Management Dilemma Research Articles

Dilemmas in Diagnosis and Management of Temporal Bone Fractures and Their Sequelae

Dilemmas in Diagnosis and Management of Temporal Bone Fractures and Their Sequelae

Joint guarantee rate index assessment of the contribution of agricultural water-saving measures to river ecological flow in water shortage areas

Reconciling higher ecological water demands and economic purposes with finite freshwater resources remains one of the great management dilemmas. Low water efficiency and large water consumption in agricultural irrigation hinder the protection of river ecological flow in the water shortage areas of Northwest China. By analyzing the surplus and shortage of river ecological protection targets, the intensity guarantee rate index is innovatively proposed to quantitatively evaluate the important contribution of improved water-saving measures for river flow restoration. It compensates for the shortcomings of the duration guarantee rate index in evaluation that may mask ecological problems. Considering ecological baseflow, fish species, and landscape water demand, the ecological flow interval (6.00–12.42 m3/s) was determined. Three scenarios are highlighted for different typical years and irrigation regimes in combination with planting structure adjustment and irrigation water utilization coefficient. In 75 %, 90 %, and 95 % typical years, the maximum total annual water-savings (Scenario 3) are 57.3, 57.1, and 87.2 million m3 (sufficient irrigation); 32.2, 33.9, and 35.5 million m3 (deficit irrigation) respectively. The guarantee degree of river ecological flow under both irrigation regimes increased from the previous 65.6 % to a maximum of 91.7 % and 81.2 %. The increase in the daily guarantee rate and decrease in the intensity guarantee rate under the aforementioned three scenarios indicate a reduction of damage depth and duration of ecological flow. By using a quantitative study, it is pointed out that improving agricultural water-saving is a reasonable and necessary way to protect the river flow.

Systematic Assessment of Practical Challenges in Rural Domestic Sewage Treatment in China: Examining Treatment Models, Ecological Risks, and Management Dilemmas

The treatment and purification of rural domestic sewage (RDS) is a pivotal focus in enhancing the living environment in rural areas. Since 2008, special funds for comprehensive rural environmental improvement have been established by the Chinese government. Numerous projects have been implemented to treat RDS, resulting in a significant enhancement of China’s rural sewage treatment ratio. However, current discussions often focus on technical investigations, process selection, and operation modes pertaining to urban sewage while overlooking the unique challenges posed by decentralized sewage treatment facilities in rural areas. This work aims to provide technical support for addressing rural sewage treatment and purification in China through an analysis of limitations associated with prevailing mainstream sewage treatment and separation technologies, ecological risks arising from new pollutants present in domestic wastewater, and subsequent management difficulties.

Modeling and scenario building for climate change adaptation planning: The case of large mining in Chile

The mining sector in Chile is a strategic industrial sector for the country. Existing evidence shows that it faces several serious climate change threats; precipitation and flooding, droughts, heatwaves, among others. This scene put pressure on the government and the industry to develop efficient adaptation plans. To date, adaptation plans are designed under the rather linear paradigm of predict-then-act or the impact-lea approach as they are characterized in the IPCC Assessment Report 5 (AR5). Literature and the IPCC reports have identified the limits of those planning paradigms showing the relevance of adaptation barriers or enabling conditions, which should be considered as intrinsic part of the planning problem.In methodological terms, planning for climate change risks implies an enriched adaptation plan problem, previously characterized only by an operative climate risk management, that must be described at the beginning of the decision-making process. In this study, our objective is to contribute to the climate change adaptation planning of large-scale mining in Chile. The study is based on a climate change adaptation planning approach that overcomes the limitations of the current paradigm. In doing so, we start from the understanding that what emerges as an object of analysis from adding to the climate risks their enabling managing conditions is a social system. The social system whose function is that social climate risk management takes place. Therefore, we call it the Social Management System for Adaptation to Climate Change (SMSACC). As such the SMSACC should be the adaptation planning key object.In the first place we modeled that system applying a qualitative system methodology and then we developed it into a mathematical model based on graph theory, in particular the signed digraphs. This allows us to simulate two types of intervention on the enlarged object of analysis of the large mining adaptation plan. On the one hand, we carried out a future scenario analysis based on prospective tools which enables us to understand the system's answer to different future behavior of its environment, including climate change. On the other hand, we simulate different strategic interventions options on the system, which facilitates understanding the system's reaction under different public policy approaches.The modeling and simulation results provided an insightful understanding of the dilemma of social adaptation management of large mining in Chile, and as such they are useful input for the planning process.

