Final Agreement Research Articles

Digital health and quality of care in Primary Health Care: an evaluation model

IntroductionThe implementation of technologies in Primary Health Care with monitoring and evaluation of the quality of health care is fundamental to direct the access and quality of health care in the context of the Sustainable Development Goals. Our objective was to develop a model for evaluating digital health interventions in primary care, considering its impact on first contact, longitudinality, integrality and coordination in health.MethodologyThis is an exploratory methodological study of a qualitative nature. This study seeks to explore strategic actors’ perceptions of an evaluation model, and was developed in a process between June 2021 and March 2024. The following stages were followed: Identification of previous models available in the literature, model development, model validation, model update. We performed a nominal group consensus technique online with seven experts. Stages taken to define the design of the model: sending the elaborated model, together with an electronic form with 18 subjective questions, such as brainstorming strategy, for recording impressions, judgment of agreement and suggestions; workshop for discussion by videoconference, at the time the objectives and the model diagram were presented, followed by debate with clarification of doubts and suggestions for clarification of the step-by-step design. After incorporating the suggestions, the model agreed upon in the workshop was subjected to another analysis by the same experts, sent in an online Google document, in which possible inconsistencies between the proposed model and the agreed one were verified, as well as the final agreement on the recommended proposal. At the end of this stage, with synchronous and asynchronous remote procedures, consensus was reached.ResultsThe proposed evaluation model presents as primary categories, structure, process and result. The structure encompasses four indicators, namely, employees; financial resources; infrastructure resources; and regulatory and strategic resources. The process is organized into three dimensions, namely: technical dimension, organizational dimension and relational dimension. The results will be evaluated in products; intermediate results; and impacts (short, medium and long term). The results will be measured by the seven pillars of quality: efficacy, effectiveness, efficiency, optimization, acceptability, legitimacy, equity.ConclusionThis study achieved the goal of developing a model to evaluate digital health interventions in Primary Health Care, helping to identify adequate and useful evaluation methods filling the gap of the lack of quality evaluation standards in the brazilian Digital Health Strategy. It presents an important difference in relation to models from different countries, as it considers the impacts on Primary Health Care quality attributes such as first contact care, longitudinality, integrality and coordination of care. The model will be used by managers and health professionals of Primary Health Care in a case study in Brazil to evaluate the quality of health care. It is expected that the proposed model may be used in other evaluation studies and countries through contextual adaptations.

Inter-rater Agreement for Movement Disorder Classification in Children with Hyperkinetic Movement Disorders.

Accurate classification is essential for addressing childhood movement disorders (MD), but the common coexistence of multiple MDs complicates this process. The aim was to assess inter-rater agreement on classifying hyperkinetic MDs among pediatric neurologists with expertise in MDs. Five pediatric neurologists were requested to examine 112 videos of 66 pediatric patients. Based on the Movement Disorder-Childhood Rating Scale, 3 queries were posed: (Q1) Is there more than 1 MD? (Q2) What is the (predominant) MD? (Q3) What is the other MD (if present)? The final agreement rates were 57.5% for Q1, 66.6% for Q2, and 43.9% for absolute agreement. All videos with absolute agreement at the first evaluation featured 1 MD, whereas only 2 videos with multiple MDs could totally agree in the final review. This study reveals significant discordance in classification even among pediatric neurologists with expertise in MDs and highlights the necessity for a standardized approach.

Chaotic systems based on higher-order oscillatory equations

This paper discusses the design process toward new lumped chaotic systems that originates in higher-order ordinary differential equations commonly used as description of ideal oscillators. In investigated third-order case, two chaotic oscillators were constructed. These systems are dual in the sense of vector field geometry local to fixed points. The existence of robust chaos was proved by both standard routines of numerical analysis and practical measurement. For the fourth-order oscillatory equation, the concept based on interaction between superinductor and supercapacitor was examined in detail. Since both “superelements” are active, the nonlinearity essential to the evolution of chaos is fully passive. It is demonstrated that complex motion is robust and does not represent long transient behavior or numerical artefact. The existence of chaos was verified using standard quantifiers of the flow, such as the largest Lyapunov exponents, recurrence plots, approximate entropy and sensitivity calculation. A good final agreement between theoretical assumptions and practical results will be concluded, on a visual comparison basis.

