Panel Of Content Experts Research Articles

Validating the Test Plan Specifications for the American Board of Family Medicine's Certification Examination.

To demonstrate the degree to which the American Board of Family Medicine's certification examination is representative of family physician practice with regard to frequency of diagnoses encounter and the criticality of the diagnoses. Data from 2012 National Ambulatory Medical Care Survey was used to assess the frequency of diagnoses encountered by family physicians nationally. These diagnoses were also rated by a panel of content experts for how critical it was to diagnose and treat the condition correctly and then assign the condition to 1 of the 16 content categories used on the American Board of Family Medicine examination. These ratings of frequency and criticality were used to create 7 different new schemas to compute percentages for the content categories. The content category percentages for the 7 different schemas correlated with the 2006 to 2016 test plan percentages from 0.50 to 0.90 with the frequency conditions being more highly correlated and the criticality conditions being less correlated. This study supports the continued use of the current Family Medicine Certification Examination content specifications as being representative of current family medicine practice; however, small adjustments might be warranted to permit better representation of the criticality of the topics.

Development of ReproKnow, a reproductive knowledge assessment for women with rheumatic diseases

BackgroundThe objective of this study was to develop an assessment tool, ReproKnow, to evaluate the reproductive health knowledge of women with a wide range of rheumatic diseases.MethodsThe 10-item multiple-choice questionnaire was developed with feedback from a panel of content experts and female patients with rheumatic diseases. Construct validity using known-groups analysis was evaluated through comparison of median total ReproKnow scores between rheumatology fellows and nurses. Female patients aged 18–50 years were recruited to take ReproKnow and demographic questionnaires in two outpatient clinics. Associations between patients’ mean total knowledge scores and demographic characteristics were assessed using independent-sample t-tests. Questions were also categorized by topical area, and the percentages were calculated.ResultsThe completion rate of questions in ReproKnow was 100% across all users. Median ReproKnow scores were significantly higher among rheumatology fellows than among nurses (p = 0.045). The 153 patients recruited to the study had at least one of 15 rheumatic diseases. Patients’ mean knowledge score was 5.05 (SD 2.24) out of a possible high score of 10. Patients who were younger, White, and more educated had significantly higher scores than did other patients (p’s < 0.05). Patients who bore children after their disease diagnosis had higher knowledge scores than did women whose children were born prior to their diagnosis; in contrast, women with histories of surgical sterilization or hysterectomy had lower knowledge scores than other women. Knowledge scores of women who used potentially fetotoxic medications did not vary from the remainder of the sample. Patients demonstrated gaps in knowledge about birth outcomes, contraceptive efficacy, and breastfeeding safety.ConclusionsInitial testing of ReproKnow suggests that it may be a promising tool to assess the reproductive health knowledge of women with diverse rheumatic diseases. Specific knowledge deficits elicited from ReproKnow may be important targets for future educational interventions.

Does attending a Delphi consensus conference impact surgeon attitudes? Survey results from the Americas HepatoPancreatoBiliary Association consensus conference on small asymptomatic pancreatic neuroendocrine tumors

BackgroundManagement of asymptomatic small well-differentiated (panNET) <2 cm remains controversial. A consensus conference was held on this topic. The impact of attending the conference and participating in the audience response survey on surgeon's clinical approach to pancreatic neuroendocrine tumors was assessed. MethodsAudience members were surveyed using a smartphone real-time response system at the beginning and end of the conference. ResultsThe majority of 75 attendees underwent fellowship training, and 30% had >10 years experience as attending surgeons. Previously published consensus statements on the topic were considered insufficient to guide surgical practice by 82% of attendees, and over 96% desired additional data. After review of the data, consensus statements, and decision-making process, a significant number of participants changed their opinions regarding indications for tissue biopsy (p = 0.001), size thresholds for excision (p = 0.002), and regional lymph node dissection (p = 0.002) independent of whether a consensus was reached by the content-expert panel. ConclusionsThis represented the first Delphi process consensus on the topic, and the survey confirmed the topic as well-chosen and timely. Attendees changed opinions on management of panNET regardless of whether formal consensus was reached. Therefore, statements of consensus combined with presentation of literature and live discussion served to impact attendees’ approach to this disease.

