Defining Reablement in the Dutch Context: A Modified Delphi Study

Introduction

For the past decade, the Netherlands has been developing and implementing reablement programs to promote independence and to empower older adults' autonomy. However, a key challenge remains the lack of clarity around the definition of reablement and its relations to usual care practices. Existing international definitions lack specificity to account for contextual differences, such as variations in healthcare systems and cultural norms. An operational definition is needed that not only fits the Dutch health and social care system and incorporates context-specific elements. This study extends the original conceptual definition by integrating these elements, offering clearer, more practical guidance for real-world application.

Materials and methods

A modified Delphi study was performed to develop a definition of reablement that fits the Dutch health and social care system, extending beyond conceptual understanding. The study comprised three expert rounds and three Delphi survey rounds.

Results

A total of 139 participants from Dutch health and social care, education, research, and representatives of clients and informal caregivers, participated. They evaluated statements in four sections: the target group, aims, type of care or support, and characteristics of reablement programs. Key discussions during the expert rounds focused mainly on 1) the target group, emphasizing the importance of involving individuals and their families, and 2) the characteristics of reablement, such as coordinating roles, team composition, and size. Input from the Delphi surveys and expert rounds led to the development of an operational definition for the Dutch context, agreed upon by 81% of stakeholders.

Conclusion

The Delphi methodology proved valuable in identifying context-specific elements and incorporating expert perspectives, creating a culturally and contextually sensitive definition. This definition distinguishes itself from the international version by offering practical guidance on areas of application and interventions, with a focus on promoting social participation, well-being, and the involvement of the individual's social network.

Using a modified Delphi approach to develop and validate a digital self-management support checklist in bariatric surgery aftercare

INTRODUCTION

Current clinical practice in bariatric surgery follow-up care is highly heterogeneous, and patients have reported needing more and extended personalised support. Especially, they want more support on how to self-manage and cope with the changes and challenges of living with the chronic aspects of obesity and a changing body following surgery. The overall aim of this study protocol is to develop and validate a digital self-management support checklist in bariatric surgery aftercare.

METHODS

We propose a protocol for a modified, electronic Delphi study design using qualitative and quantitative methods to develop and validate the content of the checklist. The study is divided into two phases: (1) generation of candidate checklist attributes and (2) validation of candidate checklist attributes. In Phase 1, two qualitative studies involving individual interviews with patients and focus groups with healthcare professionals will be conducted to derive context-specific knowledge. This knowledge will be combined with best-practice evidence and stakeholder input to generate candidate checklist attributes, that is, principles, items and features. In Phase 2, a two-round electronic Delphi survey with an expert panel will be conducted to assess the relevance, comprehensibility and comprehensiveness of candidate checklist attributes and to determine the final checklist attributes based on content validity results from the Delphi process. Reflexive thematic analysis will be used on qualitative data and descriptive statistics on quantitative data.

ETHICS AND DISSEMINATION

The study has been approved by the Regional Committee for Medical and Health Research Ethics, Region West (2023/676367). The Data Protection Officer at Førde Hospital Trust and collaborating hospital trusts have approved the project (4386-4386). The results will be presented at scientific conferences, published and open-accessed in international peer-reviewed journals.

Indications and outcomes of revision total ankle arthroplasty

INTRODUCTION

Total ankle arthroplasty (TAA) has emerged as an alternative to ankle arthrodesis for managing end-stage ankle arthritis. However, the long-term survival of TAA remains inferior to that of hip and knee replacements, leading to a higher rate of revision TAA. Understanding the indications and outcomes of revision procedures is critical for orthopedic surgeons managing complex ankle pathology.

AREAS COVERED

This review explores the indications, surgical considerations, and outcomes associated with revision TAA. A structured literature search was conducted using PubMed and Scopus (January 2000-March 2024) with keywords including 'revision total ankle arthroplasty,' 'implant failure,' 'complications,' and 'biologic augmentation.'

EXPERT OPINION

Revision TAA presents unique surgical and biomechanical challenges that require individualized treatment approaches. While it offers pain relief and functional restoration for select patients, outcomes remain less favorable compared to primary TAA. Future advancements in implant technology may improve long-term success rates. Additionally, optimizing patient selection criteria and perioperative protocols will be essential to reducing complications and enhancing outcomes. Further research is needed to refine revision techniques and establish guidelines for managing failed TAA effectively.

Validation of safety for self-retracting intraperitoneal device for small bowel in minimally invasive surgery

BACKGROUND

Modernly, abdominal surgery has shifted to minimally invasive techniques with an inclination towards fewer incisions. This has made intra-abdominal retraction more challenging. Despite development in retracting instrumentation for solid organs, the mobilization of the bowel remains challenging due to its friable nature. Therefore, there is a need to investigate the safety profile of internal retractors such as the EndoGrab for small-bowel retraction.

METHODS

Twenty locations of small bowel were selected for EndoGrab retraction in two pigs. The locations were studied for iatrogenic injury at acute and delayed stages. Evaluation of injury was assessed clinically and histologically.

RESULTS

After the EndoGrab application, no immediate signs of perforation or ischemia were observed. The clinical post-operative course was uncomplicated. Histopathology findings included serosal compression and minimal mucosal ulceration. Long-term changes showed mild changes of focal edema and fibrosis, with inter-individual variability in severity.

CONCLUSION

While there were no signs of overt macroscopic acute injury, minimal microscopic changes were evident. According to this small-scale study, the EndoGrab can provide an effective and safe solution for small-bowel self-retractors. More research is needed to acquire a higher level of evidence for safety. Such a solution could eliminate ports or assistants previously designed for retraction only.

Antibiotic-induced Bartter-like syndrome: a systematic review

BACKGROUND

Bartter syndrome encompasses salt-losing tubulopathies characterized by hypokalaemia, hypochloremic metabolic alkalosis and hyperreninemic hyperaldosteronism with normal blood pressure and renal function. Acquired Bartter-like syndrome (ABLS) is commonly associated with diuretics and antibiotics such as aminoglycosides, colistin and amphotericin B. This review aims to understand the timing of Bartter syndrome onset after exposure to inciting drugs and explore its progression and management.

METHODS

A systematic review was conducted following PRISMA guidelines. Databases searched include PubMed, Embase, medRxiv and bioRxiv. Case reports, case series and review articles from 1986 to March 2022 were screened. Forty-three cases were included, consisting of five case series and the rest as case reports.

RESULTS

The most common antimicrobial associated with ABLS was gentamicin (41.8%), followed by colistin (32.5%). The most frequent symptoms were paraesthesias (27.9%) and carpopedal spasms (27.9%), while 32.5% of patients were asymptomatic. Laboratory findings showed hypokalaemia (100%), metabolic alkalosis (97.2%), hypocalcaemia (92.5%) and hypomagnesaemia (100%), with renal wasting of these electrolytes but normal serum creatinine. The median time for Bartter-like syndrome to appear post-drug exposure was 10 days (IQR 7-18 days), with resolution occurring within 14 days (IQR 7-31 days) after drug discontinuation. Symptoms resolved completely upon cessation of the offending agent.

CONCLUSIONS

ABLS, though rare, should be suspected in patients on antimicrobials presenting with salt-losing tubulopathy. Aminoglycosides are the most frequently implicated drugs. Discontinuation of the offending drug, along with fluid and electrolyte management, leads to complete recovery.

Açaí seed extract mitigates intestinal and hypothalamic alterations in obese mice

Obesity is a significant health concern, significantly contributing to increased morbidity and mortality by disrupting multiple physiological systems. It is strongly associated with metabolic dysfunctions, including impaired glycemic homeostasis, compromised intestinal barrier integrity, and gut microbiota imbalances, all exacerbating the risk of chronic diseases. The hydroalcoholic extract of açaí seeds (ASE), rich in phenolic compounds, has demonstrated beneficial effects on obesity and hyperglycemia; however, its impacts on gut health and gut-hypothalamus communication remain unclear. This study aimed to investigate the therapeutic effect of ASE in intestinal and hypothalamic alterations associated with obesity and compare it with Metformin. Male C57BL/6 mice were fed a high-fat or standard diet for 14 weeks. The ASE (300 mg/kg/day) and Metformin (300 mg/kg/day) treatments started in the tenth week until the fourteenth week, totaling four weeks of treatment. Our data show that the treatment with ASE and Metformin reduced body weight, ameliorated lipid profile, hyperglycemia, and plasma hyperleptinemia, and decreased the oxidative damage in the gut by reducing immunostaining of 8-isoprostane and NOX-4 expression, and improved the intestinal parameters and hypothalamic gene expression. Obesity-induced dysbiosis in the HF group was marked by reduced Proteobacteria and elevated LPS plasma levels, which were improved by treatments with ASE and Metformin. These findings suggest that ASE and Metformin are promising strategies to counteract the adverse effects of obesity on intestinal health and gut-hypothalamus communication, though they act through distinct mechanisms. Therefore, we can suggest that ASE is a promising natural product for treating the intestinal alterations associated with obesity.

Literature reviews: typology and forensic applications

Secondary research models, such as literature reviews, are designed to summarize existing primary data. Literature reviews serve distinct purposes depending on their methodology and scope. In forensic science, they have been widely used to recover historical information, facilitate bibliometric investigations, compile and compare analytical techniques, promote best practices, and support decision-making. This study presented a comprehensive description of common literature review types, namely (1) narrative, (2) integrative, (3) scoping, (4) systematic (with or without meta-analysis), (5) bibliometric, and (6) umbrella reviews, highlighting their specific characteristics and applications in forensic science. Forensic experts, students, instructors, and research authors and readers must be familiar with the typology and appropriate use of literature reviews to effectively select the most suitable approach for their studies and professional practice. In this context, the goal of academic research, as pursued in the present work, is to strengthen forensic knowledge, enhance theoretical rigor, and ultimately improve practices in the field through education in scientific research methodology.