Development of a Core Outcome Measure Instrument; "LeishCOM_LCL", for Localised Cutaneous Leishmaniasis.

Localized cutaneous leishmaniasis (LCL) is a chronic ulcerating disease. A literature review identified inconsistencies in clinical trials. The aims of this study were to reach a consensus on the most important domains to measure when assessing LCL, agree on parameters to measure the domains, and develop a tool representing a Core Outcome Set (COS), for use in clinical assessment of LCL. A literature review was conducted to identify any existing COS for LCL embracing agreed Outcome Domains, i.e. what to measure and any Outcome Measurement Instruments (OMIs). As no COS was available, potential outcome domains for assessment of LCL were identified through an international collaborative approach using e-consultations and virtual discussions with expert stakeholders (n = 20) from geographically different LCL endemic countries. Subsequent judgmental validation process included a face-to-face multidisciplinary stakeholders' meeting adopting the Nominal Group Technique. A final consensual agreement on outcome domains and items required to measure these domains was established. "Clinical Cure" was defined as the ideal overall "General Concept". The five Core Outcome Domains included Signs capturing clinical morphology, diameter, and induration of an index lesion with the aid of a palpability score, Treatment Efficacy assessing percentage change in size of the lesion and re-epithelialization compared to baseline, Treatment Impact which included an investigator and patient visual analogue score, and Clinical Sequelae rating pigment change, atrophic and hypertrophic/keloid scars. It was agreed that two open-ended questions should be included to capture some aspects of Health-Related Quality of Life as a means of capturing a patient-focused approach. LeishCOM_LCL was generated to reflect a COS for LCL. This captured demographic details, agreed outcome domains and measures to assess these domains. Validation of LeishCOM_LCL will be reported in a separate paper. Development of a Patient Reported Outcome Measure will be considered in the future.

Evaluating an Excel-based tool for interpreting functional analyses: A functional analysis decision support system.

When applied to functional analysis results, structured visual inspection criteria have resulted in improvements in the levels of agreement between raters as well as earlier identification of the function of challenging behavior. However, multistep criteria can be difficult to apply in real time, which could be a barrier to widespread adoption in practice. This study evaluated a Microsoft-Excel-based functional analysis decision support system (FADSS), which could aid behavior analysts with interpreting functional analysis results. Final overall agreement between the FADSS and post hoc visual inspection was high at 95%. Final overall agreement between the post hoc results generated by FADSS and ongoing results generated by FADSS was acceptable at 81%, representing a 50% increase in efficiency. These results indicate that FADSS could aid behavior analysts when interpreting functional analysis results in real time.

Step-by-step negotiations and the Nash bargaining solution: Efficiency-free characterizations

Real-world bargainings often proceed step-by-step: the agents make intermediate agreements today and continue to negotiate tomorrow to reach a final agreement. We consider two natural properties of the bargaining solutions in such step-by-step negotiations and show that the Nash solution is the only solution that satisfies either of them, a very weak axiom of individual rationality, and Nash’s axioms except for Pareto optimality.

Commentary: core descriptor sets using consensus methods support ‘table one’ consistency

BackgroundInconsistent reporting of patient characteristics in clinical research hampers reproducibility and limits analysis opportunities. This paper proposes condition-specific ‘Core Descriptor Sets’ comprising key factors like demographics, disease severity, comorbidities, and prognosis to standardize Table 1 reporting. MethodsDevelopment entails stakeholder involvement, systematic identification of descriptors, value rating, and consensus-building using multiple Delphi rounds. Final agreement comes at an expert meeting. ConclusionBenefits include easier cross-study comparison, for example, through individual patient meta-analysis, facilitated by comparison of consistently reported individual data rather than group-level analysis. This may also support routine data analyses, subgroup and risk identification, and reduced research waste. Core Descriptor Sets describe cohorts thoroughly while minimizing research burden. They are intended to enable improved clinical characterization, personalization, reproducibility, data sharing, and knowledge building.