The Ophthalmology Surgical Competency Assessment Rubric (OSCAR) for anterior approach ptosis surgery

ABSTRACTPurpose: The International Council of Ophthalmology (ICO) is currently developing a series of standardized, internationally validated, teaching tools for key ophthalmic surgical procedures called the Ophthalmology Surgical Competency Assessment Rubrics (OSCARs). This study aims to develop an OSCAR for anterior approach ptosis surgery.Methods: An international panel of content experts, representing Australia, India, Iran, Italy, Turkey, UK, and the USA was established and worked to develop the rubric using a range of online collaboration tools. The team used the standardised OSCAR template as a baseline, developing explicit behavioural descriptors (the behaviour and performance expected for each step) that were reviewed and modified with successive models. Learners were scored a modified 4-point Dreyfus scale of skill acquisition (novice, beginner, advanced beginner, competent) with the removal of the expert domain.Results: The final OSCAR ptosis tool was developed in alignment with the ICO-OSCAR standard. Seventeen agreed and weighted stems were produced. Domains such as communication and postoperative complications were removed from this rubric as they are evaluated in other spheres of residency training. Specific comments with regard to the parameters and wording were incorporated to formulate the final rubric, which was internationally agreed and demonstrated face and content validity.Conclusions: The OSCAR for anterior approach ptosis is skill and behaviour-based, has ICO agreed standards for assessment and provides learners with specific targets for improvement. Although the OSCAR ptosis tool has face and content validity, further development could better elucidate its precise role.

Strategies for improving the lives of US women aged 40 and above living with HIV/AIDS: an evidence map

BackgroundWhile in its early years the HIV epidemic affected primarily the male and the young, nowadays, the population living with HIV/AIDS is approximately 24% women, and its age composition has shifted towards older ages. Many of the older women who live with HIV/AIDS also live with the medical and social conditions that accompany aging. This work aims to identify and characterize empirical studies of strategies for the comprehensive management of women over 40, including transgender women, who live with HIV/AIDS. Forty was chosen as an operational age cutoff to identify premenopausal women who are less likely to bear children, as well as peri- and postmenopausal women.MethodsWe conducted a literature search after discussions with a diverse panel of content experts and other stakeholders and developed an evidence map that identified 890 citations that address questions having to do with programs and barriers to engaging with programs, as well as the role of insurance and comorbidities, and have enrolled older women who live with HIV/AIDS.ResultsOf these, only 37 (4%) reported results of interest for women over 40 who live with HIV/AIDS, or examined interactions between gender and older age that would allow predictions in this subgroup. Few of the 37 eligible studies focused on women facing obvious challenges, such as immigrants, transgender, physically abused, or those recently released from prison. No studies focused on women caring for dependents, including children and grandchildren, or those diagnosed after age 40.ConclusionThe evidence base that is directly applicable to women over 40 who live with HIV/AIDS in the USA is limited, and the research need is broad. We propose research prioritization strategies for this population.

Scanning for new evidence to prioritize updates to the Dietary Reference Intakes: case studies for thiamin and phosphorus

Dietary Reference Intakes (DRIs) are fundamental to inform national nutrition policy. However, a regular systematic review of the 51 nutrients that have DRIs has limited feasibility, and many DRIs have not been reviewed in >15 y. To address this issue, individuals (nutrient review group) who were members of the Food and Nutrition Board developed a streamlined, evidence-based methodology that could be used to identify nutrients potentially in need of a systematic review. The proposed methodology, termed an evidence scan, comprises several steps. First, an analytic framework is developed to identify markers of associations between intake of a nutrient and a corresponding clinical outcome. Next, the framework is used to direct the identification of keywords for a scan of published research that is potentially relevant to intake requirements or upper intake levels for a nutrient. Last, a panel of content experts selects the abstracts that are likely to be relevant and reviews the full publications. The results may be used to determine whether a revision of the nutrient's DRI is an immediate priority but would not supplant a comprehensive systematic evidence review. To illustrate the process, 2 nutrients were selected as case studies: thiamin and phosphorus (DRIs were last set in 1998 and 1997, respectively). Using the evidence scan for thiamin, we identified 70 potentially relevant abstracts, of which 9 full publications were reviewed. For phosphorus, 127 potentially relevant abstracts were identified, and 29 full publications were reviewed. From the review of these 2 nutrients, the nutrient review group concluded that there was insufficient new evidence to assign a high priority to a comprehensive systematic review for either thiamin or phosphorus. Evidence scanning is an efficient method of identifying DRI nutrients that are most in need of either a new or an updated systematic review.

