International Expert Panel Research Articles

P300 An Expert Delphi Consensus: Early Identification of Patients at Risk of Crohn's Disease in Perianal Fistulas and Abscesses (PREFAB) and Identification and Management of Isolated Perianal Crohn's Disease (ipCD) - Part A, PREFAB

Abstract Background In ± 10% of all Crohn’s disease (CD) patients a perianal abscess (PAA) or fistula (PAF) is the manifesting symptom. The delay in diagnosis of CD, from fistula or abscess onset, is very long and associated with worse outcomes. The aim of this Delphi study was to reach consensus on a clinical decision tool to help select patients with raised suspicion of CD in PAA/PAF patients, to identify underlying CD earlier and reduce the diagnostic delay. Methods A panel of international experts in the field of proctology and/or Inflammatory Bowel Disease (IBD), consisting of surgeons, gastroenterologists and radiologists were invited to participate in the PREFAB part of this Delphi study. The first round was an electronic survey and the second round a virtual consensus meeting. In the first round, participants were asked to anonymously provide their opinion probing 1) the relevance and use of clinical characteristics (“Red Flags”) suggestive of underlying CD, 2) the use of faecal calprotectin (FCP) as an adjunct for screening for CD and 3) on the diagnostic work-up for IBD in PAA/PAF patients with raised clinical suspicion. In the second round, statements were paired/revised based on the feedback from the first round and presented in a final set of statements. Consensus was predefined as ≥70% agreement. Results A total of 30 experts participated in the first round and 25 in the second round (83.3%). Final consensus was reached for 29% of all statements in the first Delphi round and, after adjustments/merging, for all 11 statements (100%) in the second round. Ninety-seven percent of participants agreed that shortening of the delay in diagnosis by using a clinical decision tool could improve outcomes in patients with perianal disease as a first symptom. Consensus was reached on the red flags to be included in the clinical decision tool, on screening of all patients with any perianal fistula (regardless of the complexity, biological behaviour and co-existent perianal symptoms) to identify CD in an early (sub)clinical phase, on referral criteria and on the diagnostic workup and follow up of patients with raised suspicion. Conclusion A clinical decision tool for early identification of CD in patients with PAA/PAF as a first symptom could shorten delay in diagnosis and improve outcomes. Global consensus for this tool, including a practical and relevant algorithm for finding or excluding CD in patients with PAA/PAF as a manifesting sign, was reached within two rounds. This clinical decision tool will be validated in 2024 in a large, prospective multicenter study.

Incidence and survival for childhood cancer by endorsed non-stage prognostic indicators in Australia.

An international expert panel recently recommended 15 'non-stage prognostic indicators' (NSPIs) across eight childhood cancers, classified as essential or additional, for collection in population-based cancer registries. We aimed to describe the incidence distribution and survival of each of these NSPIs. Cases were extracted from the Australian Childhood Cancer Registry. The study cohort (n=4187) comprised all children aged under 15years diagnosed with an eligible cancer between 2010 and 2018, with follow-up until 31 December 2020. NSPI data were collected directly from each patient's medical records. Differences in 5-year relative survival were assessed using multivariable flexible parametric models, adjusted for sex and age group at diagnosis. The availability of data varied, exceeding 85% for all essential NSPIs apart from histologic subtype for Wilms tumours (69%) and lineage for acute lymphoblastic leukaemia (78%). Information on additional NSPIs tended to be recorded less often, particularly cytogenetic subtype for non-alveolar rhabdomyosarcoma (28%) and astrocytoma (4%). Eight NSPIs exhibited a significant difference in survival, with the largest disparity occurring among children with astrocytoma according to tumour grade (5-year relative survival of 18% for grade IV disease compared with 99% for grade I disease; p<.001). Our findings demonstrate that most of the recommended NSPIs can be retrieved from medical records in Australia in recent years, allowing the capability of assessing survival within patient subgroups of clinical interest. Reporting of NSPI data has the capability to inform local and global understanding of population-level disparities in childhood cancer survival.

Treatment decision for recurrences in non-small cell lung cancer during or after adjuvant osimertinib: an international Delphi consensus report.