Managing the Santa Cruz River: Prospects for a Future Binational Minute

This paper examines the prospects for developing and implementing a binational water management agreement for the transboundary Santa Cruz River that crosses the US–Mexico boundary near the sister cities of Nogales, Sonora–Nogales, Arizona. After considering the geography, history, socio-economic context, and binational agreements affecting utilization of the Santa Cruz River, we review the conditions influencing recent binational progress on another transboundary river, the Tijuana River. Specifically, we ask what conditions created a favorable environment in which a binational agreement for management of the Tijuana River Watershed (TRW) was developed, what specific actions by relevant policy officials took place, and how the final agreement was reached. We then compare the dynamics that unfolded in the TRW with conditions in the Santa Cruz River to identify obstacles hindering progress towards achieving an International Boundary and Water Commission (IBWC) agreement (Minute) on shared management of the Santa Cruz River in its international reach. We find that the required political conditions that favored an agreement on the Tijuana River are not yet met on the Santa Cruz, although several favorable conditions do exist. We conclude with an assessment of current prospects for advancing binational cooperation that can inform discussion of how an IBWC Minute could be drafted to address water resource management issues in the Santa Cruz River Basin.

LCA-based environmental benefit allocation between steel and cement industries in steel byproduct recycling

Among the steel byproducts, more than 80% of blast furnace slag is recycled in the cement industry. However, the criteria for allocating environmental benefits between the steel and cement industries need to be more transparent. This study aims to allocate the environmental benefits between the steel and cement industries when granulated blast furnace slag (GBFS) is recycled to replace Portland cement in the production of slag cement (SC). Specifically, this research proposes how the recycling of GBFS, a byproduct of the steel production process, can quantify environmental burdens and benefits from both attributional life cycle assessment (ALCA) and consequential life cycle assessment (CLCA) perspectives. It also suggests methods for allocating these environmental benefits between the steel and cement industries. Following the final agreement on the EU Carbon Border Adjustment Mechanism (CBAM), this study emphasizes the growing importance of interconnected allocation of environmental benefits through recycling. Various allocation methods using ALCA and CLCA approaches have been assessed, significantly impacting the analysis results. Furthermore, these findings of the study are expected to provide guidance for potential policy decisions and internal decision-making processes, highlighting the environmental benefits that GBFS recycling offers to both steel and cement industries.

Internationalization of EIA rules in the BBNJ Agreement: Impediments and possible solutions

The International Legal Agreement for the Conservation and Sustainable Use of Marine Biological Diversity of Areas Beyond National Jurisdiction (BBNJ Agreement) has been launched. The final agreement emphasizes that states are obliged to conduct Environmental Impact Assessment (EIA), providing more discretion to states that control planned activities. However, the EIA under the BBNJ negotiations, as well as the principles of international environmental law, customary international law and international organizations all call for the internationalization of the EIA and the restraint of states’ power and activities in areas beyond national jurisdiction (ABNJ). Therefore, an internationalized EIA system that subjects the state-led EIA process to global oversight or guidance is imperative. To demonstrate the necessity of EIA’s internationalization, this article analyses it from the multiple perspectives of international law and its significance to the BBNJ Agreement. Furthermore, the article examines the submissions of the Parties to the BBNJ Agreement and indicates that there is still an opportunity to internationalize the EIA system. The article concludes with recommendations that include the use of soft law documents, the internationalization of EIA guidance through list of activities, as well as the internationalization of EIA oversight through the process of public notification and consultation and rules on responsibility and liability.

Consensus for antifungal stewardship in China (2024 edition).

