To develop imaging-based measures for disease assessment in noninfectious posterior uveitis (NIPU). A mixed-methods design, beginning with a review of previously developed imaging recommendations formulated by separate subcommittees of the multimodal imaging in uveitis (MUV) initiative, followed by a structured consensus process using the nominal group technique (NGT), facilitated by an independent expert committee. An expert committee reviewed and extracted all consensus-based imaging recommendations from the MUV subcommittee manuscripts focused on five major NIPU entities. The primary objective was to categorize imaging features as suggestive of active disease (SAD), suggestive of inactive disease (SID), or equivocal. This process was conducted using the NGT to reach consensus-based imaging measures. These recommendations were further voted upon by members of the full task force. A total of 49 imaging statements were deliberated using two rounds of NGT and independent voting. For the five included diseases, a total of 21 statements qualified as features of SAD, whereas 12 statements were classified as SID. The remaining 16 statements were categorized as equivocal features that need further investigation to determine whether the disease is active. This study builds upon the multinational efforts of the MUV initiative to extend the standardization of uveitis nomenclature (SUN) work through the integration of additional multimodal imaging information. Defining clear imaging-based outcome measures for NIPU, it establishes a structured framework supporting objective disease assessment. These standardized imaging measures are expected to enhance the utility of multimodal imaging in both routine uveitis care and future clinical trials.

Consensus-based guidelines for research in bracing in idiopathic scoliosis by the SRS comprehensive care committee in collaboration with SOSORT.

With the digital cultures that youth are exposed to and participating in come potential risks and protective factors for their mental health. However, despite clear need there is a lack of guidance to help mental health professionals evaluate the role of social media, artificial intelligence, and other technologies in young people's mental health. To co-design with young people the Digital Culture Interview, an interview tool to support the clinical assessment of digital cultural factors in mental health care. We recruited a diverse group of 12 participants aged 16-35 years (mean age 22 years) from outpatient mental health clinics in Montreal, Canada. Using the nominal group technique, they identified topics they found most relevant for exploring in a clinical assessment the experiences and practices involving digital technologies. Based on the topics that received the most votes from participants, we co-developed a list of interview questions and written guidance for their administration. Participants identified and ranked 48 themes. Drawing from these, 14 questions were developed for inclusion in the Digital Culture Interview, covering four topics: identity and worldview, negative experiences online, coping, and understanding of mental health. Participants emphasised that exploring digital culture in mental health care requires patients' trust and a baseline of knowledge. If done sensitively, this may enhance the patient-clinician alliance and improve mutual understanding. The Digital Culture Interview has the potential to enhance rapport and reveal risk and protective factors that are salient to and actionable in mental health care.

Parents play a vital role in protecting their children from healthcare-associated harms, for example, through mitigating safety incidents in general practice. Despite international calls encouraging family involvement in patient safety initiatives, parental perspectives are rarely embedded in the co-design of safety improvements. To co-generate and prioritise ideas for improving paediatric safety in general practice with parents and key stakeholders, and to explore areas of agreement and disagreement between these groups. A multi-method study combined qualitative methodology with quality improvement tools involving four parent workshops (between June and July 2024) and one stakeholder workshop (November 2024). Parent participants had experience of accessing general practice services with their children; and stakeholder participants included clinicians, managers, policymakers, primary care leaders and patient advocates. Parent participants reviewed national-level safety incident data and used nominal group technique to generate ideas for change. Ideas were collated, refined and presented to key stakeholder participants, who assessed the potential 'doability' (can be acheived or performed) and impact of each idea. Parents (n = 33) generated 16 ideas for change targeting communication, access to care records and results, and shared learning and development. Stakeholders (n = 7) prioritised seven ideas, including a campaign to support parents to speak up, having flexible appointments for children and designating a parent advocate. Parents and stakeholders most strongly agreed on the need to proactively seek parent feedback and solutions. Parents are willing and able to support healthcare teams with their patient safety efforts. Their ideas align with national priorities and offer actionable strategies that general practice teams can adopt or adapt for safer paediatric care in their own populations.

Evidence and Consensus Based Guidelines for Imaging in Tubercular Choroiditis. Multimodal imaging in Uveitis (MUV) Taskforce: Report 17.

