Saudi expert consensus on acquired hemophilia A diagnosis and management

Objectives

Acquired hemophilia affects approximately one in 1 million people. Timely diagnosis is key to appropriate disease management and the prevention of life-threatening complications. Patients with this condition may initially be seen by inexperienced physicians and remain underdiagnosed for several years. This consensus statement is aimed at providing guidelines for all practitioners in the Kingdom of Saudi Arabia (KSA) to diagnose and manage acquired hemophilia A.

Methods

This consensus statement reflects the opinions drafted by a group of hematology specialists, who used an explicit systematic process to identify areas of agreement and disagreement.

Results

This consensus statement provides a guide for all practitioners in the KSA regarding the diagnosis of clinical presentation, relevance, characteristics of bleeding symptoms, and case management; it additionally provides guidance for non-specialists. All management aspects, including diagnosis and treatment modalities, are discussed.

Conclusions

Patients with acquired hemophilia may initially be seen by physicians who lack appropriate expertise in diagnosing and managing this condition. This consensus statement from the premier experts on the disease in the KSA provides details for diagnosing and managing acquired hemophilia.

An assessment of the informative value of data sharing statements in clinical trial registries

BACKGROUND

The provision of data sharing statements (DSS) for clinical trials has been made mandatory by different stakeholders. DSS are a device to clarify whether there is intention to share individual participant data (IPD). What is missing is a detailed assessment of whether DSS are providing clear and understandable information about the conditions for data sharing of IPD for secondary use.

METHODS

A random sample of 200 COVID-19 clinical trials with explicit DSS was drawn from the ECRIN clinical research metadata repository. The DSS were assessed and classified, by two experienced experts and one assessor with less experience in data sharing (DS), into different categories (unclear, no sharing, no plans, yes but vague, yes on request, yes with specified storage location, yes but with complex conditions).

RESULTS

Between the two experts the agreement was moderate to substantial (kappa=0.62, 95% CI [0.55, 0.70]). Agreement considerably decreased when these experts were compared with a third person who was less experienced and trained in data sharing ("assessor") (kappa=0.33, 95% CI [0.25, 0.41]; 0.35, 95% CI [0.27, 0.43]). Between the two experts and under supervision of an independent moderator, a consensus was achieved for those cases, where both experts had disagreed, and the result was used as "gold standard" for further analysis. At least some degree of willingness of DS (data sharing) was expressed in 63.5% (127/200) cases. Of these cases, around one quarter (31/127) were vague statements of support for data sharing but without useful detail. In around half of the cases (60/127) it was stated that IPD could be obtained by request. Only in in slightly more than 10% of the cases (15/127) it was stated that the IPD would be transferred to a specific data repository. In the remaining cases (21/127), a more complex regime was described or referenced, which could not be allocated to one of the three previous groups. As a result of the consensus meetings, the classification system was updated.

CONCLUSION

The study showed that the current DSS that imply possible data sharing are often not easy to interpret, even by relatively experienced staff. Machine based interpretation, which would be necessary for any practical application, is currently not possible. Machine learning and / or natural language processing techniques might improve machine actionability, but would represent a very substantial investment of research effort. The cheaper and easier option would be for data providers, data requestors, funders and platforms to adopt a clearer, more structured and more standardised approach to specifying, providing and collecting DSS.

TRIAL REGISTRATION

The protocol for the study was pre-registered on ZENODO ( https://zenodo.org/record/7064624#.Y4DIAHbMJD8 ).

Midwifery professional placement: Undergraduate students' experiences with novice and expert preceptors

BACKGROUND

In recent decades, increased midwifery university places have been offered to address midwifery workforce shortages. As a result, more graduate midwives entered the workforce, in turn leading to more midwifery students precepted by novice midwives when on professional placement. It is not known whether this more junior midwifery workforce impacts student experience.

AIMS

To explore undergraduate midwifery students' experiences with novice and expert midwifery preceptors, and to identify the benefits and challenges of working with novice and expert preceptors, from the perspective of undergraduate student midwives.

METHOD

This study used a qualitative descriptive approach. Nineteen third/fourth-year Bachelor of Nursing/Bachelor of Midwifery (Honours) students attended six focus groups (ranging from 2 to 5 participants). Data were analysed thematically.

RESULTS

Three overarching themes were identified: 'Building relationships'; 'Teaching and learning'; and 'Improvements to professional placement'. Benefits and challenges existed with both novice and expert preceptors. Importantly, feeling welcomed and receiving critical feedback were identified.

CONCLUSION

The student/preceptor relationship is based upon feeling welcomed, and relatability, and is developed more easily with novice preceptors. Expert preceptors provide insightful and valuable feedback and are more able to actively teach. Novice preceptors' consolidation of practice can impact student learning opportunities. Including students in decision-making aids development of critical thinking. Allocation practices which address student learning needs will improve the student professional practice experience. Midwifery students benefit from working with midwifery preceptors of all experience levels. Translating the findings from this project into preceptorship training programs for midwives will improve student satisfaction and outcomes.

Developing a framework for regular and sustainable qualitative assessment of antibiotic use in Korean medical institutions: a Delphi study

BACKGROUND

We aimed to develop a roadmap for conducting regular, sustainable, and strategic qualitative assessments of antibiotic use in medical institutions within the Republic of Korea.

METHODS

A literature review on the current state of qualitative antibiotic assessments was conducted, followed by one open round to collect ideas, two scoring rounds to establish consensus, and one panel meeting between them. The expert panel comprised 20 experts in infectious disease or antibiotic stewardship.

RESULTS

The response rate for all three surveys was 95% (19/20), while the panel meeting attendance rate was 90% (18/20). The following long-term goals were defined to assess the annual use of antibacterial and antifungal agents in all medical institutions, including clinics. The panel agreed that random sampling of antibiotic prescriptions was the most suitable method of selecting antibiotics for qualitative assessment, with the additional possibility of evaluating specific antibiotics or infectious diseases that warrant closer evaluation for promoting appropriate antibiotic use. The plan for utilization of results from evaluation involves providing feedback while maintaining anonymity and disclosure. It includes a quantitative assessment of antibiotic prescriptions and resistance rates to compare against institutional benchmarks. Furthermore, it was agreed to link the evaluation findings to the national antibiotic stewardship programme, enabling policy and institutional approaches to address frequently misused items, identified during the evaluation.

CONCLUSION

This study provides a framework for establishing a qualitative assessment of antimicrobial use for medical institutions at a national level in the Republic of Korea.

Brain-based medical education model for expert's clinical decision making

PURPOSE

The expertise of medicians in clinical decision-making is very important since it improves the quality of medical services provided to patients. This study analyzed the characteristics of the decision-making process and confirmed clinicians' electroencephalography (EEG) characteristics by measuring their cerebral activity during clinical decision-making. This study aims to present learning directions for brain-based clinical decision-making to develop medical experts.

METHODS

This study was performed in the following two projects: (1) a qualitative study of clinical decision-making in a clinical scenario and (2) an analysis of differences in cortical activity of experts and novices through EEG.

RESULTS

In the 1st study, this study found that "confirmation of the patient's chief complaints," "physical examination," and "radiography reading" steps, which showed the most prominent differences in the experts' and novices' decision making, were set as the significant steps of dentists' clinical decision making. In the 2nd study, the experts' and novices' cortical activities were measured through a 32-channel EEG. In task 6, which had the lowest accuracy of diagnoses made by the experts, the brain activities in both groups were higher than in other tasks.

CONCLUSION

This study developed and suggested a model of the decision-making process for experts and novices and suggested the basic directions for brain-based learning needed to raise experts based on brain activity.

