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.

Identification of differentially expressed genes in resting human skeletal muscle of sedentary versus strength and endurance- trained individuals using bioinformatics analysis and in vitro validation

Understanding the molecular mechanisms underlying skeletal muscle adaptation to different training regimens is essential for advancing muscle health and performance interventions. The aim of this study was to investigate molecular and genetic adaptations in the resting skeletal muscle of sedentary individuals compared to strength- and endurance-trained athletes using bioinformatics and in vitro validation. Differentially expressed genes (DEG) analysis of the GSE9405 dataset was conducted. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses were performed, followed by protein-protein interaction (PPI) network analysis and receiver operating characteristic (ROC) analysis. To validate the bioinformatics findings, the expression of two identified genes was assessed using real-time polymerase chain reaction (PCR) in professional athletes and age-matched non-athletes. Analysis of RNA expression profiles from the GSE9405 dataset identified 426 DEGs, with 165 upregulated and 261 downregulated in trained individuals. Enrichment analysis highlighted pathways related to metabolic efficiency, mitochondrial function, and muscle remodeling, all crucial for athletic performance. PRKACA and CALM3 were identified as key upregulated genes in trained individuals with central roles in these pathways. The area under the curve (AUC) values for CALM3 and PRKACA were 0.8558 and 0.8846, respectively, for differentiating the two groups. Validation in human samples confirmed that CALM3 expression was significantly higher in athletes (p = 0.00i), suggesting its critical role in muscle adaptation. However, PRKACA expression differences between the groups were not statistically significant (p = 0.32i). These findings provide insights into gene-level responses to long-term training, offering a basis for targeted interventions to enhance muscle health and athletic performance.

Therapeutic potential of synthetic and natural iron chelators against ferroptosis

Ferroptosis, a regulated form of cell death, is characterized by iron accumulation that results in the production of reactive oxygen species. This further causes lipid peroxidation and damage to the cellular components, eventually culminating into oxidative stress. Recent studies have highlighted the pivotal role of ferroptosis in the pathophysiological development and progression of various diseases such as β-thalassemia, hemochromatosis, and neurodegenerative disorders like AD and PD. Extensive efforts are in progress to understand the molecular mechanisms governing the role of ferroptosis in these conditions, and chelation therapy stands out as a potential approach to mitigate ferroptosis and its related implications in their development. There are currently both synthetic and natural iron chelators that are being researched for their potential as ferroptosis inhibitors. While synthetic chelators are relatively well-established and studied, their short plasma half-life and toxic side effects necessitate the exploration and identification of natural products that can act as efficient and safe iron chelators. In this review, we comprehensively discuss both synthetic and natural iron chelators as potential therapeutic strategies against ferroptosis-induced pathologies.

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.

Comparative Efficacy and Acceptability of Non-surgical Treatments with or without Exercise for Diastasis Recti Abdominis in Postpartum Women: A Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Diastasis recti abdominis (DRA), commonly occurring in postpartum women, is not only an aesthetic issue but is also highly associated with functional impairments. Various conservative treatment modalities have been employed in clinical practice to alleviate DRA. However, the comparative efficacy of these non-surgical treatments for improving the inter-recti distance (IRD) remains to be determined.

AIM

This current network meta-analysis (NMA) aims to compare the efficacy and acceptability of different non-surgical treatments with or without exercise for improving DRA in postpartum women.

METHODS

This NMA adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. ClinicalKey, Cochrane Library, CINAHL, Embase, PubMed, Web of Science, and ClinicalTrials.gov were systematically searched for randomized controlled trial (RCT) studies up to April 2024. The analysis included studies that met the following criteria: (1) postpartum women diagnosed with DRA defined as an IRD greater than 2 cm; (2) intervention: any non-surgical treatments for at least 2 weeks; (3) comparator: no-treatment control; and (4) outcome: changes in IRD and acceptability. The relative efficacy between the non-surgical treatments tested and the probability of treatments were evaluated.

RESULTS

Twenty-one RCTs comprising 1195 participants aged from 18 to 45 years old were included. The forest plot revealed that exercise coupling with neuromuscular electrical stimulation systems (NMES) [mean difference (MD) - 1.12 cm, 95% confidence interval (CI) - 1.66 to - 0.58], acupuncture (MD - 0.81 cm, 95% CI - 1.54 to - 0.08), corset (MD - 0.65 cm, 95% CI - 1.24 to - 0.06), and exercise alone (MD - 0.48 cm, 95% CI - 0.80 to - 0.16) led to significant reductions in IRD compared with control. Further, the treatment ranking indicated that the combination of NMES with exercise has the highest probability (91.0%) of being the best treatment for reducing IRD, followed by acupuncture with exercise (71.1%). Treatments combined with exercise demonstrated better rankings for reducing IRD than individual treatments without exercise. Acceptability did not significantly differ between the groups.

LIMITATIONS AND IMPLICATIONS

This NMA encountered limitations due to participant variability, differing measurement methods, and sparse data, necessitating careful interpretation of findings regarding postpartum DRA interventions.

CONCLUSIONS

This NMA suggests NMES combined with exercise as the best treatment tested for DRA in postpartum women.

PROSPERO REGISTRATION

CRD42024541345.

Update on the Seroepidemiology of Human Cystic Echinococcosis and Associated Risk Factors in Iran: A Systematic Review and Meta-Analysis

Background and Aims

Cystic echinococcosis (CE) poses a significant public health challenge in developing countries, including Iran. This systematic review and meta-analysis aim to enhance our understanding of CE prevalence by providing an updated assessment of the general prevalence of human CE in Iran through a comprehensive review of the literature.

Methods

PubMed, Scopus, Web of Science, Google Scholar, Magiran, and Scientific Information Database (SID) databases were searched for relevant literature published between January 1990 and December 2023. All peer-reviewed original papers evaluating the seroprevalence of human CE were included. Meta-analysis was performed using a random-effects model with 95% confidence intervals (CIs). Heterogeneity among the included studies was assessed using Cochran's Q and I 2 tests. The funnel plot and Egger's test were used to evaluate potential publication bias.

Results

Sixty-eight studies met the inclusion criteria. The overall seroprevalence of human CE in Iran's general population was 4% (95% CI 3%-6%). Significant differences in seropositivity to human CE were observed among age groups, urban versus rural residence, diagnostic methods, and in relation to the presence of dogs at home or on farm. Substantial heterogeneity was observed across the included studies (I 2 = 99.47%; p < 0.001). The funnel plot and Egger's test revealed considerable publication bias (Egger's test; p < 0.001).

Conclusion

Our findings demonstrate that CE remains prevalent in Iran, necessitating intensified health interventions and the development of targeted strategies for prevention and control. Recommendations include deworming dogs with praziquantel and vaccination of sheep with recombinant EG95 protein, removing raw offal or carcasses from the diet of dogs, hand washing, fencing of slaughterhouses with offal disposal systems, community participation for the control program and screening strategies for the diagnosis of asymptomatic cases and their timely treatment.

Reactive Oxygen Species as a Common Pathological Link Between Alcohol Use Disorder and Alzheimer's Disease with Therapeutic Implications

Chronic alcohol consumption leads to excessive production of reactive oxygen species (ROS), driving oxidative stress that contributes to both alcohol use disorder (AUD) and Alzheimer's disease (AD). This review explores how ROS-mediated mitochondrial dysfunction and neuroinflammation serve as shared pathological mechanisms linking these conditions. We highlight the role of alcohol-induced oxidative damage in exacerbating neurodegeneration and compare ROS-related pathways in AUD and AD. Finally, we discuss emerging therapeutic strategies, including mitochondrial antioxidants and inflammasome inhibitors, that target oxidative stress to mitigate neurodegeneration. Understanding these overlapping mechanisms may provide new insights for preventing and treating ROS-driven neurodegenerative disorders.

Initial Experience of Metabolic Imaging With Hyperpolarized [1-13C]pyruvate MRI in Kidney Transplant Patients

BACKGROUND

Kidney transplant is the treatment of choice for patients with end-stage renal disease. Early detection of allograft injury is important to delay or prevent irreversible damage.

