Local Consensus Research Articles

10 Optimizing implementation and continuous monitoring of a newborn screening program for severe combined immunodeficiency

Abstract Background Severe Combined Immunodeficiency (SCID) is an inborn error of immunity characterized by severely low T cell levels and function. Early diagnosis is essential to prevent serious infections and improve outcomes. Newborn screening (NBS) for SCID provides a way to detect SCID and other conditions associated with T cell lymphopenia in the neonatal period. Objectives 1) Optimize the implementation of a NBS program for SCID in British Columbia (BC), Canada; and 2) create a systematic method for monitoring the diagnoses and outcomes of infants with a positive screen to facilitate continuous improvement of the NBS program. Design/Methods An interdisciplinary working group comprised of immunologists, biochemical geneticists, and hematopathologists met at regular intervals prior to and after implementing NBS for SCID in BC. We developed an algorithm for the evaluation and initial management of infants with an abnormal NBS for SCID based on literature review and local expert consensus. Using a REDCap database, we tracked the prevalence, evaluation, diagnoses and outcomes of infants with a positive NBS. The database also monitored diagnoses and outcomes of children referred to Immunology outside of the NBS program. Plan-do-study-act cycles included creation of clinical and educational guidelines on SCID, optimization of abnormal NBS cut-off values, and reflex chromosomal microarray (CMA) testing of infants with confirmed T cell lymphopenia. Results Between October 3, 2022 and June 16, 2023, 28,816 initial samples were tested, and 30 infants had a positive screen for SCID. Of the 30 infants, 10 were ultimately diagnosed with conditions associated with T cell lymphopenia. Diagnosis led to avoidance of live viral vaccines and implementation of infection precaution measures. No infants experienced complications related to live viral vaccine administration, compared to 1 case in the preceding 12 months prior to NBS implementation. In February 2023, the threshold for an abnormal NBS was adjusted to achieve the goal positive screen frequency of 0.1%. Performing reflex CMA testing on infants with confirmed T cell lymphopenia led to rapid diagnosis of chromosomal microdeletion syndromes, avoiding unnecessary second tier testing. Since implementing NBS for SCID in BC, there have been no cases of SCID diagnosed outside of the NBS program. Conclusion Establishing an interdisciplinary working group and clinical database facilitated the smooth integration and continuous improvement of NBS for SCID in BC. This model can be applied to other healthcare systems to support teams and ensure the best possible outcomes for affected patients.

Consensus-Building Processes for Implementing Perioperative Care Pathways in Common Elective Surgeries: A Systematic Review.

To identify and understand the different approaches to local consensus discussions that have been used to implement perioperative pathways for common elective surgeries. Systematic review. Five databases (MEDLINE, CINAHL, EMBASE, Web of Science and the Cochrane Library) were searched electronically for literature published between 1 January 2000 and 6 April 2023. Two reviewers independently screened studies for inclusion and assessed quality. Data were extracted using a structured extraction tool. A narrative synthesis was undertaken to identify and categorise the core elements of local consensus discussions reported. Data were synthesised into process models for undertaking local consensus discussions. The initial search returned 1159 articles after duplicates were removed. Following title and abstract screening, 135 articles underwent full-text review. A total of 63 articles met the inclusion criteria. Reporting of local consensus discussions varied substantially across the included studies. Four elements were consistently reported, which together define a structured process for undertaking local consensus discussions. Local consensus discussions are a common implementation strategy used to reduce unwarranted clinical variation in surgical care. Several models for undertaking local consensus discussions and their implementation are presented. Advancing our understanding of consensus building processes in perioperative pathway development could be significantly improved by refining reporting standards to include criteria for achieving consensus and assessing implementation fidelity, alongside advocating for a systematic approach to employing consensus discussions in hospitals. These findings contribute to recognised gaps in the literature, including how decisions are commonly made in the design and implementation of perioperative pathways, furthering our understanding of the meaning of consensus processes that can be used by clinicians undertaking improvement initiatives. This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. No patient or public contribution. CRD42023413817.