International targets to address the prevention and treatment of child and adolescent obesity (CAO) remain largely unmet. Engaging frontline healthcare professionals (HCPs) and health service managers (HSMs) to identify barriers and actionable solutions can support appropriate and sufficient health responses. We aimed firstly to explore perspectives, identify barriers, facilitators and priorities in CAO management among HCPs and HSMs in Ireland, using an implementation science lens. Secondly, we aimed to develop recommendations on how to improve health service delivery for CAO management. This study used focus groups alongside a nominal group technique and was an integral part of a comprehensive project exploring CAO management. Data were analysed and interpreted using thematic analysis, and themes were mapped to the Consolidated Framework for Implementation Research (CFIR) to identify strengths and gaps in the health system. We also performed data triangulation to achieve a broader understanding of the complexities involved in health service delivery for CAO management. Twenty-two focus group discussions (FGDs) with 90 HCPs and 16 HSMs were conducted. Five main themes were developed: (i) diverse understanding and perception of CAO, (ii) service-level needs, (iii) partnership and integration, (iv) communication barriers and needs, and (v) policies, and politics. We mapped themes to the CFIR constructs and identified several facilitators and barriers in the current health system. Through nominal group technique, 21 priorities were identified. Five of these focused on improvements that can facilitate practice: (i) availability of clear care pathways, (ii) multidisciplinary team supports, (iii) HCP resources, (iv) training for HCPs, and (v) collaboration with stakeholders. We explored the alignment of priorities data with the themes identified from FGDs and with CFIR constructs. This informed the development of recommendations to strengthen health service delivery for CAO management. The study highlights the need for diverse resources and stakeholder collaboration to enable effective implementation of health services for CAO, while also offering strategic recommendations aimed at strengthening CAO management in health systems.

Minimum standards for co-design in public health research: Results from a double consensus process.

Post-transplant immunosuppression (IS) significantly impacts patient and graft outcomes. The Starzl Network for Excellence in Pediatric Transplantation (SNEPT), a multicenter learning health network dedicated to pediatric liver transplant, identified IS optimization as a priority project. Here we describe SNEPT's development of consensus care plans (CCPs) for induction IS after pediatric liver transplantation, using an adapted nominal group technique to achieve consensus. First, 16 SNEPT transplant centers across the U.S. and Canada shared individual center IS protocols. Collation of center-specific protocols identified five key medications (basiliximab, thymoglobulin, corticosteroids, mycophenolate mofetil, and tacrolimus). Dosing consensus and variability across all 16 center protocols were summarized by SNEPT's Optimizing IS working group. Through iterative cycles of feedback conducted in-person and virtually, 2022-2025, CCPs for each medication were developed, reviewed with stakeholders and revised. CCPs were finalized with consensus from all 16 centers. CCPs were presented at SNEPT's network-wide meeting as well as at individual center multidisciplinary meetings to assess accuracy of captured current practice and agreement with implementation. CCPs were finalized with universal network consensus and will be implemented across the network, laying foundational work for prospective quality improvement and comparative effectiveness studies.

Unnatural and unexplained deaths present critical challenges to the criminal justice, medico-legal, and public health systems. This study explored forensic professionals' perspectives on the integration of point-of-care (POC) diagnostics into unnatural death investigations in South Africa. A Nominal Group Technique (NGT) was conducted with eight key forensic stakeholders to identify and prioritize the potential benefits, facilitators, and barriers associated with POC implementation. Stakeholders ranked guidance for investigation and autopsy, improved turnaround times, and resource efficiency as the most significant POC diagnostic benefits. Scientific validity, quality assurance, and alignment with legal and regulatory frameworks were identified as critical facilitators, whereas technical limitations, quality management gaps, and legal uncertainties emerged as key barriers. Participants emphasized that POC diagnostics could support timely decision-making during death scene investigations and autopsies, reduce laboratory backlogs, and improve family and community outcomes through faster case resolution. However, successful integration requires standardized protocols, validation, and appropriate training to ensure scientific and legal defensibility. These findings provide foundational evidence to inform the responsible integration of POC diagnostics into forensic death investigations, with potential benefits for justice delivery and community health in South Africa.

