Delphi methodology in healthcare research: How to decide its appropriateness

Translation, Adaptation, and Validation of a Traditional Chinese Version of the Family Caregiver Medication Administration Hassle Scale

Background

The Family Caregiver Medication Administration Hassle Scale (FCMAHS) assesses the stress experienced by family caregivers in managing daily medication regimens for older adults. However, its suitability for the Taiwanese healthcare context has not yet been established.

Objective

To translate, cross-culturally adapt, and evaluate the reliability and validity of a Traditional Chinese version of the FCMAHS (FCMAHS-TC).

Methods

A two-phase cross-sectional study was conducted. In Phase I, the FCMAHS was translated into Traditional Chinese. In Phase II, a convergent mixed-methods study was carried out with a convenience sample of 138 family caregivers who completed the FCMAHS-TC. In parallel, 12 of those participants were interviewed to explore their experiences with medication administration tasks and associated stress. Content validity was assessed using the content validity index (CVI), whereas reliability was evaluated through Cronbach's alpha and intraclass correlation coefficients (ICCs). Exploratory factor analysis (EFA) was performed to investigate the FCMAHS-TC's factor structure. Qualitative data from interviews were analyzed using content analysis to provide triangulated evidence of scale adaptability.

Results

The FCMAHS-TC demonstrated strong internal consistency (Cronbach's alpha = 0.94) and test-retest reliability (ICC = 0.78). Expert evaluation indicated strong content validity, with the item- and scale-CVI value reaching 1.0. The EFA identified four key factors: information seeking and sharing, scheduling logistics, medication filling and prescription management, and safety issues, accounting for 59.57% of the total variance. Qualitative findings supported the factor structure identified and further highlighted care coordination among caregivers as an additional challenge.

Conclusion

The FCMAHS-TC is a valid and reliable tool for healthcare professionals in Taiwan to assess the challenges and stress associated with medication administration among family caregivers. Future research should explore social and demographic determinants of medication-related caregiving stress and develop targeted interventions to support caregivers in Taiwan.

Consensus of Expert Opinion for the Diagnosis and Management of Hypermanganesaemia With Dystonia 1 and 2

Hypermanganesaemia with Dystonia 1 and 2 (HMNDYT1 and 2) are inherited, autosomal recessive disorders caused by pathogenic variants in the genes encoding the manganese transporters SLC30A10 and SLC39A14, respectively. Impaired hepatic and enterocytic manganese uptake (SLC39A14) and excretion (SLC30A10) lead to deposition of manganese in the basal ganglia resulting in childhood-onset dystonia-parkinsonism. HMNDYT1 is characterized by additional features due to manganese accumulation in the liver causing cirrhosis, polycythaemia, and depleted iron stores. High blood manganese levels and pathognomonic MRI brain appearances of manganese deposition resulting in T1 hyperintensity of the basal ganglia are diagnostic clues. Treatment is limited to chelation therapy and iron supplementation that can prevent disease progression. Due to their rarity, the awareness of the inherited manganese transporter defects is limited. Here, we provide consensus expert recommendations for the diagnosis and treatment of patients with HMNDYT1 and 2 in order to facilitate early diagnosis and optimize clinical outcome. These recommendations were developed through an evidence and consensus-based process led by a group of 13 international experts across the disciplines of metabolic medicine, neurology, hematology, genetics, and radiology, and address the clinical presentation, diagnostic investigations, principles of treatment, and monitoring of patients with HMNDYT1 and 2.

Development and validation of the national High-Risk Medicine Classification using the Delphi method

BACKGROUND

High-risk medicines (HRMs) are medicines that have a higher risk of causing severe consequences for the patient when used in error.

OBJECTIVE

This study aimed to develop a Finnish High-risk Medicine Classification (FIN-RiskMeds) to support healthcare professionals in HRM risk management.

METHODS

The development of FIN-RiskMeds was coordinated by the Finnish Medicines Agency (Fimea) using the Delphi consensus method. The preliminary list of HRMs was based on an inventory of existing HRM lists, literature, and the expertise of the working group (WG). A three-round Delphi survey with 60 panelists and a public hearing were used to achieve consensus on the content of the classification. The consensus threshold was set at 70 %.

RESULTS

The expert panel agreed on 42 medicines or medicine classes (later 'items') to be included in the FIN-RiskMeds. A 70 % consensus was reached on 30 out of 60 items in Round 1 and on 13 out of 31 items in Round 2a. The strongest consensus was reached for warfarin, methotrexate, and opioids. The serious consequences and key risks of medicines and the medication process were described for all items after Rounds 2b and 3. Based on the WG's decision after a public hearing, the final classification consists of 38 items.

CONCLUSION

This study produced expert consensus-based classifications of HRMs and a comprehensive list of their key risks. HRMs and their risks should be identified across health and social care to prevent potential medication errors. It is necessary to develop medication processes to minimize the risks associated with HRMs.

Research themes and key data points for child and adolescent emergency department mental health presentations: A national Delphi study

OBJECTIVE

The objective was to identify a prioritized list of research themes and key data points (baseline data and research outcomes) for future studies regarding child and adolescent emergency department (ED) mental health presentations.

METHODS

A prospective survey-based Delphi process was undertaken in Australia within the Pediatric Research in Emergency Departments International Collaborative (PREDICT) network. Hospital-based and community-based clinicians, researchers, police, ambulance paramedics, pediatric patients, and their carers were recruited to generate research themes and key data points for future pediatric ED mental health research. Responses were collated and analyzed by a steering group consisting of pediatric mental health, medical, and research/academic experts. Participants then prioritized the items through three survey rounds using a 9-point Likert-type scale to generate a final prioritized list.

RESULTS

184 participants (36 patients/carers and 148 clinicians/researchers) were recruited and generated 267 items for initial prioritization; 23 completed all survey rounds. The surveys identified a consensus of 71 items: 35 research themes and 36 key data points (11 baseline data points and 25 research outcomes) for future research. The top-rated research themes included patient/staff safety within the ED, the efficacy of dedicated mental health spaces, and the importance of patient follow-up. Important baseline data points included risk factors for mental health presentations and history of child abuse and/or family violence. Top-rated research outcomes included the occurrence of severe behavioral disturbance in the ED, the use of parenteral sedation, and ED re-presentation and/or suicide attempt postdischarge.

CONCLUSIONS

The Delphi process identified a prioritized list of research themes and key data points that will inform future research on child and adolescent mental health-related ED presentations.

Questionnaire for Clinical Diagnosis of House Dust Mite's Allergy Approved by Delphi Consensus

Despite house dust mite (HDM)-allergy is the most frequent in the world, no standard questionnaire exists to help physicians in their clinical practice for screening patients with this possible diagnosis. The objective of this survey was to develop a questionnaire that could be used to identify patients with suspicion of HDM-allergy. The survey was conducted using the Delphi methodology. Nineteen international experts in allergology constituted the scientific board who established the items included in the first version of the questionnaire, defined the criteria of the selection for the next steps, and validated the final questionnaire and its interpretation. The initial version of the questionnaire included 15 items. For each item, five answers were suggested graduated by scores from "no importance" to "very high importance." The predefined conditions for the item selection after each round were a median score ≥ 7 and > 50% of responses according "high importance" and "very high importance." The electronic survey circulated within the Interasma Scientific Network platform. Eight questions based on the occurrence/worsening of symptoms induced by HDM-allergen exposure meet the survey criteria after the second and the third rounds and were included in the final questionnaire. Binomial answers for each question with 1 point accorded for "Yes" and none for "No" were suggested for the final version with a score ≥ 5 points associated with a high probability for HDM-allergy. By applying the Delphi process, we generated a brief questionnaire with binomial answers, easy to use in clinical practice for screening patients with HDM-allergy.

A network approach to addressing the needs of patients with incurable head and neck cancer and their families

Background

Patients with incurable head and neck cancer have considerable unmet needs and complex symptom burden, with evidence of substantial geographical and/or socioeconomic inequalities. Accurate information on healthcare needs, resource utilisation and service provision in the last year of life is lacking. This places limits on service delivery planning and the development and testing of interventions to better meet needs. Our partnership spans three regions, which nationally have some of the highest rates of incurable head and neck cancer.

Aims

The overall aims were to (1) establish a palliative head and neck cancer partnership, (2) identify and evaluate routine incurable head and neck cancer data sources and utilise these to develop and address research priorities.

Objectives

O1. Develop a palliative head and neck cancer network within the North of England, representing a geographical area with high incidence of incurable head and neck cancer and palliative care needs. O2. Develop and refine research questions and priorities. O3. Engage with data providers to identify relevant data sets and specific data fields to understand the potential quality and utility of these to inform research priorities.

Methods

There were three interconnected work packages: WP1: A 'snowballing' approach to establish a network of clinicians, researchers, patient and public representatives, data architects and key stakeholders with an interest in head and neck cancer palliative care. WP2: A Delphi consensus process to develop and refine research questions and priorities, based on national guidance and systematic reviews of evidence gaps. WP3: Identification of national and local data sets and exploration of the potential data quality and utility, and associated information governance processes for access.

Results

WP1: A diverse network was established, encompassing members from a wide range of professions and patient/carer groups. WP2: The Delphi consisted of two rounds involving up to 66 participants. Consensus was reached on 12 research questions representing 4 key areas of prioritisation: service provision, symptom management, psychosocial support and information provision and communication. WP3: A range of national and local data sources were identified as having the potential to address the research priorities. A directory of data sources was developed. Working in an iterative way, data sets and relevant data fields were mapped to the 12 potential research priority areas to assess the applicability of using routine data to address these priorities.

Limitations

Approximately, one-third of participants in the Delphi process dropped out in round 2. Despite attempts to be flexible in our approach, retaining participants, particularly for patients and their families on a palliative care pathway, is challenging.

Future work

The established network and consensus exercise form the basis for future service evaluations and collaborative research. These will be based on gaps and priorities agreed by patients, their families and a range of other stakeholders.

Conclusions

The network has established a cross-sectoral collaboration for improving incurable head and neck cancer and a platform to identify 12 research priority areas. Utilising routine data to address these priorities remains a challenging area, and a range of methodological research approaches will be required to take this forward.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR135361.

