Predetermined Outcome Research Articles

Real-World Persistence with Ocrelizumab in Multiple Sclerosis: a Systematic Review.

In clinical trials, the percentage of patients discontinuing treatment with ocrelizumab due to adverse events was low. However, real-world populations are often more diverse than randomized controlled trials (RCTs), therefore it is important to assess discontinuation rates in real-world studies. This systematic literature review (SLR) was conducted to identify real-world discontinuation and persistence data for ocrelizumab in studies of patients with relapsing remitting multiple sclerosis (RRMS) and primary progressive multiple sclerosis (PPMS). Searches were conducted in MEDLINE and Embase to identify relevant real-world studies that met pre-determined Population, Intervention, Comparison, Outcomes, and Study (PICOS) criteria. Only articles published in English were included, but the study country was not restricted. A total of 30 studies were included, with the majority reporting real-world persistence data that appear to be similar to or better than in the pivotal clinical trials, with only 1 study reporting higher discontinuation rates due to adverse events compared with the clinical trials. Other studies identified reported that the risk of discontinuation was higher for other disease-modifying therapies (DMTs) compared with ocrelizumab, and adherence was also higher for ocrelizumab versus other DMTs. These findings have clinical relevance, as other studies have reported improved clinical outcomes and lower care costs for patients that are persistent or adherent to other DMTs.

Prediction of post-hemorrhagic ventricular dilatation trajectory using a growth mixture model in preterm infants.

Early intervention for post-hemorrhagic ventricular dilatation (PHVD), guided by ventricular size measurements from cranial ultrasound (cUS), is associated with improved neurodevelopmental outcomes in preterm infants but benefits must be balanced against intervention risks. Anterior horn width (AHW) and ventricular index (VI) were measured from cUS for preterm infants (<29 weeks) with intraventricular hemorrhage admitted from 2010-2018. PHVD was defined as AHW > 6 mm or VI >97th percentile for postmenstrual age. Individual ventricular size trajectories were plotted, and a growth mixture model (GMM) used to identify latent trajectory classes and compare these to predetermined outcome of neurosurgical intervention. Measurements were obtained from 1543 cUS in 249 infants, of whom 39 had PHVD without and 17 PHVD with neurosurgical intervention based on signs of raised intracranial pressure. The GMM predicted trajectory identified: 93.3% of infants without PHVD, 88.2% and 30.8% of infants with PHVD with and without intervention using AHW; 100% of infants without PHVD, 52.9% and 59.0% of infants with PHVD with and without intervention using VI. The AHW GMM identified a significant proportion of infants with severe PHVD. Model refinement offers a promising approach for identifying differences in PHVD trajectory at an early stage to guide management. It is difficult to distinguish the trajectory of PHVD in the early stage of development, in particular PHVD that spontaneously arrests from slowly progressive PHVD which eventually requires intervention. We report the first modeling-based evaluation of PHVD trajectory for the prediction of short-term outcome of PHVD progression and neurosurgical intervention. With additional clinical validation and optimization to increase accuracy, predictive modeling has the potential to identify important differences in PHVD trajectory at an early stage in the clinical course, allowing for more individualized data-driven risk-benefit assessments to guide decisions on early intervention.

Strategic organisational change process for managing a bank’s change and transition from a crisis situation

Whether banking executives want or not, the implementation of strategies aimed at mitigating a crisis may in one way or another involve the change and transformation of a bank’s particular area of operations. Hence, organisational change and transformation is part and partial of the overall process of a bank’s crisis management. Unfortunately, most of the banking executives often accomplish crisis management as though it does not involve any form of change and transformation, only for the effectiveness of the crisis management strategies to be marred by the poorly managed change related complications. To address such complexities, this seminal paper used the qualitative meta-synthesis to assess, identify and extract a combination of the strategic change management processes that the banking executives can use during the implementation of changes that are essential for enhancing the successful implementation of crisis management strategies. During a bank’s crisis management, findings revealed that irrespective of the types or the dimensions undertaken by the organisational change and transformation, theories and literature still insinuate that social organisational change and transformation is not just a random process, but a more systematic process aimed at achieving some pre-determined outcomes. To accomplish that, findings imply usage of a systematic organisational change and transformation process is a necessity for enhancing Situational Analysis, Vision Setting, Communication of the Impetus for Change, Change Implementation, and Measuring and Improving Progress of Change Implementation.

