Defining the research agenda for surgical infection: a consensus of experts using the Delphi approach

Different Surgeon, Different Duration: Lack of Consensus on the Appropriate Duration of Antimicrobial Prophylaxis and Therapy in Surgical Practice

Background: The principles of antimicrobial stewardship promote the appropriate prescribing of agents with respect to efficacy, safety, duration, and cost. Antibiotic resistance often results from inappropriate use (e.g., indication, selection, duration). We evaluated practice variability in duration of antimicrobials in surgical infection treatment (Rx) or prophylaxis (Px). Hypothesis: There is lack of consensus regarding the duration of antibiotic Px and Rx for many common indications. Methods: A survey was distributed to the Surgical Infection Society (SIS) regarding the use of antimicrobial agents for a variety of scenarios. Standard descriptive statistics were used to compare survey responses. Heterogeneity among question responses were compared using the Shannon Index, expressed as natural units (nats). Results: Sixty-three SIS members responded, most of whom (67%) have held a leadership position within the SIS or contributed as an annual meeting moderator or discussant; 76% have been in practice for more than five years. Regarding peri-operative Px, more than 80% agreed that a single dose is adequate for most indications, with the exceptions of gangrenous cholecystitis (40% single dose, 38% pre-operative +24 hours) and inguinal hernia repair requiring a bowel resection (70% single dose). There was more variability regarding the use of antibiotic Px for various bedside procedures with respondents split between none needed (range, 27%-66%) versus a single dose (range, 31%-67%). Opinions regarding the duration of antimicrobial Rx for hospitalized patients who have undergone a source control operation or procedure varied widely based on indication. Only two of 20 indications achieved more than 60% consensus despite available class 1 evidence: seven days for ventilator-associated pneumonia (77%), and four plus one days for perforated appendicitis (62%). Conclusions: Except for peri-operative antibiotic Px, there is little consensus regarding antibiotic duration among surgical infection experts, despite class 1 evidence and several available guidelines. This highlights the need for further high-level research and better dissemination of guidelines.

Identifying Research Priorities in Musculoskeletal Trauma Care in Sub-Saharan Africa

Background

In low and middle-income countries (LMICs), individuals suffer from a disproportionately higher number of musculoskeletal (MSK) injuries compared with those living in a high-income setting. However, despite the higher burden of death and disability from MSK injuries in LMICs, there has been little policy, research, and funding invested in addressing this distinctly overlooked problem. Using a consensus-based approach, the aim of this study was to identify research priorities for clinical trials and research in MSK trauma care across sub-Saharan Africa.

Methods

A modified Delphi technique was utilized; it involved an initial scoping survey, a 2-round Delphi process, and, finally, review by an expert panel with members of the Orthopaedic Research Collaboration in Africa. This study was conducted among MSK health-care practitioners treating trauma in sub-Saharan Africa.

Results

Participants from 34 countries across sub-Saharan Africa contributed to the 2 rounds of the Delphi process, and priorities were scored from 1 (low priority) to 5 (high priority). Public health topics related to trauma care ranked higher than those focused on clinical effectiveness, with the top 10 public health research questions scoring higher than the top 10 questions for clinical effectiveness. Ten public health and 10 clinical effectiveness questions related to MSK trauma care were identified; the highest-ranked questions in the respective categories were related to education and training and to the management of femoral fractures.

Conclusions

This consensus-driven research priority study will guide health-care professionals, academics, researchers, and funders to improve the evidence on MSK trauma care across sub-Saharan Africa and inform funders about priority areas of future research.

Antimicrobial Resistance Profile of Bacterial Isolates Identified from Surgical Site Infections at a Referral Hospital, Northwest Ethiopia

Background

Surgical wound infections (SWI) remain as a major source of postoperative illness that increases the time of hospital stay and health care related costs globally. On top of this, the emergence and spread of drug-resistant pathogens continue to challenge the proper management of surgical wound infections.

Methods

A hospital based cross-sectional study was conducted at Felege Hiwot Referral Hospital (FHRH). A total of 165 study participants were included. Socio-demographic data were collected using a pre-tested structured questionnaire. Isolates were identified by conventional bacteriological technique and antimicrobial susceptibility test was performed using the Kirby-Bauer disc diffusion method.