PURPOSE

To investigate the feasibility of hyperpolarized (HP) [1-13C]pyruvate MRI for assessing kidney allograft metabolism.

STUDY TYPE

Prospective.

SUBJECTS

Six participants (mean age, 45.2 ± 12.4 years, two females) scheduled for kidney allograft biopsy and five patients (mean age, 59.6 ± 10.4 years, two females) with renal cell carcinoma (RCC).

FIELD STRENGTH/SEQUENCE

Three Tesla, T2-weighted fast spin echo, multi-echo gradient echo, single shot diffusion-weighted echo-planar imaging, and time-resolved HP 13C metabolite-selective imaging.

ASSESSMENT

Five of the six kidney allograft participants underwent biopsy after MRI. Estimated glomerular filtration rate (eGFR) and urine protein-to-creatine ratio (uPCR) were collected within 4 weeks of MRI. Kidney metabolism was quantified from HP [1-13C]pyruvate MRI using the lactate-to-pyruvate ratio in allograft kidneys and non-tumor bearing kidneys from RCC patients.

STATISTICAL TESTS

Descriptive statistics (mean ± SD).

RESULTS

Biopsy was performed a mean of 9 days (range 5-19 days) after HP [1-13C]pyruvate MRI. Three biopsies were normal, one showed low-grade fibrosis and one showed moderate microvascular inflammation. All had stable functioning allografts with eGFR >60 mL/min/1.73 m2 and normal uPCR. One participant who did not undergo biopsy had reduced eGFR of 49 mL/min/1.73 m2 and elevated uPCR. The mean lactate-to-pyruvate ratio was 0.373 in participants with normal findings (N = 3) and 0.552 in participants with abnormal findings (N = 2). The lactate-to-pyruvate ratio was highest (0.847) in the participant with reduced eGFR and elevated uPRC. Native non-tumor bearing kidneys had a mean lactate-to-pyruvate ratio of 0.309.

DATA CONCLUSION

Stable allografts with normal findings at biopsy showed lactate-to-pyruvate ratios similar to native non-tumor bearing kidneys, whereas allografts with abnormal findings showed higher lactate-to-pyruvate ratios.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 2.

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.

Early Identification and Referral of Patients With Diabetic Foot Complications in the Emergency Department

BACKGROUND

Prolonged length of stay (LOS) in the emergency department (ED) and lack of post-ED follow-up pose a risk of worsening infection and amputation among patients with diabetic foot complications.

LOCAL PROBLEM

Excessive ED LOS posed a risk of delayed foot care, and triage providers underutilized post-ED telehealth referrals.

INTERVENTIONS

A graphic icon on the ED dashboard, nurse-initiated order set, and staff education were implemented.

METHODS

A pre-/postimplementation design was used. Outcomes included usage of the graphic icon and order set, ED LOS, and telehealth referrals.

RESULTS

Use of the graphic icon and order sets significantly increased ( P < .001). The rate of telehealth referrals upon discharge also increased but was not significant ( P = .086). Interestingly, LOS increased after the intervention.

CONCLUSION

Using the graphic icon and order set can streamline patient referral to telehealth care. Various factors lead to an extended LOS.

Music Therapy Intervention Using a Holy Quran Recitation Improves Feeding Status, Weight Gain and Length of Stay Among Preterm Infants in the Neonatal Intensive Care Unit: A Randomized Clinical Trial

BACKGROUND

One of the most important challenges that preterm infants face is nutritional problems. Poor postnatal weight gain can lead to various complications.

PURPOSE

To determine the effects of listening to the Holy Quran on the feeding status, postnatal weight gain, and length of hospital stay of preterm infants.

METHODS

The current randomized clinical trial was conducted in the city of Qazvin in 2024. The samples included 80 preterm infants hospitalized in neonatal intensive care unit, who were randomly assigned to the intervention and control groups (40 in the Holy Quran recitation group and 40 in the control group). In addition to the routine care, the participants in the intervention group listened to the Holy Quran via headphones for 20 minutes 3 times a day, whereas the participants in the control group did not receive any intervention.

RESULTS

The mean days to achieve the first oral feeding ( P < .001), the mean days to achieve full oral feeding ( P < .001), the mean weight gain at the time of achieving the first oral feeding ( P < .046), and the mean length of hospital stay ( P < .001) were significantly lower in the intervention group than in the control group.

IMPLICATIONS FOR PRACTICE AND RESEARCH

In addition to standard treatments, listening to the Holy Quran, as a complementary method, can improve some parameters related to feeding and the quicker discharge of preterm infants.

Application of transformer architectures in generative video modeling for neurosurgical education

PURPOSE

This article explores the potential impact of OpenAI's Sora, a generative video modeling technology, on neurosurgical training. It evaluates how such technology could revolutionize the field by providing realistic surgical simulations, thereby enhancing the learning experience and proficiency in complex procedures for neurosurgical trainees.

METHODS

The study examines the incorporation of this technology into neurosurgical education by leveraging transformer architecture and processing of video and image data. It involves compiling a neurosurgical procedure dataset for model training, aiming to create accurate, high-fidelity simulations.

RESULTS

Our findings indicate significant potential applications in neurosurgical training, including immersive simulations for skill development and exposure to diverse surgical scenarios. The technology also promises to transform assessment and feedback, introducing a standardized, objective way to measure and improve trainee competencies.

CONCLUSION

Integrating generative video modeling technology into neurosurgical education marks a progressive step toward enhancing training methodologies. Despite challenges in technical, ethical, and practical domains, continuous development and evaluation could lead to substantial advancements in surgical education, preparing neurosurgeons more effectively for their demanding roles.

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.

Comparative evaluation of two different doses of nebulized intraperitoneal dexamethasone on postoperative pain in laparoscopic surgeries

Background and Aims

Postoperative pain is a major cause of discomfort after laparoscopic surgeries and thus necessitates prevention and treatment. This study aims to evaluate and compare two different doses of intraperitoneally nebulized (aerosol size: 0.4-4.5 micrometers) dexamethasone for the prevention of postoperative pain.

Material and Methods

In this double-blind, randomized control study, 135 patients undergoing laparoscopic surgeries were randomly assigned to three groups after obtaining ethical committee clearance and CTRI registration. Intraperitoneal nebulization was performed using the Aeroneb device, with group A receiving 16 mg dexamethasone, group B receiving 8 mg dexamethasone, and group C receiving 0.9% normal saline. The primary outcome was assessed by measuring visceral, somatic, and referred pain using a visual analog scale (VAS) at 6 hours postoperatively. Secondary outcomes included VAS at 1 and 24 hours, the hemodynamic response to pneumo-peritoneum, 24-hour anti-emetics, and opioid consumption.

Results

VAS score at 6 hours was 0.9 ± 1.06 in group A, 1.7 ± 1.45 in group B, and 2.3 ± 1.87 in group C for referred pain; the values were statistically significant (P = 0.01). VAS score was 0.7 ± 0.76 in group A, 1.7 ± 1.82 in group B, and 2.2 ± 2.06 in group C for dull aching pain; the results were statistically significant at 24 hours (P = 0.001). None of the values at any time point were statistically significant (P < 0.05) for incisional pain. The rise in heart rate after 5 minutes of pneumoperitoneum was the least in group A compared to group C (P = 0.01). Group C had the highest consumption of anti-emetics and rescue analgesics (P = 0.001).

Conclusions

Intraperitoneal dexamethasone nebulization of 16 mg and 8 mg both are equi-effective in decreasing the severity of pain after laparoscopic surgeries compared to normal saline nebulization (P = 0.001).

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.

