Predominant Approach Research Articles

Creating counter-publics through deliberation in the classroom: The case of philosophy for children

In recent years, the ‘deliberative turn’ of political theory has travelled to the classroom. The predominant approach focuses on the ‘educative’ aspect of deliberation by simulating a fictional public debate in which students discuss controversial political questions given by adults. However, such practice tends to pay scant attention to the critical aspect of deliberation that enables students to challenge and examine unjust socio-political structures and dominant discourses in their lives. This article cautions that classroom deliberation without its critical edge makes deliberation more tokenistic and students less agentic. To show the democratic dynamics of critical classroom deliberation, this article draws insights from the author’s fieldwork on Philosophy for Children (P4C) implemented in two Japanese schools. The case study shows that students’ engagement in critical deliberation facilitated their creation of two types of counter-publics, namely, pedagogical and political, that helped them formulate counter-strategies and counter-voices differently.

High-Quality Nursing Home and Palliative Care-One and the Same.

Many individuals receiving post-acute and long-term care services in nursing homes have unmet palliative and end-of-life care needs. Hospice has been the predominant approach to meeting these needs, although hospice services generally are available only to long-term care residents with a limited prognosis who choose to forego disease-modifying or curative therapies. Two additional approaches to meeting these needs are the provision of palliative care consultation through community- or hospital-based programs and facility-based palliative care services. However, access to this specialized care is limited, services are not clearly defined, and the empirical evidence of these approaches' effectiveness is inadequate. In this article, we review the existing evidence and challenges with each of these 3 approaches. We then describe a model for effective delivery of palliative and end-of-life care in nursing homes, one in which palliative and end-of-life care are seen as integral to high-quality nursing home care. To achieve this vision, we make 4 recommendations: (1) promote internal palliative and end-of-life care capacity through comprehensive training and support; (2) ensure that state and federal payment policies and regulations do not create barriers to delivering high-quality, person-centered palliative and end-of-life care; (3) align nursing home quality measures to include palliative and end-of-life care-sensitive indicators; and (4) support access to and integration of external palliative care services. These recommendations will require changes in the organization, delivery, and reimbursement of care. All nursing homes should provide high-quality palliative and end-of-life care, and this article describes some key strategies to make this goal a reality.

Impact of Land Use Diversity on Daytime Social Segregation Patterns in Santiago de Chile

Latin American cities are known for their high levels of marginality, segregation and inequality. As such, these issues have been the subject of substantial discussions in academia, with the predominant approach being the study of residential segregation, or what we call “nighttime segregation”. Another dimension of urban sociability, related to labor, is what we call “daytime segregation”, which has been far less studied. This article makes an original methodological contribution to the measurement of non-residential or daytime segregation based on data from mobility surveys. It seeks to explain this segregation measurement according to the diversity and distribution of land uses, as well as other characteristics of the built stock, such as land price and built-up density. We measured daytime social mix in urban spaces, and we show how it highly relates to land use diversity in a Latin American megacity, such as Santiago, Chile. We found that land use diversity plays a key role in enhancing the daytime social diversity of urban spaces, contributing to generate a more heterogeneous city and social gatherings during working days. This research is not only a contribution to the understanding of sociability patterns in cities but is also a contribution to public policy and the work of urban planners, as it informs the development of more diverse and integrated cities, which is a key tool for strengthening democracy, the exchange of ideas, the economy and social welfare.

Unifying the analysis of continuous and categorical measures of weight loss and incorporating group effect: a secondary re-analysis of a large cluster randomized clinical trial using Bayesian approach