Results

Among 165 study participants, 98 (59.4%) were males. The overall prevalence of culture confirmed surgical wound infection was 115 (69.7%). A total of 125 bacteria isolates were identified among which, Staphylococcus aureus was predominant followed by Pseudomonas aeruginosa and Klebsiella species with a proportion of 31 (24.8%), 26 (20.8%) and 17 (13.6%), respectively. Majority (80.8%) of the isolates were found multidrug resistant (MDR). Dirty wound and duration of hospital stay were found significantly associated with culture confirmed surgical wound infections.

Conclusions

S. aureus, P. aeruginosa and Klebsiella species were the most common isolates identified from surgical wound sites. Most of these pathogens were found MDR. Therefore, regular surveillance on the types of bacterial isolates and their drug resistance pattern should be considered.

Surgical Infections and the Future of Research: Re-Defining the Research Agenda for the Surgical Infection Society

Background: Infections represent a major component of surgical practice. Risk mitigation, seeking eradication and optimal patient outcomes, require a concerted, multifocal effort to understand disease and microbiology, prevent infections, and treat them. The present study was undertaken to re-define the Surgical Infection Society (SIS) research agenda for the next decade. Hypothesis: We utilized the expertise of the SIS membership to identify research questions regarding surgical infections, hypothesizing that consensus among participants could be used to re-define the future research agenda. Methods: Members of the SIS were surveyed using a modified Delphi. The three rounds of the survey were targeted at: question generation; question ranking; and reaching consensus. Each of the 15 questions to emerge was evaluated according to level of consensus, feasibility, and data availability. Results: One hundred twenty-four participants contributed. Initially, 226 questions were generated that were condensed to 35 unique questions for consideration in the subsequent two rounds. The 35 questions encompassed several research themes, with antibiotic prophylaxis (n = 8), prevention of surgical site infections (SSIs; n = 6), and improved diagnostics (n = 5) being most common. Standard deviation of importance scores was inversely proportional to the question rank, indicating greater consensus among higher ranking questions. All 15 questions had a feasibility score of greater than three (five-point Likert scale), and the majority (12/15) had a mean data availability score of less than three. In the final round of the survey, the top three topics for further research surrounded non-antimicrobial treatments, optimal treatment duration for bacteremia, and treatment duration for necrotizing soft tissue infections. Conclusions: Using a modified Delphi process, 15 research questions addressing surgical infections were identified. Such questions can assist the SIS and the SIS Foundation for Research and Education in prioritizing and enabling research efforts, and development of a strategic research plan for the next decade.

Priorities for Prehospital Evidence-Based Guideline Development: A Modified Delphi Analysis

Objective: Few areas of prehospital care are supported by evidence-based guidelines (EBGs). We aimed to identify gaps in clinical and operational prehospital EBGs to prioritize future EBG development and research funding. Methods: Using modified Delphi methodology, we sought consensus among experts in prehospital care and EBG development. Five rounds of surveys were administered between October 2019 and February 2020. Round 1 asked participants to list the top three gaps in prehospital clinical guidelines and top three gaps in operational guidelines that should be prioritized for guideline development and research funding. Based on responses, 3 reviewers performed thematic analysis to develop a list of prehospital EBG gaps, with participant feedback in Round 2. In Round 3, participants rated each gap's importance using a 5-point Likert scale, and participants' responses were averaged. In Round 4, participants rank-ordered 10 gaps with the highest mean scores identified in Round 3. In Round 5, participants indicated their agreement with sets of the highest ranked gaps. Results: Of 23 invited participants, 14 completed all 5 rounds. In Rounds 1 and 2, participants submitted 65 clinical and 58 operational gaps, and thematic analysis identified 23 unique clinical gaps and 28 unique operational gaps. The final prioritized list of clinical EBG gaps was: 1) airway management in adult and pediatric patients, 2) care of the pediatric patient, and 3) management of prehospital behavioral health emergencies, with 79% of participants agreeing. The final prioritized list of operational EBG gaps was: 1) define and measure the impact of EMS care on patient outcomes, 2) practitioner wellness, and 3) practitioner safety in the out-of-hospital environment, with 86% of participants agreeing. Conclusions: This modified Delphi study identifies gaps in prehospital EBGs that, if prioritized for development and research funding, would be expected to have the greatest impact on prehospital clinical care and operations.

Identifying the research priorities of healthcare professionals in UK vascular surgery: modified Delphi approach

Background

The Vascular Research Collaborative was established to develop a national research strategy for patients with vascular disease in the UK. This project aimed to establish national research priorities in this patient group.

