Local Experts Research Articles

Online palliative care education and mentorship in Nepal: Project ECHO - a novel approach to improving knowledge and self-efficacy among interprofessional health-care providers.

Palliative care access in Nepal is severely limited, with few health-care providers having training and skills to pain management and other key aspects of palliative care. Online education suggests an innovation to increase access to training and mentoring, which addresses common learning barriers in low- and middle-income countries. Project ECHO (Extensions for Community Health Care Outcomes) is a model of online education which supports communities of practices (COPs) and mentoring through online teaching and case discussions. The use of online education and Project ECHO in Nepal has not been described or evaluated. An online course, consisting of 14 synchronous weekly palliative care training sessions was designed and delivered, using the Project ECHO format. Course participants included health-care professionals from a variety of disciplines and practice settings in Nepal. The goal of this study was to evaluate the impact of a virtual palliative care training program in Nepal on knowledge and attitudes of participants. Pre- and post-course surveys assessed participants' knowledge, comfort, and attitudes toward palliative care and evaluated program acceptability and barriers to learning. Forty-two clinicians, including nurses (52%) and physicians (48%), participated in program surveys. Participants reported significant improvements in their knowledge and attitudes toward core palliative care domains. Most participants identified the program as a supportive COP, where they were able to share and learn from faculty and other participants. Project ECHO is a model of online education which can successfully be implemented in Nepal, enhancing local palliative care capacity. Bringing together palliative care local and international clinical experts and teachers supports learning for participants through COP. Encouraging active participation from participants and ensuring that teaching addresses availability and practicality of treatments in the local health-care context addresses key barriers of online education. This study describes a model of structured virtual learning program, which can be implemented in settings with limited access to palliative care to increase knowledge and attitudes toward palliative care. The program equips health-care providers to better address serious health-related suffering, improving the quality of life for patients and their caregivers. The program demonstrates a model of training which can be replicated to support health-care providers in rural and remote settings.

Environmental Justice Education in Nepal: Policies and Practices

Environmental justice is fundamental to education and policy, ensuring clean environments and sustainable development. The curriculum and constitution of Nepal focus on this, addressing global gaps and encouraging comprehensive wellbeing measures for educational resilience. This paper analyzes how environmental justice is reflected through equitable treatment and meaningful participation of all people in the creation, implementation, and enforcement of environmental laws, regardless of their race, culture, education, and socioeconomic status. To analyze how environmental justice has been enforced in educational policies, interviews were conducted with five policymakers who have long experience in policymaking in the educational sector. The findings revealed that indigenous knowledge, cultural thought, and belief in environmental justice areas were considered major issues in education policies and practices. This study emphasizes the interconnectedness of local and global environmental issues and the need to bridge the gap. The integration of environmental justice in the national curriculum framework highlights the role of local expertise, indigenous knowledge, and practical application. The study recognizes the significance of environmental consciousness, sustainable development, and equal access to education. This study acknowledges constitutional provisions in Nepal supporting environmentally friendly and sustainable development. It emphasizes the importance of environmental education, equitable treatment, and compensation for environmental injustices to safeguard the environment for future generations.

Increasing perceived health and mental health literacy among separated refugee Ukrainian families with urgent needs occasioned by invasion—a group intervention study with participatory methodology in Sweden