British Oncology Pharmacy Association Delphi consensus guidelines: Co-infusion of trometamol-containing calcium folinate (Leucovorin) with systemic anti-cancer treatments

Drug stability and compatibility are critical factors influencing the cost and logistics of treatment delivery, therapeutic effectiveness, and patient safety. This is particularly significant in the realm of cancer chemotherapeutics, where stability and compatibility studies play a vital role in ensuring rational and safe medicine administration. Oxaliplatin, fluorouracil, and irinotecan, commonly used in various combinations for gastrointestinal cancers, are complemented by co-administration of folinic acid in certain protocols. Notably, some folinic acid preparations include trometamol as an excipient, potentially impacting the stability of the chemotherapeutic agents if infused concomitantly. This study seeks to establish guidelines for oncology multidisciplinary teams, addressing potential risks associated with the combination of trometamol-containing folinic acid and chemotherapeutics. To achieve this, a quantitative questionnaire was distributed to members of the British Oncology Pharmacy Association (BOPA) and non-BOPA members through an online survey. Nineteen healthcare professionals with oncology experience, comprising 18 pharmacists and one nurse, completed the questionnaires. Each participant rated the validity and clarity of statements on a 5-point scale. The Delphi process concluded after the fourth round, consolidating the findings and recommendations from the multidisciplinary team. Twelve recommendations for safe practice have been made.

Consensus Recommendations for the Management of Neurosarcoidosis: A Delphi Survey of Experts Across the United States

Background and Objectives

Neurosarcoidosis poses a diagnostic and management challenge due to its rarity, phenotypic variability, and lack of randomized controlled studies to guide treatment selection. Recommendations for management based on expert opinion are useful in clinical practice and provide a framework for designing prospective studies.

Methods

In this Delphi survey study, specialists with experience in managing patients with neurosarcoidosis were invited to anonymously complete 2 surveys about key elements of evaluation, diagnosis, treatment, monitoring, and long-term management of neurosarcoidosis. Expert consensus recommendations were adopted if >80% threshold of agreement was reached.

Results

Of the 41 invited expert clinicians across the United States, 32 (78%) participated in the study. All round 1 respondents self-identified as neuroimmunologists (except for 1 pulmonologist). Consensus was reached regarding the need to consider neurosarcoidosis phenotype and severity to guide the choice of initial immunosuppression in both the acute (relapse) and maintenance phases. Experts endorsed the use of TNF-α inhibitors as first-line agents in selected phenotypes with poor prognosis. Neuroimaging was recommended to complement clinical surveillance for treatment response.

Discussion

There was agreement on several key issues, most importantly on the need to consider neurosarcoidosis phenotype and severity when deciding initial treatment. No consensus was achieved on the dosing and duration of specific immunosuppressants, nor regarding the management of the peripheral nervous system manifestation of neurosarcoidosis. These topics warrant further investigation.

Quality indicators for the community care of MSK conditions: An online modified-Delphi study

BACKGROUND

Quality indicators can be used within healthcare to measure and benchmark performance. Variations in the access and quality of healthcare for musculoskeletal conditions highlights the need for a nationally agreed set of indicators.

OBJECTIVES

The study's primary aim was to develop a set of care quality themes and indicators for musculoskeletal community care.

METHODS

An online Delphi process was used, that included clinicians, managers, researchers, and patients. In round one, participants rated 79 indicators, across six care quality themes, for their importance to quality community musculoskeletal care. Following this, participants discussed the results of the first round in an online panel and then re-rated indicators in a second-round survey. The panel discussion focused on a) the importance rating of indicators, and b) the wording of care quality themes. Consensus for high importance was set at ≥60% in both rounds of the study.

RESULTS/FINDINGS

Forty-six individuals participated in the first round of the study, with 21 participating in the second round. After the second round, six care quality themes emerged: 1) Optimising patient access and assessment, 2) Optimising patient education, self-management, and rehabilitation, 3) Optimising personalised care, 4) Optimising diagnosis, imaging, investigation, and referrals, 5) Optimising patient experience and outcomes, and 6) Population health relevant to musculoskeletal conditions. Within the six themes, 59 indicators were ranked as highly important.

CONCLUSIONS

This study has developed a set of care quality themes and indicators for community musculoskeletal care. In the next stage of indicator development, real-world data will be used to validate the indicators across several constructs.

ChatGPT Answers the 110-Question Laboratory Enzymology Student Exam: Pass or Fail?

Introduction Chatbots like ChatGPT have attracted a lot of interest lately due to their ability to generate human-like responses. Their reliability and accuracy are still questionable, and they are the topic of many studies in different fields. Therefore, the aim of this study was to examine the knowledge of two versions of chatbots regarding laboratory enzymology and to compare it with the average knowledge of students for the purpose of considering the use of ChatGPT in providing answers in this field. Material and methods An exam with 110 questions covering four topics was answered by students and ChatGPT-3.5 and ChatGPT-4.0. The accuracy of the answers of 52 students and ChatGPT was evaluated. The accuracy of answers between students and artificial intelligence was compared, and the percentage of passing the exam was 60%. All responses were reviewed by two authors with full interrater agreement. Results Total scores for students, ChatGPT-3.5, and ChatGPT-4.0 were 85.46%, 52.73%, and 74.55% (p < 0.05), whereby ChatGPT-4.0 achieved better results compared to the other chatbot. ChatGPT-3.5 and ChatGPT-4.0 achieved the best results on questions about enzymes in metabolism. The lowest scores for both chatbots were observed in the laboratory analysis of enzymes. Conclusion ChatGPT showed average results in the Laboratory Enzymology exam and scored lower than students. This proved that chatbots could be a potential tool for learning and eventual implementation in higher and/or medical education with extensive optimization but still cannot replace a human.

Saudi clinical practice guidelines for the treatment and prevention of migraine headache

OBJECTIVE

To develop clinical practice guidelines based on evidence based medicine on the use of abortive and preventive therapies for managing migraine headaches. We formulated these guidelines to offer evidence-based recommendations to improve the knowledge of physicians, healthcare professionals, and policymakers in migraine headache management.

METHOD

A panel of 11 experts from different sectors in Saudi Arabia approved 26 questions on abortive and preventive therapies for migraines. To develop each question, we searched "PubMed" and "Cochrane Library" databases for recent relevant systematic reviews published between 2013 and 2024. We employed the Grading Recommendations, Assessment, Development, and Evaluation methodological approach to ensure the certainty of the collated evidence and to formulate the recommendations. The expert panel voted electronically on each recommendation, and a consensus was defined as >70% agreement.

RESULTS

We formulated a total of 26 recommendations. Of these, 14 are focused on abortive therapy for acute migraine attacks, whereas 12 are focused on the prevention of episodic or chronic migraines. These guidelines strongly recommend the use of paracetamol and ibuprofen as the first-line treatment for mild to moderate migraine. Furthermore, we concluded that propranolol should be considered as the first-line preventive intervention for migraine.

CONCLUSION

The Saudi clinical practice guidelines offer systematically validated recommendations of migraine headaches in adults. The recommendations are potentially beneficial for all healthcare professionals managing patients with migraine headaches.

[What is the potential of ChatGPT for qualified patient information? : Attempt of a structured analysis on the basis of a survey regarding complementary and alternative medicine (CAM) in rheumatology]

INTRODUCTION

The chatbot ChatGPT represents a milestone in the interaction between humans and large databases that are accessible via the internet. It facilitates the answering of complex questions by enabling a communication in everyday language. Therefore, it is a potential source of information for those who are affected by rheumatic diseases. The aim of our investigation was to find out whether ChatGPT (version 3.5) is capable of giving qualified answers regarding the application of specific methods of complementary and alternative medicine (CAM) in three rheumatic diseases: rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and granulomatosis with polyangiitis (GPA). In addition, it was investigated how the answers of the chatbot were influenced by the wording of the question.

METHODS

The questioning of ChatGPT was performed in three parts. Part A consisted of an open question regarding the best way of treatment of the respective disease. In part B, the questions were directed towards possible indications for the application of CAM in general in one of the three disorders. In part C, the chatbot was asked for specific recommendations regarding one of three CAM methods: homeopathy, ayurvedic medicine and herbal medicine. Questions in parts B and C were expressed in two modifications: firstly, it was asked whether the specific CAM was applicable at all in certain rheumatic diseases. The second question asked which procedure of the respective CAM method worked best in the specific disease. The validity of the answers was checked by using the ChatGPT reliability score, a Likert scale ranging from 1 (lowest validity) to 7 (highest validity).

