Recommendations for Post-Operative RadioTherapy After Complete Resection of Thymoma-a French DELPHI Consensus Initiative

INTRODUCTION

Thymomas are rare intrathoracic malignancies that can relapse after surgery. Whether or not Post-Operative RadioTherapy (PORT) should be delivered after surgery remains a major issue. RADIORYTHMIC is an ongoing, multicenter, randomized phase 3 trial addressing this question in patients with completely R0 resected Masaoka-Koga stage IIb/III thymoma. Experts in the field met to develop recommendations for PORT.

METHODS

A scientific committee from the RYTHMIC network identified key issues regarding the modalities of PORT in completely resected thymoma. A DELPHI method was used to question 24 national experts, with 115 questions regarding the following: (1) imaging techniques, (2) clinical target volume (CTV) and margins, (3) dose constraints to organs at risk, (4) dose and fractionation, and (5) follow-up and records. Consensus was defined when opinions reached more than or equal to 80% agreement.

RESULTS

We established the following recommendations: preoperative contrast-enhanced computed tomography (CT) scan is recommended (94% agreement); optimization of radiation delivery includes either a four-dimensional CT-based planning (82% agreement), a breath-holding inspiration breath-hold-based planning, or daily control CT imaging (81% agreement); imaging fusion based on cardiovascular structures of preoperative and planning CT scan is recommended (82% agreement); right coronary and left anterior descending coronary arteries should be delineated as cardiac substructures (88% agreement); rotational RCMI/volumetric modulated arc therapy is recommended (88% agreement); total dose is 50 Gy (81% agreement) with 1.8 to 2 Gy per fraction (94% agreement); cardiac evaluation and follow-up for patients with history of cardiovascular disease are recommended (88% agreement) with electrocardiogram and evaluation of left ventricular ejection fraction at 5 years and 10 years.

CONCLUSION

This is the first consensus for PORT in thymoma. Implementation will help to harmonize practices.

Understanding data provenance when using electronic medical records for research: Lessons learned from the Deliver Primary Healthcare Information (DELPHI) database

Introduction

We set out to assess the impact of Choosing Wisely Canada recommendations (2014) on reducing unnecessary health investigations and interventions in primary care across Southwestern Ontario.

Methods

We used the Deliver Primary Healthcare Information (DELPHI) database, which stores deidentified electronic medical records (EMR) of nearly 65,000 primary care patients across Southwestern Ontario. When conducting research using EMR data, data provenance (i.e., how the data came to be) should first be established. We first considered DELPHI data provenance in relation to longitudinal analyses, flagging a change in EMR software that occurred during 2012 and 2013. We attempted to link records between EMR databases produced by different software using probabilistic linkage and inspected 10 years of data in the DELPHI database (2009 to 2019) for data quality issues, including comparability over time.

Results

We encountered several issues resulting from this change in EMR software. These included limited linkage of records between software without a common identifier; data migration issues that distorted procedure dates; and unusual changes in laboratory test and medication prescription volumes.

Conclusion

This study reinforces the necessity of assessing data provenance and quality for new research projects. By understanding data provenance, we can anticipate related data quality issues such as changes in EMR data over time-which represent a growing concern as longitudinal data analyses increase in feasibility and popularity.

Developing DELPHI expert consensus rules for a digital twin model of acute stroke care in the neuro critical care unit

INTRODUCTION

Digital twins, a form of artificial intelligence, are virtual representations of the physical world. In the past 20 years, digital twins have been utilized to track wind turbines' operations, monitor spacecraft's status, and even create a model of the Earth for climate research. While digital twins hold much promise for the neurocritical care unit, the question remains on how to best establish the rules that govern these models. This model will expand on our group's existing digital twin model for the treatment of sepsis.

METHODS

The authors of this project collaborated to create a Direct Acyclic Graph (DAG) and an initial series of 20 DELPHI statements, each with six accompanying sub-statements that captured the pathophysiology surrounding the management of acute ischemic strokes in the practice of Neurocritical Care (NCC). Agreement from a panel of 18 experts in the field of NCC was collected through a 7-point Likert scale with consensus defined a-priori by ≥ 80% selection of a 6 ("agree") or 7 ("strongly agree"). The endpoint of the study was defined as the completion of three separate rounds of DELPHI consensus. DELPHI statements that had met consensus would not be included in subsequent rounds of DELPHI consensus. The authors refined DELPHI statements that did not reach consensus with the guidance of de-identified expert comments for subsequent rounds of DELPHI. All DELPHI statements that reached consensus by the end of three rounds of DELPHI consensus would go on to be used to inform the construction of the digital twin model.

