352P Development of the AO spinal metastasis staging (SMS) referral tool: An international multidisciplinary expert panel and survey study

People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. Acute left colonic diverticulitis in the elderly presents with unique epidemiological features when compared with younger patients. Elderly patients have a lower risk of recurrent episodes, higher in-hospital and postoperative mortality. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) formulated the guidelines for diagnosis and treatment of acute left colonic diverticulitis in the elderly (2022 edition). This article aims to interpret the guidelines statements on the following topics: diagnosis, management, non-surgical therapy and surgical technique.

Medical conferences and educational courses in gastrointestinal (GI) endoscopy are essential for training, quality improvement, and scientific exchange, but they are also associated with a substantial environmental footprint, largely driven by travel-related greenhouse gas emissions and resource consumption. While sustainability in endoscopic practice has gained increasing attention, the environmental impact of endoscopy congresses and courses has remained insufficiently addressed. This document outlines the official position of the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA). An international multidisciplinary panel of experts conducted a systematic literature review, expert narrative appraisal where evidence was limited, and an iterative Delphi consensus process. The resulting recommendations address key domains of conference organization, including event conception, scientific program design, transportation and participation models, faculty selection, venue and accommodation, catering, waste reduction, training formats, and collaboration with industry partners. Emphasis is placed on promoting virtual and hybrid conference formats, low-emission travel options, sustainable venues and catering, and the systematic measurement and transparent reporting of environmental impact. This ESGE-ESGENA Position Statement provides practical, consensus-based, evidence-informed guidance to support GI endoscopy societies, conference organizers, industry partners, and participants in reducing the environmental impact of endoscopy-related educational activities while preserving their scientific and educational quality.

The diagnosis of hip instability remains challenging because of its multifactorial etiology and the variability of imaging practices across institutions. Hip instability refers to a clinical condition of insufficient osseous and/or soft tissue constraint with abnormal femoral head motion and symptoms, which may occur along a morphologic spectrum that overlaps with-but is not synonymous with-developmental dysplasia of the hip. Although numerous imaging modalities and imaging parameters have been proposed, there is limited consensus on which are most relevant, how they should be measured, and what diagnostic thresholds best correlate with instability. To address this gap, a Delphi consensus study with an international panel of experts to establish standardized clinical statements for the diagnostic criteria of hip instability was conducted. (1) What are the imaging modalities and protocols for investigating hip instability? (2) Which imaging parameters are most strongly associated with clinical hip instability? (3) What are the quantitative imaging thresholds for diagnosing hip instability? A consensus study using a modified Delphi technique was conducted in accordance with the Accurate Consensus Reporting Document (ACCORD) guideline. Following a scoping review, 27 statements addressing imaging modalities and protocols (question 1), imaging parameters associated with hip instability (question 2), and quantitative imaging thresholds (question 3) were developed. These statements were evaluated by a multidisciplinary international expert panel during a structured consensus meeting, with two rounds of anonymous voting and consensus defined a priori as ≥ 75% agreement. Consensus was achieved for 81% (22 of 27) of statements. There was strong agreement that radiography (AP pelvis, false-profile, Dunn view) and MRI and CT constitute the foundational imaging modalities for the assessment of hip instability, whereas cartilage mapping techniques and dynamic ultrasound were considered adjunctive modalities with a more limited and evolving role. Radiographic measurements such as lateral center-edge angle (LCEA), anterior wall index (AWI), posterior wall index, and Tönnis angle reached consensus as key morphologic indicators. Several quantitative thresholds were endorsed. An LCEA of < 20° was considered diagnostic for hip dysplasia, a condition in which clinical hip instability is highly prevalent, whereas values between 20° and 25° were considered concerning for possible clinical hip instability. Additional thresholds included an AWI of < 0.30, PWI of < 0.8, and acetabular version < 5° or > 30°. In contrast, no consensus was reached for less-established imaging metrics such as the FEAR index, crescent sign, anterior capsule thickness, and dynamic femoral head translation. This international Delphi consensus defined core imaging approaches and threshold values for the evaluation of hip instability. Although agreement was reached on key morphometric parameters and diagnostic thresholds, a lack of consensus exists around newer soft tissue and dynamic measures, highlighting important areas for future research. In patients with suspected clinical hip instability, standard radiography should be used as the first-line imaging modality, followed by targeted use of CT and MRI to evaluate three-dimensional bony morphology and soft tissue stabilizers. Imaging findings should be interpreted within a stepwise, algorithmic framework that integrates clinical assessment with multiple complementary imaging parameters rather than relying on isolated measurements. Ultimately, accurate diagnosis of hip instability depends on the integration of findings from multiple modalities. Additionally, it must be recognized that hip instability may exist even in the absence of characteristic radiologic signs.