Configurational comparative methods (CCMs) are designed for the systematic comparison of case data to identify necessary and sufficient conditions for an outcome. The complex interplay of contextual factors, implementation strategies, and intervention components makes CCMs particularly suitable for implementation studies. Factor selection is a stage in CCMs during which researchers determine a limited set of variables of interest for analysis. Guidance that helps implementation researchers to select a manageable set of factors from a plethora of potentially interesting components is warranted but lacking, especially, for pre-data collection. We provide such guidance with an emphasis on (1) intentional data collection, and (2) broad engagement of interest-holders across different stages of factor selection. Our suggested approach consists of four stages: (1) factor identification, (2) factor prioritization, (3) factor determination, and (4) factor operationalization. Throughout these stages, we highlight opportunities for engaging interest-holders. We illustrate all stages using experience from a multinational hybrid implementation-effectiveness trial in the field of infection prevention. First, we conducted a systematic review to identify potentially relevant factors. Second, we applied the Nominal Group Technique in meetings with interest-holders to prioritize previously identified factors. Third, we conducted two project workshops to decide on a final set of factors. Fourth, we operationalized factors into measurable units and assessed them using qualitative and quantitative methods. We present a methodology and applied case example for pre-data collection factor selection for CCMs. The proposed method comprises four stages, each requiring implementation researchers to balance scientific rigor with pragmatism, while ensuring meaningful engagement of interest-holders. This guidance closes a gap in existing recommendations, which have primarily focused on factor selection during data analysis. Making CCMs more accessible and increasing their use should remain a central priority in implementation science.

Co-design of a pre-surgical care intervention to support people undergoing prostatectomy for prostate cancer.

Cultural safety is a key component of quality general practice for Aboriginal and Torres Strait Islander peoples; however, few tools exist to assess this from the patient's perspective. This study aimed to explore the qualities of a general practitioner (GP) that support culturally safe consultations, as described by Aboriginal and Torres Strait Islander peoples, and to examine how these align with two consultation models: the Calgary-Cambridge Guide and clinical yarning. A mixed methods approach was used, including a survey, qualitative interviews and a modified nominal group technique (mNGT). Participants were Aboriginal and Torres Strait Islander peoples who had previously engaged with general practice care. Data were both described and analysed thematically. In total, 131 Aboriginal and Torres Strait Islander peoples participated (70 in the survey and interview; 43 in mNGT to validate the findings; and 18 in three separate mNGTs to rate desirable attributes of a GP). Participants identified several qualities underpinning a safe GP consultation. Within the top five attributes in the mNGT were universal skills - clinical competence, avoidance of jargon and attentive listening - alongside welcoming patients with a greeting and avoiding stereotyping. Although there was strong emphasis on respectful, individualised care, preferences varied significantly, highlighting the limitations of a generic approach to consultation skills. Some findings challenged core assumptions regarding clinical yarning and elements of cultural safety training. We propose a refined, integrated consultation model that enhances the Calgary-Cambridge Guide with relational elements of the social yarn, particularly during initiation of the consultation. This integrated model, grounded in Aboriginal and Torres Strait Islander peoples' perspectives yet familiar to GPs and academics, offers a promising foundation for culturally safe practice and assessment, with potential applicability across other diverse populations.

BackgroundInternational adaptation of healthcare interventions requires sensitivity to local contexts, especially in palliative care, where healthcare systems and cultural expectations about end of life differ widely. Pal-Cycles is an intervention that aims to improve transitions in care for patients with advanced cancer. This intervention was adapted for implementation in a stepped wedge trial across seven European countries (Germany, Hungary, the Netherlands, Poland, Portugal, Romania and the UK). This paper aims to illustrate the process of adapting a palliative care intervention (Pal-Cycles) to meet the needs of those using healthcare settings across seven European countries.MethodsAdapted nominal group techniques (a structured group method that supports idea generation, discussion, and prioritisation) were used, involving both in-country and cross-country adaptation meetings focused on the five key components of the original intervention design, to ensure cultural sensitivity and best fit All countries established a group of clinicians and all except two countries (Portugal and Hungary) involved groups of patients and families. The adaptation process occurred in a series of 5 meetings, which were mostly held online to accommodate participants’ schedules.ResultsA total of 36 clinicians, 14 patients or family members, and 16 facilitators participated in the adaptation process over a four-month period. Structured guidance and iterative consultation meetings ensured that the final intervention was both standardised and adaptable to each country’s healthcare setting. We produced a standardised intervention manual based on a theory of change model, ensuring consistency across countries while allowing for contextual flexibility.ConclusionsThis paper provides guidance for future cross-cultural adaptation of palliative care interventions, illustrating the value of detailed methodological planning, structured guidance, and multi-stakeholder engagement in the adaptation process.Trial registrationClinicalTrials.gov NCT06259136, registered on 6 February 2024.Supplementary InformationThe online version contains supplementary material available at 10.1186/s12904-026-02105-0.