[Rare cancers of the head and neck on behalf of the REFCOR, part 1]

Among the 16,000 new cases of malignant tumors of the head and neck diagnosed in France each year, 10% are not conventional squamous cell carcinomas. These so-called rare cancers are distinguished by their presentation and patterns of failure, which is important to recognize in order to offer specific adapted management and maximize the chances of tumor control. These cancers can be rare by their histology, which determines their local invasiveness, and their hematogenous/nodal spread. Their diagnosis can be difficult and often requires comprehensive immunohistochemistry and genomic techniques. Expert pathology review is recommended in the cases of undifferentiated tumors, sarcomas and at the slightest diagnostic doubt. These rare cancers can also be rare by their anatomical location when arising from the paranasal sinuses, salivary glands and ear. Their location requires knowledge of their specific extension routes, and may call for a specific surgical technique (skull base endoscopic sinus surgery, extended total parotidectomy, etc.) and adapted radiotherapy to spare healthy organs surrounding the tumor. This article (part 1) discusses the diagnostic and therapeutic specificities of these rare cancers, and develops the recommendations of the French ENT Cancer Expertise Network (REFCOR) concerning rare epithelial tumors, i.e., salivary tumors, sinonasal tumors, variants of conventional squamous cell carcinomas, neuroendocrine carcinomas, malignant odontogenic tumors, and ear tumors. A second article (part 2) is focused on non-epithelial tumors (sarcomas, mucosal melanomas, lymphomas, tumors of uncertain or undetermined malignancy) and describes the organization and missions of the REFCOR.

[Rare cancers of the head and neck on behalf of the REFCOR, part 2]

Among the 16,000 new cases of malignant tumors of the head and neck diagnosed in France each year, 10% are not conventional squamous cell carcinomas. These so-called rare cancers are distinguished by their presentation and patterns of failure, which is important to recognize in order to offer specific adapted management and maximize the chances of tumor control. These cancers can be rare by their histology as well as their anatomical location when arising from the paranasal sinuses, salivary glands and ear. The management of these heterogeneous rare diseases of complex treatment has considerably been structured over the last 15 years, in particular via the French ENT Cancer Expertise Network (REFCOR) and international networks and registries (EURACAN, etc.). Structuration also favors research with identification of new entities and setting up of specific therapeutic trials. A first article (part 1) discusses the diagnostic and therapeutic specificities of these rare cancers, and develops the recommendations of the REFCOR concerning rare epithelial tumors, i.e., salivary tumors, sinonasal tumors, variants of conventional squamous cell carcinomas, neuroendocrine carcinomas, malignant odontogenic tumors, and ear tumors. This second article (part 2) is focused on non-epithelial tumors (sarcomas, mucosal melanomas, lymphomas, tumors of uncertain or undetermined malignancy) and describes the organization and missions of the REFCOR.

Exploring the value of using patient-oriented MRI reports in clinical practice - a pilot study

PURPOSE

Standard radiology reports (SRR) are designed to communicate information between doctors. With many patients having instantaneous access to SRRs on patient portals, interpretation without guidance from doctors can cause anxiety and panic. In this pilot study, we designed a patient-centred prostate MRI template report (PACERR) to address some of these challenges and tested whether PACERRs improve patient knowledge and experience.

MATERIALS AND METHODS

Patients booked for clinical prostate MRI were randomly assigned to SRR or SRR + PACERR. Questionnaires included multiple-choice that targeted 4 domains (understanding, usefulness, next steps, emotional experience) hypothesized to improve with patient-centred reports and short answer questions, testing knowledge regarding MRI results. Clinical encounters were observed and recorded to explore whether adding PACERR improved communication. Likert scaled-responses and short-answer questions were compared using Mann-Whitney U test and Kruskal-Wallis test.

RESULTS

Of the 40 participants, the majority were MRI naïve (70%). Patients receiving a PACERR had higher scores in the categories of patient understanding (mean: 4.17 vs. 3.39, p=0.006), usefulness (mean: 4.58 vs. 3.07, p<0.001), and identifying next steps (mean: 1.89 vs. 3.03, p=0.003) but not emotional experience (mean: 4.18 vs. 3.79, p=0.22). PACERR participants found the layout and design more patient friendly (mean: 4.47 vs. 2.61, p<0.001) and easier to understand (mean: 4.37 vs. 2.38, p<0.001). In the knowledge section, overall, the PACERR arm scored better (87% vs. 56%, p=0.004).

CONCLUSION

With the addition of prostate MRI PACERR, participants had better understanding of their results and felt more prepared to involve themselves in discussions with their doctor.

Science, politics and institutional design in regulation

The politicization of science is a recurring phenomenon in US federal policymaking that is explained in part by the unstructured, collaborative nature of decision-making in most science-intensive US regulatory programs. In this chapter we spotlight some of the most significant worries arising from this longstanding approach to U.S. institutional design for expert agencies and offer recommendations for stronger institutional structures to help guard against the politicization of science.

Constructing Expertise: Surmounting Performance Plateaus by Tasks, by Tools, and by Techniques

Acquiring expertise in a task is often thought of as an automatic process that follows inevitably with practice according to the log-log law (aka: power law) of learning. However, as Ericsson, Chase, and Faloon (1980) showed, this is not true for digit-span experts and, as we show, it is certainly not true for Tetris players at any level of expertise. Although some people may simply "twitch" faster than others, the limit to Tetris expertise is not raw keypress time but the techniques acquired by players that allow them to use the tools provided by the hardware and software to compensate for the game's relentlessly increasing drop speed. Unfortunately, these increases in drop speed between Tetris levels make performance plateaus very short and quickly followed by game death. Hence, a player's success at discovering, exploring, and practicing new techniques for the tasks of board preparation, board maintenance, optimal placement discovery, zoid rotation, lateral movement of zoids, and other tasks important to expertise in Tetris is limited. In this paper, we analyze data collected from 492 Tetris players to reveal the challenges they confronted while constructing expertise via the discovery of new techniques for gameplay at increasingly difficult levels of Tetris.

Workplace stress of occupational safety specialists in Croatia and Serbia

BACKGROUND

Numerous studies have shown that work often causes stress in employees and even in occupational safety experts. Occupational stress can lead to serious health consequences for employees. As the job of occupational safety experts is very responsible, they are more exposed to workplace stress and more vulnerable to its consequences. This study resulted with expertise on the work related stress of safety experts in Croatia and Serbia.

OBJECTIVE

This study examined workplace stress of occupational safety experts in Croatia and Serbia.

METHODS

Surveys were used to collect original data and statistical methods were used for data processing and analysis.

RESULTS

There was a correlation between the level of stress on safety expert's jobs and stress levels related to the status of safety experts as dependent variables and the organization profile related with safety experts' employment as independent variables. Stress of safety experts related to activities and the status of safety experts were of medium level.

CONCLUSION

There is a need for preventive protection from stress in this profession. Continuous education of safety experts plays a key role in stress prevention, not only for the safety experts but it also plays a key role in stress management throughout the organization.

[Expert committees in German public health policymaking during the SARS-CoV-2 pandemic: a document analysis]

Hintergrund

In der SARS-CoV-2-Pandemie muss die Politik weitreichende Entscheidungen treffen, die von wissenschaftlichen Erkenntnissen gestützt sein sollten. Angesichts der zumeist limitierten Evidenz in Krisensituationen stellt dies eine große Herausforderung dar, insbesondere in frühen Phasen der Pandemie. Entscheidungsträger*innen haben daher wissenschaftliche Expert*innen einbezogen, welche die Evidenzlage vermitteln und kontextualisieren sollten. Die Formen dieser Konsultationen variierten stark. Zum Teil wurden sogenannte Expert*innenräte mit Vertreter*innen verschiedenster Disziplinen einberufen. Die Zusammensetzung dieser Expert*innenräte hat jedoch Fragen der Repräsentation und Transparenz aufgeworfen.