Clinical Disease Measures in Palmoplantar Pustulosis: A Scoping Review

Background Palmoplantar pustulosis (PPP) is a rare, relapsing, disease characterized by pustules, pain, and fissuring. PPP is often combined with psoriasis, most commonly palmar plantar psoriasis, in clinical trials which further complicates our understanding of treatment response. Objective The objective of this scoping review is to describe all outcome measures (clinician-reported &amp; patient-reported) used in previous PPP clinical trials. Methods A search was conducted in Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) for clinical trials and prospective cohort studies performed in adults with PPP, with an intervention and pre-determined outcomes collected at pre specified time points. Results The initial search identified 1839 records, of which 69 met our inclusion criteria. The studies were published between 1970–2023 and included a total of 3301 patients. The most common primary study outcome was the clinician-reported Palmoplantar Pustulosis Psoriasis Area Severity Index (ppPASI) ( n = 39, 56.5%) and an endpoint of 12 weeks ( n = 23, 33.3%). Other common clinician reported outcomes identified were pustule count ( n = 26, 37.7%) and the Physician Global Assessment ( n = 16, 23.2%) The majority of studies ( n = 43, 62.3%) did not include any patient reported outcome measures. Of those that did include patient reported outcome measures, the Dermatology Life Quality Index was most utilized ( n = 17, 24.6%), followed by symptoms-specific instruments measuring pain ( n = 11, 15.9%) and itch ( n = 6, 8.7%). Conclusions While the clinician-reported ppPASI has become the standard primary outcome in PPP clinical trials, there is still considerable heterogeneity and lack of specificity in the patient reported outcomes used.

Molnupiravir Use Among Patients with COVID-19 in Real-World Settings: A Systematic Literature Review.

Molnupiravir (MOV) is an oral antiviral for the treatment of individuals with mild-to-moderate COVID-19 and at high risk of progression to severe disease. Our objective was to conduct a systematic literature review (SLR) of evidence on the effectiveness of MOV in reducing the risk of severe COVID-19 outcomes in real-world outpatient settings. The SLR was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines and using pre-determined population, intervention, comparison, outcome, time, and study design inclusion criteria. Eligible studies were published between January 1, 2021, and March 10, 2023, and evaluated the real-world effectiveness of MOV compared to no treatment in reducing the risk of severe COVID-19 outcomes among outpatients ≥ 18years of age with a laboratory-confirmed diagnosis of SARS-CoV-2 infection. Nine studies from five countries were included in the review. The size of the MOV-treated group ranged from 359 to 7818 individuals. Omicron variants of SARS-CoV-2 were dominant in all study periods. Most studies noted differences in the baseline characteristics of the MOV-treated and untreated control groups, with the treated groups generally being older and with more comorbidities. Eight studies reported that treatment with MOV was associated with a significantly reduced risk of at least one severe COVID-19 outcome in at least one age group, with greater benefits consistently observed among older age groups. In this SLR study, treatment with MOV was effective in reducing the risk of severe outcomes from COVID-19 caused by Omicron variants, especially for older individuals. Differences in the ages and baseline comorbidities of the MOV-treated and control groups may have led to underestimation of the effectiveness of MOV in many observational studies. Real-world studies published to date thus provide additional evidence supporting the continued benefits of MOV in non-hospitalized adults with COVID-19.

‘Innovating’ to promote equity and inclusion in early childhood education: a framework for documenting localised pedagogical approaches

ABSTRACT This paper presents a conceptual framework for understanding ‘innovation’ in early childhood education as a process for addressing issues around social justice and inclusion. The framework is used to analyse innovative aspects of two unique, localised early childhood programmes implemented to support ethnic minority children in Northern Thailand and children of migrant labourers in urban India. Drawing on contemporary critiques that point to the global predominance of universalised models of teaching and learning, the paper highlights these contextually-responsive programmes as crucial in demonstrating the importance of ‘emergent’ pedagogical approaches for achieving equity and inclusion. To promote greater acknowledgement of programmes such as these, the paper presents a case for shifting the current focus on ‘innovation’ in education away from an emphasis on effectiveness for supporting greater efficiency of standardised, pre-determined learning outcomes, to encompass small-scale, localised approaches that support children from marginalised backgrounds.