Osimertinib is recommended by major guidelines for use in the adjuvant setting in patients with EGFR mutation-positive NSCLC following the significant improvement in disease-free survival observed in the Phase III ADAURA trials. Due to limited real-world data in the adjuvant setting, little guidance exists on how to approach potential recurrences either during or after the completion of the treatment. This study aimed to reach a broad consensus on key treatment decision criteria in the events of recurrence. To reach a broad consensus, a modified Delphi panel study was conducted consisting of two rounds of surveys, followed by two consensus meetings and a final offline review of key statements. An international panel of experts in the field of NSCLC (n=12) was used to provide clinical insights regarding patient management at various stages of NSCLC disease including patient monitoring, diagnostics, and treatment approach for specific recurrence scenarios. This study tested recurrences occurring 1) within or outside the central nervous system (CNS), 2) during or after the adjuvant-osimertinib regimen in NSCLC disease which is 3) amenable or not amenable to local consolidative therapy. Panellists agreed on various aspects of patient monitoring and diagnostics including the use of standard techniques (e.g., CT, MRI) and tumour biomarker assessment using tissue and liquid biopsies. Consensus was reached on 6 statements describing treatment considerations for the specific NSCLC recurrence scenarios. Panellists agreed on the value of osimertinib as a monotherapy or as part of the overall treatment strategy within the probed recurrence scenarios and acknowledged that more clinical evidence is required before precise recommendations for specific patient populations can be made. This study provides a qualitative expert opinion framework for clinicians to consider within their treatment decision-making when faced with recurrence during or after adjuvant-osimertinib treatment.

Defining ablative radiotherapy in patients with hepatocellular carcinoma: An expert consensus.

485 Background: External beam radiotherapy (EBRT) is a highly effective treatment in select patients with hepatocellular carcinoma (HCC). However, there are many types of EBRT described in the literature with no formal definition of what constitutes “ablative.” Thus, we convened a group of international experts to provide consensus on the parameters that define ablative EBRT in HCC. Methods: A Steering Committee was convened to generate a series of Key Criteria (KC) that could be used to define ablative EBRT for HCC. KC were based on factors related to dose, fractionation, radiobiology, target identification, and delivery technique. An international panel of experts participated in a modified Delphi (mDelphi) process to independently answer questions for each KC. Respondents were given 30 days to respond in round 1 of the mDelphi and 14 days to respond in round 2. A threshold of ≥ 70% was used to define consensus for answers to each KC. Results: Invitations were sent to 40 individuals and 35 (88%) returned responses. In the first round of the mDelphi, 3 of 7 KC reached consensus. In the second round, 100% of participants returned responses and consensus was reached in 3 of the remaining 4 KC. Based on this mDelphi analysis, there was expert agreement that ablative EBRT for HCC should be defined as 1) a BED10 ≥ 80 Gy, 2) daily imaging and multi-phasic contrast used for target delineation should be used, 3) treatment breaks (e.g., for adaptive EBRT) are allowed, but the total treatment time should be ≤ 6 weeks, 4) the equivalent dose when treating with protons should use a conversion factor of 1.1, and 5) there is no single conversion factor for carbon ions. In one KC, which questioned the expert’s opinion on the α/β ratio of HCC, consensus was not achieved. Conclusions: Using an mDelphi method assessing expert opinion, we provide the first consensus definition of ablative EBRT for HCC. Empiric data are required to define the α/β of HCC.

Hyaluronidase for Dermal Filler Complications: Review of Applications and Dosage Recommendations.

Hyaluronidase (Hyal) can reverse complications of hyaluronic acid (HA) fillers, which has contributed substantially to the popularity of such procedures. Still, there are differing opinions regarding Hyal treatment, including dosage recommendations in filler complication management. We aimed to address unanswered questions regarding Hyal treatment for HA filler complications, including timing and dosage, skin pretesting, properties of various Hyals and interactions with HA gels, and pitfalls of the treatment. PubMed and Google Scholar databases were searched from inception for articles on Hyal therapy for filler complications. Articles were evaluated regarding their contribution to the field. The extensive literature review includes international leaders' suggestions and expert panels' recommendations. There are limited controlled data but increasing clinical experience with Hyal treatment. The currently used Hyals provide good results and have an acceptable safety profile. Nonemergent complications such as the Tyndall effect, noninflamed nodules, and allergic or hypersensitivity reactions should be treated with low or moderate Hyal doses. Hyal should be considered with prior or simultaneous oral antibiotic treatment in managing inflammatory nodules. Hyal may be tried for granulomas that have not responded to intralesional steroids. Emergent complications such as vascular occlusion and blindness require immediate, high-dose Hyal treatment. Regarding blindness, the injection technique, retrobulbar versus supraorbital, remains controversial. Ultrasound guidance can increase the efficacy of the above interventions. Hyal is essential in aesthetic practice because it can safely treat most HA filler complications. Immediate Hyal treatment is required for emergent complications. Aesthetic practitioners should be versed in using Hyal and effective dosage protocols.