Unser Forschungsvorhaben untersucht, ob und wie Expert*innenräte in Deutschland auf Bundes- und Landesebene einberufen wurden, um die Regierungen und Ministerien in der SARS-CoV-2-Pandemie zu beraten. Es wurden die disziplinäre Zusammensetzung, die Geschlechterverteilung und die Transparenz der Arbeitsabläufe analysiert.

Methoden

Wir führten eine mehrstufige Dokumentenanalyse durch. Zwischen Mai und Juli 2020 wurden Anfragen an die Regierungseinrichtungen der Länder und die Bundesministerien nach dem Informationsfreiheitsgesetz gestellt. Ergänzend zur Analyse der Antwortschreiben wurde eine Sichtung und Analyse der i) Pandemiepläne, ii) der offiziellen Pressemitteilungen und iii) der kleinen Anfragen auf Bundes- und auf Landesebene zu Expert*innenräten im SARS-CoV-2-Kontext für den Zeitraum von Januar bis Anfang Dezember 2020 durchgeführt. Die Auswertung erfolgte mittels qualitativer Inhaltsanalyse.

Ergebnisse

Zehn Bundesländer und vier Bundesministerien etablierten insgesamt 21 Expert*innenräte. Für elf Gremien waren Namen und disziplinärer Hintergrund der Mitglieder bekannt. In diesen Gremien betrug der Frauenanteil 26%. Am häufigsten waren biomedizinische Fachbereiche wie Virologie, Krankenhaushygiene, Medizin, und Biologie vertreten. Weitere Disziplinen (Wirtschafts-, Rechts- und Sozialwissenschaften) und nichtwissenschaftliche Expert*innen waren in sieben Bundesländern vertreten. Die zehn Räte ohne namentliche Nennung der Mitglieder waren verschiedenen Themenbereichen (Schule und Kita, Bürgerbeteiligung, Medizin und Pflege, Wirtschaft) zuzuordnen, ihre Mitglieder waren häufig Akteur*innen aus der Praxis und Betroffene.

Diskussion

Die SARS-CoV-2-Pandemie hat zu einer verstärkten Konsultation von Expert*innen durch die Politik geführt. Die entsprechenden Gremien in Deutschland sind jedoch nicht ausreichend repräsentativ, trans- und interdisziplinär zusammengesetzt, um die Politik in komplexen Pandemielagen zu beraten und unterschiedliche Perspektiven zu berücksichtigen. Die Arbeitsweise der Gremien ist unter anderem durch einen erschwerten Zugang zu Informationen nicht ausreichend transparent.

Schlussfolgerung

Aufgrund fehlender Transparenz ist unklar, ob und wie die identifizierten Expert*innenräte Einfluss auf die Politik genommen haben. Transparenz politischer Entscheidungsprozesse und die Berücksichtigung pluralistischer Perspektiven gelten jedoch als wesentlich für die Legitimation und Güte politischer Entscheidungen in einer Pandemie und sollten in Deutschland im Pandemiemanagement gestärkt werden.

Coming to consensus: the Delphi technique

Delphi techniques are used in health care and nursing to systematically bring together explicit and implicit knowledge from experts with a research or practical background, often with the goal of reaching a group consensus. Consensus standards and findings are important for promoting the exchange of information and ideas on an interdisciplinary and transdisciplinary basis, and for guaranteeing comparable procedures in diagnostic and therapeutic approaches. Yet, the development of consensus standards using Delphi techniques is challenging because it is dependent on the willingness of experts to participate and the statistical definition of consensus.

'More of an art than a science'? The development, design and mechanics of the Delphi Technique

The Delphi Technique is a group judgement method which is typically used to reach agreement from a group of people with expertise in a particular area. It is an iterative process where panel members complete questionnaires over several rounds, often rating their agreement/disagreement against a statement, with changes made in later rounds based on the feedback received. It has been used widely in pharmacy-related studies relevant to education, research and practice. This paper provides a critical analysis of the various design choices which researchers may consider when planning a Delphi namely the panel of participants, the use of the Likert scale, the effect of feedback, what constitutes consensus and the number of rounds. It also gives an overview of the development and origins of the Delphi, and discusses the advantages and disadvantages of the technique. Advantages include that the Delphi can be conducted with panel members in different geographical locations in their own time, however the technique can therefore take longer to conduct and lacks face-to-face discussion. Patient experts may be less comfortable participating in a relatively complex survey, however the anonymous nature of the process can be more inclusive in allowing participants to feedback candidly. This paper shows the importance of careful planning of the design choices to ensure the reliability and validity of the Delphi.

Alignment adjustment using the Valgus stress technique can increase the surgical accuracy of novice surgeons during medial opening-wedge high Tibial osteotomy

Background

The purpose of this study was to compare the degree of accuracy of coronal alignment correction with use of the “alignment adjustment under valgus stress technique” between expert and novice surgeons during medial opening-wedge high tibial osteotomy (MOWHTO).

Methods

Forty-eight patients who underwent MOWHTO performed by an expert surgeon (expert group) and 29 by a novice surgeon (novice group) were enrolled in analysis. During surgery, lower-extremity alignment was corrected using the “alignment adjustment under valgus stress technique”. Normocorrection was defined as a weight-bearing line ratio between 55 and 70% and the correction accuracy was compared between expert and novice groups using the ratio of normocorrection to outliers. The clinical outcomes were also compared using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year after surgery.

Results

The undercorrection rate was 14.6% in the expert group and 13.8% in the novice group, while the overcorrection rate was 2.1% in the expert group and 3.4% in the novice group. In the ratio of normocorrection to outliers, no difference was found between the two groups at the one-year follow-up visit (83.3% in the expert group vs. 82.8% in the novice group; p > 0.05). Also, no significant differences were seen in WOMAC subscores immediately preoperatively and at 1 year after surgery (all p > 0.05).

Conclusion

Adhering to the “alignment adjustment under valgus stress technique” protocol enabled novice surgeons to achieve similar surgical accuracy as that of an expert surgeon in coronal alignment during MOWHTO.

Level of evidence

Level III.

The effects of stress on eyewitness memory: A survey of memory experts and laypeople

This survey examined lay and expert beliefs about statements concerning stress effects on (eyewitness) memory. Thirty-seven eyewitness memory experts, 36 fundamental memory experts, and 109 laypeople endorsed, opposed, or selected don't know responses for a range of statements relating to the effects of stress at encoding and retrieval. We examined proportions in each group and differences between groups (eyewitness memory experts vs. fundamental memory experts; experts vs. laypeople) for endorsements (agree vs. disagree) and selections (don't know vs. agree/disagree). High proportions of experts from both research fields agreed that very high levels of stress impair the accuracy of eyewitness testimony. A majority of fundamental experts, but not eyewitness experts, endorsed the idea that stress experienced during encoding can enhance memory. Responses to statements regarding moderating factors such as stressor severity and detail type provided further insight into this discrepancy. Eyewitness memory experts more frequently selected the don't know option for neuroscientific statements regarding stress effects on memory than fundamental memory experts, although don't know selections were substantial among both expert groups. Laypeople's responses to eight of the statements differed statistically from expert answers on topics such as memory in children, in professionals such as police officers, for faces and short crimes, and the existence of repression, providing insight into possible 'commonsense' beliefs on stress effects on memory. Our findings capture the current state of knowledge about stress effects on memory as reflected by sample of experts and laypeople, and highlight areas where further research and consensus would be valuable.