Development and Psychometric Evaluation of the Lung Cancer Screening Health Belief Scales.

Lung cancer screening is a recent recommendation for long-term smokers. Understanding individual health beliefs about screening is a critical component in future efforts to facilitate patient-provider conversations about screening participation. The aim of this study was to describe the development and psychometric testing of 4 new scales to measure lung cancer screening health beliefs (perceived risk, perceived benefits, perceived barriers, self-efficacy). In phase I, 4 scales were developed from extensive literature review, item modification from existing Breast and Colorectal Cancer Screening Health Belief Scales, focus groups with long-term smokers, and evaluation/feedback from a panel of 10 content experts. In phase II, we conducted a survey of 497 long-term smokers to assess the final scales' reliability and validity. Phase I: content validity was established with the content expert panel. Phase II: internal consistency reliability of the scales was supported with Cronbach's α's ranging from .88 to .92. Construct validity was established with confirmatory factor analysis and testing for differences between screeners and nonscreeners in theoretically proposed directions. Initial testing supports the scales are valid and reliable. These new scales can help investigators identify long-term smokers more likely to screen for lung cancer and are useful for the development and testing of behavioral interventions regarding lung cancer screening. Development of effective interventions to enhance shared decision making about lung cancer screening between patients and providers must first identify factors influencing the individual's screening participation. Future efforts facilitating patient-provider conversations are better informed by understanding the perspective of the individual making the decision.

Deconstructing Chronic Low Back Pain in the Older Adult—Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part IX: Anxiety

As a part of a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults, this article focuses on anxiety-a significant contributor of reduced health-related quality of life, increased use of medical services, and heightened disability in older adults with CLBP. A modified Delphi technique was used to develop an algorithm for the screening and clinical care of older adults with CLBP and anxiety. A 4-member content expert panel and a nine-member primary care panel were involved in this iterative development process. Evidence underlying the recommendations is not strictly based on VA populations; therefore, the algorithm can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributor's clinical practice. We present a treatment algorithm and supporting tables to be used by providers treating older adults who have anxiety and CLBP. A case of an older adult with anxiety and CLBP is provided to illustrate the approach to management. To promote early engagement in evidence-based treatments, providers should routinely evaluate anxiety in older adults with CLBP using a screening and treatment algorithm.

Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment. Part VIII: Lateral Hip and Thigh Pain.

Objective. This article presents an evidence-based algorithm to assist primary care providers with the diagnosis and management of lateral hip and thigh pain in older adults. It is part of a series that focuses on coexisting pain patterns and contributors to chronic low back pain (CLBP) in the aging population. The objective of the series is to encourage clinicians to take a holistic approach when evaluating and treating CLBP in older adults. Methods. A content expert panel and a primary care panel collaboratively used the modified Delphi approach to iteratively develop an evidence-based diagnostic and treatment algorithm. The panelists included physiatrists, geriatricians, internists, and physical therapists who treat both civilians and Veterans, and the algorithm was developed so that all required resources are available within the Veterans Health Administration system. An illustrative patient case was chosen from one of the author’s clinical practices to demonstrate the reasoning behind principles presented in the algorithm. Results. An algorithm was developed which logically outlines evidence-based diagnostic and therapeutic recommendations for lateral hip and thigh pain in older adults. A case is presented which highlights the potential complexities of identifying the true pain generator and the importance of implementing proper treatment. Conclusions. Lateral hip and thigh pain in older adults can contribute to and coexist with CLBP. Distinguishing the true cause(s) of pain from potentially a myriad of asymptomatic degenerative changes can be challenging, but a systematic approach can assist in identifying and treating some of the most common causes.

Role of Patient and Disease Factors in Adjuvant Systemic Therapy Decision Making for Early-Stage, Operable Breast Cancer: American Society of Clinical Oncology Endorsement of Cancer Care Ontario Guideline Recommendations.

