BACKGROUND: Reduced renal function impairs salt and water homeostasis, which can drive nocturnal or 24-h polyuria. Nocturia can arise early in chronic kidney disease (CKD). Evidence-based recommendations can facilitate management outside nephrology clinics.
OBJECTIVE: To conduct a systematic review (SR) of nocturia in CKD and achieve expert consensus for management in primary care and in specialist clinics outside nephrology.
METHODS: Four databases were searched from January 2000 to April 2020. A total of 4011 titles and abstracts were screened, and 108 studies underwent full-text screening. Seven studies met the inclusion criteria and two were identified through other sources. Consensus was achieved among an expert panel with public involvement using the nominal group technique (NGT).
RESULTS: Several plausible mechanisms contribute to nocturnal or 24-h polyuria in CKD, but there is little evidence on interventions to improve nocturia. NGT assessment recommendations for nocturia (at least two voids per night) in patients with CKD or at risk of CKD being assessed in a non-nephrology setting are: history (thirst, fluid intake), medication review (diuretics, lithium, calcium channel antagonists, nonsteroidal anti-inflammatory medications), examination (oedematous state, blood pressure), urinalysis (haematuria and albumin/creatinine ratio), blood tests (blood urea, serum creatinine and electrolytes, estimated glomerular filtration rate), and a bladder diary. Renal ultrasound should follow local CKD guidelines. Treatment options include optimising blood pressure control, dietary adjustment to reduce salt intake, fluid advice, and a medication review. Referral to specialist nephrology services should follow local guidelines.
CONCLUSIONS: CKD should be considered when evaluating patients with nocturia. The aim of assessment is to identify mechanisms and instigate therapy, but the latter may be more applicable to reducing wider morbidity associated with CKD than nocturia itself.
RESULTS: People with kidney disease can suffer severe sleep disturbance because of a need to pass urine overnight. We looked at published research and found some useful information about the underlying mechanisms. A group of experts was able to develop practical approaches for assessing and treating this condition.

BACKGROUND: Heart conditions affect salt and water homeostasis as a consequence of the underlying condition, compensatory processes, and therapy, and can result in nocturnal polyuria. These processes need to be identified as part of a full evaluation of nocturia.
OBJECTIVE: To conduct a systematic review of nocturia in cardiovascular disease and achieve expert consensus for primary care management. Primary care was defined as a health care setting in which the expertise did not include specialist cardiology.
METHODS: Four databases were searched from January 2000 to April 2020. A total of 3524 titles and abstracts were screened and 27 studies underwent full-text screening. Of these, eight studies were included in the analysis. The nominal group technique (NGT) was used to achieve consensus among an expert panel incorporating public involvement.
RESULTS: Most studies focused on nocturia related to blood pressure (BP), while one investigated leg oedema. Hypertension, particularly overnight blood pressure above normal, corresponds with higher risk of nocturia. NGT identified fluid and salt overload, nondipping hypertension, and some therapeutic interventions as key nocturia contributors. History taking and examination should identify raised jugular venous pressure/ankle swelling, with relevant investigations including measurement of BP, resting electrocardiogram, and B-type natriuretic peptide. Treatment recommends reducing salt (including substitutes), alcohol and caffeine. Heart failure is managed according to local guidance and controlling fluid intake to 1-2 l daily. If there is no fluid retention, reduce or discontinue diuretics or calcium channel blockers and follow up to reassess the condition. The target clinic blood pressure is 140/90 mm Hg.
CONCLUSIONS: Cardiovascular disease and its treatment are influential for understanding nocturia. Management aims to identify and treat heart failure and/or hypertension.
RESULTS: People with cardiovascular disease can suffer severe sleep disturbance because of a need to pass urine at night due to increased overnight blood pressure or heart failure. Following a detailed evaluation of the published research, a group of experts recommended practical approaches for assessing and treating these issues.

BACKGROUND: Neurological disease can affect the rate of urine production and bladder storage function, increasing nocturia severity, with additional risks if mobility or cognition is impaired.
OBJECTIVE: To conduct a systematic review (SR) of nocturia in neurological diseases and achieve expert consensus for management in clinics without neurologist input.
METHODS: Four databases were searched from January 2000 to April 2020. A total of 6262 titles and abstracts were screened and 43 studies were included for full-text screening. Eleven of these met the inclusion criteria and two studies were identified through other sources. The nominal group technique (NGT) was used to develop consensus in panel comprising experts and public representation.
RESULTS: Thirteen studies (seven in Parkinson\'s disease, five in multiple sclerosis) were included, all undertaken in secondary care. Neurological disease severity was incompletely described, and nocturia severity was generally measured subjectively. NGT consensus supported basic neurological assessment, and the use of bladder diaries where neurological impairment permits. Treatments include pelvic-floor muscle training, review of medications, risk mitigation, improving bowel function, therapy for overactive bladder syndrome (if urgency is reported in association with nocturia episodes), treatment of postvoid residual and desmopressin according to licence. Measures to improve mobility and mitigate risk when using the toilet overnight should be considered. Multifactorial issues such as obstructive sleep apnoea and hypoventilation must be considered.
CONCLUSIONS: Nocturia in neurological disease is complex and lacks a robust evidence base, with very little research done in the primary care context. Guidance should be pragmatic, with reduction of risk a key requirement, until a multidisciplinary evidence base can be developed.
RESULTS: People with a neurological disease can suffer severe sleep disturbance because of the need to pass urine several times overnight (called nocturia). We looked at published research and found very little information to help general practitioners in managing this condition. We assembled a group of experts to develop practical approaches for assessing and treating nocturia in neurological disease.

