While the historic management of food allergy includes avoidance strategies and allergic reaction treatment, oral immunotherapy (OIT) approaches have become more commonly integrated into therapeutic ...approaches. International guidelines, phase 3 trials and real‐world experience have supported the implementation of this procedure. However, OIT is an elective, rarely curative procedure with inherent risks that necessitates an increased degree of health literacy for the patients and families. Families assume the responsibility of amateur healthcare providers to ensure the daily safe administration of the allergenic food. As such, it is incumbent upon physicians to ensure that families are prepared for this role. A thorough educational and shared decision‐making approach is necessary during the counselling and consent process to adequately inform the families. Educated discussion about the efficacy and patient‐centred effectiveness, therapeutic alternatives and family goals is required to align physician and patient expectations. A frank discussion about the struggles, practical challenges, risks and contraindications can help to develop an understanding of the risk mitigation strategies employed to maintain safety. Physicians should develop a proactive approach to educate families about this, at times, burdensome procedure. This educational approach should encourage ongoing support starting prior to consent through the maintenance visits. By preparing families for their unique management role, physicians can help ensure the safe and successful integration of OIT into the therapeutic offering for the management of food allergies.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
The Soviet experience in Afghanistan provides a compelling perspective on the far-reaching hazards of military intervention. In 1985, Mikhail Gorbachev decided that a withdrawal from Afghanistan ...should occur as soon as possible. The Soviet Union's senior leadership had become aware that their strategy was unraveling, their operational and tactical methods were not working, and the sacrifices they were demanding from the Soviet people and military were unlikely to produce the forecasted results. Despite this state of affairs, operations in Afghanistan persisted and four more years passed before the Soviets finally withdrew their military forces.
In No Miracles, Michael Fenzel explains why and how that happened, as viewed from the center of the Soviet state. From that perspective, three sources of failure stand out: poor civil-military relations, repeated and rapid turnover of Soviet leadership, and the perception that Soviet global prestige and influence were inexorably tied to the success of the Afghan mission. Fenzel enumerates the series of misperceptions and misjudgments that led to the Soviet invasion of Afghanistan, tracing the hazards of their military intervention and occupation. Ultimately, he offers a cautionary tale to nation states and policymakers considering military intervention and the use of force.
► Presents an overview of TBM and CBM techniques. ► We discuss how the TBM and CBM techniques work toward maintenance decision making. ► The challenges of implementing each technique are compared. ► ...Each of techniques is found to have unique concepts, procedures and challenges.
This paper presents an overview of two maintenance techniques widely discussed in the literature: time-based maintenance (TBM) and condition-based maintenance (CBM). The paper discusses how the TBM and CBM techniques work toward maintenance decision making. Recent research articles covering the application of each technique are reviewed. The paper then compares the challenges of implementing each technique from a practical point of view, focusing on the issues of required data determination and collection, data analysis/modelling, and decision making. The paper concludes with significant considerations for future research. Each of the techniques was found to have unique concepts/principles, procedures, and challenges for real industrial practise. It can be concluded that the application of the CBM technique is more realistic, and thus more worthwhile to apply, than the TBM one. However, further research on CBM must be carried out in order to make it more realistic for making maintenance decisions. The paper provides useful information regarding the application of the TBM and CBM techniques in maintenance decision making and explores the challenges in implementing each technique from a practical perspective.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Aims and objectives
To undertake a mixed methods thematic literature review that explored how elderly adults approached decision‐making in regard to their health care following discharge.
Background
...A critical time for appropriate health decisions occurs during hospital discharge planning with nursing staff. However, little is known how the 89% of elderly living at home make decisions regarding their health care. Research into older adults’ management of chronic conditions emerges as an important step to potentially encourage symptom monitoring, prevent missed care and detect deterioration. All should reduce the risk of hospital re‐admission.
Design
A mixed methods thematic literature review was undertaken. The structure followed the PRISMA reporting guidelines for systematic reviews recommended by the EQUATOR network.