Urgent surgical patient classification: Development and validation of a novel instrument using the Delphi approach

BACKGROUND

The lack of a triage system for urgent surgical patients leads to non-standardized decision-making. Developing an instrument to objectively identify the complexity of care required for each case is challenging. The aim of this report is to develop and validate an urgent surgical patient classification instrument using the Delphi technique.

MATERIALS AND METHODS

The study was conducted in several stages: (1) definition of the construct; (2) item elaboration; (3) expert analysis; (4) item selection; (5) pretest. In the first study, scale items were designed and content validity was confirmed. In the second study, the factorial structure was analyzed. In the third study, alternative measurement models were tested. In the fourth study, criterion validity was analyzed.

RESULTS

Experts validated 14 items (31.81%) from Domain 1 with 75% agreement and specific items from Domain 2 with 100% agreement. Factor analysis indicated a two-factor solution explaining 58.4% of the variance. The bifactor model presented the best fit (χ2/df = 1.51; CFI = 0.95; TLI = 0.94; RMSEA = 0.051; SRMR = 0.043). Factors showed excellent internal consistency (α > 0.88; CR > 0.90; ω > 0.92).

CONCLUSION

This pioneering study developed and validated the content of the first specific instrument for classifying urgent surgical patients regarding their priority for care. The instrument was deemed valid in terms of content, based on expert consensus. Further studies are recommended to evaluate its practical application and perform additional psychometric measures. This instrument has the potential to enhance the organization of emergency services and operating theaters, promoting patient safety and efficient resource management in healthcare institutions. Its implementation should align with current health guidelines and policies to optimize the triage and prioritization process for urgent surgical patients.

Expert-Reviewed Nutritional Guidance for Adults with Spinal Cord Injury: A Delphi Study

Background/Objectives: Nutritional needs for people with chronic spinal cord injury (SCI) are inadequately addressed due to the lack of comprehensive evidence and scattered research. We established a consensus-based framework for addressing the nutritional needs of community-dwelling adults with chronic SCI who can ingest food orally. Methods: A web-based Delphi design was employed to ascertain an expert consensus. The Delphi panel consisted of physicians, registered dietitians (RDs), and researchers knowledgeable in SCI and nutrition. Informed by a literature review, 18 nutrition statements were rated by 15 panelists. The survey included statements about SCI-specific dietary energy assessments and macro- and micronutrients. Results: The response rate for the panel (N = 15) was 100%. Consensus levels, scores, stability levels, and response numbers were documented for each statement. The statements received consensus scores ranging from 4.14 to 8.13 on a 9-point Likert scale. Alternative expert comments and suggestions were also provided for each statement. Conclusion: Engaging a diverse panel of experts, the real-time Delphi process yielded expert-reviewed nutrition statements based on an extensive literature review and expert opinions. The rated statements contribute to the ongoing dialogue in SCI-specific nutrition, providing a practical resource for healthcare professionals working with adults with chronic SCI.

Acne scarring: protocol for development of a core outcome set for clinical trials

INTRODUCTION

Acne scarring is one of the primary sequelae that affect patients with acne, with facial scarring occurring to some extent in 95% of patients with active acne. Subtypes include atrophic, hypertrophic and keloid scarring. Treatment options include topical and surgical approaches. Despite numerous clinical trials focusing on acne scarring treatments, the absence of standardised outcome reporting across these trials raises concerns in evaluating treatment methods. To address this issue, this project aims to develop a core set of outcomes which should be uniformly assessed in all clinical trials involving acne scarring.

METHODS AND ANALYSIS

Outcomes will be extracted from four sources: a systematic literature review, patient interviews, printed and electronic sources and stakeholder involvement. The steering committee will assess the potential outcomes, adding or removing outcomes if needed. The Delphi process will be performed to understand the importance of outcomes. Two rounds of Delphi surveys will be completed by physicians, researchers and patients. Following this, a consensus meeting involving stakeholders will be held to refine the outcomes based on participant scores. The meeting will end in a voting process to determine a final recommended core outcome set (COS). This study will be conducted in collaboration with the Core Outcome Measures in Effectiveness Trials (COMET) initiative and the CHORD COUSIN Collaboration (C3). This study aims to develop a global COS to standardise assessment approaches in clinical trials of acne scarring. The final goal is to enhance uniformity of outcome reporting.

ETHICS AND DISSEMINATION

Ethical approval and consent to participate for the study have been granted by Northwestern University Institutional Review Board protocol ID: STU00097285. On completion of the COS, we plan to publish our results in peer-reviewed journals and send participants the finalised COS.

PROSPERO REGISTRATION DETAILS

This study is registered with PROSPERO (CRD42023460964), COMET (754) and C3 (https://www.c3outcomes.org/improved-acne-scarring).

Defining and subphenotyping ARDS: insights from an international Delphi expert panel

Although the definition of acute respiratory distress syndrome (ARDS) has undergone numerous revisions aimed at enhancing its diagnostic accuracy and clinical practicality, the usefulness and precision of these definitions remain matters of ongoing discussion. In this Position Paper, we report on a Delphi study to reach a consensus on the conceptual model of ARDS, specifically identifying its defining components within clinical, research, and educational contexts as well as exploring the potential role of subphenotyping. We did a four-round Delphi study, involving experts in ARDS research and management from a diverse range of geoeconomic regions and professional backgrounds. Consensus was achieved for the conceptual model of ARDS; key components to be included for an ARDS definition in the context of research, education, and patient management; and the need for further research in subphenotyping ARDS. Additionally, we highlight knowledge gaps and research priorities that could guide future investigations in this area. Our study builds on previous non-Delphi-based consensus processes (eg, the new global definition of ARDS and recent society-based guidelines) by using a rigorous Delphi method that ensured panellist anonymity and used clear quantitative criteria to mitigate potential peer pressure and group conformity. The findings underscore the need to refine the ARDS definition to better account for the heterogeneity of clinical presentations and underlying pathophysiology, and to improve diagnostic precision, including the use of subphenotyping where appropriate.

Workplace Strategies to Reduce Burnout in Veterinary Nurses and Technicians: A Delphi Study

Veterinary nurses and technicians are at risk of burnout, which negatively impacts mental and physical health, turnover, and patient care. Workplace contributors to burnout have been identified in this population, but little is known about best practice management strategies. This study used the Delphi method to explore barriers to addressing burnout and develop expert recommendations for workplace management strategies. Forty participants with a minimum of 5 years' industry experience in leadership, or wellbeing, were recruited via purposive sampling from the USA, UK, Australia, New Zealand, and Canada. Participants completed two anonymous, online, mixed-methods surveys between October 2024 and January 2025. Qualitative survey data were analysed using content analysis to identify codes and categorise solutions. Quantitative data were analysed using descriptive statistics. Barriers to addressing burnout included industry-wide barriers, such as lack of, or unclear, regulation and lack of leadership knowledge, and clinic-specific barriers, such as poor team culture, unwillingness for change, and existing burnout. Thirty-nine solutions were developed and rated as being highly, or very highly effective. These focused on themes such as improving communication, developing progression pathways, and providing leadership training and support. Existing workplace barriers must be evaluated prior to selecting strategies, to maximise effectiveness in specific contexts.

Optimizing safety in conservative physical management of the cervical spine: A modified Delphi study

BACKGROUND

Conservative cervical spine treatment is generally safe, but serious adverse events (SAEs) still occur despite various available clinical guidelines. There have been several challenges in understanding the specific circumstances of these events to direct prevention such as inconsistent reporting, misuse of professional titles, and incomplete data. There are also differences in opinions between professions. It is now important to understand expert views and consensus across professions regarding prevention strategies and minimum requirements for reporting standards for future SAEs.

METHODS

A modified Delphi method was used, involving 28 international experts from various allied health professions, including chiropractic, physiotherapy, osteopathy, and medicolegal fields. The experts took part in three rounds of online surveys to reach a consensus on reporting, characteristics, risk factors, and prevention of SAEs associated with neck treatments. An agreement of >74 % was required before consensus was reached.

RESULTS

Consensus was reached for more standardised reporting of SAEs across different types of treatments and professions. Addressing underlying health conditions and improving the recognition of potential risks, precautions, and contraindications during treatment were highlighted. Recommendations for strategies to improve safety, including early identification of risk factors and careful application of techniques, especially in vulnerable populations were also provided.

CONCLUSION

Experts called for the development of universally accepted clinician friendly clinical guidelines that focus on improving SAE reporting, early identification of SAEs, and safer technique application, particularly in special populations. Implementing these recommendations will help reduce the occurrence of SAEs and improve the safety of conservative cervical spine management across professions.

Defining terminology and outcome measures for evaluating overdose response technology: An international Delphi study

INTRODUCTION

Various novel harm reduction services leverage technology to reduce the rising number of drug poisoning deaths, particularly among those who use drugs alone. There is significant variability in terminology and outcome measures in reporting these interventions, complicating efforts to build a comprehensive knowledge base. Thus, we conducted a Delphi study to establish consensus and heterogeneity in these metrics.

METHODS

Panellists from three stakeholder groups (people who use drugs, virtual harm reduction service operators and academics) participated in a multi-round Delphi study. The first round included open-ended questions to propose items in three categories: terminology, demographic information and outcomes. Subsequent rounds included options from a previously conducted scoping review for consideration. Likert ratings were used to achieve consensus, with a 70% threshold. Final rounds involved ranking terminology that reached a consensus.

RESULTS

Of 23 initial participants, 14 completed the fourth survey round. "Overdose response technology" was identified as the most appropriate term for these harm reduction technologies. This definition includes drug contamination alerts, overdose response hotlines and applications, wearable overdose detection technology and overdose detection tools. Fourteen demographic outcomes reached a consensus for data collection, including name or handle, neighbourhood, age, gender, past overdose experience, substance used, amount and route of use. Six service use outcomes were recommended: response type, service outcomes, morbidity and mortality, overdose events, responder arrival time and post-rescue care.

DISCUSSION AND CONCLUSIONS

The study results are recommended to standardise terminology and guide future research and knowledge dissemination in the field, ensuring clear communication with a shared language.