RESULTS

After the completion of three rounds of DELPHI, 93 (77.5%) statements reached consensus, 11 (9.2%) statements were excluded, and 16 (13.3%) statements did not reach a consensus of the original 120 DELPHI statements.

CONCLUSION

This descriptive study demonstrates the use of the DELPHI process to generate consensus among experts and establish a set of rules for the development of a digital twin model for use in the neurologic ICU. Compared to associative models of AI, which develop rules based on finding associations in datasets, digital twin AI created by the DELPHI process are easily interpretable models based on a current understanding of underlying physiology.

Development of a surgical wound assessment tool to measure healing and risk factors for delayed wound healing in Vietnam: a Delphi process

OBJECTIVE

To identify items and develop a surgical wound assessment tool (SWAT) to measure progress in healing and early detection of risk factors for delayed healing in surgical wounds in patients in Vietnam.

METHOD

The development process included two phases: (i) development of the initial SWAT based on evidence-based guidelines, results of a literature review and consultation with surgeons; and (ii) a Delphi process with wound care nurse experts to refine and provide consensus on a final version of the SWAT. Data collection took place between April-August 2017.

RESULTS

In phase one, 22 items were included and were evaluated by ten Vietnamese surgeons, with item-content validity index (I-CVI) scores of 1.00 in 17 out of 22 items. The remaining items had I-CVI ranking of 0.8 to 0.9. The overall scale-content validity index was 0.97. Eight more items were recommended for inclusion, increasing the total to 30 items. In phase two, 21 Vietnamese nurse wound care experts completed all three rounds of the Delphi process. After three rounds, 24 items out of 30 reached full consensus for the final tool.

CONCLUSION

This study was the first step to confirm the content validity of the newly developed SWAT. Further development of the tool including the evaluation of validity and reliability was undertaken to strengthen the tool.

Reimagining peer review as an expert elicitation process

Journal peer review regulates the flow of ideas through an academic discipline and thus has the power to shape what a research community knows, actively investigates, and recommends to policymakers and the wider public. We might assume that editors can identify the ‘best’ experts and rely on them for peer review. But decades of research on both expert decision-making and peer review suggests they cannot. In the absence of a clear criterion for demarcating reliable, insightful, and accurate expert assessors of research quality, the best safeguard against unwanted biases and uneven power distributions is to introduce greater transparency and structure into the process. This paper argues that peer review would therefore benefit from applying a series of evidence-based recommendations from the empirical literature on structured expert elicitation. We highlight individual and group characteristics that contribute to higher quality judgements, and elements of elicitation protocols that reduce bias, promote constructive discussion, and enable opinions to be objectively and transparently aggregated.

The international WAO/EAACI guideline for the management of hereditary angioedema-The 2021 revision and update

Hereditary angioedema (HAE) is a rare and disabling disease for which early diagnosis and effective therapy are critical. This revision and update of the global WAO/EAACI guideline on the diagnosis and management of HAE provides up-to-date guidance for the management of HAE. For this update and revision of the guideline, an international panel of experts reviewed the existing evidence, developed 28 recommendations, and established consensus by an online DELPHI process. The goal of these recommendations and guideline is to help physicians and their patients in making rational decisions in the management of HAE with deficient C1 inhibitor (type 1) and HAE with dysfunctional C1 inhibitor (type 2), by providing guidance on common and important clinical issues, such as: (1) How should HAE be diagnosed? (2) When should HAE patients receive prophylactic on top of on-demand treatment and what treatments should be used? (3) What are the goals of treatment? (4) Should HAE management be different for special HAE patient groups such as children or pregnant/breast-feeding women? and (5) How should HAE patients monitor their disease activity, impact, and control? It is also the intention of this guideline to help establish global standards for the management of HAE and to encourage and facilitate the use of recommended diagnostics and therapies for all patients.

