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Fraudulent activities especially in auto insurance and credit card transactions impose significant financial losses on businesses and individuals. To overcome this issue, we propose a novel approach for fraud detection, combining convolutional neural networks (CNNs) with support vector machine (SVM), k nearest neighbor (KNN), naive Bayes (NB), and decision tree (DT) algorithms. The core of this methodology lies in utilizing the deep features extracted from the CNNs as inputs to various machine learning models, thus significantly contributing to the enhancement of fraud detection accuracy and efficiency. Our results demonstrate superior performance compared to previous studies, highlighting our model’s potential for widespread adoption in combating fraudulent activities.

脑健康定义为脑结构、功能和社会适应正常，并且没有明显的脑疾病。卒中和痴呆是神经系统疾病负担的前两位。卒中和痴呆可以协同预防，两者具有相似的危险因素。神经-血管单元是脑健康的结构基础，脑血流和脑灌注下降、血管内皮功能受损等病理生理过程可导致β-淀粉样蛋白（amyloid β-protein，Aβ）蓄积并继发神经变性。随机对照试验证实，控制血管危险因素可以延缓痴呆的发病和进展。因此，世界卒中组织提出了“通过预防卒中来预防痴呆”的观点。做好卒中人群预防和个体预防，针对特殊人群、少见原因和关键病理生理机制，做好精准预防。建立脑健康中心，通过认知风险预测、风险沟通、认知风险降低和认知增强等技术预防痴呆和促进脑健康。脑健康行动将在全球范围内获得更多的政策支持。促进脑健康，需要融合新技术，需要创新和研究。 Abstract: Brain Health is defined as a normal status of the brain in the structure and in the function, as well as in the social adaption, without overt diseases in the brain. Stroke and dementia consist the two major contributors of the neurological disorders burden. A synergism in the prevention for stroke and dementia will beneficial. The risk factors of stroke and dementia are similar. The neurovascular unit is fundamental for brain health. The decrease in the cerebral blood flow or in the cerebral perfusion, vascular endothelial cell functional lesions will lead to the amyloid β-protein accumulation and secondary neurological degeneration. The incidence of dementia had been decreased when the risk factors for vascular diseases were controlled in the randomized controlled trials. Hence, the World Stroke Orgnization proposed “ the Preventing dementia by preventing stroke ”. In addition to the population-wide strategies and strategies for individuals with high risk in stroke prevention, the strategies with precise medicine focused on the uncommon cause for stroke, the special subgroups and key pathophysiological mechanisms will improve the practice. Brain health service emphasised on prevent dementia and promote brain health through cognitive risk prediction, risk communicaion, risk reduction and cognitive enhancement. The brain health initiative, will get more support around the world. The innovations in research and technology will promote the managment of the brain health.

Subject. The new management paradigm arising from changes in the external and internal environment requires a change in the priority of elements that ensures the successful functioning of an economic entity, maintaining its competitiveness, and preserving the consumer segments of the produced goods and services. The priority of human resources means the need for a timely introduction of the evolutionary and revolutionary processes related to the labour force supply and demand, as its capacity reserve tends to decrease. Objectives. The purpose of the article is to provide an insight into the development of scientific thought, firstly, by regarding the evolution of traditional trends that characterise the modern labour market. Second, we described the emerging trends in the supply and demand of the labour force and the corresponding transformation of human resource management in organisations. Methodology. To achieve our objectives, we used general and empirical research methods. Analysis and synthesis were applied to obtain new knowledge on the topic. We used analysis to identify the components of the progress of scientific thought from the signal indicating the emergence of a trend to the identification of its drivers and challenges. Through analysis, we also identified the features of supply and demand of the labour force in the modern labour market, which is characterised by staff diversity. Statistical analysis revealed the current patterns of the changes in the Russian labour market, indicating the emergence of new trends. Synthesis made it possible to gain a single comprehensive view of the current cascade of trends and possible shifts in the behaviour of younger and older workers in the labour market. Results. The article presents the structured provisions that substantiate the impact of the cascade of trends on the development of the labour market and changes in the supply and demand for the labour force of younger and older workers. The outlined idea promotes the scientists’ conclusions about the existence of trend cascades. Managing these cascades in the labour market makes it possible to apply the conclusions of trendwatching to influence the emerging signals indicating the strengthening of a new trend that is undesirable for human resource policy. Conclusions. Significant shifts in the age structure of the population are changing the ageing megatrend, that has become global, as well as its impact on the labour market. The analysis methods used in the article, first of all, supported the researchers’ opinion that “success” as the goal of the new management paradigm can be achieved based on a knowledge of the trends that determine the vector of employer’s activities in order to keep up, succeed, and retain their positions several steps ahead of the competitors. Second, they allowed us to identify the mechanism of the emergence, development, and extinction of trends in the labour market and the formation of trend cascades. Third, they supported the theory of drivers that can change the substance and stability of the trend and, therefore, provide opportunities to manage it. Fourth, they allowed us to substantiate the changes in labour demand, which is characterised by a rapid and frequent change in the requirements for a worker to fill modern positions requiring new knowledge, practical and cognitive skills, and behavioural patterns. Fifth, they allowed us to demonstrate a priority shift towards new forms of dependent labour to match the new values and attitudes of employment applicants and employed personnel. Sixth, they allowed us to substantiate the potential of the segment of older workers in influencing the trend of ageism and the formation of ecosystem and occupational health policies in organisations. Seventh, they can be used to prevent in advance the disruption of the natural personnel rotation of different age generations in the labour market and the transfer of professional experience from the older generation of workers in the internal competitive environment.

