Management Dilemma Research Articles

Calvarial Tuberculosis: Shifting Paradigm from Surgical to Conservative Approach

Abstract Background Tuberculosis (TB) is an endemic disease in developing countries like India. However, incidence of calvarial TB is very low and it presents in varied forms posing a diagnostic dilemma and delay in management. Objectives This article reports a case series of 15 patients with varied presentations of calvarial TB from a tertiary care superspeciality center of Haryana state in India. Material and Methods Study is a retrospective analysis of 15 patients with calvarial TB treated between 2018 and 2021 in a tertiary care hospital. Clinical features, radiological findings, surgical and medical management, and outcomes were reviewed. Results Of the 15 patients, 9 were males and age ranged between 12 and 45 years. Mean duration of symptoms was 2.9 months (range 1–5 months). The most common presenting symptoms were scalp swelling, discharging sinus, and pain. Four patients were treatment defaulters of pulmonary TB and two patients were found human immunodeficiency virus positive. Brain imaging showed peripherally enhancing extradural collection with bone erosions in most cases. Eleven patients were managed conservatively with fine-needle aspiration cytology (FNAC) or local debridement/sinus excision. Four patients were managed surgically with drainage of collection, excision of necrotic bone, followed by antitubercular therapy. One patient needed cerebrospinal fluid diversion for associated hydrocephalous with tubercular meningitis which could not recover and succumbed. Conclusion Calvarial TB is a rare occurrence of common prevalent diseases. Conservative management with FNAC and sinus excision followed by antitubercular treatment are the mainstay of treatment. Surgery should be reserved for extensive lesion or lesion with mass effect.

Future Studies of the Oil and Gas Industry: Understanding the Dilemmas of Innovation Management, Governance, and Sustainability

Purpose: The study was to systematically analyze the scientific production over the last decade (2010-2021) in terms of future studies about the oil and gas (O&G) industry. Theoretical Framework: The future of the O&G industry has become the ground for research with various methods to study the finite life of this resource, global climate change, the prospect of low-carbon economies, and the transition of energy to renewable sources. Method: This systematic literature review analyzed scientific production in the last decade about the future of the O&G industry, indicating new perspectives for the field, identifying all the primary research relevant to an issue, and allowing for critical assessment and synthesis of results. Findings: There is an increase in the number of publications on the subject, emphasizing topics such as innovation management and energy consumption. There was a predominance of empirical studies that employed forecasting methods; however, foresight was used for topics such as governance and strategy. Research Implications: Contributing to a synthesis of scientific publications, although the list is not exhaustive, nevertheless provides a starting point for advancing research into the future of the industry. Originality/value: Various contributions and innovation proposals for organizations were identified. This study provides a structured scientific basis for future oil and gas industry studies.

Ethical and Legal Dilemmas in Management: The Case of the Tourism Industry During the COVID-19 Pandemic

Ethical and Legal Dilemmas in Management: The Case of the Tourism Industry During the COVID-19 Pandemic

Sustained Delivery of Rifampicin Nanoformulation Administration Intravitreally Into Rabbit Eyes for Ocular Tuberculosis.

Diagnosis and treatment of ocular tuberculosis is very challenging. It poses a significant and potential management dilemma after diagnosis as a primary, active, or secondary infection. The higher amounts of orally administered antitubercular drugs are needed to achieve the therapeutic concentration in the eye, which may lead to a higher risk of side effects. However, the intravitreal administration of drugs is not practiced because of the frequent administration of the injections. This study was carried out to develop, optimize, and characterize rifampicin-loaded poly (lactic-co-glycolic acid) (PLGA) nanoparticles to make them sustained release followed by the direct administration of plain rifampicin and rifampicin nano-formulations in the vitreous of rabbit eyes. Both groups were comparatively assessed for the sustained delivery of the two preparations in the vitreous and their systemic toxicity. The characteristics of rifampicin-loaded nanoparticles were 786 nm in size with narrow size distribution along with a zeta potential of -12 mV. The drug encapsulation efficiency and loading capacity were 67.68% w/w and 42.28% w/w, respectively. The four New Zealand white rabbits were divided into two groups and given plain rifampicin (50µl volume) and PLGA nanoformulations of rifampicin (50µl volume) in each eye. In vivo, rifampicin-loaded PLGA nanoparticles produced sustained release of rifampicin for a week, even obtaining the 0.51 µg/ml levels on the seventh day in vitreous against negligible levels after one day for free rifampicin. The Cmax levels for free Rifampicin and Rifampicin nanoparticles were 0.44 µg/ml and 1.86 µg/ml, respectively. In this experimental proof-of-concept study, we have found that rifampicin-loaded PLGA nanoparticles released rifampicin in a sustained manner for up to seven days compared to free drugs only for one day into the vitreous. The intravitreal-administered drug did not reach systemic circulation.