Development of a Trauma-Informed, Culturally Sensitive Eating-Disorder-Specific Nutrition-Focused Physical Examination Tool: A Modified Delphi Study

Objective: This study aimed to identify components of a trauma-informed, culturally sensitive eating-disorder-specific nutrition-focused physical examination (ED-NFPE) tool. Method: The modified Delphi methodology was used to develop a consensus on the clinical relevance of nine evidence-informed ED-specific nutrition examination domains and 46 components within those domains. Purposive sampling was used to recruit a panel of registered dietitian nutritionist (RDN) experts in the ED field. The panelists responded to survey statements on a five-point Likert scale. The panelists also provided qualitative feedback on domain and component additions, exclusions, modifications, and trauma-informed culturally sensitive examination practice techniques. Results: Twenty-two RDN expert panelists completed Round One of the study, and eighteen panelists completed Round Two (82% retention). Twenty-one were female. Fifteen panelists had ten or more years of experience in ED dietetics. Fifty percent held an advanced practice credential from the International Association of Eating Disorders Professionals (IAEDP). After the two survey rounds, the nine ED-NFPE domains and 46 of the 48 components achieved a consensus for clinical relevance. The panelists proposed two new examination components and provided qualitative feedback for trauma-informed culturally sensitive practice techniques in all nine domains. Conclusions: This modified Delphi study design was chosen to reach a consensus on developing an ED-NFPE tool, as there are few current evidence-based guidelines for nutrition examinations in ED care. An NFPE tool specifically designed to detect the nutrition-related findings of individuals with EDs would strengthen the overall nutrition assessment. RDNs at every level of care and with all degrees of experience could use an ED-NFPE to inform patient treatment goals.

Entrustable professional activities for physiotherapists to demonstrate digital health competency: an international delphi study

BACKGROUND

The physiotherapy workforce is going through a staggering period of change, amidst an evolving technological landscape. Whilst the profession has cautiously begun to embrace digital physiotherapy practice, there remains a lack of clear, evidence-based standardized guidance regarding tangible activities that demonstrate relevant clinical competence with digital health technologies in practice.

OBJECTIVE

Establish the world's first international consensus on entrustable professional activities (EPAs) for digital physiotherapy practice.

METHODS

International Delphi study of experts over three rounds, to establish consensus on digital physiotherapy practice EPAs and associated specifications.

RESULTS

Fifty-five participants completed the study (which was an 83.3% retention rate from round 1). Participants represented 16 countries. Over 50% were academics, and over 30% were clinicians. The final framework consisted of nine EPAs and 56 specifications for digital physiotherapy practice. The highest percentage rated specification was for "obtaining informed consent" for using digital health.

CONCLUSIONS

This Delphi study is a seminal international consensus on the core EPAs for digital physiotherapy practice. These EPAs materialize competency. As global attention to digital health continues to increase, our workforce will need to continue to mature in this space. This international consensus will support employers, universities, peak bodies, and individual physiotherapists alike to develop alongside technology. With greater evidence and the establishment of international standards, confidence in the outcomes of digital physiotherapy practice will increase.

Key strategies to reduce the global burden of myopia: consensus from the international myopia summit

In this paper, we describe key strategies to guide global collaborative efforts to further reduce the burden of myopia and myopia-related visual impairment. A modified Delphi method was applied as an iterative multistage process to collect expert and stakeholders' opinions and extract consensus strategies regarding myopia diagnosis, prevention and control. Anonymous pre-meeting preparation rounds, structured discussions for prioritisation and the development of key consensus areas were performed. Consensus was reached on three key areas to collaborate and complement existing frameworks: (1) Myopia defined not only as a refractive error but also as a disease with phenotypic features allowing for risk stratification of significant visual impairment. (2) In addition to preventive strategies, a focus is needed on preventing progression to high myopia (HM). (3) A focus on preventing and treating pathologic myopia (PM), that is, end-stage of myopia disease with irreversible visual impairment. In conclusion, the workgroup suggests a global, collaborative strategy that is needed across public health, healthcare and advocacy sectors to support efforts in reducing visual impairment from myopia. Complementary to existing preventive public health efforts, additional focus on defining myopia as a disease with risk stratification for visual impairment and an emphasis on reducing visual impairment associated with HM and PM should be considered.

Operating Department Practitioner's research priorities: A Delphi study

With the 2022 Allied Health Professions' Research and Innovation Strategy and the College of Operating Department Practitioners joining the Council for Allied Health Professions Research, understanding the Operating Department Practitioner profession's vision for research and innovation and identifying its research priorities has become important. This Delphi study aimed to establish research priorities for the Operating Department Practitioner profession. Questionnaires were distributed to Operating Department Practitioners using College of Operating Department Practitioners and social media networks. Round 1 saw 49 eligible responses; this reduced to 21 in Round 2 and 17 in Round 3. Thirty-one research priorities were identified by consensus. Priority rank was determined by mean score, percentage agreement, and coefficient of variance. By reaching a consensus, Operating Department Practitioners co-created research priorities and identified several themes that will contribute to professional development and patient care and support funding opportunities. The five key themes were Workforce Transformation, Education, Patient Safety and Experience, Innovation and Technology, and Theatre Culture.

Consensus recommendations on multiple sclerosis management in Australia and New Zealand: part 1

INTRODUCTION

Multiple sclerosis (MS) is a chronic inflammatory demyelinating and degenerative disease of the central nervous system. There were 33 335 people with MS in Australia in 2021 and 2917 in New Zealand in 2006 and the prevalence and incidence are increasing with time. Although new treatments have substantially improved outcomes in recent decades, the treatment landscape has become increasingly complex due to the expanding number of disease-modifying therapies (DMTs) and associated safety considerations.

MAIN RECOMMENDATIONS

A total of 80 consensus recommendations were developed on the current best-practice management of MS in Australia and New Zealand. Part 1 of these guidelines outlines the consensus recommendations covering domains including DMT counselling and selection, pre-DMT assessments, monitoring disease activity on DMT, switching DMT, and discontinuing DMT. The remaining recommendations are outlined in Part 2, encompassing risk mitigation strategies during treatment with DMT, managing DMT in special situations (including pregnancy, postpartum, breastfeeding, active infection including COVID-19, and malignancy), general lifestyle measures, acute MS relapses, and symptomatic treatments for MS.

CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINES

This two-part position statement provides a practical resource for clinicians on current best-practice consensus recommendations for managing adults (≥ 18 years old) with MS in the Australian and New Zealand health care settings. It outlines the 14 DMTs currently available through the Australian Pharmaceutical Benefits Scheme and eight through the New Zealand Pharmaceutical Schedule, including the unique efficacy, safety and monitoring considerations of each. Through these guidelines, we aim to support safe, timely and effective management of patients with MS in Australia and New Zealand.

Long COVID clinical evaluation, research and impact on society: a global expert consensus

BACKGROUND

Long COVID is a complex, heterogeneous syndrome affecting over four hundred million people globally. There are few recommendations, and no formal training exists for medical professionals to assist with clinical evaluation and management of patients with Long COVID. More research into the pathology, cellular, and molecular mechanisms of Long COVID, and treatments is needed. The goal of this work is to disseminate essential information about Long COVID and recommendations about definition, diagnosis, treatment, research and social issues to physicians, researchers, and policy makers to address this escalating global health crisis.

METHODS

A 3-round modified Delphi consensus methodology was distributed internationally to 179 healthcare professionals, researchers, and persons with lived experience of Long COVID in 28 countries. Statements were combined into specific areas: definition, diagnosis, treatment, research, and society.

RESULTS

The survey resulted in 187 comprehensive statements reaching consensus with the strongest areas being diagnosis and clinical assessment, and general research. We establish conditions for diagnosis of different subgroups within the Long COVID umbrella. Clear consensus was reached that the impacts of COVID-19 infection on children should be a research priority, and additionally on the need to determine the effects of Long COVID on societies and economies. The consensus on COVID and Long COVID is that it affects the nervous system and other organs and is not likely to be observed with initial symptoms. We note, biomarkers are critically needed to address these issues.

CONCLUSIONS

This work forms initial guidance to address the spectrum of Long COVID as a disease and reinforces the need for translational research and large-scale treatment trials for treatment protocols.

Development of a generalised tool for evaluating success of clinical practice guidelines implementation (A-GIST)

OBJECTIVES

To develop a generalised tool to evaluate the success of implementation of clinical practice guidelines (CPGs).

DESIGN AND SETTING

Systematic review, group brainstorming discussion and modified Delphi method.

PARTICIPANTS

A steering group (3 members) was assembled responsible for the guidance and ensuring stakeholder's involvement. A tool development group (24 members) of leading experts provided expertise in refining the frame and items during the development and participated in the Delphi process. And a secretary group (7 members) was responsible for the organization and coordination, systematic reviewing, drafting of the preliminary list of items, documenting and revising the tool according to the suggestions of the development group.

INTERVENTIONS

Four process stages were employed. First, the project was launched with core groups formed for the development. Second, based on the Reach Effectiveness Adoption Implementation Maintenance framework, a systematic review of existing methods for evaluating the success of CPGs implementation and a brainstorming discussion were conducted to form a preliminary list. Third, a modified Delphi method was organised, integrating a multidisciplinary face-to-face consultation meeting with two rounds of online Delphi consultations. Fourth, the tool was revised and finalised incorporating all expert suggestions.

RESULTS

Development teams comprising multidisciplinary experts were formed. In the systematic review, 7 biomedical literature databases were searched, and 208 pieces of literature were included. After three rounds of brainstorming discussions on items identified in the literature, a 23-item preliminary list was produced. In the modified Delphi method, 14 experts made 23 main suggestions in the face-to-face meeting on the list. 13 experts participated in the first round of Delphi consultation, reached agreement on 20 items, removed 4 items and added 1 new item. 11 experts attended the second-round consultation and had an agreement to include 20 items after revision.