Improving olfactory function and sinonasal manifestations in patients with granulomatosis with polyangiitis (GPA) - a prospective intervention study

BACKGROUND

No guidelines exist and very few papers are written suggesting how to treat chronic rhinosinusitis (CRS) in granulomatosis with polyangiitis (GPA) patients.

AIMS AND OBJECTIVES

We conducted this prospective non-randomized intervention study to define the disease burden in GPA and to optimize the CRS treatment attempting to alleviate the symptoms with a special focus on whether the olfactory function could be improved.

MATERIALS AND METHODS

We included 30 participants with GPA, who underwent olfactory training therapy combined with nasal corticosteroids twice a day for six months. At the first and second out-patient visits, the following data were collected: patients' CRS symptom were scored using a Visual Analog Scale (VAS), Sinonasal Outcome Test 22 (SNOT-22), Kennedy-Lund endoscopic score, and an olfactory threshold, discrimination, and identification (TDI) test.

RESULTS

The patients with few crusts and high compliance improved their olfactory function significantly. The total cohort improved their SNOT-22 score and the facial pain subdomain significantly. No significant improvements were made regarding the VAS score.

CONCLUSIONS AND SIGNIFICANCE

This study identified that GPA patients' CRS symptoms can be alleviated, using nasal corticosteroids and smell training therapy. Nevertheless, patients with GPA still have a high CRS-disease burden, mostly suffering from nasal crusting.

Beneficial and challenges of exosome application in ischemic heart disease

Cardiovascular diseases are the main cause of death and disability in the clinical setting. Among several pathological conditions, myocardial infarction (MI) is a common clinical finding and happens due to the reduction or complete interruption of blood support. Stem cells and progenitors are valid cell sources with significant potential to alleviate several tissue injuries. Differentiation to mature and functional cells and the release of various growth factors, and cytokines are the main reparative mechanisms by which stem cells mediate their reparative tasks. Exosomes (Exos), a subset of extracellular vesicles (EVs), exhibit great theranostic potential in biomedicine. Along with whole-cell-based therapies, the pre-clinical and clinical application of Exos has been extended in animals and humans with ischemic heart diseases (IHD). Here, in this review article, we aimed to highlight the importance of Exos in IHD and address the mechanism of action by focusing on their regenerative potential.

Developing consensus for upper limb rehabilitation, physical preparation and return to climbing in adults: protocol for an international e-Delphi study

Climbing has grown into a grassroots participation sport and Olympic discipline. The high loads expressed through the upper limb may increase the risk of injury in this population. This may also affect rehabilitation and return to sport (RTS) considerations after injury. Treatment, management, rehabilitation and RTS parameters after injury are poorly documented. The aim of this study is to reach international expert consensus on the postinjury and surgical rehabilitation, physical preparation and RTS strategies in a range of climbers. This will provide a framework for the safe RTS of climbers. The study will be reported in accordance with guidance on conducting and reporting Delphi Studies guidelines. Panel members will be recruited with expertise in either the delivery of healthcare and/or physical preparation of climbers. The electronic Delphi is anticipated to consist of three irritative rounds. Round 1 will consist of open and closed questions to generate a broad range of statements on the rehabilitation, RTS and outcome measures used after climbing injury. In round 2, all participants will be provided with a summary of the current literature of the rehabilitation and RTS strategies for upper limb sports injuries. Rounds 2 and 3 will consist of a summary of the results from the previous round including any dissonance. Participants will be asked to anonymously rate responses on a 5-point Likert scale. The study steering group and patient public involvement representatives will be involved from conceptualisation until final dissemination.

Translational approach for dementia subtype classification using convolutional neural network based on EEG connectome dynamics

Dementia spectrum disorders, characterized by progressive cognitive decline, pose a significant global health burden. Early screening and diagnosis are essential for timely and accurate treatment, improving patient outcomes and quality of life. This study investigated dynamic features of resting-state electroencephalography (EEG) functional connectivity to identify characteristic patterns of dementia subtypes, such as Alzheimer's disease (AD) and frontotemporal dementia (FD), and to evaluate their potential as biomarkers. We extracted distinctive statistical features, including mean, variance, skewness, and Shannon entropy, from brain connectivity measures, revealing common alterations in dementia, specifically a generalized disruption of Alpha-band connectivity. Distinctive characteristics were found, including generalized Delta-band hyperconnectivity with increased complexity in AD and disrupted phase-based connectivity in Theta, Beta, and Gamma bands for FD. We also employed a convolutional neural network model, enhanced with these dynamic features, to differentiate between dementia subtypes. Our classification models achieved a multiclass classification accuracy of 93.6% across AD, FD, and healthy control groups. Furthermore, the model demonstrated 97.8% and 96.7% accuracy in differentiating AD and FD from healthy controls, respectively, and 97.4% accuracy in classifying AD and FD in pairwise classification. These establish a high-performance deep learning framework utilizing dynamic EEG connectivity patterns as potential biomarkers, offering a promising approach for early screening and diagnosis of dementia spectrum disorders using EEG. Our findings suggest that analyzing brain connectivity dynamics as a network and during cognitive tasks could offer more valuable information for diagnosis, assessing disease severity, and potentially identifying personalized neurological deficits.

A decision-making model for public health authorities in circumstances of potentially high public risk

BACKGROUND

An expert multidisciplinary panel was commissioned by a UK Health Security Agency led incident management team (IMT) to support decision making in the case of an individual with extensively drug-resistant tuberculosis. The behaviour and stated intentions of the individual were potentially a significant risk to public health, and the regional IMT felt unable to adequately balance the rights of the individual, versus the public health risk, within current processes and legal powers.

METHOD

We describe the composition, organization, implementation, and conclusions of a national, expert, multidisciplinary panel.

RESULTS

The national panel convened over three structured virtual meetings to consider the balance between the rights of the individual to an unrestricted life, and the duty to protect the public's health. Evidence included briefs from the regional IMT and input from a public consultation group. Following the first two meetings the need for a literature review examining the success of surgical interventions was identified and conducted.

CONCLUSIONS

Evidence and conclusions were mapped onto a custom-designed risk assessment template. The panel provided authoritative advice regarding the case, and developed a review methodology that is transferable to similar complex public health scenarios both in the UK and internationally.

Endoscopic Management of Ampullary Adenomas: A Comprehensive Review

Ampullary adenomas are rare outgrowths at the ampulla of Vater that may progress into cancer via the adenoma-to-carcinoma sequence, particularly in individuals with hereditary polyposis syndrome. Many are diagnosed incidentally or once the lesion becomes large enough to cause obstruction. Traditionally managed surgically with high morbidity and mortality, advances in imaging and therapy have made endoscopic ampullectomy the first-line treatment for noninvasive lesions. Despite its high success rate and favorable safety profile, complications such as pancreatitis, ductal stenosis, bleeding, recurrence, and perforation can occur. Recommendations for optimal endoscopic techniques and surveillance intervals are largely based on expert opinion in interventional endoscopy and findings from small-scale studies. This review provides an updated framework for the diagnosis and management of ampullary adenomas.

A simplified stent-bridging pancreaticogastrostomy during pancreaticoduodenectomy: How I do it

BACKGROUND

Pancreaticoduodenectomy (PD) remains the standard approach for benign or malignant disease in the pancreatic head and periampullary regions. Despite attempts of diverse pancreatic anastomosis, no reliable pancreatic anastomosis has been recommended.

METHODS

Between July 2023 to December 2023, a novel method of pancreaticogastrostomy (PG) using a stent bridging the remnant pancreas and the stomach were applied to drain the pancreatic juice into the gastric cavity in 12 consecutive open and laparoscopic cases. The surgical details and postoperative outcomes were analyzed to evaluate this method.

RESULTS

The mean operation time was 318 ± 51.60 min. The mean time for the stent-bridging PG was 25.90 ± 4.86 min. No incidence of grades B or C postoperative pancreatic fistula (POPF) or anastomotic failure was occurred during the median follow-up period of 10.20 ± 1.55 months.

CONCLUSION

The stent-bridging PG had the advantages of safety, simplicity and promising efficacy by complete diversion of pancreatic juice and minimal manipulation of the pancreatic remnant under open or laparoscopic PD, proving its value as an alternative technique for mitigating the risk of POPF. By understanding the standardized procedures, surgeons can achieve consistent and reproducible results in complex pancreatic anastomosis. However, further evaluation with clinical trials is required to validate its real benefits.

Exploiting regulatory T cells (Tregs): Cutting-edge therapy for autoimmune diseases

Regulatory T cells (Tregs) are a specialized subset of suppressive T cells that are essential for maintaining self-tolerance, regulating effector T cells, managing microbial infections, preventing tumors, allergies, and autoimmune disorders, and facilitating allograft transplantation. Disruptions in Treg function or abundance contribute to an imbalance between pathogenic and protective immune cells in autoimmune diseases. Recently, one promising treatment strategy to restore immune balance involves the selective expansion or manipulation of Tregs using low-dose IL-2 therapy, adoptive Treg cell transfer, and chimeric antigen receptor (CAR)-Treg approaches. Tregs have been shown in an increasing number of research studies to prevent or even treat a variety of disorders, such as tumors, autoimmune and allergic diseases, transplant rejection, and graft-versus-host disease. A thorough comprehension of Treg function is anticipated to provide clear prospects for effective Treg immunotherapy in the treatment of a wide range of diseases. This review provides an overview of Tregs biology, including their functions, suppressive mechanisms, phenotypic markers, as well as their involvement in disease settings. Furthermore, we discuss the therapeutic potential of different Treg subpopulations and their translational applications in the treatment of autoimmune diseases.

