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PubMed2004

Preliminary results of an expert-opinion elicitation process to prioritize an informative system funded by Italian Ministry of Health for cadaveric donor management, organ allocation, and transplantation activity.

Expert-opinion elicitation (EOE) is a heuristic process for gathering evidence and data or answering questions on issues/problems of concern. The Delphi method (DM) is the most frequent technique used to obtain structured elicitation of expert opinions. It has been increasingly applied in medicine to produce guidelines and to evaluate the appropriateness of diagnostic procedures. In this study, a DM has been used as structured EOE process to assess the appropriateness and clinical priority of a data set-based informative system in the context of the Liguria-Trento Transplant Network (LTTN) Project, funded by Italian Ministry of Health. The original data set was obtained by using an interdisciplinary pool of regional experts (n = 60). This data set held 1506 items stratified in 21 categories at various surgical phases (preoperative, intraoperative, and postoperative) and transplantation types (liver, kidney, and kidney/pancreas) in adult and pediatric recipients. Some categories included cadaveric donor management, organ allocation, and acute liver failure. In the second DM round, the data set was subjected to a panel of extraregional, independent experts (n = 9) to assess scores ranging from 1 to 9 on each item, based on increasing appropriateness/priority, according to RAND/UCLA Appropriateness Method. The overall agreement between experts was 95.88%, whereas disagreement and uncertainty were 0.13% and 3.98%, respectively. A major uncertainty occurred for the data set concerning the multiorgan cadaveric donor, for liver transplantation, and for kidney transplantation in adult recipients. The use of a structured EOE process may represent an effective strategy to define the appropriateness and prioritization criteria of a large data set in the field of solid organ transplantation.

Health Services Research↗

PubMed2006

A novel model of organic waste composting in Taiwan military community.

The relatively large quantities of waste generated daily in military barracks pose a significant impact on environments in this small island of Taiwan due to limited land and crowded populations. In order to find a suitable handling method to the barracks' characteristics in Taiwan, a comprehensive selection model for various barracks carrying out waste composting was established through personal interviews and questionnaire data analyses on the military barracks. From this, the basic data for this research was also built, to evaluate the experiences and management practices in these facilities. This study found that environmental responsibility and expertise are the primary concerns and considerations among all of the military units when doing waste composting. Support of the commander, organizational image and human resource/facilities are also concerns. To offer the military barracks a selection model and policy guidelines for the waste composting treatment, an itemized score evaluation standard and a selecting chart of composting recycling methods were designed by combining the practical experimental results with economic considerations, waste classification, and Delphi expert technique.

Conservation of Natural Resources↗

PubMed2006

A decision support system for the operational planning of solid waste collection.

This study presents the conception, modeling, and implementation of a decision support system applied to the operational planning of solid waste collection systems, called SCOLDSS. The main functionality of the system is the generation of alternatives to the decision processes concerning: (a) the allocation of separate collection vehicles, as well as the determination of their routes and (b) the determination of the daily amount of solid waste to be sent to each sorting unit, in order to avoid waste of labor force and to reduce the amount of waste sent to the landfills. To develop the computer system, a combination of quantitative techniques was used, such as: simulation of discrete events and algorithms/heuristics for vehicle allocation and routing. The system was developed using the Borland Delphi environment and the commercial software Arena to carry out the simulations. We also present a computational study with real-life data from the solid waste collection in Porto Alegre, Brazil, in which we show that the results provided by the computational system outperform the operation planning currently adopted.

Algorithms↗

PubMed1997

The role of nutrition support dietitians as viewed by chief clinical and nutrition support dietitians: implications for training.