RESULTS

The answers to the open questions of part A had the highest validity. In parts B and C, ChatGPT suggested a variety of CAM applications that lacked scientific evidence. The validity of the answers depended on the wording of the questions. If the question suggested the inclination to apply a certain CAM, the answers often lacked the information of missing evidence and were graded with lower score values.

CONCLUSION

The answers of ChatGPT (version 3.5) regarding the applicability of CAM in selected rheumatic diseases are not convincingly based on scientific evidence. In addition, the wording of the questions affects the validity of the information. Currently, an uncritical application of ChatGPT as an instrument for patient information cannot be recommended.

Comparing Safety and Efficacy: Laparoscopic vs. Open Pancreaticoduodenectomy for Pancreatic Ductal Adenocarcinoma: A Meta-analysis of Randomized Control Trials

Pancreatic ductal adenocarcinoma (PDAC) has an estimated 5-year survival rate of 11% and remains a formidable challenge. Despite evolving pancreaticoduodenectomy techniques, the pinnacle status of laparoscopic surgery persists. Technological advancements since Gagner and Pomp's 1994 breakthrough have expanded its reach, yet it remains complex. Although safety reports exist, large-scale studies establishing the viability of laparoscopic surgery for PDAC are scarce. This study aimed to provide an up-to-date meta-analysis, scrutinizing all relevant trials, especially recently published ones, to discern differences between laparoscopic and open pancreaticoduodenectomy procedures. This meta-analysis, following the PRISMA guidelines, systematically searched the PubMed and Cochrane Library databases for randomized controlled trials on pancreaticoduodenectomy up to November 25, 2023. Data extraction, quality assessment, and statistical analysis, including primary and secondary outcomes, were conducted using rigorous methodology. The study employed Review Manager 5.4 for analysis, with significance set at P < 0.05. This meta-analysis, comprising five randomized controlled trials (laparoscopic, 605; open, 601; total, 1206), utilized the Cochrane Risk of Bias 2 tool, revealing minimal bias. Primary outcome analysis indicated a shorter hospital stay with laparoscopic pancreaticoduodenectomy (S.M.D. =  - 0.18, 95% CI - 0.63 - 0.28, P = 0.45) and reduced blood loss (S.M.D. =  - 1.96, 95% CI - 3.05, 0.88, P = 0.0004), but increased operative time (S.M.D. = 1.74, 95% CI 0.95 to 2.53, P < 0.0001). The secondary outcomes showed no significant differences in morbidity, mortality, resection, fistula, gastric emptying, hemorrhage, bile leak, reoperation, readmission, and surgical site infection between the two procedures. Laparoscopic pancreaticoduodenectomy (LPD) offers marginal benefits over open pancreaticoduodenectomy (OPD), including reduced blood loss and shorter hospital stays. However, LPD requires a significantly longer operative time, and no substantial differences have been observed in terms of mortality or other complications. Additional studies with lower heterogeneity are needed to thoroughly evaluate the comparative effectiveness and safety of LPD and OPD.

Factors associated with severity and outcomes of diabetic foot ulcers: A single center hospital-based cross-sectional observational study in Eastern India

Background

Diabetes mellitus (DM) affects millions globally and is associated with high morbidity, risk of infection, and potential for severe outcomes. In India, where the prevalence of diabetic foot complications is notably high, data on factors influencing the severity and outcomes of diabetic foot ulcers (DFUs) in specific regions, particularly Eastern India, remain sparse.

Methods

This hospital-based cross-sectional study included Type 2 DM patients aged over 18 years, excluding those unwilling to participate and those with ulcers classified as Wagner grade less than 2. The study involved the complete enumeration of eligible patients presenting with DFUs. Clinical and demographic data were collected, including glycemic control, physical activity levels, and microbial cultures from ulcer specimens.

Results

The study included 90 patients with a mean age of 56.1 years. Most participants were male (76.7%), with 47.8% receiving regular diabetes treatment and only 10% achieving good glycemic control. Positive swab cultures were found in 68.9% of patients, predominantly mono-microbial. Higher grade ulcers were associated with male gender (AOR 5.715), and positive swab cultures (AOR 17.470). Moderate-to-severe physical activity (AOR 9.683) and paresthesia (AOR 0.101) were significant predictors of gangrene, with absent distal pulses (COR 13.818) also indicating a higher risk for gangrene. Good glycemic control was associated with a reduced risk of gangrene (COR 0.125).

Conclusions

Maintaining good glycemic control is crucial in preventing complications such as gangrene. Physical activity is generally beneficial in DM; however, excessive or high-impact activities may exacerbate existing foot ulcers and increase the risk of gangrene.

Factors associated with delayed bleeding following ampullectomy: A retrospective cohort study

Introduction and objectives

Endoscopic ampullectomy is the preferred treatment for selected periampullary lesions, yet up to 10.6% of patients may experience delayed bleeding post-procedure. This study aims to identify predictors for bleeding, which remain poorly understood.

Methods

This was a single-center retrospective cohort study of adult patients who underwent endoscopic ampullectomy (EA) between January 2011 and September 2023. The primary outcome was the risk factors for delayed bleeding, defined as post-procedural bleeding that necessitated either an emergency department visit, hospital admission, blood transfusion, or re-intervention. Secondary outcomes included adverse events, such as perforation and pancreatitis.

Results

A total of 113 patients underwent EA, and 25 (22.1%) experienced delayed bleeding. Of these, 20 (80%) required repeat endoscopy, six (24%) needed blood transfusions, and three (12%) were managed conservatively. Multivariable logistic regression analysis identified international normalized ratio ≥1.2 (odds ratio [OR] 3.32, 95% confidence interval [95% CI] 1.03-10.74, p = 0.05), presence of high-grade dysplasia or intramucosal cancer (OR 3.76, 95% CI 1.20-11.81, p = 0.03), female sex (OR 3.14, 95% CI 1.11-8.93, p = 0.03), size of lesion (OR 1.04, 95% CI 1.01-1.08, p = 0.03) and procedure duration (OR 0.98, 95% CI 0.97-0.99, p = 0.04) as independent predictors of delayed bleeding.

Conclusion

Several factors, including features of high-grade dysplasia-intramucosal cancer, international normalized ratio ≥1.2, female sex, lesion size, and procedure duration are associated with delayed post-ampullectomy bleeding. These factors should be taken into consideration when strategizing the reduction of post-ampullectomy bleeding.

Physiotherapy of the Trunk Related to Sitting Function After Stroke: A Delphi Study

ObjectiveTo develop consensus statements from a Delphi panel about physiotherapy of the trunk related to sitting function for people with subacute stroke, with the express aim of facilitating treatment choices by novice physiotherapists.DesignA four-round e-Delphi study using free-text responses and 5-point Likert scales for agreement.ParticipantsTwenty-six panel members with expertise in clinical and/or research in neurological rehabilitation.Main measuresRound 1 consisted of 5 free-text questions. Subsequent rounds ascertained agreement and consensus on statements formulated from Round 1 responses. Consensus was defined a priori as ≥70% agreement. Round 3 presented an additional two clinical observation queries related to the statements for comment.ResultsTwenty participants completed all four rounds. Nineteen of 26 participants (73%) thought physiotherapy of the trunk was important through all stages of recovery after stroke. Different interpretations about what constitutes physiotherapy of the trunk following stroke were identified. Fourteen statements of agreement regarding physiotherapy of the trunk were formulated. The majority of statements involved different activities in sitting such as control of movement over the base of support and reaching with the unaffected arm. In addition to the statements of agreement clinical observations for implementation of the statements were developed.ConclusionsIn the absence of detail in clinical guidelines and a wide range of interventions in systematic reviews, this study provides clear and specific options for novice physiotherapists of treatment of the trunk related to functional task practice in sitting and as preparation for sit to stand.