The Outcomes of Isolated Tibiocalcaneal Arthrodesis: A Systematic Review.

Tibiocalcaneal arthrodesis (TCA) can be achieved by internal fixation (intramedullary nail or plate), external fixation, or a combination. Evidence for the optimal approach is limited. This systematic review examines the outcomes of these different approaches to guide surgical management. A MEDLINE and Oxford SOLO search was performed using "tibiocalcaneal," "ankle," "fusion OR arthrodesis." The primary outcome was union. Secondary outcomes included rates of postoperative complications, weightbearing status, rates of revision surgery, and PROMs. We included any studies with follow-up greater than 6 months that contained our primary outcome and at least 1 secondary outcome. The initial search yielded 164 articles, of which 9 studies totaling 53 cases met the criteria. The majority of articles were excluded because they were nonsurgical studies, or were not about isolated TCA but were for tibiotalocalcaneal arthrodesis, more complex reconstructions (eg, Charcot), case reports, and/or did not include the predetermined outcome measures.TCA union rate was 86.2% following external fixation, 82.4% for intramedullary nail fixation, and 83.3% for plate fixation. One patient underwent a hybrid of external and internal fixation, and the outcome was nonunion. The rate of complications following TCA was 69.8%. There is limited evidence on the best operative approach for isolated tibiocalcaneal arthrodesis. Both external and internal fixation methods had comparable union rates. External fixation had frequent complications and a more challenging postoperative protocol. Novel techniques such as 3D-printed cages and talus replacement may become a promising alternative but require further investigation.

Predicting the Outcome of Patients with Severe COVID-19 with Simple Inflammatory Biomarkers: The Utility of Novel Combined Scores-Results from a European Tertiary/Referral Centre.

Background: The clinical significance of combinations of inflammatory biomarkers in severe COVID-19 infection is yet to be proved. Although several studies have evaluated the prognostic value of biomarkers in patients with COVID-19, there are limited data regarding the value of the combination scores that could take full advantage of the prognostic value of several biomarkers and that could account for the heterogeneity of patients with severe COVID-19. We investigated the prognostic value of combination scores of admission values of inflammatory biomarkers in adults with severe COVID-19. Methods: Adults admitted to the Department of Respiratory Medicine of the UHL with severe COVID-19 (April-September 2021, NCT05145751) were included. Demographics, medical history, laboratory tests and outcome (high-flow nasal cannula (HFNC), admission to Intensive Care Unit (ICU) or death) were recorded. The optimal cut-off points of on admission values of C-reactive protein (CRP), CRP to lymphocyte ratio (CLR), lymphocyte to neutrophil ratio (LNR) and derived variation of neutrophil to lymphocyte ratio (dv-NLR (neutrophil/white blood count-lymphocyte)) for the predetermined outcome were defined. Based on the cut-off of CRP, LNR, dv-NLR and CLR, which were found to be predictors for HFNC, 3 scores were defined: CRP and LNR (C-CRP #1), CRP and dv-NLR (C-CRP #2), CRP and CLR (C-CRP #3). Likewise, based on the cut-off of CRP and CLR, which were found to be predictors for death, the score of CRP and CLR (C-CRP #3*) was defined. The combination scores were then classified as: 2 points (both biomarkers elevated); 1 point (one biomarker elevated) and 0 points (normal values). None of the biomarkers was predictive for the ICU admission, so no further analysis was performed. Binomial logistic regression analysis was used to establish the predictive role for each biomarker. Results: One hundred and fifteen patients (60% males, mean age 57.7 years) were included. Thirty-seven (32.2%) patients required HFNC, nine (7.8%) died and eight (7%) were admitted to ICU, respectively. As far as HFNC is concerned, the cut-off point was 3.2 for CRP, 0.231 for LNR, 0.90 for dv-NLR and 0.004 for CLR. Two points of C-CRP #1 and 2 points of C-CRP #3 predicted HFNC with a probability as high as 0.625 (p = 0.005) and 0.561 (p < 0.001), respectively. Moreover, 1 point of C-CRP #2 and 2 points of C-CRP #2 predicted HFNC with a probability of 0.333 and 0.562, respectively. For death, the optimal cut-off point for CRP was 1.11 and for CLR 3.2*1033. Two points of C-CRP #3* with an accuracy of 0.922 predicted mortality (p = 0.0038) in severe COVID-19. Conclusions: The combination scores of CRP and inflammatory biomarkers, based on admission values, are promising predictors for respiratory support using HFNC and for mortality in patients suffering from severe COVID-19 infection.