Large-scale consensus in incomplete social network with non-cooperative behaviors and dimension reduction

Obtaining a consensus solution is a formidable challenge for large-scale decision-making (LSDM) in social network (SN). The reaching of large-scale consensus in SN is hindered by serious difficulties, including complex decision information, incomplete social relations, a multitude of decision-makers (DMs), and non-cooperative behaviors. This paper introduces a novel three-stage consensus framework that systematically addresses these challenges by data preprocessing, dimension reduction, and optimization modeling. Firstly, the cloud model is applied to convert the probabilistic linguistic information into numerical information, facilitating computational analysis. Meanwhile, an improved t-norm trust propagation method that incorporates the impact of opinion similarity is developed, ensuring the completeness of SN. Secondly, an improved Louvain algorithm is designed to divide large group into cohesive subgroups, enhancing the manageability of LSDM. On this basis, a three-stage consensus optimization that considers non-cooperative behaviors is proposed, which boasts threefold benefits: (i) Assures the synchronous achievement of local and global consensus. (ii) Implements self-adaptive management mechanism of non-cooperative behaviors. (iii) Provides acceptable adjusted opinions for subgroups and DMs. Finally, detailed numerical experiments and comparative analyses are given to demonstrate the effectiveness of the proposed method.

From Weeds to Feeds: Exploring the Potential of Wild Plants in Horticulture from a Centuries-Long Journey to an AI-Driven Future

Given the increasing food needs of humanity and the challenges cultivated species face in adapting to the climatic uncertainties we experience, it is urgent to cultivate new species. A highly relevant repertoire for this purpose is offered by the array of edible wild plants. We analyzed data from Murcia (Spain), involving 61 species and 59 informants, and the Global Database of Wild Food Plants, which includes 15,000 species, 500 localities, and nearly 700 references. Using local consensus, global distribution, and GBIF occurrence data, we built simple unimodal or bimodal models to explore their limitations. Our study highlights that approximately 15,000 wild or feral plant species are consumed as food, underlining the urgent need to support existing crops with new species due to current food crises and climate irregularities. We examined wild plant diversity from a horticultural perspective, considering their relationships with weeds and invasive species. Partial criteria, such as local consensus or global use, were found insufficient for selecting candidate species. We propose developing a specific artificial intelligence to integrate various factors—ecological, nutritional, toxicological, agronomic, biogeographical, ethnobotanical, economic, and physiological—to accurately model a species’ potential for domestication and cultivation. We propose the necessary tools and a protocol for developing this AI-based model.

Private Enterprises and Innovative Interventions in Long-Term Care for Older People: Insights into Residual Stereotypes of Greek Rural Areas

In many areas of rural Greece there exist remnants of traditional stereotypes that were socially constructed in closed societies where the institution of the patriarchal family previously reigned and are regenerated by the dominant culture. These stereotypes have shaped over time the perception that long-term care for older adults should be provided within the family structure and exclusively by family members. Notably, it was previously considered a disgrace in Greek rural society if children moved their parents to a residential or nursing home. Public or other care facilities for older people emerged just two decades ago, except a few led by the church. However, these attitudes have been softened in recent years. European and National funded programmes have shaped different notions towards long-term care in these areas. This was facilitated by the structural changes that occurred in the Greek countryside in combination with the existing low birth rate in these areas and the presence of concrete migratory flows. The present study explores the business environment that is being formed and its potential to unleash the productive forces that have pinned down the relevant residual stereotypes. It also examines the socio-economic impact of the above enterprises on rural areas. Qualitative interviews were conducted with eight entrepreneurs who have invested in rural long-term care settings for older persons and eight elected chairpersons of local councils. Our findings indicate that regardless of financial support towards private care entities for older people, in order for the services offered to take a more prominent social role, the development of local consensus and innovative interventions is required in tandem. If achieved, such care providers can contribute to the socio-economic development of rural areas. This study provides international literature with further evidence on the crucial role of such enterprises on supportiveness towards inhabitants’ quality of life improvement while results can be useful for Greek and European decision-making centers as well as potential rural entrepreneurs.