OBJECTIVES: To determine current and ideal frequencies with which nutrition support dietitians perform each item on a list of 15 tasks and evaluate dietitian preparation for the practice of nutrition support. DESIGN: Data were collected using two questionnaires, one completed by the chief clinical dietitian and the other completed by the nutrition support dietitian at each hospital surveyed. Both versions of the questionnaires contained a list of 15 tasks that had been validated as being related to advanced nutrition support by a panel of 20 nutrition support experts using a modified Delphi method. Follow-up telephone calls were made to increase the number of responses. SAMPLE: Questionnaires were mailed to the chief clinical dietitian at 300 randomly selected, general medical/surgical hospitals with 300 or more beds in the United States and Puerto Rico. A total of 134 chief clinical dietitians (45%) and 129 nutrition support dietitians (43%) responded to the surveys; 124 (41%) and 120 (40%) questionnaires, respectively, were usable for statistical analyses. STATISTICAL ANALYSES: The Wilcoxon matched-pairs signed-ranks test was used to determine differences between nutrition support dietitian actual and ideal frequencies and between chief clinical dietitian actual and ideal frequencies for each of the 15 tasks. The Mann-Whitney U-Wilcoxon rank sum W test was used to determine differences between nutrition support dietitian and chief clinical dietitian actual frequencies and between nutrition support dietitian and chief clinical dietitian ideal frequencies for each of the 15 tasks. Descriptive statistics were used to analyze the questions regarding educational preparation for nutrition support practice and demographic data. RESULTS: The ideal frequency for each of the 15 tasks was significantly greater (P < .0001) than the actual frequency reported by nutrition support dietitians and chief clinical dietitians. Whereas chief clinical dietitians and nutrition support dietitians agreed on the ideal frequency for most tasks, the nutrition support dietitian ideal frequency indicated for the tasks "determines macronutrient composition of parenteral nutrition" and "performs physical examinations related to nutritional status, fluid status, and gastrointestinal function" was significantly greater (P < .001, P < .05), respectively) than the ideal frequency indicated by chief clinical dietitians. Of the nutrition support dietitians, 79% agreed and 16% somewhat agreed that experiences beyond those required for becoming a registered dietitian are needed to provide nutrition support dietitians with specialized clinical skills. APPLICATIONS/CONCLUSIONS: Nutrition support dietitians desire increased responsibility for delivering nutrition support to their patients and this desire is largely supported by chief clinical dietitians. Nutrition support dietitians appear to have a strong interest in postregistration qualifying experiences that would provide a foundation for expanding their roles. According to the results of this study, programs designed to provide practical, clinical experience in nutrition support are needed.

Attitude of Health Personnel↗

PubMed1997

Molecular dynamics study of free energy profiles for organic cations in gramicidin A channels.

The free energy profiles for four organic cations in right-handed single-helix gramicidin A dimers were computed by using umbrella sampling molecular dynamics with CHARMM. Ion-water column translocations were facilitated by using a novel "water-tunnel" approach. The overlapping pieces of free energy profile for adjacent windows were selected from three trajectories that differed in initial ion rotation and were aligned by the method of umbrella potential differences. Neglected long-range electrostatic energies from the bulk water and the bilayer were computed with DelPhi and added to the profile. The approach was corroborated for the formamidinium-guanidinium pair by using perturbation dynamics at axial positions 0, 6, 12, and 15 A from the channel center. The barrier to ethylammonium entry was prohibitive at 21 kcal/mol, whereas for methylammonium it was 5.5 kcal/mol, and the profile was quite flat through the channel, roughly consistent with conductance measurements. The profile for formamidinium was very similar to that of methylammonium. Guanidinium had a high entry barrier (deltaF = +8.6 kcal/mol) and a narrow deep central well (deltaF = -2.6 kcal/mol), qualitatively consistent with predictions from voltage-dependent potassium current block measurements. Its deep central well, contrasting with the flat profile for formamidinium, was verified with perturbation dynamics and was correlated with its high propensity to form hydrogen bonds with the channel at the dimer junction (not shared by the other three cations). Analysis of the ensemble average radial forces on the ions demonstrates that all four ions undergo compressive forces in the channel that are at maximum at the center of the monomer and relieved at the dimer junction, illustrating increased flexibility of the channel walls in the center of the channel.

Amidines↗

PubMed1999

Swiss consensus guidelines for hysterectomy. Swiss Society of Gynecology and Obstetrics, Switzerland.