METhodological RadiomICs Score (METRICS): a quality scoring tool for radiomics research endorsed by EuSoMII

PurposeTo propose a new quality scoring tool, METhodological RadiomICs Score (METRICS), to assess and improve research quality of radiomics studies.MethodsWe conducted an online modified Delphi study with a group of international experts. It was performed in three consecutive stages: Stage#1, item preparation; Stage#2, panel discussion among EuSoMII Auditing Group members to identify the items to be voted; and Stage#3, four rounds of the modified Delphi exercise by panelists to determine the items eligible for the METRICS and their weights. The consensus threshold was 75%. Based on the median ranks derived from expert panel opinion and their rank-sum based conversion to importance scores, the category and item weights were calculated.ResultIn total, 59 panelists from 19 countries participated in selection and ranking of the items and categories. Final METRICS tool included 30 items within 9 categories. According to their weights, the categories were in descending order of importance: study design, imaging data, image processing and feature extraction, metrics and comparison, testing, feature processing, preparation for modeling, segmentation, and open science. A web application and a repository were developed to streamline the calculation of the METRICS score and to collect feedback from the radiomics community.ConclusionIn this work, we developed a scoring tool for assessing the methodological quality of the radiomics research, with a large international panel and a modified Delphi protocol. With its conditional format to cover methodological variations, it provides a well-constructed framework for the key methodological concepts to assess the quality of radiomic research papers.Critical relevance statementA quality assessment tool, METhodological RadiomICs Score (METRICS), is made available by a large group of international domain experts, with transparent methodology, aiming at evaluating and improving research quality in radiomics and machine learning.Key points• A methodological scoring tool, METRICS, was developed for assessing the quality of radiomics research, with a large international expert panel and a modified Delphi protocol.• The proposed scoring tool presents expert opinion-based importance weights of categories and items with a transparent methodology for the first time.• METRICS accounts for varying use cases, from handcrafted radiomics to entirely deep learning-based pipelines.• A web application has been developed to help with the calculation of the METRICS score (https://metricsscore.github.io/metrics/METRICS.html) and a repository created to collect feedback from the radiomics community (https://github.com/metricsscore/metrics).Graphical

Criteria and Indicators for Centers of Clinical Excellence in Stroke Recovery and Rehabilitation: A Global Consensus Facilitated by ISRRA

Background The aim of the International Stroke Recovery and Rehabilitation Alliance is to create a world where worldwide collaboration brings major breakthroughs for the millions of people living with stroke. A key pillar of this work is to define globally relevant criteria for centers that aspire to deliver excellent clinical rehabilitation and generate exceptional outcomes for patients. Objectives This paper presents consensus work conducted with an international group of expert stroke recovery and rehabilitation researchers, clinicians, and people living with stroke to identify and define criteria and measurable indicators for Centers of Clinical Excellence (CoCE) in stroke recovery and rehabilitation. These were intentionally developed to be ambitious and internationally relevant, regardless of a country’s development or income status, to drive global improvement in stroke services. Methods Criteria and specific measurable indicators for CoCE were collaboratively developed by an international panel of stroke recovery and rehabilitation experts from 10 countries and consumer groups from 5 countries. Results The criteria and associated indicators, ranked in order of importance, focused upon (i) optimal outcome, (ii) research culture, (iii) working collaboratively with people living with stroke, (iv) knowledge exchange, (v) leadership, (vi) education, and (vii) advocacy. Work is currently underway to user-test the criteria and indicators in 14 rehabilitation centers in 10 different countries. Conclusions We anticipate that use of the criteria and indicators could support individual organizations to further develop their services and, more widely, provide a mechanism by which clinical excellence can be articulated and shared to generate global improvements in stroke care.