Preparation for Challenging Cases: What Differentiates Expert From Novice Surgeons?

OBJECTIVE

The study of expert performance provides a rich field for exploration in the surgical literature. This study aimed to examine the difference between expert and novice surgeons in their preparation for challenging cases.

DESIGN

Expert (attending) and novice (postgraduate-year 2) surgeons were presented two cases of complicated cholecystitis and were asked how they would prepare, what they would expect to encounter intraoperatively, and how they would deal with these challenges. Their responses were recorded, transcribed verbatim and analyzed using thematic analysis.

SETTING

Academic teaching hospitals.

PARTICIPANTS

Two group of expert and novice surgeons.

RESULTS

Nine experts and eleven novices from two academic centers participated. The majority of novices focused on patient history, work-up, preoperative optimization, anatomy, and anticipation of intraoperative challenges. In addition to the patient's presentation and preoperative optimization, most experts' thoughts were directed toward preparation for surgery (level of urgency, required skills in surgical team, case difficulty, and risk of conversion to open). Experts would involve the patient in the decision-making and were more likely to communicate with the operating room team. While novices attempted to predict challenges depending on gallbladder condition and intra-abdominal adhesions, the experts highlighted the importance of various elements of the operative field, the detail of the technique and possible challenges, and their troubleshooting plans. Regarding operative planning to address anticipated challenges, novices would tailor their plan to patient characteristics and verbalized an analytical "if-then" approach for all possibilities they might encounter. Experts would start with their standard technique regardless of case complexity and would deal with contingencies as they arise. Safety was a critical part of expert surgeons' plans.

CONCLUSIONS

Novices mostly conveyed descriptive knowledge based on presented facts while experts demonstrated an ability to paint a richer mental image of possible future events by creating comprehensive anticipation of the operative field. Further studies are needed to validate the results of this study.

Global burn care and the ideal burn dressing reloaded - A survey of global experts

PURPOSE

Burn care is a highly relevant medical specialty in every part of the world. Different infrastructure, healthcare systems and access to medical supplies lead to different needs, treatment strategies and outcomes. A fundamental tool in a burn care provider's armamentarium is the use of different dressings. Several studies have investigated the question of the ideal burn dressing, but none could achieve a proper global perspective. With advanced dressings being on the rise, we conducted this study to get a global understanding of the actual use and idea of the ideal burn dressing.

OBJECTIVE

The objective of this study was to investigate the understanding of an 'ideal burn dressing' on a global scale.

MATERIALS AND METHODS

A questionnaire about burn care and the ideal burn dressing has been created and translated to five of the most spoken languages world-wide (English, Spanish, French, Chinese, Indonesian). It has been uploaded to an online survey platform and sent out to burn experts worldwide. The voluntary participation was possible for a period of four weeks.

RESULTS

In total, 196 respondents from 49 countries participated in the study, yielding a response rate of 24.5%. The most important burn dressing characteristics in a cumulative ranking were (1) lack of adhesion (80.54%), (2) pain-free dressing change (79.87%), (3) requirement of fewer dressing changes, while in a linear ranking they were (1) anti-infective (35.14% 1st), pain-reduction (24.14% 2nd), and high absorbency (23.49% 3rd). Silver-based dressings are the most used dressings for superficial (45.21%) and deep (52.78%). 94.81% believe that the choice of burn dressing affects the outcome.

CONCLUSION

This investigation has delivered valuable insights into the global perspective of the ideal burn dressing. Yet, the question of the ideal burn dressing is still inconclusive. Wound dressing research is of fundamental interest for patients, healthcare providers and healthcare systems.

The Search Patterns of Abdominal Imaging Subspecialists for Abdominal Computed Tomography: Toward a Foundational Pattern for New Radiology Residents

Objectives:

The routine search patterns used by subspecialty abdominal imaging experts to inspect the image volumes of abdominal/pelvic computed tomography (CT) have not been well characterized or rendered in practical or teachable terms. The goal of this study is to describe the search patterns used by experienced subspecialty imagers when reading a normal abdominal CT at a modern picture archiving and communication system workstation, and utilize this information to propose guidelines for residents as they learn to interpret CT during training.

Material and Methods:

Twenty-two academic subspecialists enacted their routine search pattern on a normal contrast-enhanced abdominal/pelvic CT study under standardized display parameters. Readers were told that the scan was normal and then asked to verbalize where their gaze centered and moved through the axial, coronal, and sagittal image stacks, demonstrating eye position with a cursor as needed. A peer coded the reported eye gaze movements and scrilling behavior. Spearman correlation coefficients were calculated between years of professional experience and the numbers of passes through the lung bases, liver, kidneys, and bowel.

Results:

All readers followed an initial organ-by-organ approach. Larger organs were examined by drilling, while smaller organs by oscillation or scanning. Search elements were classified as drilling, scanning, oscillation, and scrilling (scan drilling); these categories were parsed as necessary. The greatest variability was found in the examination the body wall and bowel/mesentery. Two modes of scrilling were described, and these classified as roaming and zigzagging. The years of experience of the readers did not correlated to number of passes made through the lung bases, liver, kidneys, or bowel.

Conclusion:

Subspecialty abdominal radiologists negotiate through the image stacks of an abdominal CT study in broadly similar ways. Collation of the approaches suggests a foundational search pattern for new trainees.

Expert evidence: Frequently asked questions

This Faculty of Forensic and Legal Medicine guidance on the law of expert evidence is set out in the form of a series of frequently asked questions.

Environmental PCB forensics: processes and issues

PCB forensic science is the process of identifying the source(s) of polychlorinated biphenyls (PCBs) at a site in the context of a legal proceeding to aid in identifying the party(s) responsible for the cost of environmental remediation. The PCB forensic scientist should assemble and examine all the evidence and then develop opinions about sources, discharges, deposition, fate, transport, environmental impact, and other issues at dispute among the parties. PCBs are complex mixtures of compounds (Aroclors in USA) that can simultaneously reveal information about the source of the contamination, but also provide confounding and contradictory evidence. The issues are technically complex and the expert must systematically evaluate the facts, employ deep technical expertise, and use dispassionate judgment to provide expert opinions that assist the judge, jury, arbitrator, or allocator in rendering their decision as to the responsible party(s) or an apportionment of that responsibility. Different PCB products were used and disposed of that have characteristic congener mixture profiles. In the environment, these profiles can mix and weather over decades. Sampling and analysis can generate further uncertainties, notably the possible misidentification of Aroclors. The expert's challenge is to present their opinions clearly and authoritatively without overrepresenting the facts and data. This paper focuses on PCB contamination of sediment in aqueous sediment and uses a case study to illustrate application of forensic principles.

Femoral offset guide facilitates accurate and precise femoral tunnel placement for single-bundle anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study was to compare the accuracy and precision of femoral tunnel placement by expert and novice surgeons using an offset guide for single-bundle ACL reconstruction via the anteromedial (AM) portal.

METHODS

Twenty-five single-bundle ACL reconstructions performed by a novice surgeon were matched with 25 ACL reconstructions performed by an expert surgeon, based on one-to-one propensity score matching. The same technique was used by both groups for femoral tunnel placement using a 7-mm offset guide through the AM portal. Using the Bernard and Hertel grid method for postoperative three-dimensional reconstructed computed tomography, the accuracy and precision of various tunnel positions were compared.

