Pitfalls In Management Research Articles

ACUTE POISONING IN THE COMMUNITY AND ITS ASSOCIATED MORTALITY AT THE UNIVERSITY TEACHING HOSPITAL, LUSAKA, ZAMBIA

Background: Acute poisoning is a common event in the community. Despite the high prevalence of acute poisoning in the community, there are very few studies done on the subject in Zambia. Lack of research on acute poisoning has resulted in lack of information on the pattern of poisoning, morbidity, mortality and pitfalls in management.
 Methods: A retrospective study of cases of acute poisoning presenting at the University Teaching Hospital during the period 1st January 2015 to 31st December 2015 was conducted. A total of 131 case records were reviewed. Demographic information, information on the type of poisoning, presenting clinical features, case management and outcome was extracted from the medical records. The data was analysed using descriptive statistics. Frequencies and percentages were calculated for categorical data. All statistical tests were at 5% significance level. The Pearson’s chi squared test was used for comparison of proportions between groups.
 Results: Of the 131 cases reviewed, 67 were female (51%). The age group 20-39 years had the highest frequency of poisoning (50%). The majority of cases (59%) occurred in individuals of low socio-economic status. The most frequently taken poisons were organophosphates (38%). Other commonly used agents included household chemicals and medicines. The majority of cases were due to suicide attempt, and there were only 5 cases of accidental poisoning. Of the cases where due to self-poisoning with intent to cause self-harm. The reasons for self-harm behaviour were given in 115 cases, and 71 (62%) of these were due to interpersonal conflicts arising from disharmony in relationships. The rest were due to various psychological disorders including depressive illness. No reason for self-harm was indicated in 16 cases. The majority of cases (86%) recovered without any complications. Mortality rate was 5%.
 Conclusion: Most cases of poisoning with the intent of self-harm occur in individuals who are vulnerable to stress. A variety of chemical agents are ingested, with the organophosphates being the group of chemicals taken more often than other groups of chemicals. The majority of cases are intentional with very few poisoning cases being accidental. Most cases have good prognosis and the majority recover without any sequelae. Mortality from acute poisoning cases seen at the University Teaching Hospital is low.

Airport privatization with public finances under stress: An analysis of government and investor's motivations

The management model of airports has long stood as a central research area in the transport sector. There are a wide range of studies that focus on the potential benefits and pitfalls of private airport management. The results of these efficiency studies have not provided irrefutable evidence for the superiority of private management over public management, but the momentum towards privatizing airports is growing. The reason for privatization has been more related with privatization revenues for governments, rather than more efficient management. The search for maximizing the sale value can have negative impacts from a welfare perspective, for example, through excessive increases in tariffs for passengers. This research reflects on the motivations for governments to privatize, and is illustrated by a case study – Portugal – in which the privatization occurred as a result of three main large drivers: 1) a bailout programme by the IMF, the EU, and the ECB; 2) a revision of the regulatory model, and; 3) the need to increase the capacity of Lisbon's airport system in the medium term.

Pediatric Motor Stereotypies: An Updated Review

AbstractMotor stereotypies are repetitive, purposeless movements that cannot be categorized into any of the known pathological movement disorders. They can be “primary,” occurring in normal children as a normal physiological variation or “secondary,” occurring in children with autism, intellectual disability, or other developmental disorders. Observation and videotaping are crucial for excluding seizures and other pathological movement disorders. They usually last for seconds to minutes and can occur spontaneously or be triggered by fatigue, excitement, or stress. Another key feature is the ability to suppress these movements by distraction or sensory stimulation. In this article, we aim to present an updated review of this topic and highlight important diagnostic tips and management pitfalls. Recognition of such movements is critical to prevent unnecessary investigations or treatments.

Pitfalls in the diagnosis and management of aortic stenosis

In many instances the diagnosis and management of aortic stenosis (AS) is straightforward. In others, however, the diagnosis and management of AS can be extraordinary difficult. Clinicians need to be aware of the pitfalls in diagnosis and management. Diagnosis and assessment of disease severity begins with a detailed history and physical examination. Echocardiography in experienced hands is the standard investigation of choice to confirm the diagnosis and to assess its severity. While the treatment of symptomatic severe AS is surgery, asymptomatic patients with severe aortic disease and concomitant disease, like hypertension, requires an individualised approach.