An American Society of Clinical Oncology (ASCO) panel considered the Cancer Care Ontario (CCO) recommendations on the role of patient and disease factors in selecting adjuvant therapy for women with early-stage breast cancer for endorsement. ASCO staff reviewed the CCO guideline for methodologic rigor, and an ASCO panel of content experts reviewed the content of the recommendations. For making decisions regarding adjuvant therapy, nodal status, tumor size, estrogen receptor (ER), progesterone receptor (PgR), human epidermal growth factor receptor 2 (HER2) status, tumor grade, and lymphovascular invasion are relevant; Oncotype DX score and Adjuvant! Online may be used as risk stratification tools; and age, menopausal status, and medical comorbidities should be considered. Chemotherapy should be considered for patients with positive lymph nodes, ER-negative disease, HER2-positive disease, Adjuvant! Online mortality greater than 10%, grade 3 lymph node-negative tumors (T > 5 mm), triple-negative (ER-negative, PgR-negative, HER2-negative) tumors, lymphovascular invasion positivity, or estimated distant relapse risk of greater than 15% at 10 years based on Oncotype DX recurrence score (RS). Chemotherapy may not be beneficial or required for small node-negative tumors (T < 5 mm) without high-risk features or for patients with HER2-negative, strongly ER-positive, and PgR-positive cancer with micrometastatic nodal disease, T less than 5 mm, or Oncotype DX RS with an estimated distant relapse risk of less than 15% at 10 years. The ASCO panel endorses the recommendations with minor suggested revisions and highlights three areas that warrant further consideration: tumor histology and adjuvant therapy recommendations, risk stratification tools and proposed Oncotype DX RS thresholds to guide decisions about chemotherapy, and patient factors in decision making.

Deconstructing Chronic Low Back Pain in the Older Adult--Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment. Part V: Maladaptive Coping.

As part of a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults, this article focuses on maladaptive coping--a significant contributor of psychological distress, increased pain, and heightened disability in older adults with CLBP. A modified Delphi technique was used to develop a maladaptive coping algorithm and table providing the rationale for the various components of the algorithm. A seven-member content expert panel and a nine-member primary care panel were involved in the iterative development of the materials. While the algorithm was developed keeping in mind resources available within the Veterans Health Administration (VHA) facilities, panelists were not exclusive to the VHA, and therefore, materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributors' clinical practice. We present a treatment algorithm and supporting table to be used by providers treating older adults who have CLBP and engage in maladaptive coping strategies. A case of an older adult with CLBP and maladaptive coping is provided to illustrate the approach to management. To promote early engagement in skill-focused treatments, providers can routinely evaluate pain coping strategies in older adults with CLBP using a treatment algorithm.

Deconstructing Chronic Low Back Pain in the Older Adult: Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part IV: Depression

To present the fourth in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of twelve important contributors to pain and disability in older adults with CLBP. This article focuses on depression. The evaluation and treatment algorithm, a table articulating the rationale for the individual algorithm components, and stepped-care drug recommendations were developed using a modified Delphi approach. The Principal Investigator, a three-member content expert panel, and a nine-member primary care panel were involved in the iterative development of these materials. The algorithm was developed keeping in mind medications and other resources available within Veterans Health Administration (VHA) facilities. As panelists were not exclusive to the VHA, the materials can be applied in both VHA and civilian settings. The illustrative clinical case was taken from one of the contributor's clinical practice. We present an algorithm and supportive materials to help guide the care of older adults with depression, an important contributor to CLBP. The case illustrates an example of a complex clinical presentation in which depression was an important contributor to symptoms and disability in an older adult with CLBP. Depression is common and should be evaluated routinely in the older adult with CLBP so that appropriately targeted treatments can be planned and implemented.

IOM REPORT ON PSYCHOSOCIAL TREATMENTS: CBT PERSPECTIVE.

IOM REPORT ON PSYCHOSOCIAL TREATMENTS: CBT PERSPECTIVE.

Amyloid imaging in dementia: contribution or confusion?