Methods

A modified Delphi approach, an established method for reaching a consensus opinion among a group of experts in a particular field, was used to survey national multidisciplinary vascular clinical specialists. Two rounds of online surveys were conducted involving the membership of the Vascular Society, Society of Vascular Nurses, Society for Vascular Technology, and the Rouleaux Club (vascular surgical trainees). The first round invited any suggestions for vascular research topics. A steering group then collated and rationalized the suggestions, categorizing them by consensus into pathological topics and research categories, and amalgamating the various questions relating to the same fundamental issue into a single question. The second round involved recirculating these questions to the same participants for priority scoring.

Results

Round 1 resulted in 1231 suggested research questions from 481 respondents. Steering group collation and rationalization resulted in 83 questions for ranking in round 2. The second round resulted in a hierarchical list of vascular research priorities. The highest scoring priorities addressed topics related to critical lower-limb ischaemia, diabetic foot disease, amputation, wound healing, carotid plaque morphology, and service organization/delivery.

Conclusion

It is anticipated that these results will drive the UK national vascular research agenda for the next 5–10 years. It will facilitate focused development and funding of new research projects in current clinical areas of unmet need where potential impact is greatest.

Surgical Infection Society Research Priorities: A Narrative Review of Fourteen Years of Progress

Background: In 2006, the Surgical Infection Society (SIS) utilized a modified Delphi approach to define 15 specific priority research questions that remained unanswered in the field of surgical infections. The aim of the current study was to evaluate the scientific progress achieved during the ensuing period in answering each of the 15 research questions and to determine if additional research in these fields is warranted. Methods: For each of the questions, a literature search using the National Center for Biotechnology Information (NCBI) was performed by the Scientific Studies Committee of the SIS to identify studies that attempted to address each of the defined questions. This literature was analyzed and summarized. The data on each question were evaluated by a surgical infections expert to determine if the question was answered definitively or remains unanswered. Results: All 15 priority research questions were studied in the last 14 years; six questions (40%) were definitively answered and 9 questions (60%) remain unanswered in whole or in part, mainly because of the low quality of the studies available on this topic. Several of the 9 unanswered questions were deemed to remain research priorities in 2020 and warrant further investigation. These included, for example, the role of empiric antimicrobial agents in nosocomial infections, the use of inotropes/vasopressors versus volume loading to raise the mean arterial pressure, and the role of increased antimicrobial dosing and frequency in the obese patient. Conclusions: Several surgical infection-related research questions prioritized in 2006 remain unanswered. Further high-quality research is required to provide a definitive answer to many of these priority knowledge gaps. An updated research agenda by the SIS is warranted at this time to define research priorities for the future.

A consensus building exercise to determine research priorities for silver trauma

BACKGROUND

Emergency care research into 'Silver Trauma', which is simply defined as major trauma consequent upon relatively minor injury mechanisms, is facing many challenges including that at present, there is no clear prioritisation of the issues. This study aimed to determine the top research priorities to guide future research.

METHODS

This consensus-based prioritization exercise used a three-stage modified Delphi technique. The study consisted of an idea generating (divergent) first round, a ranking evaluation in the second round, and a (convergent) consensus meeting in the third round.

RESULTS

A total of 20 research questions advanced to the final round of this study. After discussing the importance and clinical significance of each research question, five research questions were prioritised by the experts; the top three research priorities were: (1). What are older people's preferred goals of trauma care? (2). Beyond the Emergency Department (ED), what is the appropriate combined geriatric and trauma care? (3). Do older adults benefit from access to trauma centres? If so, do older trauma patients have equitable access to trauma centre compared to younger adults?

CONCLUSION

The results of this study will assist clinicians, researchers, and organisations that are interested in silver trauma in guiding their future efforts and funding toward addressing the identified research priorities.