Repeated interrogations of sources of human intelligence using the Scharff technique

ABSTRACT Human Intelligence (HUMINT) sources may be questioned multiple times. However, criminal and military interrogation research focuses on single-instance interrogations. The current study employed a role-playing paradigm to examine the effect of interrogation approach on various elicitation-relevant outcomes and information gain across repeated questioning sessions using a direct approach and the Scharff Technique. In the study scenario, participants (N = 68) were given information on an extremist group planning a bombing, were given an information management dilemma, and were subsequently questioned. Participants in the Scharff Technique condition were questioned using the Scharff Technique at Time 1 and direct questioning at Time 2. Direct Approach condition participants received direct questioning at both times. All participants provided a greater information contribution at Time 2 compared to Time 1, regardless of assigned condition. Compared to participants in the Direct Approach condition, participants in the Scharff Technique condition perceived Time 1 interrogators as more knowledgeable and Time 2 interrogators as less knowledgeable. This suggests a backfire effect when switching from the Scharff technique to direct questioning. Interrogators should carefully consider the decision to employ the Scharff technique if it may be followed up with more traditional questioning approaches.

Dilemma in Diagnosis and Management of CML in Pakistan.

Dilemma in Diagnosis and Management of CML in Pakistan.

Approach to Newborns with Elevated TSH: A Different Perspective from the International Guidelines for Iodine-Deficient Countries.

Lowering of thyroid-stimulating hormone (TSH) cutoffs in newborn screening programs has created a management dilemma by leading to more frequent detection of neonates with elevated TSH concentrations due to false-positive results, transient neonatal hyperthyrotropinemia (NHT), and milder forms of congenital hypothyroidism. Current consensus guidelines recommend starting treatment if the venous TSH level is >20 mU/l in the face of a normal free thyroxin (FT4) level, which is an arbitrary threshold for treatment decisions. In countries such as Türkiye, where transient NHT may be more common due to iodine deficiency and/or overload, putting this recommendation into daily practice may lead to unnecessary and over treatments, long-term follow-ups, and increased workload and costs. In this review, we addressed alternative approaches for infants with elevated TSH concentrations detected at newborn screening. Our management approach can be summarized as follows: Infants with mild NHT (TSH<20 mU/l) should be followed without treatment. In moderate NHT (TSH 20-30 mU/l), treatment or monitoring decisions can be made according to age, TSH trend and absolute FT4 level. Moderate cases of NHT should be treated if age at confirmatory testing is >21 days or if there is no downward trend in TSH and FT4 level is in the lower half of age-specific reference range in the first 21 days. In in-between cases of moderate NHT, thyroid ultrasound can guide treatment decision by determining mild cases of thyroid dysgenesis that require life-long treatment. Otherwise, monitoring is a reasonable option. Infants with compensated hypothyroidism (TSH>30 mU/l) and persistent hyperthyrotropinemia (>6-10 mU/l after neonatal period) should receive L-thyroxine treatment. But all treated cases of isolated TSH elevation should be closely monitored to avoid overtreatment, and re-evaluated by a trial off therapy. This alternative approach will largely eliminate unnecessary treatment of infants with transient NHT, mostly caused by iodine deficiency or excess, and will reduce workload and costs by preventing unwarranted investigation and long-term follow-up.

Ethical Dilemmas in African Human Resource Management: A Literature Review

In the African context, the management of human resources (HR) involves the navigation of intricate ethical issues influenced by a myriad of social, cultural and economic factors. This study, based on systematic literature review, scrutinized ethical dilemmas in Human Resources Management in Africa. Specifically, the study assessed the areas within HR practices that are predisposed to unethical conduct and identified the core ethical issues prevalent in organizations, thereby giving rise to ethical dilemmas. The study utilized a systematic qualitative synthesis, employing the nomothetic-based content analysis, to scrutinize data extracted from 65 journal articles. The findings delineate two primary domains in which HR practices are susceptible to unethical conduct. The first is the management of core HR functions, such as recruitment, performance appraisal and remuneration, which are vulnerable to unethical practices like favoritism and corruption. The second domain involves balancing the often-conflicting interests of employers and employees. Four primary ethical issues emerged as significant sources of dilemmas: bribery and corruption, misconduct (physical, verbal, and sexual), nepotism and discrimination. These challenges suggest a pressing need for transparent, merit-based recruitment processes and regular ethics training HR professionals to navigate the complex landscape of organizational and employee interests. Implementing gender and diversity policies is crucial in addressing discrimination based on gender, ethnicity or disability. Additionally, establishing robust whistle-blowing mechanisms can enable employees to report unethical conduct confidentially, thereby strengthening organizational integrity and fostering a more inclusive professional environment. Comprehensive ethical frameworks will not only mitigate dilemmas but also enhance the overall credibility and effectiveness of HRM practices in the African context.