BackgroundAlthough frequentist paradigm has been the predominant approach to clinical studies for decades, some limitations associated with the frequentist null hypothesis significance testing have been recognized. Bayesian approaches can provide additional insights into data interpretation and inference by deriving posterior distributions of model parameters reflecting the clinical interest. In this article, we sought to demonstrate how Bayesian approaches can improve the data interpretation by reanalyzing the Rural Engagement in Primary Care for Optimizing Weight Reduction (REPOWER).MethodsREPOWER is a cluster randomized clinical trial comparing three care delivery models: in-clinic individual visits, in-clinic group visits, and phone-based group visits. The primary endpoint was weight loss at 24 months and the secondary endpoints included the proportions of achieving 5 and 10% weight loss at 24 months. We reanalyzed the data using a three-level Bayesian hierarchical model. The posterior distributions of weight loss at 24 months for each arm were obtained using Hamiltonian Monte Carlo. We then estimated the probability of having a higher weight loss and the probability of having greater proportion achieving 5 and 10% weight loss between groups. Additionally, a four-level hierarchical model was used to assess the partially nested intervention group effect which was not investigated in the original REPOWER analyses.ResultsThe Bayesian analyses estimated 99.5% probability that in-clinic group visits, compared with in-clinic individual visits, resulted in a higher percent weight loss (posterior mean difference: 1.8%[95% CrI: 0.5,3.2%]), a greater probability of achieving 5% threshold (posterior mean difference: 9.2% [95% CrI: 2.4, 16.0%]) and 10% threshold (posterior mean difference: 6.6% [95% CrI: 1.7, 11.5%]). The phone-based group visits had similar result. We also concluded that including intervention group did not impact model fit significantly.ConclusionsWe unified the analyses of continuous (the primary endpoint) and categorical measures (the secondary endpoints) of weight loss with one single Bayesian hierarchical model. This approach gained statistical power for the dichotomized endpoints by leveraging the information in the continuous data. Furthermore, the Bayesian analysis enabled additional insights into data interpretation and inference by providing posterior distributions for parameters of interest and posterior probabilities of different hypotheses that were not available with the frequentist approach.Trial registrationClinicalTrials.gov Identifier NCT02456636; date of registry: May 28, 2015.

Choice of law for immovable property issues: new directions in the European Union and the United States

In both the European Union and the United States, it is a dynamic period for private international law regarding immovable property issues. The predominant approach has been that these issues are governed by the lex rei sitae —that is, the law of the State where the immovable is located. However, through a comparative examination of recent EU Regulations on succession, matrimonial property regimes, and the property consequences of registered partnerships, and of the new Third Restatement of Conflict of Laws project in the United States, this article shows that on both sides of the Atlantic there is a trend toward reducing the scope of the lex rei sitae rule. It explores both the reasons for and the challenges posed by this trend. It also reveals that despite this trend, the lex rei sitae rule nevertheless persists in relation to certain «core» immovable property issues.

Improving feature extraction from histopathological images through a fine-tuning ImageNet model

BackgroundDue to lack of annotated pathological images, transfer learning has been the predominant approach in the field of digital pathology. Pre-trained neural networks based on ImageNet database are often used to extract “off-the-shelf” features, achieving great success in predicting tissue types, molecular features, and clinical outcomes, etc. We hypothesize that fine-tuning the pre-trained models using histopathological images could further improve feature extraction, and downstream prediction performance. MethodsWe used 100 000 annotated H&E image patches for colorectal cancer (CRC) to fine-tune a pre-trained Xception model via a 2-step approach. The features extracted from fine-tuned Xception (FTX-2048) model and Image-pretrained (IMGNET-2048) model were compared through: (1) tissue classification for H&E images from CRC, same image type that was used for fine-tuning; (2) prediction of immune-related gene expression, and (3) gene mutations for lung adenocarcinoma (LUAD). Five-fold cross validation was used for model performance evaluation. Each experiment was repeated 50 times. FindingsThe extracted features from the fine-tuned FTX-2048 exhibited significantly higher accuracy (98.4%) for predicting tissue types of CRC compared to the “off-the-shelf” features directly from Xception based on ImageNet database (96.4%) (P value = 2.2 × 10−6). Particularly, FTX-2048 markedly improved the accuracy for stroma from 87% to 94%. Similarly, features from FTX-2048 boosted the prediction of transcriptomic expression of immune-related genes in LUAD. For the genes that had significant relationships with image features (P < 0.05, n = 171), the features from the fine-tuned model improved the prediction for the majority of the genes (139; 81%). In addition, features from FTX-2048 improved prediction of mutation for 5 out of 9 most frequently mutated genes (STK11, TP53, LRP1B, NF1, and FAT1) in LUAD. ConclusionsWe proved the concept that fine-tuning the pretrained ImageNet neural networks with histopathology images can produce higher quality features and better prediction performance for not only the same-cancer tissue classification where similar images from the same cancer are used for fine-tuning, but also cross-cancer prediction for gene expression and mutation at patient level.