An Exploratory Qualitative Analysis of the Stanford-Templeton Convenings on Islam and Suicide.

For over 70years, studies have reported lower rates of completed suicide in Muslim-majority countries and individuals who identify as Muslim. To this point, the mechanisms underlying the relationship between Islam and lower risk of suicide remain understudied. In an effort to advance our understanding, we convened a bilingual international interdisciplinary panel of experts for a discussion of the current state and future directions of the field. In this paper, we present an exploratory qualitative analysis of the core themes that emerged from the group interviews. We also derive a general theoretical model of the association between Islam and suicide risk.

Consensus on the definition and criteria for failure of surgical treatment in bacterial arthritis of a native joint: An international Delphi study.

The literature presents a wide range of success rates for a single surgical intervention of bacterial-septic-arthritis, and there is a lack of clear criteria for identifying treatment failure and making decisions about reintervention. This Delphi study aims to establish a consensus among an international panel of experts regarding the definition of treatment failure and the criteria for reintervention in case of bacterial arthritis. The conducting and reporting Delphi studies (CREDES) criteria were used. Data from a systematic review was provided as the basis for the study. A list of 100 potential experts were identified. The study was designed and conducted as follows: (I) identification and invitation of an expert panel, (II) informing the participating expert panel on the research question and subject, and (III) conducting two or three Delphi rounds to reach consensus on explicit research items. Potential criteria were rated on a five-point Likert scale. Sixty orthopaedic experts from nine countries participated in this Delphi study, with 55 completing all three rounds. The mean experience as an orthopaedic surgeon was 15 years (SD ± 9). Strong (96%) consensus was reached on the definition of treatment failure: the persistence of physical signs of arthritis (e.g., pain and swelling) and/or systemic inflammation (e.g., fever and no improvement in CRP) despite surgical and antibiotic treatment. Furthermore, consensus (>80%) was reached on six criteria influencing the decision for reintervention; pain (81%), sepsis (98%), fever (88%), serum CRP (93%), blood culture (82%), and synovial fluid culture (84%). The definition of treatment failure for bacterial arthritis after a single surgical intervention was established through a three-round Delphi study. Additionally, consensus was reached on six criteria that are helpful for determining the need for reintervention. This definition and these criteria may help in the development of clinical guidelines, and will empower physicians to make more precise and consistent decisions regarding reintervention for patients, ultimately aiming to reduce over- and undertreatment and improve patient outcomes. Level V.

Anti-MOG associated disease

Myelin Oligodendrocyte Glycoprotein Antibody Associated Disease (MOGAD) is an autoimmune disease responsible for demyelination of the central nervous system that can occur in adults or children. Overlapping phenotypes between MOGAD, multiple sclerosis (MS) and neuromyelitis optica spectrum disease (NMOSD) have been described. The diagnostic criteria for MOGAD were proposed by a panel of international experts and published in 2023. Defining clinical, biological and imaging characteristics specific to this entity helps to improve diagnostic specificity. In this article, we present the clinical characteristics suggestive of MOGAD and discuss the importance of the antibody detection method and therapeutic management.

Defining the concept of mental dysregulation in patients requiring ambulance and/or emergency department care: protocol for a Delphi consensus study

IntroductionFrom the patient and staff perspective, care delivery for patients experiencing a mental health problem in ambulance and emergency department (ED) settings is challenging. There is no uniform and internationally...

