European Expert Panel Research Articles

An evidence-based recommendation on bed head elevation for mechanically ventilated patients

IntroductionA semi-upright position in ventilated patients is recommended to prevent ventilator-associated pneumonia (VAP) and is one of the components in the Ventilator Bundle of the Institute for Health Care Improvement. This recommendation, however, is not an evidence-based one.MethodsA systematic review on the benefits and disadvantages of semi-upright position in ventilated patients was done according to PRISMA guidelines. Then a European expert panel developed a recommendation based on the results of the systematic review and considerations beyond the scientific evidence in a three-round electronic Delphi procedure.ResultsThree trials (337 patients) were included in the review. The results showed that it was uncertain whether a 45° bed head elevation was effective or harmful with regard to the occurrence of clinically suspected VAP, microbiologically confirmed VAP, decubitus and mortality, and that it was unknown whether 45° elevation for 24 hours a day increased the risk for thromboembolism or hemodynamic instability. A group of 22 experts recommended elevating the head of the bed of mechanically ventilated patients to a 20 to 45° position and preferably to a ≥30° position as long as it does not pose risks or conflicts with other nursing tasks, medical interventions or patients' wishes.ConclusionsAlthough the review failed to prove clinical benefits of bed head elevation, experts prefer this position in ventilated patients. They made clear that the position of a ventilated patient in bed depended on many determinants. Therefore, given the scientific uncertainty about the benefits and harms of a semi-upright position, this position could only be recommended as the preferred position with the necessary restrictions.

The appropriate use of non-steroidal anti-inflammatory drugs in rheumatic disease: opinions of a multidisciplinary European expert panel

IntroductionGiven the safety issues of non-steroidal anti-inflammatory drugs (NSAID) and the robustness of guidelines, making treatment choices in daily clinical practice is increasingly difficult. This study aimed systematically to analyse...

Adecuación de la indicación de la colonoscopia según los nuevos criterios de EPAGE II

Introduction The appropriateness criteria for colonoscopy developed by a European expert panel (EPAGE), published in 1999, were revised this year (EPAGE II), but have not yet been evaluated. Objectives (1) To analyze colonoscopies performed at our hospital, and (2) to evaluate the appropriateness of the new EPAGE II criteria. Patients and methods We retrospectively analyzed 700 colonoscopies (48% males, mean age 58 years). Forty-five colonoscopies (6.4%) were excluded for insufficient bowel preparation or elective indication. EPAGE II criteria classified colonoscopies as “appropriate”, “inappropriate” and “uncertain”. Results Ninety-four percent (n=655) of colonoscopies were evaluated. The most frequent indication for colonoscopy (19%) was screening of colorectal cancer (CRC). Seventy percent of colonoscopies were “appropriate”, and 18% were “inappropriate”, with significant differences according to where the request was made. The most inappropriate indication was postpolypectomy follow-up, due to shorter follow-up intervals. An endoscopic diagnosis was made in 315 patients (48%), with a finding of significant lesions in 25% (n=167; CCR, adenomas, inflammatory bowel disease, angiodysplasia and benign stricture). The indications most frequently associated with relevant findings were screening of CRC (17.3%) and postpolypectomy follow-up (16.7%) but this association was non-significant. Only iron-deficiency anemia was significantly associated with CRC (p<0.0001). Conclusions Eighteen percent of requests for colonoscopy were inappropriate and 12% provided incomplete information. The indication most strongly associated with a diagnosis of CRC was iron-deficiency anemia. The EPAGE II criteria showed a significant correlation with an endoscopic diagnosis of CRC

Concentration Response Functions for Ultrafine Particles and All-Cause Mortality and Hospital Admissions: Results of a European Expert Panel Elicitation

Toxicological studies have provided evidence of the toxicity of ultrafine particles (UFP), but epidemiological evidence for health effects of ultrafines is limited. No quantitative summary currently exists of concentration-response functions for ultrafine particles that can be used in health impact assessment. The goal was to specify concentration-response functions for ultrafine particles in urban air including their uncertainty through an expert panel elicitation. Eleven European experts from the disciplines of epidemiology, toxicology, and clinical medicine selected using a systematic peer-nomination procedure participated. Using individual ratings supplemented with group discussion, probability distributions of effect estimates were obtained for all-cause mortality and cardiovascular and respiratory hospital admissions. Experts judged the small database of epidemiological studies supplemented with experimental studies sufficient to quantify effects of UFP on all-cause mortality and to a lesser extent hospital admissions. Substantial differences in the estimated UFP health effect and its uncertainty were found between experts. The lack of studies on long-term exposure to UFP was rated as the most important source of uncertainty. Effects on hospital admissions were considered more uncertain. This expert elicitation provides the first quantitative evaluation of estimates of concentration response functions between urban air ultrafine particles and all-cause mortality and hospital admissions.

