatment. In the present review, an overview of the selection factors that are considered optimal for an oncolytic virus, mechanisms of oncolysis and immunomodulation applied to the OVT, as well as new strategies to improve the efficacy of this method are described. Additionally, cause‑and‑effect relationships are examined for OVT efficacy, mediated by the tumor microenvironment, and directions for genetic manipulation of viral specificity are explored. The possibility of synergy between OVT and immune checkpoint inhibitors and other treatment approaches are demonstrated. Incorporating the details of the present review, biomarker‑guided combination therapies in precision OVT for individualized CRC care, significant issues and future trends in this required area of medicine are highlighted. Increasingly, OVT is leaving the experimental stage and may become routine practice; it provides a new perspective on overcoming CRC and highlights the importance of further research and clinical work.

Establishing a Research Agenda for Physiotherapy in Portugal: A Delphi Study

BACKGROUND

As physiotherapy research advances, identifying knowledge gaps and setting priorities is crucial for enhancing its efficiency in national and international collaborations. This study aimed to establish a physiotherapy research agenda in Portugal by integrating perspectives from physiotherapists and users of physiotherapy services.

METHODS

An online two-round Delphi study was conducted from April to August 2024 with two panels: physiotherapists and users of physiotherapy services. Participants rated 66 research priorities in the two rounds using a four-point Likert scale (1 = not important, 4 = very important), with 13 new priorities introduced in the second round. These priorities were organized into nine research categories identified from a prior scoping review: (1) (cost)effectiveness; (2) service delivery; (3) education, professional development and quality; (4) measurement instruments; (5) mechanisms behind disability, physiotherapy treatments and patient classification; (6) patients' needs, expectations, experience and context; (7) prognostic outcomes and responses to therapy; (8) decision-making strategies; and (9) technology and big data. Consensus was defined as a cut-off median score of ≥ 3.25.

RESULTS

A total of 479 physiotherapists and 70 users of physiotherapy services participated in Round 1 with final retention rates of 64% and 43%, respectively. The final 'Top 10' priorities focused on three research categories: researching optimal service delivery models, structures, and processes (n = 5); establishing the (cost)effectiveness of different physiotherapy interventions (n = 3); and exploring the best models of physiotherapy education, professional development, and quality (n = 2).

CONCLUSIONS

This study established a physiotherapy research agenda for Portugal, focusing on (cost)effectiveness, service delivery, education, professional development, and quality, integrating the perspectives of physiotherapists and users of physiotherapy services. The final priorities provide a foundation for future research and policy development.

Is it feasible for European laboratories to use SI units in reporting results?

The ultimate goal of harmonization, crucial to quality in laboratory medicine, is to improve patient outcomes by providing accurate, actionable laboratory information. Patients and healthcare professionals assume that clinical laboratory tests performed by different laboratories at different times on the same type of sample are comparable, and that results can be reliably and consistently interpreted. In this context the reporting units for tests can have a considerable influence on the numeric result. The harmonization of measurement units in laboratory report, leads to the provision of interchangeable and comparable results, thus maximizing the validity of laboratory information, and assuring a more accurate diagnosis and better treatment for the patient. However, although considerable efforts have been made in recent years, the criticisms continue. This opinion paper, prepared jointly by EFLM Committee Harmonization (C-H) and Committee Postanalytical phase (C-POST), describes the "general pragmatic approach" proposed in the drafting of guidelines for the harmonization of measurement units in reporting results, in order to ensure they are used as widely as possible.

Enhancing the outcomes of diabetic vitrectomy with pharmacological adjuvants

This editorial offers insights from a minireview by Venkatesh et al, who explored pharmacological adjuvants for diabetic vitrectomy. Specifically, they synthesized current knowledge and evaluated the efficacy of various adjunctive therapies in improving the outcomes of diabetic retinopathy and managing associated complications. Herein, we highlight the key roles of pharmacological adjuvants in optimizing surgical techniques, minimizing intraoperative challenges, and enhancing postoperative recovery. We further discuss the potential implications of this approach for clinical practice and future research directions in this evolving field. Overall, this editorial underscores the importance of incorporating pharmacological adjuvants into standard diabetic vitrectomy care to improve surgical outcomes and thus patients’ quality of life.

Biomarkers for tracking metabolic changes pre-post nutritional epigenetics diet/intervention to prevent autism and attention deficit/hyperactivity disorders in children

The prevalence of autism and attention deficit/hyperactivity disorders is increasing worldwide. Recent studies suggest the excessive intake of ultra-processed food plays a role in the inheritance of these disorders via heavy metal exposures and nutritional deficits that impact the expression of genes. In the case of the metallothionein (MT) gene, biomarker studies show dietary zinc (Zn) deficits impact MT protein levels in children with autism and are associated with the bioaccumulation of lead and/or mercury in children exhibiting autism/attention deficit/hyperactivity disorders symptomology. The impact of dietary changes on lead and mercury exposures and MT gene behavior could be determined using a randomized test and control group design. Pregnant women serving in the test-group would participate in a nutritional epigenetics education intervention/course designed to reduce ultra-processed food intake and heavy metal levels in blood while increasing whole food intake and MT and Zn levels. Changes in maternal diet would be measured using data derived from an online diet survey administered to the test and control groups pre-post intervention. Changes in maternal lead, mercury, Zn, and MT levels would be measured via blood sample analyses prior to the intervention and after childbirth via cord blood analyses to determine infant risk factors.

Telemedicine and public health–pearls and pitfalls

We hereby comment on the interesting systematic review by Grewal et al where they have provided an overall picture of the current status of available tele-health programs in the United States with emphasis on the Amazon Clinic. Their analysis is an appreciable effort in discovering the features available and features lacking in these tele-health programs. The concept of tele-health originated to curtail the need for physical attendance of patients at health clinics, and has been beneficial during the coronavirus disease 2019 pandemic. We implore that the pearls and pitfalls of these programs have to be understood by policymakers prior to forming a consensus regarding the availability, accessibility and affordability of these programs as methods of healthcare delivery. Unrestricted proliferation of tele-health programs in their current form may pose threats to patient and provider safety and medicolegal liability. However, patients and providers must work together to improve them to meet their expectations and enable them to provide the best care for the ailing public.

Advancements in diabetic retinopathy: Insights and future directions

This editorial discusses recent advancements and ongoing challenges in diabetic retinopathy, as reviewed by Morya et al in their comprehensive analysis. In their review, Morya et al discussed the pathophysiology of diabetic retinopathy and explored novel treatment modalities. This editorial highlights the importance of these advancements and emphasizes the need for continued research and innovation for the enhanced management of diabetic retinopathy. It also reflects upon the implications of the authors’ review findings for clinical practice and future research directions, underscoring the potential of emerging therapies for improving patient outcomes and providing a deeper understanding of disease mechanisms.

Prescribing lithium for the management of persons suffering from bipolar disorders: expert consensus based on a Delphi study

BACKGROUND

According to international guidelines, lithium treatment represents the gold standard for the appropriate management of persons with bipolar disorder. However, prescription rates in ordinary practice are not in line with clinical guidelines' suggestions. Clinicians prefer to use drugs other than lithium, considering its low therapeutic window, the need for regular lab tests and its side effects profile. Based on these premises, a Delphi-method study focused on highly-debated aspects of lithium treatment in bipolar disorder has been promoted with the aim to reach a consensus among an expert panel of Italian psychiatrists.