Does Lung Adenocarcinoma Subtype Predict Patient Survival?: A Clinicopathologic Study Based on the New International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society International Multidisciplinary Lung Adenocarcinoma Classification

BackgroundStaphylococcus aureus bacteraemia (SAB) is a serious and often fatal infectious disease. The quality of management of SAB is modifiable and can thus affect the outcome. Quality indicators (QIs) can be used to measure the quality of care of the various aspects of SAB management in hospitals, enabling professionals to identify targets for improvement and stimulating them to take action.ObjectivesTo develop QIs for the management of hospitalized patients with SAB.MethodsA RAND-modified Delphi procedure was used to develop a set of QIs for the management of SAB in hospitalized patients. First, available QIs for the management of SAB were extracted from the literature published since 1 January 2000 (MEDLINE and Embase databases). Thereafter, an international multidisciplinary expert panel appraised these QIs during two questionnaire rounds with an intervening face-to-face meeting.ResultsThe literature search resulted in a list of 39 potential QIs. After appraisal by 30 medical specialists, 25 QIs describing recommended care at patient level were selected. These QIs defined appropriate follow-up blood cultures (n=2), echocardiography (n=6), source control (n=4), antibiotic therapy (n=7), antibiotic dose adjustment (n=2), intravenous-to-oral switch (n=2), infectious disease consultation (n=1) and medical discharge report (n=1).ConclusionsA set of 25 QIs for the management of SAB for hospitalized patients was developed by using a RAND-modified Delphi procedure among international experts. These QIs can measure the quality of various aspects of SAB management. This information can be fed back to the relevant stakeholders in order to identify improvement targets and optimize care.

Treatment and prognosis of pediatric non-Hodgkin lymphoma (NHL) have improved dramatically in the last 30 years. However, the St Jude NHL staging classification for pediatric NHL was developed more than 35 years ago. The most recent Lugano lymphoma staging classification focused on adult lymphoma. Furthermore, major limitations of the current pediatric NHL staging classification include lack of consideration of new distinct pediatric NHL histologic entities; absence of recognition of frequent skin, bone, kidney, ovarian, and other organ involvement; and lack of newer precise methods to detect bone marrow and CNS involvement, minimal disease quantification, and highly sensitive imaging technologies. An international multidisciplinary expert panel convened in Frankfurt, Germany, in 2009 at the Third International Childhood, Adolescent and Young Adult NHL Symposium to develop a revised international pediatric NHL staging system (IPNHLSS), addressing limitations of the current pediatric NHL staging system and creating a revised classification. Evidence-based disease distribution and behavior were reviewed from multiple pediatric cooperative group NHL studies. A revised IPNHLSS was developed incorporating new histologic entities, extranodal dissemination, improved diagnostic methods, and advanced imaging technology. This revised IPNHLSS will facilitate more precise staging for children and adolescents with NHL and facilitate comparisons of efficacy across different treatment strategies, various institutions, multicenter trials, and cooperative groups by allowing for reproducible pediatric-based staging at diagnosis and relapse.

Introduction. Mesotherapy is a widely used technique around the world. However, there is currently no internationally recognized, evidence-based standard for its various clinical applications. To address this gap, we have reviewed the current state of the art, critically evaluated its clinical benefits and limitations, and proposed a set of standards including procedural steps, recommended actions, and practical instructions in the form of protocols, guidelines, and expert recommendations. Methods. A team of researchers conducted a comprehensive literature review, selecting studies published between 1976 and 2023. Drawing on the available evidence and the needs expressed by patient associations, 23 clinical questions were developed and presented to a panel of experts. Through multiple rounds of evaluation, evidence-based recommendations were formulated and subsequently submitted for structured evaluation and voting by a broad, multidisciplinary panel of international experts, representing numerous national and international scientific societies. Results. The recommendations outlined in this guideline support the use of mesotherapy across diverse clinical and organizational settings, providing a standardized framework that ensures both efficacy and patient safety in osteoarticular pain, rehabilitation, and dermatological fields. Conclusions. The era of mesotherapy based on personal beliefs now gives way to evidence-based practice. The limitations underscore the need for continued high-quality research and scheduled guideline updates.