Desired Clinical Applications of Artificial Intelligence in Emergency Medicine: An International e-Delphi Study

Abstract Objective Artificial intelligence (AI) in emergency medicine has been increasingly studied over the past decade. However, the implementation of AI requires significant buy-in from end-users. This study explored desired clinical applications of AI by emergency physicians. Methods A 3-round Delphi process was undertaken using STAT59 software. An international expert panel was assembled through purposeful sampling to reflect a diversity in geography, age, time in practice, practice setting, role, and expertise. Items generated in Round 1 were collated by the study team and ranked in Rounds 2 and 3 on a 7-point linear numeric scale of importance. Consensus was defined as a standard deviation of 1.0 or less. Results Of 66 invited experts, 29 completed Round 1, 25 completed Round 2, and 23 completed Round 3. Three statements reached consensus in Round 2 and four statements reached consensus in Round 3, including safe prescribing, guiding choice of drug, adjusting drug doses, identifying risk or prognosis, and reporting/interpreting investigation results. Conclusions Many desired clinical applications of AI in emergency medicine have not yet been explored. Clinical and technological experts should co-create new applications to ensure buy-in from all stakeholders. Specialty organizations can lead the way by establishing local clinical priorities.

What Is Medical Extended Reality? A Taxonomy Defining the Current Breadth and Depth of an Evolving Field.

Medical extended reality (MXR) has emerged as a dynamic field at the intersection of health care and immersive technology, encompassing virtual, augmented, and mixed reality applications across a wide range of medical disciplines. Despite its rapid growth and recognition by regulatory bodies, the field lacks a standardized taxonomy to categorize its diverse research and applications. This American Medical Extended Reality Association guideline, authored by the editorial board of the Journal of Medical Extended Reality, introduces a comprehensive taxonomy for MXR, developed through a multidisciplinary and international collaboration of experts. The guideline seeks to standardize terminology, categorize existing work, and provide a structured framework for future research and development in MXR. An international and multidisciplinary panel of experts was convened, selected based on publication track record, contributions to MXR, and other objective measures. Through an iterative process, the panel identified primary and secondary topics in MXR. These topics were refined over several rounds of review, leading to the final taxonomy. The taxonomy comprises 13 primary topics that jointly expand into 180 secondary topics, demonstrating the field's breadth and depth. At the core of the taxonomy are five overarching domains: (1) technological integration and innovation; (2) design, development, and deployment; (3) clinical and therapeutic applications; (4) education, training, and communication; and (5) ethical, regulatory, and socioeconomic considerations. The developed taxonomy offers a framework for categorizing the diverse research and applications within MXR. It may serve as a foundational tool for researchers, clinicians, funders, academic publishers, and regulators, facilitating clearer communication and categorization in this rapidly evolving field. As MXR continues to grow, this taxonomy will be instrumental in guiding its development and ensuring a cohesive understanding of its multifaceted nature.

The Ethical Compass: Establishing ethical guidelines for research practices in sports medicine and exercise science

Objective: Research in sports medicine and exercise science has experienced significant growth over recent years. With this expansion, there has been a concomitant rise in ethical challenges specific to these disciplines. While various ethical guidelines exist for numerous scientific fields, a comprehensive set tailored specifically for sports medicine and exercise science is lacking. Aiming to bridge this gap, this paper proposes a comprehensive, updated set of ethical guidelines specifically targeted at researchers in sports medicine and exercise science, providing them with a thorough framework to ensure research integrity. Methods: A collaborative approach was adopted, involving contributions from a diverse group of international experts in the field. A thorough review of existing ethical guidelines was conducted, followed by the identification and detailed examination of 15 specific ethical topics relevant to the discipline. Each topic was discussed in terms of its definition, consequences, and preventive measures. Results: The research in sports medicine and exercise science has grown significantly, bringing to the fore ethical challenges unique to these disciplines. Our comprehensive review identifies 15 key ethical challenges: plagiarism, data falsification, role of artificial intelligence chatbots in academic writing, overstating results, excessive/strategic self-citation, duplicate publications, non-disclosure of conflicts of interest, image manipulation, misuse of peer review, ghost and gift authorship, inadequate data retention, data fabrication, falsification of IRB approvals, lack of informed consent, and unethical human or animal experimentation. For each identified challenge, we propose practical solutions and best practices, enriched by the diverse perspectives of our collaborative international expert panel. This endeavor aims to offer a foundational set of ethical guidelines tailored to the nuanced needs of sports medicine and exercise science, ensuring research integrity and promoting ethical responsibility across these vital fields. Conclusion: This article represents a seminal contribution to the establishment of essential ethical guidelines specifically designed for the fields of sports medicine and exercise science. This article charts a clear course for researchers, clinicians, and policymakers by integrating these ethical principles at the heart of our scholarly and clinical activities. Consequently, it envisions a future where the principles of research integrity and ethical responsibility consistently inform every scientific discovery and every clinical engagement.