The State Management Dilemma: BLoC vs. Provider in Modern Flutter Development

State management is a critical aspect of Flutter application development, directly impacting the efficiency, maintainability and scalability of mobile applications. Among the various state management solutions available in Flutter, BLoC (Business Logic Component) and Provider have emerged as two of the most prominent and widely adopted patterns. This paper presents a comprehensive comparison between BLoC and Provider, analyzing their distinct approaches to managing states, their suitability for different types of applications and their respective strengths and weaknesses. Through an in-depth examination of criteria such as ease of use, learning curve, performance, scalability and community support, this study aims to guide developers in choosing the most appropriate state management solution for their specific project needs. The findings of this research highlight the contexts in which each pattern excels, offering valuable insights for both novice and experienced Flutter developers.

To Caffeinate or Not to Caffeinate? The Dilemma in Neonatal Apnea Management

To Caffeinate or Not to Caffeinate? The Dilemma in Neonatal Apnea Management

Post-operative breast imaging: a management dilemma. Can mammographic artificial intelligence help?

BackgroundImaging of the postoperative breast is a challenging issue for the interpreting physician with many variable findings that may require additional assessment through targeted ultrasound, more mammography views, or other investigations. Artificial intelligence (AI) is a fast-developing field with various applications in the breast imaging including the detection and classification of lesions, the prediction of therapy response, and the prediction of breast cancer risk. This study aimed to identify whether Artificial Intelligence improves the mammographic detection and diagnosis of breast post-operative changes and hence improves follow-up and diagnostic workflow and reduces the need for additional exposure to extra radiation or contrast material doses as in Contrast Enhanced Mammography, and the need for interventional procedures as biopsy.MethodsThis cross-sectional analytic study included 66 female patients following breast-conserving surgeries coming with breast complaints or for follow-up, with mammographically diagnosed changes.ResultsMammography had a sensitivity of 91.7%, a specificity of 94.4%, a positive predictive value (PPV) of 78.6%, a negative predictive value (NPV) of 98.1%, and an accuracy of 93.9%, while the AI method indices were sensitivity 91.7%, specificity 92.6%, (PPV) 73.3%, (NPV) 98%, and accuracy 92.4%. The calculated cut-off point for the quantitative AI (probability of malignancy “POM” score) was 51.5%. There was a statistically significantly higher average in the percentage of POM in malignant cases (76.5 ± 27.3%) compared to benign cases (27.1 ± 19.7%). However, the final indices for the combined use of mammography and (AI) were sensitivity 100%, specificity 88.9%, (PPV) 66.7%, (NPV) 100%, and accuracy 90.9%.ConclusionApplying the AI algorithm on mammograms showed positive impacts on the sensitivity of the post-operative breast assessment, with an excellent reduction of the mammographic missed cancers.

Can applying a motivation theory of elderly volunteers help solve the management dilemma of rural libraries? A case study from China

The biggest management dilemma of rural libraries stems from the shortage of librarians. This study draws upon the case analysis of Qiluo Library in China to investigate the volunteering motivation of the elderly as well as the feasibility of the model of a rural library run entirely by elderly volunteers. Through questionnaires and semi-structured interviews, it was found that the elderly had four types of motivation for volunteering at rural libraries: endogenous egoism, exogenous egoism, endogenous altruism, and exogenous altruism. Connecting motivation with rural libraries’ dilemma of personnel shortages is of great significance. Despite some challenges, the Qiluo model of library operations provides an innovative and effective way of managing rural libraries in the context of librarian shortages and an aging population, especially in areas with low elderly mobility and less-developed economies. The construction of a motivational framework of elderly volunteers also provides new ideas for addressing the library dilemma.

