The results address a growing change in multiple sclerosis care. Treatment strategies have traditionally included beginning with moderate-efficacy therapy and escalating if inflammatory activity persists, but an early-intensive approach has also become more common. High-efficacy therapies include monoclonal antibodies directed against CD20 and α4-integrin, as well as non-monoclonal agents such as cladribine and sphingosine-1-phosphate receptor modulators. The study focused only on the two monoclonal classes, because available comparative evidence suggested greater efficacy than with the other high-efficacy classes. Their use nevertheless requires balancing disease control against potential harms, including progressive multifocal leukoencephalopathy, hypogammaglobulinemia and infection.

To identify the features that mattered most, the researchers first presented eight fictional patients with combinations of demographic, clinical and MRI characteristics. The cases covered sex, age, ethnicity, comorbidities, cognitive impairment, severity of the initial neurological attack, motor impairment or ataxia, previous attacks, brain lesion load and the number and location of lesions. Participants then rated 108 modified scenarios in which one characteristic at a time was changed while the rest of the case remained constant. Recommendations were recorded on a five-point scale, with scores of 4 or 5 grouped as an indication for treatment, 3 as indecision and 1 or 2 as no indication.

After the first round, 27 of the 31 panelists attended a national online workshop to examine scenarios that had not produced consensus. The panel then completed a second round containing the unresolved statements, with all 31 again responding. Consensus for recommending treatment required a median score of at least 4 and at least 80% of ratings in the 4–5 range; consensus against treatment required a median of no more than 2 and at least 80% of ratings in the 1–2 range. Strong consensus required at least 90% agreement within the relevant rating range. This process produced 70 statements with strong consensus in favour, 18 with moderate consensus in favour, one with strong consensus against and 19 without consensus.

The strongest and most consistent influence was radiological evidence of high inflammatory or structural activity. A high brain lesion load, defined in the questionnaire as more than 20 lesions, systematically led the panel to recommend monoclonal high-efficacy therapy. The same pattern occurred with two or more spinal cord lesions, three or more gadolinium-enhancing lesions and three or more infratentorial lesions. Factors classified as intermediate because they prompted treatment recommendations in most, but not all, cases included a moderate brain lesion load of 10–20 lesions, clinically concerning symptoms during the initial attack, a previous attack within the preceding 12 months, cognitive impairment, one or two infratentorial lesions and a single spinal cord lesion.

The spinal cord finding was notable because one lesion carried more apparent weight than several other intermediate factors. Although a single spinal cord lesion did not always produce agreement on its own, its presence in combination with other concerning characteristics systematically moved the panel toward recommending monoclonal therapy. The researchers proposed that a patient with any strong factor should be considered for early monoclonal treatment, while a single spinal cord lesion would support that decision when accompanied by one or more intermediate factors. If neither category was present, they proposed discussing the choice in light of demographic and clinical-history information. This is a proposed framework reflecting expert judgment, not a validated clinical guideline.

The imaging emphasis is consistent with previous observational evidence cited by the study. A cohort of 178 people initially diagnosed with clinically isolated syndrome found that spinal cord lesions and active inflammation on MRI were associated with poorer long-term outcomes. A separate Dutch longitudinal study reported that baseline spinal cord lesions strongly predicted disability for up to 11 years, while infratentorial lesions also predicted disability. In another prospective cohort, a greater number of brain T2 lesions was associated with earlier irreversible disability. Such findings provide prognostic context for the panelists’ choices, but they do not demonstrate that choosing therapy on the basis of the Delphi thresholds will itself prevent disability.

The panel’s conclusions may also reflect the contemporary treatment environment. The study notes that the use of high-efficacy therapy has increased alongside evidence of benefit and tools for monitoring certain risks. For example, the anti-JC virus antibody index can help assess risk of progressive multifocal leukoencephalopathy in patients receiving anti-α4-integrin antibodies, and real-world data have linked its introduction with fewer such events. However, important determinants of safety and feasibility—including infection history, immunoglobulin levels, vaccination status, pregnancy plans and patient preference—were outside the Delphi exercise. The findings therefore describe what this group of neurologists would recommend in fictional cases, not what every patient should receive.

