Consensus Agreement Research Articles

Neurovascular coupling methods in healthy individuals using transcranial doppler ultrasonography: A systematic review and consensus agreement.

Neurovascular coupling (NVC) is the perturbation of cerebral blood flow (CBF) to meet varying metabolic demands induced by various levels of neural activity. NVC may be assessed by Transcranial Doppler ultrasonography (TCD), using task activation protocols, but with significant methodological heterogeneity between studies, hindering cross-study comparisons. Therefore, this review aimed to summarise and compare available methods for TCD-based healthy NVC assessments. Medline (Ovid), Scopus, Web of Science, EMBASE (Ovid) and CINAHL were searched using a predefined search strategy (PROSPERO: CRD42019153228), generating 6006 articles. Included studies contained TCD-based assessments of NVC in healthy adults. Study quality was assessed using a checklist, and findings were synthesised narratively. 76 studies (2697 participants) met the review criteria. There was significant heterogeneity in the participant position used (e.g., seated vs supine), in TCD equipment, and vessel insonated (e.g. middle, posterior, and anterior cerebral arteries). Larger, more significant, TCD-based NVC responses typically included a seated position, baseline durations >one-minute, extraneous light control, and implementation of previously validated protocols. In addition, complementary, combined position, vessel insonated and stimulation type protocols were associated with more significant NVC results. Recommendations are detailed here, but further investigation is required in patient populations, for further optimisation of TCD-based NVC assessments.

AI-based automation of enrollment criteria and endpoint assessment in clinical trials in liver diseases.

Clinical trials in metabolic dysfunction-associated steatohepatitis (MASH, formerly known as nonalcoholic steatohepatitis) require histologic scoring for assessment of inclusion criteria and endpoints. However, variability in interpretation has impacted clinical trial outcomes. We developed an artificial intelligence-based measurement (AIM) tool for scoring MASH histology (AIM-MASH). AIM-MASH predictions for MASH Clinical Research Network necroinflammation grades and fibrosis stages were reproducible (κ = 1) and aligned with expert pathologist consensus scores (κ = 0.62-0.74). The AIM-MASH versus consensus agreements were comparable to average pathologists for MASH Clinical Research Network scores (82% versus 81%) and fibrosis (97% versus 96%). Continuous scores produced by AIM-MASH for key histological features of MASH correlated with mean pathologist scores and noninvasive biomarkers and strongly predicted progression-free survival in patients with stage 3 (P < 0.0001) and stage 4 (P = 0.03) fibrosis. In a retrospective analysis of the ATLAS trial (NCT03449446), responders receiving study treatment showed a greater continuous change in fibrosis compared with placebo (P = 0.02). Overall, these results suggest that AIM-MASH may assist pathologists in histologic review of MASH clinical trials, reducing inter-rater variability on trial outcomes and offering a more sensitive and reproducible measure of patient responses.

An evaluation of fusion status following lumbar fusion surgery utilizing multi-planar computed tomography.

To report the rate of fusion in a sample of patients undergoing lumbar fusion surgery and assess interrater reliability of computed tomography (CT)-based parameters for the assessment of fusion. All adult patients who underwent lumbar fusion surgery from 2017 to 2021 were retrospectively identified. Patient demographics and surgical characteristics were collected through chart review of the electronic medical records. CT scans were reviewed independently by two attending spine surgeons and two spine fellows. Fusion was defined as evidence of bone bridging in any one of (1) posterolateral gutters, (2) facets, or (3) interbody (when applicable) on any CT views. Evidence of screw haloing was indicative of nonunion. Interrater reliability was determined using cohen's kappa. Afterwards, a consensus agreement for each component of fusion was reached between participants. The overall fusion rate among all procedures was 63/69 (91.3%). Overall 22/25 (88.0%) TLIF, 16/19 (84.2%) PLDF, 3/3 (100%) LLIF, and 22/22 (100%) circumferential fusions experienced a successful fusion. Interrater reliability was good for interbody fusion (k = 0.734) and moderate for all other measures (k = 0.561 for posterolateral fusion; k = 0.471 for facet fusion; k = 0.458 for screw haloing). Overall, interrater reliability as to whether a patient had a fusion or nonunion was moderate (k = 0.510). There was only moderate interrater reliability across most radiographic measures used in assessing lumbar fusion status. Reliability was highest when evaluating the presence of interbody fusion. The majority of fusions occurred across the facet joints.