En este estudio se ha utilizado la base de datos de publicaciones científicas Scopus para analizar los artículos que incluyen el concepto de incertidumbre política como variable de estudio en las ciencias económicas y administrativas. El análisis se basa técnicas bibliométricas aplicadas para el periodo comprendido entre los años 2010 y 2022. Dentro de los hallazgos del estudio se encuentra que el uso del concepto de incertidumbre política es amplio en investigaciones aplicadas en las ciencias económicas y administrativas. Asimismo, se observa que conceptos afines tales como: incertidumbre de la política económica, riesgo político y cambio climático, también muestran recurrencia como palabras claves de los estudios. Por último, se aprecia que países tales como Estados Unidos y China son los que más contribuyen en el número de publicaciones, así como determinados autores y revistas evidencian alto impacto a partir de la medición de métricas como el índice H.

The third edition of the International Classification of Headache Disorders (ICHD-3) defines medication-overuse headache (MOH) as a headache that develops when a person regularly uses acute or symptomatic headache medications excessively (10 or more, or 15 or more days per month, depending on the medication) for a period of time longer than 3 months. Even though it may not be reported as frequently as it actually is, it affects about 5% of the general population on average. It typically happens following repeated anti-pain medication use for pre-existing headache disorders, such as migraines. Anti-pains can also be used frequently in patients with pre-existing headache disorders for reasons other than treating headaches, such as psychological drug attachment. MOH is linked to a number of illnesses, such as anxiety, depression, and obsessive compulsive disorder (OCD). Both simple and complex types are possible. Additionally, there is no universal consensus on how to treat MOH, but drug discontinuation is the best course of action. Using the medical subject headings “Medication Overuse Headache,” “Migraine Headache,” “Tension Headache,” “Chronification of Headache,” and “Antipains,” an all-language literature search was done on PubMed, Google Scholar, and Medline up until March 2023. We looked into the epidemiology, risk factors, pathophysiology, clinical characteristics, comorbidities, diagnosis, management, and preventative measures of MOH in the literature. This article focuses on the MOH research themes.