Posterior Fossa Ependymoma in a Child with Extensive Chondro-Osseous Metaplasia Occurring at Cerebellopontine Angle and Masquerading as a Vestibular Schwannoma: An Exceptionally Rare Clinicopathological Manifestation with Review of Literature.

Ependymoma occurring at the cerebellopontine (CP) angle is an extremely uncommon sight and poses diagnostic and management dilemmas to neurosurgeons, radiologists, and neuropathologists alike. Moreover, the presence of extensive chondro-osseous metaplastic elements in ependymomas is an exceptionally infrequent histopathological manifestation. However, due to the seldom-seen nature of this histomorphological feature, there is no definite consensus regarding its etiopathogenesis and clinical consequences, and there is an extreme scarcity of literature elucidating its clinicopathological spectrum and prognostic significance. Herein, we illustrate an intriguing clinical tale of a 7-year-old male child with posterior fossa ependymoma, central nervous system (CNS) World Health Organization (WHO) grade 3, arising at the right CP angle and masquerading as a vestibular schwannoma, which in itself is a rare presentation, and additionally, exhibiting extensive chondro-osseous metaplasia, which is a very uncommon histomorphological observation. To the best of the authors' knowledge and after a comprehensive literature search, the coexistence of these two rare observations has merely been described once in international literature. This case sheds light on and highlights the importance of keeping ependymoma as a possible differential while coming across CP angle space-occupying lesions. They should be diligently distinguished from schwannomas and other masqueraders that typically occur at this site, as they have diverse management and follow-up protocols, with varying prognostic outcomes for the patients. Moreover, this case also unravels and details the clinicopathological characteristics of a scarcely described feature of chondro-osseous metaplasia in ependymomas.

Ethical dilemmas in healthcare management: A comprehensive review

This research paper comprehensively examines ethical dilemmas in healthcare management, offering insights into emerging trends, technological impacts, and anticipated guideline changes. The paper explores healthcare managers' multifaceted challenges, including conflicting stakeholder interests, the delicate balance between patient rights and organizational goals, and navigating diverse cultural values. Strategies for mitigating ethical dilemmas, such as education, policy implementation, and collaborative decision-making, are discussed. Additionally, the paper delves into the evolving ethical landscape influenced by genomic medicine, artificial intelligence, and telehealth. The implications for healthcare managers include the need for continuous education, ethical leadership, and technological literacy. As healthcare transforms, embracing ethical practices becomes imperative for fostering patient-centric, equitable, and ethically sound healthcare environments. Keywords: Healthcare Management Ethics, Ethical Dilemmas, Technological Impacts, Ethical Leadership.

Значение китайско-российского стратегического сотрудничества для развития многостороннего взаимодействия в рамках ШОС и БРИКС

In the context of global changes, the deepening of multilateral strategic cooperation between Russia and China has become an important area of demonstrating the universal value and fundamental importance of comprehensive cooperation between countries in a new era. The challenges of our time associated with protracted regional conflicts, changing paradigms of international communication, management dilemmas, a lack of strategic mutual trust, and changes in the perception of the role of each country necessitate joint efforts by states to mitigate them. It is emphasized that the SCO and BRICS mechanisms can be used for this purpose, with some adjustments. On the one hand, it is important to harmonize the management focus and functional boundaries of the SCO, to use the complementary strengths and innovative potential of the countries in the activities of the association. On the other hand, it is necessary to enhance the environmental sustainability of states and the strength of their cooperation within BRICS, to standardize the various requirements of participants and ensure the merger of their interests, to explore opportunities for cooperation based on the Sino-Russian experience and use them to develop a strategy of multilateral interaction aimed at conducting constructive reforms and establishing a multipolar international order on an equitable basis.