Invasive fungal disease (IFD) has become a serious threat to human health in China and around the world, with high mortality and morbidity. Currently, the misdiagnosis rate of IFD is extremely high, compounded with the low quality of prescription antifungals and the high incidence of adverse events associated with IFD treatment, resulting in lengthy hospitalization, low clinical response, and high disease burden, which have become serious challenges in clinical practice. Antifungal stewardship (AFS) can not only significantly increase the early diagnosis rate of IFD, reduce inappropriate utilization of antifungal drugs, improve patient prognosis, but can also improve therapeutic safety and reduce healthcare expenses. Thus, it is urgent to identify key AFS metrics suitable for China's current situation. Based on metrics recommended by international AFS consensuses, combined with the current situation of China and the clinical experience of authoritative experts in various fields, several metrics were selected, and experts in the fields of respiratory diseases, hematology, intensive care units (ICUs), dermatology, infectious diseases, microbiology laboratory and pharmacy were invited to assess AFS metrics by the Delphi method. Consensus was considered to be reached with an agreement level of ≥80% for the metric. Consensus was reached for 24 metrics, including right patient metrics (n=4), right time metrics (n=3), and right use metrics (n=17). Right use metrics were further subdivided into drug choice (n=8), drug dosage (n=4), drug de-escalation (n=1), drug duration (n=2), and drug consumption (n=2) metrics. Forty-six authoritative experts assessed and reviewed the above metrics, and a consensus was reached with a final agreement level of ≥80% for 22 metrics. This consensus is the first to propose a set of AFS metrics suitable for China, which helps to establish AFS standards in China and is also the first AFS consensus in Asia, and may improve the standard of clinical diagnosis and treatment of IFD, and guide hospitals to implement AFS, ultimately promoting the rational use of antifungal drugs and improving patient prognosis.

Consensus Guideline on the Management of Epilepsy in Egypt: A National Delphi Consensus Study.

In epilepsy, early diagnosis, accurate determination of epilepsy type, proper selection of antiseizure medication, and monitoring are all essential. However, despite recent therapeutic advances and conceptual reconsiderations in the classification and management of epilepsy, serious gaps are still encountered in day-to-day practice in Egypt as well as several other resource-limited countries. Premature mortality, poor quality of life, socio-economic burden, cognitive problems, poor treatment outcomes, and comorbidities are major challenges that require urgent actions to be implemented at all levels. In recognition of this, a group of Egyptian epilepsy experts met through a series of consecutive meetings to specify the main concepts concerning the diagnosis and management of epilepsy, with the ultimate goal of establishing a nationwide Egyptian consensus. The consensus was developed through a modified Delphi methodology. A thorough review of the most recent relevant literature and international guidelines was performed to evaluate their applicability to the Egyptian situation. Afterward, several remote and live rounds were scheduled to reach a final agreement for all listed statements. Of 278 statements reviewed in the first round, 256 achieved ≥80% agreement. Live discussion and refinement of the 22 statements that did not reach consensus during the first round took place, followed by final live voting then consensus was achieved for all remaining statements. With the implementation of these unified recommendations, we believe this will bring about substantial improvements in both the quality of care and treatment outcomes for persons with epilepsy in Egypt. This work represents the efforts of a group of medical experts to reach an agreement on the best medical practice related to people with epilepsy based on previously published recommendations while taking into consideration applicable options in resource-limited countries. The publication of this document is expected to minimize many malpractice issues and pave the way for better healthcare services on both individual and governmental levels.

Unilateral Activities in Disputed Maritime Areas and Meaningful Responses

Unilateral activities conducted in a disputed maritime area pending maritime delimitation are considered to be a violation of the pre-delimitation obligations imposed by Article 74/83(3) of the 1982 United Nations Convention on the Law of the Sea, which may trigger State responsibility. The obligations contained are negotiation in good faith and self-restraint. However, this is not a prohibition of all activities in disputed maritime areas. Through a study of the relevant case law of the international courts and tribunals, this article finds leniency towards unilateral activities in disputed maritime areas, i.e., some exceptions are permitted. In the South China Sea, reaching a final delimitation agreement can be a difficult and long-term task due to competing interests and the numerous countries involved. Facing unilateral activities undertaken in such an area, the appropriate and meaningful responses are significant to safeguard maritime rights and interests.

Confidence and Outcome Expectations in Bilateral Negotiations–A Dynamic Model

This work proposes and studies a dynamic model of two bargaining parties exchanging offers over time, considering their confidence about the share of the “pie” they obtain, which translates into expectations regarding the outcome of the bargaining process. The model predicts the sequence of offers as well as the final agreement for given confidence parameters. A mathematical analysis of the model shows the outcome is an Asymmetric Nash Bargaining Solution with exponents determined by the bargainers’ confidence. Moreover, a compensation effect can be found between confidence and risk aversion. This work also considers that confidence levels of bargainers might change during the negotiation, and we conduct a comprehensive simulation study to analyze the effect of such changes. Through Monte-Carlo simulation, we show that a bargainer is better off if its confidence increases, but the advantage is lost if the other party’s confidence increases in a similar way. In that case, concessions are smaller and negotiations last longer. Changing confidence parameters make the outcome harder to predict, as it will depend more on the final confidence than the initial one. The simulations also show that the average size of concessions, and therefore the final agreement, depend not only on whether confidence increases or decreases, but also on the change rate, with stronger effects observed when change accelerates towards the end of the process.