Topical issues of digitalization of the educational and legal space of the state

The analysis of actual problems related to the digitalization of legal education is carried out. At the present stage, it is impossible to imagine the educational process without the digital space and the subjects of educational activity involved in it: students, teachers, specialists in the field of information technology, etc. The use of a predominant digital approach in teaching is considered, which is based on special methods of transmitting information that allows solving a large number of diverse tasks in the shortest time intervals. It is noted that there is a consistent introduction of information technologies into the educational system of our state and educational institutions teaching jurisprudence are also included in this system. Each of them has systems with an electronic educational environment, where tasks are performed that form competencies provided for by the state standard and curriculum, computers, electronic textbooks, educational and teaching aids. The issue of improving the effectiveness of legal educational systems is raised, since it is known what efforts the introduction of digital technologies in the learning process requires. It is concluded that in order to achieve the goal, it is not enough to provide an educational institution with digital devices, connect to the Internet and develop digital service platforms. The implementation of this process requires not only the renewal of the entire educational system, pedagogical practice, but also a transition to new models of organization of work in general, including the use of the digital construction method.

A Multi-Agent Deep Reinforcement Learning Approach for Practical Decentralized UAV Collision Avoidance

This letter proposes an improved deep reinforcement learning controller for the decentralized collision avoidance problem. Using a unique architecture incorporating ‘long-short term memory cells’ and a reward function inspired from gradient-based approaches, the controller outperforms existing techniques in environments with variable numbers of agents. The design of the reward function is also evaluated to critique existing deep reinforcement learning approaches and used to establish a better result. The proposed controller is subsequently tested in simulation and a real-world 3-dimensional drone environment: outperforming the predominant classical approach in the literature by a significant margin.

The Current Landscape of Minimally Invasive Pancreatectomy for Neoplasms Across the US

Introduction: To evaluate recent national trends in minimally invasive pancreatectomy (MIP) for neoplastic disease and compare clinical outcomes. Methods: Adult patients who underwent elective open (OS) or MIP (laparoscopic-LS or robotic-RS) pancreaticoduodenectomy (PD) or pancreatic resection other than PD (non-PD) for malignant or benign neoplasm from 2013-2019 were identified from Premier Healthcare Database. Outcomes: length of stay (LOS), conversion to OS, blood transfusion, in-hospital mortality, and 30/90-day readmission rates. Outcomes were compared using multivariable regressions adjusting for patient and hospitals baseline characteristics. Results: Total 16,758 patients; 10,333 PD and 6,425 non-PD. OS was predominant approach for PD (89.5%) with fluctuating MIP rates (6.5%-16.1%). MIP rates were higher for non-PD (45.8%) and became the majority approach in 2016 (51.6%). Regionally, MIP was highest in the South (11.7% PD, 49.8% non-PD) and lowest in the West (7.3% PD, 35.7% non-PD). MIP technique breakdown: PDs (52.8% LS; 47.2% RS); and non-PDs (55.1% LS; 44.9% RS). In PDs, outcomes were similar except OS had fewer transfusions (OR 0.87 [0.76, 0.99]P=0.002). Conversion to OS was higher in LS than RS (OR 4.58 [3.25,6.47]P<0.001). In non-PDs, MIP had improved outcomes; OS had higher rates of splenectomy (1.22 [1.09, 1.36] P=0.001), LOS>10-days (1.63 [1.41, 1.89]P<0.001), and transfusions (1.66 [1.46, 1.89]P<0.001). Conversion to OS (OR 2.75 [2.19,3.44]P<0.001) was higher in the LS approach. Conclusions: MIP for non-PD has become the most common approach and is associated with improved outcomes, whereas MIP-PD has stagnant adoption and similar outcomes to OS. Robotics facilitates MIP completion through fewer OS-conversions.