RESULTS

No differences were found between the proximal-distal and anterior-posterior femoral tunnel placements by the two groups (proximal-distal; 30.5% involving experts, and 32.5% by novices, n.s) (anterior-posterior; 32.6% involving experts, and 31.6% by novice, n.s). The accuracy of the femoral tunnel positions, based on the average distance from the tunnel center to the center of ACL direct insertion, was similar between the two groups (n.s). No differences were found between the groups in terms of precision of femoral tunnel positions (n.s).

CONCLUSION

Novice surgeons can achieve accuracy and precision comparable to experts in creating femoral tunnels via single-bundle ACL reconstruction through the AM portal using a femoral offset guide. We recommend the use of a femoral offset guide for ACL reconstruction during the learning phase of a novice surgeon for effective tunnel placement to reduce the learning curve required to perform accurate and reproducible ACL reconstruction.

LEVEL OF EVIDENCE

Case-control study, Level III.

Posterolateral corner of the knee: an expert consensus statement on diagnosis, classification, treatment, and rehabilitation

PURPOSE

To develop a statement on the diagnosis, classification, treatment, and rehabilitation concepts of posterolateral corner (PLC) injuries of the knee using a modified Delphi technique.

METHODS

A working group of three individuals generated a list of statements relating to the diagnosis, classification, treatment, and rehabilitation of PLC injuries to form the basis of an initial survey for rating by an international group of experts. The PLC expert group (composed of 27 experts throughout the world) was surveyed on three occasions to establish consensus on the inclusion/exclusion of each item. In addition to rating agreement, experts were invited to propose further items for inclusion or to suggest modifications of existing items at each round. Pre-defined criteria were used to refine item lists after each survey. Statements reaching consensus in round three were included within the final consensus document.

RESULTS

Twenty-seven experts (100% response rate) completed three rounds of surveys. After three rounds, 29 items achieved consensus with over 75% agreement and less than 5% disagreement. Consensus was reached in 92% of the statements relating to diagnosis of PLC injuries, 100% relating to classification, 70% relating to treatment and in 88% of items relating to rehabilitation statements, with an overall consensus of 81%.

CONCLUSIONS

This study has established a consensus statement relating to the diagnosis, classification, treatment, and rehabilitation of PLC injuries. Further research is needed to develop updated classification systems, and better understand the role of non-invasive and minimally invasive approaches along with standardized rehabilitation protocols.

LEVEL OF EVIDENCE

Consensus of expert opinion, Level V.

The first online conference for breast cancer survivors-SURVIVA 2018: an innovative information tool

Purpose

The implementation of a new online conference tool, with the goal of providing competent answers, information, and support from experts in their fields, about diagnosis, treatment, and rehabilitation in breast cancer patients.

Methods

The implementation process and data of the first online conference are described.

Results

Following the idea and initiative of a breast cancer survivor, and under the umbrella of a leading oncologist in breast cancer treatment, and with the cooperation of further leading experts in the fields, plus their therapeutic teams, the new online conference SURVIVA 2018 was implemented as an innovative platform—free of charge, online, and with easy and anonymous access—to provide breast cancer survivors with in-depth information and help from the leading Austrian experts in their fields. This first online conference for German-speaking breast cancer survivors is an innovative and modern concept, which seems to have been very well accepted.

Conclusion

This concept could also be of interest to survivors of other cancer entities.

Distinguishing experts from novices by the Mind's Hand and Mind's Eye

Tetris is a complex task notable for the increasingly substantial demands it makes on perception, decision-making, and action as the game is played. To investigate these issues, we collected data on 39 features of Tetris play for each Tetris zoid (piece), for up to 16 levels of difficulty, as each of 240 players played an hour of Tetris under laboratory conditions. Using only early (level 1) data, we conducted a Principle Component Analysis which found intriguing differences among its three, statistically significant, principle components. Each of these components captures different combinations of perception, decision-making, and action which suggests differing higher level skills, tactics, and strategies. Each component is presented and discussed, and then used in a series of principle component regression analyses on subsets of these data (a) from different Tetris levels, as well as (b) from players of different levels of expertise. We validate these models with data collected at a locally held Tetris tournament. These components represent elements of expertise; namely, correlations among perceptual, decision-making, and motor features that represent processing stages and hierarchical control and which distinguish expert from novice Tetris players. These components provide evidence for an integrated complex of processes - the Mind's Hand and the Mind's Eye - that are the essence of expertise in the real-time, sequential-decision-making task of Tetris.

United Nations Secretary-General's Mechanism

The credibility and legitimacy of the United Nations Secretary-General's Mechanism (UNSGM) for investigating the alleged use of biological weapons relies in part on qualified experts trained to undertake fact-finding missions using an empirical scientific approach. As observed in the 2013 investigation into the alleged use of chemical weapons in the Syrian Arab Republic, this mechanism can be an effective tool in the verification of and as a deterrent against the use of chemical and biological weapons. The World Organisation for Animal Health (OIE) has a memorandum of understanding with the United Nations Office for Disarmament Affairs, supporting the UNSGM and providing experts for its roster for missions. As the majority of biological agents are of animal origin, the expertise of the OIE in this area, and its involvement in the UNSGM, are of paramount importance. Since 2014, experts from the OIE have participated in relevant training and are available for deployment to investigate any alleged use of a biological weapon anywhere in the world if the UNSGM were triggered.

Choice in the presence of experts: The role of general practitioners in patients' hospital choice

This paper considers the micro-econometric analysis of patients' hospital choice for elective medical procedures when their choice set is pre-selected by a general practitioner (GP). GPs have a dual role with regard to elective referrals in the English NHS, advising patients and at the same time taking account of the financial implications of referral decisions on local health budgets. The paper proposes a two-stage choice model that encompasses both patient and GP level optimization. It demonstrates that estimators that do not take account of strategic pre-selection of choice sets may be biased and inconsistent. We find that GPs as patients' agents select choice options based on quality, but as agents of health authorities also consider financial implications of referrals. When considering these choice options, patients focus on tangible hospital attributes, like amenities.

Use of functional performance tests in sports: Evaluation proposal for football players in the rehabilitation phase

Objectives

Based on the criteria of a group of experts, this study aims to select a set of functional performance tests which can be applied to evaluate the functional status of a football player in the recovery process and make a decision in relation to their return to practice.

Materials and methods

A total of 16 experts were selected by the coordinator group to judge an initial list of functional performance tests and, thus, reach a consensus about the tests which are best suited to the needs of the injured player. Each of the experts had to evaluate each one of the tests in a scale from 1 to 5 in relation to their suitability. Delphi method was used to reach consensus in the expert group.

Results

From the initial list of 25, the tests which obtained the best evaluation were: Counter movement jump (4.3±0.9), Single hop test (4.1±0.8), Triple hop test (4.1±0.9), Crossover hop test (4.1±0.7), Yo-Yo intermittent recovery (4.2±0.6), Barrow test (4.1±0.6), Shuttle run 8¥5 m (4.1±0.8). Star excursion balance test (4±0.7) and Y balance test (4.1±0.7).

Conclusion

In the opinion of the experts selected here, these tests are the ones which best respond to the needs involved in a complex decision such as RTP.