Concentration Response Functions for Ultrafine Particles and All-Cause Mortalilty and Hospital Admissions: Results of an European Expert Panel Elicitation

Concentration Response Functions for Ultrafine Particles and All-Cause Mortalilty and Hospital Admissions: Results of an European Expert Panel Elicitation

Appropriateness of therapy for active Crohn's disease: Results of a multidisciplinary international expert panel—EPACT II

The increasing number of trials testing management strategies for luminal Crohn's disease (CD) has not filled all the gaps in our knowledge and thus, in clinical practice, many decisions for CD patients have to be taken without the benefit of high-quality evidence. Methods A multidisciplinary European expert panel used the RAND Appropriateness Method to develop and rate explicit criteria for the management of individual patients with active, steroid-dependent (ST-D) and steroid-refractory (ST-R) CD. Results Overall, 296 indications pertaining to mild-to-moderate, severe, ST-D, and ST-R CD were rated. In anti-TNF naïve patients, budesonide and prednisone were found to be appropriate for mild-moderate CD, and infliximab (IFX) was appropriate when these had previously failed or had not been tolerated. In patients with a prior successful treatment by IFX, this drug, with or without co-administration of a thiopurine analog, was favoured. Other anti-TNFs were appropriate in the presence of intolerance or resistance to IFX. High-dose steroids, IFX or adalimumab were appropriate in severe active CD. For the 105 indications for ST-D or ST-R disease, the panel considered the thiopurine analogs, methotrexate, IFX, adalimumab, and surgery for limited resection, to be appropriate, depending on the outcome of prior therapies. Anti-TNFs were generally considered appropriate in ST-R. Conclusion Steroids, including budesonide for mild-to-moderate CD, remain the first-line therapy for active luminal CD. Anti-TNFs, in particular IFX as shown by the amount of available evidence, remain the second-line therapy for most indications. Thiopurine analogs, methotrexate and anti-TNFs are favoured in ST-D patients and ST-R patients.

Appropriate therapy for fistulizing and fibrostenotic Crohn's disease: Results of a multidisciplinary expert panel — EPACT II

Introduction Many therapeutic decisions in the management of fistulizing and fibrostenotic Crohn's disease (CD) have to be taken without the benefit of strong scientific evidence. For this reason, explicit appropriateness criteria for CD fistula and stenosis treatment were developed by a multidisciplinary European expert panel in 2004 with the aim of making them easily available on the Internet and thus allowing individual case scenario evaluation; these criteria were updated in 2007. Methods Twelve international experts convened in Geneva, Switzerland in December 2007. Explicit clinical scenarios, corresponding to real daily practice, were rated on a 9-point scale based on evidence from the published literature and panelists' own expertise. Median ratings were stratified into three categories: appropriate (7–9), uncertain (4–6) and inappropriate (1–3). Results Overall, panelists rated 60 indications pertaining to fistulas. Antibiotics, azathioprine/6-mercaptopurine and conservative surgery are the mainstay of therapy for simple and complex fistulas. In the event of previous failure of azathioprine/6-mercaptopurine therapy, methotrexate and infliximab were considered appropriate for complex fistulas. The panel also rated 72 indications related to the management of fibrostenotic CD. The experts considered balloon dilation, if the stricture was endoscopically accessible, stricturoplasty and bowel resection to be appropriate for small bowel fibrostenotic Crohn's disease, and balloon dilation and bowel resection appropriate for fibrostenotic colonic disease. In the presence of an ileocolonic or ileorectal anastomotic stricture of < 7 cm, endoscopic balloon dilation, and bowel resection were considered appropriate. Conclusion Antibiotics, azathioprine/6-mercaptopurine, and conservative surgery are the mainstay of therapy for fistulizing Crohn's disease. Infliximab is a therapeutic option in patients without prior response to immunosuppressant therapy. In fibrostenotic Crohn's disease, endoscopic balloon dilation, if feasible, or surgical therapy should be considered. These expert recommendations are available online ( www.epact.ch). Prospective evaluation is now needed to test the validity of these appropriateness criteria in clinical practice.

