Low Level Of Consensus Research Articles

Avoidable emergency admissions: defining the concept.

The transfer of end-of-life patients to hospital via admission to an emergency service mainly happens because of a lack of community support nearby and a lack of resources in palliative care. This study aimed to define the concept of avoidable admission to an emergency department for palliative patients. An integrative literature review was performed. The results of this were put to a panel of palliative care experts via a Delphi process to determine their consensus and agreement with the statements. The results of the two-step Delphi process reached a high level of consensus and agreement that patients with palliative needs accompanied by home palliative care teams should not go to the emergency department. There was a low level of consensus and agreement about the appropriate admission of a patient in pain in the absence of any information about previous community support. The findings allowed the definition of an 'avoidable emergency admission', which is an emergency admission for any symptom or condition that could be supported in a home context or primary health care, or any emergency admission that does not require immediate nursing or medical intervention, nor leads to greater comfort or quality of life for the patient.

A Social Network Analysis of a Multi-sector Service System for Intimate Partner Violence in a Large US City

About one in four women in the US report having experienced some form of intimate partner violence (IPV) during their lifetime and an estimated 15.5 million children live in families in which IPV occurred in the past year. Families of young children with IPV experiences often face complex needs and require well-coordinated efforts among service providers across social and health sectors. One promising partnership aims to support pregnant and parenting IPV survivors through coordination between IPV agencies and community-based maternal and early childhood home visiting programs. This study used social network analysis (SNA) to understand the interconnectedness of the system of IPV prevention and intervention for families with young children in a large US city. The SNA included 43 agencies serving this population across various service domains spanning IPV, legal, maternal and child health, and public benefit programs. An SNA survey collected data on four forms of collaboration between agencies, including formal administrative relationship, referral reciprocity, case consultation, and shared activities in community committees/organizing bodies. Density and centrality were the primary outcomes of interest. A community detection analysis was performed as a secondary analysis. The overall level of interconnectedness between the 43 responding agencies was low. Making referrals to each other was the most common form of collaboration, with a network density of 30%. IPV agencies had the highest average number of connections in the networks. There was a high level of variation in external collaborations among home visiting agencies, with several home visiting agencies having very few connections in the community but one home visiting program endorsing collaborative relationships with upwards of 38 partner agencies in the network. In serving families at risk for IPV, home visiting agencies were most likely to have referral relationships with mental health provider agencies and substance use disorder service agencies. A community detection analysis identified distinct communities within the network and demonstrated that certain agency types were more connected to one another while others were typically siloed within the network. Notably, the IPV and home visiting communities infrequently overlapped. Sensitivity analyses showed that survey participants’ knowledge of their agencies’ external collaborations varied by their work roles and agencies overall had low levels of consensus about their connectedness to one another. We identified a heterogeneous service system available to families of young children at-risk for or experiencing IPV. Overall inter-agency connectedness was low, with many siloed agencies and a lack of shared knowledge of community resources. Understanding current collaborations, silos, and centrality of agencies is an effective public health tool for allocating scarce resources across diverse service sectors to efficiently improve the system serving families experiencing IPV.

Gender essentialism and the mental representation of transgender women and men: A multimethod investigation of stereotype content

The growing visibility of transgender women and men in the US challenges a dominant cultural model of gender in which dichotomous sex assigned at birth gives rise to dichotomous gender identity in adulthood. How are these groups – verbally marked as atypical relative to their cisgender counterparts – stereotyped? Moreover, how do gender essentialist beliefs predict the content of such stereotypes? Across four studies with diverse methods of stereotype measurement, we assessed characteristics that cisgender people associate with transgender women and men, comparing these to their stereotypes of cisgender women and men. In our final study, we directly assessed how cisgender people mentally position transgender groups relative to cisgender groups. Across these studies, transgender categories were characterized in less positive ways than cisgender ones, and there was as a lower level of consensus about transgender than cisgender stereotypes. On average, transgender groups were de-gendered relative to cisgender groups, such that transgender women and men were not strongly differentiated on traditionally-gendered stereotype dimensions. Finally, we showed that participants higher in gender essentialism (relative to participants lower in gender essentialism) evaluated cisgender groups more positively and were more likely to stereotype transgender groups based on their sex assigned at birth.