BackgroundWith the increasing numbers of refugees from Ukraine affected by the ongoing war, there is a high risk of trauma-related stress due to low local health and mental health literacy care. Perceived good health is a human right. Earlier studies show that intervention for refugees can reduce and prevent post-migration stress and anxiety. The present explorative study aimed to investigate the feasibility and effectiveness of a short, trauma-focused group intervention (in Swedish “hälsoskola”) for Ukrainian-speaking refugees (EU’s mass refugee directive). This intervention was part of an ESF project aiming to get the subjects closer to the labor market in Västernorrland County, Sweden.Materials and methodsA mixed-methods design, a participatory methodology, and an evaluation were used. Data were obtained with a short questionnaire in Ukrainian. It included a visual analogue health-rating scale, an observation, and an oral evaluation in groups. For practical and ethical reasons, there was no control group. Each group met five times for 2 h, a total of 10 h excluding pre- and post-assessment. There were eight sets of five group sessions per set, a total of 40 sessions. Brief initial and concluding breathing exercises sought to reduce stress among the participants.ResultsBaseline data were obtained from 99 participants, mostly females. Data gathered directly after the group intervention from 57 participants who had filled in both the pre- and post-questionnaires showed that (1) perceived anxiety/stress was significantly reduced (chi-2 25,53, df = 4, p < 001). (2) The participants showed significantly better perceived health as assessed on a visual analogue scale (average change from 63.16 to 71.18, p < 0.001). This result was supported by the participants’ questions, which were qualitatively evaluated using thematic content analysis. Five general themes stemmed from questions raised in dialogue with the participants plus observation with the respective local expert. The participants received answers to their questions, and their perceived negative attitudes to authorities changed to more positive ones.ConclusionBy dialogue between the participants’ needs of knowledge and direct answers by the local expert, respectively, was feasible and effective as they perceived trust and health and mental health literacy increased. Implications for primary prevention are discussed.

A rapid approach to assessing the vulnerability of Mozambican fisheries’ species to climate change

Mozambique is amongst the most vulnerable of Western Indian Ocean (WIO] countries to the impacts of climate change on its marine fisheries. We used rapid assessment methods to evaluate sensitivity, exposure and vulnerability of fisheries species to climate change, appropriate for data-deficient, developing countries in the region. Species were selected based on their importance in industrial and artisanal fisheries’ landings, further prioritized by local experts. Species’ attributes likely to be sensitive to climate change were identified and scored, utilizing life history or biological characteristics. Sea Surface Temperature (SST] was the most prominent climate exposure factor and for which we could confidently predict likely future change. Most species had low or medium overall sensitivity to climate change, with only eight considered highly sensitive. Climate exposure (SST] scores were high off northern Mozambique, while the central and southern regions were generally of medium exposure. Ten species received a High vulnerability score, 14 were Medium, and 16 had a Low vulnerability score. The highly vulnerable species were all fishes, apart from one crustacean; 4 of the 9 were strongly estuarine-associated; the most vulnerable species was the parrotfish Scarus ghobban. This is the first attempt to use a rapid, semi-quantitative, specialist- and trait-based vulnerability assessment of the anticipated effect of climate change on marine fisheries species in the WIO. Challenges experienced were data paucity, limited resources, the large study area, and the complex oceanography of the region. However, a simple methodology was developed, derived from efforts elsewhere, and which can be used to undertake similar assessments for other WIO countries. Raised awareness of climate change among small-scale fishing communities is a necessity, combined with adaptation by promoting fisheries co-management. Also required is support from government to ensure that people can be flexible to change.

Farmers participatory evaluation of bread wheat varieties through seed producer cooperatives: evidence from Ethiopia

The limited engagement of farmers and their community agents in the process of variety development and evaluation is one of the main factors for lower rates of variety adoption, which resulted in lower crop productivity. Participatory bread wheat variety evaluation was jointly conducted by breeders, members of seed producer cooperative (SPC) and local experts with the objectives to identify farmers’ selection criteria, to assess farmers’ preferred varieties and to increase the SPC’s variety portfolios. Twelve released bread wheat varieties were evaluated during 2019 cropping season at Sekela district of Amhara region, Ethiopia. Pair-wise ranking was used to identify farmers’ selection criteria and direct matrix ranking to prioritize those selected criteria. Varieties were planted in two sets with and without lime application. Grain yield, followed by earliness, disease tolerance, and tillering capacity, was identified the first preferred criterion by farmers. The mean values showed that higher yield was recorded with the lime application compared to no lime application. Lemu (6.4 t/ha), Alidoro (6.3 t/ha), Dambal (6.3 t/ha), Obora (6.1 t/ha) and Liben (6.1 t/ha) had greater yield with lime application. The t-test results indicated that significant difference between with and without liming for the number of tillers per plant, spike length per plant, plant height, 1000 seed weight, and hectoliter weight, but non-significant difference for grain yield. The selected varieties should be included in the production plan of the cooperatives for large scale production to increase the variety portfolios and to address the demand of the farming community.