A systematic review on leptin's role in defining cancer: special emphasis on immunomodulation, inflammation, and therapeutic interventions

Leptin, an adipokine related to obesity, is mainly known for its role in regulating energy homeostasis and appetite by working via the leptin receptor. Recently, different groups have demonstrated that apart from adipocytes, specific cell types associated with cancer and tumor microenvironments express leptin and leptin receptors. This tumor microenvironment-associated leptin-leptin receptor signaling contributes to the different hallmarks of cancer, ranging from inflammatory changes to metastasis. Eventually, it has also been reported that high serum level of leptin, a characteristic of obese people, is linked to enhanced tumor growth. On the other hand, leptin can influence both innate as well as adaptive immunity related to cancer. Overall, leptin's role in modulating cancer is controversial. So, in this review, we summarized the role of leptin in shaping different forms of cancer that are influenced by leptin-leptin receptor signaling with special emphasis on immunomodulation and inflammatory events and also discussed the possible therapeutic interventions to date. As this review work, with the collection of different updated knowledge, has summarized the role of leptin on cancer, it would be useful material to have on hand for both beginners as well as pioneers of these and related fields.

Predicting sepsis treatment decisions in the paediatric emergency department using machine learning: the AiSEPTRON study

BACKGROUND

Early identification of children at risk of sepsis in emergency departments (EDs) is crucial for timely treatment and improved outcomes. Existing risk scores and criteria for paediatric sepsis are not well-suited for early diagnosis in ED.

OBJECTIVE

To develop and evaluate machine learning models to predict clinical interventions and patient outcomes in children with suspected sepsis.

DESIGN

Retrospective observational study.

SETTING

ED of a tertiary care hospital, UK.

PATIENTS

Electronic health records of children <16 years of age attending between 1 January 2018 and 31 December 2019. Patients presenting with minor injuries were excluded.

METHODS

Prediction models were developed and validated, using 15 key predictors from triage and post-blood test data. XGBoost, the best-performing machine learning model, integrated these predictors with triage note information extracted via Natural Language Processing.

MAIN OUTCOMES

(1) Administration of antibiotics; (2) critical care: antibiotics with fluid resuscitation above 20 mL/kg or non-elective mechanical ventilation; (3) serious infection: hospital admission for antibiotics >48 hours.Model performance was evaluated using area under the receiver operating characteristic curve (AUC), likelihood ratios and positive and negative predictive values.

RESULTS

Triage model: predicted antibiotics at triage (n=35 795; 3.2% with outcome) with an AUC of 0.80 (95% CI 0.76 to 0.84).Antibiotic model: predicted antibiotics post-blood tests (n=4700; 24.2%) with an AUC of 0.78 (95% CI 0.73 to 0.81).Critical care model: predicted critical care (n=4700; 3.3%) with an AUC of 0.78 (95% CI 0.72 to 084).Serious infection model: predicted serious infection (n=4700; 9.4%) with an AUC of 0.76 (95% CI 0.71 to 0.81).Key predictors included triage category, temperature, capillary refill time and C reactive protein.

CONCLUSION

Machine learning models demonstrated good accuracy in predicting antibiotic use following triage and moderate accuracy for critical care and serious infection. Further development and external validation are ongoing.

Nucleic acid vaccines: innovations, efficacy, and applications in at-risk populations

For more than two centuries, the field of vaccine development has progressed through the adaptation of novel platforms in parallel with technological developments. Building off the advantages and shortcomings of first and second-generation vaccine platforms, the advent of third-generation nucleic acid vaccines has enabled new approaches to tackle emerging infectious diseases, cancers, and pathogens where vaccines remain unavailable. Unlike traditional vaccine platforms, nucleic acid vaccines offer several new advantages, including their lower cost and rapid production, which was widely demonstrated during the COVID-19 pandemic. Beyond production, DNA and mRNA vaccines can elicit unique and targeted responses through specialized design and delivery approaches. Considering the growth of nucleic acid vaccine research over the past two decades, the evaluation of their efficacy in at-risk populations is paramount for refining and improving vaccine design. Importantly, the aging population represents a significant portion of individuals highly susceptible to infection and disease. This review seeks to outline the major impairments in vaccine-induced responses due to aging that may be targeted for improvement with design and delivery components encompassing mRNA and DNA vaccine formulations. Results of pre-clinical and clinical applications of these vaccines in aged animal models and humans will also be evaluated to outline current successes and limitations observed in these platforms.

Classification of trauma-related preventable death; a Delphi procedure in The Netherlands

INTRODUCTION

Trauma-related preventable death is considered death as a consequence of moderate to severe injury under (sub)optimal trauma care conditions and is used as a criterion to evaluate the management and quality of trauma care worldwide. A validated definition of trauma-related preventable death is still lacking due to differences in classification. To reach consensus on a definition and assess the necessity of an additional trauma prediction algorithm, a Delphi procedure was performed.

METHODS

A digital three-round Delphi procedure was performed. Trauma surgeons, neurosurgeons, forensic medicine physicians, anesthesiologists, and emergency care physicians working at a Level 1 or affiliated trauma center in the Netherlands were invited to participate. An electronic questionnaire was administered to assess the most suitable category of trauma-related preventable death (clinical definition, trauma prediction algorithm, clinical definition and trauma prediction algorithm or other) and the additional benefit of a trauma prediction algorithm.

RESULTS

Fifty-four panelists completed the study: 23 trauma surgeons, 13 emergency care physicians, 10 anesthesiologists, 4 neurosurgeons and 4 forensic medicine physicians. In the first round, a clinical definition and a clinical definition and trauma prediction algorithm (Trauma Score and Injury Severity Score and a combination of algorithms) were favored. The results were fed back to the panelists. In the final round, there was a tendency towards group consensus in favor of a clinical definition and trauma prediction algorithm (63 %). Consensus was reached on the most suitable algorithm: the Trauma Score and Injury Severity Score combined with the Probability of survival.

CONCLUSION

The identification of trauma-related preventable death is essential in the evaluation of trauma care. This study elucidates the difficulty of multidisciplinary consensus. However, a propensity towards consensus on a clinical definition, and consensus on the additional benefit of the PS, based on the TRISS, seems to be present.

Audiovestibular Dysfunction in Patients with Hashimoto's Disease: A Systematic Review

Although the inner ear is considered an immune-privileged organ because of the blood-labyrinth barrier, accumulating evidence has revealed an unexpected relation between Hashimoto's disease and inner ear damage manifesting as audiovestibular dysfunction. Hashimoto's disease can simultaneously affect both the auditory and vestibular systems, either through direct autoantibody attacks or through metabolic dysfunction associated with hypothyroidism. Currently, there is no consensus regarding tests or treatments for audiovestibular dysfunction related to Hashimoto's disease. In this review, we summarize the currently available evidence regarding the characteristics, pathophysiology, diagnostic approaches, and treatment of audiovestibular dysfunction in patients with Hashimoto's disease. Furthermore, we propose a specific steroid-plus-thyroxine treatment protocol to manage audiovestibular dysfunction associated with Hashimoto's disease. This condition may respond to adequate treatment, potentially allowing reversibility if it is recognized and managed in a timely manner. Conversely, delayed diagnosis or failure to recognize the subtle presentation of audiovestibular dysfunction in patients with Hashimoto's disease may lead to progressive hearing loss, immobility, and reduced quality of life. Based on the updated evidence in our review and our modified treatment protocol, we aim to provide new insights and therapeutic directions for clinicians managing audiovestibular dysfunction in patients with Hashimoto's disease. Trial registration: PROSPERO CRD420250652982.

Latin American Consensus on Ocular Lubricants and Dry Eye Disease (LUBOS): A Report on Severity Classification, Diagnosis, and Therapy

PURPOSE

This consensus aims to establish a practical severity classification for applying a tailored stepladder treatment algorithm helpful to any clinician.

METHODS

A modified Delphi methodology was used to establish a consensus on the definition, diagnosis, severity classification, and treatment algorithms for dry eye disease (DED) adapted to the needs of Latin America. The consensus focused on promoting the effective use of lubricants and providing straightforward, practical guidance for ophthalmologists treating dry eyes. Twenty-eight corneal specialists from representative Latin American countries reviewed the scientific evidence and drew on their expertise to answer specifically designed open-ended questions.

RESULTS

A simple diagnostic algorithm (clinical history, DED questionnaire, and dry eye clinical tests) identified patients with the disease. A practical severity classification system of four grades: mild, moderate, severe, and LUBOS plus DED was based on four criteria: OSDI, film break-up time, Sjögren International Collaborative Clinical Alliance ocular surface staining score, and international workshop on meibomian gland dysfunction meibomian gland functionality test. For classification, ≥2 criteria of the highest severity grade from the worse eye were considered. A stepladder therapeutic algorithm aligned with disease severity consisted of 5 steps, each with proposed and recommended treatment alternatives. Patient education, lifestyle recommendations, adverse environment avoidance, lubricants, and eyelid therapy were reinforced during the therapy period.

CONCLUSIONS

The LUBOS expert panel consensus considered the diverse geoenvironmental, socioeconomic, cultural, and ethnic factors pertinent to Latin America. This consensus offers an accessible and cost-effective tool, enabling professionals to detect, evaluate, and grade the severity of dry eye disease effectively for planning adequate therapeutic strategies that can be monitored with confidence.