Acute poisoning in the community and its associated mortality at the University Teaching Hospital, Lusaka, Zambia

Background: Acute poisoning is a common event in the community. Despite the high prevalence of acute poisoning in the community, there are very few studies done on the subject in Zambia. Lack of research on acute poisoning has resulted in lack of information on the pattern of poisoning, morbidity, mortality and pitfalls in management.
 Methods: A retrospective study of cases of acute poisoning presenting at the University Teaching Hospital during the period 1st January 2015 to 31st December 2015 was conducted. A total of 131 case records were reviewed. Demographic information, information on the type of poisoning, presenting clinical features, case management and outcome was extracted from the medical records. The data was analysed using descriptive statistics. Frequencies and percentages were calculated for categorical data. All statistical tests were at 5% significance level. The Pearson's chi squared test was used for comparison of proportions between groups.
 Results: Of the 131 cases reviewed, 67 were female (51%). The age group 20-39 years had the highest frequency of poisoning (50%). The majority of cases (59%) occurred in individuals of low socio-economic status. The most frequently taken poisons were organophosphates (38%). Other commonly used agents included household chemicals and medicines. The majority of cases were due to suicide attempt, and there were only 5 cases of accidental poisoning. Of the cases where due to self-poisoning with intent to cause selfharm. The reasons for self-harm behaviour were given in 115 cases, and 71 (62%) of these were due to interpersonal conflicts arising from disharmony in relationships. The rest were due to various psychological disorders including depressive illness. No reason for self-harm was indicated in 16 cases. The majority of cases (86%) recovered without any complications. Mortality rate was 5%.
 Conclusion: Most cases of poisoning with the intent of self-harm occur in individuals who are vulnerable to stress. A variety of chemical agents are ingested, with the organophosphates being the group of chemicals taken more often than other groups of chemicals. The majority of cases are intentional with very few poisoning cases being accidental. Most cases have good prognosis and the majority recover without any sequelae. Mortality from acute poisoning cases seen at the University Teaching Hospital is low.

NIDA Series to Explore Ways Psychiatrists Can Help Patients in Pain

Back to table of contents Previous article Next article Annual MeetingFull AccessNIDA Series to Explore Ways Psychiatrists Can Help Patients in PainVabren WattsVabren WattsSearch for more papers by this authorPublished Online:27 Feb 2017https://doi.org/10.1176/appi.pn.2017.2b3AbstractBest practices for recognizing and treating patients with chronic pain and opioid use disorder and federal plans to address the nation’s opioid epidemic will be among the topics covered at APA’s Annual Meeting in a special track.Since 1999, the number of Americans who have died from opioid overdose has quadrupled, as has the number of prescription opioids sold in this country. What can psychiatrists do to support patients struggling with chronic pain and/or opioid use disorder?Nora Volkow, M.D., director of the National Institute on Drug Abuse, points out that psychiatrists have many tools that can help fight opioid use disorder and chronic pain.David Hathcoxck“[T]he reality is that the epidemic was in part born by the inappropriate treatment of pain and overreliance on prescription opioids,” National Institute on Drug Abuse (NIDA) Director Nora Volkow, M.D., told Psychiatric News. NIDA will sponsor multiple sessions at APA’s Annual Meeting in San Diego on how psychiatrists can help patients with chronic pain and/or opioid use disorder. “Psychiatrists can play an extremely important role in highlighting other therapies, besides opioids, to treat pain,” she said.The NIDA symposium will begin Sunday, May 21, with a session on how psychiatrists with no background in pain management can recognize pain in patients. Tips on how best to treat these patients—including pharmacological and nonpharmacological approaches to pain and how to avoid common pitfalls in pain management—and when to refer to specialty care will be discussed. Recognizing and treating patients with a history of pain and opioid use disorder can be particularly challenging. As part of the NIDA series, Sean Mackey, M.D., Ph.D., chief of the Division of Pain Medicine at Stanford University School of Medicine, will present a series of cases of patients with opioid use disorder and chronic pain in a session on Monday, May 22.Among other topics, the session will address the importance of nonopioid adjuvants for pain management, such as acetaminophen and nonsteroidal anti-inflammatory drugs; nonpharmacological pain management therapies; and appropriate monitoring and risk mitigation strategies. Also on Monday, Volkow will give an overview of the current opioid epidemic and the multipronged strategy by federal health agencies to reduce rates for prescription opioid misuse and overdose. These strategies include improving the education of health care professionals on pain management, providing treatment to individuals misusing prescription opioids, and increasing the availability of the opioid antagonist naloxone, which blocks the effects of opioids and reverses an overdose. Volkow will also discuss the efforts of federal health agencies to explore the effectiveness of nonopioid treatments for pain, including cognitive-behavioral therapy, antidepressants, and neurostimualtion therapies.The symposium will conclude on Wednesday, May 24, with the session “What Is Pain to The Brain?,” co-chaired by NIDA Deputy Director Wilson Compton, M.D. The session will include a discussion of the involvement of endogenous opioid, endocannabinoid, and dopamine systems in the regulation of pain as well as how emotions contribute to pain amplification and suffering. “If you are in pain, you have a greater risk of developing depression. If you are depressed and have pain, you are at a greater risk for transitioning to chronic pain,” Volkow said. “Psychiatrists can play an important role in treating patients suffering from chronic pain.” ■Register for the 2017 Annual Meeting to attend the NIDA series, and 450+ of other educational sessions. Dates, times, and locations of the NIDA sessions will be published in the Annual Meeting program distributed at the meeting and in the APA Meetings App. ISSUES NewArchived