Pharmacologic Treatment of Acute Attacks of Episodic Migraine: A Systematic Review and Network Meta-analysis for the American College of Physicians

BACKGROUND

Migraine is common, affecting 15% of Americans.

PURPOSE

To compare benefits and harms of pharmacologic treatments for acute attacks of episodic migraine in adults and assess cost-effectiveness.

DATA SOURCES

Three electronic databases searched to October 2024, gray literature, and reference lists.

STUDY SELECTION

Two investigators independently selected English-language randomized trials.

DATA EXTRACTION

Single reviewer data extraction with second review. Dual independent risk of bias and certainty of evidence (COE) assessment.

DATA SYNTHESIS

Twenty-one head-to-head and 165 placebo-controlled trials were included in meta-analyses and network meta-analyses. Triptans were more effective than acetaminophen (low COE) and nonsteroidal anti-inflammatory drugs (NSAIDs) (high COE) for pain outcomes at 2 hours and pain freedom up to 48 hours. Triptan and acetaminophen combinations were more effective than acetaminophen alone (moderate COE) for pain outcomes at 2 hours and pain freedom up to 48 hours but not more than triptans alone (low COE). Triptan and NSAID combinations were more effective for pain outcomes at 2 hours and pain freedom up to 48 hours compared with acetaminophen (low COE), gepants (low COE), NSAIDs (high COE), and triptan monotherapy (moderate COE). Triptan regimens, however, often had a higher risk for adverse events. One study found triptans more cost-effective than ditans and gepants.

LIMITATIONS

Harms assessment was limited to randomized trials. Many comparisons lacked sufficient evidence to draw conclusions.

CONCLUSION

Triptans and combinations of triptans were more effective than NSAID and acetaminophen alone.

PRIMARY FUNDING SOURCE

American College of Physicians. (PROSPERO: CRD42023441146).

Effect of inulin supplementation on fecal and blood metabolome in alcohol use disorder patients: A randomised, controlled dietary intervention

BACKGROUND AND AIMS

Alcohol Use Disorder (AUD) is a psychiatric disorder characterized notably by gut microbial dysbiosis and insufficient dietary fiber (DF) intake. This study aims to investigate the effect of DF placebo-controlled intervention in patients suffering from AUD during a three-week period of alcohol withdrawal, in order to discover microbial-derived metabolites that could be involved in metabolic and behavioral status.

METHODS

A randomized, double-blind, placebo-controlled study was performed with 50 AUD patients supplemented with inulin (prebiotic DF) or maltodextrin (placebo) during 17 days. Fecal microbiota composition, plasma and fecal metabolomics (liquid chromatography coupled to mass spectrometry), blood markers of inflammation and hepatic alterations, and psychological assessment (questionnaires) were analyzed before and after the intervention.

RESULTS

Fecal metabolomics revealed 14 metabolites significantly modified by inulin versus placebo treatment (increased N8-acetylspermidine and decreased indole-3-butyric acid, 5-amino valeric acid betaine (5-AVAB) and bile acids). Thirteen plasma metabolites differentiated both treatments (higher levels of long-chain fatty acids, medium-chain acylcarnitines and sphingomyelin species, and reduced 3-methylhistidine by inulin versus placebo). Fecal Lachnoclostridium correlated with 6 of the identified fecal metabolites, whereas plasma lipidic moieties positively correlated with fecal Ruminococcus torques group and Flavonifractor. Interestingly, parameters reflecting liver alterations inversely correlated with sphingomyelin (SM 36:2).

CONCLUSIONS

Three weeks of inulin supplementation during alcohol withdrawal leads to specific and different changes in the plasma and fecal metabolome of AUD patients, some of these gut microbiota-related metabolites being correlated with liver function.

TRIAL REGISTRATION

NCT03803709, https://clinicaltrials.gov/ct2/show/NCT03803709.

Microbiomes as Modulators of Human and Planetary Health: A Relational and Cross-Scale Perspective

The various human microbiomes play critical roles in maintaining health and well-being, and they are continuously shaped by a complex web of internal and external factors. Research on human and environmental microbiomes is generally discrete within disciplinary areas such as medicine, microbiology, molecular ecology, etc. This paper presents a perspective based on a scoping review of the literature, aiming to explore how these interconnected microbiomes shape human health and well-being and, in turn, planetary health. We explore the working of human microbiomes from cellular mechanisms to population outcomes, and the role of intrinsic and extrinsic factors influencing these microbiomes. We argue that global trends such as the homogenization of diets, environments, and medical practices are driving shifts in microbial diversity, with far-reaching implications for human health and well-being as well as planetary health. Disruptions to microbial feedback mechanisms at individual, community, and ecosystem levels are often interconnected and exacerbated by biodiversity loss and environmental change. We underscore the need for holistic public health interventions that account for microbiome stewardship across scales. By examining these connections, we aim to highlight the importance of a systems-level understanding of the microbiome in public health.

Translating digital health services for nutrition care management of chronic conditions in outpatient settings: A multi-stakeholder e-Delphi study

AIM

To identify and achieve expert consensus on the most important and feasible strategies to implement digital health services for nutrition care management of chronic conditions in outpatient settings.

METHODS

Determinants and strategies for implementing digital health services for nutrition care management were identified in line with the literature and the Consolidated Framework for Implementation Research. These were presented to team leaders and senior clinicians, as well as dietetic and allied health directors in a two-round e-Delphi process. Consensus was reached when strategies were rated very important/feasible by at least 75% of respondents, calculated by the median, interquartile range and frequency. Following the two survey rounds, a final prioritisation survey was distributed to participants, where participants were asked to prioritise their top strategy for each determinant, which was analysed by frequency calculations.

RESULTS

Twenty participants participated in round one of the survey and 18 completed the final prioritisation round. Following the two rounds, 3 strategies did not meet consensus for importance and 7 strategies did not meet consensus for feasibility out of 25 strategies presented. Nine strategies were prioritised following the survey rounds. Key concepts of the strategies that met consensus and were prioritised related to (i) adhering to quality of care with effective evaluation processes; (ii) providing options for digital health upskilling and support; and (iii) individualising patient care.

CONCLUSION

Team leaders and senior clinicians as well as dietetic and allied health directors have indicated that there are many important digital health strategies yet not all are feasible to implement within current resourcing and systems.

Oncolytic reovirus enhances the effect of CEA immunotherapy when combined with PD1-PDL1 inhibitor in a colorectal cancer model

AIM

The effectiveness of immunotherapy with tumor associated antigen vaccines can be enhanced by combining oncolytic viruses with immune checkpoint inhibitors. This study evaluates the efficacy of oncolytic reovirus in combination with an adenovector expressing carcinoembryonic antigen (Ad-CEA) and a programmed death-1/programmed death-ligand 1 (PD-1/PD-L1) inhibitor in a mouse model.

METHODS

Mice bearing CEA-expressing CT26 tumor cells were immunized with Ad-CEA along with a PD-1/PD-L1 inhibitor. Subsequently, three doses of reovirus were injected into the tumors. Tumor size, histopathological examination, CD8 and FOXP3 expression, the cytotoxicity of spleen T cell lymphocytes, and the secretion of Interferon-γ (IFN-γ) and Tumor necrosis factor- α (TNF-α) were examined.

RESULTS

The triple therapy used in this study resulted in the lowest tumor growth and the highest level of cytotoxic immunity. The Foxp3 levels in the tumor microenvironment and TNF-α secretion decreased compared to other control groups. Additionally, this group exhibited the lowest number of mitotic figures and the highest amount of tumor-infiltrating lymphocytes.

CONCLUSION

The combination of tumor vaccines with oncolytic viruses significantly improves treatment efficacy. Furthermore, inhibiting the PD-1/PD-L1 interaction during vaccination and also with virotherapy enhances immunovirotherapy by reducing immunosuppressive effects and stimulating the immune system, leading to improved therapeutic outcomes.