Revisiting the Delphi technique - Research thinking and practice: A discussion paper

The Delphi technique is a research methodology which has traditionally been used to gain consensus among experts on complex issues characterised by uncertainty. Pioneered by the Rand Corporation in the 1950s for military applications, it has since been widely adopted across various fields, including nursing, health and social sciences and information systems on an array of multifaceted real-world issues. However, since its inception, the Delphi technique has undergone substantial methodological development and its use has now gone beyond its initial rationale. In the last two decades there has been a growing body of work illustrating an increasing methodological diversity of the method. While such diversity presents possibilities, it also challenges traditional application and methodological rigour. In an attempt to preserve the integrity of the method, generic and discipline specific guidelines have emerged providing general principles and standards. The aim of this paper is to present a much-needed critical reflection on the current application of the Delphi technique and its methodological development and to build on our paper from 2001 (Keeney et al., 2001). While the development of the Delphi method and its evolution are well recognised and reported in the literature, some controversies surrounding the approach remain and it is timely to revisit the method with a critical eye. Ultimately, the Delphi technique's flexibility is its significant strength, enabling the exploration of novel lines of inquiry, but it also presents a challenge. Striking the right balance between flexibility and rigour can lead to more meaningful insights and actionable outcomes from a Delphi study. Yet to achieve this, some level of consensus may need to be reached on the Delphi technique itself. In recognition of its 60th birthday, it is an opportune time to re-examine its key aspects and methodological advances and reflect on 'when is a Delphi not a Delphi?'

Development of a Core Outcome Set for Intervention Studies in Adults With Laryngotracheal Stenosis

OBJECTIVE

Adult acquired laryngotracheal stenosis (LTS) is a chronic condition with heterogeneous treatment options and a significant symptom burden. Synthesis of data across research studies to guide clinical decision-making is challenging due to inconsistent outcome selection and use of unvalidated measures. Our objective was to establish a core outcome set (COS) for studies of LTS interventions in adults.

METHODS

We conducted a two-round modified e-Delphi study. We reviewed published systematic reviews and qualitative studies to inform the inclusion of 42 outcomes in the first e-Delphi round, with 10 additional outcomes added by participants for the second voting round. The international expert panel included clinicians, researchers, and people living with LTS. We held two consensus meetings and a final voting round.

RESULTS

The first e-Delphi round involved 1067 participants from multiple stakeholder groups, with 575 participants voting in the second. Seventeen participants participated in the consensus meetings. The final COS included seven outcomes: (1) Level of breathlessness, (2) Ability to generate audible voice, (3) Ability to manage/clear mucus, (4) Ability to eat and drink, (5) Health-related quality of life, (6) Emotional and mental health symptoms, and (7) Frequency of treatment.

CONCLUSION

By using a rigorous Delphi process informed by multiple stakeholder groups, we gained consensus on seven core outcomes for inclusion in future research relating to LTS. Use of this COS will standardize outcomes measured in future research studies, ensuring they are comparable. Future work is required to identify the best way to measure these outcomes to fully operationalize this COS.

LEVEL OF EVIDENCE

Level V.

Combination therapies and novel delivery systems: a new frontier in overcoming TRAIL resistance in gastric cancer

Gastric cancer (GC) presents a formidable challenge in oncology, mainly due to its inherent resistance to therapies such as tumor necrosis factor-related apoptosis-inducing ligand (TRAIL). This review delineates the multifaceted mechanisms underlying TRAIL resistance in GC, encompassing the deregulation of death receptors (DRs) and decoy receptors (DcRs), aberrant signaling pathways, and the influence of the tumor microenvironment (TME). Innovative strategies such as nanoparticle-based drug delivery systems and oncolytic viral therapies are being explored to counteract these challenges. Nanoparticles enhance TRAIL delivery and efficacy by exploiting the enhanced permeability and retention (EPR) effect, while oncolytic viruses can selectively target cancer cells and stimulate immune responses. Combination therapies, integrating TRAIL with conventional chemotherapeutics like paclitaxel, cisplatin, and 5-fluorouracil, have shown promise in overcoming resistance by modulating apoptotic pathways and downregulating multidrug resistance genes. Additionally, novel agents like cyclopamine, decitabine, and genistein have emerged as effective TRAIL sensitizers by modulating apoptotic pathways and enhancing DR5 expression. Furthermore, the integration of epigenetic modifiers can restore TRAIL sensitivity by demethylating DR4 and DR5 genes. This review emphasizes the need for a comprehensive understanding of the molecular underpinnings of TRAIL resistance and the potential of combination therapies and TRAIL delivery by nanoparticles and oncolytic viruses to enhance treatment outcomes in GC. Future research should focus on elucidating predictive biomarkers and optimizing therapeutic regimens to improve the clinical efficacy of TRAIL-based strategies in GC.

Transition Care for Young Persons with Rare Bone Mineral Conditions: A Consensus Recommendation from the ECTS Rare Bone Disease Action Group

Transition care (TC) is crucial for young persons with rare bone and mineral conditions (RBMCs) as they move from pediatric to adult healthcare. Effective TC prevents care disruptions and supports medical and psychosocial needs. However, gaps in communication, a shortage of adult RBMC specialists, and challenges in navigating adult healthcare necessitate standardized care. This study aimed to develop consensus-based recommendations for TC in RBMCs, focusing on best practices for seamless transition and patient empowerment. A two-round Delphi survey (September 2023-April 2024) was conducted among European RBMC experts, including 3 pediatric and 8 adult clinicians and 3 patient representatives from the European Calcified Tissue Society (ECTS). The panel formulated and refined statements through literature review and iterative scoring. Statements reaching ≥ 70% consensus were retained. A total of 81 statements were finalized across seven domains: initiation and planning, TC requirements, patient empowerment, organization and communication, service infrastructure and funding, and clinical care. Consensus was achieved on 64 out of 81 statements, with strong agreement on general and RBMC-specific recommendations. Key priorities included structured coordination among healthcare providers and a patient-centered approach that fosters self-advocacy and self-management. This Delphi consensus provides a structured framework for TC in young persons with RBMCs, emphasizing multidisciplinary care and patient empowerment. Future studies should assess the feasibility and impact of these guidelines across diverse healthcare systems.

A scoping review of worldwide guidelines for diagnosis and treatment of Helicobacter pylori infection

BACKGROUND

This study comprehensively analyzes the diagnostic criteria, eradication indications, treatment, and other information in the latest guidelines published by various countries around the world, so that researchers can have a systematic understanding of Helicobacter pylori and further provide a basis for clinical H. pylori diagnosis and treatment.

METHODS

Nine online databases were searched to find the latest version of guidelines for H. pylori worldwide. Two researchers read the included guidelines independently and extracted the eradication indications, diagnostic criteria, and treatment in the guidelines, conducting a summary of them.

RESULTS

A total of 25 guidelines or consensus were included. Among all diagnostic methods for H. pylori infection, the urea breath test is widely recommended as the first choice. A total of 20 guidelines mentioned indications for H. pylori eradication. Among them, the indications with a higher proportion of recommendations were long-term use of non-steroidal anti-inflammatory drugs (including low-dose aspirin) in 90% of patients with peptic ulcer history or active peptic ulcer disease 80%; gastric mucosa-associated lymphoid tissue (MALT) lymphoma 75%. It is worth mentioning that 40% of the guidelines pointed out that, as long as H. pylori infection is confirmed, it should be eradicated. A total of 24 guidelines mentioned treatment for H. pylori. Among them, bismuth quadruple therapy (a combination of a bismuth, two antibiotics, and a proton pump inhibitor (PPI)) was the most recommended first-line therapy. Levofloxacin triple therapy (a combining of a bismuth, an antibiotic, and a PPI) was the most recommended second-line therapy.

CONCLUSION

Current global Helicobacter pylori management guidelines share foundational consensus, yet exhibit regional variations in diagnostic criteria, eradication indications, and therapeutic regimens due to context-specific epidemiological, socioeconomic, and antimicrobial resistance profiles. Clinical practice should prioritize regionally tailored approaches, integrating local guidelines while maintaining awareness of international recommendations to optimize decision-making. Moreover, health authorities responsible for guideline development must ensure timely updates based on dynamic surveillance of local resistance patterns and socioeconomic realities.

Changes of intestinal microbiome and its relationship with painful diabetic neuropathy in rats

OBJECTIVE

To analyze the gut bacterial microbiome in rats with painful diabetic neuropathy (PDN) compared to normal rats.

METHODS

Type 2 diabetes was induced in rats via a high-fat and high-sugar diet combined with a low dose of streptozotocin. Glucose metabolism and insulin sensitivity were evaluated using intraperitoneal glucose tolerance tests and insulin tolerance tests. The progression of peripheral neuropathy was assessed using the mechanical withdrawal threshold and thermal withdrawal latency. Histopathological analysis of rat colon tissues was performed using hematoxylin-eosin staining to observe morphological changes. The expression levels of pro-inflammatory cytokines TNF-α and IL-1β in spinal cord tissues were measured using enzyme-linked immunosorbent assay (ELISA). Fecal samples were then collected for metagenomic sequencing and analysis.

RESULT

Behavioral tests revealed reduced mechanical withdrawal threshold and thermal withdrawal latency in PDN rats. Histological analysis showed significant colonic mucosal damage and inflammatory cell infiltration, suggesting impaired intestinal barrier function. Elevated TNF-α and IL-1β levels in spinal cord tissues further highlight peripheral inflammation's role in PDN. Sequencing analysis revealed significant differences in gut microbiota composition between PDN and control rats, with altered Bacillota/Bacteroidota ratios and increased Lactobacillus abundance. Functional annotation analysis, based on the KEGG, EggNOG, and CAZy databases, indicated significant enrichment of metabolic pathways related to carbohydrate and amino acid metabolism, energy metabolism, and cell structure biogenesis in PDN rats. Cluster analysis identified higher functional clustering in Metabolism and Genetic Information Processing pathways in PDN rats.

CONCLUSION

This study demonstrates that PDN leads to altered gut microbiota composition, disrupted metabolic pathways, and increased inflammation, contributing to the pathological progression of diabetic neuropathy. This study provides new insights into the interplay between gut microbiota and diabetic neuropathy, offering potential avenues for therapeutic interventions targeting microbiome and metabolism.