METHODS

The Delphi method is a structured technique aimed to obtain a consensus from repeated rounds of questionnaires where opinion/agreement among experts are important. A Steering Committee of experts has developed a 24-items questionnaire exploring: (1) the use of lithium as first choice for treating different phases of bipolar disorder; (2) the side effect and tolerability profile of lithium treatment as hampering factors for its use in clinical practice; (3) the lithium prescribing in special target population, such as adolescents, elderly patients, and pregnant women.

RESULTS

The questionnaire was delivered to a panel of 100 Italian psychiatrists, experts in the field of managing people with bipolar disorders. An almost complete positive consensus was reached for statements dealing with the use of lithium treatment as first choice in the management of patients with bipolar disorder, and as the first choice for preventing manic/hypomanic and depressive episodes.

CONCLUSIONS

Current clinical guidelines and scientific evidence support the use of lithium as first choice treatment in patients with bipolar disorder. However, over the last decades a downward tendency in lithium's prescription has been registered worldwide. The present Delphi study confirmed the "good clinical reasons" for supporting lithium prescription in clinical practice. Our findings should be used to develop clinical practice guidelines and reduce the discrepancy between international guidelines and ordinary care.

The potential role of AI in research priority setting exercises

To help achieve the goals of accountability and research excellence, funding organisations often utilise evidence from research priority setting exercises (RPSEs), which distil, from data gathered from relevant stakeholders, a systematic and 'objective' rank-order of research priorities. RPSEs are, however, costly and labour-intensive. Also, critics of RPSEs have highlighted certain limitations: insufficient representation of difficult-to-reach stakeholders, especially in low- and middle-income countries; a lack of genuine stakeholder engagement; wide variation in the extent to which exercises are documented; a lack of specificity in the identified priorities; and minimal impact of the priorities. Artificial intelligence (AI) tools such as ChatGPT may potentially help, valuably complementing conventional RPSEs. While the opacity of AI decision-making is a limitation, advantages include speed, affordability, and highly inclusive distillation of the vastness of existing human knowledge. We encourage research identifying the extent to which AI can replicate conventional RPSEs. We suggest that AI tools could complement conventional approaches either at the initial question generation stage or in generating supplementary insights for reflection at the data analysis stage. Also, under conditions of high existing stakeholder engagement and an extant prevalence of conventional RPSEs, AI-only studies may be valuable.

Refining partial gland ablation for localised prostate cancer: the FALCON project

OBJECTIVES

To provide a contemporary statement on focal therapy (FT) for localised prostate cancer (PCa) from an international and diverse group of physicians treating localised PCa, with the aim of overcoming the limitations of previous consensus statements, which were restricted to early adopters, and to offer direction regarding the various aspects of FT application that are currently not well defined.

MATERIALS AND METHODS

The FocAL therapy CONsensus (FALCON) project began with a 154-item online survey, developed following a steering committee discussion and literature search. Invitations to participate were extended to a large, diverse group of professionals experienced in PCa management. From 2022 to 2023, a Delphi consensus study consisting of three online rounds was conducted using the Modified Delphi method. A 1-9 Likert scale was used for the survey, which was followed by an in-person expert meeting. The threshold for achieving consensus was set at 70% agreement/disagreement. Six main aspects of FT were covered: (i) patient selection; (ii) energy source selection; (iii) treatment approach; (iv) treatment evaluation and follow-up; (v) treatment cost and accessibility; and (vi) future perspectives.

RESULTS

Of 246 initial participants, 148 (60%) completed all three rounds. Based on participant feedback, 27 new statements were added in the second round, and 33 questions related to personal expertise, for which consensus was not necessary, were excluded. After the third and final round, consensus had not been reached for 69 items. These items were discussed at the in-person meeting, resulting in a consensus of 57 additional items. Consensus was finally not reached on 12 items. Given the volume of data, the voting outcomes are summarised in this article, with a detailed breakdown presented in the form of figures and tables.

CONCLUSIONS

The FALCON project delivered a significant consensus on the approach to FT for localised PCa. Additionally, it highlighted gaps in our knowledge that may provide guidance for future research.

Essential competencies of nurses working with AI-driven lifestyle monitoring in long-term care: A modified Delphi study

BACKGROUND

As more and more older adults prefer to stay in their homes as they age, there's a need for technology to support this. A relevant technology is Artificial Intelligence (AI)-driven lifestyle monitoring, utilizing data from sensors placed in the home. This technology is not intended to replace nurses but to serve as a support tool. Understanding the specific competencies that nurses require to effectively use it is crucial. The aim of this study is to identify the essential competencies nurses require to work with AI-driven lifestyle monitoring in long-term care.

METHODS

A three round modified Delphi study was conducted, consisting of two online questionnaires and one focus group. A group of 48 experts participated in the study: nurses, innovators, developers, researchers, managers and educators. In the first two rounds experts assessed clarity and relevance on a proposed list of competencies, with the opportunity to provide suggestions for adjustments or inclusion of new competencies. In the third round the items without consensus were bespoken in a focus group.

FINDINGS

After the first round consensus was reached on relevance and clarity on n = 46 (72 %) of the competencies, after the second round on n = 54 (83 %) of the competencies. After the third round a final list of 10 competency domains and 61 sub-competencies was finalized. The 10 competency domains are: Fundamentals of AI, Participation in AI design, Patient-centered needs assessment, Personalisation of AI to patients' situation, Data reporting, Interpretation of AI output, Integration of AI output into clinical practice, Communication about AI use, Implementation of AI and Evaluation of AI use. These competencies span from basic understanding of AI-driven lifestyle monitoring, to being able to integrate it in daily work, being able to evaluate it and communicate its use to other stakeholders, including patients and informal caregivers.

CONCLUSION

Our study introduces a novel framework highlighting the (sub)competencies, required for nurses to work with AI-driven lifestyle monitoring in long-term care. These findings provide a foundation for developing initial educational programs and lifelong learning activities for nurses in this evolving field. Moreover, the importance that experts attach to AI competencies calls for a broader discussion about a potential shift in nursing responsibilities and tasks as healthcare becomes increasingly technologically advanced and data-driven, possibly leading to new roles within nursing.

Modification of the Adjustment Disorder New Module20 (ADNM-20) for Use in Military Environments (ADNM-20-MIL): A Delphi and Pilot Study

OBJECTIVES

Despite its high prevalence and strong linkages with dangerous health outcomes, research on Adjustment Disorder (AjD) is hindered by lack of diagnostic clarity. AjD is categorized as a stress-related disorder, highlighting the important role of the stressor(s) on AjD symptom onset and severity. The military community shows increased risk for AjD, and existing tools do not capture the stressors most relevant and appropriate to this unique community. A diagnostic assessment tool developed specifically for this specialized population may provide critical capability to clinical assessment.

METHODS

A Delphi method was used to create a military-specific version of the standard assessment for Adjustment Disorders (ADNM-20), named ADNM-20-MIL. This tool was pilot-tested in a sample of U.S. Active Duty Service Members (ADSMs) with AjD diagnoses.