CONCLUSIONS

The Guideline Implementation Success Assessment Tool (A-GIST) was systematically developed as a comprehensive tool to assess the success of CPGs implementation. It comprises 5 dimensions, Reach, Adoption, Implementation, Effectiveness and Maintenance, encompassing 20 items that integrate perspectives from both clinicians and patients. A-GIST is designed to facilitate evaluating, benchmarking and cross-comparison of implementation success between guidelines, facilities and regions. Additionally, it provides evidence-based insights to inform the development of targeted strategies for optimising guideline implementation practices.

A structured framework for standardized 3D leg alignment analysis: an international Delphi consensus study

PURPOSE

To reach consensus among international experts on a structured framework for standardized 3D leg alignment analysis based on 3D bone models, ensuring consistency and improving clinical applicability.

METHODS

A Delphi study was performed in four rounds. Rounds 1 and 2 involved a steering and rating group that developed statements based on principles preserving the 3D complexity of anatomical structures, identified through a systematic review. These statements encompassed approaches for deriving joint centres and joint orientations, and defining coordinate systems using 3D bone models. In Rounds 3 and 4, a panel of 35 international experts, including clinicians (54%) and engineers (46%), with participants from Europe (80%), Oceania (9%), Asia (6%), and the Americas (6%), evaluated these statements. Consensus was defined as ≥80% agreement.

RESULTS

Rounds 1 and 2 resulted in 31 statements to be included in the survey. Of these, 26 achieved consensus in Round 3, with the five remaining statements refined and reaching consensus in Round 4. Experts agreed on utilising all available relevant surface data to define joint centres, joint orientations, and individual femoral and tibial coordinate systems alongside a combined leg coordinate system, and adopting central 3D axes for femoral version and tibial torsion.

CONCLUSIONS

This international Delphi consensus study provides a structured framework for a standardized 3D leg alignment analysis based on 3D bone models. This framework aims to enhance clinical applicability for preoperative planning and execution of uni- and multiplanar correction osteotomies around the knee, reduce the methodological variability in 3D leg alignment analysis literature, and improve cross-study comparability.

LEVEL OF EVIDENCE

Level V.

How to Refine and Prioritize Key Performance Indicators for Digital Health Interventions: Tutorial on Using Consensus Methodology to Enable Meaningful Evaluation of Novel Digital Health Interventions

Digital health interventions (DHIs) have the potential to improve health care and health promotion. However, there is a lack of guidance in the literature for the development, refinement, and prioritization of key performance indicators (KPIs) for the evaluation of DHIs. This paper presents a 4-stage process used in the Gravitate Health project based on stakeholder consultation and consensus for this purpose. The Gravitate Health consortium, which comprises private and public partners from across Europe and the United States, is developing innovative digital health solutions in the form of Federated Open-Source Platform and G-lens to present users with individualized digital information about their medicines. The first stage of this was the consultative process for the development of KPIs involving stakeholder (Gravitate Health project leads) consultations at the planning stages of the project. This resulted in the formation of an extensive list of KPIs organized into 7 categories. The second stage was conducting a scoping review, which confirmed the need for extensive stakeholder consultation in all stages of the KPI development, refinement, and prioritization process. The third stage was a period of further consultation with all consortium members, which resulted in the elimination of 1 category of KPIs. The fourth stage involved using the Delphi technique for refining and prioritizing the remaining 6 categories of KPIs. It is unusual to use this methodology in a nonresearch exercise, but it provided a clear consultative framework and structure that facilitated the achievement of consensus within a large consortium of 250 members on a substantial list of KPIs for the project. Consortium members ranked the relevance and importance of each KPI. The final list of KPIs provides substantial indicators sensitive to the needs of a broad group of stakeholders that are being used to capture real-world data in developing and evaluating DHIs.

A Delphi study of current practices and establishing consensus regarding assessment of fitness to drive among patients with brain tumours

PURPOSE

Evaluating fitness to drive among patients with brain tumours remains a challenge for clinicians. Due to difficulties in conducting prospective driving studies in this patient cohort, a Delphi study was performed to formulate new driving guidelines for patients with brain tumours.

METHODS

The survey questions, which were designed by utilising Australian driving guidelines and previous Delphi studies, established panelists' expertise, and then used a 9-point Likert scale to formulate new driving guidelines. An expert group of panelists comprising medical oncologists, radiation oncologists, neurosurgeons, and neurologists were chosen based on membership to professional societies with validation in part one of the survey. Two rounds of anonymised surveys were performed using REDCap for data entry, and a novel automated methodology on R for data analysis.

RESULTS

46 statements regarding fitness to drive were developed. Among the 37 surveys distributed, there were 26 responses (70.3% response rate) from round one, and 17 responses (65.4% response rate) for round two. Among the 46 statements, 19 (41.3%) achieved consensus. In addition to establishing a framework for assessing patients, there was notable consensus agreement for stable imaging required as part of evaluation and the need for continual reassessment.

CONCLUSION

Despite clinicians being aware of driving guidelines, determining fitness to drive among patients with brain tumours remains a challenge. This Delphi study identified consensus agreement for the need for stable imaging, and continually reassessing fitness to drive. These novel findings could be translated into future driving guidelines and consensus statements can be integrated into clinical practice.

User requirements for quantitative radiological reports in multiple sclerosis

OBJECTIVES

Quantitative radiological reports (QReports) can enhance clinical management of multiple sclerosis (MS) by including quantitative data from MRI scans. However, the lack of consensus on the specific information to include, on and clinicians' preferences, hinders the adoption of these imaging analysis tools. This study aims to facilitate the clinical implementation of QReports by determining clinicians' requirements regarding their use in MS management.

MATERIALS AND METHODS

A four-phase Delphi panel approach was employed, involving neurologists and (neuro)radiologists across Europe. Initial interviews with experts helped develop a questionnaire addressing various QReport aspects. This questionnaire underwent refinement based on feedback and was distributed through the MAGNIMS network. A second questionnaire, incorporating additional questions, was circulated following a plenary discussion at the MAGNIMS workshop in Milan in November 2023. Responses from both questionnaire iterations were collected and analyzed, with adjustments made based on participant feedback.

RESULTS

The study achieved a 49.6% response rate, involving 78 respondents. Key preferences and barriers to QReport adoption were identified, highlighting the importance of integration into clinical workflows, cost-effectiveness, educational support for interpretation, and validation standards. Strong consensus emerged on including detailed lesion information and specific brain and spinal cord volume measurements. Concerns regarding report generation time, data protection, and reliability were also raised.

CONCLUSION

While QReports show potential for improving MS management, incorporation of the key metrics and addressing the identified barriers related to cost, validation, integration, and clinician education is crucial for practical implementation. These recommendations for developers to refine QReports could enhance their utility and adoption in clinical practice.

KEY POINTS

Question A lack of consensus on essential features for quantitative magnetic resonance imaging reports limits their integration into multiple sclerosis management. Findings This study identified key preferences, including detailed lesion information, specific brain and spinal cord measurements, and rigorous validation for effective quantitative reports. Clinical relevance This study identified essential features and barriers for implementing quantitative radiological reports in multiple sclerosis management, aiming to enhance clinical workflows, improve disease monitoring, and ultimately provide better, data-driven care for patients through tailored imaging solutions.

Contraindications to Whole-Body Cryostimulation (WBC). A position paper from the WBC Working Group of the International Institute of Refrigeration and the multidisciplinary expert panel

Background

Whole-Body Cryostimulation (WBC) is a treatment that involves short exposures of the entire body to very cold and dry air in specially adapted cryochambers. A growing body of literature suggests the safe application of this technique in medical settings.

Aim

The primary purpose of this study was to generate an international consensus on the updated contraindications for WBC through an interactive process of questionnaire interspersed with controlled feedback from a steering committee.

Design

The study design was based on a systematic review of the literature and Delphi methodology.

Setting

Administration of electronic online questionnaires concerning contraindications to WBC.

Population

A multidisciplinary panel of 48 experts in the fields of rehabilitation, cardiology, neurology, endocrinology, oncology, clinical nutrition or in the clinical application of WBC was invited to participate in this consensus study.

Methods

A systematic search of PubMed, Scopus and Embase databases was carried out to identify possible items for inclusion in a form. A two-round Delphi survey was then conducted according to international guidelines, consisting of an electronic online questionnaire. The experts had to rate their agreement with each item in the questionnaires on a 5-point Likert scale. Expert consensus was assessed.

Results

A total of 28 European experts participated in the Delphi survey. The first round consisted of 59 items, 3 of which were discarded after data analysis. The second round was rearranged according to the previous suggestions of the panellists. All 28 experts completed the two rounds. At the end of the survey, consensus was reached and a final list of temporal and absolute contraindications to WBC was identified.

Conclusions

This process resulted in multidisciplinary expert consensus statements on contraindications to WBC. The European experts agreed on most of the decisions and produced a list of contraindications.

Clinical rehabilitation impact

The results provide a robust evidence framework to help clinicians improve clinical practice and patient safety.

Improving concordance with long-term compression therapy amongst people with venous ulceration: A Delphi study- clinician cohort

Research by Nelson and Adderley (2016)reveals that 60-80 % of individuals affected by chronic venous insufficiency (CVI) develop venous leg ulcers (VLU). The gold standard treatment for VLU is the application of compression therapy (CT), which promotes venous return, reduces venous pressure, and minimizes stasis (Bullock & Manias, 2022). Patient concordance to CT is suboptimal, with only 40 % concordance, leading to a higher risk of VLU recurrence (Eri ckson et al., 1995; Fi nlayson et al., 2014; K app et al., 2013). This poses a significant and costly healthcare challenge (Smith & McGuiness, 2010). A Delphi study was conducted to ascertain the factors that influence concordance with CT using a clinician cohort. The study asked participants to rank factors that facilitated concordance and those that acted as barrier. Results revealed that clinicians identified 44 factors that facilitated concordance and 46 factors that acted as a barrier in the initial phase. The consensus level, measured by a Kendall W Coefficient, ranged from moderate to strong amongst the participants (Zanotti & Chiffi, 2015).

Core functions and forms in home-delivered meal programs: a stakeholder-driven approach to identifying essential practices

BACKGROUND

The rapid growth of the aging population underscores the need for programs tailored to older adults' complex health needs. Home-delivered meal programs are critical, providing nutrition and socialization support to older adults with greatest economic and social need. However, variations in local implementation complicate our understanding of how specific program practices influence older adult outcomes. This present study applies the core functions and forms framework to identify and prioritize essential home-delivered meal practices-or forms-that can be replicated by other meal programs.