Unraveling the Potential of SGK1 in Osteoporosis: From Molecular Mechanisms to Therapeutic Targets

Osteoporosis (OP) is a prevalent metabolic bone disease, with several million cases of fractures resulting from osteoporosis worldwide each year. This phenomenon contributes to a substantial increase in direct medical expenditures and poses a considerable socioeconomic burden. Despite its prevalence, our understanding of the underlying mechanisms remains limited. Recent studies have demonstrated the involvement of serum glucocorticoid-regulated protein kinase 1 (SGK1) in multiple signaling pathways that regulate bone metabolism and its significant role in the development of osteoporosis. Therefore, it is of great significance to deeply explore the mechanism of SGK1 in osteoporosis and its therapeutic potential. In this paper, we present a comprehensive review of the structure and activation mechanism of SGK1, its biological function, the role of SGK1 in different types of osteoporosis, and the inhibitors of SGK1. The aim is to comprehensively assess the latest research progress with regards to SGK1's role in osteoporosis, clarify its role in the regulation of bone metabolism and its potential as a therapeutic target, and lay the foundation for the development of novel therapeutic strategies and personalized treatment in the future. Furthermore, by thoroughly examining the interactions between SGK1 and other molecules or signaling pathways, potential biomarkers may be identified, thereby enhancing the efficacy of early screening and intervention for osteoporosis.

A sleep-based risk model for predicting dementia: Development and validation in a Korean cohort

BackgroundDementia is a major public health challenge, yet existing prediction models often overlook sleep-related symptoms, despite their known links to cognitive decline.ObjectiveTo develop and validate a four-year Dementia Risk Score (DRS) incorporating self-reported sleep-related symptoms with demographic and clinical factors to predict all-cause dementia, including Alzheimer's disease.MethodsData from 3082 Korean adults aged 60-79 years were analyzed. Predictors were selected using LASSO regression and included in a multivariate logistic regression model. A point-based scoring system, the DRS, was constructed from the model coefficients. Internal validation was conducted using bootstrapping and a separate dataset.ResultsThe DRS achieved robust predictive performance, with AUC values of 0.824 in the training set and 0.826 in the validation set. Key predictors included sleep disturbance, use of sleep medications, daytime dysfunction, leg discomfort, and urge to move legs.ConclusionsThe DRS provides a practical, scalable tool for predicting dementia risk, supporting community-based screening and early intervention. External validation is needed to confirm its broader applicability.

PANS and PANDAS - symptoms beyond OCD and tics - a systematic review

This article aims to describe the symptomatology of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), and to highlight some of their potential distinctive features, by juxtaposing available data with existing literature on pediatric obsessive - compulsive disorder (OCD). Given the scarcity of high-quality studies, we decided to review a wide range of publications on the clinical presentation of PANS and PANDAS, including case series and case reports, regardless of their methodological heterogeneity. Although PANS and PANDAS share many characteristics with non-PANS/PANDAS OCD, the acute onset of obsessive-compulsive symptoms in conjunction with concomitant features, especially separation anxiety, irritability, emotional lability, or dysgraphia should prompt consideration of a possible post-infectious etiology. Further research aimed at creating more precise diagnostic tools is needed to facilitate differential diagnosis.

The innovation of traditional handicrafts and cultural identity: A multidimensional value analysis using the DEMATEL-ISM method

This study aims to explore how cultural identity influences the protection and innovation of traditional crafts through multidimensional pathways. Using the examples of macau shipbuilding and portuguese tile painting, 14 influencing factors were extracted from three dimensions-culture and expression, aesthetics and creation, and cognition and emotion-through the Delphi method and expert feedback. The decision-making trial and evaluation laboratory (DEMATEL) method was used to analyze causal relationships, and interpretive structural modelling (ISM) was employed to construct a hierarchical model consisting of core, direct, and indirect factors. The results indicate that historical continuity, knowledge transmission, and the integration of tradition and modernity are core factors, forming the cultural foundation for traditional craft innovation. Direct factors, such as creative expression, local culture, and emotional communication, play a pivotal role in connecting the core and indirect layers, while indirect factors like visual appeal, design originality, and craft education reflect the multidimensional value of traditional crafts. The study provides a clear, hierarchical pathway that explains the systematic process from cultural identity to innovation practice, offering valuable insights for sustainable craft innovation in the context of globalization.

Red flags for remote cognitive diagnostic assessment: A Delphi expert consensus study by the Canadian Consortium on Neurodegeneration in Aging

Despite the potential benefits of remote cognitive assessment for dementia, it is not appropriate for all clinical encounters. Our aim was to develop guidance on determining a patient's suitability for comprehensive remote cognitive diagnostic assessment for dementia. A multidisciplinary expert workgroup was convened under the auspices of the Canadian Consortium on Neurodegeneration in Aging. We applied the Delphi method to determine 'red flags' for remote cognitive assessment of dementia. This resulted in 14 red flags that met the predetermined consensus criteria. We then developed a novel clinical decision-making infographic that integrated these findings to support multidisciplinary clinicians in determining a patient's readiness to undergo comprehensive remote cognitive assessment.

Comparing Artificial Intelligence-Generated and Clinician-Created Personalized Self-Management Guidance for Patients With Knee Osteoarthritis: Blinded Observational Study

BACKGROUND

Knee osteoarthritis is a prevalent, chronic musculoskeletal disorder that impairs mobility and quality of life. Personalized patient education aims to improve self-management and adherence; yet, its delivery is often limited by time constraints, clinician workload, and the heterogeneity of patient needs. Recent advances in large language models offer potential solutions. GPT-4 (OpenAI), distinguished by its long-context reasoning and adoption in clinical artificial intelligence research, emerged as a leading candidate for personalized health communication. However, its application in generating condition-specific educational guidance remains underexplored, and concerns about misinformation, personalization limits, and ethical oversight remain.

OBJECTIVE

We evaluated GPT-4's ability to generate individualized self-management guidance for patients with knee osteoarthritis in comparison with clinician-created content.

METHODS

This 2-phase, double-blind, observational study used data from 50 patients previously enrolled in a registered randomized trial. In phase 1, 2 orthopedic clinicians each generated personalized education materials for 25 patient profiles using anonymized clinical data, including history, symptoms, and lifestyle. In phase 2, the same datasets were processed by GPT-4 using standardized prompts. All content was anonymized and evaluated by 2 independent, blinded clinical experts using validated scoring systems. Evaluation criteria included efficiency, readability (Flesch-Kincaid, Gunning Fog, Coleman-Liau, and Simple Measure of Gobbledygook), accuracy, personalization, and comprehensiveness and safety. Disagreements between reviewers were resolved through consensus or third-party adjudication.

RESULTS

GPT-4 outperformed clinicians in content generation speed (530.03 vs 37.29 words per min, P<.001). Readability was better on the Flesch-Kincaid (mean 11.56, SD 1.08 vs mean 12.67 SD 0.95), Gunning Fog (mean 12.47, SD 1.36 vs mean 14.56, SD 0.93), and Simple Measure of Gobbledygook (mean 13.33, SD 1.00 vs mean 13.81 SD 0.69) indices (all P<.001), though GPT-4 scored slightly higher on the Coleman-Liau Index (mean 15.90, SD 1.03 vs mean 15.15, SD 0.91). GPT-4 also outperformed clinicians in accuracy (mean 5.31, SD 1.73 vs mean 4.76, SD 1.10; P=.05, personalization (mean 54.32, SD 6.21 vs mean 33.20, SD 5.40; P<.001), comprehensiveness (mean 51.74, SD 6.47 vs mean 35.26, SD 6.66; P<.001), and safety (median 61, IQR 58-66 vs median 50, IQR 47-55.25; P<.001).

CONCLUSIONS

GPT-4 could generate personalized self-management guidance for knee osteoarthritis with greater efficiency, accuracy, personalization, comprehensiveness, and safety than clinician-generated content, as assessed using standardized, guideline-aligned evaluation frameworks. These findings underscore the potential of large language models to support scalable, high-quality patient education in chronic disease management. The observed lexical complexity suggests the need to refine outputs for populations with limited health literacy. As an exploratory, single-center study, these results warrant confirmation in larger, multicenter cohorts with diverse demographic profiles. Future implementation should be guided by ethical and operational safeguards, including data privacy, transparency, and the delineation of clinical responsibility. Hybrid models integrating artificial intelligence-generated content with clinician oversight may offer a pragmatic path forward.

A Proposed Universal "Home Time" Quality of Life Measure for Older Adults

BACKGROUND

Researchers and insurers use "home time," or an individual's time at home compared to time in different health care settings, as a population-level quality of life (QoL) or quality of care measure. With varying definitions, it is unknown which components of a home time measure most closely reflect QoL. Our objective is to develop a person-centered universal home time measure agnostic to condition.

METHODS

We used an iterative, structured approach based on Delphi methods to obtain expert input on what a measure should include, using qualitative and quantitative evidence from prior work. A total of 28 expert panelists, including Veterans Affairs (VA) leaders, clinician researchers, and non-clinician researchers, participated. In the first round, panelists voted on components (settings, weights, timeframes) to include in a home time measure. In the second round, panelists discussed results. The third round was final voting and explanations of choices and caveats.

RESULTS

Qualitative and quantitative data suggested that emergency department, inpatient care, and post-acute care settings all affect older adults' QoL in different ways, supporting inclusion; 75% of the experts endorsed all settings, and discussion suggested that future work should limit ED days to visits resulting in an inpatient admission. Our data did not reveal a clear indication for weighting settings: 56% of the expert panel suggested continuing to explore the use of weights to arrive at values that would reflect qualitative differences in settings, and 44% did not support the use of any weights. Our 6-month models resulted in QoL outcomes for all settings, and 30% of experts endorsed a 6-month timeframe, while 65% said that timeframe would depend on the situation.

CONCLUSION

A "1.0" universal person-centered home time measure that reflects QoL should include days in the emergency department, inpatient care, and post-acute care. Expert input revealed domains of agreement and disagreement. Future validation efforts that incorporate expert input are needed to iterate and arrive at the optimal measure.