Consensus study on UK weight management services' response to COVID-19: best practices in outpatient management, governance and digital solutions.

The COVID-19 pandemic put unprecedented pressure on weight management services. These services were required to adapt to continue to provide care for people living with obesity. This study sought to develop consensus recommendations on the best practice solutions adopted by weight management services in the United Kingdom during the COVID-19 pandemic. This study utilised a semi-structured interview and a modified Delphi methodology to develop a consensus of best practice recommendations identified by specialist weight management services during the pandemic. Twenty-three healthcare professionals working in weight management service across the United Kingdom participated in the study. Analysis of interview transcripts identified four key thematic domains: outpatient, patient education and support, perioperative care and team working. Of the initial 43 unique recommendations, 30 reached consensus agreement. Outpatient recommendations focused on communication strategies, patient self-monitoring and remote patient tracking. Patient education and support recommendations addressed the development of online educational resources and support groups. Perioperative care recommendations emphasised case prioritisation, waiting list support and postoperative care. Team working recommendations targeted the use of digital collaboration tools and strategies for effective teamwork. Developing consensus recommendations on best practice is a critical step for weight management and outpatient services to achieve higher standards of care. These recommendations provide a springboard for departmental discussions, paving the way for improved experiences for individuals living with obesity as they progress along their weight management journey.

The utility of virtual monochromatic dual-energy computed tomography (DECT) in meniscal imaging: a technical evaluation.

To determine the feasibility of meniscal imaging using virtual monochromatic images obtained through dualenergy computed tomography (DECT) technique, and to determine which keV levels optimise contrast resolution. All DECT exams were performed on a Discovery CT750 HD system from GE Healthcare. Virtual monochromatic images were reconstructed at 40 keV, 73 keV, 106 keV, and 139 keV. Contrast resolution of the medial and lateral menisci using a 5-point Likert scale at each keV level was determined through a consensus agreement by 2 fellowship-trained musculoskeletal radiologists. Friedman's and Wilcoxon signed rank tests were used to compare visualisation scores across different keV levels. Seventeen knee exams from 10 patients met criteria for inclusion in the study. All patients included in the study cohort were male. The median age of patients was 46 years (interquartile range, 35-53 years). Virtual monochromatic images at 40 keV demonstrated highest contrast resolution of the menisci, with a statistically significant difference between contrast resolution scores at 40 keV and 76 keV, Friedman test: p < 0.0001. Meniscal imaging is feasible using DECT virtual monochromatic images at low keV levels. Improved contrast resolution at these specified KeV values could pave the way for further research in this field to determine its role in the future as an alternative option for assessment of the menisci in patients with contraindications to MRI or in the setting of a periarticular ferromagnetic foreign body obscuring the field of view.

Recommendations for Recovery of the COVID-19 Pandemic-related Diagnostic, Screening, and Procedure Backlog in Ontario: A Survey of Healthcare Leaders.

The COVID-19 pandemic has resulted in a significant diagnostic, screening, and procedure backlog in Ontario. Engagement of key stakeholders in healthcare leadership positions is urgently needed to inform a comprehensive provincial recovery strategy. A list of 20 policy recommendations addressing the diagnostic, screening and procedure backlog in Ontario were transformed into a national online survey. Policy recommendations were rated on a 7-point Likert scale (strongly agree to strongly disagree) and organized into those retained (≥75% strongly agree to somewhat agree), discarded (≥80% somewhat disagree to strongly disagree), and no consensus reached. Survey participants included a diverse sample of healthcare leaders with the potential to impact policy reform. Of 56 healthcare leaders invited to participate, there were 34 unique responses (61% response rate). Participants were from diverse clinical backgrounds, including surgical subspecialties, medicine, nursing, and healthcare administration and held institutional or provincial leadership positions. A total of 11 of 20 policy recommendations reached the threshold for consensus agreement with the remaining 9 having no consensus reached. Consensus agreement was reached among Canadian healthcare leaders on 11 policy recommendations to address the diagnostic, screening, and procedure backlog in Ontario. Recommendations included strategies to address patient information needs on expected wait times, expand health and human resource capacity, and streamline efficiencies to increase operating room output. No consensus was reached on the optimal funding strategy within the public system in Ontario or the appropriateness of implementing private funding models.