Several limitations constrain how the consensus can be interpreted. The scenarios were hypothetical, their combinations were not a representative sample of routine patients, and changing one factor at a time may exaggerate its apparent importance or miss interactions among clinical and imaging characteristics. The study also omitted recovery after the initial attack and emerging biomarkers such as serum neurofilament light chains, cerebrospinal-fluid measures, cortical or paramagnetic-rim lesions, atrophy and optical-coherence tomography findings. The second workshop round also allowed panelists to reconsider ratings after discussing evidence, illustrating the dynamic nature of consensus. Most importantly, the proposed framework has not been validated against patient outcomes, and the ongoing TREAT-MS and DELIVER-MS randomised trials have not yet reported whether early high-efficacy treatment improves long-term clinical results. The consensus offers a structured map of current expert reasoning, but its thresholds remain exploratory until tested in empirical studies.

Subject of Research: Expert consensus on MRI and clinical factors guiding early monoclonal high-efficacy therapy for relapsing-remitting multiple sclerosis

Article Title: DELPHI expert consensus-derived factors influencing the early use of monoclonal high-efficacy therapies in treatment-naïve patients with relapsing-remitting multiple sclerosis

Article References: Bourre, B., Guerrier, O., Ayrignac, X., Suchet, L., de Seze, J., Masmoudi, I., Ricigliano, V. A. G., Vermersch, P., Ciron, J., & the CAReSEP working group (2026). DELPHI expert consensus-derived factors influencing the early use of monoclonal high-efficacy therapies in treatment-naïve patients with relapsing-remitting multiple sclerosis. Journal of Neurology, 273(11), 679. https://doi.org/10.1007/s00415-026-14167-4

Image Credits: AI Generated

DOI: 10.1007/s00415-026-14167-4

Keywords: multiple sclerosis, relapsing-remitting MS, monoclonal antibodies, high-efficacy therapy, MRI biomarkers, Delphi consensus, anti-CD20 antibodies, anti-α4-integrin antibodies, treatment-naïve patients, French neurologists, DELPHI, expert

The study, led by Luca Ünlü of the University Hospital Basel and University Medical Center Freiburg, together with Christian H. Nickel and a transdisciplinary steering committee spanning emergency medicine and psychiatry on four continents, used a modified Delphi process—a structured method for building consensus among experts who rarely see eye to eye. Between May and November 2025, the team ran four rounds of online surveys and steering committee discussions. The participants were not a random sample of clinicians: they were 25 official representatives from seven emergency medicine and psychiatry societies, including the European Society for Emergency Medicine, the American Association of Emergency Psychiatry, the Australasian College for Emergency Medicine, the Brazilian Association for Emergency Medicine, the Dutch Acute Medicine Society, the German Association for Psychiatry, Psychotherapy and Psychosomatics, and the Coalition on Psychiatric Emergencies. Crucially, the panel also included six patient representatives with prior experience of emergency department medical screening, either as patients or as relatives of patients, recruited with help from the National Alliance on Mental Illness and the Italian advocacy network E.N.E.A.

The technical logic of the Delphi method is what makes this result notable. In the first round, participants freely generated candidate screening elements: 91 statements came from the society representatives and 27 from the patient representatives. In the second round, the panel rated and refined these statements, merging overlapping items and sharpening ambiguous wording. The third round applied a predefined consensus threshold: a statement would only survive if at least 80 percent of participants agreed with it. That threshold proved demanding. Only 48 of the 91 society statements—52.8 percent—reached consensus, while 21 of the 27 patient statements—77.8 percent—cleared the bar. The surviving items were then synthesized into a single instrument, the Delphi-Informed Medical Evaluation, or DIME, tool.

Retention rates across the rounds were high for a Delphi study of this scale. Of 28 invited society representatives and steering committee members, 25—89.3 percent—participated in the first round, 23 in the second, 22 in the third, and 23 in the fourth. All six patient representatives completed every round, a detail the authors highlight as evidence that the patient perspective was not a token gesture but a sustained contribution throughout the process. The study was registered with ClinicalTrials.gov under identifier NCT06936826, and the consensus process followed the ACCORD—ACcurate COnsensus Reporting Document—guidance, a framework designed to make consensus methods transparent and reproducible rather than a black box of expert opinion.

The fourth round served as the tool’s first stress test. Rather than asking participants whether they liked the DIME tool in the abstract, the researchers confronted them with 37 standardized clinical vignettes—short, structured descriptions of hypothetical emergency department patients with psychiatric complaints. Each participant independently applied the draft tool to every vignette and decided which screening elements it called for. The researchers then measured how often the raters agreed with one another using Gwet’s agreement coefficient, a statistical measure of interrater agreement that is more robust than simple percentage agreement when agreement is high, because it corrects for agreement that would occur by chance alone.