End-of-Life Care Competency in Long-term Care Facilities for Care Providers in Thailand: A Delphi Study

The global shift toward an aging population, evident in Thailand, highlights the critical need for end-of-life care (EOLC) competencies among care providers in long-term care facilities (LTCFs). As the number of older people requiring complex and compassionate care at the end of life continues to rise, the competencies required for care providers in Thai LTCFs remain underexplored. This study aimed to identify the key competencies required to deliver effective EOLC in Thai LTCFs. A Delphi method was used, engaging a panel of 12 experts, including nurses, academics, and LTCF managers. The study achieved consensus on 7 core competencies, encompassing 32 subcompetencies essential for high-quality EOLC. These competencies include knowledge of EOLC, caregiving skills, communication, leadership, innovation, ethical decision-making, and professional development. This study provides a culturally relevant framework for EOLC competencies in Thai LTCFs, emphasizing the importance of integrating technical and interpersonal skills to enhance the quality of care for older people in their final stages of life. These findings can inform educational programs and policy development, ensuring that care providers are adequately prepared to meet the complex needs of this vulnerable population.

The Many Faces of Intestinal Tumors in Adults, Including the Primary Role of CT Imaging in Emergencies and the Important Role of Cross-Sectional Imaging: A Pictorial Review

Background/Objectives: Small bowel tumors (SBTs) encompass a diverse range of tumor types, with benign tumors being the most prevalent. However, the incidence of malignant SBTs is increasing, particularly small bowel adenocarcinoma; this poses a diagnostic challenge for clinicians and radiologists due to the varied and nonspecific clinical and radiological presentations associated with SBTs. In fact, SBTs can present differently in emergencies, often mimicking inflammatory diseases or manifesting as complications such as intussusception, small bowel obstruction (SBO), intestinal ischemia, perforation, gastrointestinal bleeding, or metastatic disease. These tumors can remain asymptomatic for extended periods. Methods: We present a pictorial review on the role of imaging in evaluating SBTs, focusing on the emergency setting where diagnosis can be incidental. We also include some representative cases that may be useful for radiologists and residents in clinical practice. Results: Despite these challenges, contrast-enhanced computed tomography (CECT) is usually the best modality to use in emergencies for evaluating SBTs, and in some cases, a diagnosis can be made incidentally. However, when possible, multimodal imaging through cross-sectional imaging remains crucial for the non-invasive diagnosis of SBTs in stable patients, as endoscopic procedures may also be impractical. A complementary CT study with distension using negative oral contrast media, such as water, polyethylene glycol, or mannitol solutions, can improve the characterization of SBTs and rule out multiple SBT locations, particularly in small bowel neuroendocrine tumor (NET) and gastrointestinal tumor (GIST) localization. Positive water-soluble iodine-based oral contrast, such as Gastrografin (GGF), can be used to evaluate and monitor the intestinal lumen during the nonsurgical management of small bowel obstruction (SBO) or in suspected cases of small bowel perforations or the presence of fistulas. Magnetic resonance enterography (MRE) can aid in improving the characterization of SBTs through a multiplanar and multisequence study. Positron emission tomography combined with CT is generally an essential modality in evaluating metastatic disease and staging and assessing tumor prognosis, but it has limitations for indolent lymphoma and small NETs. Conclusions: Therefore, the integration of multiple imaging modalities can improve patient management and provide a preoperative risk assessment with prognostic and predictive indicators. In the future, radiomics could potentially serve as a "virtual biopsy" for SBTs, allowing for better diagnosis and more personalized management in precision medicine.

Applying a Modified Version of the Prediction of Alcohol Withdrawal Severity Scale in a Canadian Community Withdrawal Management Setting

INTRODUCTION

Severe alcohol withdrawal syndrome (SAWS) can lead to significant morbidity and mortality. The Prediction of Alcohol Withdrawal Severity Scale (PAWSS) has been validated in general acute care environments, but its efficacy in withdrawal management settings remains underexplored. This study aimed to assess the utility of a modified PAWSS and identify appropriate cutoff scores in a community withdrawal management setting in Vancouver, Canada.

METHODS

From October 2019 to September 2022, we reviewed charts at Vancouver Detox Centre. Modified PAWSS versions replaced question 9 on the original PAWSS with: (i) breath analysis readings; (ii) alcohol consumption in the previous 24 h; and (iii) clinical assessments. We performed receiver operating characteristic analysis and used Youden's index to determine modified PAWSS' diagnostic accuracy against SAWS presentation, defined by a score of 15 or greater on the Clinical Institute Withdrawal Assessment Alcohol, Revised, seizures or delirium tremens and/or benzodiazepine administration.

RESULTS

Among 228 individuals (165 male, 63 female), 175 (75%) met SAWS criteria during admission. For breath analysis readings, an optimal PAWSS cutoff score had 55% sensitivity (95% confidence interval [CI] 46%-63%) and 74% specificity (95% CI 54%-87%). For alcohol consumption in the last 24 h, a cutoff score of 7 had 44% sensitivity (95% CI 36%-51%) and 85% specificity (95% CI 70%-93%). For clinical assessment, a cutoff score of 6 had 53% sensitivity (95% CI 45%-61%) and 71% specificity (95% CI 58%-85%).

DISCUSSION AND CONCLUSIONS

Within a community withdrawal setting, the prevalence of SAWS was high, rendering the modified PAWSS less valuable. Although higher cutoff scores improved specificity, poor sensitivity hindered identification of low-risk SAWS individuals.

Inducing and measuring positive affective state in domesticated equines: A Delphi consultation

Over the last twenty years the definition of good animal welfare has advanced from the 'absence of negative welfare states' to the aim of identifying the presence of positive welfare states; however, research on positive animal welfare is relatively new. Consequently, through expert consultation, this study aimed to synthesise knowledge regarding domesticated equine emotional state, specifically methods to induce and measure positive affective states, which could be of significant benefit to equine welfare across sectors. A Delphi consultation of experts in the field of equine behaviour, welfare and affective state was undertaken to derive consensus agreement on definitions used when considering positive affective state in equines and methods suitable for inducing and measuring these states within experimental investigations. Ninety-three international experts participated in a robust three-round Delphi consultation with data gathered analysed qualitatively (thematic analysis) and quantitatively (ranking data, consensus benchmarks and Content Validity Index (CVI) / Content Validity Ratio (CVR) analyses). Retention rates were high (78 %), and consensus (minimum 70 % agreement) was reached within Round three of the consultation. Nineteen methods for inducing positive affect reached consensus (provision of high value food, an affiliative companion and a substrate to roll in where the highest ranked), and twelve behavioural (assessment of body language, facial actions and horse-horse interactions were ranked highest) and three physiological (evaluation of heart rate, heart rate variability and respiratory rate) variables for measuring positive affect also reached consensus. This consultation highlights several important considerations surrounding the induction and measurement of positive affective state in equines, including consideration of the individual's personality and individual preference within any measures of affective state. We therefore recommend that establishing individual preference should be a prerequisite of research into positive affective states. It is anticipated that the results of this study can be used to provide new direction for research on positive affective states by providing expert agreed methods and measures for policy and practice through expert agreed approaches to induce positive affect in horses.

Computational Approaches for PPARγ Inhibitor Development: Recent Advances and Perspectives

The development of peroxisome proliferator-activated receptor gamma (PPARγ) inhibitors has attracted significant interest for treating metabolic disorders, cancer, and inflammatory diseases. This review highlights the crucial role of computational modelling in advancing PPARγ inhibitor development, emphasizing how these techniques streamline the identification, optimization, and evaluation of new drug candidates. Key methods include molecular docking, QSAR, and molecular dynamics simulations, which enhance the efficiency and accuracy of inhibitor design. Computational modelling has deepened our understanding of PPARγ binding mechanisms and conformational dynamics, allowing researchers to predict and optimize ligand-receptor complex stability. Despite these advancements, challenges remain, such as improving predictions of pharmacokinetic properties (ADME) to evaluate drug-like qualities. In conclusion, computational modelling has significantly enhanced PPARγ inhibitor discovery and development, offering new opportunities to address complex diseases. Continued refinement of these models, combined with experimental validation and emerging technologies, is crucial for overcoming current limitations and achieving successful clinical outcomes.

Cervical Disc Replacement in Athletes: A Modified Delphi Consensus Survey of Expert Opinion

BACKGROUND CONTEXT

The safety and efficacy of cervical disc replacement (CDR) for spinal disorders in contact sport athletes is not clear. Current research is limited and highlights mixed results regarding return-to-sport (RTS) among athletes with CDR.

PURPOSE

We sought to perform a modified Delphi consensus survey of expert opinion on CDR in athletes.

STUDY DESIGN/SETTING

A cross-sectional, modified Delphi consensus survey of different scenarios regarding RTS for athletes with CDR was conducted among a panel of expert spine surgeons.

PATIENT/RESPONDENT SAMPLE

An international panel of 34 spine surgeons involving both neurosurgeons and orthopaedic surgeons with sport expertise was identified.

OUTCOME MEASURES

Consensus regarding return to any level of sport as defined above was queried as the main outcome measure, with consensus defined a-priori at ≥70%.

METHODS

A 2×2 scheme was used to classify sport risk: 1=low impact/low frequency; 2=low impact/high frequency; 3=high impact/low frequency; 4=high impact/high frequency that also served as the different levels of sport that respondents could recommend returning to for the theoretical athlete. Descriptive statistics were performed with survey respondent data to generate the percentages of respondents recommending return to each level of sport for all scenarios.