Pitfalls in the diagnostic management of pulmonary embolism in pregnancy

Women are at increased risk of venous thromboembolism (VTE) during pregnancy and VTE remains one of the main causes of maternal mortality in developed countries (Konstantinides SV, et al. Eur Heart J 2014; 35(43):3033-69, 69a-69k). Although an accurate diagnosis of acute pulmonary embolism (PE) in pregnant patients is thus of crucial importance, the diagnostic management of suspected PE is challenging for this specific patient category. As D-dimer levels increase physiologically throughout pregnancy, the optimal D-dimer threshold to rule out PE during pregnancy remains unknown. Available clinical decision rules, such as the Wells score and the revised Geneva rule, have not been evaluated in pregnant patients. Also, although ventilation-perfusion (V-Q) lung scan and computed tomography pulmonary angiography (CTPA) can be used in the pregnant population, both modalities have disadvantages of radiation exposure to both mother and foetus. Because of these uncertainties, clinical guidelines provide contradicting recommendations with weak levels of evidence. In this review, we illustrate these dilemmas and provide practice recommendation for the diagnostic management of suspected PE in pregnancy using two real-life patient cases.

A rare case to primary spinal hydatid cyst presenting with neurodeficit

Hydatid disease, a parasitic infection caused by Echinococcus granulosus predominantly occur in liver and lungs. Skeletal involvement is uncommon and occurs in only 0.2 to 1 % of all cases. Primary spinal hydatidosis of spine is very rare. We report such a rare case of primary spinal hydatid cyst presenting with neurodeficit, which was treated surgically with excision, decompression and fixation, with aim to create the awareness among surgeon about this rare clinical presentation and pitfalls in diagnosis and management and suggest them to include it in differential diagnosis of the atypical spinal presentation. Hydatid disease necessitates high clinical suspicion, careful neuroradiological evaluation, aggressive surgical intervention, adjuvant chemotherapy and strict follow up to detect recurrence early.

Trends in nonoperative management of traumatic injuries – A synopsis

Nonoperative management of both blunt and penetrating injuries can be challenging. During the past three decades, there has been a major shift from operative to increasingly nonoperative management of traumatic injuries. Greater reliance on nonoperative, or “conservative” management of abdominal solid organ injuries is facilitated by the various sophisticated and highly accurate noninvasive imaging modalities at the trauma surgeon’s disposal. This review discusses selected topics in nonoperative management of both blunt and penetrating trauma. Potential complications and pitfalls of nonoperative management are discussed. Adjunctive interventional therapies used in treatment of nonoperative management-related complications are also discussed.Republished with permission from:Stawicki SPA. Trends in nonoperative management of traumatic injuries – A synopsis. OPUS 12 Scientist 2007;1(1):19-35.