Reducing non-communicable diseases among Palestinian populations in Gaza: A participatory comparative and cost-effectiveness modeling assessment.

We sought to assess the effectiveness and cost-effectiveness of potential new public health and healthcare NCD risk reduction efforts among Palestinians in Gaza. We created a microsimulation model using: (i) a cross-sectional household survey of NCD risk factors among 4,576 Palestinian adults aged ≥40 years old in Gaza; (ii) a modified Delphi process among local public health experts to identify potentially feasible new interventions; and (iii) reviews of intervention cost and effectiveness, modified to the Gazan and refugee contexts. The survey revealed 28.6% tobacco smoking, a 40.4% prevalence of hypertension diagnosis (with a 95.6% medication treatment rate), a 25.6% prevalence of diabetes diagnosis (with 95.3% on treatment), a 21.9% prevalence of dyslipidemia (with 79.6% on a statin), and a 9.8% prevalence of asthma or chronic obstructive pulmonary disease (without known treatment). A calibrated model estimated a loss of 9,516 DALYs per 10,000 population over the 10-year policy horizon. The interventions having an incremental cost-effectiveness ratio (ICER) less than three times the GDP per capita of Palestine per DALY averted (<$10,992 per DALY averted)(<$10,992 per DALY averted) included bans on tobacco smoking in indoor and public places [$34 per incremental DALY averted (95% CI: $17, $50)], treatment of asthma using low dose inhaled beclometasone and short-acting beta-agonists [$140 per DALY averted (95% CI: $77, $207)], treatment of breast cancer stages I and II [$730 per DALY averted (95% CI: $372, $1,100)], implementing a mass media campaign for healthier nutrition [$737 per DALY averted (95% CI: $403, $1,100)], treatment of colorectal cancer stages I and II [$7,657 per DALY averted (95% CI: $3,721, $11,639)], and (screening with mammography [$17,054 per DALY averted (95% CI: $8,693, $25,359)]). Despite high levels of NCD risk factors among Palestinians in Gaza, we estimated that several interventions would be expected to reduce the loss of DALYs within common cost-effectiveness thresholds.

Ethnoprimatology reveals new extended distribution of critically endangered banded langur Presbytis femoralis (Martin, 1838) in Pahang, Malaysia: Insights from indigenous traditional knowledge and molecular analysis.

The banded langur (Presbytis femoralis) is a critically endangered primate, restricted to Johor, Malaysia, with an estimated population size of less than 500 individuals. Traditionally, distribution studies on this highly threatened primate have relied on conventional methods such as DNA identification, live counting, and camera trapping. However, ethnoprimatology offers an alternative approach to data collection, involving the active participation of indigenous and local communities possessing valuable knowledge and experience with local primate species. This study employed an integrated approach incorporating ethnoprimatology by utilizing pooled local expert opinion, local surveys, interviews, and fecal DNA analysis, resulting in a novel distribution range for the banded langur. The combination of expert opinions revealed this species' most optimistic distribution scenario across Johor and Pahang, inhabiting various ecosystems, including lowland forests, peat swamps, and human-modified landscapes. Further interviews and surveys conducted within the Orang Asli community in Tasik Chini and Tasek Bera have provided additional support for the revised distribution, documenting occurrences of banded langur utilization in indigenous practices, such as food consumption, cultural beliefs, medicinal applications, and craftsmanship. Phylogenetic analysis demonstrated genetic differentiation between populations in Johor and Pahang, with the populations in the southern part of Peninsular Malaysia likely serving as ancestral sources for other populations. Consequently, this study not only elucidated the updated distribution of banded langur through DNA records and direct observations but also established the efficacy of ethnoprimatology as a precursory tool for uncovering the present distribution patterns of other primate species in Malaysia.