Appropriate management of special situations in Crohn's disease (upper gastro-intestinal; extra-intestinal manifestations; drug safety during pregnancy and breastfeeding): Results of a multidisciplinary international expert panel—EPACT II

Introduction High-grade evidence is lacking for most therapeutic decisions in Crohn's disease. Appropriateness criteria were developed for upper gastro-intestinal, extra-intestinal manifestations and drug safety during conception, pregnancy and breastfeeding in patients with Crohn's disease, to assist the physician in clinical decision making. Methods The European Panel on the Appropriateness of Crohn's Disease Therapy (EPACT II), a multidisciplinary international European expert panel, rated clinical scenarios based on evidence from the published literature and panelists' own clinical expertise. Median ratings (on a 9-point scale) were stratified into three categories: appropriate (7–9), uncertain (4–6 with or without disagreement) and inappropriate (1–3). Experts were also asked to rank appropriate medications by priority. Results Proton pump inhibitors, steroids, azathioprine/6-mercaptopurine and infliximab are appropriate for upper gastro-duodenal Crohn's disease; for stenosis, endoscopic balloon dilation is the first-line therapy, although surgery is also appropriate. Ursodeoxycholic acid is the only appropriate treatment for primary sclerosing cholangitis. Infliximab is appropriate for Pyoderma gangrenosum, ankylosing spondylitis and uveitis, steroids for Pyoderma gangrenosum and ankylosing spondylitis, adalimumab for Pyoderma gangrenosum and ankylosing spondylitis, cyclosporine-A/tacrolimus for Pyoderma gangrenosum. Mesalamine, sulfasalazine, prednisone, azathioprine/6-mercaptopurine, ciprofloxacin, and probiotics, may be administered safely during pregnancy or for patients wishing to conceive, with the exception that male patients considering conception should avoid sulfasalazine. Metronidazol is considered safe in the 2nd and 3rd trimesters whereas infliximab is rated safe in the 1st trimester but uncertain in the 2nd and 3rd trimesters. Methotrexate is always contraindicated at conception, during pregnancy or during breastfeeding, due to its known teratogenicity. Mesalamine, prednisone, probiotics and infliximab are considered safe during breastfeeding. Conclusion EPACT II recommendations are freely available online ( www.epact.ch). The validity of these criteria should now be tested by prospective evaluation.

Connecting patient needs with treatment management

To propose ideas for the development of a core strategy for monitoring patients with schizophrenia to ensure physical health and optimal treatment provision. A panel of European experts in the field of schizophrenia met in Bordeaux in June 2006 to discuss, 'Patient management optimisation through improved treatment monitoring.' Key consensus from the discussion deemed that weight gain, oral health and ECG parameters were core baseline parameters to be monitored in all patients with schizophrenia. Further, an identification of a patient's own barriers to treatment alongside local health service strategies might comprise elements of an individualised management strategy which would contribute to optimisation of treatment. Any monitoring strategy should be kept simple to encourage physician compliance. A practical solution to the difficulties of providing holistic patient care would be to suggest a limited set of physical parameters to be monitored by physicians on a regular basis.

Management of invasive candidiasis and candidemia in adult non-neutropenic intensive care unit patients: Part I. Epidemiology and diagnosis

Invasive candidiasis and candidemia are frequently encountered in the nosocomial setting, particularly in the intensive care unit (ICU). To review the current management of invasive candidiasis and candidemia in non-neutropenic adult ICU patients based on a review of the literature and a European expert panel discussion. Candida albicans remains the most frequently isolated fungal species followed by C. glabrata. The diagnosis of invasive candidiasis involves both clinical and laboratory parameters, but neither of these are specific. One of the main features in diagnosis is the evaluation of risk factor for infection which will identify patients in need of pre-emptive or empiric treatment. Clinical scores were built from those risk factors. Among laboratory diagnosis, a positive blood culture from a normally sterile site provides positive evidence. Surrogate markers have also been proposed like 1,3 beta-D: glucan level, mannans, or PCR testing. Invasive candidiasis and candidemia is a growing concern in the ICU, apart from cases with positive blood cultures or fluid/tissue biopsy, diagnosis is neither sensitive nor specific. The diagnosis remains difficult and is usually based on the evaluation of risk factors.

