Comprehensive Consensus Research Articles

Outcomes of Acute Subdural Hematoma in Adults with a GCS Score of 3 : An Analysis from Five Regional Trauma Centers.

Acute Subdural Hematoma (A-SDH) in patients with a Glasgow Coma Scale (GCS) score of 3 presents significant challenges in clinical decision-making owing to high mortality rates and the likelihood of severe disability. Here, we analyzed data to assess the number of surgical treatments and overall treatment outcomes for patients with A-SDH admitted in a comatose state and discussed the value of such aggressive surgical interventions based on these findings. A retrospective analysis was conducted using data from five regional trauma centers in Korea registered with the Korean Neurotrauma Data Bank System. This study included adult patients (aged ≥19 years) admitted between January 2018 and June 2021 to a comatose state due to A-SDH. Patients were classified into death and survivor groups based on their outcomes, and their demographic, clinical, and radiological characteristics were compared. Additionally, Patients were divided into a combined group of deaths and vegetative state survivors and a group of remaining survivors to compare the differences and assess the impact of death and vegetative state. Among a total of 109 patients, the mean age was 59.28 years, and the mortality rate was 80.7%. Among the 21 survivors, 12 (57.1%) remained vegetative. Surgical treatment was performed in 42 patients (38.5%), resulting in a lower mortality rate (64.3%) than conservative treatment (91.0%). However, the rate of the vegetative state was higher in the surgical group (21.4%) than in the conservative group (4.5%). Pupil reactivity was a significant predictor, with mortality rates of 44.4%, 57.1 %, and 85.9% for reactive, unilaterally unreactive, and bilaterally unreactive pupils, respectively. The surgical group had a significantly longer hospital stay (23.69±29.15 days) compared to the conservative group (6.45±13.75 days). It is time to go one step further from death with the dignity law and have a comprehensive consideration and social consensus on 'how to end life.' A model that can more accurately predict situations in which decompressive surgery should be considered for patients in a comatose state due to A-SDH is required. Neurosurgeons must have a comprehensive understanding of the patient's progress, the anticipated prognosis, and the various financial and psychological burdens on the family and must be able to communicate this information thoroughly.

The Function of OPEC in International Climate Change Law: the Route Taken to COP 28 and the Route Ahead

Abstract Since the consumption of fossil fuels is the main source of GHGs emissions and consequently climate change, the approach of OPEC to climate change is very important. The recent position of OPEC regarding the proposal to phasing out fossil fuels at COP 28 in 2023 showed how significant its approach can be in the evolution process of this regime. The question is what function OPEC has had and should have in the evolution of the climate change law. The results of this research show that in the first encounter of OPEC with the issue, due to the inherent conflict of the economic interests of member states with the goals of the climate change regime, it adopted an obstructive approach. But gradually, due to the global acceptance of the regime and comprehensive consensus regarding the scientific certainty of the threats of climate change, OPEC, reluctantly and inevitably, adjusted its former opposite position to some extent through its active participation in climate negotiations. However, in light of the increasing trend of GHGs emissions by the member states, which indicates the inability of OPEC to align the practice of its members with the goals of climate change, and the recent strong position of OPEC regarding the elimination of fossil fuels in COP 28, concerns have been raised about the future function of OPEC in the climate change legal regime. To play a constructive role in the future and use the available opportunities to reduce the climate change damage to the interests of the member countries over the long term, it should adopt initiatives such as functional changes and integration of climate issues into its strategies and projects in member states to be a supportive partner in the fight against climate change.

Telesurgery a Systematic Literature Review and Future Directions.