RESULTS

Throughout the Delphi process, military-specific stressors were identified and integrated into the ADNM-20-MIL, then refined and validated, ensuring their applicability and relevance to the military context.

CONCLUSIONS

The ADNM-20-MIL will enable timely diagnosis and targeted treatment for AjD, which remains a highly prevalent and destabilizing diagnosis in ADSMs.

Impact of COVID-19 pandemic-related restrictive measures on overall mental and physical health and well-being, specific psychopathologies and emotional states in representative adult Greek population: Results from the largest multi-wave, online national survey in Greece (COH-FIT)

BACKGROUND

Greece faced particular COVID-19-pandemic-related challenges, due to specific socio-cultural-economic/public-health factors and drastic restrictive policies.

OBJECTIVES

To understand trajectories of overall mental and physical health, well-being, emotional states and individual psychopathology in response to pandemic-related restrictive measures within general adult Greek population across the first two pandemic waves.

METHODS

Using multiple time-point cross-sectional data from the "Collaborative Outcomes study on Health and Functioning during Infection Times" (COH-FIT), we examined changes in outcomes from retrospective pre-pandemic ratings (T0) to three distinct intra-pandemic time points (lockdown 1: T1, between lockdowns: T2, lockdown 2: T3). Primary outcomes included WHO-5 well-being scores and a composite overall psychopathology "P-score", followed by a wide range of secondary outcomes.

RESULTS

10,377 participant responses were evaluated, including 2737 representative-matched participants. Statistically significant differences in well-being and overall psychopathology before and after quarantine (T0 vs. T1-T3), as well as across the assessed time frames (T1, T2, and T3) emerged in both samples. Global mental and physical health, individual psychopathology scores (anxiety, depression, PTSD, OCD, panic, mania, mood swings, sleep and concentration problems), emotional states (anger, helplessness, fear of infection, boredom, frustration, loneliness and overall stress scores), BMI and pain scores also showed statistically significant time differences in both samples, with the exemption of self-injury and suicidal attempt scores, showing lower intra-pandemic scores.

CONCLUSIONS

This is the largest multi-wave report on well-being, mental and physical health across different pandemic restriction periods in Greece, suggesting a substantial negative effect of lockdowns on most outcomes at least during the acute pandemic waves.

Consensus Recommendations for Sustainable and Equitable Neonatology Staffing: A Delphi Approach

BACKGROUND AND OBJECTIVE

The specialty of neonatology faces significant and growing challenges related to patient safety, physician well-being, and workforce sustainability that highlight the necessity for innovative work models. Our objective was to develop consensus recommendations to improve neonatologist staffing practices in the United States.

METHODS

We used a modified Delphi process with 32 diverse subject-matter expert stakeholders to reach consensus. We derived 60 initial potential recommendations for improved staffing from the literature and our 2 previous studies of physician leaders. We defined consensus as 80% or higher agreement and strong consensus as 90% or higher agreement. We ultimately eliminated statements that achieved less than 80% consensus from the recommendations.

RESULTS

Fifty-one individual statements reached consensus and were grouped into 24 final recommendations to improve neonatology staffing. Topics of focus included clinical allocations (eg, clinic work is counted in hours/year), shift characteristics (eg, clinical work after 24 hours is minimized), allocation of nonclinical work (eg, nonclinical work is accounted for in full-time equivalent), and staffing flexibility (eg, options to restructure clinical work are provided for specific circumstances such as aging and pregnancy). Significant discussion on many statements focused on ensuring that recommendations were both feasible and not overly prescriptive for individual institutions.

CONCLUSIONS

We reached consensus on a set of neonatologist staffing recommendations that emphasize the critical issues related to patient safety and physician well-being. Future work will focus on advocating for widespread implementation of these recommendations and evaluating their effect on patient safety, physician well-being, and sustainability of the neonatal workforce.

Developing a Prototype Home-Based Toothbrushing Support Tool for Families in Scotland: A Mixed-Methods Study With Modified Delphi Survey and Semi-Structured Interviews

BACKGROUND

Scotland's National Oral Health Programme for Children, Childsmile, provides targeted home toothbrushing support for families of young children (0-3 years) in the home setting. The study describes the adaptation of an existing dental practice-based intervention from the Netherlands using pictorial cards (Uitblinkers) for use in the programme. The aims were to modify Uitblinkers for the setting and context in Scotland by: (1) identifying the barriers that parents/carers in need of extra support face in implementing supervised toothbrushing; (2) explore consensus about behaviour change techniques that are appropriate and valid to address these; and (3) making recommendations for the design of a co-produced home-support tool and identifying facilitators for implementation in practice.

METHODS

A modified Delphi study was carried out consisting of two survey rounds with a purposively recruited expert panel (n = 21) to develop consensus on home toothbrushing barriers (aim 1), behaviour change techniques (aim 2) and considerations for implementation (aim 3). Proposition statements for the Delphi were derived from literature, discussions with project advisors and from Uitblinkers, an existing behaviour change intervention for parents developed by the Academic Centre for Dentistry Amsterdam (ACTA) and delivered in dental practice. Then 12 in-depth, semi-structured interviews were conducted with Dental Health Support Workers in Scotland (delivering the home support toothbrushing intervention) to gather the views on the proposed toothbrushing barriers, behaviour change techniques and considerations for implementation (aim 1 to 3). Delphi results are presented descriptively in terms of percentage agreement and priority ratings. Interview transcripts were analysed using Template Analysis.

RESULTS

From the Delphi study, a final set of 11 overlapping child, parent and environmental/social toothbrushing barriers was agreed upon (aim 1), to be addressed through a tool based on applied Motivational Interviewing, and a combination of Operant Conditioning, Stimulus Control and Goal-Setting techniques (aim 2). Experts supported the tool as realistic for delivery in the home setting, provided staff were trained. A physical 'paper' tool was preferred to a proposed electronic version (aim 3). Themes from interviews were: (1) the barriers present an exhaustive set and are valid from staff experience with families; (2) Motivational interviewing is appropriate and fits with usual practice; (3) the included behaviour change techniques are workable; (4) the tool is generally feasible within the operation of Childsmile home visits; (5) the tool is not less applicable for children with additional support needs.

CONCLUSIONS

A card-based conversational intervention to provide targeted home toothbrushing support for families of young children (0-3 years) in the home setting in Scotland, drawing from a template from the Netherlands, has been deemed worthy of further testing based on expert consensus and staff views on barriers faced, appropriate behaviour change techniques to address these and the design of a physical tool.

Principles of the superior labrum and biceps complex: an expert consensus from the NEER Circle

BACKGROUND

The superior labrum and biceps complex is commonly implicated in shoulder pain and there remains discordance regarding the surgical management of superior labrum anterior to posterior (SLAP) tears. The purpose of this study was to establish an expert consensus regarding the management of superior labrum and biceps complex pathology.

