Pitfalls In Management Research Articles

Addressing Pitfalls in Management of Diabetic Ketoacidosis with a Standardized Protocol

Objective: To determine the efficacy and safety of a diabetic ketoacidosis (DKA)-Power Plan (PP) for guiding intravenous (IV) insulin infusions prior to anion gap (AG) closure and administering subcutaneous (SC) insulin ≥1 hour before discontinuing IV insulin. Methods: Retrospective chart review of patients with DKA before (pre-PP) (n = 60) and following (post-PP) (n = 60) implementation of a DKA-PP. Groups were compared for percentage of patients for whom IV insulin therapy was continued until AG closure, the percentage of patients receiving SC insulin ≥1 hour before discontinuation of IV insulin, and percentage of patients with rebound DKA during the index hospitalization. Results: Admission plasma glucose (514 mg/dL vs. 500 mg/dL; P = .36) and venous pH (7.2 vs. 7.2; P = .57) were similar in pre- and post-PP groups. Inappropriate discontinuation of IV insulin occurred less frequently in post-PP patients (28% vs. 7%; P = .007), with a lower frequency of rebound DKA (40% vs. 8%; P = .001) following acute management. More post-PP patients received SC insulin ≥1 hour before discontinuation of IV insulin (65% vs. 78%; P = .05). Conclusion: Implementation of a DKA-PP was associated with appropriate discontinuation of IV insulin in more patients, more frequent administration of SC insulin ≥1 hour prior to discontinuation of IV insulin, and fewer episodes of rebound DKA. Abbreviations: ADA = American Diabetes Association; AG = anion gap; BG = blood glucose; DKA = diabetic ketoacidosis; DKA-PP = DKA-Power Plan; ICU = intensive care unit; IQR = interquartile range; IV = intravenous; IVF = IV fluid; LOS = length of stay; SC = subcutaneous.

Using a Decision Tree to Guide Bowel Management in Spina Bifida

BackgroundWhen born with spina bifida, there are numerous neurologic disorders that accompany this birth defect, including neurogenic bowel. Proactive, systematic, and rational approaches can lead to continence and a more functional lifestyle [1]. MethodsBased on the evidence in the literature and expert experience, our approach to bowel management was developed as a step by step, individualized approach. This was converted to a decision tree for easy guidance of treatment decisions. The approach includes teaching patients and families normal bowel function, changes resulting from neurogenic bowel, common pitfalls in bowel management, and techniques that may improve outcomes. The decision tree, starting with dietary management, breaks into a two-fold attack, oral and rectal. Our data as part of the National Spina Bifida Patient Registry (NSBPR) database was compared to public data from the NSBPR. ResultsPreliminary data from the NSBPR in 2011 reported bowel continence in 42.1% (n = 898) compared to our clinical outcomes of 72.1% (n = 43). As the variable of bowel continence was further defined and more patients were enrolled, the clinic results were comparable to the national reports. ConclusionConsistency among providers and caregivers is critical to evaluating the management of continence in spina bifida. While this protocol warrants further evaluation, it is offered as an evidence-based, step by step, approach to bowel management in spina bifida with good outcomes for patient management.

Pitfalls in diagnosis and management of suspected urinary tract infection in an urban tropical primary care setting.

Diagnosis and management of urinary tract infection (UTI) are complex, and do not always follow guidelines. The aim of this study was to determine adherence to the 2014 Malaysian Ministry of Health guidelines for managing suspected UTI in a Malaysian primary care setting. We retrospectively reviewed computerized medical records of adults with suspected UTI between July-December 2016. Excluded were consultations misclassified by the search engine, duplicated records of the same patient, consultations for follow-up of suspected UTI, patients who were pregnant, catheterised, or who had a renal transplant. Records were reviewed by two primary care physicians and a clinical microbiologist. From 852 records, 366 consultations were a fresh episode of possible UTI. Most subjects were female (78.2%) with median age of 61.5 years. The major co-morbidities were hypertension (37.1%), prostatic enlargement in males (35.5%) and impaired renal function (31.1%). Symptoms were reported in 349 (95.4%) consultations. Antibiotics were prescribed in 307 (83.9%) consultations, which was appropriate in 227/307 (73.9%), where the subject had at least one symptom, and leucocytes were raised in urine full examination and microscopic examination (UFEME). In 73 (23.8%) consultations antibiotics were prescribed inappropriately, as the subjects were asymptomatic (14,4.6%), urine was clear (17,5.5%), or UFEME did not show raised leucocytes (42,13.7%). In 7 (2.3%) consultations appropriateness of antibiotics could not be determined as UFEME was not available. Several pitfalls contributed to suboptimal adherence to guidelines for diagnosis and management of suspected UTI. This illustrates the complexity of managing suspected UTI in older subjects with multiple co-morbidities.