Management of invasive candidiasis and candidemia in adult non-neutropenic intensive care unit patients: Part II. Treatment

Invasive candidiasis and candidemia are frequently encountered in the nosocomial setting particularly in the intensive care unit (ICU). To review the current management of invasive candidiasis and candidemia in non-neutropenic adult ICU patients based on a review of the literature and an European expert panel discussion. Empiric and directed treatment for invasive candidiasis are predicated on the hemodynamic status of the patient. Unstable patients may benefit from broad-spectrum antifungal agents, which can be narrowed once the patient has stabilized and the identity of the infecting species is established. In stable patients, a more classical approach using fluconazole may be satisfactory provided that the patient is not colonized with fluconazole resistant strains or there has been recent past exposure to an azole (<30 days). In contrast, pre-emptive therapy is based on the presence of surrogate markers.

A roadmap to disentangle the molecular etiology of schizophrenia

Schizophrenia is a severe mental disorder striking mainly young adults and leading to life-long disability in a substantial portion of the sufferers. On the other hand, substantial knowledge about its etiology and pathogenesis is still lacking. Therefore the European Science Foundation (ESF) sponsored a meeting of a panel of European experts on schizophrenia research to discuss the state of art and future perspectives of key topics in this area. The fields covered genetics, epidemiology, animal models, molecular neuropathology and imaging. This was a first step to establish a network of European groups dedicated to Schizophrenia research. The coming calls of the frame work program will be used to strengthen this network in order to achieve substantial progress in understanding and treating this devastating illness.

Reducing residual cardiovascular risk: the relevance of raising high-density lipoprotein cholesterol in patients on cholesterol-lowering treatment

Reducing low-density lipoprotein cholesterol (LDL-C) with statin therapy represents the cornerstone of dyslipidaemia management in patients with cardiovascular disease, as reflected in current treatment guidelines. Yet even among statin-treated patients who achieve LDL-C targets (&lt; 2.59 mmol/L [100 mg/dL]), the residual risk of further cardiovascular events remains unacceptably high. Although clinical studies indicate that intensive LDL-C lowering may provide some additional benefit, this does not suppress the excess cardiovascular risk sufficiently. This European Expert Panel therefore recognises that there is an unmet clinical need in the management of these patients. Additional intervention to modify other clinically important risk factors should be viewed as a priority. A reduced level of high-density lipoprotein cholesterol (HDL-C) &lt; 1.03 mmol/L (40 mg/dL) in men and &lt; 1.29 mmol/L (50 mg/dL) in women is an important independent predictive factor for coronary heart disease. HDL-C levels are also predictive of cardiovascular risk in statin-treated patients, irrespective of their LDL-C levels. Therefore, HDL-C represents a logical therapeutic target for reducing cardiovascular risk further in statin-treated patients, including those who achieve LDL-C targets. Given that low HDL-C is common among dyslipidaemic patients with cardiovascular disease, a therapeutic strategy aimed at effectively raising HDL-C, while at the same time lowering LDL-C to target levels, would be expected to offer clinical benefit beyond that achieved through LDL-C reduction alone. Although both nicotinic acid and fibrates raise HDL-C, nicotinic acid has greater potency. Studies show that combination therapy with prolonged-release (PR) nicotinic acid and a statin has an acceptable tolerability profile, normalises an atherogenic lipoprotein profile, and is able to induce regression of atherosclerosis and reduce coronary risk in patients with established cardiovascular disease and suboptimal HDL-C levels. In conclusion, this European Expert Panel recommends that combination therapy with a statin and an HDL-C raising agent, such as PR nicotinic acid, should be considered in these patients, who remain at high residual risk despite achieving target LDL-C levels with statin monotherapy. Ongoing studies are essential to confirm the clinical outcome benefits of this approach.

Laparoscopy for abdominal emergencies

Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

Hormone Replacement Therapy and Cardiovascular Disease: A Statement for Healthcare Professionals From the American Heart Association