BACKGROUND: Sleep disorders affect responsiveness to sensory information and can cause nocturnal polyuria and reduced sleep depth; hence, these are potentially influential in understanding the mechanism of nocturia.
OBJECTIVE: To report the systematic review (SR) and expert consensus for primary care management of nocturia in sleep disorders.
METHODS: Four databases were searched from January to April 2020. A total of 1658 titles and abstracts were screened, and 23 studies potentially applicable were included for full-text screening. The nominal group technique (NGT) was used to derive a consensus on recommendations for management using an expert panel with public involvement.
RESULTS: Thirteen studies met the SR inclusion criteria, all of which studied obstructive sleep apnoea (OSA), with ten evaluating the effect of continuous positive airway pressure. The NGT consensus discussed the assessment of OSA with other key sleep disorders, notably insomnia, restless legs syndrome/periodic limb movements of sleep, and parasomnias, including non-rapid eye movement (non-REM) parasomnias and REM sleep behaviour disorder (RBD). The NGT considered that the use of screening questions to reach a clinical diagnosis is a sufficient basis for offering conservative therapy within primary care. Reasons for referral to a sleep clinic are suspected sleep disorder with substantially impaired daytime function despite conservative treatment. Suspected RBD should be referred, and if confirmed, neurology opinion is indicated. Referrals should follow local guidelines. Persisting nocturia is not currently considered an indication for referral to a sleep clinic.
CONCLUSIONS: Sleep disorders are potentially highly influential in nocturia, but are often overlooked.
RESULTS: People with sleep disorders can experience nocturia due to easy waking or increased bladder filling. We looked at published research, and information was limited to one form of sleep disturbance-obstructive sleep apnoea. We assembled a group of experts, to develop practical approaches for assessing and treating nocturia in the potentially relevant sleep disorders.

BACKGROUND: Salt and water homeostasis is regulated hormonally, so polyuria can result from endocrine disease directly or via secondary effects. These mechanisms are not consistently considered in primary care management of nocturia.
OBJECTIVE: To conduct a systematic review (SR) of nocturia in endocrine disease and reach expert consensus for primary care management.
METHODS: Four databases were searched from January 2000 to April 2020. A total of 4382 titles and abstracts were screened, 36 studies underwent full-text screening, and 14 studies were included in the analysis. Expert and public consensus was achieved using the nominal group technique (NGT).
RESULTS: Twelve studies focused on mechanisms of nocturia, while two evaluated treatment options; none of the studies took place in a primary care setting. NGT consensus identified key clinical evaluation themes, including the presence of thirst, a medical background of diabetes mellitus or insipidus, thyroid disease, oestrogen status, medications (fluid loss or xerostomia), and general examination including body mass index. Proposed investigations include a bladder diary, renal and thyroid function, calcium, and glycated haemoglobin. Morning urine osmolarity should be examined in the context of polyuria of >2.5 l/24 h persisting despite fluid advice, with urine concentration >600 mOsm/l after fluid restriction excluding diabetes insipidus. Treatment should involve education, including adjustment of lifestyle and medication where possible. Any underlying endocrine disorder should be managed according to local guidance. Referral to endocrinology is needed if there is hyperthyroidism, hyperparathyroidism, or morning urine osmolarity <600 mOsm/l after overnight fluid avoidance.
CONCLUSIONS: Endocrine disease can result in nocturia via varied salt and water regulation pathways. The aim of management is to identify and treat causative factors, but secondary effects can restrict improvements in nocturia.
RESULTS: People with altered hormone function can suffer from severe sleep disturbance because of a need to pass urine caused by problems in controlling water and salt levels. An expert panel recommended the best ways to assess and treat these problems on the basis of the rather small amount of up-to-date published research available.