METHODS

The NEER Circle is an organization of shoulder experts recognized for their service to the American Shoulder and Elbow Surgeons (ASES) society. Consensus among 92 identified experts was sought with a series of surveys pertaining to the management of superior labrum and biceps complex (SBC) pathology. The initial survey featured questions crafted to determine the experience of the panel in treating SBC pathology. The second survey was designed to elicit opinions concerning the diagnosis and treatment of SBC pathology. The third survey aimed to establish consensus across 48 scenarios, tasking panelists with categorizing 4 surgical modalities as either preferred, acceptable, or not acceptable. The available options included débridement, SLAP repair, biceps treatment, or a combined repair and biceps treatment. In the final survey, the panelists were tasked with diagnosing SBC pathologies by assessing arthroscopic footage and evaluating treatment options within 45 scenarios. A minimum of 80% agreement was required to attain consensus, designating a treatment as either preferred or unacceptable.

RESULTS

Response rates ranged from 52.2% to 58.7%. Discordance exists regarding aspects of the physical examination, patient history, imaging, nonoperative management, and the surgical approach in SBC injuries. Of the 78 clinical scenarios, 26 reached consensus agreement. Treating the biceps was the favored approach in older, more sedentary patients with evidence of biceps tendinopathy. Performing a SLAP repair was favored in scenarios depicting younger, more active patients with signs of an unstable biceps anchor or mechanical symptoms. A SLAP repair was typically contraindicated in the setting of an older patient, concomitant rotator cuff tear, and/or a prior failed SLAP repair. The management of overhead throwing athletes, particularly those that are professionals, remained controversial, although SLAP repair is generally favored in younger pitchers.

CONCLUSION

The optimal management of superior labrum and biceps complex pathology requires a systematic approach based on the individual's age, occupational demands, and functional requirements. Age was the predominant factor influencing surgical decision making. SLAP repairs are generally favored in younger, active patients, whereas treating the biceps is preferred in lower-demand patients aged >30 years. Little consensus was observed regarding the management of competitive athletes.

The participation of lifeworld experts in Delphi processes: A reflection on method and practice

Delphi studies have established themselves in the health sciences as a means to systematically and, ideally, synthesize expert opinions into a consensus on concrete issues. As participatory health research increases in relevance, lifeworld experts (e.g., patients, caregiving relatives) are being included in Delphi surveys and their opinions placed alongside those of professional and scientific experts. Looking at the theory and methodology, we discuss the opportunities and challenges concerning result quality and derive practical implications for conducting Delphi studies involving lifeworld experts alongside scientific and/or professional experts. Delphi techniques are understood here to be social interaction processes whose outcomes are a result of the participating experts' conscious, cognitive judgment processes, and also shaped by individual, situational and cultural factors. The more heterogeneous the expert panel, in particular when lifeworld experts are participating, the more these influences vary. Expert panel composition and how diversity is handled prove significant to Delphi study results. Our argument is based on an in-depth analysis of a systematic review of Delphi studies with lifeworld experts. We found that the inclusion of lifeworld experts in Delphi studies usually occurs relatively unsystematically and, furthermore, that results are not analysed separately according to expert group, although there would be good reasons for this. We have oriented the reporting here on PRISMA. To enhance the outcomes of Delphi studies that incorporate lifeworld experts alongside scientific and/or professional experts, we put forward specific recommendations that address potential biases arising from the participation of lifeworld experts.

Promoting Patient Safety Through Patient Engagement at the Organisational Level: A Delphi-Based Needs Assessment Among Patient and Family Advisory Councils

BACKGROUND

Patient and family advisory councils (PFACs) are increasingly recognised as a promising approach for improving patient safety (PS) through patient engagement (PE) at the organisational level. However, PFAC stakeholders often lack the necessary knowledge and competence to engage effectively in PS-related issues with healthcare organisations. Moreover, evidence on specific needs for knowledge and competence improvement remains limited, hindering the development of future interventions.

OBJECTIVE

This study aimed (a) to identify needs for PS-related competency and knowledge improvement among PFAC stakeholders and (b) to assess current and desired levels of PFAC engagement, roles and factors influencing PFACs' work.

DESIGN

We established an exploratory mixed-methods design with a modified, two-round Delphi approach. We first used qualitative content analysis to analyse interview data (Round 1) and then consolidated statements for a quantitative questionnaire (Round 2). Responses were analysed descriptively and for consensus (criterion: 85% agreement). Mixed-methods analysis was conducted sequentially and convergently.

SETTING AND PARTICIPANTS

PFAC stakeholders are affiliated with German healthcare organisations, including patient representatives and professionals from healthcare organisations. MAIN VARIABLE AND OUTCOME STUDIED: (a) Needs for competency improvement on PS and communication, self-assessed knowledge and preferred training formats and (b) PFAC engagement levels, roles and factors influencing PFACs' work.

RESULTS

Across 6 different oncology-focused PFACs from German university hospitals, 19 stakeholders participated across both rounds. Seventeen needs for competency improvement in PS and communication were identified. After establishing consensus, 10 distinct domains of need were agreed upon (e.g., PS fundamentals, legal basis for PE and respectful communication). While PFAC engagement in PS was inconsistent, participants expressed a strong desire for further involvement. Key implementation factors included limited access to organisational processes, lack of resources and unequal conditions between research- and care-oriented councils.

DISCUSSION AND CONCLUSION

This study highlights the need for targeted training and structural support to strengthen PFACs' role in PS. Competency improvement and role clarity were deemed essential for effective collaboration. Enhancing PFAC engagement in PS requires tailored educational programmes, transparent structures and institutional support. This study provides an empirical basis for interventions to improve PE in PS at the organisational level.

PATIENT OR PUBLIC CONTRIBUTION

A patient representative was actively involved throughout the research process, contributing to the development of study materials and providing independent feedback on interview guides and questionnaires. Her input helped to shape the materials, improve their accessibility to lay audiences and ensure the inclusion of patient-relevant issues. The research team discussed her feedback in detail and revised study materials accordingly. Beyond the content presented in this manuscript, she contributed to shaping a subsequent intervention that emerged from the study's needs assessment, which was designed as a participatory approach to incorporate patient and stakeholder perspectives from the outset. In addition, she and participating stakeholders of the patient advisory councils are committed to disseminating project findings and developing recommendations to help translate research into practice from a patient perspective.

CLINICAL TRIAL REGISTRATION

The study was pre-registered in the German Clinical Trials Register (ID: DRKS00034733).

Volumetric Assessment of Resorption Patterns of Bilateral Alveolar Clefts in Cone-Beam Computed Tomography in Two- Stage Bone Graft

OBJECTIVE

Few studies have analysed the outcome of bone grafts in bilateral alveolar clefts and the bone fill with a two-step surgery method. The currently applied three-dimensional method used in this study enables a comprehensive description of the bone fill of bilateral clefts after bone grafting. The study aimed to describe alveolar cleft volume and bone fill after alveolar bone grafting of bilateral alveolar clefts treated with two-step bone grafting, with a comparison between the first and the second bone graft site. A secondary aim was to investigate whether the cleft volume on the non-surgical side changed after contralateral surgery.

MATERIALS AND METHODS

In this retrospective study, 60 CBCT scans from 20 patients were included (8 girls and 12 boys) with an age range of 6.5-11.5 years (mean age 8.7). The cleft volume was measured in pre- and post-operative CBCT scans and assessed in ITK-SNAP to calculate the bone fill of the cleft.