Skincare practices in extremely premature infants: A survey of tertiary neonatal intensive care units from Australia and New Zealand

To investigate skincare practices in the first 2 weeks of life in extremely premature infants across tertiary neonatal intensive care units (NICUs). A web-based secure survey invite was emailed to the medical directors of tertiary NICUs. The survey included questions on various aspects of skincare practices in the first 2 weeks of life in extremely premature infants (born before 28 weeks gestation). The person most familiar with local skincare practices was asked to complete the survey and only one response per unit was requested. We performed a descriptive analysis. We received responses from 30 out of 32 NICUs (response rate 93%). Twenty-five NICUs (89%) reported offering resuscitation and intensive care to infants born at ≥23 weeks gestation. All NICUs reported occurrences of skin breakdown, including medical adhesive-related skin injury (30%), abrasion/friction-associated skin injury (46%), perineal skin breakdown (55%), pressure site injury (47%) and diaper dermatitis (60%). A high level of consensus (≥75%) was observed for certain practices, such as the use of polyethylene occlusive plastic wraps at birth and aqueous chlorhexidine solution for sterile procedures, but a low level of consensus (<25%) was observed for many other practices, including the skin risk assessment tool used. Skin injuries in extremely premature infants are common and skincare practices vary considerably amongst NICUs. Clinical practice improvement projects and further clinical research will help improve consistency amongst NICUs. Further research is needed to assist the development of evidence-based guidelines and benchmarking for skincare practices in these vulnerable infants.

Semantic adaptation of the Global Psychotrauma Screen for children and adolescents in the United States

ABSTRACT Background: The review of trauma screening tools for children and adolescents indicates a need for developmentally and linguistically appropriate, globally applicable, free, and easily accessible trauma screening instruments. Objective: The aim of this study is to adapt the Global Psychotrauma Screen (GPS) for children and adolescents in the United States. Method: Using the modified Delphi method, this study included the GPS Expert Consensus (GPS-EC) and the GPS Stakeholder Consensus (GPS-SC) substudies. In the GPS-EC, ten reviewers who specialize in trauma services independently revised the GPS child and adolescent versions in four rounds. In the GPS-SC, a stratified minimum sample of children and adolescents (n = 24) and their parents (n = 24) were interviewed to collect feedback on the revised GPS versions. Results: In the GPS-EC Round 1, a low level of consensus was observed on the anxiety (restlessness) and depression (loss of interest) items. In Round 2, a high level of consensus was achieved on all but PTSD hypervigilance and detachment, and CPTSD self-concept items. Round 3 indicated a low level of consensus on the exposure and functioning items. Full consensus was achieved in Round 4 on all items. In the GPS-SC, children had more difficulties than adolescents with the exposure, dissociation, and risk-protection items. Conclusions: Based on the results of this study, the semantic adaptation process concluded with implementation of six decisions on the final GPS versions for children and adolescents: adding a non-binary gender choice for adolescents; removing the exposure section; using a full-sentence structure for children and a phrase structure for adolescents; retaining the two-part items on PTSD intrusion and avoidance, retaining self-blame but removing other-blame in the PTSD-blame item; providing specific descriptions of depersonalization and derealization in the dissociation items; and removing risk-protection and functioning items for children.