Although the term management accounting has been used around the world since the second half of the 20th century, and in Georgia, the scientists have been arguing about the essence of this phenomenon since about the 80s. Is it an independent science? Is it part of science that does not have an independent subject? This is pseudoscience, e.g., such a phenomenon does not exist at all and so on. The dispute is largely due to the reality of accounting science and practice in the specific countries. It would be a mistake to think of the management accounting as a novelty for the domestic economy. In the 1920s and early 1930s, the functions of accounting services were much broader than in the later years of Soviet rule. The accountant of that time was engaged both as in accounting and as in planning and analytical work. Along with development of the socialist economic system in the country and the strengthening of central planning, there was the gradual separation from the Accounting Service of the Planning and Financial Departments, with the transfer of part of the accounting authority to them. As a result, the activities of the accountant were actually reduced to the accounting of the facts of the economic life of the enterprise. As a result, the activities of the accountant were actually reduced to the accounting of the facts of the economic life of the enterprise. Historically, the development of management accounting in theory and practice has been accompanied by controversy. One of the issues to be discussed is the concept of management accounting: Or it is a field of economic work in the enterprise, which includes methods of reporting operations, analysis, planning, staff motivation, etc.; Or this activity may be limited to the functions of collecting and summarizing financial and non-financial information required by management; e.g., independent from economic analysis, planning, management, sociology, psychology, and etc. Examining the various sources of educational, methodological and scientific literature, you can find many definitions of management accounting, which indicates the lack of a unified methodological approach to the essence of management accounting. This is due to the uniqueness of the organizational basis for establishment of the management accounting system in each economic entity, which is largely determined by the characteristics of its activities and the requirements imposed on management by management information. With the development of technology and organization of production, with diversification of the products, improvement of organizational management structures, increased competition, the need for constant reduction of costs per unit of production, the organization’s management requires the new types of information generated through the management accounting subsystem. There have been used the several methods of obtaining the relevant literature, in particular the literature review is concept-oriented, or paradigm-oriented and not author-oriented: using a review of structured literature as a research method, this article addresses the following three research questions: How is the research on management accounting developing? What are the differences between modern accounting and accounting? What is the future of governance accounting, both in practice and in science? We identified the type of research and conducted the comprehensive literature search. The aim of the article is to explore and determine the evolution of the essence of management accounting, the key aspects of development. In the article is discussed the evolution of the development of management accounting, the distinguishing features between the accounting and management accounting, and understanding of the essence of management accounting is evaluated. Based on the bibliographic research and analysis of empirical materials, based on the opinions of experts, elaborated theoretical and materials, it was revealed that managerial accounting has its purpose, subject, objects, tasks and principles, which distinguishes it from accounting. In recent years, the term “management accounting” has become very popular, although there is still an ambiguous attitude in understanding its essence. The management accounting differs from the accounting primarily in that its data is intended not for external users (states, banks, business partners) but for internal “use”. The ultimate goal of management accounting is to help the manager make the right decisions. Therefore, if a simple (financial) accountant must strictly follow the reporting forms and instructions, then the management accounting specialist is free to choose the forms, methods and techniques of analysis, the main thing for him is to properly understand the essence of economic processes in the enterprise and give timely advice to the leader. Management accounting is nothing more than the management information support system. During the decades of its existence, the innate techniques and methods of management accounting have been developed and continue to develop, therefore, it has its own methodology. It can be described as the combination of two main subject areas: as a science; as a practical field of activity.

Today, chronic wounds continue to be a problem for patients and in the budget expenditures allocated to health by countries. Although chronic wounds occur due to predisposan factors, they are mainly caused by deterioration in the healing process of the skin. According to the definition that has gained prominence recently, a wound is deemed chronic when its volume has not decreased by 50% in the end of four weeks or its size not decreased 10 - 15% per week.1 With the prolongation of the average life expectancy and the increase in diseases such as diabetes mellitus, peripheral vascular diseases, pressure ulcers and chronic complications, the incidence of chronic wounds that impair skin integrity has also increased.

Abstract. The introduction of International Financial Reporting Standards (IFRS) has led to a fundamental change in financial reporting requirements. They aim to present the company’s opportunities and risks in such a way that the objectives of management can be assessed by third parties and other parties. This article discusses the basic requirements that management must meet in the context of accounting in accordance with IFRS. To obtain truthful information about the state of affairs in the company, management must receive and analyze management reports to make the right strategic decisions. IFRS 8 Operating Segments (IFRS 8) assists them in this. The main purpose of this standard is to disclose information by the company to users to assess the nature and financial impact of the activities implemented, as well as the types of economic conditions in which it operates. The article describes the implementation of IFRS 8 as a management function, as well as the impact on various other management functions. In accordance with IFRS 8, the application of the management approach should also be explained in the notes to the financial statements. However, this only applies to listed companies. At the same time, this approach also serves to implement a management approach for unlisted companies for the company’s own purposes. One of the enhanced management tools is also the audit of segment reporting. The audit helps to confirm the veracity of the data of such reporting. As part of the audit of the annual financial statements, it is necessary to check whether the acquired knowledge corresponds to the results of audit procedures for other categories of reports. The result of the audit of segment reporting should be recorded by auditors in working papers (audit documentation). Any inaccuracies in segment reporting should be reported in the audit report. This article describes in detail the audit procedures in accordance with International Standards on Auditing (ISA). Also, the requirements for the preparation of audit documentation for the audit of segment reporting in accordance with ISA and the standards of the Institut der Wirtschaftsprüfer, Germany (IDW Prüfungsstandards (IDW PS)). Keywords: IFRS, ISA, audit, managment, audit documentation, financial report, international standards. Formulas: 0; fig.: 2; tabl.: 0; bibl.: 11.