First modified Delphi consensus statement on robotic-assisted da Vinci sleeve gastrectomy

BackgroundSleeve gastrectomy (SG) is the most commonly performed metabolic and bariatric surgery (MBS) procedure. Technical considerations related to the performance of SG are well established and reported in the literature but not in relation to robotic-assisted (RA) SG. We report the results of the first modified Delphi consensus-building exercise addressing technical considerations of RA da Vinci (dV) SG. ObjectivesDevelop best practices for the performance of robotic-assisted da Vinci sleeve gastrectomy. SettingSurvey based consensus statement. MethodsA consensus building committee (CBC) was created comprising 10 experts in the field of RA surgery and MBS based on strict selection criteria. The CBC developed 49 consensus statements which were then shared with 240 experts in RA surgery. Our stopping criterion was stability in responses (≤15%). The consensus cut point was 70%. ResultsThe overall response rate was 49%. In the first round of voting, there was consensus agreement on 25 statements (51%), consensus disagreement on 14 (28%), and no consensus on the remaining statements (21%). In the second round of voting, we reached agreement on 3 additional statements. Experts recommended the use of the number of pauses generated by the stapler to guide choice of staple height (91.2%) and to upsize the staple height when using buttressing (92%). There was also consensus (81.4%) that the use of the closed staple height of 1.00 mm (white) is acceptable and that stapling of the antrum using a 1.5-mm staple (blue load) is also acceptable (73%). ConclusionsCollective expert opinion structured through a modified Delphi consensus statement presents a practical guide for surgeons interested in performing dV-SG.

#2997 Characterising the natural history of renal recovery after AKI in a prospective cohort—does timing matter?

Abstract Background and Aims Acute kidney injury (AKI) is associated with an increased risk of chronic kidney disease (CKD). Failure of recovery of serum creatinine by 90 days after AKI strongly associates with subsequent long-term reductions in renal function, however there is no consensus agreement on the definition of renal recovery. Further, detailed prospective descriptions of the ‘renal recovery phase’ between AKI and 90 days are lacking. Here we describe outcomes at serial timepoints (days 30, 60 and 90) for a prospective cohort of hospitalised patients with AKI. Method Single centre, prospective cohort study of participants with all stages of AKI. Each participant was characterised in detail, including AKI aetiology, co-morbidities and frailty. Baseline blood and urine samples were obtained at the time of consent. Participants were then followed up at days 30, 60 and 90 with clinical measurements and blood and urine sample collection. Blood tests included serum creatinine and GFR measured by the CKD-EPI equation. The proportion of participants with renal recovery at different creatinine above baseline thresholds as well as major adverse kidney events (MAKE) a composite outcome of death, new dialysis, and persistent renal dysfunction, defined as a 25% or greater decline in GFR was determined at day 30, 60 and 90. Where data was missing, last creatinine / GFR was carried forward for day 60 and 90, or discharge creatinine for day 30. Results A total of 124 participants were recruited. 63% of patients had AKI on hospital admission. The median baseline creatinine was 88 (IQR 70–117) μmol/L and median GFR was 68 (46–87) mL/min/1.73 m2. Median peak creatinine of 306 (IQR 177–458) μmol/L. The majority of AKI was severe (stage 1 (24%) vs stages 2 &amp; 3 (76%)). The most common primary aetiology of AKI was dehydration (46%) followed by sepsis (22%). Table 1 demonstrates the number of participants with ‘recovered’ renal function as defined by a creatinine above baseline of 10%, 20% and 50% from baseline (the latter being reversal of KDIGO AKI stage 1) across the timepoints. Non-recovery of renal function was common across all time points, ranging from 22% to 59% at day 90 depending on which definition of recovery was applied. Table 2 summarises the rate of major adverse kidney events (MAKE) for day 30, 60 and 90, that was predominantly driven by persistent renal dysfunction. Conclusion This study is one of the few prospective descriptions of the AKI recovery from time of AKI to day 90. Whilst it is known that failure to recover creatinine by day 90 is predictive of future renal dysfunction, these data suggest that there is little dynamic change after day 30 and suggests that interventions to prevent the AKI to CKD transition should be targeted in the first 30 days after AKI in order to have the biggest impact. These data also highlight the need for a consensus definition of non-recovery of renal function. Future work on this cohort will therefore include relating different thresholds of renal recovery to outcomes.

Treatment of thrombotic cardiovascular diseases in people with haemophilia: A Japanese consensus study.