Human Health Impacts of Aviation Biofuel Production: Exploring the Application of Different Life Cycle Impact Assessment (LCIA) Methods for Biofuel Supply Chains

The life cycle human health (HH) impacts related to aviation biofuels have been understood in a limited way. Life cycle impact assessment (LCIA) methods for assessing HH are often associated with a high level of uncertainty and a low level of consensus. As a result, it remains challenging to perform a robust assessment of HH impacts with a suitable LCIA method. This study aims to systematically compare six commonly used LCIA methods for quantifying HH impacts, in order to empirically understand the potential impacts of aviation biofuel production on HH and how the results are affected by the choice of methods. Three aviation biofuel production pathways based on different feedstocks (sugarcane, eucalyptus, and macauba) were analyzed and compared to fossil aviation biofuels, on the basis of a functional unit of 1 MJ aviation fuel. The majority of the LCIA methods suggest that, in respect to midpoint impacts, macauba-based biofuel is associated with the lowest impacts and eucalyptus-based biofuel the highest; whereas at endpoint level, the results are more scattered. The LCIA methods agree that biomass conversion into aviation biofuel, H2 production, and feedstock cultivation are major contributors to life cycle HH impacts. Additionally, we provide a guideline for determining an appropriate method for assessing HH impacts.

A Review of Controversial Issues in the Management of Head and Neck Cancer: A Swiss Multidisciplinary and Multi-Institutional Patterns of Care Study-Part 3 (Medical Oncology).

Background: The Head and Neck Cancer Working Group of Swiss Group for Clinical Cancer Research (SAKK) has investigated the level of consensus (LOC) and discrepancy in everyday practice of diagnosis and treatment in head and neck cancer.Materials and Methods: An online survey was iteratively generated with 10 Swiss university and teaching hospitals. LOC below 50% was defined as no agreement, while higher LOC were arbitrarily categorized as low (51–74%), moderate (75–84%), and high (≥85%).Results: Any LOC was achieved in 62% of topics (n = 60). High, moderate, and low LOC were found in 18, 20, and 23%, respectively. Regarding Head and Neck Surgery, Radiation Oncology, Medical Oncology, and biomarkers, LOC was achieved in 50, 57, 83, and 43%, respectively.Conclusions: Consensus on clinical topics is rather low for surgeons and radiation oncologists. The questions discussed might highlight discrepancies, stimulate standardization of practice, and prioritize topics for future clinical research.

A Review of Controversial Issues in the Management of Head and Neck Cancer: A Swiss Multidisciplinary and Multi-Institutional Patterns of Care Study-Part 1 (Head and Neck Surgery).

Background: The Head and Neck Cancer Working Group of Swiss Group for Clinical Cancer Research (SAKK) has investigated the level of consensus (LOC) and discrepancy in everyday practice of diagnosis and treatment in head and neck cancer.Materials and Methods: An online survey was iteratively generated with 10 Swiss university and teaching hospitals. LOC below 50% was defined as no agreement, while higher LOC were arbitrarily categorized as low (51–74%), moderate (75–84%), and high (≥85%).Results: Any LOC was achieved in 62% of topics (n = 60). High, moderate and low LOC were found in 18, 20, and 23%, respectively. Regarding Head and Neck Surgery, Radiation Oncology, Medical Oncology, and biomarkers, LOC was achieved in 50, 57, 83, and 43%, respectively.Conclusions: Consensus on clinical topics is rather low for surgeons and radiation oncologists. The questions discussed might highlight discrepancies, stimulate standardization of practice, and prioritize topics for future clinical research.

A Review of Controversial Issues in the Management of Head and Neck Cancer: A Swiss Multidisciplinary and Multi-Institutional Patterns of Care Study-Part 2 (Radiation Oncology).