The numbers tell a striking story. Among the society representatives, applying the DIME tool to the 37 vignettes produced a Gwet agreement coefficient of 0.86, with a 95 percent confidence interval of 0.78 to 0.93 and a p-value below 0.001—a level the authors characterize as almost perfect agreement. Among the patient representatives, the coefficient was 0.76, with a confidence interval of 0.66 to 0.86 and the same p-value below 0.001, corresponding to substantial agreement. In practical terms, this means that when clinicians and patients from different countries, cultures, and professional traditions applied the same tool to the same hypothetical patient, they overwhelmingly reached the same conclusions about what medical screening was warranted. For a process that has historically generated more conflict than consensus, that level of agreement is remarkable.

The background problem the DIME tool addresses is well documented in the emergency medicine literature. Medical screening in the emergency department is performed to identify underlying medical conditions that may contribute to a patient’s psychiatric presentation or require treatment in their own right—think of delirium caused by an infection, agitation driven by intoxication, or psychosis secondary to a brain lesion. But the objectives and appropriate scope of this screening have never been standardized. Emergency physicians and psychiatrists frequently disagree about which tests are necessary, and the consequences are measurable: potentially unnecessary testing, prolonged emergency department length of stay, and increased costs. Patients with psychiatric complaints often wait longest, undergo the most redundant workups, and receive the least consistent evaluation. The DIME tool is designed to identify adult emergency department patients with psychiatric complaints who are at low risk for acute medical illness—effectively giving both specialties a shared, explicit framework for deciding when enough is enough.

The inclusion of patient voices is one of the study’s most distinctive technical features. Patient and public involvement has become an increasingly formalized element of health research, with reporting frameworks such as GRIPP2-SF—the Guidance for Reporting Involvement of Patients and the Public 2 Short Form—used to document how lay perspectives shaped the work. In this study, the patient representatives did not merely comment on a finished product; they generated their own statements in the first round, and those statements survived the 80 percent consensus threshold at a higher rate than the professional statements did. The synthesis of both streams of statements into the final tool means the DIME instrument reflects what patients consider important about being medically screened, not only what specialists consider defensible. The authors note that the patient perspective was incorporated with assistance from the National Alliance on Mental Illness and E.N.E.A., an organization of experts by experience based in Rome.

The authorship itself illustrates the transdisciplinary ambition. The panel includes figures such as Christopher R. Carpenter of the Mayo Clinic, Philipp Sterzer of the University of Basel’s Department of Psychiatry, Judith Tintinalli of the University of North Carolina, a towering name in emergency medicine education, and Michael P. Wilson of Virginia Tech-Carilion, whose work spans both emergency medicine and psychiatry. The DIME study group extends the effort to clinicians in New Zealand, Brazil, Australia, Spain, France, the Netherlands, the United Kingdom, and the United States. The work was funded by scientific funds of the Emergency Department of the University Hospital Basel, with open access funding provided by the University of Basel, and the article is published under a Creative Commons Attribution 4.0 license, making the tool freely available to any department that wants to examine it.

The authors are careful about what this study does and does not establish. The DIME tool is a consensus-based instrument, evidence-informed but not yet validated: it has not been tested against real patients, real outcomes, or real emergency department workflows. The researchers state explicitly that prospective multicenter validation studies are required before clinical implementation. That caveat matters, because a tool that performs well on paper vignettes among motivated expert raters may behave differently in a crowded department at three in the morning, applied by a tired resident to a frightened and agitated patient. Still, the study delivers something the field has lacked: a single, internationally agreed framework, endorsed by emergency physicians, psychiatrists, and patients on four continents, for deciding which adult psychiatric emergency patients need what medical evaluation. If prospective validation confirms its safety, the DIME tool could shorten waits, cut unnecessary testing, and—perhaps most importantly—end the turf war that has too often stood between psychiatric patients and the care they came for.