Cardiovascular diseases (CVD) that require long-term anticoagulant and antiplatelet therapy presents a problem in people with haemophilia (PWH) who receive factor replacement therapy to reduce bleeding risk. Currently, there are no Japanese guidelines for the management of PWH with CVD. To develop expert guidance on managing CVD in PWH in Japan. A steering committee of four experts (two haemophilia specialists, one thrombosis specialist, one cardiologist) identified 44 statements related to five key themes. An online questionnaire was produced comprising a mix of 4-point Likert scale and multiple-choice questions that was sent to specialists in the management of PWH with CVD in Japan. Consensus was defined as high or very high if a respective ≥75% or ≥90% of respondents agreed with a statement. Of 16 potential respondents, responses were received from 15 specialists. Of the Likert scale questions, 71% (29/41) achieved ≥90% agreement (very strong agreement), 17% (7/41) achieved 75%-89% agreement (strong agreement) and 15% (6/41) did not achieve consensus agreement. The three multiple-choice questions failed to identify a strong preference. Agreement on specific target trough clotting factor levels for managing certain clinical situations, such as when in the presence of non-valvular atrial fibrillation or myocardial infarction, was also achieved. The results of this consensus study provide a framework for cardiologists and haematologists to manage PWH who are at risk of, or who have, CVD. Implementation of the recommendations provided herein may improve outcomes for PWH with CVD.

Incidental findings in brain CT scans of patients with head trauma

Objective: Incidental findings (IFs) are newly discovered abnormal findings unrelated to the primary purpose of imaging. Brain computed tomography (CT) scan is one of the most essential and initial imaging evaluations for head trauma patients, which may also have nontraumatic IFs. We aim to investigate the prevalence and nature of IFs in brain CT scans of head trauma patients. Methods: We conducted a cross-sectional study to evaluate brain CT scans of 1006 head trauma patients over one year (April 2021 to March 2022), to identify incidental findings by consensus agreement of two radiologists. We categorized the incidental findings into four categories based on appropriate follow-up recommendations. Results: We included 1006 head trauma patients who underwent brain CT scan, of which 126 incidental findings were discovered in brain CT scan of 107 patients. The prevalence of incidental findings was 10.6% (107/1006). The most common incidental finding was brain atrophy (n=15, 11.9%). The mean age of patients with IFs was significantly higher than those without IFs, but there was no difference between the two groups regarding gender. Conclusion: The discovery rate of incidental findings of brain CT scans in head trauma patients was considerable. Serious medical findings that need immediate evaluation were found in 5.6% of patients, mostly over the age of 40. Therefore, patients who have clinically significant incidental findings need improved documentation and follow-up to evaluate the long-term outcomes and reliability of imaging results.

Abstract PO3-07-03: Development &amp; Validation of an AI-supported Workflow for Clinical Scoring of HER2, ER, PR &amp; Ki67 Immunohistochemistry in Breast Cancer Tissue