Nature Restoration and Agriculture and Forestry: At the Opposite Side of the Fighting Ring or Compatible After All? An Analysis of the Proposal and the Final Agreement on the Nature Restoration Law

Nature Restoration and Agriculture and Forestry: At the Opposite Side of the Fighting Ring or Compatible After All? An Analysis of the Proposal and the Final Agreement on the Nature Restoration Law

CybAttT: A Dataset of Cyberattack News Tweets for Enhanced Threat Intelligence

The continuous developments in information technologies have resulted in a significant rise in security concerns, including cybercrimes, unauthorized access, and cyberattacks. Recently, researchers have increasingly turned to social media platforms like X to investigate cyberattacks. Analyzing and collecting news about cyberattacks from tweets can efficiently provide crucial insights into the attacks themselves, including their impacts, occurrence regions, and potential mitigation strategies. However, there is a shortage of labeled datasets related to cyberattacks. This paper describes CybAttT, a dataset of 36,071 English cyberattack-related tweets. These tweets are manually labeled into three classes: high-risk news, normal news, and not news. Our final overall Inner Annotation agreement was 0.99 (Fleiss kappa), which represents high agreement. To ensure dataset reliability and accuracy, we conducted rigorous experiments using different supervised machine learning algorithms and various fine-tuned language models to assess its quality and suitability for its intended purpose. A high F1-score of 87.6% achieved using the CybAttT dataset not only demonstrates the potential of our approach but also validates the high quality and thoroughness of its annotations. We have made our CybAttT dataset accessible to the public for research purposes.

Exploring tourism trends: a comparative analysis between global trends and higher education programs in Colombia

Background Following the signing of the “Final Agreement for the Termination of the Conflict” in Colombia, an unprecedented boost for tourism is observed, promoting rural development and environmental protection. In the academic realm, Colombian universities offer tourism training programs to develop professionals with skills in management, sustainability, and technology. Methods Information is gathered from the Scopus database on tourism trends and from the National Information System for Higher Education (SNIES) on academic programs in tourism in Colombia until 2022. Geographical maps are employed to visualize the global scope of publications in Scopus and the locations of programs in Colombia. Text mining is used on Scopus abstracts and profiles of Colombian programs, generating word density graphs, frequency tables, and word clustering graphs. Results 707 articles from Scopus originating from 86 countries are selected, and 46 profiles of Colombian universities with tourism programs in 19 regions are compiled. Maps and tables demonstrate the geographical location of article density globally and of universities in Colombia. Word clouds, frequency tables, and dendrograms are generated using the abstracts and profiles. Conclusions Text mining analysis reveals similarities and differences between research and education in tourism in Colombia. There is convergence in management and development, reflecting aligned interests in both datasets. Words like ethics and sustainability indicate a shared commitment to a responsible perspective in the sector. Scopus emphasizes research, while Colombian universities prioritize practical training, especially in tourism management. This difference raises questions about the impact on graduates’ preparedness and their contribution to tourism development in Colombia. The geographical location of programs in Colombia shows a clear connection between academia and the tourism sector, facilitating synergies and continuous improvements.

From Indication-Based Pricing to Blended Approach: Evidence on the Price and Reimbursement Negotiation in Italy.