An international Delphi consensus for surgical quality assessment of lymphadenectomy and anastomosis in minimally invasive total gastrectomy for gastric cancer

BackgroundMinimally invasive total gastrectomy (MITG) is a mainstay for curative treatment of patients with gastric cancer. To define and standardize optimal surgical techniques and further improve clinical outcomes through the enhanced MITG surgical quality, there must be consensus on the key technical steps of lymphadenectomy and anastomosis creation, which is currently lacking. This study aimed to determine an expert consensus from an international panel regarding the technical aspects of the performance of MITG for oncological indications using the Delphi method.MethodsA 100-point scoping survey was created based on the deconstruction of MITG into its key technical steps through local and international expert opinion and literature evidence. An international expert panel comprising upper gastrointestinal and general surgeons participated in multiple rounds of a Delphi consensus. The panelists voted on the issues concerning importance, difficulty, or agreement using an online questionnaire. A priori consensus standard was set at > 80% for agreement to a statement. Internal consistency and reliability were evaluated using Cronbach's α.ResultsThirty expert upper gastrointestinal and general surgeons participated in three online Delphi rounds, generating a final consensus of 41 statements regarding MITG for gastric cancer. The consensus was gained from 22, 12, and 7 questions from Delphi rounds 1, 2, and 3, which were rephrased into the 41 statetments respectively. For lymphadenectomy and aspects of anastomosis creation, Cronbach’s α for round 1 was 0.896 and 0.886, and for round 2 was 0.848 and 0.779, regarding difficulty or importance.ConclusionsThe Delphi consensus defined 41 steps as crucial for performing a high-quality MITG for oncological indications based on the standards of an international panel. The results of this consensus provide a platform for creating and validating surgical quality assessment tools designed to improve clinical outcomes and standardize surgical quality in MITG.

The risks of private sector investment in affordable housing development: An Afrocentric perspective

The state delivery of affordable and sustainable housing continues to be a complicated challenge in Africa, and there is a need to encourage private sector participation. As a result, this study examines the risks associated with private sector participation in affordable housing and supporting infrastructure investment and the strategies towards mitigating the risks from an Afrocentric perspective. The evidence from a systematic literature review was coupled with the opinion of an international expert panel to address the paper’s aim and provide recommendations for developing improved housing and supporting infrastructure in Sub-Saharan Africa. The review outcomes and the qualitative data from the panel discussion were analysed using thematic analysis. The results revealed that market dynamics, land supply and acquisition constraints, cost of construction materials, unsupportive policies, and technical and financial factors constitute risks to affordable housing in the region. Mitigation strategies include leveraging joint efforts, strengths, and resource bases, increasing access to land and finance for private sector participation, developing a supportive government framework to promote an enabling environment for easy access to land acquisition and development finance, local production of building materials, research and technology adoption. In line with the United Nations (UN) Agenda 2030 targets and principles, reforms are required across the housing value chain, involving the private sector and community. Application of the study’s recommendations could minimise the risks of affordable housing delivery and enhance private sector participation.

An International Expert-Based CONsensus on Indications and Techniques for aoRtic balloOn occLusion in the Management of Ruptured Abdominal Aortic Aneurysms (CONTROL-RAAA)