Female entrepreneurship in emerging and developing countries: a systematic literature review

PurposeDespite the increase in female entrepreneurship literature, very few studies exist that systematize the extant literature, especially in emerging and developing countries. This article fills part of this gap; it maps, categorizes and groups the objectives, theoretical approaches and research methods on female entrepreneurship conducted in one or more of the 155 emerging and developing countries.Design/methodology/approachA systematic literature review (SLR) was conducted, using Scopus and Web of Science, over a 10-year timeframe (2010–2020). Out of 465 papers, 77 were selected for content analysis.FindingsMost articles focus on understanding women entrepreneurs' challenges, the factors affecting their entrepreneurial performance and encouraging entrepreneurship. Qualitative research was found to be the predominant approach, while mixed studies appeared less frequently.Practical implicationsThis paper sheds light on female entrepreneurship characteristics, including business competence, performance and entrepreneurial orientation. Further, it can help female entrepreneurs to recognize the most relevant aspects regarding performance, the essential driving factors and entrepreneurial motivations, among others.Originality/valueFirst, this paper groups the objectives and the theoretical and methodological approaches that guide female entrepreneurship research. Second, it identifies distinct gaps, grouped and explored using unpublished thematic categories. Finally, the authors propose an extensive future research agenda regarding female entrepreneurship in emerging and developing countries.

Viewpoint: the need to evolve to a service logic mindset in Latin America

PurposeThe purpose of this viewpoint is to discuss the need to evolve from a service marketing approach to a service logic mindset throughout the organization in Latin America. In doing so, it addresses a void in the service literature due to the lack of attention on its uniqueness in this region.Design/methodology/approachTo confirm the predominant approach of studying service and the need for a paradigm shift in service organizations, two independent journal article searches during 1989–2020 were conducted. The purpose was to learn where Latin American service researchers are focusing their research efforts and to discuss how the meaning of service applies to this region.FindingsForty-eight journal articles were analyzed and six distinctive groups were identified where service researchers are focusing their work on Latin America. Service has been studied mainly from the marketing perspective; with limited original research published in indexed journals; focused on making product-oriented promises, increasingly enabled by technology. The need for developing a service logic mindset throughout the organization has begun to be emphasized rather recently in the field. The variety of meanings of service and the complex context represent challenges for this enterprise.Research limitations/implicationsFuture research is needed to work on a more comprehensive conceptualization of service at higher levels of analysis. Further context studies are required to enrich knowledge on service in Latin America. Service researchers and organizations should work on these two challenges to continue moving from the marketing perspective of service to a service logic mindset throughout the organization.Originality/valueThe paper points out the relevance of conducting further service research in Latin America, arguing that service has been studied mainly from the marketing perspective, and claiming the need to move to a service logic mindset. This viewpoint opens a discussion in the service research community toward a paradigm shift that, although inspired in Latin America, may not be necessarily limited to this region.

Perioperative Morbidity and Complications in Patients With an Established Ileostomy Undergoing Major Abdominal Surgery: A Retrospective Study.

Background: Recently formed ileostomies may produce an average of 1,200 ml of watery stool per day, while an established ileostomy output varies between 600–800 ml per day. The reported incidence of renal impartment in patients with ileostomy is 8–20%, which could be caused by dehydration (up to 50%) or high output stoma (up to 40%). There is a lack of evidence if an ileostomy could influence perioperative fluid management and/or surgical outcomes.Methods: Subjects aged ≥18 years old with an established ileostomy scheduled to undergo an elective non-ileostomy-related major abdominal surgery under general anesthesia lasting more than 2 h and requiring hospitalization were included in the study. The primary outcome was to assess the incidence of perioperative complications within 30 days after surgery.Results: A total of 552 potential subjects who underwent non-ileostomy-related abdominal surgery were screened, but only 12 were included in the statistical analysis. In our study cohort, 66.7% of the subjects were men and the median age was 56 years old (interquartile range [IQR] 48-59). The median time from the creation of ileostomy to the qualifying surgery was 17.7 months (IQR: 8.3, 32.6). The most prevalent comorbidities in the study group were psychiatric disorders (58.3%), hypertension (50%), and cardiovascular disease (41.7%). The most predominant surgical approach was open (8 [67%]). The median surgical and anesthesia length was 3.4 h (IQR: 2.5, 5.7) and 4 h (IQR: 3, 6.5), respectively. The median post-anesthesia care unit (PACU) stay was 2 h (IQR:0.9, 3.1), while the median length of hospital stay (LOS) was 5.6 days (IQR: 4.1, 10.6). The overall incidence of postoperative complications was 50% (n = 6). Two subjects (16.7%) had a moderate surgical wound infection, and two subjects (16.7%) experienced a mild surgical wound infection. In addition, one subject (7.6%) developed a major postoperative complication with atrial fibrillation in conjunction with moderate hemorrhage.Conclusions: Our findings suggest that the presence of a well-established ileostomy might not represent a relevant risk factor for significant perioperative complications related to fluid management or hospital readmission. However, the presence of peristomal skin complications could trigger a higher incidence of surgical wound infections.