The expert and the foreigner: Reflections of forensic transcultural psychopathology on a total of 86 reports by experts on criminal liability

In recent times Italy has been experiencing massive migration flows, therefore the attention on the issue of crimes committed by foreigners is increasing. But within trials, in the evaluation of criminal liability of foreigners, how do experts deal with them? Do the performed evaluations take cultural diversity into account? The present study took origin from these questions and examined a total of 86 reports by experts on criminal liability of foreign persons (16 females and 70 males). Examinees have been declared indictable in 31 cases (36%), totally mentally ill in 40 cases (45%) and with diminished liability in 15 cases (17%); when liability was excluded, examinees were diagnosed in 11 cases with mood disorders, in 23 cases with personality disorders, in 4 cases with adaptation disorders and post-traumatic stress disorder and in 10 cases with different diagnoses (in some cases more than one diagnosis was present). None of the reports used the section of the DSM concerning "cultural framing". Tests were used in 48 surveys (56% of cases), with more tests for each examinee, for a total of 39 Rorschach, 14 Raven test, 8 Minnesota Multiphasic Personality Inventory - MMPI - 4 Wechsler Adult Intelligence Scale - WAIS - level test, 8 Thematic Apperception test. When subjects were diagnosed with mental disorder and with diminished liability, 42 (79%) were also socially dangerous. Results highlight the importance of the relationship between the expert and the foreigner. Many factors ought to be critically considered by experts dealing with foreigners, like cultural awareness, knowledge of verbal communication, critical consideration of meanings and diagnosis, knowledge of the foreigners' personal story, presence of tests with inexact information and cultural fallacy.

[Definition of endometriosis expert centres]

OBJECTIVES

The Collège national des gynécologues obstétriciens français (CNGOF), in agreement with the Société de chirurgie gynécologique et pelvienne (SCGP), has set up a commission in 2017 to define endometriosis expert centres, with the aim of optimizing endometriosis care in France.

METHODS

The committee included members from university and general hospitals as well as private facilities, representing medical, surgical and radiological aspects of endometriosis care. Opinion of endometriosis patients' associations was obtained prior to writing this work. The final text was presented and unanimously validated by the members of the CNGOF Board of Directors at its meeting of October 13, 2017.

RESULTS

Based on analysis of current management of endometriosis and the last ten years opportunities in France, the committee has been able to define the contours of endometriosis expert centres. The objectives, production specifications, mode of operation, missions and funding for these centres were described. The following missions have been specifically defined: territorial organization, global and referral care, communication and teaching as well as research and evaluation.

CONCLUSION

Because of its daily impact for women and its economic burden in France, endometriosis justifies launching of expert centres throughout the country with formal accreditation by health authorities, ideally as part of the National Health Plan.

Laparoscopic Surgery for Gallbladder Cancer: An Expert Consensus Statement

BACKGROUND

Despite the increasing number of reports on the favorable outcomes of laparoscopic surgery for gallbladder cancer (GBC), there is no consensus regarding this surgical procedure.

OBJECTIVE

The study aimed to develop a consensus statement on the application of laparoscopic surgery for GBC based on expert opinions.

METHODS

A consensus meeting among experts was held on September 10, 2016, in Seoul, Korea.

RESULTS

Early concerns regarding port site/peritoneal metastasis after laparoscopic surgery have been abated by improved preoperative recognition of GBC and careful manipulation to avoid bile spillage. There is no evidence that laparoscopic surgery is associated with decreased survival compared with open surgery in patients with early-stage GBC if definitive resection during/after laparoscopic cholecystectomy is performed. Although experience with laparoscopic extended cholecystectomy for GBC has been limited to a few experts, the postoperative and survival outcomes were similar between laparoscopic and open surgeries. Laparoscopic reoperation for postoperatively diagnosed GBC is technically challenging, but its feasibility has been demonstrated by a few experts.

CONCLUSIONS

Laparoscopic surgery for GBC is still in the early phase of the adoption curve, and more evidence is required to assess this procedure.

Survey Results of the Expert Meeting on Laparoscopic Surgery for Gallbladder Cancer and a Review of Relevant Literature

BACKGROUND

Favorable outcomes of laparoscopic surgery for gallbladder cancer (GBC) have been reported; yet consensus on the indications and surgical techniques for laparoscopic surgery for GBC is lacking.

OBJECTIVE

To evaluate the current status of laparoscopic surgery for GBC by analyzing the results of a survey of experts and by reviewing the relevant published literature.

METHODS

Before an expert meeting was held on September 10, 2016 in Seoul, Korea, an international survey was undertaken of expert surgeons in the field of GBC surgery.

RESULTS

The majority of surgeons who responded agreed that laparoscopic surgery has an acceptable role for suspicious or early GBC, and that laparoscopic extended cholecystectomy has a value comparable to that of open surgery in selected patients with GBC. However, the selection criteria for laparoscopic surgery for overt GBC and the details of the surgical techniques varied among surgeons.

CONCLUSIONS

This survey and literature review revealed that laparoscopic surgery for GBC is performed in highly selected cases. However, the favorable outcomes in the published reports and the positive view of experienced surgeons for this operative procedure suggest a high likelihood that laparoscopic surgery will be more frequently performed for GBC in the future.

Towards automated detection, semi-quantification and identification of microbial growth in clinical bacteriology: A proof of concept

Background

Automation in microbiology laboratories impacts management, workflow, productivity and quality. Further improvements will be driven by the development of intelligent image analysis allowing automated detection of microbial growth, release of sterile samples, identification and quantification of bacterial colonies and reading of AST disk diffusion assays. We investigated the potential benefit of intelligent imaging analysis by developing algorithms allowing automated detection, semi-quantification and identification of bacterial colonies.

Methods

Defined monomicrobial and clinical urine samples were inoculated by the BD Kiestra™ InoqulA™ BT module. Image acquisition of plates was performed with the BD Kiestra™ ImagA BT digital imaging module using the BD Kiestra™ Optis™ imaging software. The algorithms were developed and trained using defined data sets and their performance evaluated on both defined and clinical samples.

Results

The detection algorithms exhibited 97.1% sensitivity and 93.6% specificity for microbial growth detection. Moreover, quantification accuracy of 80.2% and of 98.6% when accepting a 1 log tolerance was obtained with both defined monomicrobial and clinical urine samples, despite the presence of multiple species in the clinical samples. Automated identification accuracy of microbial colonies growing on chromogenic agar from defined isolates or clinical urine samples ranged from 98.3% to 99.7%, depending on the bacterial species tested.

Conclusion

The development of intelligent algorithm represents a major innovation that has the potential to significantly increase laboratory quality and productivity while reducing turn-around-times. Further development and validation with larger numbers of defined and clinical samples should be performed before transferring intelligent imaging analysis into diagnostic laboratories.

A Brief History of the Expert Witness

Expert witnesses are now an accepted part of criminal and civil trials. The use of expert witnesses and the admissibility of their science has developed over the last 250 years, when the concept of allowing an expert witness to give opinion evidence on the facts of other witnesses was allowed by Lord Mansfield in the case of Folkes v. Chadd in 1782. This paper briefly describes how court procedures have changed over the centuries before opinion evidence was admitted and then traces the history of the expert witness in England, USA, and Canada, examining issues of admissibility and duties of the expert from the 18th century to the 21st century. The paper further describes the change in admissibility with US decisions in Frye and Daubert and how they have affected courts in the UK and Canada. Also described are recent decisions in the UK on duties of experts and immunity from suit.

Comparing expert- and literature-informed consequence assessments for environmental policy risks receiving national attention

Strategic risk appraisal (SRA) has been applied to compare diverse policy level risks to and from the environment in England and Wales. Its application has relied on expert-informed assessments of the potential consequences from residual risks that attract policy attention at the national scale. Here we compare consequence assessments, across environmental, economic and social impact categories that draw on 'expert'- and 'literature-based' analyses of the evidence for 12 public risks appraised by Government. For environmental consequences there is reasonable agreement between the two sources of assessment, with expert-informed assessments providing a narrower dispersion of impact severity and with median values similar in scale to those produced by an analysis of the literature. The situation is more complex for economic consequences, with a greater spread in the median values, less consistency between the two assessment types and a shift toward higher severity values across the risk portfolio. For social consequences, the spread of severity values is greater still, with no consistent trend between the severities of impact expressed by the two types of assessment. For the latter, the findings suggest the need for a fuller representation of socioeconomic expertise in SRA and the workshops that inform SRA output.