Probabilistic Interpretation of Entrepreneurial Opportunity Using the Many-Worlds Model

This research engages with the uncertainties and unknowable in entrepreneurship with literature on the philosophy of quantum mechanics in an analogical way. Often characterized as a journey into an uncertain future, entrepreneurship stands out as a dynamic and unpredictable domain driven by a compelling and indefinable force. This research’s central argument revolves around the notion that within the entrepreneurial landscape, many latent propensities exist, each carrying its distinct probability of manifesting into various outcomes. Unlike a deterministic process with a single predetermined outcome, entrepreneurship is a complex interplay of potentialities. To capture this multifaceted perspective, we leverage the principles and formalism of quantum mechanics, renowned for its emphasis on potentiality over actuality until subjected to observation and action. This philosophical framework describes the inherent potentialities embedded within entrepreneurial opportunities. This study introduces a groundbreaking Many-Worlds model inspired by the interpretations of quantum mechanics. In this model, the act of observation serves as a catalyst, unraveling a spectrum of potential outcomes, each characterized by its probability. These potentialities materialize based on entrepreneurs’ intentional actions and decisions, reflecting their commitment to shaping the future of their ventures. In summary, our study bridges the gap between entrepreneurship and quantum mechanics by proposing a novel framework that portrays entrepreneurship as an exploration of a quantum-like landscape of possibilities. By emphasizing the significance of intentionality and action, our research sheds new light on entrepreneurship’s dynamic and unpredictable nature, illustrating how entrepreneurs play a pivotal role in transforming potential into reality.

Investigating top-down and bottom-up strategic alignment of event leveraging outcomes: the case of the 2021 UCI Road World Championships

ABSTRACT Research question It is generally agreed upon that deliberate planning is needed to achieve pre-determined positive outcomes from sport events (i.e. event leveraging). There is less consensus around the specific strategies that should be used to achieve such outcomes, and ownership of such strategies. A largely conceptual suggestion has been made that both top-down and bottom-up stakeholders should be involved in event leveraging. Therefore, the purpose of this paper is to investigate the (mis)alignment of top-down and bottom-up stakeholders’ event leveraging objectives and how this (mis)alignment relates to objective achievement. Research methods In the context of the city of Leuven (Belgium), and the 2021 UCI Road World Championships, a case study methodology was employed with three phases of data collection and analysis of (1) top-down stakeholder documents; (2) semi-structured interviews with bottom-up stakeholders (n = 8); and (3) online questionnaires with residents (n = 3662). Results and findings We found alignment for only one top-down and bottom-up objective (i.e. promote cycling as a means of active transportation), which was found to be achieved through examining residents’ use of cycling for groceries. The remaining objectives were not aligned, and therefore were not fully met or sustained as indicated through resident opinion and behaviour. Implications The findings provide empirical support for previous conceptual notions that both top-down and bottom-up strategies to event leveraging are needed. Future research can help support leveraging sport events by working with both top-down and bottom-up stakeholders prior to hosting to help facilitate objective alignment, and foster relationships to maximize outcomes.