Central Chest Pain and ST Elevation: A Curious Case of a Negative Troponin

Apical hypertrophic cardiomyopathy (HCM) is an uncommon variant of hypertrophic cardiomyopathy which predominantly affects the left ventricular (LV) apex [[1]Sakamoto T. Apical hypertrophic cardiomyopathy (apical hypertrophy): an overview.J Cardiol. 2001; 37: 161-178PubMed Google Scholar]. We present the case of a patient with apical HCM and the incidental finding of coronary artery fistulae who presents with features of STEMI. A 69 year old Caucasian woman presented to a rural ED with 3 hours of central chest pain and dizziness. This occurred on a background of intermittent ischaemic pain on exertion for the preceding 6 months. An ECG showed anterior ST elevation with deep T wave inversion in V5 and V6, as well as inferior leads. However, a point of care troponin returned negative and was confirmed on serial formal testing. Thrombolysis was not administered and the patient was transferred to a tertiary centre. Coronary angiography revealed no obstructive disease, but the incidental finding of tortuous vessels and the presence of a fistula to the LV. Left ventriculography demonstrated a ‘spade-like’ configuration of the LV cavity. The diagnosis of apical HCM was confirmed on transthoracic echocardiography. Apical HCM is usually asymptomatic, although ischaemic symptoms may be present [[2]Eriksson M.J. Sonnenberg B. Woo A. Rakowski P. Parker T.G. Wigle E.D. Rakowski H. Long-term outcome in patients with apical hypertrophic cardiomyopathy.J Am Coll Cardiol. 2002; 39: 638Crossref PubMed Scopus (311) Google Scholar]. Coronary fistulae are predominantly due to variations in embryological development, although trauma and previous cardiac surgery can also contribute. Small fistulae are generally asymptomatic, however the co-existence of apical HCM in this case may have precipitated a ‘coronary steal’ syndrome that may explain symptoms. The patient declined further investigation and was managed conservatively, but was a reminder of the need to correlate clinical and biochemical findings to avoid management pitfalls.

THE NEED FOR A COMPREHENSIVE ENERGY MANAGEMENT INFORMATION SYSTEM FOR INDUSTRIES

Electricity costs in South Africa are increasing rapidly, and the funding hurdle rates for energy conservation incentives are decreasing. Therefore, with rising international competition and increasing operational costs, marginal industries need to focus on energy management strategies where larger savings can be achieved with lower capital expenditure. This paper sketches the need for a comprehensive energy management information system (EMIS). Common industrial energy management pitfalls are identified and energy conservation incentives are outlined. New focus points that improve client awareness and in turn improve the sustainability of energy management interventions are also highlighted. However, benefitting from energy incentives is becoming more complex. Therefore, many clients do not benefit from these incentives unless specialised Energy Service Companies (ESCos) are employed. ESCos, however, require large amounts of data to manage clients’ energy effectively. Herein lies the need for a comprehensive EMIS that aids ESCos and their clients with the energy management process. An EMIS was developed and implemented for several industries in South Africa. Data is automatically collected, processed, analysed, and presented on a daily basis. A case study investigates the exorbitant amounts of data and reports that are managed automatically, which further highlights the need for a comprehensive EMIS.

Juvenile Myoclonic Epilepsy in Rural Western India: Not Yet a Benign Syndrome.

Purpose. To study prevalence of uncontrolled seizures in patients with juvenile myoclonic epilepsy [JME] and assess factors responsible for it. Methods. An ambispective study of all patients with JME attending our epilepsy clinic was done. We recruited all patients with JME evaluated between 1 January 2009 and 31 December 2013 and followed them up to 31 December 2015. Results. Amongst 876 patients with epilepsy, JME was present in 73 patients. Amongst them, 53 [72.6%] had uncontrolled seizures prior to neurology consultation. Factors responsible for uncontrolled seizures included pitfalls in diagnosis like absence of prior neurology consultation missed history of myoclonus in prior consults and pitfalls in interpretation of EEG. Pitfalls in management were incorrect antiepileptic drug use, underdosing of AED, noncompliance with lifestyle, noncompliance with medicines, associated psychogenic nonepileptiform events, patients deliberately missing medicines for secondary gain, and concomitant alternative medicine use. 45 (84.9%) patients had “pseudorefractoriness.” True refractoriness [seizures despite 2 correctly dosed rational drugs] was seen in 8 (15.1%) patients only. Conclusion. Three-fourth of our patients had uncontrolled seizures initially, predominantly due to pitfalls in its diagnosis and management. Improving patient awareness and primary physician training for JME management is the need of the hour.