Future-Generation Perception: Equal or Not Equal? Long-Term Individual Discount Rates for Poland

Energy-related investments gain increasing attention nowadays, particularly in Poland due to clean-energy investment needed to limit greenhouse gas emissions (GHG) and counteract climate change. However, economic appraisal is problematic: the longevity of impacts inextricably involves intergenerational ethical considerations. A crucial parameter is the choice of a discount rate. The predominant approach to estimate the discount rate in EU countries is the Ramsey rule, based on macroeconomic data, but not referring directly to society’s preferences. Those are considered by studies using surveys to elicit individual discount rates (IDR), but rarely concentrating on intergenerational time frame. The paper aims at delivering an insight into the intergenerational intertemporal preferences for Poland (households, n = 471) focusing on whether respondents are willing to declare zero discount rate intergenerationally and whether their choices differ between the short- and long-term perspectives and between human lives and money. To elicit IDR, two hypothetical investment scenarios were designed: lifesaving programs and lottery gains with delays from 10 to 150 years accompanied by attitude and socioeconomic questions. The results indicate that IDR follows hyperbolic time-decline, and a considerable share of respondents (around 20%) are willing to treat future generations as equally important in the case of human lives, while this proportion for monetary gains is two times lower. The IDR drivers differ between lives and money in respect of socioeconomic profile and attitude characteristics as well as between intragenerational and intergenerational time frames. The findings support (a) the rationale for distinct treatment of intergenerational allocations, (b) the divergence of preferences between public and private impacts, and (c) the switch from single to declining discount rate regime in Poland.

Robotic Total Endoscopic Coronary Bypass in 570 Patients: Impact of Anastomotic Technique in Two Eras

BackgroundIn coronary artery bypass grafting, including robotic off-pump totally endoscopic coronary artery bypass (TECAB), the anastomotic technique is the most critical part of the procedure. We reviewed results in 570 patients over a 7-year period and compared outcomes between two eras based on predominant anastomotic technique: connectors vs running suture. MethodsBetween July 2013 and December 2020, 570 patients underwent off-pump TECAB: group 1 consisting of 378 patients, from July 2013 to August 2018, using predominantly the C-Port Flex A distal anastomotic stapler (Aesculap); and group 2 consisting of 192 patients, from September 2018 to December 2020, using predominantly a sutured technique (7-0 Pronova; Johnson & Johnson). Retrospective analysis of clinical outcomes was performed. ResultsOff-pump TECAB was completed in 98.8% (563 of 570 patients) with an observed/expected mortality of 0.6% (6 of 570 patients). The anastomotic device was used in 89% of 626 grafts in group 1 and only 11% of 305 grafts in group 2 (P = .001). There were no differences in multivessel TECAB (57% vs 53%; P = .331) or bilateral internal thoracic artery use (50% vs 43%; P = .127) in group 1 vs group 2, respectively. Operative time was shorter in group 1 (242 ± 84 vs 273 ± 88 minutes; P < .001). Early clinical outcomes were similar between groups, except for hospital stay, which was longer in group 1 (2.9 vs 2.3 days; P < .001). Graft patency was similar (98% vs 95%; P = .295) in group 1 vs group 2, respectively. ConclusionsChanging the predominant approach from stapled anastomosis to a sutured technique during robotic TECAB resulted in longer operative times. Both approaches led to excellent outcomes, including graft patency. The shorter operative times conferred by using staplers may flatten the learning curve and facilitate broader adoption of TECAB.