Identifying Barriers and Implementation Strategies to Inform TBI Screening Adoption in Behavioral Healthcare Settings.

Identify barriers to the adoption of the Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) in behavioral healthcare organizations and match these barriers to implementation strategies to inform future implementation efforts. Twenty behavioral health providers. Qualitative study involving individual, semi-structured interviews regarding barriers to adopting the OSU TBI-ID. Data were thematically analyzed around constructs from the Consolidated Framework for Implementation Research (CFIR). Results were matched to strategies using the Expert Recommendations for Implementing Change (CFIR/ERIC) matching tool. Ten barriers were identified across 4 CFIR domains. Inner-Setting barriers were inadequate leadership engagement, priorities, resources, and organizational incentives. Individual-Characteristics barriers were insufficient knowledge about the connection between TBI and behavioral health and how to conduct the OSU TBI-ID with fidelity, low self-efficacy to conduct screening, and inadequate motivation and buy-in to conduct screening. Outer-Setting barriers were lack of state-level mandates and inadequate incentives to conduct screenings. The Process domain barrier was an insufficient engagement of key personnel. Strategy recommendations include: identify and prepare champions; alter incentive and allowance structures; inform local opinion leaders; build a coalition; access new funding; conduct local consensus discussions; involve executive boards; capture/share local knowledge; conduct educational meetings; assess for readiness and identify determinants; identify early adopters; fund and contract for the clinical innovation; create a learning collaborative; and conduct a local needs assessment. This is the first study to examine barriers to adopting the OSU TBI-ID in real-world practice settings. Our results suggest that multilevel implementation strategies addressing mechanisms of change are necessary at the provider, organizational, and systems levels to overcome the complex barriers affecting TBI screening adoption and implementation. Future research is needed to test these strategies and their mechanisms of action on the adoption, implementation, and sustainment of TBI screening, as well as their effect on client-level outcomes.

Clique-like Point Cloud Registration: A Flexible Sampling Registration Method Based on Clique-like for Low-Overlapping Point Cloud.

Three-dimensional point cloud registration is a critical task in 3D perception for sensors that aims to determine the optimal alignment between two point clouds by finding the best transformation. Existing methods like RANSAC and its variants often face challenges, such as sensitivity to low overlap rates, high computational costs, and susceptibility to outliers, leading to inaccurate results, especially in complex or noisy environments. In this paper, we introduce a novel 3D registration method, CL-PCR, inspired by the concept of maximal cliques and built upon the SC2-PCR framework. Our approach allows for the flexible use of smaller sampling subsets to extract more local consensus information, thereby generating accurate pose hypotheses even in scenarios with low overlap between point clouds. This method enhances robustness against low overlap and reduces the influence of outliers, addressing the limitations of traditional techniques. First, we construct a graph matrix to represent the compatibility relationships among the initial correspondences. Next, we build clique-likes subsets of various sizes within the graph matrix, each representing a consensus set. Then, we compute the transformation hypotheses for the subsets using the SVD algorithm and select the best hypothesis for registration based on evaluation metrics. Extensive experiments demonstrate the effectiveness of CL-PCR. In comparison experiments on the 3DMatch/3DLoMatch datasets using both FPFH and FCGF descriptors, our Fast-CL-PCRv1 outperforms state-of-the-art algorithms, achieving superior registration performance. Additionally, we validate the practicality and robustness of our method with real-world data.

Consensus for Heterogeneous Multiagent Systems: Output Rate-Coded Secure Control.