Core outcome sets (COS) standardise the outcomes reported in clinical trials and research, reducing outcome heterogeneity and enabling evidence synthesis. Most neonatal COS have been developed in high-income country (HIC) contexts and may not reflect the priorities, health system capacities, or disease burden of low- and middle-income countries (LMICs). Kenya's neonatal mortality rate remains high at 21 per 1000 live births, yet no COS exists for neonatal care and research in Kenya or, more broadly, in sub-Saharan Africa. This study aimed to develop a contextually appropriate COS for neonatal care and research in Kenya, and to assess the feasibility of adapting an existing HIC COS for use in an LMIC setting. A mixed qualitative and consensus-based approach was used, guided by the COMET handbook. The process comprised three phases: a rapid review of outcomes reported in neonatal trials from sub-Saharan Africa compared with an existing HIC COS; qualitative stakeholder engagement through key informant interviews (KIIs) and focus group discussions (FGDs) with healthcare providers, national-level policymakers, and mothers of previously admitted neonates at two Kenyan hospitals representing urban and rural settings; and an in-person consensus workshop using the nominal group technique with 13 multidisciplinary stakeholders. Thematic analysis followed Braun and Clarke's six-phase framework. Outcomes endorsed by ≥ 70% of consensus meeting participants were included in the final COS. Seventeen stakeholders participated in KIIs, and 15 mothers participated in two FGDs. Sixteen candidate outcomes were presented at the consensus meeting. Five outcomes achieved immediate universal consensus: survival, length of hospital stay, ability to feed/weight gain/growth, cognitive ability, and visual impairment/retinopathy of prematurity (RoP). Following discussion and voting, a further seven outcomes were endorsed: impact on mothers and wider family, financial costs to the mother, pain, adverse events due to medicines, respiratory distress, quality of life, and sepsis/infections. The final COS comprises twelve outcomes. Seven overlapped with the existing HIC COS, though with contextually adapted definitions. Five outcomes are Kenya-specific, reflecting the out-of-pocket payment structure, high comorbidity burden, and family-centred care priorities of the Kenyan health system. Adapting an HIC neonatal COS for use in an LMIC context is feasible, but requires systematic definitional adaptation, engagement with existing local frameworks such as WHO Essential Newborn Care guidelines, and attention to diagnostic capacity constraints. The Kenya COS captures both clinical and life-impact outcomes, reflecting the priorities of diverse stakeholder groups including mothers. Realising its value requires phased implementation sensitive to urban-rural differences in facility capacity, investment in workforce training, and stronger collaboration between clinicians and researchers to ensure outcome measurement serves both care improvement and evidence generation. This is not a clinical trial. not applicable.

High-quality pharmacoepidemiological research is essential for credible real-world evidence (RWE). This expert consensus-based review explores how pharmaceutical Quality Management Systems (QMS) developed for studies using primary data collection (e.g., clinical trials, registries) can be adapted to support studies utilising secondary data to generate RWE, in line with regulatory expectations. The aim was to identify fit-for-purpose considerations for proportional oversight, data integrity, and regulatory-grade evidence generation. An international working group (WG) comprising RWE experts from industry, academia, and independent consultancy (including QMS specialist) assessed which elements of QMS frameworks developed for primary data collection are applicable to RWE studies utilising secondary data sources and those elements where adaptation would be required. Using the Nominal Group Technique, the WG identified and prioritised relevant quality systems and adaptation needs. In parallel, a targeted literature review of guidance and reports from International Coalition of Medicines Regulatory Authorities (ICMRA) member sites (focusing on the EU, USA and UK) assessed guidance against prioritized quality systems. Of 21 quality systems identified, 12 were considered most relevant to RWE studies utilising secondary data, with ten requiring contextual adaptations. The literature review identified 26 publications referencing one or more of these systems; quality manuals (69.2% (n=18)) and quality control (34.6% (n=9)) were most frequently addressed, whilst other systems were inconsistently covered; vendor management was not explicitly addressed. Overall, this review highlights the need for fit-for-purpose adaptation of existing QMS frameworks to support regulatory-relevant, scientifically robust RWE generated from secondary use of existing data sources.

Polyendocrine metabolic ovarian syndrome, the new name for polycystic ovary syndrome: a multistep global consensus process.