How can emerging economies meet development and climate goals in the transport-energy system? Modelling co-developed scenarios in Kenya using a socio-technical approach

Transport-energy transitions pose complex challenges that have been extensively studied in high-income countries in response to national mandates for climate action. Low- and middle-income countries, however, have low but rapidly growing motorisation rates and face very different challenges in adopting new technologies to foster economic development and ensure equitable access to clean transportation. Here, we present a set of narrative scenarios for the future of the Kenyan transport-energy system co-developed through engagement with 41 local experts and decision-makers. Through the co-development of a Kenyan transport-energy system model, we present a decision-support tool, populated with those scenarios, to assist policymakers at regional, national and international levels in building policy and investment pipelines to support low-carbon economic growth. We find that Kenya’s transport-energy system can meet both development and climate goals, but this demands strong policy support for efficient public transport and targeted support for road vehicle electrification. Increased support for non-motorised transport is essential to provide equitable access to services and economic opportunities. Favourable pathways result in significant e-mobility uptake, which is anticipated to increase electricity demand by 5%–56% from 2023 to 2040, relative to the IEA Kenya Energy Outlook’s Stated Policies scenario, representing a 2.7–3.9x increase in Kenya’s total electricity demand over the same period. From a macro-fiscal perspective, results show that e-mobility has two important consequences for Kenya. Firstly, under high e-mobility scenarios, there is a negative fiscal impact that taxation revenues from the sale of transport fuels reduce by up to 41% relative to the low e-mobility scenario (though, notably, they still increase marginally from the 2023 level because of increasing transport demand). Secondly, high e-mobility scenarios have a positive impact on balance of payments by reducing the fuel import bill by up to 69% relative to the low e-mobility baseline. This corresponds to a reduction in foreign exchange requirement of up to $4.2bn annually by 2050.

Validity evidence for a team-leading assessment tool in pediatric emergency resuscitations using video review.

Effective leadership of health care action teams has demonstrated positive influence on team performance and patient care, but there is no consensus on how to assess these skills. We developed a novel team leadership assessment tool for leaders of interprofessional pediatric resuscitation teams and collected validity evidence for this tool using video review. This was a prospective cohort study from November 2021 to October 2022. A novel team leadership assessment tool was developed using literature review and local expertise and then piloted and refined using medical simulation. Pediatric emergency medicine (PEM) fellows from a single tertiary care pediatric medical center were enrolled, and videos of one medical resuscitation and one trauma resuscitation were collected per fellow each month. Three reviewers underwent reviewer training and then scored the videos using the assessment tool. Raters provided feedback on feasibility and ease of use using a 5-point Likert scale. Inter-rater reliability for the assessment tool using Gwet's agreement coefficient and the association between performance and clinical level of training using generalized linear mixed model were calculated. Twelve PEM fellows enrolled and 146 videos were reviewed. The inter-rater reliability for each domain ranged from 0.45 (p < 0.0001) to 0.59 (p < 0.0001), with the inter-rater reliability of the total score being 0.49 (p < 0.0001). The reviewers' mean ratings of the elements of the tool were as follows: clarity of the domains (4.6/5), the independence of each domain from each other (3.9/5), the ease of use of the 5-point Likert scale (4.5/5), the usefulness of the provided examples for each domain (4.6/5), and the ability to assess each domain without having to rewatch (4.5/5). The tool differentiated between levels of clinical training for two of the six domains (p < 0.02). We developed a novel team leadership assessment tool for pediatric resuscitation team leaders that demonstrated moderate inter-rater reliability. The tool was easy to use and feasible for educators to assess the performance of PEM trainees in complex high-stakes clinical situations.

A mixed-methods review and adaptation of a novel clinical pharmacy tool: The MA2VER2ICK Tool Study