OBJECTIVE: The quality of the indication for hysterectomy is widely discussed at present. In early 1996, the committee for quality assurance of the Swiss Society of Gynecology and Obstetrics decided to set up nationally accepted guidelines for the indication of hysterectomy. METHODS: A modified Delphi approach was used. In a first step, general guidelines and actions prior to hysterectomy were defined. An expert panel of 17 Swiss gynecologists rated 74 frequent indications, twice for appropriateness (more benefits than risks for the patient), once for necessity (n = 34; procedure has to be offered or discussed with the patient), and outlined suggestions to be performed prior to hysterectomy. RESULTS: In a home rating round before the first panel met, there was an agreement rate of 48%. In 45% we observed neither agreement nor disagreement; in 7% we found disagreement. After the panel discussion 89% of experts agreed, 11% were indeterminate, and there was no disagreement. The necessity ratings showed agreement in 68% while 32% were indeterminate. The average median rating on a 1-9 point scale (1 = extremely inappropriate, 9 = extremely appropriate or necessary) was 5.4 over all single indications for appropriateness and 7.8 in single indications for necessity. After a second panel for consensus all panelists agreed on both appropriateness and necessity. CONCLUSION: The results of the appropriateness and necessity consensus presented in this paper reflect the findings of a 17 member Swiss panel. This joint effort by a medical society may be a step towards the direction of a peer controlled healthcare system.

Congresses as Topic↗

PubMed1996

Clinical aspects of a multicenter clinical trial of implant-retained mandibular overdentures in patients with severely resorbed mandibles.

In a multicenter clinical trial treatment, the effects of overdentures on different implant systems in patients with severely resorbed mandibles were compared 1 year after the insertion of new dentures. The implant systems used were the transmandibular implant (TMI), the IMZ (IMZ), and the Brånemark system (BRA). Treatment was randomly assigned to 88 patients according to a balanced allocation method. Evaluation included peri-implant and radiographic parameters. According to the Delphi method a Clinical Implant Performance scale (CIP) was constructed based on all conceivable complications of the different implant systems. During the healing period, one IMZ and one BRA implant were lost, and one TMI implant was removed after functional loading. The results of the peri-implant and radiographic parameters and the CIP scale revealed no significant differences between the three implant systems.

Adult↗

PubMed2002

A methodology for objective assessment of errors: an example using an endoscopic sinus surgery simulator.

A well-proven methodology (the modified Delphi method) was used to generate a first-order approximation of errors that should be measured in a virtual reality surgical simulator (the ES3). The methodology and the errors derived were crafted in such a way as to be generalizable. Although some of the error measures are specific for sinus surgery, the same type of methodology can be used for other otolaryngologic, general, and [table: see text] subspecialty surgical procedures. The value of this process is that it can provide a uniform framework for investigators in surgical education and training to establish error measurements in their particular procedures or disciplines and to generate data and outcomes that are comparable, interoperable, and sharable with other investigators. Admittedly, the process is time consuming and rigorous, but it does provide a solid scientific basis to generate evidence-based data for the validation of training methods and for outcomes analysis.

Clinical Competence↗

PubMedDate not supplied

Marine mammals as global pollution indicators for organochlorines.

Blubber tissues of the following marine mammals differing in their geographic distribution (North Atlantic, North Pacific, Bering Sea/Arctic Ocean), trophic level, and feeding habits were analyzed for their organochlorine contents: two seal species (harbor seals--Phoca vitulina, northern fur seals--Callorhinus ursinus), three toothed whale species (belukha whales--Delphinapterus leucas, one common dolphin--Delphinus delphis, one pilot whale--Globicephala melaena), and one baleen whale species (a bowhead whale--Balaena mysticetus). As xenobiotics were quantified the seven indicator congeners of the polychlorinated biphenyls (PCB 28, 52, 101, 118, 138, 153, and 180), three isomers of the hexachlorocyclohexanes (alpha-, beta- and gamma-HCH) as well as six components of the DDT-group (4,4'-DDT, 4,4'-DDD, 4,4'-DDE, 2,4'-DDT, 2,4'-DDD, and 2,4'-DDE). When comparing the xenobiotic levels of these marine mammals, it showed that the animals from the western North Atlantic were contaminated about 15 times more with organochlorines than the animals from the eastern North Pacific and the Bering Sea/Arctic Ocean. The total organochlorine burden, the 4,4'-DDE-percentage as well as the metabolic PCB patterns correlate with the trophic levels of the marine mammals studied. The quantitative analyses were done by high-resolution capillary gas chromatography with electron capture detection (HRGC/ECD) whereas the analyses of the metabolic PCB patterns were done by high-resolution capillary gas chromatography and mass selective detection (HRGC/MSD).