Study quality is emerging as an essential component of evidence syntheses. It allows practitioners and policymakers to make informed decisions based on the quality of the evidence reviewed. Study quality is typically assessed by checklists of pre-determined quality criteria. Few study quality checklists have been systematically evaluated, and none have been developed specifically for survey studies in psychology. The present study addresses this evidence gap by developing the quality of survey studies in psychology (Q-SSP) checklistusing an expert-consensus method. An international panel of experts in psychology research and quality assessment (N = 53) evaluated the inclusion and importance of candidate quality items and offered commentary. The resulting checklist was used to evaluate a set of survey studies and inter-rater reliability of checklist scores was computed. A preliminary test of criterion validity of checklist scores was conducted using on a sample of survey studies with ‘known differences’ in study quality verified by experts. Experts exhibited high agreement on inclusion and importance ratings of the candidate items. Minor adjustments were made to the candidate items based on experts' feedback. Inter-rater reliability of study quality scores using the checklist was high. Some evidence for criterion validity of scores using the checklist was obtained. Overall, we provide preliminary data to support the Q-SSP checklist as a potential means to evaluate the quality of survey studies in psychology. We recommend a future large-scale study using the Q-SSP checklist to assess study quality in studies with known differences in quality verified by experts.

To evaluate the research performance in ophthalmology in Germany based on the findings of the recent research map of the German Ophthalmological Society ( DOG) and to suggest strategies for future improvements on anational level both to DOG as well as to politics. The focus is on preclinical and translational clinical research. International expert panel evaluation and discussion organized by the Task Force Research of the German Ophthalmological Society (DOG). The international view on the German ophthalmological research landscape was generally positive. The value for money relationship was judged as very good. As Germany is facing an aging society and vision impairment will create an ever-increasing socioeconomic burden, the reviewers suggested several lines of future activities: an increased activity of securing intellectual property, more lay audience lobbying, intensified collaboration and critical mass building between "lighthouses" of ophthalmic research in Germany, as well as the establishment of aGerman national eye institute equivalent. The ophthalmological research performance in Germany was rated to be very good by an international expert panel. Nonetheless significant improvements were requested in the fields of translation (clinical trials, IP), synergy between specialized institutions and governmental funding for aGerman center for eye research.

Background Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive condition that can cause debilitating symptoms.[1] The burden of untreated ATTR-CM was recently evaluated in an international, multicentre, real-world survey study.[2] Identifying predictors of ATTR-CM burden can help improve patients’ therapeutic journey. Purpose To identify predictors of disease burden on patients with ATTR-CM treated with symptomatic but not disease-modifying therapy using data from the recent international real-world survey study. Methods The original study surveyed 208 patients with untreated ATTR-CM recruited from international amyloidosis centres of excellence in 7 countries between July 2021 and August 2022. This post hoc analysis used univariate and multivariate models to evaluate selected survey variables as predictors of patient burden. Variables and outcomes included in the models are described in the figure. Univariate associations were confirmed with a t-test and Pearson correlation coefficient. The full multivariate models included all variables and were then optimised using forward selection and CV Press criteria with 8-fold cross-validation to identify the best predictors. Results The patient population in the original study were generally male (86%) and elderly (median 81 [range: 46 – 90] years), with wild-type ATTR-CM (91% of 155 with genetic testing; median time since diagnosis: 6 months). Of the 199 patients with a recorded NYHA classification, 60% were class II, 22% were class III, 18% were class I, and none were class IV. The investigator reported each neurologic symptom variable (Figure) as a current symptom in 25–41 patients, and gastrointestinal or urinary problems in 36 patients. Out-of-pocket expenses in the prior 3 months were reported by 78 patients. Respective median (IQR) KCCQ-OS, -CS and -TS scores were 67.7 (46.4–84.4; n = 183), 69.0 (49.5–87.5; n = 202), and 75.0 (52.1–91.7; n = 208); HADS-A and HADS-D scores were 5.0 (3.0–8.0; n = 205), and 6.0 (3.0–10.0; n = 204); SF-12 PCS and MCS scores were 36.3 (27.5–43.5; n = 206) and 46.8 (39.4–54.4; n = 206); and PROMIS Fatigue T-score was 50.8 (45.8–57.8; n = 203). In the unadjusted univariate models, NYHA class and the neurologic symptom variable of weakness, especially in the legs, were independently associated with all outcome measures of burden. Closely reflecting the statistically significant predictors in the full multivariate models, older age (continuous or age over 80 years), symptomatic heart failure (NYHA class II or III), female sex, and having weakness, especially in the legs, were among the best predictors of a higher burden in several optimized models (Table). Conclusions In this study of patients with ATTR-CM receiving symptomatic but not disease-modifying therapy, our analysis suggests that older age, female sex, and cardiac or neurologic symptoms are often predictors of higher disease burden.Figure:Variables and outcome measuresTable:Optimised models