New indications for existing medicines are increasing over time. In most countries, drug pricing and reimbursement conditions are renegotiated every time a new indication is approved. There is a growing interest in the price negotiation model for new indications, specifically comparing an indication-based versus blended approach. However, little evidence currently exists regarding the complexity of these negotiations and their impact on actual prices. Italy has recently transitioned from an indication-based approach to a blended price model. This study aims to measure the impact of price and reimbursement negotiation of new indications on discounts (i.e. actual prices) and on the negotiation duration, used as a proxy of its complexity. We considered new indications approved through a European centralized procedure from January 2013 to March 2022 for which the price and reimbursement status was approved in Italy between January 2015 and March 2022, amounting to 52 new indications. Data on the timeframe of the Italian price and reimbursement process and its phases were obtained from publicly available sources. Discounts for the first indication and their subsequent increases for new indications were estimated by comparing ex-factory prices and tendered prices. To calculate p-values, we employed the Mann-Whitney test, and multiple regression models were utilized to examine correlations between negotiation time and the characteristics of the medicines. The mean time to reimbursement was 603 days, in contrast to 583 days for the first launch. Price negotiation took longer for rare diseases, cancer drugs, and in case of therapies with minor added therapeutic value. On average, the additional discount (on top of discounts for prior indications) was 13%, significantly lower than the mean discount for the first indications approved (24.9%). The discounts increment was lower, but negotiation took longer if a Managed Entry Agreement accompanied the final agreement. Additionally, discounts have increased over the years. The negotiation for new indications takes longer than the first one, and provides, on average, an additional discount of 13%. While our findings bear the potential for significant policy implications, they necessitate prudent interpretation due to a limited number of observations. The increasing trend in additional discounts over time applied to all indications in recent negotiations, may suggest a descending trend of value for new indications and a shift from an indication-based pricing approach to a blended model. Otherwise, budget impact considerations might have outweighed a value-based approach in the recent negotiations. If so, two potential options for restoring a value-based approach are returning to an indication-based pricing or giving explicit and higher weight to value within a blended model.

Success or Failure? News Framing of the COP26 Glasgow Summit and its Effects on Citizens’ Beliefs About Climate Change

The UN climate summits represent decisive moments for climate change policy. Under significant media coverage, world leaders gather for intense negotiations over policies to address global warming. Given the enormous political, economic, and environmental issues at stake, news media typically frame these summits in terms of success or failure. Still, we know surprisingly little about how these mediated mega events influence public perceptions both during and beyond the specific summit. Focusing on the 2021 Glasgow summit (COP26), this study combines a media content analysis and a two-wave panel survey with a rolling cross-section component, to determine how news framing influenced both summit-specific and more generic climate change beliefs among citizens in Sweden. Findings show (1) that beliefs about the success/failure of the summit took shape immediately following the summit, (2) that news framing effects were particularly pronounced when the final agreement was settled, and (3) that these instantaneous framing effects on summit-specific beliefs left small but lasting imprints on citizens’ generic climate change beliefs several weeks after the summit. These findings have implications for both climate opinion and theories of dynamic news framing effects.

Next-generation tourniquet: Recommendations for future capabilities and design requirements.

Advances in tourniquet development must meet new military needs for future large-scale combat operations or civilian mass casualty scenarios. This includes the potential use of engineering and automation technologies to provide advanced tourniquet features. A comprehensive set of design capabilities and requirements for an intelligent or smart tourniquet needed to meet the challenges currently does not exist. The goal of this project was to identify key features and capabilities that should be considered for the development of next-generation tourniquets. We used a modified Delphi consensus technique to survey a panel of 34 tourniquet subject matter experts to rate various statements and potential design characteristics relevant to tourniquets systems and their use scenarios. Three iterative rounds of surveys were held, followed by virtual working group meetings, to determine importance or agreement with any given statement. We used a tiered consensus system to determine final agreement over key features that were viewed as important or unimportant features or capabilities. This information was used to refine and clarify the necessary tourniquet design features and adjust questions for the following surveys. Key features and capabilities of various were agreed upon by the panelists when consensus was reached. Some tourniquet features that were agreed upon included but are not limited to: Capable of being used longer than 2 hours, applied and monitored by anyone, data displays, semiautomated capabilities with inherent overrides, automated monitoring with notifications and alerts, and provide recommended actions. We were able to identify key tourniquet features that will be important for future device development. These consensus results can guide future inventors, researchers, and manufacturers to develop a portfolio of next-generation tourniquets for enhancing the capabilities of a prehospital medical provider. Prognostic and Epidemiological; Level V.