Adipose Tissue↗

PubMed1998

Heavy metals in dolphins stranded on the French Atlantic coast.

Heavy metal concentrations (total and organic Hg, Ti, Cr, Cu, Zn, Cd and Pb) were determined in the muscle, liver and kidney of 36 dolphins stranded on the French Atlantic coast between 1977 and 1990: 29 common dolphins Delphinus delphis, five bottlenose dolphins Tursiops truncatus and two striped dolphins Stenella coeruleoalba. Total Hg concentration in the liver increased with age, while relative methylmercury concentration decreased, reflecting the existence of a slow demethylation process. To a lower extent, a similar pattern was observed in the kidney and muscle. No age-related increase was found for other heavy metals, although the highest levels for Cd and Cr were always found in adults. No difference in contamination could be detected between the 1977-1980 and 1984-1990 periods.

Animals↗

PubMed1999

Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis, and other airway disorders.

BACKGROUND: There have been no recent assessments of the economic burden of sinusitis in the peer-reviewed literature. OBJECTIVE: We sought to estimate the 1996 total direct health care expenditures for the treatment of sinusitis. METHODS: This study determined (1) direct expenditures of medical and surgical encounters in which sinusitis was the primary diagnosis and (2) attributable expenditures when related airway diseases were the primary diagnosis and sinusitis was a comorbid condition. An expert panel used the Delphi consensus-building technique to determine the proportions for the latter. RESULTS: Overall health care expenditures attributable to sinusitis in 1996 were estimated at $5.8 billion, of which $1.8 billion (30.6%) was for children 12 years or younger. A primary diagnosis of acute or chronic sinusitis accounted for 58.7% of all expenditures ($3.5 billion). About 12% each of the costs for asthma and chronic otitis media and eustachian tube disorders were attributed to diagnosis and treatment of comorbid sinusitis. Nearly 90% of all expenditures ($5.1 billion) were associated with ambulatory or emergency department services. CONCLUSION: The economic burden of sinusitis in the United States is significant. However, the limitations of this type of evaluation suggest the $5.8 billion amount may be an underestimate of the true direct costs.

Adult↗

PubMed1999

Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses.

BACKGROUND: The Quality of Reporting of Meta-analyses (QUOROM) conference was convened to address standards for improving the quality of reporting of meta-analyses of clinical randomised controlled trials (RCTs). METHODS: The QUOROM group consisted of 30 clinical epidemiologists, clinicians, statisticians, editors, and researchers. In conference, the group was asked to identify items they thought should be included in a checklist of standards. Whenever possible, checklist items were guided by research evidence suggesting that failure to adhere to the item proposed could lead to biased results. A modified Delphi technique was used in assessing candidate items. FINDINGS: The conference resulted in the QUOROM statement, a checklist, and a flow diagram. The checklist describes our preferred way to present the abstract, introduction, methods, results, and discussion sections of a report of a meta-analysis. It is organised into 21 headings and subheadings regarding searches, selection, validity assessment, data abstraction, study characteristics, and quantitative data synthesis, and in the results with "trial flow", study characteristics, and quantitative data synthesis; research documentation was identified for eight of the 18 items. The flow diagram provides information about both the numbers of RCTs identified, included, and excluded and the reasons for exclusion of trials. INTERPRETATION: We hope this report will generate further thought about ways to improve the quality of reports of meta-analyses of RCTs and that interested readers, reviewers, researchers, and editors will use the QUOROM statement and generate ideas for its improvement.