Abstract Background: Immunohistochemical evaluation of HER2 status, the hormone receptors ER and PR, and the proliferation marker Ki67 forms part of the routine clinical diagnostic pathway for invasive breast carcinomas, and is the cornerstone of treatment stratification, informing both prognosis and patient management. Pathologist scoring of immunohistochemistry (IHC) at the microscope is time-consuming and prone to significant inter- and intra-observer variability. We developed HALO Breast AI, a decision-support system designed to improve efficiency and diagnostic accuracy through automating whole slide image (WSI) scoring. Here, we present preliminary results of a validation study of HALO Breast AI. Methods: HALO Breast AI was developed with routine diagnostic cases sourced from three institutes. The algorithm was trained using 107,755 pathologist-reviewed annotations to identify and threshold DAB-positive tumor cells within automatically segmented tumor regions. Internal validation was conducted on 80 unseen WSI, using 60,012 pathologist-reviewed annotations to assess analytical performance. Comparison of the algorithm scores to the mode of 3 expert pathologists (where at least 2 out of 3 agreed) was used to assess consensus agreement. Clinical performance and generalizability were assessed by comparing the algorithm scores to clinical data from two independent external institutes across 200 unseen WSI (n=50 per marker) from institute one and 300 unseen WSI (n=100 per marker [ ER, PR &amp; HER2, only]) from institute 2. Results: The median image F1-score for tumor classification was 0.91, while the median image F1-score for cell level validation was 0.96. Internal validation showed agreement between HALO Breast AI and the mode of 3 expert pathologists of 100% for ER, 90% for PR, 95% for Ki67 and 90% for HER2. High concordance was measured between the algorithm and the pathologists’ scores, with Light’s kappa of 0.91 for ER, 0.85 for PR, 0.79 for HER2 and 0.82 for Ki67. Performance on WSI obtained from external institute one, showed agreement between the clinical score obtained from HALO Breast AI and the clinical data of 96% for ER, 94% for PR, 84% for HER2 and 84% for Ki67. External institute two showed agreement of 90% for ER, 90% for PR and 83% for HER2. Of the ER &amp; PR cases that were in disagreement at the 1% clinical cut-off, the algorithm percent-positive scores were within a 1-3% range in 5 out of the 5 from institute 1 and 14 out of the 20 from institute 2. So, although on a categorical scale the AI assigned category disagreed with the clinical category, the results were close on a continuous scale. Conclusions: HALO Breast AI accurately detects tumor regions and tumor cells within breast cancer tissue and demonstrates high clinical agreement when scoring routine diagnostic IHC. Additionally, HALO Breast AI shows good generalisability, with a consistently strong performance across inherent variability that exists between external, independent data sets. Computer-aided diagnostic tools such as HALO Breast AI have the potential to support pathologists in the diagnostic setting by improving workflow efficiency and standardising results. Citation Format: Meredith Lodge, Alastair Ironside, Ashley Graham, Antonio Polonia, Stefan Reinhard, Wiebke Solass, Inti Zlobec, Peter Caie. Development &amp; Validation of an AI-supported Workflow for Clinical Scoring of HER2, ER, PR &amp; Ki67 Immunohistochemistry in Breast Cancer Tissue [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-07-03.

Saudi National Clinical Practice Guidelines for Management of Adult Systemic Lupus Erythematosus.

To provide evidence-based clinical practice recommendations for managing Systemic Lupus Erythematosus (SLE) in Saudi Arabia. This EULAR-adapted national guideline in which a multidisciplinary task force utilized the modified Delphi method to develop 31 clinical key questions. A systematic literature review was conducted to update the evidence since the EULAR publication. After reaching a consensus agreement, two rounds of voting and group discussion were conducted to generate consolidated recommendations/statements. A significant number of patients in Saudi Arabia experience delays in accessing rheumatologists, highlighting the significance of timely referral to SLE specialists or rheumatologists to ensure accurate diagnosis and prompt treatment. The primary goal of Glucocorticoid (GC) therapy in SLE patients is to establish disease control with a minimum dose and duration. Steroid-sparing agent utilization facilitates steroid-sparing goals. Hydroxychloroquine is recommended for all SLE patients, though physicians must carefully monitor toxicity and prioritize regular medication adherence assessment. SLE management during pregnancy starts from preconception time by assessing disease activity, major organ involvement, hypercoagulability status, and concomitant diseases that may negatively impact maternal and fetal outcomes. Multidisciplinary care with close monitoring may optimize both maternal and fetal outcomes. For patients with antiphospholipid antibodies, low-dose aspirin prophylaxis is recommended. Also, Long-term anticoagulant medications are fundamental to prevent secondary antiphospholipid syndrome due to high thrombosis recurrence. This Saudi National Clinical Practice guidelines for SLE management provide evidence-based recommendations and guidance for healthcare providers in Saudi Arabia who are managing patients with SLE. These guidelines will help to standardize healthcare service, improve provider education, and perhaps lead to better treatment outcomes for SLE patients.

Assessing the safety of physical rehabilitation in critically ill patients: a Delphi study