To undertake a systematic review of the medical literature on telesurgery, with a key focus on identifying the key technical and non-technical themes searched in medical articles and to analyze gaps in the current knowledge base on telesurgery. It has now been over two decades since the first successful case of telesurgery and since this time there have been significant technological and telecommunications advancements. A systematic review of the literature was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Details of the protocol for this systematic review were registered on PROSPERO (CRD42024511530). In total, 102 unique references which were allocated into five categories; technical, cybersecurity, ethical, financial, regulatory considerations to discuss key themes. The vast majority of references were related to technical considerations which have demonstrated the feasibility of telesurgery. The non-technical considerations have a paucity of literature and a lack of guidance on telesurgery which appears to still be the major barriers to telesurgery. Telesurgery presents many interdisciplinary challenges, encompassing both important technical and non-technical (such as cybersecurity, ethical, financial, and regulatory) considerations. Further research, collaboration between stakeholders, collaborative community of experts, and the development of comprehensive consensus frameworks are essential steps toward the widespread adoption of telesurgery.

Chinese expert consensus on blood lipid management in patients with diabetes (2024 edition).

Diabetes is a significant independent risk factor for atherosclerotic cardiovascular disease (ASCVD), with dyslipidemia playing a critical role in the initiation and progression of ASCVD in diabetic patients. In China, the current prevalence of dyslipidemia in diabetes is high, but the control rate remains low. Therefore, to enhance lipid management in patients with diabetes, the Endocrinology and Metabolism Physician Branch of the Chinese Medical Doctor Association, in collaboration with the Experts' Committee of the National Society of Cardiometabolic Medicine, has convened experts to develop a consensus on the management of dyslipidemia in patients with type 1 or type 2 diabetes. The development of this consensus is informed by existing practices in lipid management among Chinese diabetic patients, incorporating contemporary evidence-based findings and guidelines from national and international sources. The consensus encompasses lipid profile characteristics, the current epidemiological status of dyslipidemia, ASCVD risk stratification, and lipid management procedures in diabetic patients. For the first time, both low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol have been recommended as primary targets for lipid intervention in diabetic patients. The consensus also includes a summary and recommendations for lipid management strategies in special diabetic populations, including children and adolescents, individuals aged 75 years and older, patients with chronic kidney disease, metabolic-associated fatty liver disease, and those who are pregnant. This comprehensive consensus aims to improve cardiovascular outcomes in diabetic patients by contributing to the dissemination of key clinical advancements and guiding clinical practice.

Methodology for the selection and evaluation of outcomes for Chinese herbal injection in acute exacerbation of chronic obstructive pulmonary disease (AECOPD): a comprehensive study

Objective To develop a comprehensive framework for selecting outcomes in evaluating the clinical efficacy of Chinese herbal injections and to scientifically select outcomes for the clinical randomized controlled trial (RCT) of Tan-Re-Qing injection intervening AECOPD. Methods A comprehensive literature review and consensus methods, including focus groups and Delphi surveys, were utilized. Results Literature analysis identified 513 publications, encompassing regulatory guidance, guidelines, expert consensus, and RCTs. Initial dimensions include clinical efficacy, safety, and health economics. Primary outcomes should align with study objectives. Recommended evaluation domains include death, treatment outcome, future impact, quality of life, and safety. Commonly recommended outcomes comprise mortality, arterial blood gases, CAT, exacerbation frequency, adverse events, and lung function. Network meta-analysis identified specific therapeutic efficacy markers (white blood cell count, IL-6, IL-8). Quality of life assessment recommended SF-12, EQ-5D, or CAT. Emphasis on AECOPD frequency and lung function was noted. Delphi survey yielded 41 outcomes across various domains for evaluating Tan-Re-Qing in AECOPD. Conclusion The findings contribute to developing a robust and reliable trial design for Tan-Re-Qing injection in AECOPD. The methodology employed in this study ensures a systematic and comprehensive approach to the selection of outcomes for the clinical evaluation of future studies in this field.