Authorship↗

PubMed2003

Marine mammals from northeast Atlantic: relationship between their trophic status as determined by delta13C and delta15N measurements and their trace metal concentrations.

The relationship between trophic position through delta13C and delta15N and trace metal concentrations (Zn, Cd, Cu and Hg) was investigated in the tissues of six marine mammal species from the Northeast Atlantic: striped dolphin Stenella coeruleoalba, common dolphin, Delphinus delphis, Atlantic white-sided dolphin Lagenorhynchus acutus, harbour porpoise Phocoena phocoena, white beaked-dolphin Lagenorhynchus albirostris, grey seal Halichoerus grypus stranded on French Channel and Irish coasts. White-beaked dolphins, harbour porpoises, white-sided dolphins, common and striped dolphins display the same relative and decreasing trophic position, as measured by delta15N values, along both the Irish and French channel coasts, reflecting conservative trophic habits between these two places. Hepatic and renal Cd concentrations were significantly correlated to muscle delta13C and delta15N values while Hg, Zn and Cu did not. These results suggest that Cd accumulation is partly linked to the diet while other factors such as age or body condition might explain Hg, Zn or Cu variability in marine mammals. Combined stable isotope and trace metal analyses appear to be useful tools for the study of marine mammal ecology.

Animals↗

PubMed2003

Cost-minimization analysis of pegylated liposomal doxorubicin versus topotecan for the treatment of ovarian cancer in Italy.

BACKGROUND: Ovarian cancer is the most prevalent gynecologic cancer in women. Unfortunately for patients whose cancer is resistant to first-line therapies (platinum and paclitaxel), only a few second-line regimens have both significant efficacy and minimal treatment-related toxicity. Furthermore, the use of these agents increases treatment costs due to adverse events (AEs) related to tolerability and toxicity. OBJECTIVE: The aim of the present study was to assess the comparative patient-specific treatment costs associated with 2 second-line therapies, both benchmark therapies used to treat ovarian cancer patients in Italy: pegylated liposomal doxorubicin (PLD) and topotecan, which appear to have similar efficacy but different tolerability and toxicity profiles. METHODS: A cost-minimization analysis was performed in line with the point of view of Italy's National Health Service. Data on treatment efficacy and the number and types of AEs associated with drug toxicity were taken from a recent Phase III clinical trial comparing PLD with topotecan for the treatment of ovarian cancer. Resource-use estimates for each AE were based on the opinions of a panel of experts (Delphi method). Unit costs were drawn from national sources and a sensitivity analysis was performed. RESULTS: The mean total per-patient cost in the PLD arm was 8812 euro(minimum, 8281 euro; maximum, 9314 euro) compared with 15,788 euro in the topotecan arm (minimum 12,014 euro; maximum 18,847 euro). The higher acquisition cost of PLD offset the higher cost of managing the AEs related to treatment with topotecan. CONCLUSIONS: The present analysis suggested the net cost-saving capability of PLD compared with topotecan. PLD required fewer ambulatory care-center visits for treatment administration and was associated with fewer severe AEs than topotecan.

Antineoplastic Agents↗

PubMedDate not supplied

Basic aseptic technique for medical students: Identifying essential entry-level competencies.

PURPOSE: Medical students must be competent in basic aseptic technique (BAT) to function effectively in the operating room. However, a comprehensive literature review revealed a deficit of research in standardized BAT training for the operating room in medical school curricula. METHODS: A modified reactive Delphi technique was used to survey an expert panel of 100 surgical educators. A focus group provided initial responses to key questions, and the panel completed 2 surveys. In the first survey, the panel identified elements for a BAT curriculum for the operating room. In the second survey, the panel received feedback from the first survey and was asked to respond in light of those results. RESULTS: An 81% response rate was obtained from the first survey. A 74% response rate was obtained from the second survey. Seven of the 18 essential entry-level competencies (EELCs) identified were ranked as the most important. The top 5 instructional strategies and the top 3 methods for evaluation were also selected. The panel identified the third-year curriculum as the preferred time of training and a nurse preceptor/educator as the preferred instructor. CONCLUSIONS: These results provide a minimum set of educational objectives that can be used to develop a standardized curriculum in BAT for the operating room for medical students.