Abstract Introduction The MA2VER2ICK Tool[1] (see Figure 1) is a clinical pharmacy mnemonic developed in 2016 by the pharmacy department of Tallaght University Hospital, through a combination of literature searching and local expert consensus opinion. The intended purpose of the tool was to guide clinical pharmacists in pharmaceutical care planning. Since inception, the tool has not been formally evaluated. Locally, users report the tool as useful; although, there is scope for improvement, to better support clinical pharmacists. Aim Identify and gain consensus on suggestions to adapt the existing tool. Methods A two-stage mixed-methods approach was adopted. This comprised focus groups to facilitate idea generation and appraise contents of the existing tool, followed by a nominal group technique process[2] to agree the content and structure of the final tool. A purposive sample of clinical pharmacists were selected to participate in the focus groups and nominal group technique panel, based on responses to a screening questionnaire pre-circulated to all clinical pharmacists employed at the study site. Thematic analysis of the focus group transcripts was conducted by two independent researchers, with key themes and related recommendations to improve the tool identified. These recommendations were presented to the nominal group technique panel via an anonymous survey, where numerical rating scores were assigned over two rounds, with an intervening panel discussion. An increase in the mean rating score and convergence of the standard deviation indicated consensus for a recommendation. Results Two focus groups (5 participants each) of 45 minutes duration took place. Both focus groups resulted in similar findings, with seven major themes identified relating to adapting the tool. Overall, eight recommendations were formulated, with suggestions to adapt the content, structure, usability and application of the tool. Consensus agreement was reached on seven recommendations, each receiving a panel rating score &amp;gt; 90%. One recommendation was rejected, receiving a panel rating score &amp;lt; 30%. Conclusion This study demonstrates that the MA2VER2ICK Tool is a comprehensive clinical pharmacy resource. Few amendments were required to the original tool, indicating user satisfaction with and the utility of the tool, together with a high degree of consensus for the adaptations made. VTE: venous thromboembolism; Rx: prescription; CRP: C-reactive protein.

A prospective audit on adult thromboprophylaxis and therapeutic anticoagulation prescribing and administration practices in Galway University Hospitals

Abstract Introduction Anticoagulants are high-alert medications that can cause significant patient harm if used inappropriately.[1] These preparations have been identified as a significant medication safety concern in Galway University Hospitals and are one of the most frequently reported medication incidents in Ireland.[2] A key performance indicator agreed by the local Medication Safety Subgroup and Drugs and Therapeutics Committee was to conduct an anticoagulation audit against local guidelines to identify patterns and develop quality improvements. Methods A prospective audit was conducted over six weeks from September to November 2022 by five interprofessional data collectors using a data collection tool and accessing drug records and clinical notes. Development of the tool was guided by national[1] and local guidelines as well as design input from local expert specialist doctors and pharmacists. Adult inpatients on all wards receiving thromboprophylaxis (after 24 hours of admission) or therapeutic anticoagulation were included. Paediatrics and psychiatry were excluded. The protocol and tool were approved by the local Clinical Audit Committee, piloted with three inpatients, and communicated to all data collectors prior to commencement. Generated data were anonymous and securely stored. Data analysis was carried out by two independent researchers to confirm reliability of results. Results A total of 242 inpatients were audited on 26 wards: -Patients prescribed thromboprophylaxis (52%; 126/242). -Patients prescribed therapeutic anticoagulation (26%; 63/242) -Patients not prescribed anticoagulants (22%; 54/242) Most patients (92%; 216/234) did not have a thromboprophylaxis risk assessment form completed/signed. Nineteen patients (35%; n=54) not prescribed thromboprophylaxis or therapeutic anticoagulation should have been prescribed anticoagulation. High compliance with guidelines (&amp;gt;80%) included: i) anticoagulants prescribed in correct section of drug record, ii) appropriate agents prescribed, iii) correct dose and frequency, iv) few dose delays and omissions, and v) indication mostly documented. Low compliance with guidelines (&amp;lt;35%) included: -Patient height and weight not documented: unable to calculate creatinine clearance to determine accurate dose. -Incorrect administration times for once daily therapeutic dosing (should be in morning to facilitate surgery next day) and twice daily dosing (mostly 8am and 10pm = gap of 14 hours and 10 hours). Conclusion Results have identified varying levels of compliance with local anticoagulation guidelines. To date, there has been continuous targeted education and training on appropriate anticoagulation use for doctors, nurses, and pharmacy staff inclusive of the development and implementation of a new bespoke eLearning module for high-alert medications (which includes the appropriate use of anticoagulants specific to Galway University Hospitals). High leverage strategies, such as electronic prescribing, is a current consideration to standardise practices. Strengths include study robustness, interprofessional collaboration, and transferability to other hospitals. Perhaps reducing the scope in a re-audit which will be conducted in 2024 to identify any improvements in medication safety and patient care with these agents may allow for further in-depth analysis.