Subject of Research: Emergency Medicine

Article Title: International Delphi on a medical screening tool for emergency department patients with psychiatric complaints

Article References: Ünlü, L., Carpenter, C. R., Sterzer, P., Christ, M., Azad, N., Griese, J. A., Nordstrom, K., Skinner, C., Alsma, J., Stiebel, V., Kurzhals, S., Pascoe, E., Brister, T., van der Eycken, E., Maia, I. W. A., Tintinalli, J., Bingisser, R., Wilson, M. P., Nickel, C. H., … Zun, L. S. (2026). International Delphi on a medical screening tool for emergency department patients with psychiatric complaints. BMC Medicine. https://doi.org/10.1186/s12916-026-05324-7

Image Credits: AI Generated

DOI: 10.1186/s12916-026-05324-7

Keywords: emergency department, medical screening, psychiatric complaints, Delphi study, consensus, DIME tool, emergency medicine, psychiatry, patient involvement, BMC Medicine, International, Delphi

The Delphi method, originally developed at the RAND Corporation in the early 1950s, is a structured, iterative consensus-building technique designed to elicit and aggregate expert opinion on topics where robust empirical evidence is lacking or incomplete. It relies on four core principles: anonymity of participants, iterative questioning across successive rounds, controlled feedback provided between rounds, and statistical aggregation of group responses. In the health sciences, the method has gained widespread adoption for the development of clinical guidelines and recommendation statements, particularly in contexts where randomized controlled trial evidence is unavailable or difficult to obtain. The SIOT consensus applied this methodology to NSAID prescribing in orthopedics, a field where significant variability persists in practice and adherence to existing guidelines.

The consensus process began with a scientific board of seven members—six clinicians and one methodologist—who defined the clinical questions, identified key topics, and conducted a systematic literature review using PubMed/MEDLINE. The board proposed twenty statements spanning four domains, which were then submitted to a broader expert panel of twenty-eight members for evaluation using a six-point Likert scale. Consensus was defined as at least seventy-five percent of ratings concentrating within a single tertile of ascending relevance. In the first round, held on twenty-nine October 2025, twelve statements reached consensus. Six revised statements reached consensus in the second round, held on three December 2025, while two were eliminated because of persistent opinion dispersion.

Among the most significant recommendations to emerge from the process is the endorsement of short-cycle NSAID therapy, limited to cycles of a maximum of seven to ten days, within a multimodal analgesia approach. The panel agreed that because renal, cardiovascular, and gastrointestinal risks are closely related to NSAID dose and duration of treatment, current recommendations suggest that NSAIDs may be considered relatively safe when prescribed at the lowest effective dose for a period not exceeding ten days. Multimodal analgesia combinations incorporating NSAIDs have been established as an effective pain management strategy in several studies, particularly in the perioperative setting, and the consensus reinforces this framework as the standard of care for effective and opioid-sparing pain management in orthopedics.

The consensus also supports the use of symptomatic slow-acting drugs for osteoarthritis, known as SYSADOAs, to reduce NSAID consumption in patients with osteoarthritic pain. A recent meta-analysis confirmed the efficacy of SYSADOAs in osteoarthritis, with evidence supporting their NSAID-sparing effect in this clinical context. The panel agreed that when administered as part of conservative treatment strategies for osteoarthritic pain, SYSADOAs can help reduce the use of NSAIDs, offering a pharmacological alternative that may improve long-term safety profiles for patients requiring sustained pain management. This recommendation is particularly relevant given that osteoarthritis is among the most prevalent musculoskeletal disorders worldwide and one of the leading causes of chronic pain and disability.

In the domain of traumatic pain, the consensus reached agreement on two statements with important clinical implications. The panel recommended NSAIDs perioperatively in frail fracture patients within multimodal analgesia protocols to reduce opioid intake and limit the onset of complications, including delirium. Evidence from recent randomized controlled trials supports this approach: in one trial conducted in one hundred thirty-two patients aged sixty-five years or older undergoing hip fracture surgery, the prevalence of postoperative delirium was significantly lower in the anti-inflammatory bundle group compared with the placebo group. In another trial, the combination of oral acetaminophen and intravenous ketorolac was a viable alternative to opioid-based pain management in closed tibial shaft fractures treated with intramedullary nailing, decreasing opioid consumption without affecting pain scores or union rates.

The panel also affirmed that short-term administration of an NSAID, defined as less than ten to fifteen days, in the postoperative period and upon discharge of a patient operated on for a fracture is not associated with a significant risk of pseudoarthrosis. Several studies and meta-analyses have shown that short-term NSAID use does not significantly affect bone healing rates or increase the incidence of delayed union. However, the consensus was refined in the second round to establish that regular use of NSAIDs should be limited in patients at risk of developing stress fractures. Emerging evidence suggests that NSAIDs may inhibit remodeling within cortical bone, which could lead to increased bone density with extended use in a similar fashion as antiresorptive medications, potentially increasing the risk of stress fractures in physically active populations.