Journal Article↗

PubMed2002

PC-based visual stimuli for behavioural and electrophysiological studies of optic flow field detection.

A PC-based visual-stimulus-generation package for behavioural and electrophysiological studies of responses to optic flow is described. Developed for studies of crab vision, the package is particularly well suited for use with animals that have very large fields of view, i.e. +/-120 degrees. Programs, written in the Borland Delphi language, use the OpenGL graphics library to create realistic representations of motion in a three dimensional environment. Large-field stimuli include simulations of self-motion (rotation and translation, separately or in combination) relative to a square-wave grating or other, user-selected, background. The package also includes representations of approaching and receding objects, and rotating spiral patterns for the investigation of neural responses to looming/anti-looming. Additionally, the package provides local motion stimuli, translating or rotating targets presented at many points in the receptive field, which can be used to derive response maps of large-field motion-sensitive interneurones. In all these stimuli, inconsistencies in animation timing that have hitherto hindered the use of standard PCs running Microsoft Windows for such applications have been minimised by using an improved real-time clock to control the animation cycle.

Animals↗

PubMed2002

A pharmacoeconomic evaluation of results from the Coronary Angioplasty Amlodipine Restenosis Study (CAPARES) in Norway and Canada.

INTRODUCTION: The objective of this analysis was to evaluate the health economic benefits of using amlodipine in patients undergoing angioplasty procedures in Canada and Norway. METHODS: A decision tree model was constructed to find the total expected cost per patient for a 4-month time period following an initial angioplasty. The model used clinical data from the Coronary Angioplasty Amlodipine Restenosis Study (CAPARES), a prospective, randomized, double blind, placebo-controlled trial conducted to investigate the effects of amlodipine on restenosis and clinical events in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). Outcomes of interest to this analysis included MI, repeat PTCA, CABG, and all-cause mortality. Clinical experts from Canada and Norway were enlisted and a modified Delphi study approach was used to quantify healthcare resources consumed for each clinical outcome. RESULTS: The use of amlodipine decreased the rates of MI, PTCA, and CABG by 2.0, 4.7, and 2.7%, respectively. The total expected cost per patient using amlodipine was $6,398.30 (US$4,323) in Canada and kr 59,993.27 (US$6,846) in Norway. The total expected cost per patient not using amlodipine was $6,519.37 (US$4,405) in Canada and kr 64,292.17 (US$7,337) in Norway. The model demonstrated potential cost-savings over a 4-month follow up period resulting from the improved clinical outcomes for patients using amlodipine with PTCA--$121,071 (US$81,844) per 1000 patients in Canada and kr 4,298,899 (US$490,074) per 1000 patients in Norway. CONCLUSIONS: The adjunctive use of amlodipine is a cost-effective therapeutic strategy to achieve more favorable clinical outcomes in patients undergoing PTCAs in Canada and Norway.

Amlodipine↗

PubMed2001

Three-dimensional visualization of lung blood flow heterogeneity based on fluorescent microsphere technique and fractal dimension: The Blood Flow Analysis System - BFA System.

The heterogeneity of regional pulmonary blood flow (RPBF) can be assessed by fractal analysis. The fractal dimension (FD) is a scale-independent measure of spatial heterogeneity of blood flow. The relative dispersion (RD) is often used to obtain the heterogeneity of RPBF but it is influenced by the resolution of measurement. The Blood Flow Analysis (BFA) System was developed in Delphi to represent the three-dimensional structure of lung blood flow and calculates statistics of FD, RD, spatial correlation of neighbored tissue samples and shows histograms of blood flows at diverse time points during different experiments. The BFA System reads a text file with flows, measured with fluorescent microsphere technique, and constructs the lung anatomy with volumetric pixels showing the flows with a color schema. It is possible to rotate the lungs into two axis (XY) and the statistics are shown with 3D graphics. The System maintains a database with data from various studies at same time. The BFA System was validated with four data sets from previous experiments. The BFA System has shown consistency and it is a new tool to help researchers during lung perfusion studies.

Animals↗