A 10-month impact evaluation of a journal club among diagnostic radiographers in a single NHS Trust: A service evaluation study

IntroductionJournal clubs (JC) have emerged as a popular tool within medical and health professions to deliver outcomes such as promotion of evidence-based practice (EBP), improvement of critical appraisal skills, as well as stimulation of research interest among participating professionals. However, the delivery of these outcomes within the diagnostic radiography profession has not been evidenced and this is the aim of this service evaluation. MethodsThis evaluation adopted a pre- and post-evaluation survey design to explore the impact of a novel JC introduced among diagnostic radiographers in a UK NHS Trust. Impact was assessed based on four pre-determined outcomes such as Knowledge of EBP, Attitude to EBP, Critical Appraisal Skill and Research interest. Open ended questions in the post evaluation survey were also used to obtain participants feedback on JC activities attended. ResultsEvaluation of the four pre-determined outcomes indicated that JC activities participated by diagnostic radiographers resulted in positive changes across all evaluated categories. Attitude to EBP was the only outcome to show a statistically significant positive change across all participants, highlighting that the JC affected EBP attitudes positively for those that attended. Furthermore, thematic analysis of open-ended questions indicated that the collaboration experienced among JC members during critical appraisal of articles was a motivation for continued participation while factors such as high clinical workload and absence of management in meetings were identified as mitigating barriers. ConclusionParticipation in the JC showed positive improvements in all pre-determined categories. The collaborative nature of JC was motivating for staff, however barriers such as management absence in meetings, and high clinical workload did cause some challenges. Research is recommended to look at the longer-term impact of JC activities amongst diagnostic radiographers.

OP52 Treating Osteoporosis In Postmenopausal Women With Denosumab (Prolia®): A Systematic Review And Network Meta-Analysis

IntroductionIt is estimated that osteoporosis affects over 200 million people globally. Postmenopausal women (PMW) have an increased risk of developing osteoporosis due to low estrogen levels. This study assessed the safety and effectiveness of denosumab (Prolia®) relative to placebo, selective estrogen receptor modulators (SERMs) (bazedoxifene and raloxifene), and bisphosphonates (alendronate, ibandronate, risedronate, and zoledronate) for the treatment of osteoporosis in PMW.MethodsSystematic searches were conducted in three biomedical databases (PubMed, the Cochrane Library, and Embase) to identify randomized controlled trials (RCTs) of PMW with osteoporosis allocated to denosumab, placebo, bisphosphonates, or SERMs. The Cochrane Risk of Bias 2.0 tool was used to critically appraise included RCTs. Pairwise and Bayesian network meta-analyses were performed on the following predetermined outcomes: fractures (vertebral and nonvertebral); adverse events (AEs); mortality; serious AEs (SAEs); withdrawals due to AEs; bone mineral density (BMD); and AEs caused by denosumab discontinuation.ResultsThe analyses included 12 RCTs (22 publications, 25,879 participants). Denosumab, ibandronate, alendronate, zoledronate, and risedronate produced a statistically significant improvement in total hip (TH) and lumbar-spine (LS) BMD, compared with placebo. Similarly, ibandronate, risedronate, and alendronate showed a statistically significant improvement in femoral neck (FN) BMD. Risedronate produced a statistically significant decrease in nonvertebral fractures (risk ratio 0.20, 95% confidence interval: 0.00, 0.97) relative to placebo. However, there were no significant differences between any of the interventions for rates of vertebral fractures, AEs, SAEs, withdrawals due to AEs, or mortality, compared with placebo.None of the included trials reported evidence on AEs caused by denosumab discontinuation.ConclusionsDenosumab was associated with significant improvements in both LS and TH BMD relative to placebo. Similarly, compared with placebo, denosumab was not associated with significant changes in nonvertebral or vertebral fractures. Denosumab was not associated with significant changes in safety outcomes relative to placebo. Given that some of the analyses suffered from statistical imprecision, these findings should be interpreted with caution. Regarding policy, continued funding of denosumab needs to be reviewed.