Does the State of Scientific Knowledge and Legal Regulations Sufficiently Protect the Environment of River Valleys?

The pressure of human activity in river valley environments has always been high. Even today, despite the increasing awareness of societies around the world regarding the need to protect water and biodiversity, there are concerns that the current river valley management systems are insufficient. Therefore, the aim of this study was to assess the state of knowledge about the soils and forest ecosystems of river valleys in terms of the possibility of protecting river valley environments. This study used data obtained from the Forest Data Bank (FDB) database, which focuses on forests in Poland. After analyzing 17,820 forest sections where the soils were described as fluvisols, it was found that forest areas associated with fluvisols (typical, fertile soils of river valleys) are quite well recognized and protected in Poland. Most (55%) forested fluvisols are located in Natura 2000 sites (an important European network of biodiversity hotspots), 4% in nature reserves, and 1% in national parks. Additionally, the main forest habitat type associated with fluvisols is riparian forest, composed mainly of Quercus, Ulmus, and Fraxinus, which is protected as Natura 2000 habitat type 91F0. Preserving the sustainability of the forest is also a form of soil protection. Despite the identification of soils and forests in river valleys, as well as appropriate legal tools, their protection may be ineffective due to the fragmentation of forms of protection and the lack of a coherent system for managing river valleys. Because the conservation status of the river valleys is also influenced by the management of areas located outside the river valleys, in order to protect river valley ecosystems, integrated conservation plans for entire catchments should be implemented. Due to potential conflicts related to the management of areas with diverse expectations of local communities, it would be advisable for such plans to be created by local experts but under the supervision of a specialist/specialists from outside the area covered by a given river basin.

Wind Lore as Environmental Knowledge in Southern Vanuatu

Wind lore constitutes an important domain of environmental knowledge in eight cultures of southern Vanuatu (Aneityum, Futuna, Aniwa, Nafe, Naka, Netwar, Nanu, and Nahual). Our study reviews previous studies in Oceania which document wind systems as used primarily for long-distance navigation. The named winds of southern Vanuatu are not merely abstract directional markers, nor primarily for use in navigation, but are closely tied to the local geography, agriculture, health, and seasonal changes. Winds are part of everyday, embodied experience and cognitive-spiritual understanding of the environment. Wind lore is gradually being forgotten, but can still be described in detail by experts. We conclude by situating wind lore within a culture complex that includes knowledge of agriculture, fishing, time-reckoning, and weather magic. Our documentation of these systems is ongoing, and in collaboration with local experts.

Risks on the Belt and Road in Eurasia: Local Perspectives and Options

ABSTRACT A binary, geopolitical narrative of a new “Great Game” for power in Central Asia may be too simplistic. It remains unclear what regionalisation trends will become embedded in Central Asia, with the apparent rise of China. The paper examines potential for China's Belt and Road Initiative to build new Eurasian economic interdependence through connectivity infrastructure and to reduce dependency for some actors on Russia. A political risk and grounded theory approach is taken, utilising in-depth interviews with local experts and stakeholders to develop a risk/opportunity framework. Conclusions from the research indicate China is unlikely in the foreseeable future to replace Russia as regional hegemon, but is likely to drive greater economic integration. Empirical investigation of dynamics on the ground - including the spectrum of options available to actors - is recommended for realist understanding of economic and other international connectivity trends across Central Asia.

Cost-Effectiveness Analysis of Fluocinolone Acetonide Intravitreal (FAI) Implant for Chronic Noninfectious Uveitis Affecting the Posterior Segment of the Eye (NIU-PS) in China.