Tangled: Unraveling a Rare Combination of Multiple Coronary Artery Fistulas and Severe Aortic Stenosis in a 70-Year-Old Man

INTRODUCTION: Coronary artery fistulas (CAFs) are rare congenital or acquired anomalies that connect one or more coronary arteries to a cardiac chamber or a great vessel without an intervening capillary bed. Most are asymptomatic and are usually incidental findings on echocardiography or angiography for an unrelated cause. Occasionally, complications occur, which include endocarditis, thrombosis, steal syndrome, and heart failure.Here, we present a rare case of multiple CAFs draining to the main pulmonary artery in a patient with severe aortic stenosis (AS) presenting a unique management dilemma. CASE PRESENTATION: Five weeks before admission, a 70-year-old man with good baseline functional capacity, independent on all activities of daily living, developed exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. His symptoms persisted for a week prompting consult at another institution where he was managed as a case of acute heart failure and given diuretics, which resolved his symptoms. His two-dimensional (2D) echocardiogram showed eccentric left ventricular hypertrophy with adequate segmental and global wall motion and contractility, a left ventricular ejection fraction of 62% by the Simpson method, normal right ventricular diameter with adequate wall motion and contractility, dilated left atrial dimensions with a left atrial volume index of 50.98 mL/m2, moderate mitral regurgitation, normal right atrial diameter, thickened mitral valve leaflets without restriction of motion, thickened and calcified aortic valve, severe AS (aortic valve area of 0.37 cm2, mean gradient of 78.77 mm Hg, and peak gradient of 124.88 mm Hg), severe aortic regurgitation, mild tricuspid and pulmonic regurgitation, and normal pulmonary artery pressure (13 mm Hg by tricuspid regurgitant jet).

Peutz-Jeghers syndrome: management for recurrent intussusceptions.

Peutz-Jeghers syndrome (PJS) is an autosomal dominant disorder characterized by hamartomatous gastrointestinal polyps along with the characteristic mucocutaneous freckling. Multiple surgeries for recurrent intussusception in these children may lead to short bowel syndrome. Here we present our experience of management in such patients. From January 2015 to December 2023, we reviewed children of PJS, presented with recurrent intussusceptions. Data were collected regarding presentation, management, and follow-up with attention on management dilemma. Diagnosis of PJS was based on criteria laid by World Health Organization (WHO). A total of nine patients were presented with age ranging from 4 to 17years (median 9years). A total of eighteen laparotomies were performed (7 outside, 11 at our centre). Among 11 laparotomies done at our centre, resection and anastomosis of bowel was done 3 times while 8 times enterotomy and polypectomy was done after reduction of intussusception. Upper and lower gastrointestinal endoscopy (UGIE & LGIE) was done in all cases while intraoperative enteroscopy (IOE) performed when required. Follow-up ranged from 2months to 7years. Children with PJS have a high risk of multiple laparotomies due to polyps' complications. Considering the diffuse involvement of the gut, early decision of surgery and extensive bowel resection should not be done. Conservative treatment must be tried under close observation whenever there is surgical dilemma. The treatment should be directed in the form of limited resection or polypectomy after reduction of intussusception.

The TMD management dilemma.

As temporomandibular disorders (TMDs) become ever more prevalent in both primary and secondary care settings, successful management is increasingly challenging in both sectors. The authors aim to explore the dilemma of TMD management as the patient journeys through from primary to secondary care and offer educational tools to support practitioners in managing this complex patient cohort, as well as outlining alternative solutions for the delivery of TMD management strategies.

Antiviral therapies for the management of persistent coronavirus disease 2019 in immunocompromised hosts: A narrative review.

Antiviral agents with activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have played a critical role in disease management; however, little is known regarding the efficacy of these medications in the treatment of SARS-CoV-2 infection in immunocompromised patients, particularly in the management of persistent SARS-CoV-2 positivity. This narrative review discusses the management of persistent coronavirus disease 2019 in immunocompromised hosts, with a focus on antiviral therapies. We identified 84 cases from the literature describing a variety of approaches, including prolonged antiviral therapy (n = 11), combination antivirals (n = 13), and mixed therapy with antiviral and antibody treatments (n = 60). A high proportion had an underlying haematologic malignancy (n = 67, 80%), and were in receipt of anti-CD20 agents (n = 51, 60%). Success was reported in 70 cases (83%) which varied according to the therapy type. Combination therapies with antivirals may be an effective approach for individuals with persistent SARS-CoV-2 positivity, particularly those that incorporate treatments aimed at increasing neutralizing antibody levels. Any novel approaches taken to this difficult management dilemma should be mindful of the emergence of antiviral resistance.

Diagnostic and management dilemmas of pregnancies at the utero-tubal junction: A case series and management algorithm.