Choice of Endodontic Fiber Posts and its Influence on Dental Malpractice: An in vitro Evaluation

AIMS AND OBJECTIVES

The fiber post type used in restoring endodontically treated teeth may affect the dental expert decision in the case of dental malpractice. The aim of this study was to evaluate the low-cost commercial fiber post in comparison with a higher cost or well-known documented fiber post system.

MATERIALS AND METHODS

A total of 20 premolars were selected for the study; following endodontic treatment, specimens were randomly divided into two groups of 10 specimens each according to the type of fiber post used: (1) Low-cost commercial fiber post (OYAPost, Taper Lucent, OYARICOM) and (2) higher cost well-known fiber post (Rely X Fiber post, 3M ESPE). Both fiber posts were cemented using self-adhesive cement (Rely X Unicem). Samples were subjected to push-out bond strength and to failure analysis. One-way analysis of variance was used (p < 0.005).

RESULTS

There was no significant difference between the bond strength of the two tested groups (p > 0.05), while statistically significant difference (p < 0.05) was noted between the different post space regions (cervical, middle, and apical).

CONCLUSION

Based on the evidence from the study, it can be concluded that the type of fiber post should not affect the dental expert decision in the case of dental malpractice/lawsuit.

CLINICAL SIGNIFICANCE

All types of low-cost fiber posts may behave similarly to other higher cost or well-documented fiber posts.

Relationship between mode of sport training and general cognitive performance

PURPOSE

To investigate whether athletes who engage in different modes of sports training correspondingly exhibit different patterns of performance on general cognition tasks.

METHODS

Sixty participants were recruited into an endurance, motorically complex, or control group, and were administered a series of physical tests and neuropsychological assessments.

RESULTS

Athletes in the endurance group demonstrated the highest levels of cardiovascular fitness and those in the motorically complex group exhibited the highest levels of motor fitness. Nonetheless, no differences in cognitive performance were observed between the 3 groups.

CONCLUSION

These findings indicate that the mode of sport training, which results in either high cardiovascular or high motor fitness, bears no relationship to measures of general cognition in elite athletes. The present findings suggest that coaches and athletic trainers should be encouraged to monitor athletes' stress levels during training in order to maximize the beneficial effects of such training on general cognitive performance.

Comparison of five video-assisted intubation devices by novice and expert laryngoscopists for use in the aeromedical evacuation environment

BACKGROUND

The critically ill or injured patient undergoing military medical evacuation may require emergent intubation. Intubation may be life-saving, but it carries risks. The novice or infrequent laryngoscopist has a distinct disadvantage because experience is critical for the rapid and safe establishment of a secured airway. This challenge is compounded by the austere environment of the back of an aircraft under blackout conditions. This study determined which of five different video-assisted intubation devices (VAIDs) was best suited for in-flight use by U.S. Air Force Critical Care Air Transport Teams by comparing time to successful intubation between novice and expert laryngoscopists under three conditions, Normal Airway Lights on (NAL), Difficult Airway Lights on (DAL) and Difficult Airway Blackout (DAB), using manikins on a standard military transport stanchion and the floor with a minimal amount of setup time and extraneous light emission.

METHODS

A convenience sample size of 40 participants (24 novices and 16 experts) attempted intubation with each of the 5 different video laryngoscopic devices on high-fidelity airway manikins. Time to tracheal intubation and number of optimization maneuvers used were recorded. Kruskal-Wallis testing determined significant differences between the VAIDs in time to intubation for each particular scenario. Devices with significant differences underwent pair-wise comparison testing using rank-sum analysis to further clarify the difference. Device assembly times, startup times and the amount of light emitted were recorded. Perceived ease of use was surveyed.

RESULTS

Novices were fastest with the Pentax AWS in all difficult airway scenarios. Experts recorded the shortest median times consistently using 3 of the 5 devices. The AWS was superior overall in 4 of the 6 scenarios tested. Experts and novices subjectively judged the GlideScope Ranger as easiest to use. The light emitted by all the devices was less than the USAF-issued headlamp.

CONCLUSIONS

Novices intubated fastest with the Pentax AWS in all difficult airway scenarios. The GlideScope required the shortest setup time, and participants judged this device as the easiest to use. The GlideScope and AWS exhibited the two fastest total setup times. Both devices are suitable for in-flight use by infrequent and seasoned laryngoscopists.

The role of surgical expertise with regard to chronic postoperative inguinal pain (CPIP) after Lichtenstein correction of inguinal hernia: a systematic review

OBJECTIVE

The aim of this study was to evaluate whether a relation exists between surgical expertise and incidence of chronic postoperative inguinal pain (CPIP) after inguinal hernia repair using the Lichtenstein procedure .

BACKGROUND

CPIP after inguinal hernia repair remains a major clinical problem despite many efforts to address this problem. Recently, case volume and specialisation have been found correlated to significant improvement of outcomes in other fields of surgery; to date these important factors have not been reviewed extensively enough in the context of inguinal hernia surgery.

METHODS

A systematic literature review was performed to identify randomised controlled trials reporting on the incidence of CPIP after the Lichtenstein procedure and including the expertise of the surgeon. Surgical expertise was subdivided into expert and non-expert.

RESULTS

In a total of 16 studies 3086 Lichtenstein procedures were included. In the expert group the incidence of CPIP varied between 6.9 and 11.7 % versus an incidence of 18.1 and 39.4 % in the non-expert group. Due to the heterogeneity between groups no statistical significance could be demonstrated.

CONCLUSION

The results of this evaluation suggest that an association between surgical expertise and CPIP is highly likely warranting further analysis in a prospectively designed study.

Outbreak definition by change point analysis: a tool for public health decision?

Background

Most studies of epidemic detection focus on their start and rarely on the whole signal or the end of the epidemic. In some cases, it may be necessary to retrospectively identify outbreak signals from surveillance data. Our study aims at evaluating the ability of change point analysis (CPA) methods to locate the whole disease outbreak signal. We will compare our approach with the results coming from experts’ signal inspections, considered as the gold standard method.

Methods

We simulated 840 time series, each of which includes an epidemic-free baseline (7 options) and a type of epidemic (4 options). We tested the ability of 4 CPA methods (Max-likelihood, Kruskall-Wallis, Kernel, Bayesian) methods and expert inspection to identify the simulated outbreaks. We evaluated the performances using metrics including delay, accuracy, bias, sensitivity, specificity and Bayesian probability of correct classification (PCC).

Results

A minimum of 15 h was required for experts for analyzing the 840 curves and a maximum of 25 min for a CPA algorithm. The Kernel algorithm was the most effective overall in terms of accuracy, bias and global decision (PCC = 0.904), compared to PCC of 0.848 for human expert review.

Conclusions

For the aim of retrospectively identifying the start and end of a disease outbreak, in the absence of human resources available to do this work, we recommend using the Kernel change point model. And in case of experts’ availability, we also suggest to supplement the Human expertise with a CPA, especially when the signal noise difference is below 0.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0271-x) contains supplementary material, which is available to authorized users.