Efficacy of tyrosine-kinase-2 and phosphodiesterase-4 inhibitors for scalp psoriasis: a systematic review and meta-analysis

Objectives Psoriasis of the scalp is challenging to manage. The only approved oral tyrosine kinase 2 and phosphodiesterase 4 inhibitors for psoriasis are deucravacitinib and apremilast. The aim of this study was to explore their efficacy for scalp psoriasis utilizing data from randomized controlled trials. Methods We searched Medline, Scopus, Web of Science, CENTRAL, and ClinicalTrials.gov up to August 4, 2023. To determine risk of bias, the revised Risk of Bias assessment tool 2.0 was used. Inverse variance random effects meta-analyses were executed. Heterogeneity was assessed utilizing Q and I2 statistics. Pre-determined outcomes included the proportion of participants with cleared scalp skin (Scalp Physician’s Global Assessment [ScPGA] of 0/1), mean change in Psoriasis Scalp Severity Index (PSSI), and mean improvement in Dermatology Life Quality Index (DLQI). Results Ten RCTs fulfilled inclusion criteria. Both apremilast (RR = 2.41, 95% CI = 2.08–2.79, Tau2 = 0, I2 = 0) and deucravacitinib (RR = 3.86, 95% CI = 3.02–4.94, Tau2 = 0, I2 = 0) were more effective in inducing ScPGA of 0/1 at 16 weeks compared to placebo. Furthermore, deucravacitinib was more effective than apremilast (RR = 1.70, 95% CI = 1.44–2.00, Tau2 = 0, I2 = 0). An analysis could not be executed for the rest of the outcomes. Conclusions Apremilast and deucravacitinib are effective for scalp psoriasis. Deucravacitinib may be more efficient in clearing the scalp.

Accounting Practices and Guiding Principles Influencing Shared Value Creation

This study explored the shared value and the types. Porter and Kramer’s shared-value model is analysed; its critiques are outlined, and other approaches along with their weaknesses suggested by previous researchers, are explored. A documentary research approach, which consists of reviewing, analysing and examining information was adopted. The sources included journal articles, books, frameworks and guidelines. The results of the study indicated/revealed that value is not only accounted for in financial terms but also in intangible drivers, value creation processes result in predetermined output and outcomes which cannot be predetermined. The study also indicated that shared- value is a term that is not distinctively and commonly used as its components were not clearly spelt out. Researchers/ scholars have failed to distinguish it from other similar models of social and environmental responsibility. The study concludes that creating shared value from social and relations capital contributes towards increased productivity and sustainability of a company.

Atopic dermatitis phenotypes based on cluster analysis ofthe Danish Skin Cohort.

Despite previous attempts to classify atopic dermatitis (AD) into subtypes (e.g. extrinsic vs. intrinsic), there is a need to better understand specific phenotypes in adulthood. To identify, using machine learning (ML), adult AD phenotypes. We used unsupervised cluster analysis to identify AD phenotypes by analysing different responses to predetermined variables (age of disease onset, severity, itch and skin pain intensity, flare frequency, anatomical location, presence and/or severity of current comorbidities) in adults with AD from the Danish Skin Cohort. The unsupervised cluster analysis resulted in five clusters where AD severity most clearly differed. We classified them as 'mild', 'mild-to-moderate', 'moderate', 'severe' and 'very severe'. The severity of multiple predetermined patient-reported outcomes was positively associated with AD, including an increased number of flare-ups and increased flare-up duration and disease severity. However, an increased severity of rhinitis and mental health burden was also found for the mild-to-moderate phenotype. ML confirmed the use of disease severity for the categorization of phenotypes, and our cluster analysis provided novel detailed information about how flare patterns and duration are associated with AD disease severity.

A Study on the Impact of Small-Scale Courtyard Landscape Layouts on Spatial Oppressiveness in Dense High-Rise Environments

Numerous studies have shown that the oppressiveness brought on by high-rise buildings can be somewhat mitigated by landscapes. However, there is a lack of research that specifically examines the relationship between courtyard landscape layouts and spatial oppressiveness. This study focuses on the relationship between the landscape layout of a small courtyard and spatial oppressiveness. It entails tests that are conducted in two phases of experiments that examine visual, behavioral, and psychological aspects. In the first experiment, participants were asked to freely explore four sample scenarios without any predetermined outcome, and their behavioral coordinates were recorded as behavioral data. Using the semantic differential (SD) method, participants in the second experiment used four example panoramic landscapes to assess oppressiveness and supply psychological indicators (including oppressiveness, attractiveness, territoriality, and desire to stay). Additionally, this study quantified the visual elements’ solid angles in the scenes through panoramic image segmentation. The results ultimately show that landscape layouts, particularly the surrounding and dispersed layouts, are more effective in alleviating the oppressiveness induced by surrounding buildings compared to the centralized layout. Furthermore, the study explains the process of how landscape layouts mitigate oppressiveness through visual elements and behavioral intention.

Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU.

Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.

Nursing Care for Mrs. S Who Experienced Diabetes Mellitus with Nutrition Deficit Problems in the Bougainville Room of the Dr. Koesnadi Bondowoso General Hospital

Background:Diabetes Mellitus is a chronic disease characterized by the body's inability to metabolize carbohydrates, fats and proteins which causes hyperglycemia (high blood glucose levels). Patients with Diabetes Mellitus will experience changes in appetite and experience weight loss. Method: This study uses a case study research design with clients experiencing diabetes mellitus with nutritional deficit problems in the Bougenvil room of the Dr. H. Koesnadi Bondowoso General Hospital, starting from May 15, 2023 to May 17, 2023, data collection in the form of interviews, observations, physical examinations, documentation studies and questionnaires.&#x0D; Results: The results of this study were obtained from research, namely nutritional deficits in accordance with theory, diagnoses in accordance with the theoretical review. In nursing interventions in accordance with the circumstances experienced by the client, while implementation refers to predetermined interventions and evaluation refers to predetermined outcome criteria in accordance with theory and the final evaluation of calories met is rice (735 kcal) and 1 glass of milk (260 kcal).&#x0D; Conclusion: Nutritional deficits are insufficient nutritional intake to meet metabolic needs. The purpose of writing is to provide nursing care to clients who experience diabetes mellitus with nutritional deficit problems.

CHALLENGES IN THE NATURAL ENVIRONMENT ARE THE KEY TO CHILDREN'S SUCCESS IN PROBLEM SOLVING

Every person faces problems every day. A problem is an obstacle or challenge that needs to be overcome in order to achieve a goal. For children problem solving is natural process, the world appears new and unfamiliar to them. The problem-solving process encourages children to create a team, negotiate, offer solution options, pursue goals, and celebrate achievements together. Parents and educators should encourage children's curiosity and teach them not what they already know how and what to do independently but teach them what they don't know yet. They should observe which problems they can solve on their own and which ones they need to solve with an adult. We conducted a study of inspired and spontaneous challenges in nature, aiming to determine children's ability to understand, evaluate, interpret and apply knowledge to problem-solving. When organizing activities in the natural environment, we applied the method of spontaneous and inspired challenges. We sought to compare these methods and determine which one provides more creative freedom and long-term success for children. The study of inspired and spontaneous challenges revealed that all challenges in the natural environment led children to successful problem-solving. However, inspired challenges lead the child's thinking and creative process to a pre-determined outcome. Dialogue with the educator is maintained from the beginning of the activity. Success is predictable. Spontaneous challenges require more effort from children in accepting, evaluating and interpreting them. Success is not immediately predictable. All suggestions for problem-solving methods are correct, but they look for the most optimal one. Dialogue with the educator begins when a problem arises. Long-term success is in place. An important condition for problem-solving is providing space for children's decisions, self-expression, and creativity. By valuing the child's opinion, we strengthen their self-confidence and encourage them not to be afraid to solve problems." Keywords: natural environment, problem solving, pre-school education, science education

Political Experimentation in the Age of Global Revolutions

AbstractThis essay reviews six recent books that explore how revolutionary upheavals pushed imperial and republican projects alike to experiment with novel political ideas and mechanisms. These initiatives came in response to calls for representation and equality throughout the Age of Revolution. In doing so, these books reveal the failures and successes of these projects in responding to these demands. The authors of these works show that republican and imperial processes of state-building and legitimacy-building did not have a predetermined outcome—quite the opposite. To constitute themselves as valid political alternatives, revolutionary, imperial, and republican projects had to adapt to different actors’ expectations, contingencies, and growing geopolitical tensions. By exposing those adaptation processes, the six books under review demonstrate that the Age of Revolution was a period of intense political experimentation across the ideological spectrum.