A pregnancy at the utero-tubal junction is a rare type of ectopic pregnancy and is associated with high maternal morbidity if it remains undetected. In the present study we discuss four cases of ectopic pregnancies at the utero-tubal junction which caused diagnostic and management dilemmas. Four cases of early pregnancies with the gestational sac (G-sac) implanted near the utero-tubal junction are described. In case 1 this was suspected after a failed attempt at dilatation and curettage at our hospital, cases 2 and 3 presented with amenorrhea and pain abdomen and case 4 was diagnosed on first pregnancy documentation scan after frozen embryo transfer. As initial two-dimensional (2D) transvaginal scan (TVS) failed to diagnose the exact location of the G-sac, three-dimensional (3D) TVS helped to localize the exact location of pregnancy and subsequent individualized management. Case 1 had a partial intramural ectopic pregnancy managed by laparotomy and removal of the ectopic sac. The second and third cases were eccentric uterine pregnancies. The fourth was an interstitial ectopic pregnancy managed by a laparoscopic loop and stitch technique. This case series describes the role of 3D TVS for the evaluation of pregnancies implanted at the utero-tubal junction and individual management of eccentric intrauterine, interstitial ectopic and intramural ectopic pregnancies. A diagnostic algorithm for such types of cases and management options is discussed.

Case Series on Abnormal Low-lying Implantation of Ectopic Pregnancy: A Diagnostic and Management Dilemma

Case Series on Abnormal Low-lying Implantation of Ectopic Pregnancy: A Diagnostic and Management Dilemma

Towards active citizenship and caring democracy? User participation in Norwegian long-term care

The conceptualisation of a caring democracy provides strong arguments against neoliberal welfare states. However, there is currently a knowledge gap regarding how non-market-oriented welfare states are striving to reach their intention of a caring democracy. Based on a qualitative study, this article uses the case of Norwegian long-term care services for older people to provide insight into how this intention is practised in everyday care service settings when the current development is about active citizenship. The findings show ethical dilemmas for care managers and healthcare professionals, positioned on the front line of combining the creation of active citizens with the democratisation of services.

SDOH and Immigration Status: Offering Advocacy and Adhering to Ethical Practice Across the Care Continuum.

Social determinants of health (SDOH), the environmental, economic, and social factors that influence people's health outcomes, are widely recognized across health and human services. In addition, there are other factors that can exacerbate SDOH; among them is immigration status. Its influence is so profound that it has been suggested that immigration be considered an SDOH in and of itself (National Academies of Sciences, Engineering, and Medicine, 2018). Across the continuum, case managers need to be aware of the immigration status of their clients (the individuals for whom they advocate and provide services). This is particularly important when addressing the care needs and discharge plans for clients in acute care, community-based health, and workers' compensation. With workers' compensation, when an individual is undocumented and severely injured, immigration status directly impacts the services they may receive under state mandates. Moreover, such limitations can present ethical dilemmas for case managers, including what happens to workers if they are returned to their home countries. SDOH and immigration status can impact individuals in acute care, subacute care, community-based care, and workers' compensation. SDOH and immigration status highlight the disparities that exist within health and human services. Although equity is a core value of case management practice, the case manager's ability to provide equal access to care and resources can be severely limited because of the individual's immigration status. At all times, case managers must practice within their licensure and certifications. By recognizing that immigration status should be an SDOH, case management professionals and health and human services organizations can elevate the discussion of how to care for individuals with catastrophic injuries and illnesses who are undocumented.

ASO Author Reflections: Hilar Biliary Strictures-A Persistent Diagnostic and Management Dilemma.

ASO Author Reflections: Hilar Biliary Strictures-A Persistent Diagnostic and Management Dilemma.

Imaging Mismatch of Nail in the Eyeball: What’s next?

Introduction : A retained foreign body (FB) can lead to severe complications, the most devastating of which is eye loss. We present a discrepancy of imaging that resulted in a dilemma in the approach management of a mixed global-adnexal FB case.
 Case Illustration : A 31-year-old man came to the emergency room with blurry vision for 1.5 hours after a nail hit his right eye (RE). The visual acuity of RE is light perception. Ophthalmological examination revealed a central Y-shaped full-thickness corneal laceration with iris and vitreous prolapse. The lens appeared cloudy, and the posterior segment was difficult to assess. Imaging showed a foreign metal object asa nail in the oculi to intraconal without penetration to the orbital wall. He was planned to undergo FB extraction with corneal laceration repair and aspiration of lens mass irrigation. However, the nail was hard to find intraoperatively because the vitreous and choroid kept coming out. Hence evisceration with DFG was performed. The nail was found more posteriorly and attached to the bone.
 Discussion : While primary repair is the standard practice for open globe injury, managing retained intraocular metallic foreign bodies is controversial. Imaging such as CT scans can help determine the location of FB and approach management. In this case, imaging showed the FB was in the iris plane and not penetrating the orbital wall, so primary repair and FB extraction were planned.
 Conclusion : The imaging may not always be accurate in determining the exact location of FB, and the surgical approach may need to be adjusted accordingly.