Brain Network Integrity Changes in Subjective Cognitive Decline: A Possible Physiological Biomarker of Dementia

Objective: The current study seeks to illustrate potential early and objective neurophysiological biomarkers of neurodegenerative cognitive decline by evaluating features of brain network physiological performance and structure utilizing different modalities. Methods: This study included 17 clinically healthy individuals with self-reported cognitive decline (Subjective Cognitive Decline group, SCD, no objective finding of cognitive decline), 12 individuals diagnosed with amnestic Mild Cognitive Impairment (aMCI), 11 individuals diagnosed with Dementia, and 15 healthy subjects. All subjects underwent computerized cognitive performance testing, MRI scans including T1 for gray matter (GM) volume quantification, DTI for quantification of white matter (WM) microstructure fractional anisotropy (FA) and mean diffusivity (MD), and brain network function evaluation using DELPHI (TMS-EEG) measures of connectivity, excitability, and plasticity. Results: Both DELPHI analysis of network function and DTI analysis detected a significant decrease in connectivity, excitability, and WM integrity in the SCD group compared to healthy control (HC) subjects; a significant decrease was also noted for aMCI and Dementia groups compared to HC. In contrast, no significant decrease was observed in GM volume in the SCD group compared to healthy norms, a significant GM volume decrease was observed only in objectively cognitively impaired aMCI subjects and in dementia subjects. Conclusions: This study results suggest that objective direct measures of brain network physiology and WM integrity may provide early-stage biomarkers of neurodegenerative-related changes in subjects that have not yet displayed any other objective measurable cognitive or GM volume deficits which may facilitate early preventive care for neurodegenerative decline and dementia.

Vasoactive agents in acute mesenteric ischaemia in critical care. A systematic review

Background: Acute mesenteric ischaemia (AMI) is a surgical emergency which has an associated high mortality.  The mainstay of active treatment includes early surgical intervention, with resection of non-viable bowel, and revascularisation of the ischaemic bowel where possible. Due to the physiological insult of AMI however, perioperative care often involves critical care and the use of vasoactive agents to optimise end organ perfusion. A number of these vasoactive agents are currently available with varied mechanism of action and effects on splanchnic blood flow. However, specific guidance on which is the optimal vasoactive drug to use in these settings is limited. This systematic review aimed to evaluate the current evidence comparing vasoactive drugs in AMI. Methods: A systematic search of Ovid Medline, Ovid Embase, Cochrane CENTRAL and the Cochrane Database of Systematic Review was performed on the 5th of November 2020 to identify randomised clinical trials comparing different vasoactive agents in AMI on outcomes including mortality. The search was performed through the Royal College of Surgeons of England (RCSEng) search support library. Results were analysed using the Rayyan platform, and independently screened by four investigators. Results: 614 distinct papers were identified. After screening, there were no randomised clinical trials meeting the inclusion criteria. Conclusions: This review identifies a gap in literature, and therefore recommends an investigation into current practice and clinician preference in relation to vasoactive agents in AMI. Multicentre randomised controlled trials comparing these medications on clinical outcomes will therefore be required to address this question.

Vasoactive agents in acute mesenteric ischaemia in critical care. A systematic review

Background: Acute mesenteric ischaemia (AMI) is a surgical emergency which has an associated high mortality.  The mainstay of active treatment includes early surgical intervention, with resection of non-viable bowel, and revascularisation of the ischaemic bowel where possible. Due to the physiological insult of AMI however, perioperative care often involves critical care and the use of vasoactive agents to optimise end organ perfusion. A number of these vasoactive agents are currently available with varied mechanism of action and effects on splanchnic blood flow. However, specific guidance on which is the optimal vasoactive drug to use in these settings is limited. This systematic review aimed to evaluate the current evidence comparing vasoactive drugs in AMI. Methods: A systematic search of Ovid Medline, Ovid Embase, Cochrane CENTRAL and the Cochrane Database of Systematic Review was performed on the 5th of November 2020 to identify randomised clinical trials comparing different vasoactive agents in AMI on outcomes including mortality. The search was performed through the Royal College of Surgeons of England (RCSEng) search support library. Results were analysed using the Rayyan platform, and independently screened by four investigators. Results: 614 distinct papers were identified. After screening, there were no randomised clinical trials meeting the inclusion criteria. Conclusions: This review identifies a gap in literature, and therefore recommends an investigation into current practice and clinician preference in relation to vasoactive agents in AMI. Multicentre randomised controlled trials comparing these medications on clinical outcomes will therefore be required to address this question.