RESULTS

Of the 34 sports spine surgeons invited to participate (55.9% neurosurgeons and 44.1% orthopaedic surgeons), all completed 9 questions as part of a larger survey. Regarding radiculopathy, consensus was achieved that CDR is an acceptable treatment for cervical radiculopathy in a high impact/high frequency athlete for 1-level disease (73.5%). However, only 58.8% responded that they would offer a CDR in this scenario. Regarding spinal cord compression, consensus was not achieved that CDR is an acceptable treatment for a high impact/high frequency forces athlete for 1-level disease with cord compression with/without myelopathy (47.1%). The most common reasons behind not offering a CDR included certainty of the anterior cervical discectomy and fusion (ACDF), safety concerns (e.g., adequacy, efficacy, stability), and lack of data/evidence. Postoperatively, following a 1-level CDR for myelopathy or radiculopathy, 57.6% of participants responded that they would advise the athlete may return to high impact/high frequency sport, whereases following a 2-level CDR, only 23.5% of all participants responded they would advise the same. For 1-level CDR, the most endorsed timelines for return to practice were 6 weeks (26.5%) and 3 months (26.5%) and for games was 3 months (41.2%). For 2-level CDR, the most endorsed timeline for return to practice was 3 months (26.5%) and for games was 3 months (41.2%).

CONCLUSIONS

Consensus was achieved that CDR is an acceptable treatment for radiculopathy (74%) but not myelopathy (47%) in high impact/high frequency athletes; however, only 59% of surgeons would offer a CDR for athletes with radiculopathy. Reasons for CDR hesitancy were certainty of outcomes with ACDF, safety concerns, and lack of long-term data. Although consensus was reached for some indications herein, this study highlights ongoing heterogeneity in the use of CDR for contact sport athletes and concerns regarding its safety. Future research should focus on gathering primary data on safety, durability, and long-term efficacy of CDR among athletes of different sports.

Criteria For Agreement When Conducting Local Consensus Discussions: A Qualitative Study

Purpose

Healthcare is a complex, multi-layered team environment where effective change often requires reaching consensus among relatively autonomous stakeholders. Although conducting informal consensus discussions is a frequently used implementation strategy in real-world clinical settings, limited information exists about what defines consensus when using these methods. Specifying the criteria for consensus is important, as it can shape the design of consensus-building strategies. This study aimed to identify and define the key domains of consensus used in local consensus discussions to standardise healthcare practices.

Patients and Methods

A qualitative study was conducted in one private hospital in Australia using a modified, grounded theory methodology. Clinical, non-clinical and leadership staff involved in developing standardised perioperative pathways using informal consensus discussions were recruited. Data were collected via semi-structured interviews and naturalistic participant observations between February 2023 and May 2024. Data collection and analysis occurred concurrently until theoretical saturation was achieved. Data were analysed using open coding with constant comparison, focussed and theoretical coding to develop theoretical concepts.

Results

Sixteen hours of observations with 31 participants and nine semi-structured interviews were conducted. Analysis identified four distinct consensus criteria: i) unanimous consensus, ii) delegated consensus, iii) assumed consensus and iv) concessional consensus. While unanimity was the preferred outcome, other consensus types emerged as viable alternatives when unanimous agreement was challenging to achieve. Each criterion had differing factors and mechanisms which influenced reaching the consensus criterion, underpinning assumptions, and considerations for practice, which formed four domains of consensus.

Conclusion

These domains provide a structured framework for classifying consensus criteria when conducting local consensus discussions in healthcare. The findings broaden our understanding of consensus in local healthcare discussions, moving beyond a singular focus on unanimity. By clearly defining consensus types, organisations can strategically select consensus methods that best support decision-making and intervention implementation.

Terminal Hospitalizations in Liver Transplant Recipients: Reducing Costs and High-Intensity Care Through Palliative Care

IntroductionEnd-of-life care for liver transplant recipients is often characterized by high utilization of invasive procedures, prolonged hospital stays, and elevated health care costs. Despite evidence demonstrating that palliative care can reduce aggressive interventions, improve patient-centered outcomes, and lower costs, its integration into transplant care remains inconsistent.MethodsA retrospective analysis was conducted using the National Inpatient Sample database (2016-2021). Hospitalizations ending in death for liver transplant recipients were compared to non-recipients regarding invasive procedures, health care costs, and the impact of palliative care consultations. Assessed procedures included: mechanical ventilation, tracheostomy, enteral and parenteral nutrition support, red blood cell transfusion, renal replacement therapy, central line placement, and cardiopulmonary resuscitation. Multivariable regression models adjusted for demographic and clinical covariates were utilized.ResultsAmong 4,582,658 terminal hospitalizations, liver transplant recipients (n = 5995) were younger (mean age: 66.0 vs 70.9 years, P < 0.001), had higher comorbidity burdens, and were more likely to have undergone one or more of the assessed procedures (74.7% vs 58.4%, P < .001) compared to non-recipients. Hospitalization costs were increased in transplant recipients ($62,630 vs $46,930, P < .001). Palliative care consultations were associated with reduced procedure utilization (69.9% vs 83.7%, P < .001), shorter hospital stays, and lower costs ($46,930 vs $62,630, P < .001).DiscussionLiver transplant recipients face unique end-of-life care challenges, including greater reliance on high-intensity interventions and associated costs. Palliative care is associated with less invasive procedures and lower costs, highlighting the need for its integration into transplant care pathways.

Does intraoperative antiseptic solution soaking reduce microbial contamination in spine surgery? A randomized controlled trial

BACKGROUND CONTEXT

Surgical site infections (SSIs) are a significant complication in spine surgery, particularly in instrumented procedures, leading to increased morbidity and healthcare costs. Despite standard preoperative disinfection protocols, bacterial contamination remains prevalent. Strategies such as intraoperative antiseptic irrigation have been explored to mitigate contamination, yet the comparative efficacy of different antiseptic solutions remains unclear.

PURPOSE

This study aimed to evaluate the effectiveness of intraoperative antiseptic solution soaking with normal saline (NS), povidone-iodine (PVP-I), and chlorhexidine gluconate (CHG) in reducing bacterial contamination in lumbar instrumented fusion surgery.

STUDY DESIGN/SETTING

A single-center, single-blinded, randomized controlled trial was conducted at a tertiary medical center in Taiwan.

PATIENT SAMPLE

A total of 105 patients undergoing posterior lumbar interbody fusion surgery were enrolled and randomly assigned to three groups: NS (n=35), PVP-I (n=35), or CHG (n=35). Patients with prior lumbar procedures, known allergies to antiseptics, previous spinal infections, trauma, or tumors were excluded.

OUTCOME MEASURES

The primary outcome was the reduction in bacterial contamination, assessed via intraoperative cultures from three sites-superficial tissues, deep tissues, and implant surfaces-before and after antiseptic irrigation. Secondary outcomes included the incidence of postoperative SSIs and clinical complications over a 6-month follow-up period.

METHODS

Patients were randomized into three groups, each receiving a 3-minute soak with the assigned antiseptic solution before wound closure, followed by normal saline irrigation. Swab samples were collected pre- and postirrigation for bacterial culture and 16S rRNA PCR analysis. Statistical analysis was performed using logistic regression and Bonferroni correction for multiple comparisons.

RESULTS

Among 105 patients, preirrigation bacterial culture positivity rates were 49.5% in superficial tissues, 31.4% in deep tissues, and 32.4% on implants. Postirrigation, NS showed no significant bacterial reduction, while PVP-I reduced superficial contamination (55.0%, p=.015) but no significant effect in deeper tissues and implants. CHG showed the greatest bacterial reduction, significantly outperforming NS (OR: 0.06, 95% CI: 0.01-0.54, p=.011) and PVP-I (OR: 0.06, 95% CI: 0.01-0.56, p=.012) on implant surfaces. Despite these differences in culture rate, SSI rates remained low and comparable among groups (p=.72), with no reported antiseptic-related complications.

CONCLUSION

This study confirms that bacterial contamination remains high despite standard preoperative disinfection in lumbar fusion surgery. Among the tested antiseptic solutions, CHG demonstrated superior efficacy in reducing bacterial residues, particularly on implant surfaces. These findings support CHG as a promising antiseptic for intraoperative irrigation in spine surgery. Further multi-center studies are needed to validate its impact on reducing SSIs and improving long-term outcomes.

LEVEL OF EVIDENCE

Level II.

Dietary inflammatory index and the risk of esophageal cancer: a systematic review and meta-analysis

BACKGROUND AND AIM

It is well-recognized that inflammation is an adaptive pathophysiological response in many types of cancer. Research on nutrition's critical role in inflammation, a risk factor for all forms of cancer, is growing. The dietary inflammatory index (DII) was created lately to assess if a diet is pro- or anti-inflammatory in terms of inflammation. Indeed, several studies have demonstrated the correlation between DII and the risk of several cancer types. This meta-analysis set out to look into the relationship between DII and the different forms of esophageal cancer.

METHOD

PubMed, Cochrane library, Embase, Scopus, and Web of Science databases were searched up to May 2024 to retrieve relevant articles. RAYYAN intelligent tool for systematic reviews was incorporated for the screening of studies. Original articles written in English Studies that investigated the inflammatory index of diet in individuals who developed esophageal cancer were included in this study.STATA v18 software was used to conduct the meta-analysis. Egger's test for publication bias assessment was implemented. Newcastle Ottawa scale was used to evaluate the qualities of the included studies. A plot digitizer was used to extract digital data.

RESULT

A total of 13 studies were included in the systematic review, with 6 studies contributing to the meta-analysis, comprising 10,150 participants. The participants were categorized into high and low DII groups, with the low DII group (n = 3,403) serving as the reference. The meta-analysis demonstrated a significant association between high DII and increased risk of esophageal cancer. Specifically, individuals in the high DII group were 29% more likely to develop esophageal cancer, with a pooled odds ratio (OR) of 1.29 (95% Confidence Interval [CI]: 1.16-1.43), as calculated using a random-effects model. Moderate heterogeneity was observed (I2 > 50%). Egger's test indicated evidence of publication bias (p < 0.05). Subgroup and sensitivity analyses confirmed the robustness of this association across populations and study designs.