BackgroundPhysical rehabilitation of critically ill patients is implemented to improve physical outcomes from an intensive care stay. However, before rehabilitation is implemented, a risk assessment is essential, based on robust safety data. To develop this information, a uniform definition of relevant adverse events is required. The assessment of cardiovascular stability is particularly relevant before physical activity as there is uncertainty over when it is safe to start rehabilitation with patients receiving vasoactive drugs.MethodsA three-stage Delphi study was carried out to (a) define adverse events for a general ICU cohort, and (b) to define which risks should be assessed before physical rehabilitation of patients receiving vasoactive drugs. An international group of intensive care clinicians and clinician researchers took part. Former ICU patients and their family members/carers were involved in generating consensus for the definition of adverse events. Round one was an open round where participants gave their suggestions of what to include. In round two, participants rated their agreements with these suggestions using a five-point Likert scale; a 70% consensus agreement threshold was used. Round three was used to re-rate suggestions that had not reached consensus, whilst viewing anonymous feedback of participant ratings from round two.ResultsTwenty-four multi-professional ICU clinicians and clinician researchers from 10 countries across five continents were recruited. Average duration of ICU experience was 18 years (standard deviation 8) and 61% had publications related to ICU rehabilitation. For the adverse event definition, five former ICU patients and one patient relative were recruited. The Delphi process had a 97% response rate. Firstly, 54 adverse events reached consensus; an adverse event tool was created and informed by these events. Secondly, 50 risk factors requiring assessment before physical rehabilitation of patients receiving vasoactive drugs reached consensus. A second tool was created, informed by these suggestions.ConclusionsThe adverse event tool can be used in studies of physical rehabilitation to ensure uniform measurement of safety. The risk assessment tool can be used to inform clinical practise when risk assessing when to start rehabilitation with patients receiving vasoactive drugs.Trial registration This study protocol was retrospectively registered on https://www.researchregistry.com/ (researchregistry2991).

A mixed-methods review and adaptation of a novel clinical pharmacy tool: The MA2VER2ICK Tool Study

Abstract Introduction The MA2VER2ICK Tool[1] (see Figure 1) is a clinical pharmacy mnemonic developed in 2016 by the pharmacy department of Tallaght University Hospital, through a combination of literature searching and local expert consensus opinion. The intended purpose of the tool was to guide clinical pharmacists in pharmaceutical care planning. Since inception, the tool has not been formally evaluated. Locally, users report the tool as useful; although, there is scope for improvement, to better support clinical pharmacists. Aim Identify and gain consensus on suggestions to adapt the existing tool. Methods A two-stage mixed-methods approach was adopted. This comprised focus groups to facilitate idea generation and appraise contents of the existing tool, followed by a nominal group technique process[2] to agree the content and structure of the final tool. A purposive sample of clinical pharmacists were selected to participate in the focus groups and nominal group technique panel, based on responses to a screening questionnaire pre-circulated to all clinical pharmacists employed at the study site. Thematic analysis of the focus group transcripts was conducted by two independent researchers, with key themes and related recommendations to improve the tool identified. These recommendations were presented to the nominal group technique panel via an anonymous survey, where numerical rating scores were assigned over two rounds, with an intervening panel discussion. An increase in the mean rating score and convergence of the standard deviation indicated consensus for a recommendation. Results Two focus groups (5 participants each) of 45 minutes duration took place. Both focus groups resulted in similar findings, with seven major themes identified relating to adapting the tool. Overall, eight recommendations were formulated, with suggestions to adapt the content, structure, usability and application of the tool. Consensus agreement was reached on seven recommendations, each receiving a panel rating score &amp;gt; 90%. One recommendation was rejected, receiving a panel rating score &amp;lt; 30%. Conclusion This study demonstrates that the MA2VER2ICK Tool is a comprehensive clinical pharmacy resource. Few amendments were required to the original tool, indicating user satisfaction with and the utility of the tool, together with a high degree of consensus for the adaptations made. VTE: venous thromboembolism; Rx: prescription; CRP: C-reactive protein.

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.

The will to consensus

AbstractIn a democracy, when a group of deliberators have a set of differing (and contrary) views and beliefs about a particular policy or action, p, a recommended course of action is for them to pursue, and ultimately reach, a consensus on p. The pursuit of consensus allows deliberators to ‘reach over the aisle’ in accommodating dissenting views through rational dialogue until a consensual agreement is reached by all the deliberators. What fuels this pursuit of consensus is the ‘will to consensus’—a ‘frame of mind’ or a ‘disposition’ to resolve disagreements into a consensus. In this paper, I will raise some conceptual problems with positing a ‘will to consensus’ that is prior to, and supervenes on, the rational discussion of deliberators. Instead of a ‘will to consensus’, democratic theorists should be content with the minimal claim of a ‘will to dialogue’.

A comparison of function lumen imaging probe measurements of anal sphincter function in fecal incontinence.