Revisiting the Surgical Infection Society Delphi Analysis of the Research Agenda in Surgical Infections: Advancements and Unanswered Questions

Background: In 2006, the Surgical Infection Society (SIS) used a modified Delphi process to enlist SIS member-experts to identify 15 research priorities in the field of surgical infectious diseases; it was intended to serve as a research road map for the next one to two decades. We sought to evaluate the progress made in each of these priority areas. Hypothesis: We examined the progress achieved with respect to the 15 research areas identified by the Delphi process at that time, hypothesizing that advances in knowledge would be achieved in most domains, if not all. Methods: Surgical Infection Society members were surveyed to determine whether each priority area question had been satisfactorily answered in the last 14 years; to assess the quality of evidence answering each question (1-3 scale); and to delineate whether there is a current unmet need for continued research in each area. Randomized controlled trials (RCTs) regarding these initiatives were also identified via literature search and their citations in the literature were tabulated. Results: Sixty-six members of the SIS responded to the survey. Thirteen of 15 research priority areas saw an increase in data perceived to be available as adjudged by experts, as well an increase in the number of RCTs addressing that topic. However, there were only six questions that were deemed by experts to be answered sufficiently, primarily regarding antibiotic duration for certain conditions and the impact of glycemic control on infection. The questions that remained unanswered related to nosocomial infections, sepsis/septic shock, prevention of SSI, and antimicrobial pharmacokinetics. For a majority of the questions that experts believed were not answered sufficiently (8/9), respondents opined that continued research into these areas was warranted. Conclusion: Whereas 40% (6/15) of the research questions prioritized by the SIS in 2006 were answered to the satisfaction of member-experts, there are many questions that remain unanswered despite an increase of available data. Revisiting these research priorities highlights advancements made in the field of surgical infections, but also helps identify the areas that would benefit from continued study. That a majority of questions remain unanswered underscores an opportunity for member-experts to collaborate on SIS-managed or -endorsed RCTs.

Calculated parenteral initial treatment of bacterial infections: Intra-abdominal infections

This is the seventh chapter of the guideline "Calculated initial parenteral treatment of bacterial infections in adults - update 2018" in the 2nd updated version. The German guideline by the Paul-Ehrlich-Gesellschaft für Chemotherapie e.V. (PEG) has been translated to address an international audience. The chapter deals with the empirical and targeted antimicrobial therapy of complicated intra-abdominal infections. It includes recommendations for antibacterial and antifungal treatment.

The Importance of Perioperative Prophylaxis with Cefuroxime or Ceftriaxone in the Surgical Site Infections Prevention after Cranial and Spinal Neurosurgical Procedures

Introduction Surgical site infections pose a significant problem in the treatment of neurosurgical procedures, regardless of the application of perioperative prophylaxis with systemic antibiotics. The infection rate in these procedures ranges from less than 1% to above 15%. Different antibiotics and administration regimes have been used in the perioperative prophylaxis so far, and there are numerous comparative studies regarding their efficiency, however, it is generally indicated that the choice thereof should be based on information and local specifics connected to the most probable bacterial causers, which would possibly contaminate the surgical site and cause infection, and moreover, the mandatory compliance with the principles of providing adequate concentration of the drug at the time of the anticipated contamination. Objective Comparing the protective effect of two perioperative prophylactic antibiotic regimes using cefuroxime (second generation cephalosporin) and ceftriaxone (third generation cephalosporin) in the prevention of postoperative surgical site infections after elective and urgent cranial and spinal neurosurgical procedures at the University Clinic for Neurosurgery in Skopje in the period of the first three months of 2016. Design of the study Prospective randomized comparative study. Outcome measures Establishing the clinical outcome represented as prevalence of superficial and deep incision and organ/space postoperative surgical site infections. Material and method We analyzed prospectively 40 patients who received parenteral antibiotic prophylaxis with two antibiotic regimes one hour before the routine neurosurgical cranial and spinal surgical procedures; the patients were randomized in two groups, according to the order of admission and participation in the study, alternately, non-selectively, those persons who fulfilled inclusion criteria were placed in one of the two programmed regimes with cefuroxime in the first, and cefotaxime in the second compared group. All relevant demographic and perioperative patient data were analyzed for both comparative groups, especially the factors known to cause disposition (predisposition) to infections. The prevalence of postoperative infections was evaluated as the primary outcome in both comparative groups, while the secondary outcome was the postoperative infection rate after cranial and spinal neurosurgical procedures at the Neurosurgical clinic in Skopje (having in consideration that so far no data have been published in this context), as well as the prevalence of the risk factors for occurrence of postoperative infections, pre-surgically in patients undergoing neurosurgical interventions locally in the Republic of Macedonia. Results A total of three cases of postoperative infections were registered, two of which classified as superficial incisional, while one case organ/space infection - meningitis (elective intervention) without etiological confirmation. Both comparative groups were statistically similar, without any statistically significant differences in the basic demographic and perioperative characteristics, especially in relation to the incidence of the factors, which, regardless of the antibiotic prophylaxis, show predisposition to postoperative infections. All three cases with infections were registered in the group of persons who received prophylaxis with ceftriaxone preoperatively, with isolated etiological S. aureus agent (elective intervention) in one of them, and methicillin resistant staphylococcus aureus (MRSA) in another (urgent intervention) with superficial incisional SSI. There was no case of SSI in the group of patients who received cefuroxime before surgery. Conclusion Administration of parenteral antibiotics before surgery reduces the incidence of postoperative infections after neurosurgical procedures, especially in cases with increased risk factors for SSI, such as ACA score of ≥ 2/3, the duration of the surgical intervention ≥ 4 hours, contaminated wound and comorbidities. Perioperative antibiotic prophylaxis should be directed to better coverage of the S.aureus arrays.