A particularly notable recommendation identifies ketoprofen lysine salt as having a favorable risk-benefit profile for postdischarge pain management, especially for treatments lasting up to seven to fourteen days. The efficacy of ketoprofen for acute postoperative pain has been supported by a Cochrane review, and evidence from multiple clinical trials demonstrates that ketoprofen achieves the highest ratio between anti-inflammatory and analgesic effects among non-selective NSAIDs. A recent review outlined the advantages of ketoprofen lysine salt versus ketoprofen acid in terms of greater gastric tolerability and quicker onset of action. Furthermore, a large epidemiological study derived from a database of eight and a half million new NSAID users identified seventy-nine thousand five hundred fifty-three cases of acute myocardial infarction, finding that ketoprofen appeared to be the most widely used drug with the lowest cardiovascular risk among the NSAIDs studied.

The consensus emphasizes individualized NSAID selection based on cardiovascular, renal, and antiplatelet risk factors. The panel agreed that the presence of cardiovascular risk factors or pathology in patients with chronic orthopedic pain requires a carefully personalized choice of NSAID, and that the presence of impaired renal function requires the same individualized approach with systematic monitoring of the patient’s hydration status. Nephrotoxicity risk is elevated in elderly patients, hypovolemia, high-dose NSAID exposure, concurrent use of vasoconstrictors, and concomitant therapy with renin-angiotensin-aldosterone system inhibitors or diuretics. The panel also highlighted that the potential interference of NSAIDs with platelet aggregation processes requires particular attention in patients receiving acetylsalicylic acid therapy, as NSAIDs with long half-lives can compete with aspirin for COX-1 binding, potentially reducing its antiplatelet efficacy.

The pathophysiology underlying NSAID analgesia involves the inhibition of the cyclooxygenase family of enzymes, which are involved in the formation of prostaglandins in both the periphery and the central nervous system. Prostaglandin E2 promotes the inflammatory response in the periphery and the sensitized neuronal state in the dorsal horn of the spinal cord. At peripheral sites of inflammation, the activation of PGE2 receptors on nociceptor terminals causes neuronal depolarization and sensitization, facilitating their activation by other inflammatory mediators such as bradykinin. In response to nociceptive input, COX-2 expression is upregulated in several areas of the central nervous system, and PGE2 is released in the dorsal horn, where it acts both pre- and postsynaptically to contribute to central sensitization. Beyond cyclooxygenase inhibition, NSAIDs may also modulate additional inflammatory pathways and nociceptive processing, and there is evidence that they act centrally in structures such as the periaqueductal gray and the rostral ventromedial medulla to activate descending inhibitory pain pathways.

The SIOT consensus provides evidence-informed, clinically actionable recommendations for NSAID use across the principal orthopedic pain scenarios, aiming to improve prescribing appropriateness and patient safety in routine practice. The engagement of specialists representing diverse Italian clinical hospitals facilitated the synthesis of complementary perspectives and heterogeneous clinical experiences. The recommendations proposed through this document, founded upon scientific evidence and informed by clinical practice, constitute a resource for delivering pragmatic guidance readily translatable into routine clinical care. As the burden of musculoskeletal pain continues to grow globally, with osteoarthritis imposing an increasing cost at both individual and societal levels, consensus documents such as this one represent an important step toward standardizing care and optimizing outcomes for the millions of patients who rely on NSAIDs for pain relief every day.

Subject of Research: Use of NSAIDs in orthopedic pain management: a Delphi consensus promoted by the Italian Society of Orthopedics and Traumatology (SIOT)

Article Title: Use of NSAIDs in orthopedic pain management: a Delphi consensus promoted by the Italian Society of Orthopedics and Traumatology (SIOT)

Article References: Tranquilli Leali, P., Di Martino, A., Mercurio, M., Spinelli, M. S., Coluzzi, F., Gargano, F., Berti, L., Rivera, F., Grossi, P., Solarino, G., Urbani, A., Scaglione, F., & Randelli, P. S. (2026). Use of NSAIDs in orthopedic pain management: a Delphi consensus promoted by the Italian Society of Orthopedics and Traumatology (SIOT). Frontiers in Pain Research, 7, Article 1944515. https://doi.org/10.3389/fpain.2026.1944515

Image Credits: AI Generated

DOI: 10.3389/fpain.2026.1944515

Keywords: NSAIDs, orthopedic, pain, management, Delphi, consensus, promoted, Italian, Society, Orthopedics, Traumatology, SIOT

Pancreatic portal hypertension is a distinct type of portal hypertension caused by various pancreatic diseases or by pancreatic surgery. Unlike the far more common portal hypertension driven by cirrhosis of the liver, this variant arises when inflammation, cysts, tumors, or scarring in the pancreas compress or obstruct the splenic vein and neighboring splanchnic vessels. Blood that cannot drain through its usual route finds alternative channels, engorging vessels around the stomach and esophagus and enlarging the spleen. The result is a condition that mimics liver disease on the surface but has an entirely different anatomy and, crucially, a different treatment logic.