There is mounting evidence and enthusiasm for molecular imaging contribution to the diagnosis of neurodegenerative dementia. A key advance in the imaging field has been the development of selective ligands that can reveal the presence of pathologic deposition of A -amyloid in the cerebral cortex, consistent with dementia due to Alzheimer disease (AD) or a related neurodegeneration [1]. Recently, three amyloid-avid radiotracers with potential for clinical use have been developed (see [2] for review), and are approved for use by the US FDA and by European regulators. The Society of Nuclear Medicine and Molecular Imaging, together with the Alzheimer’s Association, convened a panel of content experts to recommend the appropriate use of these new tools [3]. Conservatively, the panel recommended as the first indication, the use of amyloid imaging probes to distinguish patients with frontotemporal dementias (FTD) from patients with amyloiddependent neurodegenerations such as typical AD and a significant proportion also of patients with dementia with Lewy bodies (DLB). Clinical rationale for this application follows from recognition that diagnosis of FTD can be difficult[4-6], and may be missed in as many as 70% of patients [7]. This circumstance can lead to inappropriate use of symptomatic medications and incorrect prognostication, and even more importantly, may limit the accuracy and power of future therapeutic trials focused on FTD vs. AD pathological pathways. The recommended use of amyloid imaging in dementia includes focus on patients with features atypical of AD, including prominent aphasia or prominent frontal lobe dysfunction or with relatively early age of dementia onset; each of these features increases the likelihood of an FTD variant over AD. In the present issue of the Journal, Kobylecki et al. [8] report their experience with the use of [ 18 F]florbetapir in the distinction of FTD vs. AD in demented patients recruited from a university-affiliated cognitive disorders clinic. The intent of the research was to assess the ability of the radiofluorinated tracer to reproduce the previously published results of amyloid imaging with [ 11 C]PiB from several laboratories [9-11]. In essence, patients with clinical presentations favoring FTD over AD should have “negative” amyloid scans, and patients with AD should have “positive” scans. However, as often encountered in biomedical research, the study results may raise as many questions as they answer. Kobylecki reports that the recommended clinical interpretation approach to [ 18 F]florbetapir scans resulted in identification of “positive” patterns in 25% of FTD and in 10% of normal comparison subjects. They identified “positive” scans in 80% of AD subjects. These findings raise critically important issues: Are the rating recommendations and rules for clinical amyloid reporting sub-optimal? Do the clinical diagnostic amyloid tracers perform differently than predictions based on the research amyloid tracer [ 11 C]PiB?

Gauging Item Alignment Through Online Systems While Controlling for Rater Effects

The alignment of test items to content standards is critical to the validity of decisions made from standards‐based tests. Generally, alignment is determined based on judgments made by a panel of content experts with either ratings averaged or via a consensus reached through discussion. When the pool of items to be reviewed is large, or the content‐matter experts are broadly distributed geographically, panel methods present significant challenges. This article illustrates the use of an online methodology for gauging item alignment that does not require that raters convene in person, reduces the overall cost of the study, increases time flexibility, and offers an efficient means for reviewing large item banks. Latent trait methods are applied to the data to control for between‐rater severity, evaluate intrarater consistency, and provide item‐level diagnostic statistics. Use of this methodology is illustrated with a large pool (1,345) of interim‐formative mathematics test items. Implications for the field and limitations of this approach are discussed.

Results from England's 2014 Report Card on Physical Activity for Children and Youth.

The Active Healthy Kids 2014 England Report Card aims to provide a systematic assessment of how England is performing in relation to engaging and facilitating physical activity (PA) in children and young people. The systematic methods and processes that underpin the Active Healthy Kids Canada Report Card were used and adapted. Data and evidence were consolidated, reviewed by a panel of content experts, and used to inform the assignment of letter grades (A, B, C, D, F) to 9 core indicators related to PA. Children's Overall Physical Activity received a grade of C/D. Active Transportation and Organized Sport Participation received grades of C and C-, respectively. The indicators of School and Community and the Built Environment were graded favorable with grades of A- and B, respectively. Active Play, Sedentary Behaviors, Family and Peers, and Government Strategies and Investments were graded as INC (incomplete) due to a lack of nationally representative data and/or as a result of data not mapping onto the benchmarks used to assign the grades. Substantial provision for PA opportunities in England exists. Yet more effort is required to maximize use of these resources to increase PA participation.