To the Editor: I was personally disturbed by the American Heart Association (AHA) statement on hormone therapy and cardiovascular disease that recently was published in Circulation .1 Two different medical journals, Climacteric 2 and Maturitas ,3 recently published a position paper from the Workshop on Controversial Issues in Climacteric Medicine: Hormone Replacement Therapy (HRT) and Cardiovascular Diseases, which was organized in October 2000 by the International Menopause Society (IMS). All persons interested in the health care of postmenopausal women should read it. Menopause experts, including internists and cardiologists, see the cardiovascular issue from a perspective different from that of American cardiologists, although they are interpreting the same database and research articles and, ultimately, are reaching similar conclusions. The authors of the AHA statement report that the biological basis of estrogen benefits the cardiovascular apparatus and mention epidemiological data showing a 35% reduction of cardiovascular events in normal women using hormones after menopause. However, their conclusions and final messages are different, referring mainly to the secondary prevention trial named the Heart and Estrogen/Progestin Replacement Study (HERS). The term HRT , as it is used in the article, includes treatment with estrogen alone or in combination with different progestins and using different schedules of administration. At the end of the article, the authors say that their conclusions are based primarily on a fixed dose of oral conjugated …

Evaluating Cost-Effectiveness of an Air Traffic Management System for Europe: Development and Application of Methodological Framework

In response to growing air transport congestion, new air traffic management (ATM) concepts have been put forward to ameliorate existing problems. By their nature, ATM systems are highly complex, and their development and implementation require substantial financial resources. Moreover, the introduction of a new ATM system generates tangible as well as intangible benefits and costs. Therefore, a methodological framework capable of addressing all specific characteristics of the ATM system cost-effectiveness evaluation should be developed. The objective of this paper is twofold: first, to develop a methodological framework for evaluating the TORCH system (i.e., a new ATM concept for Europe), and second, to present the results of the application of the proposed framework for assessing the cost-effectiveness of the TORCH system. The proposed methodology was applied with the help of a panel of European ATM experts. The application results are intuitively appealing and indicate a strong convergence of the expert opinions concerning the most preferable ATM system. More specifically, the results of the evaluation suggest that an investment in TORCH will improve the safety, operational, and environmental performance of the ATM system as well as the working conditions of the air traffic controllers, and at the same time, the TORCH system will be marginally cost-effective.

Principles of Practice from the European Expert Panel on the Contemporary Treatment of Schizophrenia

Providing optimal treatment for people with schizophrenia is a difficult long-term problem for clinicians and healthcare providers. Over the years a variety of approaches to treatment have evolved and, until now, there have been no widely accepted standards for care. To determine the principles underpinning the best practice for schizophrenia treatment, an Expert Panel of European psychiatrists and psychologists has worked to distil current theory, collective practical experiences and published literature into 17 basic Principles of Practice . These are not intended to duplicate or replace local treatment policies or guidelines. Instead, they describe best practice in diagnosis, patient assessment and long-term treatment of schizophrenia as it exists at the beginning of the 21st century and is likely to exist in the near future. The Principles of Practice broadly fall into four main categories: (1) assessment, diagnosis and care provision; (2) treatment in day-to-day practice; (3) building a positive therapeutic alliance; and (4) a long-term clinical commitment. Running through all the Principles are several common threads - the fundamental importance of the therapeutic alliance between the clinician and the patient, the need to plan both for treatment efficacy and avoidance of side-effects and the importance of long-term treatment planning. It is intended that psychiatrists and other healthcare professionals can use the Principles as a benchmark for optimum patient management, and as a tool when negotiating the future of local and national schizophrenia management services. Furthermore, the Principles of Practice represent a first step in the development of a new patient-centred philosophy for the care of people with schizophrenia.

A time of opportunity in schizophrenia

The European Expert Panel on the contemporary treatment of schizophrenia set out to create a document that would enhance the clinical practice of schizophrenia across Europe. Drawing on the interests and strengths of the multinational group, the Panel took a new look at the current management of schizophrenia and identified areas where common practice and best practice currently diverge. Thorough analysis of the literature plus critical clinical judgement has resulted in the Principles of Practice , which represent a new philosophy for the care of people with schizophrenia. This 17-point statement covers the entire range of schizophrenia management, from diagnosis and assessment of the first episode, through to long-term care of the patient with chronic illness. Much of the literature that informed the Panel discussion is presented in the papers that form this Supplement.

5. Appropriateness of gastroscopy: bleeding and dysphagia.

Within the framework of a European Union concerted action, we convened a European expert panel to consider the appropriateness of gastrointestinal endoscopy in a wide variety of clinical situations [1]. One of the areas where the appropriateness of endoscopy was examined was an array of symptoms often evoking suspicion of serious disease. Under the heading of alarm symptoms, the following situations were considered by the expert panel: upper GI bleeding, dysphagia, odynophagia and unexplained weight loss.