Background: The Head and Neck Cancer Working Group of Swiss Group for Clinical Cancer Research (SAKK) has investigated the level of consensus (LOC) and discrepancy in everyday practice of diagnosis and treatment in head and neck cancer.Materials and Methods: An online survey was iteratively generated with 10 Swiss university and teaching hospitals. LOC below 50% was defined as no agreement, while higher LOC were arbitrarily categorized as low (51–74%), moderate (75–84%), and high (≥85%).Results: Any LOC was achieved in 62% of topics (n = 60). High, moderate, and low LOC were found in 18, 20, and 23%, respectively. Regarding Head and Neck Surgery, Radiation Oncology, Medical Oncology, and biomarkers, LOC was achieved in 50, 57, 83, and 43%, respectively.Conclusions: Consensus on clinical topics is rather low for surgeons and radiation oncologists. The questions discussed might highlight discrepancies, stimulate standardization of practice, and prioritize topics for future clinical research.

A Review of Controversial Issues in the Management of Head and Neck Cancer: A Swiss Multidisciplinary and Multi-Institutional Patterns of Care Study-Part 4 (Biomarkers).

Background: The Head and Neck Cancer Working Group of Swiss Group for Clinical Cancer Research (SAKK) has investigated the level of consensus (LOC) and discrepancy in everyday practice of diagnosis and treatment in head and neck cancer.Materials and Methods: An online survey was iteratively generated with 10 Swiss university and teaching hospitals. LOC below 50% was defined as no agreement, while higher LOC were arbitrarily categorized as low (51–74%), moderate (75–84%), and high (≥85%).Results: Any LOC was achieved in 62% of topics (n = 60). High, moderate, and low LOC were found in 18, 20, and 23%, respectively. Regarding Head and Neck Surgery, Radiation Oncology, Medical Oncology, and biomarkers, LOC was achieved in 50, 57, 83, and 43%, respectively.Conclusions: Consensus on clinical topics is rather low for surgeons and radiation oncologists. The questions discussed might highlight discrepancies, stimulate standardization of practice, and prioritize topics for future clinical research.

Radiotherapy for pelvic nodal recurrences after radical prostatectomy: patient selection in clinical practice

AimThere is no general consensus on the optimal treatment for prostate cancer (PC) patients with intrapelvic nodal oligorecurrences after radical prostatectomy. Besides androgen deprivation therapy (ADT) as standard of care, both elective nodal radiotherapy (ENRT) and stereotactic body radiotherapy (SBRT) as well as salvage lymph node dissection (sLND) are common treatment options. The aim of our study was to assess decision making and practice patterns for salvage radiotherapy (RT) in this setting.MethodsTreatment recommendations from 14 Swiss radiation oncology centers were collected and converted into decision trees. An iterative process using the objective consensus methodology was applied to assess differences and consensus.ResultsPSMA PET/CT was recommended by 93% of the centers as restaging modality. For unfit patients defined by age, comorbidities or low performance status, androgen deprivation therapy (ADT) alone was recommended by more than 70%. For fit patients with unfavorable tumor characteristics such as short prostate-specific antigen (PSA) doubling time or initial high-risk disease, the majority of the centers (57–71%) recommended ENRT + ADT for 1–4 lesions. For fit patients with favorable tumor characteristics, there were low levels of consensus and a wide variety of recommendations. For 1–4 nodal lesions, focal SBRT was offered by 64% of the centers, most commonly as a 5-fraction course.ConclusionsAs an alternative to ADT, ENRT or SBRT for pelvic nodal oligorecurrences of PC are commonly offered to selected patients, with large treatment variations between centers. The exact number of lymph nodes had a major impact on treatment selection.

EXPERT EVALUATION OF FORMATION AND DEVELOPMENT OF COMPETENCE IN LABOUR AND CIVIL PROTECTION STUDIES

Labour protection specialists need to improve and develop their competence in order to ensure a safe, healthy and sustainable working environment in the relevant economic sector. Competence and its components, as well as the criteria and parameters are very important factors in the formation and development of competence in adult education. The aim of the study was to carry out expert evaluation of the developed competence components’ model in labour and civil protection as well as the criteria and parameters, basing on the analysis of theoretical knowledge. The methodological basis included studies, analyses and evaluation of the relevant publications in the context of the competence - components of competence their criteria and carrying out an expert evaluation of the component model, its parameters and criteria. The expert evaluation found that it is necessary to replace the communication component in the model of competence components with the component of intelligibility. The evaluation of intuition, skills, attitude and professional ethics are those were in most cases consensus was reached, thus being unanimously evaluated. Unanimous were also the evaluations of knowledge, creativity, emotional intelligence and reflection. A relatively low level of consensus was reached in the evaluation of communication. Attitude as a component of competence was unanimously ranked first in terms of significance.