Expert management consensus for the application of point-of-care testing in emergency and critical care (2024)

Point-of-care testing (POCT) is a testing approach that can be completed promptly, and for patients with acute and severe diseases, it can help clinicians identify changes in patients' conditions early and save patients' lives. Currently, the application of POCT in critical and emergency situations lacks a comprehensive clinical management consensus, leading to a lack of standardized guidance for its practical application. In order to standardize the application of POCT in critical and emergency situations, Emergency Medicine Association of Wuhan Medical Association organized multiple experts in the field of emergency and critical care to discuss and identify the current clinical issues that require standardized consensus in the application of POCT in emergency and critical care. Furthermore, a comprehensive literature search of domestic and international literature was conducted, and discussions and modifications were organized among emergency and critical care medicine experts. Ultimately, the Expert management consensus for the application of point-of-care testing in emergency and critical care (2024), which involves personnel management, equipment management and data management was formed. This consensus aims to provide more comprehensive standards and guidance for the application of POCT in critical care, thereby improving the quality of patient care and medical efficiency.

Blood Astrocyte Biomarkers in Alzheimer Disease: A Systematic Review and Meta-Analysis.

Neuroinflammation, particularly early astrocyte reactivity, is a significant driver of Alzheimer disease (AD) pathogenesis. It is unclear how the levels of astrocyte biomarkers change in patients across the AD continuum and which best reflect AD-related change. We performed a systematic review and meta-analysis of 3 blood astrocyte biomarkers (glial fibrillary acidic protein [GFAP], chitinase-3-like protein 1 [YKL-40], and S100B) in patients clinically diagnosed with AD. MEDLINE and Web of Science were searched on March 23, 2023, without restrictions on language, time, or study design, for studies reporting blood levels of the astrocyte biomarkers GFAP, YKL-40, or S100B in patients on the AD continuum (including those with mild cognitive impairment [MCI] and dementia) and a cognitively unimpaired (CU) control population. AD diagnosis was based on established diagnostic criteria and/or comprehensive multidisciplinary clinical consensus. Studies reporting indirect biomarker measures (e.g., levels of biomarker autoantibodies) were excluded. Risk of bias assessment was performed using the revised Quality Assessment of Diagnostic Accuracy Studies tool. Pooled effect sizes were determined using the Hedge g method with a random-effects model. The review was prospectively registered on PROSPERO (registration number CRD42023458305). The search identified 1,186 studies; 36 met inclusion criteria (AD continuum n = 3,366, CU n = 4,115). No study was assessed to have a high risk of bias. Compared with CU individuals, patients on the AD continuum had higher GFAP and YKL-40 levels (GFAP effect size 1.15, 95% CI 0.94-1.36, p < 0.0001; YKL-40 effect size 0.38, 95% CI 0.28-0.49, p < 0.0001). Both biomarkers were elevated in more advanced clinical stages of the disease (i.e., in AD dementia compared with MCI due to AD: GFAP effect size 0.48, 95% CI 0.19-0.76, p = 0.0009; YKL-40 effect size 0.34, 95% CI 0.10-0.57, p = 0.0048). No significant differences in blood S100B levels were identified. We demonstrated significant elevations in blood GFAP and YKL-40 levels in patients on the AD continuum compared with CU individuals. Furthermore, within the AD clinical spectrum, significant elevation correlated with more advanced disease stage. Our findings suggest that both biomarkers reflect AD-related pathology. Our findings are limited by the lack of cultural and linguistic diversity in the study populations meta-analyzed. Future meta-analyses using a biomarker-defined AD population are warranted.

The impact of smoking on ventral and inguinal hernia repair: a systematic review and meta-analysis.