The impact of normothermic machine perfusion and acuity circles on waitlist time, mortality, and cost in liver transplantation: A multicenter experience

Ex situ normothermic machine perfusion (NMP) helps increase the use of extended criteria donor livers. However, the impact of an NMP program on waitlist times and mortality has not been evaluated. Adult patients listed for liver transplant (LT) at 2 academic centers from January 1, 2015, to September 1, 2023, were included (n=2773) to allow all patients ≥6 months follow-up from listing. Routine NMP was implemented on October 14, 2022. Waitlist outcomes were compared from pre-NMP pre-acuity circles (n=1460), pre-NMP with acuity circles (n=842), and with NMP (n=381). Median waitlist time was 79 days (IQR: 20-232 d) at baseline, 49 days (7-182) with acuity circles, and 14 days (5-56) with NMP ( p <0.001). The rate of transplant-per-100-person-years improved from 61-per-100-person-years to 99-per-100-person-years with acuity circles and 194-per-100-person-years with NMP ( p <0.001). Crude mortality without transplant decreased from 18.3% (n=268/1460) to 13.3% (n=112/843), to 6.3% (n=24/381) ( p <0.001) with NMP. The incidence of mortality without LT was 15-per-100-person-years before acuity circles, 19-per-100 with acuity circles, and 9-per-100-person-years after NMP ( p <0.001). Median Model for End-Stage Liver Disease at LT was lowest with NMP, but Model for End-Stage Liver Disease at listing was highest in this era ( p <0.0001). The median donor risk index of transplanted livers at baseline was 1.54 (1.27-1.82), 1.66 (1.42-2.16) with acuity circles, and 2.06 (1.63-2.46) with NMP ( p <0.001). Six-month post-LT survival was not different between eras ( p =0.322). The total cost of health care while waitlisted was lowest in the NMP era ($53,683 vs. $32,687 vs. $23,688, p <0.001); cost-per-day did not differ between eras ( p =0.152). The implementation of a routine NMP program was associated with reduced waitlist time and mortality without compromising short-term survival after liver transplant despite increased use of riskier grafts. Routine NMP use enables better waitlist management with reduced health care costs.

Protective and risk factors of anxiety in children and adolescents during COVID-19: A systematic review and three level meta-analysis

BACKGROUND

In order to gain a deepened understanding of the impact of public health emergency and to develop effective interventions and preventions, this study aimed to evaluate risk and protective factors associated with anxiety in children and adolescents and to explore potential moderators in the background of COVID-19 within the framework of socio-ecological model.

METHODS

A literature search was conducted in Web of Science, MEDLINE, PubMed, Scopus, EBSCO, ScienceDirect, Emerald, and CNKI for studies published from early 2020 to early 2023 that examined factors associated with anxiety among children and adolescents with age range of 6 to 17 years old. Random effects models and a three-level meta-analytic approach were used.

RESULTS

In total, 141 articles and 1,018,171 subjects were included, with 1002 effect sizes extracted. 32 protective factors and 48 risk factors were examined, yielding significance for 14 protective factors and 29 risk factors, including individual factors (e.g., gender, logOR = -0.37, 95 % CI [-0.47, -0.27], p < 0.001; age, logOR = -0.12, 95 % CI [-0.22, -0.02], p = 0.02; emotional functioning, logOR = -1.45, 95 % CI [-1.84, -1.05], p < 0.001; pre-existing condition logOR = 0.94, 95 % CI [0.58, 1.30], p < 0.001; electronic device or internet addiction, logOR = 1.81, 95 % CI [0.74, 2.88], p < 0.001), family factors (e.g., family socioeconomic status, logOR = -0.25, 95 % CI [-0.39, -0.10], p < 0.001; family functioning, logOR = -1.31, 95 % CI [-1.60, -1.02], p < 0.001; anxiety level of caregiver, logOR = 1.06, 95 % CI [0.75, 1.37], p < 0.001), community factors (e.g., overall social support, logOR = -0.93, 95 % CI [-1.84, -1.05], p < 0.001; school burden, logOR = 0.56, 95 % CI [0.21, 0.90], p = 0.002), and COVID-19-related factors (e.g., higher exposure risk in local community or city, logOR = 0.48, 95 % CI [0.17, 0.78], p = 0.002; distant learning, logOR = 0.73, 95 % CI [0.19, 1.28], p = 0.008; COVID-19-related distress, logOR = 1.42, 95 % CI [0.55, 2.29], p = 0.001;). The majority of studies showed no publication bias. Age group moderated the relationship between gender and level of anxiety (F (1,96) = 4.42, p = 0.038), and no other moderator showed significance.

LIMITATIONS

This study does not reveal causality but correlation in nature, and our findings should be interpretated with caution.

CONCLUSIONS

Public health emergencies could bring challenges to the mental health of children and adolescents. Prevention and intervention strategies for children and adolescents with high risks, and family-based and community-based programs should be encouraged to buffer the adverse impact on children and adolescents. This study has been prospectively registered at PROSPERO (registration number: CRD42022316746).

Dose-response relationship of aspirin and sudden sensorineural hearing loss risk in type 2 diabetes: Aspirin dosage on SSNHL risk in T2D

BACKGROUND

Sudden sensorineural hearing loss (SSNHL) affects 5 to 27 per 100,000 annually, often leading to permanent hearing loss and reduced quality of life. Type 2 diabetes (T2D) may heighten SSNHL risk via vascular damage. Aspirin is used in T2D for cardiovascular protection, yet its effect on SSNHL is uncertain and may vary by dose.

METHODS

We conducted a cohort study using Taiwan's National Health Insurance Research Database to assess SSNHL risk associated with aspirin use in T2D patients. Eligible T2D patients were categorized based on cumulative aspirin exposure (cDDD ≥ 28 vs. <28) and matched on key covariates. Cox proportional hazards models and Fine and Gray's competing risk model assessed SSNHL and all-cause mortality across quartiles of cumulative aspirin dose.

RESULTS

Among 51,657 matched pairs, SSNHL incidence was similar between aspirin users and non-users, but a dose-response effect emerged: patients in the highest cDDD quartile (Q4) had a significantly reduced SSNHL risk (adjusted HR 0.43, 95 % CI, 0.32-0.58; p < 0.0001), while lower quartiles showed increased risks. Aspirin use was associated with reduced all-cause mortality (adjusted HR 0.77, 95 % CI, 0.75-0.80). Fine and Gray's competing risk model confirmed that this reduction in mortality did not bias the observed dose-dependent protective effect of aspirin on SSNHL. Even after accounting for competing mortality risk, aspirin's protective association with SSNHL remained significant in the highest quartile (Q4, aHR 0.46, 95 % CI, 0.34-0.62; p < 0.0001), indicating an independent protective effect.

CONCLUSIONS

Our findings suggest a dose-dependent relationship where high cumulative doses of aspirin reduce SSNHL risk in T2D patients, underscoring the importance of adequate dosing for potential protective effects. Further research is necessary to clarify this dose-response relationship.

Management of human epidermal growth factor receptor inhibitors-related acneiform rash: A position paper based on the first Europe/USA Delphi consensus process

BACKGROUND

There is a need for unified guidance in the management of acneiform rash induced by epidermal growth factor receptor inhibitors (EGFRi) among dermatologists.

OBJECTIVE

To establish unified international guidelines for the management of acneiform rash caused by EGFR inhibitors, based on an experts' Delphi consensus.

METHODS

The initiative was led by five members of the European Academy of Dermatology and Venereology Task Force 'Dermatology for Cancer Patients' who developed a questionnaire that was circulated to a group of 32 supportive oncodermatology experts in Europe, Canada, Argentina, the US States and Asia. The questionnaire consisted of 84 statements in total, regarding diagnosis and treatment of EGFRi-induced acneiform rash. Experts responded to an anonymous 5-point Likert scale survey. The coordinators collected the first-round responses that were checked for consensus (≥75% agreement in positive [agree or strongly agree] or in negative [disagree or strongly disagree] vote). The statements that did not reach strong consensus in the first round were revised, according to experts' feedback, for a second-round survey.