Human‐affected disturbances in vegetation cover and peatland development in the late Holocene recorded in shallow mountain peatlands (Central Sudetes, SW Poland)

The aim of this study is to assess the impact of biotic and abiotic factors on peatland formation in the Central Sudetes (central Europe) during the late Holocene. The research methodology adopted allowed us to determine whether vegetation development and shallow peatland formation were affected by human activity. Knowledge of past changes might be useful in evaluating recent and future changes, and to avoid pitfalls in the present management of peatland ecosystems. A palaeoecological research study of four peatlands was conducted in the Stołowe Mountains (Central Sudetes, SW Poland). The results showed that these shallow peatlands originated in the middle to late Holocene (from 3301 BC to AD 1137). Palaeoecological records reflect continuous human impact on vegetation development and peat accumulation from the Middle Ages to the present (late Holocene). The strongest agrarian settler activity is observed in the High Middle Ages (AD 1200–1500). The human‐induced or wildfires observed in the late Holocene were an integral component of peatland ecosystems in the Central Sudetes. Moreover, palaeoecological analysis (sphagnum spores decline) and radiocarbon dating (AD 1870) confirmed drainage of the study area in the 19th century, which greatly affected the vegetation communities.

The World Anti-Doping Code: can you have asthma and still be an elite athlete?

Key pointsThe World Anti-Doping Code (the Code) does place some restrictions on prescribing inhaled β2-agonists, but these can be overcome without jeopardising the treatment of elite athletes with asthma.While the Code permits the use of inhaled glucocorticoids without restriction, oral and intravenous glucocorticoids are prohibited, although a mechanism exists that allows them to be administered for acute severe asthma.Although asthmatic athletes achieved outstanding sporting success during the 1950s and 1960s before any anti-doping rules existed, since introduction of the Code’s policies on some drugs to manage asthma results at the Olympic Games have revealed that athletes with confirmed asthma/airway hyperresponsiveness (AHR) have outperformed their non-asthmatic rivals.It appears that years of intensive endurance training can provoke airway injury, AHR and asthma in athletes without any past history of asthma. Although further research is needed, it appears that these consequences of airway injury may abate in some athletes after they have ceased intensive training.The World Anti-Doping Code (the Code) has not prevented asthmatic individuals from becoming elite athletes. This review examines those sections of the Code that are relevant to respiratory physicians who manage elite and sub-elite athletes with asthma. The restrictions that the Code places or may place on the prescription of drugs to prevent and treat asthma in athletes are discussed. In addition, the means by which respiratory physicians are able to treat their elite asthmatic athlete patients with drugs that are prohibited in sport are outlined, along with some of the pitfalls in such management and how best to prevent or minimise them.

Pitfalls in Management of Childhood Tumours

Childhood cancer is broadly defined as the malignancy arising in pediatric patients upto 14 years of age. The common cancers in this group include acute lymphoblastic leukemia (ALL), lymphomas, CNS tumors, neuroblastoma, Wilms tumor, retinoblastoma, rhabdomyosarcoma, Ewing Sarcoma, Osteosarcoma etc. Today many of these patients are surviving more and more, not only due to early and correct diagnosis, but also due to availability of better chemotherapy drugs, radiation delivery facilities and supportive care, thereby allowing better survival and cure rates for most of these cancers. An increased number of patients and survivors of childhood malignancies are posing unique problems for the Oncologists, family members and the society.