Individual studies indicate poorer outcomes for smokers after hernia repair. Previous meta-analyses have examined the impact of smoking on specific outcomes such as recurrence and surgical site infection, but there has been a lack of comprehensive consensus or systematic review on this subject. Addressing this gap, our study undertakes a systematic review and meta-analysis to assess the impact of smoking on the outcomes of ventral hernia repair (VHR) and inguinal hernia repair. A thorough search of Cochrane Central, Scopus, SciELO, and PubMed/MEDLINE, focusing on studies that examined the effect of smoking on inguinal and VHR outcomes was conducted. Key outcomes evaluated included recurrence, reoperation, surgical site occurrences (SSO), surgical site infection (SSI), and seroma. Out of 3296 screened studies, 42 met the inclusion criteria. These comprised 25 studies (69,295 patients) on VHR and 17 studies (204,337 patients) on inguinal hernia repair. The analysis revealed that smokers had significantly higher rates of recurrence (10.4% vs. 9.1%; RR 1.48; 95% CI [1.15; 1.90]; P < 0.01), SSO (13.6% vs. 12.7%; RR 1.44; 95% CI [1.12; 1.86]; P < 0.01) and SSI (6.6% vs. 4.2%; RR 1.64; 95% CI [1.38; 1.94]; P < 0.01) following VHR. Additionally, smokers undergoing inguinal hernia repair showed higher recurrence (9% vs. 8.7%; RR 1.91; 95% CI [1.21; 3.01]; P < 0.01), SSI (0.6% vs. 0.3%; RR 1.6; 95% CI [1.21; 2.0]; P < 0.001), and chronic pain (9.9% vs. 10%; RR 1.24; 95% CI [1.06; 1.45]; P < 0.01) rates. No significant differences were observed in seroma (RR 2.63; 95% CI [0.88; 7.91]; P = 0.084) and reoperation rates (RR 1.48; 95% CI [0.77; 2.85]; P = 0.236) for VHR, and in reoperation rates (RR 0.99; 95% CI [0.51; 1.91]; P = 0.978) for inguinal hernias between smokers and non-smokers. Analysis using funnel plots and Egger's test showed the absence of publication bias in the study outcomes. This comprehensive meta-analysis found statistically significant increases in recurrence rates, and immediate postoperative complications, such as SSO and SSI following inguinal and VHR. Also, our subgroup analysis suggests that the MIS approach seems to be protective of adverse outcomes in the smokers group. However, our findings suggest that these findings are not of clinical relevance, so our data do not support the necessity of smoking cessation before hernia surgery. More studies are needed to elucidate the specific consequences of smoking in both inguinal and ventral hernia repair. ID CRD42024517640.

Re-irradiation practice and ESTRO/EORTC consensus recommendations: 2023 ASTRO education panel.

Indications for re-irradiation are increasing both for palliation and potentially curative attempts to achieve durable local control. This has been in part driven by the technological advances in the last decade including image-guided brachytherapy, volumetric-modulated arc therapy and stereotactic body radiotherapy. These enable high dose focal irradiation to be delivered to a limited target volume with minimal normal tissue re-irradiation. The European Society for Radiotherapy and Oncology (ESTRO) and the European Organisation for Research and Treatment of Cancer (EORTC) have collaboratively developed a comprehensive consensus on re-irradiation practices, aiming to standardise definitions, reporting, and clinical decision-making processes. The document introduces a universally applicable definition for re-irradiation, categorised into two primary types based on the presence of geometric overlap of irradiated volumes and concerns for cumulative dose toxicity. It also identifies "repeat organ irradiation" and "repeat irradiation" for cases without such overlap, emphasising the need to consider toxicity risks associated with cumulative doses. Additionally, the document presents detailed reporting guidelines for re-irradiation studies, specifying essential patient and tumour characteristics, treatment planning and delivery details, and follow-up protocols. These guidelines are designed to improve the quality and reproducibility of clinical research, thus fostering a more robust evidence base for future re-irradiation practices. The consensus underscores the necessity of interdisciplinary collaboration and shared decision-making, highlighting performance status, patient survival estimates, and response to initial radiotherapy as critical factors in determining eligibility for re-irradiation. It advocates for a patient-centric approach, with transparent communication about treatment intent and potential risks. Radiobiological considerations, including the application of the linear-quadratic model, are recommended for assessing cumulative doses and guiding re-irradiation strategies. By providing these comprehensive recommendations, the ESTRO-EORTC consensus aims to enhance the safety, efficacy, and quality of life for patients undergoing re-irradiation, while paving the way for future research and refinement of treatment protocols in the field of oncology.