Application of the content expert process to develop a clinically useful low-literacy Chronic Kidney Disease Self-Management Knowledge Tool (CKD-SMKT)

Both chronic kidney disease (CKD) and end-stage renal disease (ESRD) have tremendous impacts on health care expenditures. Several CKD knowledge-related instruments are available; however, most tools include content focusing on measuring pre-dialysis or dialysis options of patients with CKD and kidney transplant recipients. To develop a clinically useful, low-literacy Chronic Kidney Disease Self-Management Knowledge Tool (CKD-SMKT) with the guidance of a panel of content experts. Initially, the authors generated a list of potential items to include in the CKD-SMKT. Sixteen content experts reviewed two drafts of the CKD-SMKT and provided qualitative and quantitative assessments. The Lexile(®) Framework for Reading was used to assess reading grade level of the CKD-SMKT. Eleven items were rated as "essential" (content validity ratio>0.49, P<.05) by content experts and composed the final CKD-SMKT. The final version of the CKD-SMKT had an overall Lexile score of 470, equivalent to a ≈3rd grade reading level. The CKD-SMKT is a content valid instrument designed to assess kidney disease patients' knowledge of various key self-management behaviors, which upon subsequent field testing will be suitable for use in the clinic setting. Its conciseness and suitability for administration to all kidney disease patients, including those with low literacy makes it an attractive tool for the busy clinician.

Role Delineation Study for the American Society for Pain Management Nursing

A role delineation study, or job analysis, is a necessary step in the development of a quality credentialing program. The process requires a logical approach and systematic methods to have an examination that is legally defensible. There are three main phases: initial development and evaluation, validation study, and development of test specifications. In the first phase, the content expert panel discussed performance domains that exist in pain management nursing. The six domains developed were: 1) assessment, monitoring, and evaluation of pain; 2) pharmacologic pain management; 3) nonpharmacologic pain management; 4) therapeutic communication and counseling; 5) patient and family teaching; and 6) collaborative and organizational activities. The panel then produced a list of 70 task statements to develop an online survey which was sent to independent reviewers with expertise in pain management nursing. After the panel reviewed the results of the pilot test, it was decided to clarify a few items that did not perform as expected. After the questionnaire was finalized it was distributed to 1,500 pain management nurses. The final yield was 585 usable returns, for a response rate of 39%. Thirty-three percent of the respondents reported a bachelor's degree in nursing as the highest degree awarded. Over 80% indicated that they were certified in pain management. Over 35% reported working in a staff position, 14% as a nurse practitioner, and 13% as a clinical nurse specialist. Part of the questionnaire asked the participants to rate performance expectation, consequence or the likelihood that the newly certified pain management nurse could cause harm, and the frequency of how often that nurse performs in each of the performance domains. The performance expectation was rated from 0 (the newly certified pain management nurse was not at all expected to perform the domain task) to 2 (after 6 months the newly certified pain management nurse would be expected to perform the domain task). The consequences of the degree would be the inability of the newly certified pain management nurse to perform duties or tasks in each domain was rated from 0 (no harm) to 4 (extreme harm). The first domain received the highest average frequency rating. The pharmacologic domain received the highest mean rating on consequence. The reliability of all scales was 0.95 or higher, which indicated that the questionnaire consistently measured what it was intended to measure. The quality of the questionnaire is an indicator that certification is one measure of nursing excellence.

AHPBA/SSO/SSAT Consensus Conference on Resectable and Borderline Resectable Pancreatic Cancer: Rationale and Overview of the Conference