Clinical Feature of Langerhans Cell Histiocytosis of the Orbit : A First Case Series in Indonesia

Introduction : Langer hans histiocytosis (LCH) is an inexplicable disease characterized by proliferation of Langerhans and intermixed with inflammatory cell, in particular eosinophil, which represents only 1% pediatric orbital tumours. Orbital involvement of LCH is a rare clinical entity as the disease simulate variety of malignancies and present as a diagnostic and management dilemma for ophthalmologist.
 Case Illustration : Two cases of toddler presented with unilateral progressive upper eyelid swelling and proptosis for more than a month. Both cases has history of orbital trauma 1 month before swelling was observed. Initial CT scan revealed extraconal mass, with destruction of lateral orbital wall and frontal bone. Both patients had histopathological biopsy confirmed eosinophlic cytoplasm. One patient confirmed immunohistochemistry markers S100 and CD1a which is specific for Langerhans cells. Both patients continue with chemotherapy as definitive treatment.
 Discussion : LCH is a wide clinical spectrum which manifestation simulate other pediatric orbital malignancies. Case illustration present unilateral eyelid swelling with history of trauma may resemble other diagnosis unless further work up is performed. This case series exhibits clinical manifestations that may be suggestive of LCH. Considering rapid progression of disease, definitive diagnosis is a mandatory based on histopatological analysis through biopsy surgery.
 Conclusion : LCH is rare disease, it should be considered as one of deferential diagnosis in pediatric orbital malignancy with initial presentation acute unilateral eyelid swelling, proptosis, history of trauma, extraconal mass and destruction of bones as radiological features. This might be helpful for early recognition and prompt treatment of disease suggestive of LCH.

The Sustainable Development of Bridges in China: Collapse Cause Analysis, Existing Management Dilemmas and Potential Solutions

The construction of sustainable bridge projects has become a global mission and challenge in the 21st century. Unfortunately, there has been a rise in bridge collapse incidents due to various factors in recent years both during the construction and service phases. These incidents have resulted in significant loss of life and property damage, exacerbating the five sustainable development issues faced by bridge engineering: natural, resource, environmental, social, and economic factors. As a result, the prevention and resolution of bridge collapse accidents have garnered attention from professionals, research institutions, and government departments, making it a prominent research area. In line with the sustainable development concept of bridge engineering, this article classifies the causes of bridge collapses into two categories: those occurring during the construction phase and those happening during the service phase; the latter includes lack of inspection, maintenance and management, external natural factors, and human factors. Furthermore, this article thoroughly examines the existing national management framework, identifying the dilemmas that hinder its effectiveness in regulating bridge collapse prevention. Finally, several effective suggestions are proposed for the prevention of bridge collapse incidents. These recommendations aim to motivate governments, project owners, designers, constructors, managers, and users to actively develop and promote high-quality sustainable bridges.

In-situ Artefact Documentation of Underwater Cultural Heritage Using Third-Party Data

Abstract Large underwater construction projects generate hundreds of potential cultural heritage objects requiring archaeological assessment and – potentially – mitigation. Some can easily be avoided in planning, whereas others cannot. Singular objects tend to present a dilemma in heritage management: their archaeological significance tends to lie in their association to an – at the time of finding – unknown context rather than in the object itself. Though these objects may be protected by heritage legislation, they are often undesired in museum collections, and even if destined for disposal, they can only be salvaged and documented at significant cost. Their cultural heritage ‘value’ is often, though mostly tacitly, considered low or at least undecided. We argue that in-situ preservation by record can be a viable solution for such objects, provided that appropriate documentation methods are employed. Fortunately, these objects are often targeted by other types of pre-construction surveys and inspections, usually conducted using remotely operated vehicles (ROVs), making hours of third-party video footage available to the archaeologist. This article examines if existing third-party video inspection data can be used towards acceptable archaeological recording without compromising the cost-efficiency so crucial to the industry. Hence, the focus of this article is the typical industry-standard inspection-, work class-, or even low-end hobby-ROV (from where the jump to legacy data or, indeed, crowdsourcing is obvious), suggesting a few simple amendments to data acquisition specifications which may potentially save the cost of a dedicated archaeological inspection campaign.