METHODS

This study was conducted within a pragmatic randomized effectiveness trial comparing two home-delivered meal models and their impacts on health outcomes among older adults. The study involved nine meal programs across the United States and used a three-phase approach characterized by the following: (1) core functions of home-delivered meal programs were identified based on Title III of the Older Americans Act; (2) the full spectrum of program "forms" was gathered through site visits, surveys, and listening sessions; and (3) a modified e-Delphi process was conducted with stakeholders to determine consensus on the most essential forms of home-delivered meal programming.

RESULTS

Three core functions were identified from Title III of the Older Americans Act: provide meals to reduce hunger and malnutrition, provide opportunities for socialization, and provide opportunities to promote health and well-being. Out of 103 identified program forms, 25 were deemed essential for achieving the core functions of home-delivered meal programs. Essential practices included dietary customization, emergency meal provision, and meaningful client-driver interactions, as examples.

DISCUSSION

This study demonstrates that while program variability allows flexibility to meet local client needs, establishing core functions and essential forms provides a foundation for evaluating home-delivered meal program effectiveness. The findings inform home-delivered meal program improvements at the national level, emphasizing a balance between standardized practices and local adaptations. This work serves as a model for characterizing complex interventions in community-based settings, advancing the science of implementation and the impact of home-delivered meals on older adult populations.

TRIAL REGISTRATION

NCT registration: NCT05357261 ; April 27, 2022.

Delphi Consensus on the Distinct Clinical and Histopathological Features of Lichen Planopilaris and Frontal Fibrosing Alopecia: Insights From the Hair Diseases EADV Task Force

BACKGROUND

Frontal fibrosing alopecia (FFA) has been defined as a lichen planopilaris (LPP) variant, and both are characterized by lymphocytic scarring alopecia. Despite histopathological similarities, they differ clinically, suggesting potentially different pathogenetic factors. This Delphi study aimed to collect expert opinions to clarify the relationship between FFA and LPP.

METHODS

The Delphi method was employed via an anonymous survey among experts in hair disorders from the Hair Diseases Task Force of the European Academy of Dermatology and Venereology (EADV), ensuring broad international representation. Two rounds of online questionnaires assessed the definition, clinical presentation, diagnosis, and management of LPP and FFA. The statements, developed based on an extensive literature review, were validated by the core expert panel. A 5-point Likert scale was utilized to quantify agreement levels, with strong consensus defined as ≥ 75% agreement or disagreement. Statements lacking strong consensus in the first round were revised and merged for inclusion in the second round.

RESULTS

Seventeen experts from seven countries joined the Delphi consensus process. In the first round, 65 statements underwent qualitative content analysis, yielding strong consensus in 30.7% of cases. Participants provided written justifications for their assessments. In the second round, an increased consensus rate (53.7%) was reached after the expert panel statement's revision.

CONCLUSIONS

This study confirms that FFA and LPP are clinical variants within the same lichenoid spectrum. While moderate consensus supports FFA as a variant of LPP, uncertainties remain regarding its demographic distribution, the presence of vellus hairs, and blue-gray dots. The study refines diagnostic and management approaches but is limited by the absence of dermatopathologists and basic researchers.

Adult glioblastoma in England: Incidence, treatment, and outcomes with novel population-based strata

INTRODUCTION

Malignant brain tumours are the leading cause of cancer death in the under 40's and they have the highest average-years of life lost. England has a long-running system for national cancer data collection. In this work we present data on incidence, treatment and survival in all adult glioblastoma patients in England diagnosed between 2013 and 2018.

METHODS

GlioCova uses a linked pseudo-anonymised data set of all adult patients in England diagnosed with a primary brain tumour between 2013 and 2018. We identified all patients with a glioblastoma (GBM) based on ICD-10 diagnosis and tumour morphology.

RESULTS

In the 6-year period of the study (2013-2018 inclusive), 15,181 patients were diagnosed with a GBM in England. The national age-standardised incidence was 4.98 adult glioblastoma patients per 100,000 per year, with men having a higher incidence than women (6.3 and 3.8 respectively). Overall, 79 % of patients received treatment (76 % female vs. 81 % male, p = 0.22), with younger patients more likely to be treated than older patients. Median overall survival was 16 months in those receiving aggressive treatment, but 7 months in the whole cohort. 21 % of patients received no treatment, and 17 % of patients underwent surgery or biopsy alone.

CONCLUSION

Age-adjusted incidence of GBM is stable, although absolute numbers are rising, and prognosis remains poor. Only 29 % of patients receive aggressive multi-modality treatment, and we suggest that taking a population-level approach to GBM reveals significant areas for improvement.

Identification of essential topics and procedural skills for inclusion in a contextualised undergraduate anaesthesia and critical care clerkship in Rwanda: results of a modified Delphi process

INTRODUCTION

Low anaesthesia workforce numbers contribute to shortfalls in access to surgical care globally. Investment in contextualised education and training can help address this issue by inspiring graduates to enter into training and imparting important knowledge and skills to non-specialists. We undertook a modified Delphi study to identify physician anaesthesiologist consensus on themes, topics, and skills for inclusion in undergraduate anaesthesia and critical care (ACC) medical school curricula in sub-Saharan Africa (SSA) and Rwanda.

METHODS

A list of ACC topics/skills was compiled through grey literature review, guiding survey development for a 3-round Delphi process. The first two rounds solicited responses from physician anaesthesiologists across SSA. The final round included only Rwandan physician anaesthesiologists. Respondents rated topics/skills on a 4-point Likert scale from 1 ("exclude from the curriculum") through 4 ("essential for inclusion"). Item-level Content Validity Index (I-CVI, the proportion of respondents rating a topic/skill as 3 or 4) was used for stratification. A first-round I-CVI threshold of 80% and 70% for subsequent rounds was used to define consensus for inclusion. Excluded topics/skills were considered for re-inclusion in subsequent rounds; 50% agreement was set as threshold for re-inclusion. The first round also sought consensus regarding aims, objectives, and delivery methodology.

RESULTS

A total of 147 topics/skills across 12 domains were identified for initial survey inclusion. Fifty-one respondents from 12 countries completed round one. Ninety-six (65.3%) topics/skills met consensus threshold. One additional skill ("pain assessment") was incorporated into round two following suggestions from respondents. The clerkship outcome ranked as most important and achievable was to 'inspire students to undertake anaesthesia specialty training' (n = 25, 49.0% and n = 26, 51.0% respectively). Thirty-six respondents from 12 countries completed round two. Eighty (82.5%) topics/skills met consensus threshold. Seventeen Rwandan specialists completed round three. Seventy-eight (97.5%) topics/skills met consensus threshold. From 67 previously excluded topics/skills, 14 (20.9%) met re-inclusion threshold.

DISCUSSION AND CONCLUSION

A modified Delphi process identified 92 essential topics/skills for inclusion in a Rwandan undergraduate ACC clerkship. Experts prioritised 'inspiring students' over 'achieving clinical competence' for undergraduates. A similar Delphi approach may be useful for educational content development in other settings across the African continent and for other specialties.

TRIAL REGISTRATION

Not applicable (study described is not a clinical trial). UGHE IRB protocol number: 194.

Determining the Prioritization of Behavior Change Techniques for Long-Term Stroke Rehabilitation: Delphi Survey Study

Background

Stroke results in both physical disability and psychological distress. The impact can be minimized through rehabilitation, but it is a long-term process, making it difficult for patients to adhere to treatment. Thus, a better understanding of long-term behavior change interventions for patients with stroke is needed as well as how such interventions can support not only rehabilitation of motoric functions but also mental well-being.

Objective

The aim of this study is to understand both the most important behavior change technique (BCT) clusters for long-term stroke rehabilitation in general as well as which are most relevant for each aspect of stroke rehabilitation: behavioral, cognitive, and emotional.

Methods

We applied the 16 BCT clusters. The study used a 2-round Delphi survey, as reliable consensus was obtained among a group of 12 international experts. Experts represented three main backgrounds involved in behavioral intervention in the health context: (1) specialists in behavioral science (n=4), (2) behavioral designers (n=4), and (3) expert health care professionals (n=4). Experts were brought together in this way for the first time. In the first round, web-based questionnaires were used to collect data from the experts. This was followed by a personalized second round. Consensus was determined by statistically aggregating the responses and evaluating IQR and percentage consensus. BCT clusters reaching consensus (IQR ≤1 and percentage ≥50%) were then ranked.

Results

In total, 12 of 16 BCT clusters reached consensus for general importance in stroke rehabilitation, with 11, 9, and 6 BCT clusters achieving consensus for, respectively, the behavioral, cognitive, and emotional aspects of rehabilitation. The overall most relevant BCT clusters were repetition and substitution, social support, feedback and monitoring, and self-belief, with similar outcomes for behavioral and cognitive rehabilitation. For emotional rehabilitation, social support and identity were emphasized. The least relevant BCT clusters were natural consequences, covert learning, and comparison of behavior.

Conclusions

This expert panel study using a 2-round Delphi survey ranked the importance of BCT clusters for long-term stroke rehabilitation. The process yielded a number of novel insights highlighting differences in importance between general rehabilitation and that specifically focused on the behavioral, cognitive, and emotional aspects of stroke recovery. This provides a first but important step toward unlocking the prioritization of BCT clusters for long-term intervention contexts such as stroke rehabilitation and enables effective intervention mapping addressing long-term behavior change and treatment adherence.

Expert Consensus on Vitamin B6 Therapeutic Use for Patients: Guidance on Safe Dosage, Duration and Clinical Management

Purpose

Vitamin B6 is a crucial water-soluble vitamin found in many foods and is involved in numerous physiological processes, including neurotransmitter synthesis and nervous system function. Although essential for overall health, both deficiency and excessive intake of vitamin B6 may lead to health complications, particularly peripheral neuropathy. This consensus statement aims to provide healthcare professionals with clear guidance on the safe and effective use of vitamin B6, focusing on its benefits, risks, recommended dosages, and treatment course.