Prescription patterns and dosages of antiepileptic drugs in prevalent patients with epilepsy in Taiwan: A nationwide retrospective cross-sectional study

ObjectiveTo evaluate the prescription patterns and prescribed daily dose (PDD)/defined daily dose (DDD) ratios of antiepileptic drugs (AEDs) in prevalent patients with epilepsy in Taiwan. Materials and methodsA nationwide retrospective cross-sectional study was conducted for prevalent patients with epilepsy in 2016 using the Taiwanese National Health Insurance Research Database. The prescription records of AEDs of all prevalent patients with epilepsy were retrieved. The mean PDDs and PDD/DDD ratios of AEDs in adult patients were obtained to evaluate dosing adequacy. A chi-square test and two-sample t test were used to analyze the differences in AED prescription patterns and dosages, respectively, among patients with different ages, sexes, comorbidities, and therapeutic approaches. ResultsA total of 118,937 prevalent patients with epilepsy were enrolled. The predominant therapeutic approach was monotherapy, especially in the elder adults, accounting for 82.9% of elder adult patients with epilepsy. The proportion of AED monotherapy was higher in patients with dementia (78.9%) and stroke (80.6%). The top three antiepileptic monotherapies were valproic acid (28.7%), levetiracetam (19.1%), and phenytoin (16.9%); however, oxcarbazepine (22.8%) was substituted for carbamazepine (3.9%) as monotherapy for patients aged 0–17 years. Among adult patients with epilepsy, the PDD/DDD ratio of each AED in monotherapy was less than 1.00. The mean PDD of each AED was higher in polytherapy than in monotherapy (p < 0.01), except for lacosamide. The mean PDDs of all evaluated AEDs in monotherapy were lower in elder adult patients than in younger adult patients, most of which reached statistical significance (p < 0.001). ConclusionsIn Taiwan, valproic acid was the most prescribed AED for prevalent patients with epilepsy. The mean PDDs of most AEDs were lower than the DDDs developed by the World Health Organization.

Autoencoding With a Classifier System

Autoencoders are data-specific compression algorithms learned automatically from examples. The predominant approach has been to construct single large global models that cover the domain. However, training and evaluating models of increasing size comes at the price of additional time and computational cost. Conditional computation, sparsity, and model pruning techniques can reduce these costs while maintaining performance. Learning classifier systems (LCS) are a framework for adaptively subdividing input spaces into an ensemble of simpler local approximations that together cover the domain. LCS perform conditional computation through the use of a population of individual gating/guarding components, each associated with a local approximation. This article explores the use of an LCS to adaptively decompose the input domain into a collection of small autoencoders where local solutions of different complexity may emerge. In addition to benefits in convergence time and computational cost, it is shown possible to reduce code size as well as the resulting decoder computational cost when compared with the global model equivalent.

Managing ‘Adhesive Small Bowel Obstruction’ in Tanzania: A Single Center Retrospective Review of Treatment Approach and its Outcomes

Background The management of adhesive small bowel obstruction has evolved significantly in high income countries with improvements in diagnosis and treatment, from conservative to minimally invasive approaches. In Tanzania, like in many low and middle income economies, these developments have not been herald. Addressing adhesive small bowel obstruction in this setting is therefore vital to improve outcomes. This study aimed to explore current treatment modalities and their outcome among patients with ‘adhesive small bowel obstruction’ at Muhimbili national hospital. Methodology A descriptive retrospective, cross-sectional study was conducted at Muhimbili National Hospital covering the period 2014 to 2016. Patients with a documented diagnosis of adhesive Small Bowel Obstruction were sought from medical records. Using a predefined data capture sheets, age, sex, type of management, complications, mortality and time to feeding (among patients who were managed conservatively) were captured. The study had 80% power to detect a mortality rate of 8.7% at 95% confidence interval. Descriptive statistics were populated and summarized as proportions while mortality between the operated versus the conservative group compared using chi square test with significant value set at p value of <5%. Results A total of 127 patients with diagnosis of adhesive small bowel obstruction were identified. The mean age was 40.5±17.6 and a slight male predominance at a ratio of 1.6:1. Operative approach was predominant over conservative at ratio of 1.7:1. One third of the surgical group had bowel resection and anastomosis performed. In 18.8% of the operated cases, a complication was reported with Enterocutaneous fistula and surgical site infection being the most common. Overall mortality was 8.7% being higher in the operated group at 10%. Conclusion Open surgical approach is the predominant management approach in patients with Adhesive Small Bowel Obstruction. One in three of surgically managed required bowel resection signifying late presentation. Managing adhesive small bowel obstruction carries high morbidity and mortality. There is no standardized protocol for the management of these patients at the tertiary level. Recommendation Locally adoptable protocol for diagnosis and treatment of adhesive small bowel obstruction is needed. This should maximize on resources that are available even at district level facilities with much consideration of the role of surgery.