RESULTS

After bone grafting, 47% of the first bone-grafted cleft was filled with bone, and 33% of the second bone-grafted cleft, without significant difference between them (p = 0.03). The mean preoperative cleft volume was 0.42cm3 and the mean residual cleft volume after bone graft was 0.23cm3. There was however a significant difference when comparing the bone fill between the nasal and the dental part (p < 0.001).

CONCLUSION

Almost half of the cleft volume was filled with bone after bone grafting. The order of the bone graft side did not influence the bone fill of the cleft.

Best practice recommendations for physiotherapists providing telerehabilitation to First Nations people: a modified Delphi study

OBJECTIVES

This study aimed to develop best practice recommendations for physiotherapists providing telerehabilitation to First Nations people.

DESIGN

Modified Delphi study.

PARTICIPANTS

Eighteen experts from four groups were selected: (a) physiotherapists who provide telerehabilitation to First Nations people, (b) Carrier Sekani Family Services leaders (CSFS, First Nations-led health organization/research partners), (c) telehealth experts from British Columbia (BC), Canada, and (d) First Nations individuals (end users) with experience in telerehabilitation.

METHODS

Panelists rated recommendations on telehealth best practices in two rounds using an online questionnaire. Recommendations were synthesized from a scoping review and two qualitative studies. Each statement was rated on a four-point Likert scale indicating whether it was essential, useful, not useful, or unnecessary for inclusion in the best practices. Statements endorsed by ≥80% of panel members were considered for inclusion in the final document.

RESULTS

Following the Delphi process, 77 recommendations covering foundational components, information technology utilization, professional expertise, therapeutic relationships, cultural safety, and the telehealth visit were validated for inclusion in the policy document. Participants also validated the methodology.

CONCLUSION

The recommendations offer a valuable resource for continuing education and professional development, empowering physiotherapists to enhance their skills and competencies in delivering culturally competent telerehabilitation to the First Nations population. The adoption of these best practices ensures that First Nations people are getting the best standard of care, potentially enhancing uptake and experiences with telehealth. It also enables healthcare organizations and policymakers to monitor adherence to established standards and identify areas for improvement. CONTRIBUTION OF THE PAPER.

Automatic gesture recognition and evaluation in peg transfer tasks of laparoscopic surgery training

BACKGROUND

Laparoscopic surgery training is gaining increasing importance. To release doctors from the burden of manually annotating videos, we proposed an automatic surgical gesture recognition model based on the Fundamentals of Laparoscopic Surgery (FLS) and the Chinese Laparoscopic Skills Testing and Assessment (CLSTA) tools. Furthermore, statistical analysis was conducted based on a gesture vocabulary that had been designed to examine differences between groups at different levels.

METHODS

Based on the CLSTA, the training process of peg transfer can be represented by a standard sequence of seven surgical gestures defined in our gesture vocabulary. The dataset used for model training and testing included eighty videos recorded at 30 fps. All videos were rated by senior medical professionals from our medical training center. The dataset was processed using cross-validation to ensure robust model performance. The model applied is 3D ResNet-18, a convolutional neural network (CNN). An LSTM neural network was utilized to refine the output sequence.

RESULTS

The overall accuracy for the recognition model was 83.8% and the F1 score was 84%. The LSTM network improved model performance to 85.84% accuracy and an 85% F1 score. Every operative process starts with Gesture 1 (G1) and ends with G5, with wrong placement is labeled as G6. The average training time is 92 s (SD = 36). Variance was observed between groups for G1, G3, and G6, indicating that trainees may benefit from focusing their efforts on these relevant operations, while assisting doctors also in more effectively analyzing the training outcome.

CONCLUSION

An automatic surgical gesture recognition model was developed for the peg transfer task. We also defined a gesture vocabulary along with the artificial intelligence model to sequentially describe the training operation. This provides an opportunity for artificial intelligence-enabled objective and automatic evaluation based on CLSTA in the clinic implementation.

Use of the Delphi method as an instrument of community participation in health needs assessment

We conducted a comprehensive analysis of the usefulness of the Delphi technique for facilitating community participation in local health needs assessments within the Andalusian Local Health Action Network, Spain. We developed an ad hoc online questionnaire based on the Social Determinants of Health model and applied it to a panel of experts in two municipalities in the province of Seville (Andalusia, Spain) between May and June 2021. Our results reflected good panelist participation. The questionnaire successfully enabled the prioritization of both new and original items, some of which were incorporated into local health policies. We concluded that the Delphi method was effective for facilitating participation in local health needs assessments offering a replicable, cost-effective approach that accelerated local policy development and supported the implementation of Health in All Policies within local government.

Neurological Deficits Following Regional Anesthesia and Pain Interventions: Reviewing Current Standards of Care

Regional anesthesia (RA) has become an integral part of modern anesthesia practice and acute pain management strategies. It provides effective pain relief, reduces opioid consumption, and facilitates enhanced recovery after surgery. However, like any medical intervention, RA is not without risks. RA is associated with potential complications, including neurological deficits which can range from mild and transient to severe and permanent. These neurological deficits may result from non-adherence to established standards of care and deviations from the clinical practice guidelines. An online database search was conducted across multiple websites to identify the relevant articles. The inclusion criteria were articles in English, published between January 2010 and July 2024. The search included various study types, such as case series, observational studies, cross-sectional analyses, cohort studies, longitudinal studies, systematic reviews, and practice guidelines. A total of 38 articles met the inclusion criteria and were included in this comprehensive review which examines the neurological complications associated with regional anesthesia and pain interventions, with a particular focus on how deviations from the standards of care contribute to adverse neurological outcomes. Furthermore, it highlights preventive strategies aimed at minimizing the risks of these complications and improving patient safety.

Position statement of the Spanish Working Group on Crohn's Disease and Ulcerative Colitis on the use of Telemedicine in Inflammatory Bowel Disease

Inflammatory Bowel Disease (IBD) is a chronic digestive condition that requires continuous monitoring by healthcare professionals to determine appropriate therapy and manage short- and long-term complications. Telemedicine has become an essential approach for managing chronic conditions such as IBD, improving care accessibility and continuity, decreasing hospitalization rates, and optimizing patient follow-up. It enables rapid treatment adjustments and encourages patient self-management. Additionally, it reduces the burden on the healthcare system by decreasing unnecessary in-person visits and provides real-time support, thereby improving quality of life and clinical outcomes. The objective of this position statement by the Spanish Working Group on Crohn's Disease and Ulcerative Colitis (GETECCU) is to establish recommendations for the use of telemedicine in its different modalities (teleconsulting, telemonitoring, mobile applications and telepharmacy) for patients with IBD and address the legal, ethical, and technical aspects necessary for its proper implementation.