The functional lumen imaging probe (FLIP) is a test of anal sphincter distensibility under evaluation by specialist centers. Two measurement protocols termed "stepwise" and "ramp" are used, risking a lack of standardization. This study aims to compare the performance of these protocols to establish if there are differences between them. Patients with fecal incontinence were recruited and underwent measurement with both protocols at a tertiary pelvic floor referral unit. Differences in minimum diameter, FLIP bag pressure, and distensibility index (DI) at rest and during squeeze were calculated at various FLIP bag volumes. Twenty patients (19 female, mean age 61 [range: 38-78]) were included. The resting minimum diameter at 30 and 40 mL bag volumes were less in the stepwise protocol (mean bias: -0.55 mm and -1.18 mm, p < 0.05) along with the DI at the same bag volumes (mean bias: -0.37 mm2/mmHg and -0.55 mm2/mmHg, p < 0.05). There was also a trend towards greater bag pressures at 30 mL (mean bias: +2.08 mmHg, p = 0.114) and 40 mL (mean bias: +2.81 mmHg, p = 0.129) volumes in the stepwise protocol. There were no differences between protocols in measurements of minimum diameter, maximum bag pressure, or DI during voluntary squeeze (p > 0.05). There are differences between the two commonly described FLIP measurement protocols at rest, although there are no differences in the assessment of squeeze function. Consensus agreement is required to agree the most appropriate FLIP measurement protocol in assessing anal sphincter function.

Development of a bronchopulmonary dysplasia nutrition focused physical examination tool: A modified Delphi study.

The objectives of this study were to identify factors impacting nutrition needs in infants and children with bronchopulmonary dysplasia (BPD). A modified Delphi approach to obtain consensus among pediatric registered dietitian nutritionists (RDNs) was used to create a BPD-specific nutrition focused physical examination (NFPE) tool. RDNs, recruited through pediatric nutrition professional associations, completed a survey rating proposed NFPE components on a Likert scale of 1-5 allowing open-ended responses in a two-round Delphi. Responses were analyzed, deidentified, and results were returned to panelists for in-round feedback. Consensus was defined a priori as 75% agreement for usefulness or relevance ± 1 standard deviation. Six domains (anthropometrics, body composition, development, gastrointestinal, respiratory, and physical signs) and 38 components achieved consensus. Components for an evidence-based tool to enhance nutrition assessment in infants and children with BPD were identified with consensus agreement by an expert panel of 19 pediatric RDNs.

Empowering STEAM Learning Implementation through Investigating Indonesian Teacher Experts’ Views with a Delphi Method

STEAM education has been increasingly adopted by teachers globally in educational settings spanning from elementary school to high school level. However, the challenge is in ensuring that STEAM education adaptation remains relevant to students. In this study, we examined Indonesian teacher experts’ points of view on the pedagogical guidelines for assisting teachers in developing STEAM lessons that are relevant for their students in the Indonesian context. This study employed the Delphi method and involved the participation of eighty teacher experts during a series of three rounds of evaluation processes by analyzing the consensus levels and agreement between rounds. Data were obtained through an online form and subsequently analyzed by descriptive qualitative methods to investigate the quality of several design principles and acquire teacher experts’ recommendations. The findings revealed the consensus between the three rounds on the quality of the design principles. Moreover, the results of this study highlight main dimensions involving technology usage, assessment, contextual problems, integrated STEAM learning, and classroom implementation, which might contribute to advancing knowledge in the field of STEAM education. Therefore, the findings provide recommendations for future research and explorations by focusing on the main dimensions that should be prioritized.

The SAGES MASTERS program bariatric surgery pathway selects 10 seminal publications on revisional bariatrics.

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program designated bariatric surgery as a clinical pathway. Among the tiers of the Masters Program, revisional bariatric surgery is the highest tier of "mastery" within the pathway. This article presents the top 10 seminal studies representing the current landscape of revisional bariatrics. The literature was systematically searched and seminal articles designated by consensus agreement of the SAGES Metabolic and Bariatric Surgery committee using multiple criteria, including impact on the field, citation frequency, and expert opinion. Articles were reviewed by committee members and presented in summarized fashion. The top 10 papers are presented in grouped thematic categories covering the early evolution of revisional bariatrics, changing criteria for reoperative bariatric surgery, divergence of revision versus conversion bariatric surgery, and recent technologic innovations in revisional bariatric surgery. Each summary is presented with expert appraisal and commentary. These seminal papers represent a snapshot of the dynamic field of revisional bariatric surgery and emphasize the need to not only remain current with contemporary trends but also keep a patient-oriented perspective on patient and intervention selection for optimal success.