Chronic non-infectious uveitis affecting the posterior segment (NIU-PS), which can be recurrent and persistent for numerous years, mainly affects people of working age and significantly increases the risk of visual impairment. This study aimed to investigate the cost-effectiveness of fluocinolone acetonide intravitreal (FAI) implant in the treatment of patients with chronic NIU-PS from the Chinese healthcare perspective. A Markov model with a 2-week cycle was constructed from the perspective of the Chinese healthcare system over a lifetime time horizon. The model consists of four health states: on-treatment, treatment failure, blindness, and death. The outcomes for effectiveness were based on the Chinese real-world study (RWS). Utilities and mortality rates were derived from published literature and standard sources. Costs were determined from the MENET website, prices of medical service items at local providers, published literature, and expert surveys. Outcomes were measured in quality-adjusted life years (QALYs). Sensitivity analyses were performed to account for the impact of uncertainty. It was estimated that in the base case, the FAI implant provided 0.43 incremental QALYs compared with the limited current practice (LCP) at an additional cost of $7503.72 (¥50,575.05), resulting in an incremental cost-effectiveness ratio (ICER) of $17,373.49 (¥117,097.33) per QALY gained. Parameters related to utility emerged as the primary influencers on the outcomes. In probabilistic sensitivity analysis (PSA), considering the willingness-to-pay (WTP) threshold of $19,072 (¥128,547) and $38,145 (¥257,094), the FAI implant had 67.70% and 99.50% probability of being cost-effective, respectively. As demonstrated in the scenario analysis, if the FAI implant aligns its price reduction with the average rate from the 2023 negotiation of the National Reimbursement Drug List (NRDL), it would result in lower costs and represent an absolute advantage. The FAI implant, which can effectively reduce the recurrence rate and maintain the incremental costs within the WTP limit, is likely to be cost-effective in treating chronic NIU-PS in China.

Urban treescapes as everyday workplaces and knowledge battlegrounds: Lessons from Bangkok, Thailand

Urban greening expertise and programs are pursued and circulated globally to enhance urban livability and sustainability, but the outcomes are often mixed and are accompanied by side effects. Drawing on the concept of “worlding,” this paper examines the processes and outcomes of a training program that introduced tree climbing techniques from overseas to reduce the aggressive pruning practices by the municipal workforce in Bangkok, Thailand. Steered by Thai civil society organizations (CSOs) and international arborists, the training program was supported by the city government and local forestry experts. However, the outcomes were limited. A variety of temporal, logistical, and place-specific factors (including traffic, weather, size and accessibility of trees), constrained the applicability of the introduced techniques for pruning street trees in Bangkok. These crucial urban contextual factors were neglected in the training program design due to knowledge conflicts between the “civic experts” and “lay practitioners,” which undermined the potential of the training program. Illustrating urban treescapes as everyday workplaces and knowledge battlegrounds, this paper argues that aspirations for world-leading expertise might hamper the expression of tacit knowledge that stems from and coordinates with a specific urban context. The conclusion highlights the importance of inclusivity to achieve successful transnational circulation of greening expertise and broader urban transformative attempts involving global knowledge exchange.

A decision-making framework for the funding of shipping decarbonization initiatives in non-EU countries: insights from Türkiye

The decarbonization of the shipping industry is a critical imperative in the global fight against climate change. Non-EU countries, being significant contributors to shipping emissions, play a crucial role in shaping the industry's sustainable future. However, securing funding for shipping decarbonization initiatives in these countries presents challenges, such as limited access to capital, lack of financial initiatives, political and regulatory uncertainties, technological risks, lack of local expertise, and the effects of global economic volatility. Addressing these challenges demands innovative strategies. The paper explores ways of effectively allocating funds for decarbonization projects in the shipping industry of non-EU countries, Türkiye in particular, using a structured decision-making framework tailored to their specific needs and challenges. We adopt the Moment Integrated Solution Method (THEMIS) to identify the “best” option from the range of alternative strategies identified in the framework. Our findings show that the use of incentive mechanisms is the most prioritized funding alternative, followed by the implementation of a sound Cap-and-Trade system and the promotion of strict local regulations to combat emissions. These imply that the prioritization of funding mechanisms, market-driven approaches, and more stringent regulation are key drivers in maritime decarbonization efforts. The Türkiye case study on strategies to achieve a greener maritime industry in developing countries also shows that securing funding for decarbonization requires a concerted effort by governments, private entities, and international organizations.