Methods
PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus online databases were searched using keywords, inclusion and exclusion criteria. References drawn from relevant publications, identified by experts and published between 1995 and 2017 were also considered. Twenty‐five qualitative, quantitative and mixed methods studies and reviews were critically appraised (CASP 2013) before inclusion in the review. Analysis of each study's findings was undertaken using Braun and Clarke's (2006) steps to identify major themes and sub‐themes.
Results
Four main themes associated with health‐related decision‐making in the elderly were identified: “the importance of maintaining independence,” “decision making style,” “management of conditions at home” and “discharge planning.”
Conclusion
Health care decision preferences in the elderly emerged as highly complex and influenced by multiple factors. Development of a tool to assess these components has been recommended.
Relevance to clinical practice
Nurses play a vital role in exploring and understanding the influence that maintaining independence has with each patient. This understanding provides an initial step toward development of a tool to assist collaboration between patients and healthcare professionals involved in their care.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK, VSZLJ
The demand for electrical energy has increased since the population of and automation in factories have grown. The manufacturing industry has been growing dramatically due to the fast-changing ...market, so electrical energy for manufacturing processes has increased. As a result, solar energy has been installed to supply electrical energy. Thus, assessing a solar panel company could be a complex task for manufacturing companies that need to assess, install, and operate solar panels when several criteria with different hierarchies from decision-makers are involved. In addition, the stages of a solar panel system could be divided into analysis, installation, operation, and disposal, and all of them must be considered. Thus, the solar panel company must provide a holistic solution for each stage of the solar panel lifespan. This paper provides a fuzzy decision-making approach (Fuzzy TOPSIS) to deal with the assessment of solar companies using the S4 framework in which the sensing, smart, sustainable, and social features are labeled with linguistic values that allow the evaluation of companies using fuzzy values and linguistic labels, instead of using crisp values that are difficult to define when decision-makers are evaluating a solar company for installation of the solar panels. The S4 features are considered the benefits of the evaluation. In the case study presented, three solar panel companies with different alternatives are evaluated on the basis of three decision-makers from manufacturing companies using the S4 framework. This paper considers the benefits of solar companies in the context of decision-makers participating in a multi-decision selection of such a company to install solar panels, so that the selection process is more effective. Thus, the proposed Fuzzy TOPSIS method proved efficient when selecting a solar panel company from among many options that best meets the needs of manufacturing companies.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Juvenile idiopathic arthritis (JIA) is a common pediatric rheumatic condition and is associated with symptoms such as joint pain that can negatively impact health-related quality of life. To ...effectively manage pain in JIA, young people, their families, and health care providers (HCPs) should be supported to discuss pain management options and make a shared decision. However, pain is often under-recognized, and pain management discussions are not optimal. No studies have explored decision-making needs for pain management in JIA using a shared decision making (SDM) model. We sought to explore families' decision-making needs with respect to pain management among young people with JIA, parents/caregivers, and HCPs.
We conducted semi-structured virtual or face-to-face individual interviews with young people with JIA 8-18 years of age, parents/caregivers and HCPs using a qualitative descriptive study design. We recruited participants online across Canada and the United States, from a hospital and from a quality improvement network. We used interview guides based on the Ottawa Decision Support Framework to assess decision-making needs. We audiotaped, transcribed verbatim and analyzed interviews using thematic analysis.
A total of 12 young people (n = 6 children and n = 6 adolescents), 13 parents/caregivers and 11 HCPs participated in interviews. Pediatric HCPs were comprised of rheumatologists (n = 4), physical therapists (n = 3), rheumatology nurses (n = 2) and occupational therapists (n = 2). The following themes were identified: (1) need to assess pain in an accurate manner; (2) need to address pain in pediatric rheumatology consultations; (3) need for information on pain management options, especially nonpharmacological approaches; (4) importance of effectiveness, safety and ease of use of treatments; (5) need to discuss young people/families' values and preferences for pain management options; and the (6) need for decision support. Themes were similar for young people, parents/caregivers and HCPs, although their respective importance varied.