Evaluation of White Matter Integrity Utilizing the DELPHI (TMS-EEG) System

Objective

The aim of this study was to evaluate brain white matter (WM) fibers connectivity damage in stroke and traumatic brain injury (TBI) subjects by direct electrophysiological imaging (DELPHI) that analyzes transcranial magnetic stimulation (TMS)-evoked potentials (TEPs).

Methods

The study included 123 participants, out of which 53 subjects with WM-related pathologies (39 stroke, 14 TBI) and 70 healthy age-related controls. All subjects underwent DELPHI brain network evaluations of TMS-electroencephalogram (EEG)-evoked potentials and diffusion tensor imaging (DTI) scans for quantification of WM microstructure fractional anisotropy (FA).

Results

DELPHI output measures show a significant difference between the healthy and stroke/TBI groups. A multidimensional approach was able to classify healthy from unhealthy with a balanced accuracy of 0.81 ± 0.02 and area under the curve (AUC) of 0.88 ± 0.01. Moreover, a multivariant regression model of DELPHI output measures achieved prediction of WM microstructure changes measured by FA with the highest correlations observed for fibers proximal to the stimulation area, such as frontal corpus callosum (r = 0.7 ± 0.02), anterior internal capsule (r = 0.7 ± 0.02), and fronto-occipital fasciculus (r = 0.65 ± 0.03).

Conclusion

These results indicate that features of TMS-evoked response are correlated to WM microstructure changes observed in pathological conditions, such as stroke and TBI, and that a multidimensional approach combining these features in supervised learning methods serves as a strong indicator for abnormalities and changes in WM integrity.

Introducing a Novel Approach for Evaluation and Monitoring of Brain Health Across Life Span Using Direct Non-invasive Brain Network Electrophysiology

Objective

Evaluation and monitoring of brain health throughout aging by direct electrophysiological imaging (DELPHI) which analyzes TMS (transcranial magnetic stimulation) evoked potentials.

Methods

Transcranial magnetic stimulation evoked potentials formation, coherence and history dependency, measured using electroencephalogram (EEG), was extracted from 80 healthy subjects in different age groups, 25–85 years old, and 20 subjects diagnosed with mild dementia (MD), over 70 years old. Subjects brain health was evaluated using MRI scans, neurocognitive evaluation, and computerized testing and compared to DELPHI analysis of brain network functionality.

Results

A significant decrease in signal coherence is observed with age in connectivity maps, mostly in inter-hemispheric temporal, and parietal areas. MD patients display a pronounced decrease in global and inter-hemispheric frontal connectivity compared to healthy controls. Early and late signal slope ratio also display a significant, age dependent, change with pronounced early slope, phase shift, between normal healthy aging, and MD. History dependent analysis demonstrates a binary step function classification of healthy brain vs. abnormal aging subjects mostly for late slope. DELPHI measures demonstrate high reproducibility with reliability coefficients of around 0.9.

Conclusion

These results indicate that features of evoked response, as charge transfer, slopes of response, and plasticity are altered during abnormal aging and that these fundamental properties of network functionality can be directly evaluated and monitored using DELPHI.

A DELPHI study on aspects of study design to overcome knowledge gaps on the burden of disease caused by serogroup B invasive meningococcal disease

Background

Value assessment of vaccination programs against serogroup B invasive meningococcal disease (IMD) is on the agenda of public health authorities. Current evidence on the burden due to IMD is unfit for pinning down the nature and magnitude of the full social and economic costs of IMD for two reasons. First, the concepts and components that need to be studied are not agreed, and second, measures of the concepts that have been studied are weak and inconsistent. Thus, the economic evaluation of the available serogroup B meningococcal (MenB) vaccines is difficult. The aims of this DELPHI study are to: (1) agree on the concepts and components determining the burden of MenB diseases that need to be studied; and (2) seek consensus on appropriate methods and study designs to measure quality of life (QoL) associated with MenB induced long-term sequelae in future studies.