Objective: To report on the recommendations of an expert-based consensus on the indications, timing, and techniques of aortic balloon occlusion (ABO) in the management of ruptured abdominal aortic aneurysms (rAAA). Methods: Eleven facilitators created appropriate statements regarding the study issues that were voted on using a 4-point Likert scale with open-comment fields, by a selected panel of international experts (vascular surgeons and interventional radiologists) using a 3-round modified Delphi consensus procedure (study period: January-April 2023). Based on the experts’ responses, only the statements reaching grade A (full agreement ≥75%) or B (overall agreement ≥80% and full disagreement &lt;5%) were included in the final study report. The consistency of each round’s answers was also graded using Cohen’s kappa, the intraclass correlation coefficient, and, in case of double resubmission, Fleiss kappa. Results: Sixty-three experts were included in the final analysis and voted on 25 statements related to indication and timing (n=6), and techniques (n=19) of ABO in the setting of rAAA. Femoral sheath or ABO should be preferably placed in the operating room, via a percutaneous transfemoral access, on a stiff wire (grade B, consistency I), ABO placement should be suprarenal and last less than 30 minutes (grade B, consistency II), postoperative peripheral vascular status (grade A, consistency II) and laboratory testing every 6 to 12 hours (grade B, consistency) should be assessed to detect complications. Formal training for ABO should be implemented (grade B, consistency I). Most of the statements in this international expert-based Delphi consensus study might guide current choices for indications, timing, and techniques of ABO in the management of rAAA. Clinical practice guidelines should incorporate dedicated statements that can guide clinicians in decision-making. Conclusions: At arrival and during both open or endovascular procedures for rAAA, selective use of intra-aortic balloon occlusion is recommended, and it should be performed preferably by the treating physician in aortic pathology. Clinical Impact This is the first consensus study of international vascular experts aimed at defining the indications, timing, and techniques of optimal use of ABO in the clinical setting of rAAA. Aortic occlusion by endovascular means (or ABO) is a quick procedure in properly trained hands that may play an important role as a temporizing measure until the definitive aortic repair is achieved, whether by endovascular or open means. Since data on its use in hemodynamically unstable patients are limited in the literature, owing to practical challenges in the performance of well-conducted prospective studies, understanding real-world use by experts is of importance in addressing critical issues and identifying main gaps in knowledge.

A New Inherited Syndrome Causing Sudden Cardiac Death with Distinct ST-Segment Depression and Ankyrin-2-Mutation.

Sudden cardiac death (SCD) is a serious threat. In individuals under the age of 35 years sudden arrhythmic death is the most frequent cause. In younger persons, genetically determined cardiac diseases (eg, cardiomyopathies and ion-channel diseases) account for an important proportion of these cases. We investigated the case of a 23-year-old male with SCD, specific ECG changes and left ventricular hypertrophy. Family history was significant for SCD in the paternal line. A precise analysis was performed by an international multidisciplinary expert panel including autopsy of the index patient's heart, molecular autopsy, whole-exome sequencing, analysis of the pedigree and examination of available family members. Three cases of SCD were reported in paternal relatives. The index patient exhibited specific ECG changes (ST-depression), which were also found in five paternal relatives and the brother of the index patient. Post-mortem analysis of the heart yielded mild idiopathic concentric hypertrophy without myocardial disarray. The genetic analysis of the index patient showed two nucleotide variations in two different genes (ANK2: c.11791G>A, MYO18B: c.3761G>A), which were also expressed in five relatives. Two family members had showed all indicators of the inherited syndrome including distinct ECG changes and genetic changes. We describe a distinct inheritable syndrome causing SCD, characterized by specific ECG changes and mutations of ANK2 and MYO18. As far as we know this is the first description of this syndrome.

Analysis of Treatment Patterns and Outcomes in Patients Ages 60-74 in the Post-Venetoclax Era