A consensus exercise identifying priorities for research into clinical effectiveness among children's orthopaedic surgeons in the United Kingdom

Aims

High-quality clinical research in children's orthopaedic surgery has lagged behind other surgical subspecialties. This study used a consensus-based approach to identify research priorities for clinical trials in children's orthopaedics.

Methods

A modified Delphi technique was used, which involved an initial scoping survey, a two-round Delphi process and an expert panel formed of members of the British Society of Children's Orthopaedic Surgery. The survey was conducted amongst orthopaedic surgeons treating children in the United Kingdom and Ireland.

Results

A total of 86 clinicians contributed to both rounds of the Delphi process, scoring priorities from one (low priority) to five (high priority). Elective topics were ranked higher than those relating to trauma, with the top ten elective research questions scoring higher than the top question for trauma. Ten elective, and five trauma research priorities were identified, with the three highest ranked questions relating to the treatment of slipped capital femoral epiphysis (mean score 4.6/ 5), Perthes' disease (4.5) and bone infection (4.5).

Conclusion

This consensus-based research agenda will guide surgeons, academics and funders to improve the evidence in children's orthopaedic surgery and encourage the development of multicentre clinical trials. Cite this article: Bone Joint J 2018;100-B:680-4.

Expert consensus regarding drivers of antimicrobial stewardship in companion animal veterinary practice: a Delphi study

Antimicrobial resistance (AMR) is a global challenge facing both human and animal healthcare professionals; an effective response to this threat requires a 'One-Health' approach to antimicrobial stewardship (AMS) to preserve important antibiotics for urgent clinical need. However, understanding of barriers and enablers to effective AMS behaviour in companion animal veterinary practice is currently limited. We conducted a Delphi study of 16 nationally recognised experts from UK-based veterinary policymakers, university academics and leaders of professional bodies. This Delphi study sought to identify veterinary behaviours which experts believe contribute to AMR and form vital aspects of AMS. Analysis of Delphi findings indicated a perceived hierarchy of behaviours, the most influential being antibiotic prescribing behaviours and interactions with clients. Other veterinary behaviours perceived as being important related to interactions with veterinary colleagues; infection control practices; and the use of diagnostic tests to confirm infection. Key barriers and enablers to AMS within each of these behavioural domains were identified. Specific interventions to address important barriers and enablers are recommended. To the authors' knowledge, this is the first study to establish expert consensus at a national level about which 'behaviours' (aspects of veterinarian practice) should be targeted in relation to AMR and AMS in companion animal veterinary practice.

Outcomes of Surgical Sepsis

BACKGROUND

Discussion of outcomes of surgical sepsis is no longer straightforward. Definitions of sepsis have changed recently and updated data are scant. Surgical patient populations are often heterogeneous; the patient population being considered must be described with precision. Traditional 30-d operative mortality may not be the most relevant outcome to consider. What should change or be the emphasis going forward?

METHODS

Review and synthesis of pertinent English-language literature.

RESULTS

Epidemiologic data are abundant for short-term outcomes of sepsis in general, but despite the fact that approximately 30% of patients with sepsis are surgical patients, sepsis outcome data for surgical patients are scant, especially for durations longer than 30 d, and essentially non-existent for patients defined under the new Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria. Interpretability of extant data is hampered by non-standard and changing definitions.