Methods

We designed a DELPHI questionnaire based on the findings of a recent systematic review on the QoL associated with IMD-induced long-term sequelae, and iteratively interviewed a panel of international experts, including physicians, health economists, and patient representatives. Experts were provided with a controlled feedback based on the results of the previous round.

Results

Experts reached consensus on all questions after two DELPHI rounds. Major gaps in the literature relate (i) to the classification of sequelae, which allows differentiation of severity levels, (ii) to the choice of QoL measures, and (iii) to appropriate data sources to examine long-term changes and deficits in patients’ QoL.

Conclusions

Better conceptualisation of the structure of IMD-specific sequelae and of how their diverse forms of severity might impact the QoL of survivors of IMD as well as their family network and care-providers is needed to generate relevant, reliable and generalisable data on QoL in the future. The results of this DELPHI panel provide useful guidance on how to choose the study design, target population and appropriate QoL measures for future research and hence, help promote the appropriateness and consistency in study methodology and sample characteristics.

Electronic supplementary material

The online version of this article (10.1186/s12955-019-1159-0) contains supplementary material, which is available to authorized users.

OMERACT 2018 Modified Patient-reported Outcome Domain Core Set in the Life Impact Area for Adult Idiopathic Inflammatory Myopathies

OBJECTIVE

To present and vote on a myositis modified patient-reported outcome core domain set in the life impact area at the Outcome Measures in Rheumatology (OMERACT) 2018.

METHODS

Based on results from international focus groups and Delphi surveys, a draft core set was developed.

RESULTS

Domains muscle symptoms, fatigue, level of physical activity, and pain reached ≥ 70% consensus and were mandatory to assess in all trials. Domains lung, joint, and skin symptoms were mandatory in specific circumstances. This core set was endorsed by > 85% at OMERACT 2018.

CONCLUSION

We propose a life impact core set for patients with idiopathic inflammatory myopathies and will proceed with instrument selections.

Development of standard clinical endpoints for use in dengue interventional trials: introduction and methodology

Background

As increasing numbers of dengue vaccines and therapeutics are in clinical development, standardized consensus clinical endpoint definitions are urgently needed to assess the efficacy of different interventions with respect to disease severity. We aimed to convene dengue experts representing various sectors and dengue endemic areas to review the literature and propose clinical endpoint definitions for moderate and severe disease based on the framework provided by the WHO 2009 classification.

Methods

The endpoints were first proposed and discussed in a structured expert consultation. After that, the Delphi method was carried out to assess the usefulness, validity and feasibility of the standardized clinical disease endpoints for interventional dengue research.

Results

Most respondents (> 80%) agreed there is a need for both standardized clinical endpoints and operationalization of severe endpoints. Most respondents (67%) felt there is utility for moderate severity endpoints, but cited challenges in their development. Hospitalization as a moderate endpoint of disease severity or measure of public health impact was deemed to be useful by only 47% of respondents, but 89% felt it could bring about supplemental information if carefully contextualized according to data collection setting. Over half of the respondents favored alignment of the standard endpoints with the WHO guidelines (58%), but cautioned that the endpoints could have ramifications for public health practice. In terms of data granularity of the endpoints, there was a slight preference for a categorical vs numeric system (e.g. 1–10) (47% vs 34%), and 74% of respondents suggested validating the endpoints using large prospective data sets.

Conclusion

The structured consensus-building process was successful taking into account the history of the debate around potential endpoints for severe dengue. There is clear support for the development of standardized endpoints for interventional clinical research and the need for subsequent validation with prospective data sets. Challenges include the complexity of developing moderate disease research endpoints for dengue.

Perceptions of Patients, Caregivers, and Healthcare Providers of Idiopathic Inflammatory Myopathies: An International OMERACT Study

OBJECTIVE

Patient-reported outcome measures (PROM) that incorporate the patient perspective have not been well established in idiopathic inflammatory myopathies (IIM). As part of our goal to develop IIM-specific PROM, the Outcome Measures in Rheumatology (OMERACT) Myositis special interest group sought to determine which aspects of disease and its effects are important to patients and healthcare providers (HCP).

METHODS

Based on a prior qualitative content analysis of focus groups, an initial list of 24 candidate domains was constructed. We subsequently conducted an international survey to identify the importance of each of the 24 domains to be assessed in clinical research. Patients with IIM, their caregivers, and HCP treating IIM completed the survey.