Objective: Salivary gland ultrasound (SGUS) is emerging as a valid tool in the management of primary Sjögren's syndrome (pSS). This study aimed to investigate whether pSS patients with normal-appearing or pathological SGUS findings showed different clinical, laboratory, and pathologic pSS-related features, and to compare the results by using two different SGUS scores.Methods: Consecutive pSS patients, according to the ACR-EULAR classification criteria, were evaluated. Salivary glands were scored using the early 1992 score by De Vita et al. and the latest 2019 OMERACT score, both being semiquantitative 0–3 scoring systems focused on ultrasonographic parenchymal inhomogeneity (grades 0 and 1, normal-appearing; grades 2 and 3, pathological). The patients were then divided into two groups: “SGUS normal-appearing” if all the salivary glands had normal-appearing parenchyma (grade 0 or 1), or “SGUS pathological” if the grade was 2 or 3 in at least one salivary gland. The associations between SGUS and pSS-related clinical, laboratory, and pathological features were then investigated in the two groups.Results: One hundred pSS patients were evaluated, the mean age (±SD) was 60.9 ± 12.0 years, and mean disease duration was 11.7 ± 7.2 years. Twenty-nine out of 100 (29%) patients were in the “SGUS normal-appearing” group and 71/100 (71%) were in the “SGUS pathological” group. A normal-appearing SGUS was significantly associated with the absence of anti-La/SSB antibodies (p < 0.001) and normal unstimulated salivary flow rate (p = 0.02) by both univariate and multivariate analyses. By univariate analysis, a normal-appearing SGUS was significantly associated also with the absence of rheumatoid factor (p = 0.002) and of serum monoclonal component (p = 0.003), ESSDAI < 5 (p = 0.03), and with a negative lip biopsy (p = 0.029). No associations were found with other items, including anti-Ro/SSA (p = 0.145), Schirmer's test (p = 0.793), ESSPRI (p = 0.47), and demographic data. No differences in these results were observed by using the two SGUS scoring systems.Conclusion: The SGUS allowed the identification of different phenotypes of pSS, and different SGUS scores focused on salivary gland inhomogeneity may be effective to this end.

In practice, a systematic approach is needed that allows you to combine the assessment and further changes in marketing activities. Such an approach should take into account the adoption of managerial decisions regarding improving the efficiency of marketing based on a system of assessment indicators, both marketing activities and the business as a whole, and provide for a program of coordinated changes in business and marketing, which allows to improve these indicators. taking into account the characteristics of the external environment and the resource potential of the enterprise. The result of using this approach is a more efficient state of marketing and business systems, ensuring their interconnection and coordination, taking into account market conditions. The development and implementation of a systematic approach contributes to the application of the theory and methodology of change management in the context of increasing the effectiveness of marketing activities.

Cuando un negocio ha tenido éxito y desea expandirse requiere no sólo de los recursos necesarios sino del desarrollo de un esquema para gestionar y controlar la operación de las nuevas unidades. Por lo tanto, se ha decidido concentrar los esfuerzos de este documento en una empresa pequeña de servicios dedicada a la preparación de alimentos y bebidas, que pretende expandirse y abrir una tercera sucursal que opere de manera controlada y estandarizada a semejanza de las dos anteriores mediante la propuesta de una gestion enfocada a procesos, considerando un diagnóstico inicial y aplicando las herramientas y metodologías relacionadas. Abstract When a business has been successful and wants to expand, it requires not only necessary resources but the development of a scheme to manage and control the operation of new units. Therefore, it has been decided to concentrate the efforts of this document in a small service company dedicated to food preparation and drinks, which wants to expand and open a third branch that operate in a controlled and standardized manner like the two previous ones by the proposal of a management focused on processes, considering an initial diagnosis and applying the related tools and methodologies.