Physical Restraint Use in Intensive Care Units: Exploring the Decision-Making Process and New Proposals. A Multimethod Study.

Aim: The general aim of this study was to explore the decision-making process followed by Intensive Care Unit (ICU) health professionals with respect to physical restraint (PR) administration and management, along with the factors that influence it. Method: A qual-quant multimethod design was sequenced in two stages: an initial stage following a qualitative methodology; and second, quantitative with a predominant descriptive approach. The multicenter study was undertaken at 17 ICUs belonging to 11 public hospitals in the Madrid region (Spain) across the period 2015 through 2019. The qualitative stage was performed from an interpretative phenomenological perspective. A total of eight discussion groups (DG) were held, with the participation of 23 nurses, 12 patient care nursing assistants, and seven physicians. Intentional purposive sampling was carried out. DG were tape-recorded and transcribed. A thematic analysis of the latent content was performed. In the quantitative stage, we maintained a 96-h observation period at each ICU. Variables pertaining to general descriptive elements of each ICU, institutional pain-agitation/sedation-delirium (PAD) monitoring policies and elements linked to quality of PR use were recorded. A descriptive analysis was performed, and the relationship between the variables was analyzed. The level of significance was set at p ≤ 0.05. Findings: A total of 1070 patients were observed, amounting to a median prevalence of PR use of 19.11% (min: 0%–max: 44.44%). The differences observed between ICUs could be explained by a difference in restraint conceptualization. The various actors involved jointly build up a health care culture and a conceptualization of the terms “safety-risk”, which determine decision-making about the use of restraints at each ICU. These shared meanings are the germ of beliefs, values, and rituals which, in this case, determine the greater or lesser use of restraints. There were different profiles of PR use among the units studied: preventive restraints versus “Zero” restraints. The differences corresponded to aspects such as: systematic use of tools for assessment of PAD; interpretation of patient behavior; the decision-making process, the significance attributed to patient safety and restraints; and the feelings generated by PR use. The restraint–free model requires an approach to safety from a holistic perspective, with the involvement of all team members and the family.

Appreciating complexities, changing contexts and accountability challenges in sexual and reproductive health rights.

Social accountability is fast being recognised as an important strategy for realisation of sexual and reproductive health rights. However, the predominant approach tends to focus on use of top-down monitoring and accountability tools that do not capture the complexity of politics surrounding this deeply contested terrain. This paper draws on discussions that took place at the COPASAH Global Symposium in October 2019 where grassroots practitioners shared their experiences of seeking accountability and reflected on the myriad challenges in this process. The paper calls for greater nuance and awareness of context in the design and implementation of social accountability interventions, which engage with power and politics between the forces that determine people's access to SRH rights.

The International Responsibility to Protect in a Post-Liberal Order

AbstractThis article considers the implications of a post-liberal order for the international responsibility to protect. It focuses on two questions. First, what challenges will the international responsibility to protect face in a post-liberal order? Second, in light of these challenges, how would the requirements of the international responsibility to protect differ in the post-liberal order? In response to the first question, the article argues that in a post-liberal order the international responsibility to protect is likely to be subject to the “Influence Challenge,” whereby its ability to constrain and influence states decreases. In response to the second question, it argues that the requirements of the international responsibility to protect would be affected in several ways, including necessitating greater consideration of questions of prioritization and requiring a re-evaluation, and potential abandonment, of the currently predominant approach to the responsibility to protect.