This article investigates an output rate-coded secure control based on backstepping for the consensus of heterogeneous multiagent systems (MASs) with output-triggering condition. Due to the nondifferentiable virtual control inputs caused by discontinuous triggering signals, it presents a technical obstacle in implementing the recursive backstepping, rendering previous results inapplicable. To address this problem, an auxiliary high-order filter is elaborately constructed to guarantee the required-order derivatives of virtual control inputs. As this filter is driven by local triggering consensus error, it allows our MASs to have different system orders and relative degrees. Besides, to reduce communication bit and strengthen communication security, we propose a novel distributed rate-coded algorithm from an encoding-decoding viewpoint. When it is triggered, agent's output is encrypted into an L -length codeword, then transmitted to neighbors without exposing any sensitive system states or real control inputs. It is shown that all the closed-loop system signals are ultimately bounded, and the mean square consensus tracking error can be reduced by appropriately selecting control parameters. Simulations illustrate our theoretical finding.

MAC: Maximal Cliques for 3D Registration.

This paper presents a 3D registration method with maximal cliques (MAC) for 3D point cloud registration (PCR). The key insight is to loosen the previous maximum clique constraint and mine more local consensus information in a graph for accurate pose hypotheses generation: 1) A compatibility graph is constructed to render the affinity relationship between initial correspondences. 2) We search for maximal cliques in the graph, each representing a consensus set. 3) Transformation hypotheses are computed for the selected cliques by the SVD algorithm and the best hypothesis is used to perform registration. In addition, we present a variant of MAC if given overlap prior, called MAC-OP. Overlap prior further enhances MAC from many technical aspects, such as graph construction with re-weighted nodes, hypotheses generation from cliques with additional constraints, and hypothesis evaluation with overlap-aware weights. Extensive experiments demonstrate that both MAC and MAC-OP effectively increase registration recall, outperform various state-of-the-art methods, and boost the performance of deep-learned methods. For instance, MAC combined with GeoTransformer achieves a state-of-the-art registration recall of 95.7% / 78.9% on 3DMatch / 3DLoMatch. We perform synthetic experiments on 3DMatch-LIR / 3DLoMatch-LIR, a dataset with extremely low inlier ratios for 3D registration in ultra-challenging cases. Code will be available at: https://github.com/zhangxy0517/3D-Registration-with-Maximal-Cliques.

Nutritional management after necrotizing enterocolitis and focal intestinal perforation in preterm infants.

Nutritional management of preterm infants recovering from necrotizing enterocolitis (NEC) or focal intestinal perforation (FIP) is challenging, especially in infants managed surgically. The logistics of how, when, and what to feed are unclear and current nutritional practices are primarily based on physiological principles and consensus opinion in individual units, rather than high-quality evidence. The aim of this narrative review is to summarize the literature on nutritional management after NEC or FIP in preterm infants: when to restart enteral nutrition, type of enteral nutrition to use, and how to advance nutrition. We also discuss treatment of micronutrient deficiencies, cholestasis, replacement of stoma losses, and optimal time of stoma closure. In conclusion, there are insufficient high-quality studies available to provide evidence-based recommendations on the best nutritional practice after NEC or FIP in preterm infants. A local or national consensus based early nutrition guideline agreed upon by a multidisciplinary team including pediatric surgeons, pediatricians/neonatologists, nurses, and nutritionists is recommended. Further studies are urgently needed. IMPACT: There is no good quality evidence or nutritional standard across neonatal units treating infants after medical or surgical NEC or FIP. With this review we hope to start providing some consistency across patients and between providers treating patients with NEC and FIP. Mother's own milk is recommended when restarting enteral nutrition after NEC or FIP. In the absence of high-quality evidence, a consensus based early nutrition guideline agreed upon by a multidisciplinary team is recommended. Nutritional research projects are urgently needed in NEC and FIP patients.

Communicate to Care: Implementing Health Literacy in a Pediatric Ears, Nose, and Throat Clinic.