CONCLUSIONS

Sepsis and organ dysfunction may be decreasing in prevalence and magnitude among surgical patients, but terminology must be standardized to enhance the interpretability of data generated in the future. It behooves journal editors, reviewers, and authors to insist upon standardized definitions and rigorous study design and data interpretation. Longer term data (e.g., 90-d mortality as opposed to in-hospital or traditional 30-d mortality) will be needed to justify to payers the complex, expensive care that these patients require. There is an urgent need to redefine the research agenda for surgical infections.

Management of Severe Sepsis of Abdominal Origin

Severe sepsis is a life-threatening condition that may occur as a sequela of intra-abdominal infections (IAIs) of all types. Diagnosis of IAIs is predicated upon the combination of physical examination and imaging techniques. Diffuse peritonitis usually requires urgent surgical intervention. In the absence of diffuse peritonitis, abdominal computed tomography remains the most useful test for the diagnosis of IAIs, and is essential to both guide therapeutic interventions and evaluate suspected treatment failure in the critically ill patient. Parameters most consistently associated with poor outcomes in patients with IAIs include increased illness severity, failed source control, inadequate empiric antimicrobial therapy, and healthcare-acquired, as opposed to community-acquired infection. Whereas community-acquired IAI is characterized predominantly by enteric gram-negative bacilli and anaerobes that are susceptible to narrow-spectrum agents, healthcare-acquired IAI (e.g., anastomotic dehiscence, postoperative organ-space surgical site infection) frequently involves at least one multi-drug resistant pathogen, necessitating broad-spectrum therapy guided by both culture results and local antibiograms. The cornerstone of effective treatment for abdominal sepsis is early and adequate source control, which is supplemented by antibiotic therapy, restoration of a functional gastrointestinal tract (if possible), and support of organ dysfunction. Furthermore, mitigation of deranged immune and coagulation responses via therapy with recombinant human activated protein C may improve survival significantly in severe cases complicated by septic shock and multiple organ dysfunction syndrome.

Moving forward through consensus: protocol for a modified Delphi approach to determine the top research priorities in the field of orthopaedic oncology

INTRODUCTION

Orthopaedic oncology researchers face several obstacles in the design and execution of randomised controlled trials, including finite fiscal resources to support the rising costs of clinical research and insufficient patient volume at individual sites. As a result, high-quality research to guide clinical practice has lagged behind other surgical subspecialties. A focused approach is imperative to design a research programme that is economical, streamlined and addresses clinically relevant endpoints. The primary objective of this study will be to use a consensus-based approach to identify research priorities for international clinical trials in orthopaedic oncology.

METHODS AND ANALYSIS

We will conduct a 3-phase modified Delphi method consisting of 2 sequential rounds of anonymous web-based questionnaires (phases I and II), and an in-person consensus meeting (phase III). Participants will suggest research questions that they believe are of particular importance to the field (phase I), and individually rate each proposed question on 5 criteria (phase II). Research questions that meet predetermined consensus thresholds will be brought forward to the consensus meeting (phase III) for discussion by an expert panel. Following these discussions, the expert panel will be asked to assign scores for each research question, and research questions meeting predetermined criteria will be brought forward for final ranking. The expert panel will then be asked to rank the top 3 research questions, and these 3 research questions will be distributed to the initial group of participants for validation.

ETHICS AND DISSEMINATION

An ethics application is currently under review with the Hamilton Integrated Research Ethics Board in Hamilton, Ontario, Canada. The results of this initiative will be disseminated through peer-reviewed publications and conference presentations.

Chartered Society of Physiotherapy's identification of national research priorities for physiotherapy using a modified Delphi technique

OBJECTIVE

To define research priorities to strategically inform the evidence base for physiotherapy practice.

DESIGN

A modified Delphi method using SurveyMonkey software identified priorities for physiotherapy research through national consensus. An iterative process of three rounds provided feedback. Round 1 requested five priorities using pre-defined prioritisation criteria. Content analysis identified research themes and topics. Round 2 requested rating of the importance of the research topics using a 1-5 Likert scale. Round 3 requested a further process of rating. Quantitative and qualitative data informed decision-making. Level of consensus was established as mean rating ≥ 3.5, coefficient of variation ≤ 30%, and ≥ 55% agreement. Consensus across participants was evaluated using Kendall's W.

PARTICIPANTS

Four expert panels (n=40-61) encompassing a range of stakeholders and reflecting four core areas of physiotherapy practice were established by steering groups (n=204 participants overall).