Finding fun in the fatigue: Exploring healthism among group fitness instructors

The concept of health is culturally contingent, and fitness practices provide a venue to gain insights into the construction of health. In this case study–based article, I focus on group fitness instructors’ narratives on healthiness and fitness rituals. By combining Foucault’s notion of the ‘microphysics of power’ and the socio-cultural phenomenon healthism, I employ a genealogical approach that reveals how healthism renders a discursive space for group fitness instructors (‘local fitness experts’) to navigate their understanding of health norms. A qualitative method consisting of 22 semi-structured interviews was used. Group fitness instructors teaching in Austria for a global group fitness distributor (Les Mills) were interviewed. The results show that eliminating risks to health is the highest imperative to the instructors, which is traced back to a dichotomy between ‘disciplined training’ and ‘fun training’, where fun training is seen as feminine and risky. Furthermore, instructors underline their health literacy through skeptical consumerism – choosing health for the sacrifice of fun or finding fun in the fatigue.

Management of malignant Gastric Outlet Obstruction (mGOO) due to pancreatic cancer in the era of EUS-Gastrojejunostomy: an international practice survey and case vignette study by Pancreas 2000 from the European Pancreatic Club.

Malignant Gastric Outlet Obstruction (mGOO) has been standardly treated by surgical Gastrojejunostomy (S-GJ) or Endoscopic Stenting (ES). Recently, EUS-Gastrojejunostomy (EUS-GJ) has emerged as an alternative, despite its worldwide diffusion is heterogeneous. The aim of this survey was to assess clinical decision-making around mGOO and to explore current opinions regarding EUS-GJ. An online survey, spread through social networks and EPC newsletter, was created exploring opinions regarding indications, contraindications, benefits/risks, availability of mGOO treatments; 2 case vignettes explored clinical decision-making in different scenarios. Overall, 290 pancreatologists from 44 countries responded, of whom 35% surgeons and 65% gastroenterologists. The most common treatment for mGOO was ES (86%), followed by laparoscopic GJ (76%). EUS-GJ was accessible to 59% of respondents, with 10% proficient in this technique. Gold-standard treatment for mGOO varied by specialty; 45% of gastroenterologists preferred ES, 20% EUS-GJ, and 10% surgical GJ, while among surgeons, these were 24%, 8%, and 25%, respectively. A higher annual volume of mGOO treated correlated with increased EUS-GJ adoption and reduced surgical advice. For 51%, EUS-GJ will become the primary treatment for mGOO, notably higher among gastroenterologists and high-volume centers. For 14%, EUS-GJ spread will be limited in the future, or used only when ES fails (19%). Life expectancy, disease stage and patient's frailty are the main decision driver in therapeutic choice, whereas future surgical resectability does not contraindicate any treatment for 75%. EUS-GJ's main advantages were its minimally invasive nature and clinical efficacy, offset by its steep learning curve. This survey revealed significant differences in the management of mGOO, depending on specialties, local expertise and treatment volume, suggesting the lack of standardized algorithms. Life expectancy and patients' frailty are the main decision drivers. Regarding EUS-GJ, its availability remains suboptimal, with learning curve as the main perceived barrier.

Enhancing the SUSTAINable uptake of evidence to minimise harms from alcohol and other drugs in New South Wales, Australia.

Although alcohol and other drug use is increasingly the focus of policy and research efforts, there are challenges identifying and applying evidence-based strategies to minimise harms for alcohol and other drugs in health care and community settings. These challenges include limited available research, variability across settings, and lack of 'fit' between research evidence and their intended settings. In this commentary, we describe a novel approach to develop and evaluate tailored, sustainable strategies to enhance the uptake of evidence-based activities into health services and community settings. Our approach involves four key principles: (i) identifying evidence-based alcohol and other drug harm minimisation strategies; (ii) partnering with local experts to identify and tailor strategies; (iii) implementing strategies into existing practice/infrastructure to build in sustainability; and (iv) using sustainable co-designed outcome measures including value-based health-care principles to measure uptake, feasibility and acceptability, health outcomes and economic implications. We propose that this approach offers a way forward to enhance the relevance and suitability of research in health services and community settings and has potential to be applied in other sectors.