Pediatric Traumas and Paradigm Shifts: The Necessary Adaption of the Steerable Microcatheter in Pediatric Interventional Radiology.

The use of traditionally available intra-arterial devices have historically been designed with the adult patient population in mind. Currently, there are not manufactured devices specifically tailored for use during pediatric interventional procedures, pressuring interventional operators to adapt commonplace and readily available devices for interventional management. Experienced interventional operators understand that pediatric and adult interventions can entail vastly different management, affecting patient care and outcomes. To address the pitfalls in pediatric interventional management, an accredited fellowship specifically for pediatric interventional radiology is available. However, devices must equally evolve with the training available in order to adequately address interventional management of the pediatric patient population. Interventional device innovation can be considered the initial step towards bridging the technical and procedural gaps necessary for refining pediatric intervention. The introduction of steerable microcatheters in interventional radiology has innovated procedural protocols, but has never been documented in pediatric patients until this time.

Craniocervical Dissociation in Pediatric Patients: Pearls and Pitfalls of Diagnosis and Management.

The aims of this study were to document the injury pattern in pediatric traumatic craniocervical dissociation (CCD) and identify features of survivors. Pediatric traumatic CCDs, diagnosed between January 2004 and July 2016, were reviewed. Survivors and nonsurvivors were compared. Categorical and continuous variables were analyzed with Fisher exact and t tests, respectively. Twenty-seven children were identified; 10 died (37%). The median age was 60 months (ranges, 6-109 months [survivors], 2-98 months [nonsurvivors]). For survivors, the median follow-up was 13.4 months (range, 1-109 months). The median time to mortality was 1.5 days (range, 1-7 days). The injury modality was motor vehicle collision in 18 (67%), pedestrian struck in 8 (30%), and 1 shaken infant (3%). For nonsurvivors, CCD was equally diagnosed by plain radiograph and head/cervical spine computed tomography scan. For survivors, CCD was diagnosed by computed tomography in 7 (41%), magnetic resonance imaging in 10 (59%), and none by radiograph. Seven diagnosed by magnetic resonance imaging (41%) had nondiagnostic initial imaging but persistent neck pain. Magnetic resonance imaging was obtained and was diagnostic of CCD in all 7 (P < 0.01). Survivors required significantly less cardiopulmonary resuscitation (P < 0.01), had lower Injury Severity Scores (P < 0.01), higher Glasgow Coma Scale scores (P < 0.01), and shorter transport times (P < 0.01). Significantly more involved in motor vehicle collisions survived (P = 0.04). Nine (53%) had no disability at follow-up evaluation. In pediatric CCD, high-velocity mechanism, cardiac arrest, high Injury Severity Score, and low Glasgow Coma Scale score are associated with mortality. If CCD is correctly managed in the absence of cardiac arrest or traumatic brain or spinal cord injury, children may survive intact.

The Effect of Strategic Management Practices on the institutional Performance; the case of Dedebit credit and saving institution in Eastern Tigray