Evidence-based expert consensus on clinical management of safety of Bruton's tyrosine kinase inhibitors (2024).

Bruton's tyrosine kinase inhibitors (BTKis) have revolutionized the treatment of B-cell lymphomas. However, safety issues related to the use of BTKis may hinder treatment continuity and further affect clinical efficacy. A comprehensive and systematic expert consensus from a pharmacological perspective is lacking for safety issues associated with BTKi treatment. A multidisciplinary consensus working group was established, comprising 35 members from the fields of hematology, cardiovascular disease, cardio-oncology, clinical pharmacy, and evidence-based medicine. This evidence-based expert consensus was formulated using an evidence-based approach and the Delphi method. The Joanna Briggs Institute Critical Appraisal (JBI) tool and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach were used to rate the quality of evidence and grade the strength of recommendations, respectively. This consensus provides practical recommendations for BTKis medication based on nine aspects within three domains, including the management of common adverse drug events such as bleeding, cardiovascular events, and hematological toxicity, as well as the management of drug-drug interactions and guidance for special populations. This multidisciplinary expert consensus could contribute to promoting a multi-dimensional, comprehensive and standardized management of BTKis.

The Contribution of Advertising to Sales Volume: A Case Study of MTN Uganda, Kasese Branch

This research investigates the impact of advertising on the sales volume of MTN Uganda Ltd, with a specific emphasis on the Kasese Municipality branch. The objective of the study was to comprehend the effects of advertising on customer buying behavior and its consequent effect on sales. A total of 50 respondents were surveyed, consisting of 30 men (60%) and 20 females (40%). The age distribution spanned from 18 to over 48 years, with the majority (40%) falling between the 18-27 age group. According to the report, Coca-Cola was the product that people drank the most, accounting for 36% of consumption. Fanta came in second place with 16% consumption, followed by Stoney with 12%. Advertising had a substantial effect on consumer purchasing choices, as 62% of participants acknowledged its impact. A comprehensive consensus, with a 100% agreement, was established on the robust correlation between advertising and sales volume. The primary characteristics discovered in the effect of advertising are high visibility (52%), quality impression (20%), attention-drawing strength (16%), and perceived size (12%). Furthermore, the research emphasized that cost, size, and design are crucial factors to be taken into account when developing advertising campaigns. Additional elements that influenced the sales volume were flavor, which accounted for 20% of the effect, advertising, which accounted for 24% of the impact, and availability, which accounted for 10% of the impact. The study revealed two main limitations: the high cost of advertising, accounting for 40% of the identified issues, and the use of recycled bottles, which constituted 20% of the limitations. To address these challenges, two potential solutions were proposed: the use of promotional tools, which accounted for 30% of the offered remedies, and the avoidance of recycled bottles, which also constituted 30% of the proposed solutions. The report asserts that advertising has a crucial function in augmenting the sales volume for MTN Uganda Ltd. The results emphasize the significance of efficient advertising tactics in influencing customer buying behavior and enhancing sales. Keywords: Advertising; Sales Volume; Consumer Behavior; MTN Uganda; Kasese Municipality

Comprehensive consensus representation learning for incomplete multiview subspace clustering

Incomplete multiview clustering (IMVC) aims to address clustering problems caused by missing views. While some progress has been made, the current approaches still have some problems. First, the existing IMVC methods excessively rely on the original high-dimensional multiview data, leading to suboptimal results when the data are heavily contaminated. Second, the utilization of high-dimensional data often overlooks the complementarity of and consistency across multiple views. Third, the cluster structure of the input data is not adequately considered, which is detrimental to the resulting clustering performance. To address these problems, we propose a novel method: comprehensive consensus representation learning for incomplete multiview subspace clustering (CLR-IMVC). Specifically, CLR-IMVC assumes that all views are generated from a latent representation space. We model the original incomplete multiple views and the latent space to explore their correlations. Subsequently, we use the latent space to generate complete views and construct a subspace self-representation matrix for each view. Moreover, we innovatively treat the latent representation itself as new a view and likewise extract its self-representation matrix. Furthermore, we construct a third-order tensor by using these self-representation matrices and impose low-rank constraints on the tensor to explore the high-order correlations among the matrices. In addition, a consensus representation learning term is added to explore the consistency information between the views and the latent space, ultimately generating a robust clustering structure. Finally, the proposed method can be effectively solved by the augmented Lagrangian multiplier (ALM). Extensive experiments conducted on diverse datasets demonstrate the effectiveness of CLR-IMVC.