Despite positive outcomes in controlled trials, organizations have been slow to adopt health literacy practices. The purpose of the Communicate to CARE (Clear Communication, Achieve Understanding with Teach-Back, Receptive to our patient family needs, Empathetic care delivery) study was to use theories and strategies from implementation science to scale up health literacy practices in a pediatric Ears, Nose, and Throat (ENT) clinic. Expanding on previous efforts that simply reflected on barriers, the CARE team identified barriers within the local context pre-implementation to select strategies to directly address barriers during health literacy implementation. The RE-AIM framework was used to evaluate the reach, effectiveness, adoption, implementation, and maintenance of health literacy practices. Over 18 months, the CARE team delivered multiple implementation strategies, including external facilitator, microlessons, preparing champions, audit and feedback, local consensus discussions, and small test of change. We tailored health literacy practices to clinic team roles to accommodate the clinic workflow. ENT team mean ratings on acceptability, appropriateness, and feasibility remained >4 indicating a high likelihood of successful implementation. Caregiver always ratings significantly increased from baseline to 12 months for easy-to-understand medication instructions (74%-96%), test results (54%-96%), know what to do if had questions (89%-96%), and encouraged to talk about health problems (76%-90%). Caregiver ratings dropped slightly at 18 months, indicating a need for booster training. While one third of caregivers reported Teach-Back practice across all time periods, the ENT team reported increased practice from baseline (42%), 6 (61%) and 12 months (70%). Over the first 12 months, the external facilitator delivered implementation strategies with weekly contact, tapering contact over the final 6 months. The local champion became engaged in the CARE study through a quality improvement project with meaningful outcomes for the clinic and an incentivization program for scholarly endeavors. Lunch and learn sessions helped build relationships between the CARE and ENT team to discuss and problem solve issues. The 5-item CAHPS health literacy composite proved to be sensitive to changes during implementation of health literacy practices. Integrating these items into standard follow up surveys with patients and families would help realize the return on investment for health literacy implementation. [HLRP: Health Literacy Research and Practice. 2024;8(3):e166-e174.].

Geopsychiatry: Climate change, migration, and mental health

Geopsychiatry, a newly emerging discipline within psychiatry, examines the influence of geopolitical determinants on mental health and mental illness. Geopolitical determinants include conflict and wars, global austerity, climate change, public health crises (such as the coronavirus disease 2019 (COVID-19)), and migration. This study focuses on the two significant areas of climate change and migration. Climate change can affect mental health directly or indirectly in a variety of ways, including chronic (global warming) and acute (heat waves and environmental disasters) events. Certain groups of migrants, including migrating children, older migrants, refugees, and asylum seekers, are particularly vulnerable to developing psychiatric disorders. The convergence of climate change and migration is significantly complicating the already highly difficult situation for mental health services worldwide, particularly in low- and middle-income countries where access to care is limited. Despite this, the majority of studies examining mental health impacts of these events originate from high-income countries, and there is still a lack of effective preventive and treatment strategies. In 2023, the World Psychiatric Association (WPA) set up a Special Interest Group on Geopsychiatry with a clear and explicit aim to summarize current evidence and propose strategies to tackle geopolitical challenges on mental health. The Special Interest Group aims to support regional and local groups across all psychiatric disciplines and stakeholders dedicated to building local consensus, prioritizing research, crafting policies, and collating and sharing good clinical practices. With such significant effort, we can expand our understanding and collaboration on geopsychiatry and make changes to the care of people with geopolitical and mental health challenges around the globe.

LMIC-25. EXPANDING THE PEDIATRIC NEURO-ONCOLOGY TELECONFERENCE EXPERIENCES, A LUXURY, OR A NECESSITY?

