Bringing an end to diabetes stigma and discrimination: an international consensus statement on evidence and recommendations

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

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.

We Call for iCAALL: International Collaboration in Asthma, Allergy and Immunology

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.

BackgroundThe King’s Fund report ‘Leadership and engagement for improvement in the NHS: Together we can’ describes the purpose of effective leadership, in a simplified manner, to improve population health and...

Introduction Sleep plays an important role in emotional regulation. Emotional regulation can be disrupted by psychosocial stress, including social judgment. It is not known whether sleep can regulate emotions arising from social judgment. The aim of this study is to determine if sleep can reduce emotional reactivity associated with negative social judgment. Methods On day one, subjects participated in a social judgment task (SJT) in the morning, followed by a nap or wake condition. Subjects’ physiological responses to social judgment task (skin conductance and heart rate) and mood were measured before and after the SJT, after the nap/wake condition, and once on day three. Results Mood ratings decreased after social judgment for all subjects, but increased following the nap intervention. Mood ratings improved after the 2 day delay. There were no changes in social status. Skin conductance during judgment decreased for subjects in nap condition, but not wake. After a 2 day delay, skin conductance decreased across subjects, with those in nap condition experiencing greater decrease. Heart rate response during social judgment exposure decreased only for those in nap group, with a 2 day delay showing decreased heart rate response across all subjects. Conclusion A nap directly following social judgment buffers negative response to the experience by decreasing emotional reactivity as measured by mood, skin conductance, and heart rate response. No differences were found between nappers and non-nappers on day three, suggesting that sleep benefits emotional reactivity associated with the stress of social judgment and that these benefits can happen with a nap or a night of sleep, more than a period of wake. Support University of California, Irvine.

ObjectiveFor people who experience social inequities and structural violence, pain and related care are inexorably linked to experiences of injustice and stigma. The purpose of this study was to examine in greater depth the experiences of pain and discrimination and stigma across diverse marginalized communities in order to recommend equity-oriented healthcare approaches.MethodsThis community-based qualitative study reports on four focus groups that included 36 people living with pain. All participants identified with one of three groups known to experience high levels of inequities and structural violence including an Indigenous group, a LGBTQ2S group, and two newcomer and refugee groups.ResultsPain was entangled with and shaped by: social locations and identities, experiences of violence, trauma and related mental health issues, experiences of discrimination, stigma and dismissal, experiences of inadequate and ineffective health care, and the impacts of these intersecting experiences.ConclusionsEquity-oriented responses to chronic pain would recognize pain not only as a biomedical issue but as a social justice issue. The EQUIP Framework is an approach to integrating trauma- and violence-informed care; culturally-safe care; and harm reduction in health care that may hold promise for being tailored to people experiencing pain and social marginalization.

Internalizing mental illness stigma is related to poorer well-being, but less is known about the factors that predict levels of internalized stigma. This study explored how experiences of discrimination relate to greater anticipation of discrimination and devaluation in the future and how anticipation of stigma in turn predicts greater stigma internalization. Participants were 105 adults with mental illness who self-reported their experiences of discrimination based on their mental illness, their anticipation of discrimination and social devaluation from others in the future, and their level of internalized stigma. Participants were approached in several locations and completed surveys on laptop computers. Correlational analyses indicated that more experiences of discrimination due to one's mental illness were related to increased anticipated discrimination in the future, increased anticipated social stigma from others, and greater internalized stigma. Multiple serial mediator analyses showed that the effect of experiences of discrimination on internalized stigma was fully mediated by increased anticipated discrimination and anticipated stigma. Experiences of discrimination over one's lifetime may influence not only how much future discrimination people with mental illness are concerned with but also how much they internalize negative feelings about the self. Mental health professionals may need to address concerns with future discrimination and devaluation in order to decrease internalized stigma.