Neonatal hypoglycemia: analytical review

Neonatal Hypoglycemia (NH) is one of the most frequent metabolic abnormalities, occurs in the neonatal period, affecting up to 15% of healthy neonates. The definition of NH remains controversial due to the lack of significant correlations between glucose levels blood glucose levels, clinical symptoms, and long-term outcomes. Some approaches define NH on the basis of clinical symptoms, others on the basis of plasma glucose levels. Because of this, there are currently no uniform recommendations on indications for glycemic fixation, reference values and critical glycemic thresholds. In recent years anumber of clinical recommendations for NH in different countries. Thus, the definition of clinically significant hypoglycemia remains one of the most confusing and controversial issues in modern neonatology. We analyzed the available clinical guidelines on neonatal hypoglycemia for the period from 2015 to the present, as well as the available dilemmas of clinical management of children with NH.

Thyroid Storm in the Presence of Acute Liver Failure - A Management Dilemma

Thyroid Storm in the Presence of Acute Liver Failure - A Management Dilemma

Dilemmas of educational management in times of exception: Challenges for the initial level

Dilemmas of educational management in times of exception: Challenges for the initial level

Natural History of the Remnant Pancreatic Duct after Pancreatoduodenectomy for Non-Invasive Intraductal Papillary Mucinous Neoplasm: Results from an International Consortium.

Little is known about the prognostic significance of pancreatic duct (PD) dilation following pancreatoduodenectomy for intraductal papillary mucinous neoplasms (IPMN). Although PD dilation is typically the hallmark radiographic feature of IPMN, other causes of PD dilation exist, including anastomotic stricture, pancreatitis, senescence, and postsurgical passive dilation. Therefore, PD dilation after pancreatoduodenectomy for IPMN represents a diagnostic and management dilemma. The purpose of this study was to evaluate the significance of PD dilation after pancreatoduodenectomy for noninvasive IPMN. All patients who underwent pancreatoduodenectomy for noninvasive IPMN at nine pancreatic academic centers between 2013 and 2018 were included. Variables were entered prospectively into institutional databases and retrospectively reviewed for the purpose of this study. Dilation of the PD remnant was defined as a duct diameter of ≥5mm, according to international guidelines. Four-hundred and eighty-one patients were included in this study. The mean age of the patients was 66 years (range 30-90). Patients were surveilled for a median of 4.5 (+/-2.3; max 10.6) years. During follow-up, 132 patients (27.4%) developed PD dilation in the remnant tissue after a median of 3.3 years. Multivariable analysis demonstrated that older age at the time of pancreatoduodenectomy (P=0.01) and longer surveillance duration (P=0.002) were predictors of PD dilation. Interestingly, neither the pathological IPMN subtype (branch-duct vs. main duct/mixed, P=0.96) nor the preoperative PD diameter (P=0.14) was associated with an increased risk of PD dilation in the remnant. During follow-up, IPMN recurrence was suspected in the remaining 72 patients (18.4%), solely because of ductal dilation on cross-sectional imaging in 97% (70/72). Completion pancreatectomy was performed in only 16 patients (3.3%), of whom only four (0.8%) had invasive carcinoma. Three of these four patients had high-grade dysplasia in the original pancreatoduodenectomy specimen, whereas only one had a low-grade dysplastic lesion initially. On multivariable analysis, no variable was predictive of IPMN recurrence in the remnant. New main duct dilation in the pancreatic remnant after pancreatoduodenectomy for IPMN is common, occurring in 27% of the patients. The duration of surveillance is the main factor associated with remnant PD dilation, suggesting that this is likely a physiologic phenomenon. Although recurrence of IPMN in the remnant is often suspected, only 0.8% of patients develop an invasive carcinoma in the pancreatic remnant requiring completion pancreatectomy.

Clinical Utility of Molecular Tumor Board Review for Identification of Possible Germline Pathogenic Variants on Tumor Next-Generation Sequencing Reports.

Tumor next-generation sequencing (NGS) testing identifies possible germline pathogenic variants (PGPVs), creating a dilemma for appropriate recognition, triage, and management. The objective of this study was to determine the clinical utility of an institutional molecular tumor board (MTB) in assessing tumor NGS reports for PGPVs. Our institutional MTB reviews all NGS reports to provide treatment and further testing recommendations, including genetic counseling referral and consideration of genetic testing (GC/GT). We studied the patients reviewed by the MTB who were recommended for GC/GT to determine the frequency of referral to a GC, germline test completion, rate of pathogenic germline variants (PGVs), factors related to PGVs, and germline conversion rate (GCR). Of the 2,355 patients reviewed by the MTB during the study period, 609 (25.9%) had a recommendation for GC/GT. Of the 609 with a GC/GT recommendation, only 181 (29.7%) were referred for GC/GT by their treating physicians, and only 107 (17.6%) completed GT. Of the 107 patients completing GT, 29 (26%) had a confirmed PGV. The only factors significantly associated with PGVs were testing due to a PGPV and higher mean variant allele fraction on the tumor NGS. Only 40 patients with a GC/GT recommendation (14.3%) due to a PGPV completed GT; however, the GCR was 42.5% (n = 17/40). The MTB review of PGPV is clinically valuable, identifying PGPV in 12% of patients undergoing tumor NGS and a GCR of 42.5%. Rates of GC/GT completion were relatively low due to under-referral by treating physicians. Given the high GCR, the authors encourage institutional algorithms to help increase GC/GT rates for patients found to have PGPV following tumor NGS testing.