Abstract INTRODUCTION Videoteleconference in neurooncology is feasible and sustainable. The well-established 20 years’ Sickkids/KHCC teleconferencing is an example. Since 2018, several regional centers joined these meetings to discuss their patients’ management plans. We aimed to evaluate the impact of this experience. METHODS We retrospectively reviewed the 56 meetings’ minutes (9/2018-12/2023) and compared the pre-conference suggested plans with the post-conference recommendations. We recorded if the recommendations were implemented and the impact perceived. RESULTS In total, 251 patients were discussed: KHCC (137) and non-KHCC (114). Four of the regional participating oncologists had dedicated pediatric neuro-oncology training. Patients were selected for discussion due to challenges in their management (i.e. with relapsed tumors, rare diagnoses, unexpected tumor behavior). Main diagnoses were: Low-grade-glioma (28%), High-grade-glioma (21%), and Medulloblastoma (17%). Of the 227 patients where the local team suggested a care plan, the teleconference recommendations concurred with the proposed plan in 50% of the cases, agreed on but provided an alternative plan option in 18% and disagreed on in 32% of the cases. The difference in recommendations mostly affected the proposed treatment modality (15%). In 64% of the discordant plans and 50% of the alternative plans, the treating team applied the recommendations. Challenges to apply the recommendations were mainly linked to patients’ factors (53%, plan refusal, traveling abroad, clinical deterioration), local multidisciplinary team consensus on a different plan (29%) or logistic difficulties (18%, e.g. drug access). CONCLUSIONS Improvement in patients’ care was likely achieved with the continuous effort of the local teams to implement the recommendations. Participating oncologists valued the shared educational experience learned from each other’s case discussions, especially those related to molecular-testing and implications on treatment. Joining such regional teleconferences is of particular importance to small-volume centers or those lacking a pediatric neurooncologist. Regional and international collaborations are a necessity when it comes to improving the care of children with CNS tumors.

Improving Election Integrity: Blockchain and Byzantine Generals Problem Theory in Vote Systems

In the digital age, maintaining election integrity is critical, especially in Africa, where the security of electronic elections is often questioned. This study presents a blockchain-based vote counting and validation (BBVV) system developed using a mixed methods approach that combines stakeholder questionnaires to capture system specification and randomized historical election data analysis, following the Design Science Research strategy. Using the theory of the Byzantine General Problem, the BBVV protocol is proposed, which provides an accurate local count of votes at polling stations before national aggregation. The system was tested with randomized historical election data on the Algorand blockchain TestNet and confirmed that a local consensus on the vote count could be reached before it is added to the national tally on the blockchain. Our results show that in the cases where consensus was reached, this was the instance in only about 5% of the voting scenarios, with only 10% of the total vote being considered valid due to the strict consensus requirements. In addition, significant discrepancies were found between officials, with no consensus reached in 95% of cases which was due to the rogue values generated by a randomized dataset. The performance of the BBVV system was evaluated using transaction metrics, saturation, throughput, traffic, and latency to assess its efficiency, scalability, and reliability. The results suggest that blockchain technology can significantly improve the integrity of elections by ensuring a transparent, secure, and accurate vote-counting process. Future work will focus on improving the adaptability and scalability of the BBVV system for different electoral situations.

Finite-time cooperative tracking for high-maneuvering aerial target with sensor network

The finite-time distributed state estimation (DSE) problems based on sensor network for discrete-time nonlinear systems are considered in this paper. Considering the uncertainty of the target maneuvers, the interactive multiple models (IMM) based distributed estimation framework is established by local filter and consensus fusion. In the proposed distributed algorithm, partial of the output of the system can be collected by some sensors and the sensor network is supposed to be collectively observable. According to the consensus protocol, the final estimate results are obtained by fusing local estimate results of each sensor after the consensus fusion stage. The distributed estimate results can be obtained with finite-time when the consensus fusion step is larger than the diameter of the network, and the convergence rate of estimate error of the proposed distributed estimate algorithm can be guaranteed. Besides, the existence of the lower and upper bounds of the error covariance matrix are proved with some necessary assumptions. Finally, numerical simulation example is given for tracking the target with different maneuvers.

Ultrasound in Cardiopulmonary Arrest and Resuscitation: Constructing Comprehensive Implementation Frameworks in High-Risk Settings.