First branchial cleft anomaly presenting with a complete duplication of the external auditory canal—A photo anatomic review

Abstract First branchial cleft anomalies are an uncommon group of congenital malformations. Anatomically complex in origin, they present with an impressive array of signs and symptoms. There are several classification systems available, rendering them challenging in terms of preoperative assessment and surgical planning. The objective of this report is to describe the presentation, surgical treatment, and outcome of a child presenting with a complex cerumen containing duplication of the external ear canal running medial to the facial nerve. Diagnostic and management pitfalls in the approach to pediatric patients with first branchial anomalies are outlined. A review of the literature is presented.

LAPAROSCOPIC MANAGEMENT OF A LARGE HYDATID CYST OF LIVER (CASE REPORT)

Background: Hydatid disease in humans is endemic in sheep rearing regions. However, a worldwide distribution is encountered. This is a parasitic disease caused by Echinococcus granulossus, which is a cestode. Liver is the most affected organ. Surgery is the mainstay of treatment in hydatid cyst of liver. Since the popularization of laparoscopic surgery, hydatid cyst of liver is being treated laparoscopically in few of the centers. Spillage and anaphylactic reactions are the main pitfalls of laparoscopic management of the hydatid cyst of the liver. We present a case of hydatid cyst of liver, which was managed laparoscopically using Palanivelu Hydatid System (PHS) without any spillage or anaphylactic reaction.

How do doctors in training react to seizures?

There are scant data on how doctors approach seizures in the acute setting. We sought to study (a) exposure to seizure disorders as well as relevant training and (b) reactions to seizures in the acute setting, among medical residents undergoing physician training. The exposure to and training on seizure disorders were assessed using a structured questionnaire first. Then, they were tested with 20 videos consisting of 10 epileptic seizures (ESs) and 10 psychogenic nonepileptic seizures (PNESs). After each video, we asked three questions to test (a) the diagnosis and the practice of administration of benzodiazepines to terminate the seizure, (b) the estimation of seizure duration, and (c) the practice of intubation. The accuracy of diagnosis was measured by the area under the summary receiver operating characteristics curve (AUC). The difference between true seizure duration and estimated duration was evaluated using paired-sample t-test. A total of 48 trainees participated in the study. The majority witnessed seizures in movies (37, 77.1%) and television (35, 72.9%). Only 12 (25%) received bedside teaching on seizure disorders. Their diagnostic accuracy of seizures was very poor (AUC=0.54). Participants significantly underestimated the duration of seizures. Thirty-five doctors made an illogical decision to intubate but not to terminate the seizure with intravenous benzodiazepine. The diagnostic accuracy of seizures is poor among trainees, and their estimates of seizure duration are unreliable. Our study highlights potential pitfalls in the acute management of seizures and the need for more training on seizure disorders.

Pitfalls in the Quality Management of Cancer Care

There are a lot of pitfalls threatening the quality management of our patients. Conflicts of interest, overuse, underuse and misuse of diagnostic and treatment modalities can harm patients and are difficult to detect. A lot of confounding factors are present. It is very difficult to define the right standard, because it will depend on your personal point of view and the quality of the evidence based system. Quality measurements must integrate the different elements of care, looking at health care as a complex adaptive system. We must be aware of budget restrictions, bureaucracy and last but not least: The Human Factor, Fraud and Money!

INVOCATION OF A STEP-IN CLAUSE IN PRISON PPPs: SUSTAINABILITY OR MANAGEMENT VAGARY?

The extension of the PPP procurement method to custodial services was met with a lot of resistance and disapproval from some quarters within and without the government circles in South Africa. The model utilized in the two facilities currently in operation is design, construct, finance, operate and maintain. The recent invocation of a “step-in” clause in one of the facility was regarded as a vindication that private operators are contextually unsuitable to manage the correctional facilities in South Africa. This research interrogated the monitoring mechanisms set up to oversee the running of the facility and the operational management pitfalls that necessitated this intervention. Through interviews with the private operators, consultants, government officials and the PPP Unit, proper insight was garnered about what could have gone wrong. It was demonstrated that private management is not foolproof against the challenges of managing a facility housing dangerous convicts. Because of the operational challenges encountered by private operators there was a strong advocation for an adaptation of the PPP model where there is a hybrid in management, since South Africa initially entered into PPP arrangements due to lack of finance not due to ineffective management acumen. The study is instructive to future correctional services facilities and inspirational to other jurisdictions where the arrangement is currently mooted.