The clinical significance of the new consensus lies partly in a quiet epidemiological shift. According to the guideline authors, the detection rate of pancreatic portal hypertension has steadily increased in recent years with the widespread application of advanced imaging techniques and endoscopy. Computed tomography and magnetic resonance imaging now routinely capture the pancreatic region in exquisite detail, while endoscopic ultrasound allows physicians to peer directly at the vessels surrounding the pancreas. Diseases that once went unrecognized are now being identified with growing frequency, making a standardized management framework increasingly urgent.

Yet the condition remains notoriously difficult to catch early. The consensus panel notes that the clinical manifestations of pancreatic portal hypertension are often insidious, compromising early identification. Patients may carry the vascular changes for years without symptoms, and the first warning signs frequently emerge only at an advanced stage. By that point, some complications, such as splenomegaly and upper gastrointestinal bleeding, have already taken hold. Bleeding from engorged gastric varices can be dramatic and life threatening, while an enlarged spleen can trap platelets and complicate the broader management of the underlying pancreatic disease.

To build the guideline, the Chinese Society of Gastroenterology of the Chinese Medical Association invited a panel of skilled experts to participate in a Delphi consensus process, systematically reviewing and discussing the available evidence on the causes, risk factors, clinical manifestations, diagnosis, therapy, and prognostic assessment of pancreatic portal hypertension. The Delphi method is a structured technique for extracting reliable group judgment from a large panel: experts answer questionnaires independently, the results are aggregated and fed back, and the process repeats until statements stabilize. After three rounds of questionnaire surveys and votes, the panel formulated 19 consensus statements to provide clinical guidance on the diagnosis and management of the condition.

The scope of the consensus is deliberately broad. By covering etiology, risk factors, clinical presentation, diagnostic strategy, therapeutic options, and prognostic assessment in a single document, the guideline fills a gap that existing publications on pancreatic diseases or portal hypertension had left open. Although the concept of pancreatic portal hypertension has been recognized in existing guidelines and consensus documents on the management of pancreatic diseases or portal hypertension, its management strategy had never been comprehensively summarized. Clinicians confronting a patient with pancreatic disease and unexplained gastric varices or splenic enlargement have had to piece together guidance from scattered sources, and the new consensus aims to end that improvisation.

Technically, the diagnostic challenge centers on distinguishing pancreatic portal hypertension from cirrhotic portal hypertension and from other causes of splanchnic vein thrombosis. Cross-sectional imaging plays the decisive role: contrast-enhanced computed tomography and magnetic resonance imaging can reveal the obstructing pancreatic lesion, the occluded or compressed splenic vein, and the collateral vessels that betray the redirected blood flow. Endoscopic evaluation identifies the varices that carry bleeding risk, while laboratory findings such as thrombocytopenia from hypersplenism can provide supporting clues. The consensus framework gives clinicians a structured pathway for assembling these pieces into a confident diagnosis, even when the liver itself is entirely healthy.

On the therapeutic side, the management logic differs fundamentally from that of cirrhotic portal disease. Because the obstruction is often localized to the splenic vein, treating the underlying pancreatic lesion can sometimes restore normal venous drainage, and interventions aimed at the vascular obstruction itself, including endovascular approaches, have been explored in the literature. The consensus statements address how to weigh bleeding risk against the risks of intervention, how to manage acute upper gastrointestinal bleeding when it occurs, and how to coordinate vascular care with the treatment of the primary pancreatic condition, whether that is acute pancreatitis, chronic pancreatitis, autoimmune pancreatitis, or a pancreatic tumor.