Information obtained from point-of-care ultrasound during cardiopulmonary arrest and resuscitation (POCUS-CA) can be used to identify underlying pathophysiology and provide life-sustaining interventions. However, integration of POCUS-CA into resuscitation care is inconsistent. We used expert consensus building methodology to help identify discrete barriers to clinical integration. We subsequently applied implementation science frameworks to generate generalizable strategies to overcome these barriers. Two multidisciplinary expert working groups used KJ Reverse-Merlin consensus building method to identify and characterize barriers contributing to failed POCUS-CA utilization in a hypothetical future state. Identified barriers were organized into affinity groups. The Center for Implementation Research (CFIR) framework and Expert Recommendations for Implementing Change (CFIR-ERIC) tool were used to identify strategies to guide POCUS-US implementation. Sixteen multidisciplinary resuscitation content experts participated in the working groups and identified individual barriers, consolidated into 19 unique affinity groups that mapped 12 separate CFIR constructs, representing all 5 CFIR domains. The CFIR-ERIC tool identified the following strategies as most impactful to address barriers described in the affinity groups: identify and prepare champions, conduct local needs assessment, conduct local consensus discussions, and conduct educational meetings. KJ Reverse-Merlin consensus building identified multiple barriers to implementing POCUS-CA. Implementation science methodologies identified and prioritized strategies to overcome barriers and guide POCUS-CA implementation across diverse clinical settings.

New-onset diabetes after renal transplantation: Need for local consensus with the advent of renal transplantation in Oran, Algeria

New-onset diabetes after renal transplantation: Need for local consensus with the advent of renal transplantation in Oran, Algeria

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 > 90%. One recommendation was rejected, receiving a panel rating score < 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.

Fully distributed adaptive asymptotical consensus tracking control of uncertain high‐order nonlinear multi‐agent systems with event‐triggered communication

AbstractIn this article, the distributed adaptive asymptotical consensus tracking control is considered for a class of high‐order nonlinear multi‐agent systems with matched unknown parameters under the event‐triggered communication mechanism. The controllers, adaptive laws and triggering conditions are presented under directed topology with a spanning tree, relieving communication burden among the connected agents since continuous monitoring of in‐neighbors is no longer needed. To handle the cross‐coupling term associated with asymmetric Laplacian matrix and unknown parameters of all agents when the candidate Lyapunov function is defined in terms of local consensus errors, adaptive immersion and invariance control technique is adopted. Adaptive estimators are also designed to estimate the constants related to global information, with which the proposed control scheme is fully distributed. It is shown that all closed‐loop system signals are globally uniformly bounded and all agents can track the reference signal asymptotically while ruling out Zeno behavior though a subset of the agents cannot have direct access to the reference signal information. A numerical example is illustrated to show the effectiveness of the proposed control protocol.

Distributed Saturated Impulsive Control for Local Consensus of Nonlinear Time-Delay Multiagent Systems With Switching Topologies

In this paper, the local consensus problem of nonlinear time-delay multi-agent systems with switching topologies via distributed saturated impulsive control is discussed and the maximum domain of attraction is well estimated. Specifically, we develop a new estimation approach that is quite distinct from the contractive invariant set to estimate the domain of attraction. Moreover, a novel composite impulsive-instant-dependent Lyapunov function is constructed and an improved convex hull representation with more slack variables is adopted to minimize the conservativeness. And then, some delay-independent sufficient criteria in the form of bilinear matrix inequalities that guarantee local consensus of nonlinear time-delay multi-agent systems are obtained by means of the Lyapunov-Razumikhin technique and proof by contradiction. Through appropriate transformation, some linear matrix inequalities-based optimization problems constrained by the proposed local consensus criteria are formulated, and the corresponding numerical solutions are solved by the Yalmip. Finally, a simulation example is given to confirm the validity and superiority of the proposed theoretical results.