Establishing consensus on nutrition competencies for medicine: a Delphi study

BackgroundSignificant research, regulatory bodies and even governmental resolutions have identified meaningful nutrition education for medical and other healthcare professionals as a priority. Doctors are well placed to provide nutrition care,...

ТЕКСТОВЫЙ АНАЛИЗ ПРЕДПРИНИМАТЕЛЬСКОЙ ОРИЕНТАЦИИ: ТЕОРИЯ И ПРАКТИКА

Entrepreneurial Orientation (EO) is a key theme in the field of entrepreneurial research, having a profound impact on the development and success of businesses. This paper utilizes a textual analysis approach to comprehensively review the literature on EO, examining the concept from three aspects: the conceptualization of EO, the construction of measurement scales, and empirical research findings. We find that there is debate within the academic community regarding the definition and dimensional structure of EO, the construction and choice of measurement scales, and the mechanisms and moderating factors linking EO to business performance, with no comprehensive consensus achieved. This lack of consensus provides a rich field of options for future theoretical and empirical research on EO. Future studies should focus on achieving theoretical consistency and establishing a dominant academic discourse, while also recommending the integration of alternative measurement tools and improved analytical methods to expand the scope and depth of empirical research. This will enrich the development of EO theory and its application across various economic and social domains.

Meningioma: International Consortium on Meningiomas consensus review on scientific advances and treatment paradigms for clinicians, researchers, and patients.

Meningiomas are the most common primary intracranial tumors in adults and are increasing in incidence due to the aging population and increased access to neuroimaging. While most exhibit nonmalignant behavior, a subset of meningiomas are biologically aggressive and are associated with treatment resistance, resulting in significant neurologic morbidity and even mortality. In recent years, meaningful advances in our understanding of the biology of these tumors have led to the incorporation of molecular biomarkers into their grading and prognostication. However, unlike other central nervous system (CNS) tumors, a unified molecular taxonomy for meningiomas has not yet been established and remains an overarching goal of the Consortium to Inform Molecular and Practical Approaches to CNS Tumor Taxonomy-Not Official World Health Organization (cIMPACT-NOW) working group. Additionally, clinical equipoise still remains on how specific meningioma cases and patient populations should be optimally managed. To address these existing gaps, members of the International Consortium on Meningiomas including field-leading experts, have prepared this comprehensive consensus narrative review directed toward clinicians, researchers, and patients. Included in this manuscript are detailed overviews of proposed molecular classifications, novel biomarkers, contemporary treatment strategies, trials on systemic therapies, health-related quality-of-life studies, and management strategies for unique meningioma patient populations. In each section, we discuss the current state of knowledge as well as ongoing clinical and research challenges to road map future directions for further investigation.