The application of genome selection to kiwifruit breeding

One of the difficulties in breeding for fruit traits in dioecious plants such as kiwifruit is the selection of male parents. Currently the breeding values of potential male parents for fruit traits are estimated by progeny tests, which are both expensive and time consuming. A potential major advantage of applying genome selection (GS) to kiwifruit is that GS does not rely exclusively on progeny information, and this will allow the direct selection of sex-limited traits. The availability of a genome sequence of a diploid Actinidia chinensis is a major step forward for the application of GS in kiwifruit, but there are still significant hurdles that need to be overcome. The current sequence assembly could be improved; kiwifruit are highly heterozygous; and most breeding populations are polyploid. We report on the application of restriction enzyme-based genotyping-by-sequencing (GBS) in diploid A. chinensis to obtain genotype information for an initial application of GS to 86 individuals from a diploid A. chinensis training population. Two plants were used as controls for the repeatability of GBS, a pair of libraries were produced and sequenced from each of these and only a low level of consensus was discovered 89.3% for the first pair and 78.1% for the second. The correlations between genome estimated breeding values (GEBVs) were greater than 0.5 for seven out of the 11 traits tested, suggesting that the application of GS will be useful for kiwifruit breeding but improvement in the genotyping approach is needed.

The rate of success of the conservative management of liver trauma in a developing country

BackgroundThe conservative treatment of liver trauma has made important progress over the last 10 years at the Trauma University Hospital in Tirana, Albania. The percentage of success was 58.7%. The aims of this study were to analyze the conservative treatment of liver trauma and to compare the results with those in the literature.MethodsThis study was conducted prospectively from January 2009 to December 2012. We analyzed 173 patients admitted to our hospital with liver trauma. Liver injuries were evaluated according to the American Association for the Surgery of Trauma and the World Society of Emergency Surgery classification, while the anatomic gravity of the associated injuries was defined using the Injury Severity Score system. The potential mortality was estimated with the Revised Trauma Score.ResultsOut of the 173 patients with liver trauma, 83.2% were male. The main cause of liver trauma was motor vehicle crashes (50.9%). Blunt trauma was the cause of liver injury in 129 cases (74.6%), and penetrating trauma occurred in 44 cases (25.4%). Initially, the decision was to manage 88 cases (50.9%) via the conservative approach. Of these, 73 cases (42.2%) were successfully treated with conservative treatment, while in 15 cases (17.2%), this approach failed. The success rate of conservative treatment by grade of injuries was as follows: grade I (38.4%), grade II (30.1%), grade III (28.8%), and grade IV (2.7%). The likelihood of the success of conservative treatment had a significant correlation with the grade of the liver injury (p < 0.00001), associated intra-abdominal injuries (p = 0.00051), and complications (z = 2.3169, p = 0.02051). The overall mortality rate of liver trauma was 13.2%.ConclusionsThe likelihood of success in using conservative treatment had a significant correlation with the grade of liver injury and associated intra-abdominal injuries. The limited hospital resources and low level of consensus on conservative treatment had a negative impact on the level of success.

Exit, cohesion, and consensus: social psychological moderators of consensus among adolescent peer groups.

