Methodology for the development of National Multidisciplinary Management Recommendations using a multi-stage meta-consensus initiative.

BACKGROUND: Methods for developing national recommendations vary widely. The successful adoption of new guidance into routine practice is dependent on buy-in from the clinicians delivering day-to-day patient care and must be considerate of existing resource constraints, as well as being aspirational in its scope. This initiative aimed to produce guidelines for the management of head and neck squamous cell carcinoma of unknown primary (HNSCCUP) using a novel methodology to maximise the likelihood of national adoption. METHODS: A voluntary steering committee oversaw 3 phases of development: 1) clarification of topic areas, data collection and assimilation, including systematic reviews and a National Audit of Practice; 2) a National Consensus Day, presenting data from the above to generate candidate consensus statements for indicative voting by attendees; and 3) a National Delphi Exercise seeking agreement on the candidate consensus statements, including representatives from all 58 UK Head and Neck Multidisciplinary Teams (MDT). Methodology was published online in advance of the Consensus Day and Delphi exercise. RESULTS: Four topic areas were identified to frame guideline development. The National Consensus Day was attended by 227 participants (54 in-person and 173 virtual). Results from 7 new systematic reviews were presented, alongside 7 expert stakeholder presentations and interim data from the National Audit and from relevant ongoing Clinical Trials. This resulted in the generation of 35 statements for indicative voting by attendees which, following steering committee ratification, led to 30 statements entering the National Delphi exercise. After 3 rounds (with a further statement added after round 1), 27 statements had reached 'strong agreement' (n = 25, 2, 0 for each round, respectively), a single statement achieved 'agreement' only (round 3), and 'no agreement' could be reached for 3 statements (response rate 98% for each round). Subsequently, 28 statements were adopted into the National MDT Guidelines for HNSCCUP. CONCLUSIONS: The described methodology demonstrated an effective multi-phase strategy for the development of national practice recommendations. It may serve as a cost-effective model for future guideline development for controversial or rare conditions where there is a paucity of available evidence or where there is significant variability in management practices across a healthcare service.

Jejunal free flap for reconstruction of pharyngeal defects in patients with head and neck cancer-the Birmingham experience.

We retrospectively audited operative complications, success of flaps, and speech and swallowing outcomes in patients with head and neck cancer who had reconstruction with jejunal free tissue transfer to the pharynx. A total of 104 patients had jejunal free flaps between 1987 and 2009 at University Hospital, Birmingham. Management was by a multidisciplinary team, and the same vascular surgeon did all the anastomoses. We investigated the relations between patients, operative factors, and postoperative complications, and noted the ischaemic time of the flaps and coexisting conditions of the patients. Outcomes measured included initial and final survival rates of flaps, donor and recipient site complications, and speech and swallowing outcomes on discharge and up to 2 years postoperatively. Of the 104 patients, 14 (13%) had initial flap complications but overall flap survival was 97%. A total of 11 (11%) patients developed a fistula at a mean of 15 days postoperatively and 11 (11%) had minor donor site complications. A total of 95 (91%) were able to resume oral diet on discharge. Of the 44 who were followed up on discharge, 32 (73%) were able to maintain oral intake at 2 years and 31 (70%) could use their voice in everyday situations. The jejunal free flap enables the tumour to be removed, and reconstruction and restoration of function to be done in a single operation using tissue that is versatile. The operation is associated with low morbidity at the donor and recipient sites, and results in good speech and swallowing outcomes. The flap can also be used to reconstruct pharyngolaryngeal defects.

Proving the skeptics wrong: why major health reform can happen despite the odds.

Notwithstanding the pessimistic prognostications of Washington's cynical elite, broad health reform is achievable precisely because it is an economic and fiscal imperative. Indeed, the stakeholders with the greatest power to promote or undermine progress are on board, concluding that the status quo is unsustainable and the second best option is no longer to do nothing.

Glucose uptake after resistance training of different intensities but of equal work volume.

High-intensity (HI) resistance exercise augments postexercise glucose uptake to a greater degree than low-intensity (LO) resistance exercise; however, few studies have equated the work volumes between intensity levels. The purpose of this study was to compare the effect of acute HI and LO resistance exercise of equal work volume on glucose uptake in resistant-trained men. Fifteen healthy male (22.9 +/- 3.8 years old), resistance-trained (6.7 +/- 3.9 years) subjects completed three treatment sessions: CON (no-exercise control), HI (3 x 8, 85% 10-RM), and LO (3 x 15, 45% 10-RM). HI and LO sessions consisted of eight exercises. Glucose uptake was measured the following morning by using the hyperinsulinemic euglycemic clamp technique. Glucose disposal was measured by analyzing the glucose infusion rate during the final 30 minutes of steady-state blood glucose concentrations. Insulin sensitivity was calculated by dividing the glucose infusion rate by the average insulin infusion. Results indicate that fasting blood glucose levels were not significantly different among treatment sessions (CON = 80.5 +/- 5.3 versus HI = 77.0 +/- 4.9 versus LO = 77.1 +/- 6.0 mg.dL). Glucose uptake was not significantly different among treatment sessions (CON = 11.3 +/- 3.0 versus HI = 11.7 +/- 2.7 versus LO = 11.4 +/- 2.8 mg.kg FFM.min). Insulin sensitivity did not change among treatment sessions (CON = 0.26 +/- 0.09 versus HI = 0.28 +/- 0.07 versus LO = 0.27 +/- 0.06 (mg.kg FFM.min)/(uU.mL)). The data indicate that the resistance training sessions did not modify acute insulin sensitivity. This may have been because of the high levels of fitness of the subjects, which allowed for the cellular adaptations for enhanced insulin sensitivity and glucose uptake that are unaffected by this volume of acute exercise.