Prediction of Pralidoxime Dose in Patients with Organophosphate Poisoning Using Machine Learning Techniques

Background: Early and appropriate antidotal therapy is crucial for patients with organophosphate poisoning. Objectives: Given the lack of a comprehensive consensus on the optimal dose of pralidoxime for patients with organophosphate poisoning, this study aims to develop a machine learning-based prediction model to determine the individualized pralidoxime dose for these patients. Methods: The dataset was divided into training and test sets with a 70:30 ratio. Feature selection was conducted using Pearson’s correlation coefficient (filter approach) method. Both classification and regression were employed to develop the prediction model using the selected features. The performance of the developed models was evaluated using ten-fold cross-validation and various metrics, including sensitivity, specificity, accuracy, F1-score, and AUC. The models were implemented and assessed using the scikit-learn library in Python. Results: After applying exclusion criteria, data from 325 patients were utilized to train and test the machine-learning models. In the classification approach, the random forest method achieved superior performance with an AUC of 98.6. In the regression approach, the gradient boosting regressor, with an R2 value of 65.4, outperformed other algorithms. Feature selection revealed that muscular weakness, plasma cholinesterase activity, and blood urea nitrogen were the most significant predictors of pralidoxime dose in the classification model. In the regression model, the top predictors were age, HCO3-VBG, and atropine bolus. Many of the selected features coincide with those identified in previous studies, with muscular weakness being particularly significant in both models. Conclusions: The most effective algorithms could be employed to develop a clinical decision support system for personalized pralidoxime dosage prediction in patients with organophosphorus poisoning. However, the study is constrained by its small sample size, retrospective design, and the absence of an external validation cohort. Conducting a prospective multicenter study with a larger sample size is crucial to validate the findings of this study.

REPAIRS Delphi: A UK and Ireland Consensus Statement on the Management of Infected Arterial Pseudoaneurysms Secondary to Groin Injecting Drug Use

Consensus guidelines on the optimal management of infected arterial pseudoaneurysms secondary to groin injecting drug use are lacking. This pathology is a problem in the UK and globally, and operative management options remain contentious. This study was designed to establish consensus to promote better management of these patients, drawing on the expert experience of those in a location with a high prevalence of illicit drug use. A three round modified Delphi was undertaken, systematically surveying consultant vascular surgeons in the UK and Ireland using an online platform. Seventy five vascular surgery units were invited to participate, with one consultant providing the unit consensus practice. Round one responses were thematically analysed to generate statements for round two. These statements were evaluated by participants using a five point Likert scale. Consensus was achieved at a threshold of 70% or more agreement or disagreement. Those statements not reaching consensus were assessed and modified for round three. The results of the Delphi process constituted the consensus statement. Round one received 64 (86%) responses, round two 59 (79%) responses, and round three 62 (83%) responses; 73 out of 75 (97%) units contributed. Round two comprised 150 statements and round three 24 statements. Ninety one statements achieved consensus agreement and 15 consensus disagreement. The Delphi statements covered sequential management of these patients from diagnosis and imaging, antibiotics and microbiology, surgical approach, wound management, follow up, and additional considerations. Pre-operative imaging achieved consensus agreement (97%), with computerised tomography angiogram being the modality of choice (97%). Ligation and debridement without arterial reconstruction was the preferred approach at initial surgical intervention (89%). Multidisciplinary management, ensuring holistic care and access to substance use services, also gained consensus agreement. This comprehensive consensus statement provides a strong insight into the standard of care for these patients.

Optimized cytogenetic risk-group stratification of KMT2A-rearranged pediatric acute myeloid leukemia