A machine learning-derived angiogenesis signature for clinical prognosis and immunotherapy guidance in colon adenocarcinoma

Colon adenocarcinoma (COAD) is one of the most prevalent malignancies worldwide and its prognosis is extremely poor. Angiogenesis has been linked to clinical outcomes, tumor progression, and treatment sensitivity. However, the role of angiogenesis in the COAD microenvironment and its interaction with immunotherapy remains unclear. In this study, an integrative machine learning approach, including ten algorithms, was used to construct a prognostic consensus angiogenesis-related signature (CARS) for COAD. The optimal CARS constructed using the RSF + StepCox [forward] algorithm had superior performance for clinical prognostic prediction and served as an independent risk predictor for COAD. Patients in the low-CARS group, characterized by immune activation, elevated tumor mutation/neoantigen burden, and greater responsiveness to immunotherapy, had a superior prognosis. Patients in the high-CARS group exhibited a poor prognosis with higher angiogenesis activity and immunosuppressive status, indicating lower immunotherapy benefits. However, axitinib and olaparib may be promising treatment options for such patients. Taken together, we constructed a prognostic CARS that provides prognostic stratification and elucidates the characteristics of the tumor microenvironment, which might guide the selection of personalized treatments for patients with COAD.

Kawasaki disease in the pre- and post-COVID-19 era: shifts in patterns and outcomes from a multi-center study

PURPOSE

Kawasaki disease (KD) is an acute vasculitis of childhood, with potential complications such as coronary artery aneurysms (CAAs). The COVID-19 pandemic introduced challenges in KD diagnosis and management due to its overlap with multisystem inflammatory syndrome in children (MIS-C). This study aims to compare the clinical presentation, laboratory findings, treatment approaches, and outcomes of KD before and after the COVID-19 pandemic across four centers in the United Arab Emirates (UAE).

METHODS

This retrospective study analyzed pediatric KD cases (classified per the American Heart Association "AHA" criteria) from four tertiary hospitals in the UAE. Patients were categorized into group 1 (pre-COVID-19: January 2017-January 2020) and group 2 (post-COVID-19: February 2020-January 2023). Patients not meeting the AHA criteria and those with MIS-C were excluded. Data collection included demographics, clinical and laboratory features, and echocardiograms, with coronary artery abnormalities assessed per AHA guidelines.

RESULTS

Among 138 included patients (67 in group 1, 71 in group 2), incomplete KD was significantly more common post-COVID-19 (45% vs. 25%, p = 0.020). Lower occurrence of cervical lymphadenopathy (72% vs. 50%, p = 0.009) and strawberry tongue (90% vs. 70%, p = 0.006) were noted. Compared to group 1, group 2 had higher use of steroids (40.8% vs. 12.5%, p =  < 0.001) and biologics (8% vs. 1.5%, p = 0.502). Although not statistically significant, CAAs were more frequent in group 2 (21% vs. 10%, p = 0.139), with trends toward increased giant CAAs.

CONCLUSIONS

Our study highlights shifts in the patterns of KD in the post-COVID-19 era. We observed a higher prevalence of incomplete KD cases over the 3 years following the pandemic.

WHAT IS KNOWN

• Post-COVID-19 pandemic era demonstrated the emergence of multi-system inflammatory syndrome in children (MIS-C) which overlaps with Kawasaki disease (KD). • While most studies of KD and COVID-19 compare KD with MIS-C, very few describe changes in KD well after the peak of the pandemic.

WHAT IS NEW

• This study combines data from four healthcare centers of KD patients classified per the American Heart Association (AHA) criteria with the exclusion of MIS-C patients to provide direct comparison of KD before and after COVID-19. • Compared to the pre-COVID-19 era, KD cases post-COVID-19 tend to present in an incomplete form with less occurrence of cervical lymphadenopathy and strawberry tongue.

Predictive factors for neuromodulator response in patients with nonacid gastroesophageal reflux-induced chronic cough: a retrospective data analysis

Background

Nonacid gastroesophageal reflux-induced cough (GERC) remains understudied, with limited research on effective treatment options. Recently, neuromodulators such as gabapentin and baclofen have shown promise in managing nonacid GERC.

Objectives

This study aimed to identify factors associated with response to neuromodulator therapy in nonacid GERC.

Study design

A retrospective study.

Methods

We analyzed medical records of patients diagnosed with nonacid GERC who received gabapentin or baclofen as an add-on therapy enrolled between December 2019 and January 2024. Retrospective analysis of general information, cough-related questionnaires, MII-pH parameters, and other assessments was conducted to establish a regression analysis model for identifying multiple factors associated with neuromodulator response.

Results

In this retrospective cohort study, data from 184 patients were analyzed, with 106 (57.6%) classified as responders and 78 (42.4%) as nonresponders. Clinical factors significantly associated with neuromodulator efficacy included gender (OR = 4.324, p = 0.027), age (OR = 0.803, p = 0.002), and exposure to cough-aggravating factors (OR = 6.345, p < 0.001). Furthermore, multiple regression analysis further identified specific Hull Airway Reflux Questionnaire (HARQ) items-"Cough with certain foods" (OR = 2.523, p = 0.034), "Cough with eating" (OR = 4.445, p < 0.001), and "Cough brought on by singing or speaking" (OR = 5.003, p = 0.007)-as significant predictors. Additionally, Medication Adherence Questionnaire (MAQ) items such as "Forgetfulness" (OR = 0.257, p = 0.005) and "Stopping medication when "feeling better" (OR = 0.787, p = 0.017) were also identified as significant predictors of treatment response.

Conclusion

Neuromodulators can relieve nonacid GERC in patients unresponsive to standard anti-reflux therapy. Factors such as male gender, younger age, less exposure to cough irritants, and higher HARQ and lower MAQ scores can effectively predict the efficacy of neuromodulators.

Endoscopic management of infected necrotizing pancreatitis: Advancing through standardization

Infected necrotizing pancreatitis (INP) remains a life-threatening complication of acute pancreatitis. Despite advancements such as endoscopic ultrasound (EUS)-guided drainage, lumen-apposing metal stents, and protocolized step-up strategies, the clinical practice remains heterogeneous, with variability in endoscopic strategies, procedural timing, device selection, and adjunctive techniques contributing to inconsistent outcomes. This review synthesizes current evidence to contribute to a structured framework integrating multidisciplinary team decision-making, advanced imaging (three-dimensional reconstruction, contrast-enhanced computed tomography/magnetic resonance imaging), EUS assessment, and biomarker-driven risk stratification (C-reactive protein, procalcitonin) to optimize patient selection, intervention timing, and complication management. Key standardization components include endoscopic assessment and procedural strategies, optimal timing of intervention, personalized approaches for complex pancreatic collections, and techniques to reduce the number of endoscopic debridements and mitigate complications. This work aims to enhance clinical outcomes, minimize practice heterogeneity, and establish a foundation for future research and guideline development in endoscopic management of INP.

Developing an evaluation framework for public health environmental surveillance: Protocol for an international, multidisciplinary Delphi consensus study

INTRODUCTION

Public health environmental surveillance has evolved, especially during the coronavirus pandemic, with wastewater-based surveillance being a prominent example. As surveillance methods expand, it is important to have a robust evaluation of surveillance systems. This consensus study will develop an evaluation framework for public health environmental surveillance, informed by the expanding practice of wastewater-based surveillance during the pandemic.

METHODS

The public health environmental surveillance evaluation framework will be developed in five steps. In Step 1, a multinational and multidisciplinary executive group will be formed to guide the framework development process. In Step 2, candidate items will be generated by conducting relevant scoping reviews and consultation with the study executive group. In Step 3, an international electronic Delphi will be conducted over two rounds to develop consensus on items for the framework. In Step 4, the executive group will reconvene to finalize the evaluation framework, discuss standout items, and determine the dissemination strategies. Lastly, Step 5 will focus on disseminating the evaluation framework to all parties involved with or affected by wastewater-based surveillance using traditional and public-oriented methods.