Findings suggest a need for evidence-based information and communication about pain management options, which would be addressed by decision support interventions and HCP training in pain and SDM. Work is underway to develop such interventions and implement them into practice to improve pain management in JIA and in turn lead to better health outcomes.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Despite the growing role of simulation in procedural teaching, bronchoscopy training largely is experiential and occurs during patient care. The Accreditation Council for Graduate Medical Education ...sets a target of 100 bronchoscopies to be performed during pulmonary fellowship. Attending physicians must balance fellow autonomy with patient safety during these clinical teaching experiences. Few data on best practices for bronchoscopy teaching exist, and a better understanding of how bronchoscopy currently is supervised could allow for improvement in bronchoscopy teaching.
How do attending bronchoscopists supervise bronchoscopy, and in particular, how do attendings balance fellow autonomy with patient safety?
This was a focused ethnography conducted at a single center using audio recording of dialog between attendings and fellows during bronchoscopies, supplemented by observation of nonverbal teaching. Interviews with attending bronchoscopists and limited interviews of fellows also were recorded. Interviews were transcribed verbatim before analysis. We used constant comparative analysis to analyze data and qualitative research software to support data organization and thematic analysis. Education researchers from outside of pulmonary critical care joined the team to minimize bias.
We observed seven attending bronchoscopists supervising eight bronchoscopies. We noted distinct teaching behaviors, classified into themes, which then were grouped into four supervisory styles of modelling, coaching, scaffolding, and fading. Observation and interviews illuminated that assessing fellow skill was one tool used to choose a style, and attendings moved between styles. Attendings accepted some, but not all, variation in both performing and supervising bronchoscopy.
Attending pulmonologists used a range of teaching microskills as they moved between different supervisory styles and selectively accepted variation in practice. These distinct approaches may create well-rounded bronchoscopists by the end of fellowship training and should be studied further.
Objective
To describe the perspectives of healthcare professionals regarding the implementation of Shared decision‐making (SDM) in primary healthcare centres (PHCCs) in Saudi Arabia.
Methods
...Qualitative semi‐structured interviews were conducted with a purposive and snowball sample of healthcare professionals in PHCCs. Interviews have been recorded, transcribed, translated and thematically analysed. Themes were mapped to the COM‐B model.
Results
Sixteen healthcare professionals were interviewed. The data analysis identified six themes and 14 sub‐themes. The six themes are patient related factors, health professional related factors, environmental context and resources, patient–physician communication, patient–physician preferences toward SDM and physicians' perceived value and benefits of SDM. Physicians are unlikely to practice SDM in the context of time pressures, shortage of physicians, lack of treatment options, and decision‐making aids. The findings also underscored the importance of building a trustworthy physician‐patient relationship through the use of effective conversation techniques.
Conclusions
There are multiple barriers to SDM in primary care. Unless these barriers are addressed, it is unlikely that physicians will effectively or fully engage in SDM with patients.
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DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK
During decision making, neurons in multiple brain regions exhibit responses that are correlated with decisions. However, it remains uncertain whether or not various forms of decision-related activity ...are causally related to decision making. Here we address this question by recording and reversibly inactivating the lateral intraparietal (LIP) and middle temporal (MT) areas of rhesus macaques performing a motion direction discrimination task. Neurons in area LIP exhibited firing rate patterns that directly resembled the evidence accumulation process posited to govern decision making, with strong correlations between their response fluctuations and the animal's choices. Neurons in area MT, in contrast, exhibited weak correlations between their response fluctuations and choices, and had firing rate patterns consistent with their sensory role in motion encoding. The behavioural impact of pharmacological inactivation of each area was inversely related to their degree of decision-related activity: while inactivation of neurons in MT profoundly impaired psychophysical performance, inactivation in LIP had no measurable impact on decision-making performance, despite having silenced the very clusters that exhibited strong decision-related activity. Although LIP inactivation did not impair psychophysical behaviour, it did influence spatial selection and oculomotor metrics in a free-choice control task. The absence of an effect on perceptual decision making was stable over trials and sessions and was robust to changes in stimulus type and task geometry, arguing against several forms of compensation. Thus, decision-related signals in LIP do not appear to be critical for computing perceptual decisions, and may instead reflect secondary processes. Our findings highlight a dissociation between decision correlation and causation, showing that strong neuron-decision correlations do not necessarily offer direct access to the neural computations underlying decisions.
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IJS, KISLJ, NUK, SBMB, UL, UM, UPUK
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