Methods

This consensus statement was developed using a Delphi approach involving a panel of six experts from various medical specialties. This process includes a comprehensive literature review, two rounds of anonymous online surveys, and a virtual expert roundtable discussion. The GRADE approach was used to assess the quality of evidence for each recommendation.

Results

The expert panel reached consensus on five key statements. These key recommendations encompass the function of vitamin B6, complications due to vitamin B6 deficiency, dosage recommendations, adverse events, and monitoring guidance throughout the course of treatment. A washout period of 20-40 days for the complete clearance of vitamin B6 was calculated based on pharmacokinetic parameters. A clinical pathway for managing patients who might benefit from vitamin B6 treatment was proposed.

Conclusion

This consensus statement highlights the importance of recognizing the benefits and potential risks of vitamin B6. While the therapeutic dosage of vitamin B6 can be beneficial to treat deficiency, excessive intake can lead to adverse effects. This statement emphasizes the need for individualized patient care considering factors such as medical history, lifestyle, and potential drug interactions. Further research is needed to establish clearer dosage guidelines, understand the mechanisms of vitamin B6-induced neurological side effects, and optimize patient outcomes.

Developing Meaningful Score Differences for the Bayley-4 and Vineland-3 in Angelman Syndrome using a Delphi Panel

Objectives

To develop within-patient meaningful score differences (MSDs) on the Bayley Scales of Infant Development, Fourth Edition (Bayley-4), and the Vineland Adaptive Behavior Scales, Third Edition (Vineland-3), for individuals with Angelman syndrome (AS).

Methods

A Delphi method, involving a panel of 19 caregivers of individuals with AS, was used to establish MSDs for Bayley-4 and Vineland-3 Growth Scale Values. MSD was defined as the smallest change that would noticeably impact the daily functioning of an individual with AS or family quality of life in a way that was important to the individual with AS or their family. For each subscale of the Bayley-4 and Vineland-3, the panel was presented with 2 to 4 vignettes describing varying levels of baseline functioning and asked to select a MSD from a range of potential values. An iterative process involving three rounds of ratings and two rounds of discussion was used to build consensus. The median caregiver rating from round 3 was retained as the final recommended MSD value for each vignette.

Results

Final MSD ratings for the five subscales of Bayley-4 and 10 subscales of the Vineland-3 had an agreement rate of 70% or higher. MSD thresholds for each subscale were not single cut-offs, but rather reflected a range of MSD values dependent on level of baseline functioning.

Conclusions

The Delphi Panel method incorporates the caregiver perspective to provide preliminary estimates of what constitutes meaningful within person change on the Bayley-4 and Vineland-3 in individuals with AS with various levels of baseline functioning.

Highlights

⍰ To acquire regulatory approval in drug development, sponsors must demonstrate both statistical significance and clinical meaningfulness of a treatment effect.While several clinical trials are underway in AS, within person meaningful score difference thresholds are not yet established for the most commonly used outcome measures, namely the Bayley and Vineland.⍰ Aligning with FDA guidance, we have developed an innovative qualitative approach using a Delphi panel to incorporate caregiver perspectives in defining meaningful change and generated preliminary patient-informed meaningful score differences (MSDs) for individuals with Angelman Syndrome.⍰ What caregivers of individuals with AS consider to be a MSD on the measures depends primarily on the baseline severity of their child's presentation.

Prioritizing gaps in stroke care: A two-round Delphi process

BACKGROUND

Despite international recognition of stroke as a significant health priority, discrepancies persist between the target values for stroke quality measures and the actual values that are achieved in clinical practice, referred to as gaps. This study aimed to reach consensus among international experts on prioritizing gaps in stroke care.

METHODS

A two-round Delphi process was conducted, surveying an international expert panel in the field of stroke care and cerebrovascular medicine, including patient representatives, healthcare professionals, researchers, policymakers, and medical directors. Experts scored the importance and required effort to close 13 gaps throughout the stroke care continuum and proposed potential solutions. Data were analyzed using descriptive statistics and qualitative analysis methods.

RESULTS

In the first and second Delphi rounds, 35 and 30 experts participated, respectively. Expert consensus was reached on the high importance of closing 11 out of 13 gaps. Two out of 13 gaps were considered moderately important to close, with expert consensus for one of these two gaps. Expert consensus indicated that only one gap, related to the prevention of complications after stroke, requires moderate effort to close, whereas the others were considered to require high effort to close. Key focus areas for potential solutions included: "Care infrastructure," "Geographic disparities," "Interdisciplinary collaboration," and "Advocacy and funding."

CONCLUSIONS

While closing gaps in stroke care primarily requires high effort and substantial resources, targeted interventions in the identified key focus areas may provide feasible and clinically meaningful improvements.

Methodology used to develop the minimum common data elements for surveillance and Reporting of Musculoskeletal Injuries in the MILitary (ROMMIL) statement

Background

The objective was to summarize the methodology used to develop the international minimum data elements for surveillance and Reporting of Musculoskeletal Injuries in the MILitary (ROMMIL) statement. This is a recommended list of elements to be collected and reported when conducting injury surveillance research in military settings.

Methods

A Delphi methodology was employed to reach consensus. Preliminary steps included conducting a literature review and surveying a convenience sample of military stakeholders to 1) identify barriers and facilitators of military musculoskeletal injury (MSKI) prevention programs, 2) identify relevant knowledge gaps, and 3) establish future research priorities. A sequential three-round Delphi consensus survey followed, including relevant stakeholders from militaries around the world, using results to conduct an asynchronous knowledge user meeting (mixture of in-person and live video conference and recording) to explore the level of agreement among subject matter experts. Knowledge users, including former and current military service members, civilian practitioners working in military health networks, and international subject matter experts having experience with policy, execution, or clinical investigation of MSKI mitigation programs, MSKI diagnoses, and MSKI risk factors in military settings. For each round, participants scored questions on a Likert scale of 1-5. Scores ranged from No Importance (1) to Strong Importance (5).

Results

Literature review and surveys helped inform the scope of potential variables. Three rounds were necessary to reach minimum consensus. Ninety-five, 65, and 42 respondents participated in the first, second and third rounds, respectively.

Conclusions

Achieving consensus across relevant knowledge users representing military organizations globally can be challenging. This paper details the methodology employed to reach consensus for a core minimum data elements checklist for conducting MSKI research in military settings and improve data harmonization and scalability efforts. These methods can be used as a resource to assist in future consensus endeavors of similar nature.

The road to successful implementation of innovation in radiotherapy: A research-based implementation protocol

BACKGROUND AND PURPOSE

Radiotherapy (RT) is rapidly advancing, yet only 50 % of innovations are implemented promptly. Despite the availability of Implementation Science (ImpSci) theories, models, and frameworks (TMFs), a theory-practice gap persists in effectively applying these insights in RT clinical practice. This study aims to develop a consensus-based implementation protocol for RT innovations using validated ImpSci knowledge.

MATERIAL AND METHODS

A literature review of TMFs (May-August 2023) and 20 semi-structured interviews with Dutch RT professionals (August-December 2023) identified key RT components for implementation. These insights informed a draft RT implementation protocol, which was refined through a three-round international Delphi study (March-September 2024) involving 11 RT and 5 ImpSci experts. Consensus was determined using a 5-point Likert scale, analysing medians, interquartile ranges (IQRs), and percentage scoring.

RESULTS

The Knowledge-to-Action (KTA) Framework and input from expert interviews were used to draft the protocol. Delphi response rates were 100 %, 93.8 %, and 88.9 % across rounds. In round 1, 88.9 % of elements achieved consensus (median = 4.0, IQR = 0.0-1.3); only the application of a prediction model for timely implementation (step 3c) needed revision after rounds 1 and 2. In round 3, also for step 3c consensus was reached (median = 4.0, IQR = 0.3). The protocol includes defining innovation types, stakeholder analysis, tailored implementation strategies, and a phased evaluation plan to ensure sustainability.

CONCLUSION

This is the first consensus-based RT innovation implementation protocol, addressing the theory-practice gap with a structured clinical approach. Future research should validate the protocol and assess the impact of preparation on implementation success.

Development and validation of the social frailty scale for the older adult in China

Objectives

Existing social frailty instruments are not tailored to the linguistic and cultural characteristics of Chinese-speaking patients; a version addressing this gap will increase clinical understanding of their healthcare experience and may help guide social frailty. To develop a Chinese version of a Social Frailty Scale (CVSFS) for the older adult and to examine the psychometric properties of this instrument.

Method

Based on the recommendations of the COSMIN guidelines, the scale development inclued three phases: development of the initial scale, optimisation of scale items, and validation test for scale. The initial CVSFS 1.0 version was developed through literature review, semi-structured interviews, research team discussion, and Delphi method. Then, cross-sectional survey was conducted (n = 265) and scale items were optimized based on the survey results using item analysis and exploratory factor analysis (EFA) to form CVSFS 2.0 version. Lastly, the cross-sectional survey (n = 287) was repeated using CVSFS 2.0 version, and the reliability and validity of the scale's measurement properties were tested.

Results

The initial scale stage of development formed a 42-item CVSFS 1.0 version. After item analysis and EFA, six items were excluded to form a four-dimension with 36-item CVSFS 2.0 version including individual level, family level, interpersonal level, community and social level. The CVSFS 2.0 version demonstrated good reliability and validity, with a Cronbach's α coefficient of 0.926 and a McDonald's ω estimate of 0.931, split-half reliability of 0.928, and test-retest reliability of 0.978. The I-CVI of the scale was calculated to be 0.889~1.000, and the S-CVI/Ave was 0.930. Confirmatory factor analysis results indicated satisfactory fit indices: χ2/df = 2.17, GFI = 0.813, TLI = 0.932, CFI = 0.937, RMSEA = 0.064.

Conclusions

The CVSFS 2.0 version developed in this study based on a social-ecological framework has high reliability and validity, making it a suitable instrument for evaluating social frailty among the older adult in China.