DISCUSSION

The Delphi consensus study will provide multidisciplinary and multinational consensus for the evaluation framework, by providing a set of minimum criteria required for the evaluation of public health environmental surveillance systems. The evaluation framework is intended to support the sustainability of environmental surveillance and improve its implementation, reliability, credibility, and value.

Agile Implementation of a Digital Cognitive Assessment for Dementia in Primary Care

PURPOSE

This study aimed to assess how agile implementation-driven iterative processes and tailored workflows can facilitate the implementation of a digital cognitive assessment (DCA) tool for patients aged 65 years or older into primary care practices.

METHODS

We used agile implementation principles to integrate a DCA tool into routine workflows across 7 primary care clinics. The intervention involved a structured selection process for identifying an appropriate DCA tool, stakeholder engagement through iterative sprints (structured, time-bound cycles), and development of tailored workflows to meet clinic-specific needs. A brain health navigator role was established to support patients with positive or borderline screenings, and assist primary care clinicians with follow-up assessment. We used the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to evaluate the intervention's performance over a 12-month period.

RESULTS

The intervention engaged 69 (63.8%) of 108 clinicians across the 7 clinics. DCA screening was completed in 1,808 (10.8%) of 16,708 eligible visits. We selected the Linus Health Core Cognitive Evaluation tool as our DCA tool based on stakeholder evaluations. Screening workflows were tailored to each clinic. The brain health navigator received 447 referrals for further assessment of a positive or borderline screening result. Four clinics fully adopted the intervention, achieving a DCA completion rate of at least 20%, and 5 clinics were still routinely using the DCA tool at 12 months.

CONCLUSIONS

Agile implementation effectively helped integrate the DCA tool into primary care workflows. Customized workflows, stakeholder engagement, and iterative improvements were crucial for adoption and sustainability. These insights can guide future efforts for early detection and management of cognitive impairment in primary care, ultimately improving patient outcomes and easing the burden on health care professionals.

Training and Assessing Teamwork in Interprofessional Virtual Reality-Based Simulation Using the TeamSTEPPS Framework: Protocol for Randomized Pre-Post Intervention Study

BACKGROUND

Interprofessional teamwork is essential for patient outcomes in emergency medicine; yet, effective training in this area is scarce. Virtual reality (VR) provides a promising, resource-efficient solution for simulating emergency scenarios and facilitating interprofessional collaboration. While VR-based training has shown benefits for medical skill and knowledge acquisition, assessing teamwork within such environments remains a challenge due to the lack of validated measurement tools. Existing teamwork assessment instruments, developed for physical simulations, may not fully apply to VR due to differences in communication modalities, interaction mechanics, and observer perspectives.

OBJECTIVE

This study aims to adapt and validate the TeamSTEPPS framework to assess teamwork in VR-based training. Subsequently, these adapted instruments will enable the investigation of whether interprofessional teamwork can be successfully trained in VR scenarios.

METHODS

Prior to the study, measurement instruments for subjective (Teamwork Perceptions Questionnaire) and objective teamwork quality (Team Performance Observation Tool, TPOT) will be adapted and validated for use in VR scenarios. Validation of the adapted version of the Team Performance Observation Tool includes expert consensus via a modified Delphi method as well as validity and reliability testing using recorded VR teamwork sessions. The study itself is designed as a prospective pre-post study with a planned enrollment of 65 nursing and 65 medical students working in randomly assigned interprofessional teams. On 3 timepoints (day 1, day 8, and day 15), participants engage in a VR scenario simulating 1 out of 3 different emergency medical conditions (esophageal variceal bleeding, exacerbated chronic obstructive pulmonary disease, and atrial fibrillation due to urinary tract infection). As an intervention, a structured training video on successful teamwork according to the TeamSTEPPS concept is shown on day 8 immediately before the second VR scenario. Teamwork is assessed objectively with the adapted version of the Team Performance Observation Tool and subjectively with the adapted Teamwork Perceptions Questionnaire. Medical performance will be recorded automatically by the VR software based on the medical measures conducted by the team.

RESULTS

As of May 2024, a total of 28 interprofessional teams have been enrolled. Data analysis will begin in late 2025.

CONCLUSIONS

This study addresses the challenge of adapting teamwork assessment tools to VR environments and may provide insights into the potential of VR-based training for improving interprofessional collaboration in medical education. Future research could include a control group to measure the effects of team training more rigorously or use more enhanced technologies (eg, natural language processing) to capture the full range of teamwork behavior.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/68705.

Changes in female cancer diagnostic billing rates over the COVID-19 period in the Ontario Health Insurance Plan

Background

The initial response to coronavirus disease 2019 (COVID-19) in Ontario included suspension of cancer screening programs and deferral of diagnostic procedures and many treatments. Although the short-term impact of these measures on female cancers is well documented, few studies have assessed the mid- to long-term impacts.

Objectives

To compare annual billing prevalence and incidence rates of female cancers during the COVID-19 period (2020-2022) to pre-COVID-19 levels (2015-2019).

Design

Retrospective analysis of aggregated claims data for female cancer diagnostic codes from the Ontario Health Insurance Plan (OHIP).

Methods

Linear regression analysis was used to fit pre-COVID-19 (2015-2019) data for each OHIP billing code and extrapolate counterfactual values for the years of 2020-2022. Excess billing rates were calculated as the difference between projected and actual rates for each year.

Results

In 2020, OHIP billing prevalence rates for cervical, breast, uterine, and ovarian cancers decreased relative to projected values for that year by -50.7/100k, -13.9/100k, -3.5/100k, and -3.8/100k, respectively. The reverse was observed in 2021 with rate increases of 47.8/100k, 59.1/100k, 2.5/100k, and 3.7/100k, respectively. In 2022, the excesses were further amplified, especially for cervical and breast cancers (111.2/100k and 78.67/100k, respectively). The net excess patient billing rate for 2020-2022 was largely positive for all female cancer types (108.3/100k, 123.7/100k, 5.2/100k, and 1.8/100k, respectively). Analysis of billing incidence rates showed similar trends.

Conclusion

The expected female cancer billing rate decreases in 2020 were followed by large increases in 2021 and 2022, resulting in a cumulative excess during the COVID-19 period. Further research is required to assess the nature of these changes.

A Delphi study to identify and prioritize research areas in sickle cell disease in India

Sickle Cell Disease (SCD) poses a significant health burden in India, necessitating comprehensive research to address its complex challenges. This Delphi study engaged a diverse panel of experts and stakeholders to identify and prioritize critical research questions on SCD in India. A total of 74 experts participated in the process of prioritizing research questions in SCD. In the first Delphi round, 52 participants, including scientists, clinicians, policymakers, and representatives from governmental and non-governmental organizations, attended this meeting, where 163 SCD research areas were generated. These areas were refined by the Delphi team in consultation with the core working group, and 16 priority questions were circulated to 81 experts (of which 65 responded) for rating 3 top priority questions. The study revealed three key research priorities: implementation research considering community perceptions addressing stigma, improving diagnostic methods, and developing affordable treatment options. Experts also emphasized the need for patient-centered research, addressing psychosocial challenges, and incorporating innovative treatments and diagnostic tools. The findings provide important insights for advancing SCD research and inform the direction of future SCD research in India, focusing on early detection, innovative treatments, and patient-centered care.