Impacts of CSR autonomy, self-expressiveness and hedonic value of CSR activity on guest citizenship and hotel brand preference

Recruiting guests to participate in corporate social responsibility (CSR) activities during a vacation presents a dilemma for hotel managers – will such requests spoil a holiday? The study is significant because of increased investment by hotels in CSR activities and greater inclusion of hotel guests in CSR activities. We extend psychological wellbeing theory to evaluate the relative importance of CSR autonomy in enhancing guest engagement. A scenario based on a guest’s return to an actual hotel recently visited was designed and a convenience sample of 249 survey respondents analyzed using structural equation modeling. While hedonic value of the CSR activity provided the greatest effect on brand preference, both self-expressiveness and CSR autonomy significantly impacted brand preference. Effects for all constructs were mediated through cocreated citizenship behavior. The study has substantial theoretical implications for scholars and practical implications for CSR marketing communication campaigns to guests conducted by hotel managers and non-governmental organizations.

Outcomes following surgical clipping of re-ruptured previously untreated intracranial aneurysms.

Re-rupture of untreated intracranial aneurysm is a potentially life-threatening condition. Despite tremendous advances in the diagnosis and treatment of intracranial aneurysms, such events are not rare and continue to pose a management dilemma. In this study, we examined the clinical, radiological and treatment details of patients who underwent microsurgical clipping for re-rupture of previously untreated intracranial aneurysms. Re ruptures were categorized as early and late re ruptures (< or > 7 days of inter ictus interval respectively). Modified Rankin Score (mRS) was used for functional outcome assessment and logistic regression analysiswas used to test the predictors of long-term outcome. Re-ruptured intracranial aneurysms comprised 5% (n = 32/637) of the aneurysm clippings done at our center in this time span. The mean mRS score at discharge and at last follow-up were 3 and 3.04 respectively. Twenty-four (75%) patients were alive at a mean follow-up of 36 months. Early re-ruptures were associated with worse mean mRS scores at discharge (3.9 vs 2.5, p = 0.03) including the perioperative deaths (n = 4, 12.5%). The functional status at discharge and a poor preoperative clinical grade predicted apoor long-term outcome. Therefore, the long-term outcomes are primarily dependent on the short-term outcomes and to a lesser extent, the clinical grade at presentation. Those presenting with poor preoperative clinical grade, especially in the setting of an early re rupture, have a very poor prognosis and do not benefit from surgery.

A rare presentation of bone cement implantation syndrome as hypertensive anaphylaxis: A diagnostic and management dilemma.

Bone cement implantation syndrome characteristically involves acute alterations in the function of respiratory and cardiovascular systems. We present a case report of cement reaction with unusual presentation, that is, hypoxia, hypertension and tachycardia. A 74-year-old hypertensive male on regular medications sustained a slip and fall, presented with a right intertrochanteric neck of femur fracture, now posted for cemented hemiarthroplasty. Intraoperatively, after applying bone cement, the patient developed sweating, dyspnoea, bilateral wheezing and tachypnoea and desaturation of up to 80%-84%. Respiratory symptoms were associated with tachycardia (140-160 bpm) and hypertension (220/110 mm Hg). The surgeon was alerted about the event, the patient was reassured, and respiration was assisted with positive pressure ventilation with supplementation of 100% oxygen. Several mechanisms have been proposed, such as the toxic effect of systemically absorbed methyl methacrylate, exothermic reaction, fat and marrow embolism, high marrow pressure during cementing and anaphylactic reaction. The administration of adrenaline, which can worsen the clinical picture, is the mainstay in managing anaphylaxis. The association of hypertension and tachycardia with bone cement implantation syndrome, previously not reported, can have distinct pathomechanisms and cause a diagnostic and management dilemma.