Prevention strategies against academic burnout: the perspective of Romanian health sciences students in the aftermath of the COVID-19 pandemic

Background

Burnout in academia can have important long-term consequences. This study aimed to investigate academic burnout and the perception of its prevention strategies among Romanian health sciences students.

Methods

Three hundred and five health sciences students (from General Medicine, Dental Medicine, Pharmacy, and Midwifery and Nursing) (36 men, 269 women, mean age 21.9, standard deviation 1.911) self-rated their burnout using the Burnout Assessment Tool (BAT) and a visual analog scale, and answered a survey with open and closed questions about the most effective coping strategies to prevent burnout.

Results

Above average scores (mean = 3.05; SD = 0.67) on burnout were met (with the highest scores on exhaustion and psychological distress and the lowest on mental distance and psychosomatic symptoms). Women were more affected than men by burnout and associated emotional impairment and secondary symptoms. Participants rated supportive relationships as the most effective in preventing burnout (mean = 3.75; SD = 0.55), followed by relaxation-meditation (mean = 3.32; SD = 0.85), while they also positively valued cognitive-behavioral therapy (those with high burnout scores), and physical activity (those with low burnout scores). Organizational strategies have included re-evaluating the university curriculum (mean = 3.83; SD = 0.48) and increasing access to psychological support programs (mean = 3.72; SD = 0.58) and to programs that increase self-efficacy and resilience (mean = 3.65; SD = 0.61). The qualitative analysis showed that freely chosen individual strategies included, in descending order, detachment, active actions, healthy lifestyle, and specialist help, while the most preferred organizational were better academic organization and program optimization.

Conclusion

These results may be useful in designing more sustainable and effective burnout prevention strategies in health sciences academic settings.

Adaptation and modification of the professional identity formation scale for postgraduate trainees in basic health science: a mixed method study

BACKGROUND

The professional identity formation (PIF) of postgraduate trainees in basic health sciences is critical to their educational journey. Yet, appropriate measurement tools are lacking. This research aimed to adapt and modify an existing PIF scale to assess the professional identities of postgraduate basic health sciences trainees.

METHODS

A mixed-method study was conducted to validate a modified PIF scale. An instrument was developed following AMEE Guide 87 (A. R. Artino et al.) (1). Seven medical educationalists and basic health science postgraduate supervisors established its content validity and reliability. Cognitive interviews were conducted with 15 participants, and the tool was validated through the Delphi technique. Piloting was undertaken on a simple random sample of 500 postgraduate trainees. Psychometric analyses, including structure factor analysis, internal consistency testing, and qualitative content analysis, were used to evaluate the modified scale.

RESULTS

Five factors related to professional identity formation were identified: "Commitment to Professional Identity, belonging and Values," "Pursuit of Knowledge and Excellence," "Professional Growth and Collaboration," Personal Growth and Reflection," and "Confidence and impact." The modified PIF scale demonstrated robust psychometric properties, including a well-defined factor structure, significant reliability, and high internal consistency. With a Cronbach alpha 0.97, the PIF scale's five kept variables accounted for 99.99% of the variance.

CONCLUSIONS

The study found the modified PIF scale to be a reliable tool for assessing the professional identities of postgraduate trainees in basic health sciences. It developed a 50-item tool with five valid factors to evaluate professional identity for postgraduate trainees.

Development of a classification system for potential sources of error in robotic-assisted spine surgery

PURPOSE

Robotic-assisted spine surgery (RASS) has increased in prevalence over recent years, and while much work has been done to analyze differences in outcomes when compared to the freehand technique, little has been done to characterize the potential pitfalls associated with using robotics. This study's goal was to leverage expert opinion to develop a classification system of potential sources of error that may be encountered when using robotics in spine surgery. This not only provides practitioners, particularly those in the early stages of robotic adoption, with insight into possible sources of error but also provides the community at large with a more standardized language through which to communicate.

METHODS

The Delphi method, which is a validated system of developing consensus, was utilized. The method employed an iterative presentation of classification categories that were then edited, removed, or elaborated upon during several rounds of discussion. Voting took place to accept or reject the individual classification categories with consensus defined as ≥ 80% agreement.

RESULTS

After a three-round iterative survey and video conference Delphi process, followed by an in-person meeting at the Safety in Spine Surgery Summit, consensus was achieved on a classification system that includes four key types of potential sources of error in RASS as well as a list of the most commonly identified sources within each category. Initial sources of error that were considered included: cannula skidding/skive, penetration, screw misplacement, registration failure, and frame shift. After completion of the Delphi process, the final classification included four major types of pitfalls including: Reference/Navigation, Patient Factors, Technique, and Equipment Factors (available at https://safetyinspinesurgery.com/ ).

CONCLUSION

This work provides expert insight into potential sources of error in the setting of robotic spine surgery. The working group established four discrete categories while providing a standardized language to unify communication.

Identifying the attributes of adherence to tuberculosis treatment in Indonesia: A Delphi study

Adherence to tuberculosis (TB) treatment is essential for achieving successful health outcomes. Establishing a consensus among healthcare professionals regarding the definition and key attributes of adherence to TB treatment is essential. The aim of this study was to explore the perspectives of experts and patients on the attributes of adherence to TB treatment. A total of 20 TB specialists and 10 pulmonary TB patients from various regions in Indonesia participated in a three-round Delphi study designed to categorize and validate these attributes. In the first round, participants were interviewed to gather qualitative insights. In the second and third rounds, experts assessed the level of agreement on identified attributes using a five-point Likert scale. The strength of consensus was measured using the interquartile range (IQR), following the best practices outlined in the Conducting and REporting DElphi Studies (CREDES) guidelines. The experts achieved a substantial consensus, with over 85% agreement on the identified attributes. The findings indicated that adherence to TB treatment encompasses the ability of pulmonary TB patients to follow agreed-upon recommendations, including both medication adherence and lifestyle modifications. These lifestyle changes include improved nutritional care, smoking cessation, abstaining from alcohol, stress management, improved physical activity, better sleep, and rest quality, and preventive behaviors related to TB. In conclusion, the findings enhanced the understanding of adherence to TB treatment by highlighting its multifaceted nature. The consensus emphasized that adherence extends beyond medication-taking behaviors to include essential lifestyle changes, underscoring the comprehensive approach needed to support TB patients effectively.

International consensus on research priorities in hypospadias using a Delphi study approach

INTRODUCTION

Hypospadias is a common congenital anomaly of the male genitalia that poses significant management and treatment challenges. Gaining a comprehensive understanding of priority research questions in hypospadiology will be essential to reach agreement on the optimal approach to assessment, treatment, and outcome prediction for affected patients.

METHODS

We employed a consensus-building Delphi method to identify and prioritize research questions in the hypospadias field. Additionally, we integrated questions sourced from the artificial intelligence platform ChatGPT to capture multiple perspectives. Engaging a diverse panel of experts including clinicians, researchers, and patient advocates from across the globe, the Delphi process aimed to distill collective expertise and insights through iterative rounds of structured questionnaires and feedback.

RESULTS

The analysis identified key themes in hypospadias research, covering etiology, tissue engineering, pre-clinical models, device/technology evaluation, phenotyping, surgical techniques, surgical training and postoperative outcomes. These themes highlight crucial areas for future investigation to improve understanding of hypospadias, treatment options, and patient outcomes, thereby guiding both research and clinical practice.

DISCUSSION

By harnessing the collective wisdom and perspectives of multiple stakeholders, this Delphi study establishes a roadmap for prioritizing research initiatives to effectively unravel the complexities of hypospadias. Integration of ChatGPT outputs into our Delphi-based approach also outlined how future studies can harness the collective wisdom of human experts together with artificial intelligence methods. The outcomes of this novel endeavor hold promise for shaping future research agendas, informing clinical practice guidelines, and fostering multidisciplinary collaborations to drive innovation and ultimately improve outcomes for hypospadias patients worldwide.

Baby steps to mastery: building blocks for novices in pediatric regional anesthesia

Pediatric regional anesthesia offers significant benefits, yet its adoption faces barriers, including perceived overcomplexity. This study aimed to identify and establish a set of core, high-value, low-complexity nerve blocks to improve perioperative pain management in pediatric patients. A four-round modified Delphi consensus study was conducted with an international panel of pediatric and regional anesthesia experts. An initial long list of regional techniques was compiled by the Steering Committee and refined through iterative input. Panelists rated each technique on a 10-point Likert scale for importance. Consensus was defined as ≥75% of panelists assigning a mean importance score of ≥8. Techniques receiving 50%-74% agreement were categorized as having strong agreement and considered for inclusion. The final selection was confirmed through a virtual roundtable discussion. Thirty-three experts representing 12 pediatric and regional societies participated. Consensus was reached on six regional techniques, with strong agreement (*) on two additional techniques, identifying eight core pediatric regional anesthesia blocks: supraclavicular brachial plexus block, rectus sheath block, transverse abdominis plane block*, suprainguinal fascia iliaca block*, femoral nerve block, adductor canal block, popliteal sciatic nerve block, and landmark-based caudal block. This consensus-driven framework defines a core set of pediatric regional anesthesia techniques that balance clinical effectiveness, feasibility, and accessibility. These findings provide a practical entry point for practitioners looking to incorporate pediatric regional anesthesia into their practice, regardless of prior experience. Future efforts should focus on standardized training, implementation research, and policy initiatives to support widespread adoption and improve perioperative pain management in children globally.

Structured Exercise Program for Hip Arthroplasty: An Expert Consensus Using the Delphi Technique

Background

A structured exercise program following hip arthroplasty for hip fractures is crucial for improving patients' physical function and quality of life. Despite the increasing incidence of hip fractures, there is a dearth of literature on exercise programs for hip arthroplasty performed for fractures. This study aimed to obtain an expert consensus on a structured exercise program for hip arthroplasty patients.

Methods

A literature search was performed in electronic databases such as PubMed, Web of Science, PEDro, and Scopus, and evidence was pooled and formulated into items for the protocol. A three-round, online modified Delphi survey was conducted to validate the results of the framed exercise protocol which included national and international physiotherapy experts as panelists.