KNN algorithm for accurate identification of IFP lesions in the knee joint: a multimodal MRI study

Knee-related disorders represent a major global health concern and are a leading cause of pain and mobility impairment, particularly in older adults. In clinical medicine, the precise identification and classification of knee joint diseases are essential for early diagnosis and effective treatment. This study presents a novel approach for identifying infrapatellar fat pad (IFP) lesions using the K-Nearest Neighbor (KNN) algorithm in combination with multimodal Magnetic Resonance Imaging (MRI) techniques, specifically mDxion-Quant (mDQ) and T2 mapping (T2m). These imaging methods provide quantitative parameters such as fat fraction (FF), T2*, and T2 values. A set of derived features was constructed through feature engineering to better capture variations within the IFP. These features were used to train the KNN model for classifying knee joint conditions. The proposed method achieved classification accuracies of 94.736% and 92.857% on the training and testing datasets, respectively, outperforming the CNN-Class8 benchmark. This technique holds substantial clinical potential for the early detection of knee joint pathologies, monitoring disease progression, and evaluating post-surgical outcomes.

Control of alveolar bone development, homeostasis, and socket healing by salt-inducible kinases

Alveolar bone supports and anchors teeth. The parathyroid hormone-related protein (PTHrP) pathway plays a key role in alveolar bone biology. Salt-inducible kinases (SIKs) are important downstream regulators of PTH/PTHrP signaling in the appendicular skeleton, where SIK inhibition increases bone formation and trabecular bone mass. However, the function of these kinases in alveolar bone remains unknown. Here, we report a critical role for SIK2/SIK3 in alveolar bone development, homeostasis, and socket healing after tooth extraction. Inducible SIK2/SIK3 (Ubq-creERt;Sik2f/f;Sik3f/f) deletion led to dramatic alveolar bone defects without changes in tooth eruption. Ablating these kinases impairs alveolar bone formation due to disrupted osteoblast maturation, a finding associated with ectopic periostin expression by fibrous cells in regions of absent alveolar bone at steady state and following molar extraction. Notably, this phenotype is the opposite of the increased trabecular bone mass observed in long bones following SIK2/SIK3 deletion. Distinct phenotypic consequences of SIK2/SIK3 deletion in appendicular versus craniofacial bones prompted us to identify a specific transcriptomic signature in alveolar versus long bone osteoblasts. Thus, SIK2/SIK3 deletion illuminates a key role for these kinases in alveolar bone biology and highlights the emerging concept that different osteoblast subsets utilize unique genetic programs.

Multi-compartment metabolic assessment of the kidneys by co-hyperpolarized 13C MRI

PURPOSE

The purpose of this study was to show that hyperpolarized (HP) carbon-13 (13C) MRI with multiple co-HP substrates can probe the time course of renal metabolic changes in diabetes.

METHODS

[1-13C]pyruvate and [1,3-13C2]acetoacetate were co-HP for simultaneous metabolic assessment of cytosolic and mitochondrial compartments, respectively. A custom multi-band spectral-spatial radiofrequency pulse was designed for enhanced detection of downstream metabolites of both substrates. In vivo co-HP 13C kidney spectra were acquired serially in rats with uncontrolled insulin-deficient diabetes over a period of 8 weeks. Time courses of changes in apparent metabolic conversions of [1-13C]pyruvate and [1,3-13C2]acetoacetate were evaluated and compared with routine clinical markers of kidney disease obtained by serum and urine sampling.

RESULTS

Metabolic conversions of both co-HP substrates showed large shifts in diabetic kidney with chronic hyperglycemia. Production of both HP [1-13C]lactate and [1,3-13C2]β-hydroxybutyrate increased over time, with β-hydroxybutyrate signal significantly elevated at 4 weeks, sustained at 8 weeks. Lactate trended higher at 4 weeks, with a larger, significant increase at 8 weeks. Serum and urine markers of renal function were unaltered from baseline throughout the time course, without significant change in serum creatinine nor evidence of albuminuria.

CONCLUSION

Noninvasive 13C MRI using multiple co-HP metabolic substrates, whose activities are localized to distinct cellular compartments, could enable early detection of diabetic kidney damage.

A Comprehensive Video Dataset for Surgical Laparoscopic Action Analysis

Laparoscopic surgery has been widely used in various surgical fields due to its minimally invasive and rapid recovery benefits. However, it demands a high level of technical expertise from surgeons. While advancements in computer vision and deep learning have significantly contributed to surgical action recognition, the effectiveness of these technologies is hindered by the limitations of existing publicly available datasets, such as their small scale, high homogeneity, and inconsistent labeling quality. To address the above issues, we developed the SLAM dataset (Surgical LAparoscopic Motions), which encompasses various surgical types such as laparoscopic cholecystectomy and appendectomy. The dataset includes annotations for seven key actions: Abdominal Entry, Use Clip, Hook Cut, Suturing, Panoramic View, Local Panoramic View, and Suction. In total, it includes 4,097 video clips, each labeled with corresponding action categories. In addition, we comprehensively validated the dataset using the ViViT model, and the experimental results showed that the dataset exhibited superior training and testing capabilities in laparoscopic surgical action recognition, with the highest classification accuracy of 85.90%. As a publicly available benchmark resource, the SLAM dataset aims to promote the development of laparoscopic surgical action recognition and artificial intelligence-driven surgery, supporting intelligent surgical robots and surgical automation.

Development of quality indicators for a community pharmacy setting

OBJECTIVES

Community pharmacies in Norway offer accessible healthcare services that require monitoring. Relevant and realistic quality indicators (QIs) must be developed to establish standards. This study aimed to establish consensus on healthcare quality measures in a community pharmacy setting by implementing two distinct approaches.

METHODS

A comprehensive multi-phase research design was implemented to identify, define, and select potential QIs for community pharmacies. Potential QIs were identified and nominated from workshops, focus groups, and literature. Thirteen panellists were recruited for a modified Delphi study over two rounds. We used the RAND/UCLA Appropriateness Method (RAM) panel median ratings and disagreement index (DI) to assess appropriateness and disagreement and define consensus.

KEY FINDINGS

We identified 192 QIs from workshops, focus groups and literature searches. After duplicates were removed and QIs with similar wording were merged, 137 QIs were nominated for the first Delphi round. The panellists deemed 61 appropriate, two inappropriate and excluded six QIs in the first round. The remaining 68 QIs were assessed in Round 2, where 23 achieved consensus as appropriate without disagreement. After DI was calculated, the number of QIs categorized as appropriate without disagreement after Round 1 and 2 was 34 and 10, respectively.

CONCLUSION

This study demonstrates the use of the RAM combined with the DI to establish consensus on healthcare quality measures, i.e. QIs for community pharmacy services. Our findings indicate that the number of QIs considered acceptable is strongly impacted by the method chosen to handle disagreement in the ratings. Incorporating DI and conventional RAM disagreement calculations reduced the number of QIs deemed acceptable by half.