The panel was large and geographically diverse, drawing gastroenterologists, endoscopists, interventional radiologists, hepatobiliary surgeons, and intensive care specialists from major hospitals across China, from Shenyang in the northeast to Chengdu, Shanghai, Guangzhou, and Xi’an. Corresponding authors include Xingshun Qi of the General Hospital of Northern Theater Command, Hao Wu and Chengwei Tang of West China Hospital, Sichuan University, and Xiaozhong Guo of the General Hospital of Northern Theater Command. Four junior researchers, Xingshun Qi, Yuhang Yin, Zhiyin Huang, and Yuzheng Zhuge, contributed equally to the work, which was partially supported by the National Key R&D Program of China.

The methodological rigor of the consensus reflects modern guideline standards. The panel employed structured evidence frameworks, including PICO and PECO question formats for framing clinical questions, and used the GRADE system for grading the quality of evidence behind each recommendation. Reporting followed the RIGHT checklist for practice guidelines, and the document was appraised with the AGREE II instrument. Literature searches spanned Chinese databases such as CNKI and VIP alongside international sources, ensuring that both Chinese clinical experience and global evidence informed the final statements. The authors declare no competing interests, and the guideline is published under a Creative Commons license allowing free access for clinicians worldwide.

For the international medical community, the significance of the consensus extends beyond China’s borders. Pancreatic portal hypertension is a global condition, arising wherever pancreatitis, pseudocysts, tumors, or pancreatic surgery compromise the splenic vein, and clinicians on every continent face the same diagnostic and therapeutic dilemmas. A comprehensive, openly available framework for the causes, risk factors, clinical manifestations, diagnosis, therapy, and prognostic assessment of the disease gives physicians everywhere a reference point for building their own local protocols. As advanced imaging continues to reveal more cases that once went undetected, the demand for such standardized guidance will only grow, and the 19 statements now offer a foundation that future international guidelines can refine and extend.

Subject of Research: Medicine

Article Title: Chinese consensus on the management of pancreatic portal hypertension

Article References: Qi, X., Yin, Y., Huang, Z., Zhuge, Y., Cai, S., Chen, M., Chen, P., Chen, S., Chen, W., Ding, Z., Du, Y., Guo, G., Guo, W., He, F., He, W., Hu, S., Huang, L., Ke, L., Kong, D., … Tang, C. (2026). Chinese consensus on the management of pancreatic portal hypertension. BMC Medicine. https://doi.org/10.1186/s12916-026-05289-7

Image Credits: AI Generated

DOI: 10.1186/s12916-026-05289-7

Keywords: pancreatic portal hypertension, portal hypertension, consensus, gastrointestinal bleeding, splenomegaly, BMC Medicine, Delphi, pancreatic disease, Chinese, management, pancreatic, portal

The scale of the undertaking is what sets it apart. Psychiatric hospital care is inherently multimodal, typically combining pharmacotherapy, psychotherapy, social therapy, occupational therapy, exercise therapy and various forms of creative therapies. Whether a patient receives one of these interventions rather than another, and whether that intervention works as intended, may be shaped by a constellation of diversity-related factors including age, migration background, sexual orientation, religious beliefs and socioeconomic status. Yet, as the research team notes, the impact of such factors on psychiatric inpatient care processes and outcomes has never been comprehensively examined in German psychiatric hospitals. PSY-DIVER is designed to close that gap with an evidence base large enough to withstand scrutiny.

At the heart of the quantitative component lies an extraordinary data resource: routine data from the nine psychiatric hospitals of the LVR, the Rhineland Regional Council. The researchers will analyze approximately 500,000 inpatient and day-care clinic cases and 1.7 million outpatient cases spanning 2015 to 2024, with a planned extension to more recent retrospective data during the project period. This decade-long window allows the team to examine not just isolated treatment decisions but entire care trajectories, from admission through treatment allocation to discharge outcomes, across an extraordinarily diverse patient population treated in a real-world network of hospitals.

One of the study’s most technically interesting elements is how it plans to extract diversity-related information that structured hospital records simply do not capture. Structured routine data will be enriched by automated extraction of additional diversity-related variables from clinical free text using a rule-based natural language processing pipeline combined with locally hosted large language models operating in a secure local environment. This hybrid approach matters for two reasons. First, factors such as migration background, sexual orientation or religious beliefs are often documented only in narrative clinical notes rather than coded fields. Second, hosting the language models locally addresses the privacy concerns that inevitably arise when sensitive psychiatric records are processed computationally, keeping patient data inside the hospital network rather than sending it to external services.