Results

In round 1, 59 items about rehabilitation were mailed to the panelists, and 50 items reached a consensus. Round 2 had 19 items, and 13 items reached a consensus. Consensus was sought on items for which the authors disagreed by sending them for review before the next round. In round three, a model exercise program was framed based on the results of previous rounds and was mailed to the panelists for their feedback. Based on their comments and suggestions, the framework of the structured exercise program was finalized.

Conclusions

Based on the results of the Delphi survey, the exercise protocol for hip arthroplasty was framed and validated. The validated exercise program can serve as guidance for physiotherapists in enhancing optimal recovery following hip arthroplasty.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-025-01335-3.

Setting the foundation for a national collaborative learning health system in acute TBI rehabilitation: CARE4TBI Year 1 experience

Introduction

A learning health system (LHS) approach is a collaborative model that continuously examines, evaluates, and re-evaluates data eventually transforming it into knowledge. High quantity of high-quality data are needed to establish this model. The purpose of this article is to describe the collaborative discovery process used to identify and standardize clinical data documented during daily multidisciplinary inpatient rehabilitation that would then allow access to these data to conduct comparative effectiveness research.

Methods

CARE4TBI is a prospective observational research study designed to capture clinical data within the standard inpatient rehabilitation documentation workflow at 15 TBI Model Systems Centers in the US. Three groups of stakeholders guided project development: therapy representative work group (TRWG) consisting of frontline therapists from occupational, physical, speech-language, and recreational therapies; rehabilitation leader representative group (RLRG); and informatics and information technology team (IIT). Over a 12-month period, the three work groups and research leadership team identified the therapeutic components captured within daily documentation throughout the duration of inpatient TBI rehabilitation.

Results

Data brainstorming among the groups created 98 distinct categories of data with each containing a range of data elements comprising a total of 850 discrete data elements. The free-form data were sorted into three large categories and through review and discussion, reduced to two categories of prospective data collection-session-level and therapy activity-level data. Twelve session data elements were identified, and 54 therapy activities were identified, with each activity containing discrete sub-categories for activity components, method of delivery, and equipment or supplies. A total of 561 distinct meaningful data elements were identified across the 54 activities.

Discussion

The CARE4TBI data discovery process demonstrated feasibility in identifying and capturing meaningful high quantity and high-quality treatment data across multiple disciplines and rehabilitation sites, setting the foundation for a LHS coalition for acute traumatic brain injury rehabilitation.

Consensus on the Potential of Large Language Models in Healthcare: Insights from a Delphi Survey in Korea

OBJECTIVES

Given the rapidly growing expectations for large language models (LLMs) in healthcare, this study systematically collected perspectives from Korean experts on the potential benefits and risks of LLMs, aiming to promote their safe and effective utilization.

METHODS

A web-based mini-Delphi survey was conducted from August 27 to October 14, 2024, with 20 selected panelists. The expert questionnaire comprised 84 judgment items across five domains: potential applications, benefits, risks, reliability requirements, and safe usage. These items were developed through a literature review and expert consultation. Participants rated their agreement or perceived importance on a 5-point scale. Items meeting predefined thresholds (content validity ratio ≥0.49, degree of convergence ≤0.50, and degree of consensus ≥0.75) were prioritized.

RESULTS

Seventeen participants (85%) responded to the first round, and 16 participants (80%) completed the second round. Consensus was achieved on several potential applications, benefits, and reliability requirements for the use of LLMs in healthcare. However, significant heterogeneity was found regarding perceptions of associated risks and criteria for safe usage of LLMs. Of the 84 total items, 52 met the criteria for statistical validity, confirming the diversity of expert opinions.

CONCLUSIONS

Experts reached a consensus on certain aspects of LLM utilization in healthcare. Nonetheless, notable differences remained concerning risks and requirements for safe implementation, highlighting the need for further investigation. This study provides foundational insights to guide future research and inform policy development for the responsible introduction of LLMs into the healthcare field.

Technical skills assessment during simulated cleft lip repair

INTRODUCTION

Cleft lip repair is a challenging procedure with a steep learning curve. A cleft lip simulator can augment the operating experience to shorten the learning curve. This study evaluated the efficacy of a high-fidelity cleft lip simulator using a newly developed cleft lip technical assessment tool.

METHODS

Four plastic surgery residents and 6 fellows performed 3 sequential cleft lip repairs. Three staff surgeons performed 1 cleft lip repair. Each procedure was video recorded and assessed by 3 staff cleft surgeons using a newly developed cleft lip technical assessment scale and a previously developed global rating scale. The reliability (intraclass correlation coefficient [ICC]) of the assessment scores was determined. The first simulation session was compared among participants to determine whether the scales and simulator could distinguish between skill level. Learning curves were determined using successive assessment scores among the trainees.

RESULTS

The average ICC for the cleft lip-specific and global scores were 0.72 (range 0.65-0.82) and 0.70 (range 0.60-0.79), respectively. All scale items demonstrated statistically significant interrater reliability. The staff surgeons significantly outperformed the trainees in the first simulation session for both assessment scores (p < 0.05). The trainees demonstrated improved performance after each session.

CONCLUSIONS

A cleft lip assessment scale was developed and found to be reliable at evaluating technical skill in simulated cleft lip repair. Repeated use of the cleft lip simulator improved performance in simulated cleft lip repair.

Consensus on Symptom Selection for Endometriosis Questionnaires: A Modified e-Delphi Study

OBJECTIVE

To build consensus on most important symptoms and related consequences for use in questionnaires to characterise individuals with suspected and confirmed endometriosis in the general population.

DESIGN

A questionnaire of 107 symptoms and related consequences of endometriosis was collaboratively developed by patients, medical doctors and researchers and further assessed in a two-round e-Delphi study. Participants assessed the relevance of the symptoms, and a priori it was decided that 70% was the threshold for inclusion of a symptom.

SETTING

Participants represented 7 countries, including Australia, Denmark, France, Hungary, the United Kingdom, the United States, and Turkey.

POPULATION

Individuals with endometriosis, medical doctors and researchers with expertise in endometriosis.

METHODS

A modified e-Delphi study.

MAIN OUTCOME MEASURES

Consensus-based selection of symptoms for endometriosis questionnaires.

RESULTS

Seventy-six participants completed the first Delphi round and 65 completed the second round. Four symptoms met consensus in the first round (menstrual pain, pain during sexual intercourse, cyclic pain during defecation, and infertility), with two additional symptoms reaching consensus in the second round (cyclic pain and increased doctor/health care contacts for abdominal/pelvic pain).

CONCLUSION

This study highlighted six symptoms relevant for inclusion in endometriosis research questionnaires: menstrual pain, pain during sexual intercourse, cyclic pain during defecation, cyclic pain, infertility, and a high number of doctor/health care visits due to abdominal/pelvic pain. Recognising a broad range of potential symptoms is essential for raising awareness and supporting early detection efforts.

A Delphi consensus project to capture experts' opinion on hyperkalaemia management across the cardiorenal spectrum

The main purpose of this project was to capture experts' opinion on hyperkalaemia management and form best practice recommendations for cardiorenal patients in Greece. A steering committee of nephrologists and cardiologists developed 37 statements. An online questionnaire completed by 32 experts in cardiorenal management in Greece. Median score used to determine the level of agreement and disagreement index (DI) used to determine the level of consensus for each statement. Statements divided in four sectors: hyperkalaemia risk management, preventative measures, treatment and collaboration between specialties. The rate of the first round of the consensus was 94.6%. Median score was >7 for 36 of 37 statements and DI ≤ 1 for 35 of 37. Among other statements, consensus reached for recognizing levels K+ > 5.0 mEq/L as associated with elevated mortality risk; retaining renin-angiotensin-aldosterone system inhibitors (RAASi) on maximum recommended dose for cardiorenal patients; and using novel K+ binders to help enabling guideline-recommended doses of RAASi therapy. Cardiologists compared to nephrologists showed higher reluctance to discontinue down-titrate RAASi and MRA in patients with K+ levels above 5 mEq/L. Additionally, 88.9% of nephrologists and 71.4% of cardiologists agreed that cross-specialty alignment on a serum K+ concentration level (K > 5.5 mEq/L) is needed to initiate hyperkalaemia treatment. Both cardiologists and nephrologists showed disagreement with the statement on keeping titration in cardiorenal patients with K+ > 5.5 mEq/L or preserving fruit and vegetable consumption when moderate or severe hyperkalaemia exhibits. This Delphi project pointed out nephrologists' and cardiologists' agreement on hyperkalaemia management in cardiorenal patients; thus, it can help a cross-specialty optimal management of cardiorenal patients, with hyperkalaemia not being an obstacle for disease-optimizing therapy. Novel potassium binding agents can enable guideline-recommended doses of potassium-sparing medication.

Revitalising traditional Indian games: inclusive game adaptations for children with cerebral palsy

BACKGROUND

Children with cerebral palsy (CP) present unique challenges to physical activity due to various factors. Despite the benefits of inclusive approaches and adapted physical education, low- and middle-income countries face specific barriers including environmental, equipment, personal, policy, social and professional barriers. Traditional Indian games, with their cultural significance and potential therapeutic benefits, offer a promising avenue for inclusive adaptations. At present we couldn't find any studies that explore's the method of adaptation of traditional Indian games for children with cerebral palsy of varying functional levels.

PURPOSE

The aim of the study was to explore the adaptation of traditional Indian games for children with CP of varying functional levels.

METHODS

Traditional Indian games were identified through ethnographic qualitative research, and adapted using the Delphi process involving experts from various fields. A total of 10 traditional games were selected based on their health benefits using an operationalised conceptual model. The CHANGE IT model of adapted physical activity was used to systematically adapt each game. Validation of the model was then performed on children with CP [a smaller sample size, n = 10] with different levels of functioning.

RESULTS

The games varied in playing positions, surfaces and phases. Modifications included changes in game rules, play environment, equipment and time duration. The study validation through informal interview among the parents of CP children revealed that adapted traditional game protocol shown improvements in their children's activity levels and participation.

CONCLUSIONS

While this is a preliminary exploration, no firm conclusion can be drawn. The model presented in this study lays the foundation for future randomised controlled trials to validate the effects of adapted traditional Indian games on children with cerebral palsy of different functional levels.