FINDINGS

Response rates of 53-78% across three rounds were good. The identification of 24/185 topics for musculoskeletal, 43/174 for neurology, 30/120 for cardiorespiratory and medical rehabilitation, and 30/113 for mental and physical health and wellbeing as priorities demonstrated discrimination of the process. Consensus between participants was good for most topics. Measurement validity of the research topics was good. The involvement of multiple stakeholders as participants ensured the current context of the intended use of the priorities.

CONCLUSIONS

From a process of national consensus involving key stakeholders, including service users, physiotherapy research topics have been identified and prioritised. Setting priorities provides a vision of how research can contribute to the developing research base in physiotherapy to maximise focus.

Developing a research agenda for the American Society of Colon and Rectal Surgeons: results of a delphi approach

PURPOSE

By use of a systematic approach, the aim of this project was to survey a group of colorectal specialists and reach a consensus on the research questions of highest importance in terms of clinical care.

METHODS

A modified Delphi process was performed. In Round 1 research questions were solicited from members of The American Society of Colon and Rectal Surgeons. A review group categorized the results, combined similar questions, and presented them to The American Society of Colon and Rectal Surgeons membership in Round 2 for prioritizing according to importance. In Round 3 the 50 questions with the highest scores in Round 2 were reranked by The American Society of Colon and Rectal Surgeons membership to produce the 20 highest-priority research questions.

RESULTS

A total of 203 respondents in Round 1 submitted 746 questions. The review team reduced these to 105 individual questions encompassing 21 topics in colorectal surgical practice. In Rounds 2 and 3, 399 and 360 respondents, respectively, prioritized the questions presented. The final 20 items included 14 questions related to colorectal cancer, and 6 were on benign disease topics.

CONCLUSIONS

The research agenda produced by this study reflects the clinical issues of greatest importance to colorectal surgeons. The results are of potential benefit to researchers, funding organizations, medical journals, and ultimately, patients.

Research priorities in pediatric rheumatology: The Childhood Arthritis and Rheumatology Research Alliance (CARRA) consensus

BACKGROUND

North American pediatric rheumatologists have created an investigator-initiated research network (the Childhood Arthritis and Rheumatology Research Alliance - CARRA) to facilitate multi-centre studies. One of the first projects undertaken by this network was to define, by consensus, research priorities for the group, and if possible a first group-sponsored clinical trial in which all members could participate.

METHODS

We determined consensus using the Delphi approach. This approach has been used extensively in health research to reach consensus in large groups. It uses several successive iterations of surveys eliciting ideas and opinions from specialists in the field. Three surveys were designed based on this method and were distributed to members of CARRA to elicit and rank-order research priorities.

RESULTS

A response rate of 87.6% was achieved in the final survey. The most highly ranked research suggestion was to study infliximab treatment of uveitis unresponsive to methotrexate. Other highly ranked suggestions were to study i) the treatment of systemic arthritis with anakinra and ii) the treatment of pediatric systemic lupus erythematosus with mycophenolate mofetil.

CONCLUSION

The Delphi approach was an effective and practical method to define research priorities in this group. Ongoing discussion and cooperation among pediatric rheumatologists in CARRA and others world-wide will help in developing further research priorities and to facilitate the execution of clinical trials in the future.

Intra-abdominal infections

PURPOSE OF REVIEW

The aim of this article is to outline developments in the three cornerstones of treatment of intra-abdominal infections during critical illness: source control; antimicrobial therapy; and mitigation of deranged immune and coagulation responses.

RECENT FINDINGS

Although adequate source control remains the goal of mechanical management of intra-abdominal infections, neither planned re-laparotomy nor open-abdomen management appears to offer a survival benefit as compared with on-demand re-laparotomy. Novel approaches to restoration of a functional gastrointestinal tract have emerged as alternatives to more invasive surgery. A persistent increase in the prevalence of intra-abdominal infections caused by multidrug resistant pathogens has led researchers to investigate shorter-course antimicrobial therapy and other antibiotic administration strategies with encouraging initial results. Therapy with recombinant human activated protein C should now be considered for patients with severe abdominal sepsis associated with a high risk of death.

SUMMARY

Because randomized controlled trials of intra-abdominal infections involve critically ill patients infrequently, only limited evidence-based recommendations regarding the management of these patients may be drawn. Therapy should focus above all else on timely obtainment of adequate source control, in conjunction with judicious use of antimicrobial therapy dictated by individual patient risk factors for infection with multidrug resistant pathogens.