CONCLUSION

our study concludes that a higher level of DII is associated with a higher risk of esophageal cancer development. This study suggests that modifying inflammatory properties of dietary patterns can reduce the risk of incidence of esophageal cancer.

Task Specificity of Dynamic Resistance Training and Its Transferability to Non-trained Isometric Muscle Strength: A Systematic Review with Meta-analysis

BACKGROUND

Resistance training (RT) specificity has been confirmed for movement patterns (e.g., multi-joint or single joint), movement velocities, ranges of motion, and contraction types (e.g., dynamic vs isometric). However, a systematic analysis of the effects of dynamic mass-loaded (e.g., isoinertial) RT on dynamic versus isometric strength tests is lacking.

OBJECTIVE

We aimed to examine the specific effects of dynamic RT on dynamic (isoinertial) versus isometric muscle strength, including possible moderating factors (e.g., training length, single joint and multi-joint, upper body and lower body, RT status) and mechanisms (e.g., hypertrophy, muscle activation).

METHODS

A systematic literature search was conducted in MEDLINE (EBSCO), Web of Science, and Scopus up to March 2024. The included interventions contained at least ten training sessions, both dynamic and isometric muscle strength assessments before and after the training period, and healthy participants aged 16-60 years (encompassing untrained and trained individuals). Advanced RT approaches, such as electrical stimulation, isokinetic training, velocity-based training, and blood flow restriction training, were excluded. Within-subject, weighted standardized mean differences (SMDs) of the pre-intervention to post-intervention tests were calculated for both dynamic and isometric muscle strength measures using a random-effects model. Univariate sub-group analyses of RT status, intervention length, complexity (i.e., single-joint or multi-joint exercises), and body segments (i.e., upper and lower body) were independently computed. Random-effects meta-regressions were computed to examine if dynamic RT effects on dynamic and isometric muscle strength are predicted by RT effects on muscle hypertrophy or muscle activity.

RESULTS

Overall, 43 studies with 1660 participants across 72 different RT interventions were eligible for inclusion. The overall effect on dynamic strength was significant and moderate magnitude (SMD = 0.98, 95% confidence interval 0.91-1.06, p < 0.001), whereas the transfer to non-trained isometric strength measures was significant but small (SMD = 0.42, 95% confidence interval 0.35-0.49, p < 0.001). Sub-analyses demonstrated moderate-to-large task-specific effects (range SMD; 95% confidence interval 0.75-1.30) of conducting dynamic RT and only small-to-medium effects (range SMD; 0.29-0.70) of the transferability of muscle strength to the non-trained isometric contraction form. Muscle hypertrophy and activity changes did not significantly predict dynamic RT effects on dynamic and isometric muscle strength (p ≥ 0.222).

CONCLUSIONS

Our findings demonstrated task specificity of dynamic RT, as dynamic strength increased with a two-fold larger effect size than non-trained isometric muscle strength. Medium-to-large effects were observed for the dynamic strength improvements in the different sub-group analyses with small-to-medium effects in the isometric improvements. The limited transferability of dynamic (task-specific) strength to non-trained isometric contractions suggests that these two strength outcomes represent different neuromuscular domains.

Cost-effectiveness of daily home haemodialysis versus in-centre haemodialysis: A propensity score matching analysis based on real-world data from the French healthcare system

Background Daily home haemodialysis (HD) offers several advantages over conventional 3-times-weekly in-centre HD, with better preservation of quality of life and treatment flexibility, but its costs and potential benefits on mortality are poorly understood. Methods Individual healthcare data from the French National Health Data System for patients with end-stage kidney disease undergoing dialysis cross-referenced with the French National Cost Scale of the health ministry. After exclusion of patients treated < 90 days, and those without a treatment schedule or incomplete data for a social disadvantage score, 42 605 patients were selected (28 317 prevalent and 14 288 incident HD patients). After propensity score matching, 265 incident patients (in-centre HD, n = 212; daily home HD, n = 53) and 765 prevalent patients (in-centre HD, n = 612; daily home HD, n = 153) were analysed. Findings The global cost of daily home HD in incident patients was lower than in-centre HD (€1403/week vs. €1652/week, respectively). In prevalent patients, the cost was also slightly lower for daily home haemodialysis than compared to in-centre haemodialysis (€1360/week vs. €1456/week, respectively). The gross death rate in incident patients treated by in-centre HD after a 2-year follow-up was 10·4 % vs. 1·9 % for patients treated by daily home HD (p = 0·049, at Chi2 test; relative risk=5·5). Using a Cox proportional hazard regression model, in-centre HD was associated with a 7-fold higher risk of death (hazard ratio=7·888, p = 0·045). Interpretation Daily home HD is a more cost-effective and patient-centred treatment option than in-centre HD. Funding This research was funded by Physidia Ltd and Ramsay Health Care, France.

Evaluating natural language processing derived linguistic features associated with current suicidal ideation, past attempts, and future suicidal behavior

BACKGROUND

People with psychosis have a higher suicide risk than the general population. Natural language processing (NLP) has been used to understand communication in psychosis and suicide risk prediction, but not to predict future suicidal behavior in people with psychosis. We utilized NLP-derived linguistic features from a dyadic task among people with psychotic disorders to predict current suicide ideation, past suicide attempts, and future suicidal behavior.

METHODS

N = 112 adults with psychotic disorders completed the Columbia-Suicide Severity Rating Scale at baseline and one-year follow-up to capture lifetime suicide attempts, current suicidal ideation, and suicidal behavior during the follow-up period. At baseline, participants completed a dyadic role-play task called the Social Skills Performance Assessment. Lexical features, lexical diversity, and sentiment features were extracted from task transcripts. Models for each outcome were generated using a 70 %-30 % train-test split with MLPRegressor. SHapley Additive exPlanations (SHAP) was utilized for feature analysis.

RESULTS

A total of 42.9 % of participants had baseline suicidal ideation, 67.9 % had at least one past suicide attempt, and 13.3 % had at least one reported new suicidal behavior at one-year follow-up. The models had strong predictive performance for past attempts (F1 = 0.75) and current ideation (F1 = 0.74-0.79), with future suicide behavior models showing the strongest predictive performance (F1 = 0.86-0.93). The top features varied across suicide ideation, past attempts, and future behavior.

DISCUSSION

NLP-derived features from a dyadic task were associated with high predictive accuracy for future suicidal behavior. Pending replication, these findings suggest that NLP-derived linguistic features from dyadic tasks could contribute to understanding suicide risk among people with psychosis.

Off-label drug use in palliative medicine: Delphi study for the consensus of evidence-based treatment recommendations

BACKGROUND

Off-label use of drugs is an integral part of everyday clinical practice in palliative medicine. However, it is associated with many uncertainties, that is, drug therapy safety or legal issues including cost coverage. Healthcare professionals often lack time and resources for comprehensive literature search and patient-specific risk-benefit analyses.

AIM

The aim of this project is to develop, evaluate and rate agreement/disagreement on treatment recommendations for off-label use in adult palliative medicine.

DESIGN

Online Delphi study with two rounds each to rate agreement/disagreement with treatment recommendations for off-label use in adult palliative medicine. An international expert panel consisting of physicians, pharmacists and nurses working in palliative care evaluated previously developed recommendations based on the best available evidence.

SETTING

/participants:Professionals (physicians, pharmacists, nursing staff) working in inpatient and home palliative care involved in the medication process were recruited as experts to participate. Between 64 and 75 experts participated in the first two Delphi studies.

RESULTS

A total of 64/68 recommendations on 21 drugs and 14 applications were agreed upon. Topics related to routes of administration as well as indications for sialorrhea, bronchorrhea, xerostomia, pruritus, singultus, fistula, gastroparesis and hot flashes. Recommendations that reached consensus are available to health care professionals via a free of charge database.

CONCLUSION

For many off-label use applications, it is likely that there will be no registration studies and therefore no drug approvals in the future. The consensus-based recommendations are intended to facilitate individual treatment planning for prescribers and to enable a more reflected handling of off-label use.

Identifying Research Priorities for Cognition in CKD: A Delphi Study

Key Points

Background

Cognition is a research priority for people living with CKD, but identification of critical research questions is lacking. This study aimed to determine which cognition-related research questions are most important to CKD stakeholders.

Methods

A modified Delphi technique with three survey rounds was used. The study sample included three panels (People with lived CKD experience, Researchers, and Clinicians) recruited through international patient and kidney research networks, kidney societies, and snowball sampling with email invitations. Survey rounds were distributed electronically through Research Electronic Data Capture. In round 1 (October 2021–May 2022), respondents contributed three important research questions regarding cognition in CKD (free text). After deduplication and qualitative synthesis, respondents ranked the importance of these questions on a nine-point Likert scale in round 2 (February–April 2023). Questions with mean and median ratings of >7 by at least two respondent panels or rated critically important by the lived experience panel were reranked in round 3 (August–September 2023) and assessed for consensus to identify the final list of priority research questions.

Results

Respondents (n=152) identified 125 and 44 discrete questions after rounds 1 and 2, respectively. The final shortlist included 27 questions in eight categories. The most critical research question identified was “What factors prevent cognitive impairment in people receiving dialysis?” Overall, respondents prioritized questions focusing on prevention and treatment of cognitive impairment. Scores between the panels were significantly different for 16 questions. Those with lived CKD experience prioritized quality of life, researchers emphasized developing interventions to mitigate cognitive impairment, and clinicians prioritized the effect of CKD treatment on cognitive impairment.

Conclusions

Through an established consensus methodology involving key stakeholder groups, we identified 27 critical research questions about cognition in CKD. These questions should guide future study design and outcome selection.