RESULTS

Strong consensus was reached in 75/84 (89.3%) of the statements, whilst moderate consensus was achieved in 6/84 elements. Key points include consideration of low-dose isotretinoin for refractory grade II/III acneiform rash, use of topical steroid-sparing agents like topical pimecrolimus in the maintenance phase and use of doxycycline in either 100 or 200 mg per day as prophylactic treatment. Interestingly, experts did not recommend topical antibiotics, neither for prevention, nor for treatment. Consensus failure in 3/84 objects is mostly related to the lack of robust data on these topics.

CONCLUSION

This consensus offers crucial insights often overlooked by radiotherapists, general practitioners, dermatologists and oncologists, and it is expected to improve the management of oncologic patients treated with EGFRi in different settings and continents.

Surgical management of liver tumors

Two percent of pediatric malignancies arise primarily in the liver; roughly 60% of these cancers are hepatoblastoma (HB). Despite the rarity of these cases, international collaborative efforts have led to the consistent histological classification and staging systems, which facilitate ongoing clinical trials. Other primary liver malignancies seen in children include hepatocellular carcinoma (HCC) with or without underlying liver disease, fibrolamellar carcinoma (FLC), undifferentiated embryonal sarcoma of the liver (UESL), and hepatocellular neoplasm not otherwise specified (HCN-NOS). This review describes principles of surgical management of malignant pediatric primary liver tumors, within the context of comprehensive multidisciplinary care.

Impact of smoking on oral mucosa: A cytological and cellular proliferation study

BACKGROUND

Cigarette smoking is known to induce various cellular changes and proliferative activities within the oral mucosa. This study compares the effects of smoking on cellular proliferation and cytological alterations using the AgNORs and Pap staining methods.

METHODS

We performed statistical analyses to evaluate the mean AgNORs count in smokers and non- smokers. Additionally, we assessed the presence of reactive cellular changes in smokers using the Pap staining method. Cytological alterations, including inflammatory changes, were documented in both groups, and we focused on the prevalence of such changes in smokers.

RESULTS

The mean AgNORs count was found to be 3.68 in smokers, which is consistent with marked reactive cellular changes. Inflammatory changes and reactive cellular changes, observed in 33.3 % and 59.3 % of cases, respectively, were significantly more prevalent in smokers. These findings suggest that smoking induces epithelial alterations, even in the absence of clinical symptoms, due to the physiochemical environment created by the elements in tobacco. This study also supports previous research indicating that cigarette smoking modifies cell growth control processes and increases cell proliferation in the oral mucosa.

CONCLUSION

Cigarette smoking significantly elevates cellular proliferation, as indicated by the increased AgNORs counts in smokers. The combined use of Pap staining and AgNORs counting proved effective at detecting cellular proliferation before clinical symptoms appeared in smokers. Additional research is recommended to assess the impact of factors such as age, sex, and daily cigarette consumption on different oral regions. Comparative studies involving other proliferation indicators, such as Ki-67 or molecular testing, are also advised.

A T2 Translational Science Modified Delphi Study: The Ethical Triage and Treatment of Entrapped and Mangled Extremities in Resource-Scarce Environments

BACKGROUND

There is a lack of ethical triage and treatment guidelines for the entrapped and mangled extremity (E&ME) in resource-scarce environments (RSE): mass casualty incidents, low- to middle-income countries, complex humanitarian emergencies including conflict, and prolonged transport times (RSE). The aim of this study is to use a modified Delphi (mD) approach to produce statements to develop treatment guidelines of the E&ME in RSE.

METHOD

Experts rated their agreement with each statement on a 7-point linear numeric scale. Consensus amongst experts was defined as a standard deviation ≤ 1. Statements attaining consensus after the first round moved to the final report. Those not attaining consensus moved to the second round in which experts were shown the mean response of the expert panel and their own response for the opportunity to reconsider their rating for that round. Statements attaining consensus after the second round moved to the final report. This process was repeated in the third round. Statements attaining consensus were moved to the final report. The remaining statements did not attain consensus.

RESULTS

Seventy-seven experts participated in the first, 75 in the second, and 74 in the third round. Twenty-three statements attained consensus. Twenty-one statements did not attain consensus.

CONCLUSION

A modified Delphi technique was used to establish consensus regarding the numerous complex factors influencing treatment of the E&ME in RSEs. Twenty-three statements attained consensus and can be incorporated into guidelines to advance the ethical treatment of the E&ME in RSEs.

Prerequisites for Clinical Implementation of Whole-Heart 4D-Flow MRI: A Delphi Analysis

Whole-heart 4D-flow MRI is a valuable tool for advanced visualization and quantification of blood flow in cardiovascular imaging. Despite advantages over 2D-phase-contrast flow, clinical implementation remains only partially exploited due to many hurdles in all steps, from image acquisition, reconstruction, postprocessing and analysis, clinical embedment, reporting, legislation, and regulation to data storage. The intent of this manuscript was 1) to evaluate the extent of clinical implementation of whole-heart 4D-flow MRI, 2) to identify hurdles hampering clinical implementation, and 3) to reach consensus on requirements for clinical implementation of whole-heart 4D-flow MRI. This study is based on Delphi analysis. This study involves a panel of 18 experts in the field on whole-heart 4D-flow MRI. The experience with and opinions of experts (mean 13 years of experience, interquartile range 6) in the field were aggregated. This study showed that among experts in the cardiovascular field, whole-heart 4D-flow MRI is currently used for both clinical and research purposes. Overall, the panelists agreed that major hurdles currently hamper implementation and utilization. The sequence-specific hurdles identified were long scan time and lack of standardization. Further hurdles included cumbersome and time-consuming segmentation and postprocessing. The study concludes that implementation of whole-heart 4D-flow MRI in clinical routine is feasible, but the implementation process is complex and requires a dedicated, multidisciplinary team. A predefined plan, including risk assessment and technique validation, is essential. The reported consensus statements may guide further tool development and facilitate broader implementation and clinical use. LEVEL OF EVIDENCE: NA TECHNICAL EFFICACY: Stage 5.

[New and current therapeutic goals of chronic inflammatory bowel disease]

Chronic inflammatory bowel diseases (IBD), such as Crohn's disease (MC) and ulcerative colitis (CU), are serious immune-mediated diseases that affect the gastrointestinal tract and represent a considerable burden for patients. In recent decades, the treatment of IBD has shifted from symptomatic control to more precise, long-term goals. Advances in IBD research have led to therapy goals having been redefined and expanded in order to achieve complete inflammation control and prevent complications in the long term.An important component of modern therapeutic approaches is the definition of specific markers that serve as indicators for the achievement of these therapeutic goals. These markers enable objective monitoring of the success of treatment and thus offer a clear approach for controlling the therapy. The present article focuses on the new therapeutic goals in IBD treatment and discusses the role of therapeutic target markers in clinical practice.A central goal in modern IBD therapy is endoscopic healing, i.e. the complete macroscopic healing of the intestinal mucosa. In clinical practice this includes in particular an ulcer-free mucosa. In contrast to clinical remission alone, endoscopic healing provides an objective assessment of the inflammatory state and correlates strongly with an improved long-term prognosis.The histologic remission goes beyond endoscopic healing and aims to endoscopic healing to no longer detect signs of inflammation at the microscopic level. This is particularly relevant as the results show that patients who achieve a complete histological remission have an even lower recurrence rate and better long-term results than those who only achieve a clinical or endoscopic remission.Even though no curative therapy for IBD currently exists, the complete cure remains the ultimate goal of research. In current practice, this goal is still unattainable in current practice, but progress in genetic and immunological research offers hope. In the long term, the aim is to innovative approaches such as gene editing or immunotherapy to cure the disease. This could mean that patients are not only free of symptoms, but also freed from the burden of the disease in the long term.