OBJECTIVE: To reach a consensus, among experts, on the role of aflibercept in diabetic macular edema (DME) through literature review.
METHODS: Two round tables, involving 12 Italian experts, were organized: in the first one, 6 pharmacologic and clinical questions were selected and analyzed by a systematic literature review, using a population, intervention, control, and outcomes framework; in the second one, the nominal group technique was used to discuss relevant evidence related to each question. The consensus was assessed using the 5-point Delphi score.
RESULTS: Agreement on statements was reached on 6/6 questions. The final statements were as follows: 1) High levels of both vascular endothelial growth factor (VEGF) and placental growth factor play an important role in the pathogenesis of DME. 2) The aflibercept pharmacologic profile is notably different from that of other anti-VEGF. 3) Aflibercept significantly improves functional and anatomical outcomes, and rapidly improves best-corrected visual acuity up to its peak; these results remain stable over time. 4) Diabetic macular edema aflibercept treatment requires a 5-monthly injection loading phase. Alternatively, a personalized pro re nata (PRN) regimen based on monthly monitoring and strict retreatment criteria can be used. 5) As an alternative to the bimonthly fixed regimen, in the maintenance phase the treatment schedule may be a PRN regimen with strict retreatment criteria or a treat and extend regimen. 6) No concerns on aflibercept ocular and systemic safety emerged from the literature.
CONCLUSIONS: Consensus was reached among experts on how to best treat patients with DME with aflibercept.

BACKGROUND: Considering the perspectives of individuals with cognitive disability is important for their participation in their self-directed health care. The nominal group technique (NGT) has been identified as a method to gather opinions of people with cognitive disability; however, a synthesis of methodological considerations to undertake when employing the approach among people with cognitive disability is non-existent.
METHODS: A systematic review guided by the preferred reporting items for systematic review and meta-analysis protocols was undertaken. Five databases (CINAHL, ISI Web of Science, ProQuest Social Science Journals, Scopus, and MEDLINE) were searched for peer-reviewed literature published before September 2016. Methodological considerations pertaining to the four stages of the NGT- generating ideas, recording ideas, clarification, and ranking - were extracted from each study.
RESULTS: Nine publications contributing to eight studies were included. Methodological considerations focused on (i) the number of participants within discussion groups, (ii) research question introduction, (iii) support individuals and accessible methods, (iv) ranking, and (v) researcher training and counselling services.
CONCLUSIONS: The use of the NGT to gain the health care perspectives of adults with cognitive disability is promising. Conducting nominal group techniques informed by the methodological considerations identified within this review can work towards ensuring that the health care perspectives of people with cognitive disability are considered. Implications for rehabilitation The emergent policy move towards self-directed health care for people with disability requires that the health care perspectives of people with disability are considered. Effective consultation and discussion techniques are essential to gain the health care perspectives of people with cognitive disability. After undertaking methodological considerations, the NGT can be an effective approach towards gaining the health care perspectives of people with cognitive disability.

OBJECTIVE: Consensus methods are used by healthcare professionals and educators within nursing education because of their presumed capacity to extract the profession\'s\' \"collective knowledge\" which is often considered tacit knowledge that is difficult to verbalize and to formalize. Since their emergence, consensus methods have been criticized and their rigour has been questioned. Our study focuses on the use of consensus methods in nursing education and seeks to explore how extensively consensus methods are used, the types of consensus methods employed, the purpose of the research and how standardized the application of the methods is.
METHODS: A systematic approach was employed to identify articles reporting the use of consensus methods in nursing education. The search strategy included keyword search in five electronic databases [Medline (Ovid), Embase (Ovid), AMED (Ovid), ERIC (Ovid) and CINAHL (EBSCO)] for the period 2004-2014. We included articles published in English, French, German and Greek discussing the use of consensus methods in nursing education or in the context of identifying competencies.
METHODS: A standardized extraction form was developed using an iterative process with results from the search. General descriptors such as type of journal, nursing speciality, type of educational issue addressed, method used, geographic scope were recorded. Features reflecting methodology such as number, selection and composition of panel participants, number of rounds, response rates, definition of consensus, and feedback were recorded.
RESULTS: 1230 articles were screened resulting in 101 included studies. The Delphi was used in 88.2% of studies. Most were reported in nursing journals (63.4%). The most common purpose to use these methods was defining competencies, curriculum development and renewal, and assessment. Remarkably, both standardization and reporting of consensus methods was noted to be generally poor. Areas where the methodology appeared weak included: preparation of the initial questionnaire; the selection and description of participants; number of rounds and number of participants remaining after each round; formal feedback of group ratings; definitions of consensus and a priori definition of numbers of rounds; and modifications to the methodology.
CONCLUSIONS: The findings of this study are concerning if interpreted within the context of the structural critiques because our findings lend support to these critiques. If consensus methods should continue being used to inform best practices in nursing education, they must be rigorous in design.