Facial Comparison from CCTV footage: The competence and confidence of the jury

CCTV footage is commonly used in the court room to help visualise the crime in question and to help identify the offender. Unfortunately the majority of surveillance cameras produce such poor quality images that the task of identifying individuals can be extremely difficult. This study aimed at determining whether the task of identifying the offender in CCTV footage was one which a jury should be competent to do, or whether expert evidence would be beneficial in such cases. The ability of potential jury members, the general public, was tested by asking participants to play the role of a jury member by means of an online survey. Potential jury members viewed CCTV in which a simulated offence took place, and were subsequently asked to compare still images of a defendant to the offender to try to determine if they were competent and confident about making a judgement as to whether the defendant committed the crime. Factors such as age, gender and profession of the potential jury members were considered, as well as the type of crime committed, in order to establish if these play any role in the decision made by potential jury members. These factors did not appear to play a significant role; however confidence was also investigated and it became very evident that this was a factor that must be taken into consideration when determining the requirement for expert contribution in facial comparisons. Jury members may well be willing and competent to a basic level in carrying out a facial comparison but if they lack a certain level of confidence in their ability and decision making then this task is more suitable for an expert with experience and skills in this field.

SAGES expert Delphi consensus: critical factors for safe surgical practice in laparoscopic cholecystectomy

BACKGROUND

Although it has been 25 years since the introduction of laparoscopy to cholecystectomy, outcomes remain largely unchanged, with rates of bile duct injury higher in the modern age than in the era of open surgery. The SAGES Safe Cholecystectomy Task Force (SCTF) initiative seeks to encourage a culture of safety in laparoscopic cholecystectomy (LC) and reduce biliary injury. An expert consensus study was conducted to identify interventions thought to be most effective in pursuit of this goal.

METHODS

An initial list of items for safer practice in LC was identified by the SCTF through a nominal group technique (NGT) process. These were put forward to 407 SAGES committee members in two-stage electronically distributed Delphi surveys. Consensus was achieved if at least 80 % of respondents ranked an item as 4 or 5 on a Likert scale of importance (1-5). Additionally, respondents ranked five top areas of importance for the following domains: training, assessment, and research.

RESULTS

Thirty-nine initial items were identified through NGT. Response rates for each Delphi round were 40.2 and 34 %, respectively. Final consensus was achieved on 15 items, the majority of which related to non-technical factors in LC. Key domains for training, assessment, and research were identified. Critical view of safety was deemed most important for overall safety, as well as training and assessment of LC. Intraoperative cholangiography was identified as an additional priority area for future research.

CONCLUSIONS

Consensus items to progress surgical practice, training, assessment, and research have been identified, to promote safe practice and improve patient outcomes in LC.

Lifting strategies of expert and novice workers during a repetitive palletizing task

Thirty manual material handlers (15 experts and 15 novices) were invited to perform series of box transfers under conditions similar to those of large distribution centers. The objective of the present study was to verify whether multiple box transfers leading to fatigue would also lead to differences between expert and novice workers in joint motions and in back loading variables (L5/S1 moments). The task consisted in transferring 24 15-kg boxes from one pallet to another (4 layers of boxes; 6 boxes/layer: 3 in the front row, 3 in the back) at a self-determined pace and then at an imposed pace of 9 lifts/min for a total of 240 lifts. The underlying idea was to set a challenging task that would force the experts to use their skills. Full-body 3D kinematic data were collected as well as external foot forces. A dynamic 3D linked segment model was used to estimate the net moments at L5/S1. The results clearly show that the experts bent their lumbar spine less (10° less) and were closer (4 cm) to the box than novice workers. Knee flexions were similar in both groups except when the box was lifted from ground level (expert ≈ 71°, novice ≈ 48°). The peak resultant moment was not statistically different (expert = 168 Nm, novice = 184 Nm) although experts had lower values on average than novices when lifting heights (and deposit heights) of the boxes increased. Therefore, experts differed from novice workers mostly in the posture-related variables. These differences are especially important to consider when the box is located on the ground, as the back posture and back loading are then at their greatest magnitude and could have a major impact on the distribution of internal forces on the spine.

Consistently modeling the same movement strategy is more important than model skill level in observational learning contexts

The experiment undertaken was designed to elucidate the impact of model skill level on observational learning processes. The task was bimanual circle tracing with a 90° relative phase lead of one hand over the other hand. Observer groups watched videos of either an instruction model, a discovery model, or a skilled model. The instruction and skilled model always performed the task with the same movement strategy, the right-arm traced clockwise and the left-arm counterclockwise around circle templates with the right-arm leading. The discovery model used several movement strategies (tracing-direction/hand-lead) during practice. Observation of the instruction and skilled model provided a significant benefit compared to the discovery model when performing the 90° relative phase pattern in a post-observation test. The observers of the discovery model had significant room for improvement and benefited from post-observation practice of the 90° pattern. The benefit of a model is found in the consistency with which that model uses the same movement strategy, and not within the skill level of the model. It is the consistency in strategy modeled that allows observers to develop an abstract perceptual representation of the task that can be implemented into a coordinated action. Theoretically, the results show that movement strategy information (relative motion direction, hand lead) and relative phase information can be detected through visual perception processes and be successfully mapped to outgoing motor commands within an observational learning context.

The development and implementation of a hospital based paediatric orthopaedic nursing transition program

Within Australia and the rest of the world paediatric orthopaedic nursing as a subspeciality nursing workforce faces challenges due to a lack of formal education programs that support the development of knowledge. Despite these challenges the need to ensure the availability of competent and knowledgeable nursing staff to positively contribute to health care outcomes remains unchanged. Thus a need has arisen to develop locally implemented education programs. A multi-tiered paediatric orthopaedic nursing transition program which incorporates work based learning processes combined, with formal assessment components, has been designed utilising Benner's "theory of novice to expert" to facilitate the growth of experts in the clinical setting driven by the requirements of individual clinical settings. The implementation of this program has led to increased confidence in the clinical setting for nursing staff which has positively influenced the care of children and their families in the orthopaedic service.

Critical research needs for identifying future changes in Gulf coral reef ecosystems

Expert opinion was assessed to identify current knowledge gaps in determining future changes in Arabian/Persian Gulf (thereafter 'Gulf') coral reefs. Thirty-one participants submitted 71 research questions that were peer-assessed in terms of scientific importance (i.e., filled a knowledge gap and was a research priority) and efficiency in resource use (i.e., was highly feasible and ecologically broad). Ten research questions, in six major research areas, were highly important for both understanding Gulf coral reef ecosystems and also an efficient use of limited research resources. These questions mirrored global evaluations of the importance of understanding and evaluating biodiversity, determining the potential impacts of climate change, the role of anthropogenic impacts in structuring coral reef communities, and economically evaluating coral reef communities. These questions provide guidance for future research on coral reef ecosystems within the Gulf, and enhance the potential for assessment and management of future changes in this globally significant region.

Learning curves in expert and non-expert laparoscopic surgeons for robotic suturing with the da Vinci(®) Surgical System

We investigated learning curves for robotic suturing of expert and non-expert laparoscopic surgeons to explore the length of time required to reach an acceptable plateau of technical skills. Laparoscopic suturing skills were evaluated in a training box with conventional laparoscopic instrumentation in phase 1. In phase 2, robotic suturing skills were evaluated during a training program on non-surviving animals by analyzing time required for five intracorporal stitches on the small bowel. Learning curves were plotted. A significant difference in technical skills between the expert and non-expert surgeons was demonstrated in phase 1 and at the beginning of phase 2. Both surgeons reached a learning-curve plateau exhibiting similar robotic suturing skills at the end of 90 min of training. Skills were subsequently retained equally by both surgeons. Short duration of training was sufficient for the non-expert laparoscopic surgeon to match the robotic suturing performance of the expert laparoscopic surgeon.