Requirements and Study Design for the Next Proton FLASH Clinical Trials: an International Multidisciplinary Delphi Consensus

PURPOSE

The FLASH effect, defined as normal tissue sparing while maintaining tumor control with ultra-high dose-rate irradiation, has been demonstrated preclinically in different tumors and tissues. Although the biological mechanisms are unclear, there is a need for clinical trials investigating the value of proton FLASH irradiation (pFLASH). The purpose of this study was to establish an expert consensus regarding prerequisites, study design, and endpoints for the next clinical trials exploring the clinical potentials of pFLASH.

METHODS AND MATERIALS

Delphi methodology was used to develop a systematic expert consensus. An international expert panel was composed of 21 clinicians, physicists, and biologists, well-balanced in expertise and geography, using predefined inclusion criteria. Statements were scored on a 5-point Likert scale in 2 rounds of online questionnaire voting. The definition of consensus was set a priori.

RESULTS

The response rate was 100% in both rounds. Preclinical in vivo demonstration of the FLASH effect in normal tissue while maintaining tumor response was deemed essential before starting a clinical trial in a specific tumor site. The next clinical pFLASH trials are advised to include adult patients only, with a minimal expected overall survival of 1 year for palliative settings or, preferably, oligometastatic disease in the ablative setting. The pFLASH effect should be studied in a single treatment modality setting with toxicity reduction as the primary endpoint. Recommendations were formulated on the use of clinical targets and organs at risk constraints, requirements for evaluation and reporting, and accuracy levels and pretreatment verification of dose rates. No consensus was reached on the use of multiple beams, multiple fractions, and fraction dose.

CONCLUSIONS

There is a need for additional data regarding the influence of fractionation and multiple beam planning. The results of this study can be used to develop roadmaps to guide future clinical trial design.

Deciphering the Role of Oxidative Stress in Male Infertility: Insights from Reactive Oxygen Species to Antioxidant Therapeutics

Male infertility represents a major health concern, accounting for approximately 50% of all infertility cases in couples. This condition arises from multiple etiologies, with oxidative stress gaining increasing attention in recent studies. During the final stages of sperm maturation, the majority of the cytoplasm is discarded, leaving sperm with a diminished antioxidant defense system, which makes them highly susceptible to the detrimental effects of reactive oxygen species (ROS). ROS can be generated from both intrinsic and extrinsic sources. Intrinsically, ROS are primarily produced by mitochondrial activity, while extrinsic factors include alcohol consumption, smoking, circadian rhythm disruption, gut microbiota imbalance, and leukocyte infiltration. Excessive ROS production leads to DNA damage, apoptosis, and epigenetic modifications in sperm, ultimately impairing sperm motility and contributing to infertility. This review provides a comprehensive examination of ROS sources and examines the mechanisms by which ROS induce sperm damage. Furthermore, it explores the therapeutic potential of antioxidants in mitigating oxidative stress and improving sperm quality.

Quality indicators for substance use disorder care: a scoping review protocol

INTRODUCTION

Substance use disorders (SUDs) are a major public health challenge, affecting millions of individuals globally and contributing to substantial morbidity and mortality. Individuals with SUDs face numerous barriers to accessing high-quality healthcare, leaving vulnerable populations susceptible to the undertreatment of SUDs. Despite the availability of clinical practice guidelines and effective interventions for SUD, there is a notable gap in the implementation and adherence to evidence-based care.Measuring the quality of care (QoC) is a critical initial step toward enhancing the treatment and services provided to individuals with SUDs. While quality indicators (QIs) for SUD care have been established in various regions, including the USA, Canada and the UK, the application of QIs for the routine measurement of QoC for SUDs is not common. Identifying and characterising the areas of low QoC in SUD management can highlight critical targets for quality improvement initiatives. However, QoC measurement in SUD care is complex, with potentially redundant indicators derived from different sources, each with its own definitions, criteria and data requirements. This scoping review aims to explore the range of QIs that are currently available to assess the QoC for individuals with SUDs.

METHODS

The review will follow the Arksey and O'Malley framework and incorporate methods proposed by the Joanna Briggs Institute (JBI) and Levac et al. Reporting will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping review guidelines (PRISMA). Stage 1: the research question will be identified, clarifying the purpose of the scoping review. Stage 2: six academic databases (Cochrane Library, Embase, CINAHL, Medline, APA PsycINFO and Scopus) and grey literature sources will be searched for studies reporting QIs and published from 1990 until 2023. Stage 3: study screening and selection will be completed by two reviewers independently to review titles, abstracts and full texts based on study inclusion criteria. Stage 4: a pilot data charting form has been developed to capture information from each study, including study design, population details, setting, methodology for QI development and reported QIs. Stage 5: data synthesis and consultation will employ thematic analysis and frequency counts to categorise identified QIs within established domains for quality of healthcare. Any discrepancies in data extraction or thematic synthesis will be identified and resolved using a third reviewer when necessary. A consultation exercise using a modified Delphi process will engage experts to prioritise identified QIs, aligning with JBI recommendations for stakeholder involvement in scoping reviews.

PATIENTS AND PUBLIC INVOLVEMENT

Patients and the public will not be directly involved in the design or conduct of this scoping review. However, stakeholder consultation, including individuals with lived experience of SUDs, will be incorporated during the Delphi process to prioritise identified QIs for SUD care.

ETHICS AND DISSEMINATION

Ethics approval is not necessary for stages 1-4 of this scoping review as it will not involve primary data collection. Ethics approval will be obtained from the University of Calgary Health Research Ethics Board prior to the commencement of stakeholder consultation (Stage 5) in January 2025. This scoping review was preregistered on the Open Science Framework. The results of this scoping review will be disseminated through peer-reviewed publications and conference presentations. Findings will be shared with local clinicians through presentations and with the research and clinical community at relevant conferences. This study represents a necessary first step towards establishing routine QoC measurement for SUDs. Results will be used in a stakeholder consensus exercise aimed at identifying key QIs for SUD care in Alberta, Canada, that will guide the future development of continuous QoC measurement using population-based data.

Effects of Blueberry Consumption on Fecal Microbiome Composition and Circulating Metabolites, Lipids, and Lipoproteins in a Randomized Controlled Trial of Older Adults with Overweight or Obesity: The BEACTIVE Trial

Background/Objectives: Generous consumption of phytonutrient-rich foods, including blueberries, provides benefits to multiple physiologic and metabolic systems. This study explored the potential that regular, generous blueberry intake could favorably modulate fecal microbiome composition in sedentary older (>60 years) men and women with overweight or obesity (BMI ≥ 25 to 32 kg/m2). Methods: Participants (n = 55) were randomized to daily consumption of either lyophilized blueberry powder (equivalent to 1.5 cups of blueberries) or an indistinguishable placebo powder; both groups participated in weekly supervised exercise classes. Fecal samples were collected at 0 and 12 weeks and frozen. Following this, 16S rRNA gene sequencing was used to profile each participant's fecal microbiome. Blood biomarkers of cardiometabolic health were measured via nuclear magnetic resonance spectroscopy (NMR) pre- and post-treatment. Results: Comparing the baseline and endpoint results for the blueberry (n = 15) and placebo (n = 19) groups, there were no significant overall compositional differences or differences in the level of diversity in the fecal microbiome. However, in subjects whose diet included blueberry powder, there was a significant enrichment (p = 0.049) in the relative abundance of Coriobacteriales incertae sedis, a taxonomic group of bacteria that facilitates the metabolism of dietary polyphenols. The placebo group exhibited significant reductions in total cholesterol, LDL-C, non-HDL-C, total LDL-P, large LDL-P, and ApoB, while the blueberry group exhibited significant reductions in total HDL-P and ApoA-I after 12 weeks compared to baseline. Conclusions: Generous blueberry consumption may upregulate the ability of the older human gut to utilize dietary polyphenols by altering the fecal microbiome. Longer, larger-scale studies with blueberries or blueberry powder are needed to observe improvements in cardiometabolic risk factors in older adults with overweight or obesity.