Introduction Clear standards of care exist for patients with AML under the age of 60 who are eligible for intensive chemotherapy (IC), as well as for patients over the age of 75 or who are unfit for IC. Fit patients between the ages of 60-74 have historically been understudied, but have lower rates of remission and increased rates of toxicity with intensive regimens compared to younger individuals with AML. We sought to evaluate treatment patterns and outcomes in this patient group. Methods We performed a single-center, retrospective analysis of consecutive patients ages 60 through 74 years at the time of their AML diagnosis who received frontline therapy between April 2018 and September 2022. Low intensity therapy (LIT) regimens included combinations of a hypomethylating agent, low dose cytarabine, venetoclax, cladribine, and/or targeted agents. IC regimens included an anthracycline and higher-dose cytarabine-based regimens (≥1g/m 2) +/- targeted agents. Clinical and genomic data including patient demographics, laboratory results including bone marrow pathology and mutational data, treatment responses, and allogeneic hematopoietic stem cell transplantation (HCT) data including conditioning regimen and donor type (when applicable) were abstracted from the medical record. Minimal residual disease (MRD) status was assessed by multi-parameter flow cytometry with a sensitivity of 0.02%. The statistical analysis was performed using R 1. Results 143 patients were included in the analysis; 47 (33%) received front line IC, and 96 (67%) received LIT. Baseline characteristics are shown in Table 1. Patients receiving IC were younger, more likely to be female, and more likely to have a favorable ELN risk stratification 2, but otherwise balanced. The percentage of patients receiving IC remained the same in each calendar year. Patients in the IC and LIT groups had similar rates of complete remission (CR; 70% vs 70%, respectively, p = 0.96). Among those achieving CR, 22 (67%) patients in the IC group achieved MRD-negativity vs. 35 (52%) in the LIT group (p = 0.17). The median duration of remission was 9 months in the IC group and 12 months in the LIT group (p = 0.17). The median overall survival (OS) was 17 months for IC and 15 months for LIT (p = 0.16). For patients harboring FLT3-ITD, IDH1, IDH2, or TP53 mutations, there was no difference in OS based on receipt of either IC or LIT, nor was there any difference in OS according to ELN 2022 risk category. A significantly higher proportion of patients who received IC underwent HCT (68% vs 42%, p = 0.003). In both groups, OS was significantly longer for patients who received HCT. Treatment-related mortality (TRM) was comparable in each group, with 5 (11%) and 8 (8%) deaths in IC vs. LIT, respectively. The median number of days hospitalized within the first 60 days after induction therapy was notably different at 32 days for IC and 5.5 days for LIT (p &amp;lt; 0.00001), with 34 (35%) LIT patients who had 0 days of hospitalization post-induction compared to IC patients who universally were hospitalized as part of their induction treatment plan. Conclusion In our cohort, patients with AML between the ages of 60-74 had comparable rates of CR, MRD negativity, duration of response, and overall survival whether treated with IC or LIT, with no difference when stratified by mutational status or ELN risk. Intensively-treated patients were younger and more likely to receive HCT but both groups had an OS benefit from HCT. Our data suggest that in the era of novel agents such as venetoclax, less intensive induction strategies may be appropriate for IC-eligible patients between the ages of 60-74. References 1R Core Team (2021). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. https://www.R-project.org/. 2Döhner H, Wei AH, Appelbaum FR, Craddock C, DiNardo CD, Dombret H, Ebert BL, Fenaux P, Godley LA, Hasserjian RP, Larson RA, Levine RL, Miyazaki Y, Niederwieser D, Ossenkoppele G, Röllig C, Sierra J, Stein EM, Tallman MS, Tien HF, Wang J, Wierzbowska A, Löwenberg B. Diagnosis and management of AML in adults: 2022 recommendations from an international expert panel on behalf of the ELN. Blood. 2022 Sep 22;140(12):1345-1377. doi: 10.1182/blood.2022016867. PMID: 35797463.

Development of an international prehospital CPR-induced consciousness guideline: A Delphi study

Background Improved prehospital systems are contributing to increased presentations of CPR-Induced Consciousness (CPRIC). Data registries do not report CPRIC presentations and thus continued lack of evidence exists, causing a significant variation of prehospital CPRIC management guidelines. The result is variation in recognizing and managing CPRIC. Steps are needed to improve knowledge of CPRIC and model evidence-based guidelines. Objective An international panel of experts was recruited to create CPRIC definitions, guidelines, and a reporting framework which can be used for reporting purposes. Methods A Delphi methodology was used to gain consensus, defined as ≥70% agreement rate, on three domains or areas of interest: Definition, management guideline and data reporting. Participants were invited from the author's professional organizations, as well as social media outlets to recruit as many international clinicians as possible. The study administered four rounds of online surveys. Each round had multiple consensus statements for participants to respond to. Results Eighty-two percent of panelists reported seeing or managing CPRIC suggesting either improved awareness or increased exposure. Consensus was achieved in all three domains. There was agreement on a clear definition of CPRIC. The panel developed two subgroups of CPRIC; interfering and non-interfering CPRIC. Ketamine was the preferred choice to treat CPRIC. Panelists overwhelmingly felt CPRIC needed to be included into the Utstein guidelines. Conclusions This study successfully created definitions of CPRIC, management guidelines, and a data reporting framework. Using this study as a building block, the study team hopes stronger, evidence-based guidelines can now be researched and published.