RESULTS

In this survey, a total of 638 respondents completed the survey, consisting of 510 patients, 101 HCP, and 27 caregivers from 48 countries. Overall, patients were more likely to rank "fatigue," "cognitive impact," and "difficulty sleeping" higher compared with HCP, who ranked "joint symptoms," "lung symptoms," and "dysphagia" higher. Both patients and providers rated muscle symptoms as their top domain. In general, patients from different countries were in agreement on which domains were most important. One notable exception was that patients from Sweden and the Netherlands ranked lung symptoms significantly higher compared to other countries including the United States and Australia (mean weighted rankings of 2.86 and 2.04 vs 0.76 and 0.80, respectively; p < 0.0001).

CONCLUSION

Substantial differences exist in how IIM is perceived by patients compared to HCP, with different domains prioritized. In contrast, patients' ratings across the world were largely similar.

Advancing the Development of Patient-reported Outcomes for Adult Myositis at OMERACT 2016: An International Delphi Study

OBJECTIVE

To define a set of core patient-reported domains and respective instruments for use in idiopathic inflammatory myopathies (IIM). Previously, we reported a systematic literature review on patient-reported outcomes (PRO) in IIM followed by conducting international focus groups to elicit patient perspectives of myositis symptoms and effects.

METHODS

Based on qualitative content analysis of focus groups, an initial list of 26 candidate domains was constructed. We subsequently conducted an international modified Delphi survey to identify the importance of each of the 26 domains. Participants were asked to rate each domain on a scale of 0-10 (0 = not important, 10 = very important).

RESULTS

In this first round of the Delphi survey, 643 patients participated from the United States (n = 543), Sweden (n = 49), and South Korea (n = 51). Of the 26 domains, 19 (73%) were rated of high importance (≥ 7/10). The top 5 domains were muscle symptoms, fatigue, interactions with healthcare, medication side effects, and pain. During Outcome Measures in Rheumatology (OMERACT) 2016, we discussed the goal for ultimate reduction in the number of domains and the importance of considering representation of healthcare providers from other specialties, caregivers, representatives of pharmaceutical industries, and regulatory authorities in the next rounds of Delphi to represent broader perspectives on IIM.

CONCLUSION

Further prioritization and a reduction in the number of domains will be needed for the next Delphi. At the next biennial OMERACT meeting, we aim to present and seek voting on a Myositis Preliminary PRO Core Set to enable ultimate measure selection and development.

What works for wellbeing in culture and sport? Report of a DELPHI process to support coproduction and establish principles and parameters of an evidence review

Aims:

There is a growing recognition of the ways in which culture and sport can contribute to wellbeing. A strong evidence base is needed to support innovative service development and a 3-year research programme is being undertaken to capture best evidence of wellbeing impacts and outcomes of cultural and sporting activities in order to inform UK policy and practice. This article provides an overview of methods and findings from an initial coproduction process with key stakeholders that sought to explore and agree principles and parameters of the evidence review for culture, sport and wellbeing (CSW).

Methods:

A two-stage DELPHI process was conducted with a purposeful sample of 57 stakeholders between August and December 2015. Participants were drawn from a range of culture and sport organisations and included commissioners and managers, policy makers, representatives of service delivery organisations (SDOs) and scholars. The DELPHI 1 questionnaire was developed from extensive consultation in July and August 2015. It explored definitions of wellbeing, the role of evidence, quality assessment, and the culture and sport populations, settings and interventions that are most likely to deliver wellbeing outcomes. Following further consultation, the results, presented as a series of ranked statements, were sent back to participants (DELPHI 2), which allowed them to reflect on and, if they wished, express agreement or disagreement with the emerging consensus.

Results:

A total of 40 stakeholders (70.02%) responded to the DELPHI questionnaires. DELPHI 1 mapped areas of agreement and disagreement, confirmed in DELPHI 2. The exercise drew together the key priorities for the CSW evidence review.

Conclusion:

The DELPHI process, in combination with face-to-face deliberation, enabled stakeholders to engage in complex discussion and express nuanced priorities while also allowing the group to come to an overall consensus and agree outcomes. The results will inform the CSW evidence review programme until its completion in March 2018.