AbstractA comprehensive international consensus on the cytogenetic risk-group stratification of KMT2A-rearranged (KMT2A-r) pediatric acute myeloid leukemia (AML) is lacking. This retrospective (2005-2016) International Berlin-Frankfurt-Münster Study Group study on 1256 children with KMT2A-r AML aims to validate the prognostic value of established recurring KMT2A fusions and additional cytogenetic aberrations (ACAs) and to define additional, recurring KMT2A fusions and ACAs, evaluating their prognostic relevance. Compared with our previous study, 3 additional, recurring KMT2A-r groups were defined: Xq24/KMT2A::SEPT6, 1p32/KMT2A::EPS15, and 17q12/t(11;17)(q23;q12). Across 13 KMT2A-r groups, 5-year event-free survival probabilities varied significantly (21.8%-76.2%; P < .01). ACAs occurred in 46.8% of 1200 patients with complete karyotypes, correlating with inferior overall survival (56.8% vs 67.9%; P < .01). Multivariable analyses confirmed independent associations of 4q21/KMT2A::AFF1, 6q27/KMT2A::AFDN, 10p12/KMT2A::MLLT10, 10p11.2/KMT2A::ABI1, and 19p13.3/KMT2A::MLLT1 with adverse outcomes, but not those of 1q21/KMT2A::MLLT11 and trisomy 19 with favorable and adverse outcomes, respectively. Newly identified ACAs with independent adverse prognoses were monosomy 10, trisomies 1, 6, 16, and X, add(12p), and del(9q). Among patients with 9p22/KMT2A::MLLT3, the independent association of French-American-British–type M5 with favorable outcomes was confirmed, and those of trisomy 6 and measurable residual disease at end of induction with adverse outcomes were identified. We provide evidence to incorporate 5 adverse-risk KMT2A fusions into the cytogenetic risk-group stratification of KMT2A-r pediatric AML, to revise the favorable-risk classification of 1q21/KMT2A::MLLT11 to intermediate risk, and to refine the risk-stratification of 9p22/KMT2A::MLLT3 AML. Future studies should validate the associations between the newly identified ACAs and outcomes and unravel the underlying biological pathogenesis of KMT2A fusions and ACAs.

A case study of the impact of carbon emissions and inflation on nonlinear dense neutrosophic fuzzy inventory system of varying demand with delayed deterioration

In a comprehensive consensus, human should reduce the carbon emission on the way to reduce the adverse effect of global warming. Manufacturing firms contributes significant amount of carbon emissions in the environment. In many countries, regulatory authorities are taking actions to reduce emissions. Thus, in this paper we have analysed the effect of carbon emissionfor non-instantaneous deteriorating items having advertisement and price dependent demand. The paper also focused on the effect of inflation where shortages are partially backlogged and partially lost in sales. In this paper a new concept of non-linear triangular dense neutrosophic number with its basic properties are developed. Further the classifications of symmetry, asymmetry is introduced and thereafter De-neutrosophication technique has been applied for crispification. Since the effect of some parameters like carbon emissions, advertising, and inflation are uncertain so we have considered it in this new aforesaid form to grab the uncertain characters of the underlying parameters. The classification of the uncertain parameter based on the symmetric and asymmetric nature and linear-nonlinear nature of triangular dense neutrosophic number have been also investigated here. Additionally, the effect of the model is examined under different situations for both linear and non-linear triangular dense fuzzy, dense intuitionistic, dense neutrosophic. Finally, a numerical example is considered to illustrate the model and it is observed that the model is optimum when the parameters are considered in Asymmetric Convex Non-Linear number for shorter replenishment cycle. Also, comparative study has been done by performing sensitivity analysis through the case study and provides managerial insight into this outcome.

Updated guidelines for prescribing opioids to treat patients with chronic non-cancer pain in Korea: developed by committee on hospice and palliative care of the Korean Pain Society.

There are growing concerns regarding the safety of long-term treatment with opioids of patients with chronic non-cancer pain. In 2017, the Korean Pain Society (KPS) developed guidelines for opioid prescriptions for chronic non-cancer pain to guide physicians to prescribe opioids effectively and safely. Since then, investigations have provided updated data regarding opioid therapy for chronic non-cancer pain and have focused on initial dosing schedules, reassessment follow-ups, recommended dosage thresholds considering the risk-benefit ratio, dose-reducing schedules for tapering and discontinuation, adverse effects, and inadvertent problems resulting from inappropriate application of the previous guidelines. Herein, we have updated the previous KPS guidelines based on a comprehensive literature review and consensus development following discussions among experts affiliated with the Committee on Hospice and Palliative Care in the KPS. These guidelines may assist physicians in prescribing opioids for chronic non-cancer pain in adult outpatient settings, but should not to be regarded as an inflexible standard. Clinical judgements by the attending physician and patient-centered decisions should always be prioritized.