Juvenile myoclonic epilepsy (JME) is a well-defined sub-syndrome of idiopathic generalized/genetic epilepsy, usually presenting in adolescence and characterized by myoclonic jerks, predominately in the arms, associated with tonic-clonic seizures and less often generalized absences. Although the evidence base for a relationship between JME and sleep disorders is weak, most experts regard sleep disorders as an actual comorbidity. This paper reviews the literature underpinning the development of sleep disorders in JME patients. Data that report associated causes of sleep problems in JME patients are discussed, as is the importance of counseling on lifestyle issues. Lastly, a practical approach to managing sleep disorders in young men and women with JME is summarized.

Background: Various nonsurgical interventions have been used for the management of patients with temporomandibular joint (TMJ) disorders, but their clinical effectiveness remains unclear. Hence, the purpose of this systematic review and meta-analyses was to assess the evidence of the effectiveness of nonsurgical interventions in the management of TMJ disorders. Materials and Methods: A literature search on five databases such as PubMed, PubMed Central Cochrane, TRIP, NGCH databases and hand searching was conducted for a period from October 1995 to 2015. Randomized control trials (RCTs) on the nonsurgical management of TMJ disorders were included and reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The quality of the articles was assessed by JADAD scoring. Finally, out of 23 RCTs, 11 articles having any of the primary outcomes (pain pressure threshold [PPT], pain, maximal pain-free mouth opening, and level of dysfunction) were selected. The extracted data were analyzed using NCSS software. Results: The results showed the evidence of pain reduction (P = 0.00), maximal pain-free mouth opening (P = 0.0138), and decrease in level of dysfunction (P = 0.0007) but no improvement in PPT to a significant level (P = 0.6600). Conclusion: Our results suggest that the simplest, cost-effective nonsurgical treatments have a positive therapeutic effect on the initial management of TMJ disorders. However, a consistent methodology recording both the objective and subjective outcomes would be a better choice for added reliability.

Social care providers need to ensure quality services to service users. The problem is characterized by insufficient attention to the quality management of service provided by social care institutions, quality assessment and indicators of service quality assessment, which are important when evaluating principles of service quality by the managers of institutions and employees of different positions. The purpose of the research is to reveal the approach of the management of social care institutions towards the results of the quality assessment of the services provided. In order to collect empirical data in 2017 quantitative study was carried out. The SPSS data processing program is used to analyze the research data. The specific efficiency of quality indicators of social care institutions are calculated in accordance with the 10 qualitative principles of the EQUASS system: leadership, personnel, rights, ethics, partnership, participation, orientation to person, complexity, performance orientation and continuous improvement. Research Subjects: Employees of social welfare institutions providing long-term / shortterm social care services for the elderly in Lithuania according to the list of occupations of employees in the field of social services (2014). The research involved 105 heads of institutions, 122 social workers, 36 employment specialists and 78 social work assistants working in social care institutions providing services for the elderly people. Results of the research: The research results revealed that, according to the subjective opinion of the research participants, the service quality level in social care institutions working with elderly people is rather high. The research ascertained that managers of social care institutions are familiar and they are implementing the criteria of leadership principle. The overall results of the respondents‘ responses revealed that there should be a more active promotion of staff for satisfaction and motivation (66%), while managers' opinion on this criterion did not differ from the assessment of other criteria (77%). The research showed that the subjective assessment of managers in implementing the partnership principle should inform employees about partnerships with other institutions and to maintain closer cooperation with external organizations (77.1%). The EQUASS quality principles which were used in research by dividing them into sub-criteria of quality, allowed to reveal specific performance indicators that indicate the available performance‘s effectiveness of the managers of the company in accordance with the quality criteria and ascertain the approach of the management of care institutions towards the results of the quality assessment of the services provided.

The aim of this paper is analys of the state of electronic services within the postal system in Serbia in order to improve the management of this services. As an indicator of the state of development we can use benchmarking index of development of postal e-services. Benchmarking index is created by PCA (Principal Component Analysis) method in statistical software Minitab which has been designed for PCA. The development of electronic economy has influence on postal system to improve postal electronic services. In conclusion we can say those who make the decisions and management experts have to define appropriate strategy of e-services.