The natural language processing pipeline represents a growing trend in health services research, where named entity recognition and related techniques are increasingly used to unlock the clinical richness buried in free text. By combining rule-based methods, which offer transparency and reproducibility, with large language models, which offer flexibility in understanding varied clinical phrasing, the PSY-DIVER team aims to construct diversity variables at a scale and granularity that manual chart review could never achieve across two million cases. The resulting dataset will allow statistical analyses of whether treatment allocation, treatment processes and treatment outcomes differ systematically across patient groups defined by gender and other diversity characteristics.

But numbers alone cannot explain why disparities might exist, and this is where the study’s qualitative and participatory design comes in. Primary data collection will include 31 semi-structured interviews with mental health service users, relatives and professionals, capturing lived experience and clinical perspective on how diversity-related factors play out in everyday ward life. These interviews will be followed by quantitative online surveys with approximately 300 service users, 100 relatives and 100 professionals, allowing the team to test whether themes emerging from the interviews hold across larger samples of stakeholders.

Participation is not merely a data collection strategy for PSY-DIVER; it is built into the project’s governance. The study includes participatory project governance featuring a co-creation workshop, and the team thanks the members of its participatory steering group and scientific advisory board, along with its project partner, the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN). This architecture reflects a broader movement in mental health research toward involving those with lived experience of psychiatric care not as subjects but as collaborators, on the premise that service users and relatives are best placed to identify the questions that matter and to interpret findings in ways that resonate with real clinical realities.

The final phase of the project translates integrated findings into actionable guidance. A two-round Delphi process will bring together approximately 40 professional experts and experts by experience in a structured consensus process to formulate recommendations for more diversity-sensitive psychiatric hospital care. The Delphi method, which iterates anonymous feedback rounds until participants converge on shared judgments, is well suited to contested topics where empirical evidence must be weighed alongside values and practical feasibility. By including experts by experience alongside clinicians in the consensus panel, the study ensures that its final recommendations reflect the perspectives of the people the recommendations are meant to serve.

The protocol has passed the formal safeguards expected of clinical research. The study was approved by the Ethics Committee of the North Rhine Medical Association under number 2026038, and data collection and analysis follow the Declaration of Helsinki. The trial was registered with the German Clinical Trials Register on April 30, 2026, under number DRKS00040088. The authors declare no competing interests, and the article is published open access under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, meaning the protocol itself is freely available to researchers, clinicians and patient advocates worldwide.

Why does this matter beyond Germany’s Rhineland? Psychiatric care systems across high-income countries face persistent questions about equity, and the intersectional interplay of gender, age, migration background, sexual orientation, religion and socioeconomic status is increasingly recognized as central to understanding why some patients receive effective care while others do not. PSY-DIVER’s combination of large-scale routine data, primary stakeholder data and a participatory consensus process offers a template that other health systems could adapt. If the study confirms that diversity-related factors are associated with differences in treatment allocation, treatment processes or outcomes, its recommendations could push psychiatric hospitals toward more equitable and diversity-sensitive services. If it finds no such associations, that too would be a valuable, publishable result. Either way, the project signals a maturing of health services research in psychiatry: an era in which the question is no longer whether diversity matters in mental health care, but precisely how, for whom, and what should be done about it. The study is led by a team including Sönke Johann Peters, Svenja Kratzke, Marwan Ahmed, Ana Staninska, Altina Aliu, Marisa Felicitas Flaspöler, Jürgen Zielasek, Carolin Schuster and corresponding author Euphrosyne Gouzoulis-Mayfrank, based at the LVR Institute for Research and Education in Cologne, with affiliations extending to the LVR Clinics Cologne, Heinrich Heine University Düsseldorf, Leuphana University Lüneburg and the University of Cologne.

Subject of Research: Diversity-related factors in psychiatric hospital care examined through a participatory mixed-methods study protocol

Article Title: Gender and other diversity-related factors in psychiatric hospital care: protocol for the participatory mixed-methods PSY-DIVER study

Article References: Peters, S. J., Kratzke, S., Ahmed, M., Staninska, A., Aliu, A., Flaspöler, M. F., Zielasek, J., Schuster, C., & Gouzoulis-Mayfrank, E. (2026). Gender and other diversity-related factors in psychiatric hospital care: protocol for the participatory mixed-methods PSY-DIVER study. BMC Psychiatry, 26(1), Article 744. https://doi.org/10.1186/s12888-026-08630-9

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DOI: 10.1186/s12888-026-08630-9

Keywords: psychiatric hospital care, diversity, gender, intersectionality, mixed methods, participatory research, clinical routine data, natural language processing, health services research, Delphi, mental health, health equity