On January 24, 2008, the American Hepato-PancreatoBiliary Association convened a Consensus Conference on Resectable and Borderline Resectable Pancreatic Cancer. The conference was cosponsored by the Society of Surgical Oncology, the Society for Surgery of the Alimentary Tract, The University of Texas M. D. Anderson Cancer Center, and the Gastrointestinal Symposium Steering Committee. The goals of this conference were to define resectable and borderline resectable pancreatic cancer and to review the indications and contraindications for surgery, neoadjuvant therapy, and adjuvant therapy for these lesions. The meeting took place over 1 day and was divided into three sessions addressing (1) pretreatment assessment, (2) surgical treatment, and (3) combined-modality treatment. This issue of Annals of Surgical Oncology has three articles outlining the consensus statements, each accompanied by an editorial. The methods used in this consensus conference have been described previously. After consultation among experts from the three sponsoring societies, a group of experts was identified and invited to participate in this conference. Each expert was asked to present on a given area and to outline two or three consensus statements at the end of his or her presentation. A panel of content experts commented on the consensus statements, and then the audience was given the opportunity to comment on the consensus statements. After the symposium, three manuscripts, each summarizing one of the sessions, were written by the speakers and session cochairs. Each manuscript was then given to the corresponding session panelists, who wrote a brief editorial highlighting areas of controversy and importance and providing alternative perspectives. The consensus statements define ‘‘resectable’’ and ‘‘borderline resectable.’’ This important first step provides a starting point for discussion regarding the appropriate use of surgery, neoadjuvant therapy, and adjuvant therapy. Use of consistent definitions of resectable and borderline resectable will facilitate comparison between institutions and future published works, which currently is limited because of the variety of definitions used in the published literature dealing with pancreatic cancer. The consensus statements also highlight the acceptable methods of radiologic and endoscopic assessment of resectable and borderline resectable pancreatic tumors, the clinical settings in which preoperative biopsy is needed, and the specific indications for the selective use of laparoscopic staging. Further, the consensus statements recommend against extended lymphadenectomy, define the clinical setting in which vascular reconstruction may be necessary, and recommend that operating surgeons have facility with these techniques. There is also a call for standardized margin definitions and a description of the limited role of ‘‘palliative’’ pancreaticoduodenectomy. The consensus statements identify the clinical setting in which before-surgery systemic therapy and radiation therapy may be warranted and highlight the conflicting evidence regarding postoperative chemotherapy alone versus combined chemoradiotherapy. Finally, areas requiring further study are identified and highlighted. The conference participants and the consensus statements generated reflect the importance of ongoing collaborative multidisciplinary care of patients with pancreatic cancer. Society of Surgical Oncology 2009

Endoscopic Hemostasis Practices in Nonvariceal Upper GI Hemorrhage (NVUGIH): Results of a National Vignette Survey

Background: Although endoscopic hemostasis is standard of care in NVUGIH, there is still uncertainty about what defines “best practice” in various clinical circumstances. Three areas, in particular, have been the subject of debate and practice variation: (1) snaring adherent ulcer clots, (2) use of hemoclips in active bleeding, and (3) monotherapy vs. dual therapy in active bleeding. We conducted a national vignette survey to measure current practice patterns in these 3 areas in a group of experts and “non-expert” community providers. Methods: We developed an online survey that included clinical vignettes of patients with NVUGIH. The vignettes were developed with a panel of content experts to ensure face validity and comprehensiveness. In each vignette, respondents first viewed a standardized patient presentation, and then received management questions guided by branching conditional logic. Upon EGD, respondents viewed an image of an actively “spurting” vessel in one vignette, and an adherent clot in another vignette. The survey elicited provider knowledge and beliefs about various aspects of NVUGIH care, including use of endoscopic hemostasis. We surveyed a random sample of 360 GIs from the AGA membership rolls, and 40 internationally recognized NVUGIH experts. Results: 47% responded (N = 188; 25 experts). In the adherent clot vignette, 88% of experts opted to snare the clot and treat the underlying stigmata, whereas 56% of “non experts” endorsed this method (group Δ = 26%; 95% CI of Δ = 11-52%; p = 0.02). In multivariable regression adjusting for provider demographics, practice setting, and experience, experts were 6 times more likely to snare vs. non-experts (OR = 5.99; 1.6-22.3; p = 0.001). Among the 15% of respondents who did not correctly identify the image as a clot (N = 23), 48% used epi + heater probe injection, while the rest used one of 7 alternatives. In the “spurting vessel” vignette, 33% of respondents used a hemoclip, either alone (7%) or with epi (27%). 87% of respondents used dual therapy (60% epi + probe, 27% epi + clip). Of those using monotherapy, most endorsed using clip alone. Expert vs. non-expert for hemoclip and dual therapy = NS. Conclusions: (1) Experts are much more likely than “non experts” to snare an overlying clot, suggesting a relative lack of buy-in, familiarity, or comfort of community GIs with this technique. (2) Use of clip is gaining traction, although <50% of experts and non-experts prefer it over alternatives, suggesting that further research is necessary to clarify its role. (3) Most providers use dual therapy, although a notable minority prefers clip monotherapy - a strategy deserving further research.