Virtually all social diffusion work relies on a common formal basis, which predicts that consensus will develop among a connected population as the result of diffusion. In spite of the popularity of social diffusion models that predict consensus, few empirical studies examine consensus, or a clustering of attitudes, directly. Those that do either focus on the coordinating role of strict hierarchies, or on the results of online experiments, and do not consider how consensus occurs among groups in situ. This study uses longitudinal data on adolescent social networks to show how meso-level social structures, such as informal peer groups, moderate the process of consensus formation. Using a novel method for controlling for selection into a group, I find that centralized peer groups, meaning groups with clear leaders, have very low levels of consensus, while cohesive peer groups, meaning groups where more ties hold the members of the group together, have very high levels of consensus. This finding is robust to two different measures of cohesion and consensus. This suggests that consensus occurs either through central leaders' enforcement or through diffusion of attitudes, but that central leaders have limited ability to enforce when people can leave the group easily.

Online Tonsillectomy Resources: Are Parents Getting Consistent and Readable Recommendations?

Objective Parents frequently refer to information on the Internet to confirm or broaden their understanding of surgical procedures and to research postoperative care practices. Our study evaluated the readability, comprehensiveness, and consistency around online recommendations directed at parents of children undergoing tonsillectomy. Study Design A cross-sectional study design was employed. Setting Thirty English-language Internet websites. Subjects and Methods Three validated measures of readability were applied and content analysis was employed to evaluate the comprehensiveness of information in domains of perioperative education. Frequency effect sizes and percentile ranks were calculated to measure dispersion of recommendations across sites. Results The mean readability level of all sites was above a grade 10 level with fewer than half of the sites (n = 14, 47%) scoring at or below the eight-grade level. Provided information was often incomplete with a noted lack of psychosocial support and skills-training recommendations. Content analysis showed 67 unique recommendations spanning the full perioperative period. Most recommendations had low consensus, being reported in 5 or fewer sites (frequency effect size <16%). Conclusion Many online parent-focused resources do not meet readability recommendations, portray incomplete education about perioperative care and expectations, and provide recommendations with low levels of consensus. Up-to-date mapping of the research evidence around recommendations is needed as well as improved efforts to make online information easier to read.

On climate, conflict and cumulation: suggestions for integrative cumulation of knowledge in the research on climate change and violent conflict

Possible links between climate change and intra-state violent conflict have received major scholarly attention in recent years. But with few exceptions there is still a low level of consensus in this research field. The article argues that one reason for this disagreement is a lack of integrative cumulation of knowledge. Such an integrative cumulation is prevented by three obstacles, which have until now hardly been discussed in the literature. The first is the use of inadequate terms, discussed here with a focus on the labels ‘Malthusian’/‘cornucopian’ and the operationalization of key variables. Secondly, the weaknesses of large-N studies in research on climate change and violent conflict are not sufficiently reflected. These include a lack of data on crucial concepts as well as deficits of widely used datasets. Thirdly, literature that deals with a possible link between adverse environmental change and peace (termed here ‘environmental peace perspective’) has neither been systematized nor adequately considered in the debate so far. The article provides examples of these shortcomings and makes suggestions of how to address each of them. It also develops an integrative theoretical framework for the environmental peace perspective which facilitates its consideration in research on climate change and violent conflict.

Indigenous knowledge of medicinal plants used by the Reang tribe of Tripura state of India