Commentary Cunningham et al. conducted a cost-effectiveness analysis of the diagnostic process for femoroacetabular impingement (FAI) syndrome. With the tremendous increase of the therapeutic and diagnostic costs of this pathology, the data presented in this study are noteworthy from a clinical and a financial standpoint. The article concludes that advanced imaging, including magnetic resonance imaging (MRI) and magnetic resonance arthrography (MRA), are not cost-effective methods when compared with the history and physical examination (H&P) with or without diagnostic hip injection, and thus should not be routinely performed to diagnose FAI. It was suggested that hip MRI and MRA should have a place in the diagnostic algorithm of FAI only in cases of “challenging clinical scenarios.” The use of diagnostic hip injection was proven to be favorable for general practitioners and less useful for hip specialists. FAI syndrome was redefined in an international consensus statement and was endorsed by 25 clinical societies1. Hip pain can be the result of bone lesions and cartilage damage, as well as labral, capsular, and ligamentum teres pathology. Although the H&P and hip radiographs can identify osseous abnormalities, labral or capsular pathology is left undiagnosed, and evaluation of the cartilage is impossible without MRI. With the substantial expansion of hip arthroscopic techniques2, it is possible to address osseous and soft-tissue lesions that, if left untreated, result in deterioration of hip biomechanical function and osteoarthritis3. The novelty of and rapid progression in diagnostic and treatment modalities in hip preservation surgery have resulted in an imbalance of medical knowledge between general practitioners and hip specialists. Cunningham et al. propose that H&P with injection is more likely to be cost effective for general practitioners. Administration of hip injection requires technical expertise since severe damage can occur in the hip when performed inappropriately. The former point is reflected in the results of the study: the willingness to pay (WTP) was $57,000/quality-adjusted life year (QALY) using the injection sensitivity rate in the general practitioner scenario. This amount is almost 50% lower than the accepted WTP threshold in the United States, which is $100,000. The elimination of the use of MRI and MRA in cases of “challenging clinical scenarios” would be reasonable if the level of education was equal between general practitioners and hip specialists because characterizing a clinical scenario as “clinically challenging” relies substantially on clinical expertise, which can differ considerably even among hip specialists. Hip joint ultrasonography in the diagnosis of FAI syndrome has attracted research interest. Ultrasound is less expensive and more accessible than MRI and MRA examination, but diagnostic accuracy depends on the examiner’s skills. Buck et al. reported that the acetabular labrum can be visualized using ultrasound, but only partially4. Evaluation of the interference of the labrum with the other joint structures during hip motion under ultrasound visualization could help to better understand the patient’s symptomatology and aid in preoperative planning. MRI has been used in studies as the gold standard to validate ultrasound for the diagnosis of cam impingement, with promising outcomes4,5, but not enough evidence exists to establish it as a reliable examination to diagnose FAI syndrome. Another advantage of preoperative MRI examination is the detection of occult malignant bone or soft-tissue tumors concomitant with FAI pathology, where arthroscopic hip intervention could cause tissue spread and subsequent metastatic disease. While Cunningham et al. support the reduction of MRI and MRA usage to diagnose FAI syndrome, currently there is no other validated tool to diagnose hip soft-tissue and cartilage lesions. A possible solution to limit the financial burden when diagnosing FAI syndrome would be an increase in training opportunities for health-care professionals to advance their knowledge of FAI syndrome (apart from the cam and pincer mechanisms), with specialized physical examination tests and radiographic views (cross-table lateral, Dunn view, or false-profile view). This would eliminate the need for repeated radiographs by specialized physicians who usually encounter a patient who has been diagnosed with FAI syndrome based on symptomatology, impingement tests, and/or anteroposterior pelvic radiographs. Overuse of MRI and MRA and the associated costs need to be addressed by establishing validated hip-screening protocols to diagnose FAI syndrome. This will bridge the “gap” between general practitioners and hip specialists when diagnosing this disease and prevent the misuse of MRI and MRA and overcharging of the health-care system.

Firmly establishing oral health care professionals’ roles as vaccinators within the health care system