ObjectivesDespite adherence to guideline-based pharmacotherapy, many people with diabetic kidney disease (DKD) were unable to meet glycaemic and blood pressure targets. The purpose of this paper was to report the unmet needs of people with early-stage DKD.DesignA sequential mixed-methods approach was used, comprising a quantitative survey followed by an exploratory qualitative phase using nominal group technique (NGT) discussions with people with DKD.SettingPatients were recruited from 45 primary care clinics in Peninsular Malaysia from March to May 2024.ParticipantsSurvey data were collected from 131 adults with an estimated glomerular filtration rate between 30 and 89 mL/min/1.73 m2 and with suboptimal glycaemia and blood pressure outcomes. Exploratory NGT discussions were conducted with seven participants.Main outcome measuresThe online survey used the WHO definition of unmet healthcare need as the ‘failure to seek healthcare when needed during the past twelve months’ to assess the prevalence and associated factors. Qualitative data and ranking of other perceived unmet needs of these people with DKD and suboptimal clinical outcomes were collected through NGT discussions.ResultsThe prevalence of reported unmet healthcare needs per the WHO definition was 13%, with history of diabetic foot ulcer (adjusted OR (AOR) 6.67, 95% CI 1.22 to 37.25) and urban residence (AOR 3.70, 95% CI 1.26 to 12.89) reported as associated factors. NGT identified three patient-prioritised unmet needs: ‘dietary support’, ‘better medication’ and ‘mental health support’. Female participants prioritised obtaining medication and kidney health information, whereas male participants emphasised self-monitoring support.ConclusionThe low prevalence of WHO-defined unmet need, alongside patient-prioritised concerns extending beyond standard measures, suggests that current operational definitions may not fully capture patient-perceived unmet healthcare needs in DKD.

While pre-exposure prophylaxis (PrEP) research predominantly focuses on men who have sex with men (MSM), PrEP uptake among women who use drugs (WWUD), female sex workers (FSWs), and female partners of people who inject drugs (PWID) is limited. This study fills a critical gap in the literature by examining the unique barriers and facilitators to PrEP uptake among these under-researched female populations, relative to MSM. This pre-implementation study employed a human-centered design approach guided by the Capability, Opportunity, and Motivation-Behavior (COM-B) model. Five focus group sessions using nominal group technique (NGT) were conducted with 66 participants from key populations (MSM, WWUD, FSWs, and female partners of PWID) across three cities (Tbilisi, Kutaisi, and Batumi) to systematically generate and prioritize barriers and facilitators. This study applied the Behavior Change Wheel (BCW) framework to map identified barriers and facilitators to specific intervention functions, highlighting actionable strategies to improve PrEP uptake. Semi-structured interviews with healthcare providers were conducted to contextualize system-level factors. Participants prioritized 15 distinct barriers, with clear differences between groups. MSM most often identified opportunity-related barriers, such as rigid clinic hours, confidentiality concerns, and prior negative healthcare experiences. In contrast, women primarily reported informational and social barriers, including lack of accurate information about PrEP and eligibility, anticipated stigma, and fear of being seen at AIDS centers. Other top barriers included low perceived HIV risk and fear of social stigma. Key facilitators included providing PrEP in neutral, non-stigmatizing delivery settings (i.e., separate from AIDS centers or MSM-specific venues) and offering tele-PrEP and injectable options. Provider insights aligned with participant findings. Findings highlight the need for better access to information and alternative PrEP delivery strategies that decouple PrEP from AIDS centers and MSM-identified venues, including neutral access points, tele-PrEP models, pharmacy or primary care delivery to improve acceptability and reach among at-risk women.

Co-developing Canadian hospital research tracking criteria: Findings from a National Consensus Building Meeting using the nominal group technique

Nearly one in ten hospitalized adults is readmitted within 30days. Though many models exist to predict risk of hospital readmission, many perform poorly and do not address the priorities of patients or providers that use them. In this study, we aimed to identify their priorities to inform a readmission risk prediction framework. Using nominal group technique (NGT) methodology, we completed in-person and virtual meetings between February and April 2025 involving 22 total participants from Alberta, Canada. Participants included people with lived experience of a hospital readmission as a patient or caregiver as well as multidisciplinary healthcare providers. Discussions focused on the use of prediction tools, risk communication, and readmission type and relevant predictors. Priorities were collated, and each candidate suggestion within a topic was individually ranked by each participant indicating perceived importance. Priorities were then summarized and rank ordered using a mean standardized priority score. Nine participants with lived experience (median age 56-65, 67% women, 33% rural) and 13 clinicians (median age group 36-45, 69% women, 77% physicians) participated in the meetings. Features most highly ranked by patients included using the tool to better inform patients and to plan discharge meetings, while those of clinicians focused on using a relevant time horizon, primarily risk of readmission ≤ 30days, as well as presenting alerts of readmission risk within the patients' discharge summary. Both groups supported targeting all unplanned hospital readmissions and identified potential predictors including social determinants of health and laboratory markers. There were 163 total and 52 unique candidate predictors suggested, many of which were novel compared to existing models. Patients and healthcare providers prioritized key features for readmission risk prediction frameworks, many of which differ from existing models. These findings can be used to inform the development of novel tools tailored to user needs.