Bazaars are most active and comprehensive center of urban life in Iran and according to its nature, have the economic and social functions. The nature and severity of risks associated with the quantity and quality of materials and enrgy available has led the growing importance of preventive safety assessment in Bazaars. The main objective of this study is to provide a model for risk assessment and management in urban Bazaars. After familiar with the studied systems, interviews with experts, using the Delphi method and paired comparisons, framwork of risk assessment and management was designed.The framework was tested and verified in Hamadan Bazaars. Results showed that the total risk of Hamadan Bazaars, 20.5% of zones in high risk area, and 79.5% were in cautious area. Using of 22 parameters to determine Bazaar zone risks and focus on total, preventive, detective and control risk was the strenght of this study.

O lúpus cutâneo é a principal manifestação clínica do lúpus eritematoso sistêmico. Diferentes formas de apresentações clínicas e histopatológicas compõem o quadro cutâneo. A diferenciação de tais apresentações clínicas é de grande relevância para melhor abordagem terapêutica dos pacientes. Ampla variedade de intervenções terapêuticas está atualmente disponível para o tratamento do lúpus cutâneo. Nessa revisão, serão abordadas as principais opções terapêuticas, medicamentosas e não-medicamentosas, além das novas terapias ainda em estudo.Cutaneous lupus is the most common systemic lupus erythematosus clinical manifestation. Skin lesions are classified according to the clinical and histopathologic features, which are of great relevancy for the management of the disease. Nowadays several therapeutic interventions are available to the treatment of cutaneous lupus. In this review we will approach the most widely used and also the new therapies which are under study.

Este artigo descreve a trajetória da produção científica do Curso de Gerenciamento de Serviços de Enfermagem da UNIFESP a partir da análise das monografias produzidas pelos alunos nos dez anos de existência do curso. Com o objetivo de Identificar temas e objetivos e desenhar linhas de pesquisa a que corresponderam esses trabalhos, 113 monografias foram estudadas. A apuração de freqüência simples e relativa das variáveis estudadas e a classificação da temática segundo referencial teórico sobre o assunto indicou que, no início, os estudos não se atinham à área de abrangência do curso, mas paulatinamente foram se orientando para esta, com destaque para " Recursos Humanos" , o que se acelerou com a criação de grupo de pesquisa focado na sub-especialidade " Gerenciamento em Enfermagem" .Este artículo describe la trayectoria de la producción científica del curso de Administración de Servicios de Enfermería de la UNIFESP a partir del análisis de las monografías producidas por los alumnos en los diez años de existencia del curso. Con el objetivo de identificar los temas y objetivos y delinear líneas de pesquisa referentes a esos trabajos, 113 monografías fueron estudiadas. La apuración de frecuencia simple y relativa de las variables estudiadas y la clasificación de temática según el referencial teórico sobre el asunto indicó que, al inicio, los estudios no se restringieron al área de abarcamiento del curso pero paulatinamente, fueron se orientando hacia esta, con destaque para " Recursos Humanos" , lo que se aceleró con la institución del grupo de pesquisa con foco en la subespecialidad " Administración en Enfermería" .This article describes the scientific production trajectory of the Post-Graduate Program in Nursing Services Mangement at São Paulo Federal University based on the analysis of monographies produced by the students over the last 10 years. The study aimed at identifying subjects and objectives and to delineate research lines of these studies, 113 monographs were analyzed. The verification of the simple and relative frequency of the studied variables and the thematic classification according to the theoretical referential on this subject showed that at the beginning the studies did not considered the area of course extent but gradually they began to reach it with emphasis in " Human Resources" , which was accelerated with the establishment of a research group with the focus in the sub-specialty " nursing management" .

In recent years, Australian universities have been driven by a diversity of external forces, including funding cuts, massification of higher education, and changing student demographics, to reform their relationship with students and improve teaching and learning, particularly for those studying off-campus or part-time. Many universities have responded to these forces either through formal strategic plans developed top-down by executive staff or through organic developments arising from staff in a bottom-up approach. By contrast, much of Murdoch University’s response has been led by a small number of staff who have middle management responsibilities and who have championed the reform of key university functions, largely in spite of current policy or accepted practice. This paper argues that the ‘middle-out’ strategy has both a basis in change management theory and practice, and a number of strengths, including low risk, low cost, and high sustainability. Three linked examples of middle-out change management in teaching and learning at Murdoch University are described and the outcomes analyzed to demonstrate the benefits and pitfalls of this approach.