Medical extended reality (MXR) has emerged as a dynamic field at the intersection of health care and immersive technology, encompassing virtual, augmented, and mixed reality applications across a wide range of medical disciplines. Despite its rapid growth and recognition by regulatory bodies, the field lacks a standardized taxonomy to categorize its diverse research and applications. This American Medical Extended Reality Association guideline, authored by the editorial board of the Journal of Medical Extended Reality, introduces a comprehensive taxonomy for MXR, developed through a multidisciplinary and international collaboration of experts. The guideline seeks to standardize terminology, categorize existing work, and provide a structured framework for future research and development in MXR. An international and multidisciplinary panel of experts was convened, selected based on publication track record, contributions to MXR, and other objective measures. Through an iterative process, the panel identified primary and secondary topics in MXR. These topics were refined over several rounds of review, leading to the final taxonomy. The taxonomy comprises 13 primary topics that jointly expand into 180 secondary topics, demonstrating the field's breadth and depth. At the core of the taxonomy are five overarching domains: (1) technological integration and innovation; (2) design, development, and deployment; (3) clinical and therapeutic applications; (4) education, training, and communication; and (5) ethical, regulatory, and socioeconomic considerations. The developed taxonomy offers a framework for categorizing the diverse research and applications within MXR. It may serve as a foundational tool for researchers, clinicians, funders, academic publishers, and regulators, facilitating clearer communication and categorization in this rapidly evolving field. As MXR continues to grow, this taxonomy will be instrumental in guiding its development and ensuring a cohesive understanding of its multifaceted nature.

Inadvertent intra-arterial injection of sclerosants is an uncommon adverse event of both ultrasound-guided and direct vision sclerotherapy. This complication can result in significant tissue or limb loss and significant long-term morbidity. To provide recommendations for diagnosis and immediate management of an unintentional intra-arterial injection of sclerosing agents. An international and multidisciplinary expert panel representing the endorsing societies and relevant specialities reviewed the published biomedical, scientific and legal literature and developed the consensus-based recommendations. Actual and suspected cases of an intra-arterial sclerosant injection should be immediately transferred to a facility with a vascular/interventional unit. Digital Subtraction Angiography (DSA) is the key investigation to confirm the diagnosis and help select the appropriate intra-arterial therapy for tissue ischaemia. Emergency endovascular intervention will be required to manage the risk of major limb ischaemia. This includes intra-arterial administration of vasodilators to reduce vasospasm, and anticoagulants and thrombolytic agents to mitigate thrombosis. Mechanical thrombectomy, other endovascular interventions and even open surgery may be required. Lumbar sympathetic block may be considered but has a high risk of bleeding. Systemic anti-inflammatory agents, anticoagulants, and platelet inhibitors and modifiers would complement the intra-arterial endovascular procedures. For risk of minor ischaemia, systemic oral anti-inflammatory agents, anticoagulants, vasodilators and antiplatelet treatments are recommended. Inadvertent intra-arterial injection is an adverse event of both ultrasound-guided and direct vision sclerotherapy. Medical practitioners performing sclerotherapy must ensure completion of a course of formal training (specialty or subspecialty training, or equivalent recognition) in the management of venous and lymphatic disorders (phlebology), and be personally proficient in the use of duplex ultrasound in vascular (both arterial and venous) applications, to diagnose and provide image guidance to venous procedure. Expertise in diagnosis and immediate management of an intra-arterial injection is essential for all practitioners performing sclerotherapy.

BackgroundWaterpipe (WP) smoking is increasing globally. The rise of WP has been fuelled by widespread misperception of reduced-harm compared to cigarettes. Health warning labels (HWLs) are one strategy to communicate...

Do mathematicians integrate computer algebra systems in university teaching? Comparing a literature review to an international survey study