Ethnopharmacological relevanceTraditional remedies used for the treatment of various ailments are considered to be very important in the primary health care of Reang people living in Tripura state of Northeast India. Novel information gathered from the present investigation is important in preserving folk indigenous knowledge of Reang tribe. MethodsSystematic and exhaustive field surveys were conducted during 2003 to 2004 in Reang inhabited areas of Tripura state of Northeast India covering all the seasons, to gather information on medicinal herbs used by them in the treatment of various ailments. Information was collected from 55 traditional herbalists of different age through structured questionnaires and personal observations made during the field visit. The data obtained was analyzed through informant consensus factor (FIC) to determine the homogeneity of informant's knowledge on medicinal plants also the fidelity level (FL) to authenticate the uniqueness of a species to treat a particular ailment. ResultsIn the present study a total of 125 medicinal plants species belonging to 116 genera and 59 families were presented, used for treating 42 different ailments. The major plant parts used are leaves and most of the remedies are suggested to take orally. The greatest parts of plants used for curing various ailments were found locally. The consensus analysis revealed that the fever and gastro-intestinal diseases have the highest informant consensus factor FIC of 0.79 followed by the dermatological problems (FIC 0.78). It is equal (FIC 0.77) for both general health problems and inflammation and pain while urinogenital problems showed relatively low levels of consensus (FIC 0.63). The level of informants' consent was high for most ailment categories indicating greater homogeneity among informants. In the present study we analyzed the disease categories to highlight some of the important plant species in terms of Fidelity level. Greater parts of the plant species achieve highest fidelity level, while only 4% acquire lower FL. The species with high citation and informant concurrence value are reasonably significant. Cyathea, a rare tree fern used for major cuts or wounds for immediate blood coagulation. Extensive local application may threaten the species if not judiciously managed. ConclusionThe traditional pharmacopoeia of the Reang ethnic group incorporates a myriad of diverse flora available locally. Traditional knowledge of the remedies is passed down through oral traditions without any written document. This traditional knowledge is however, currently threatened mainly due to acculturation and deforestation. Therefore, documenting medicinal plants and associated indigenous knowledge can be used as a basis for developing management plans for conservation and sustainable use of medicinal plants of the study area. In addition, findings of this study can be used as an ethnopharmacological basis for selecting plants for future phytochemical and pharmaceutical studies.

By Unanimous Decision? A Second Look At Consensus In The Film Industry

This article reports analyses of the verdicts of various film organizations that annually present awards to motion pictures and investigates whether they award/nominate the same movies in a given year. This research disputes previous findings that reported a high level of agreement between those juries, by the means of reliability analysis and the Cronbach's alpha composite. Arguments were raised for why these earlier findings were flawed and why the use of Cronbach's alpha is problematic. Different aspects of consensus are discussed, after which a new measure (β) is introduced. This is followed by a detailed comparison between particular juries with regard to the percentage share of their decisions that award the most successful (chosen by multiple other juries as well) and the least successful (uniquely awarded) films. This measure shows how often a singular jury decides in line with the others and how much does it stray from the consensus. The article also broadens the theoretical discussions about the reasons for (not) expecting a consensus to arise between various expert juries. It argues that by adopting a cultural economic perspective we become aware of various reasons, most importantly competition between the award events and the juries tend towards a lower level of consensus.

Consensus statement on the multidisciplinary management of patients with recurrent and primary rectal cancer beyond total mesorectal excision planes

The management of primary rectal cancer beyond total mesorectal excision planes (PRC-bTME) and recurrent rectal cancer (RRC) is challenging. There is global variation in standards and no guidelines exist. To achieve cure most patients require extended, multivisceral, exenterative surgery, beyond conventional total mesorectal excision planes. The aim of the Beyond TME Group was to achieve consensus on the definitions and principles of management, and to identify areas of research priority. Delphi methodology was used to achieve consensus. The Group consisted of invited experts from surgery, radiology, oncology and pathology. The process included two international dedicated discussion conferences, formal feedback, three rounds of editing and two rounds of anonymized web-based voting. Consensus was achieved with more than 80 per cent agreement; less than 80 per cent agreement indicated low consensus. During conferences held in September 2011 and March 2012, open discussion took place on areas in which there is a low level of consensus. The final consensus document included 51 voted statements, making recommendations on ten key areas of PRC-bTME and RRC. Consensus agreement was achieved on the recommendations of 49 statements, with 34 achieving consensus in over 95 per cent. The lowest level of consensus obtained was 76 per cent. There was clear identification of the need for referral to a specialist multidisciplinary team for diagnosis, assessment and further management. The consensus process has provided guidance for the management of patients with PRC-bTME or RRC, taking into account global variations in surgical techniques and technology. It has further identified areas of research priority.