Strategic management was first originated in the Military and adopted to the business sector as important management tool in response to the unpredictable, turbulent, and chaotic world. It is the process of determining what an organization intends to be in the future and how it will get there. It is a tool which helps to define the best future for the organization and the best path to reach that destination. The overall objective of the study is to examine the Effect of Strategic Management Practices on the institutional Performance; the case of Dedebit credit and saving institution in Eastern Tigray. This study the Effect of Strategic Management Practices among 128 sampled Dedebit credit and saving institution out of 346-targeted population at eastern Tigray. Stratified sampling was employed to select the respondents in this study. The study utilized both quantitative and qualitative approaches. Data was collected through questionnaires and documents of the organization also SPSS was used to analyze data. Data analysis was carried out using descriptive statistics and multi regression model. The descriptive part presents the stages of effect of strategic management Dedebit credit and saving institution using graphs and table based on the position held and experience. The empirical study shows strategic management implementation was found to be of more challenging than the designing process. Most respondents confirmed their capability of translating the strategic into action plans also self-initiated to prepare a comprehensive strategic plan rather than considering as an imposition of their donors. Findings showed that most DECSI try to manage strategically by aligning Initiatives with Strategy, engaging staff fully in strategy implementation, keeping staff fully informed about corporate strategic direction, monitoring strategy and implementation in order to adapt it where necessary to meet the challenges and realities of the times and structuring the organization to be effective in its strategy implementation. The study also showed that all the strategic management practices had significant positive effects on organization performance. Furthermore, the study showed that the most ensnaring pitfall of strategic management is the inability of organizations to translate strategy into a corporate purpose. This was followed by short term planning, failure to create accountability for results, inability to foster belief in the strategy, ignoring external trends, overconfidence based on existing success and failure to respond to structural changes in the market. Finally, the study showed that strategic management practices have direct positive relationship with corporate performance. Based on the findings, the study recommended that managements of savings and loans companies factor into their strategic management decisions, the marketing environment and the prevailing macro conditions in order to come out with an effective strategic plan that would have positive impact on institutional performance. Keywords: strategic management practices, performance, DECSI, Eastern Zone.

Diagnostic dilemma and management pitfalls of acute liver failure in resource limited Sub Saharan Africa: a case report

Background: Despite recent advances in management of acute liver failure (ALF), morbidity and mortality are still significantly high. Management strategies amongst others involve determination of etiology and greater than 50% of cases often require liver transplantation. Case Presentation: A 36-year old Cameroonian male presented to our facility (a tertiary level health institution in Cameroon) with 10 days history of gastrointestinal symptoms (diarrhea, abdominal pain, and vomiting) for which he auto-medicated with herbs and intravenous cefriaxone for 3 days. Two days prior to the presentation he developed yellowish discoloration of the eyes which prompted consultation. His evolution inpatient was marked by development of ALF Lack of necessary diagnostic tools and intensive care unit substandard care led to worsening of ALF. The patient died on day 6 of hospitalization. Conclusion: The case presented brings to lamp light the dificulties encountered in making an aetiologic diagnosis for ALF and the substandard care provided in patients with ALF in resource-limited setings. A lot still needs to be done to empower facilities in developing nations in care of ALF. Key words: acute liver failure, diagnosis, management, pitfalls, case report.

Adnexal torsion in symptomatic women: a single-centre retrospective study of diagnosis and management

This retrospective study aimed to evaluate the sonographic diagnosis and management strategy of symptomatic adnexal torsion at a teaching hospital in Hyderabad, India. All women with abdominal pain and preoperative or operative diagnosis of adnexal torsion from January 2011 to December 2015 were included. A total of 76 women with 78 episodes were included; 28 (36%) occurred during pregnancy. The ovarian mass (in 71%) and pregnancy (in 35%) constituted the most common risk factors. The overall sensitivity, specificity, positive predictive value, negative predictive value and the accuracy of ultrasound were 75%, 27%, 86%, 15% and 68%, respectively. Ultrasonography was more sensitive in detecting torsions in the non-pregnant subgroup but had a higher specificity during pregnancy. An oophorectomy was performed in 9% of the women due to gangrene. Benign paraovarian cysts and teratomas were the most frequent lesions to undergo torsion. The obstetric outcome was good, the miscarriage rate being 5%.Impact statementWhat is already known on this subject? Adnexal torsion presents a diagnostic and therapeutic challenge. There are various sonographic criteria that aid in the clinical diagnosis. Discoloured ovaries do not routinely warrant removal.What the results of this study add? The sonographic diagnosis is inaccurate in a third of the cases. Torsion without the involvement of the ovary does not exhibit any of the classic ultrasound findings other than a torted pedicle and therefore a sonographic diagnosis may be difficult. Discoloured ovaries had a normal appearance at future surgeries, reinforcing the concept that an oophorectomy (after detorsion) should be the exception rather than the rule even if the ovary is bluish black.What the implications are of these findings for clinical practice and/or further research? Training in pelvic ultrasound to complement clinical judgement and regular audits of treatment must be conducted in order to minimise pitfalls in diagnosis and management. An ultrasound examination cannot be used as a sole diagnostic criterion to confirm or exclude torsion and a clinical assessment takes precedence.

Pitfalls in anaphylaxis diagnosis and management at a university emergency department.

Some previous reports revealed suboptimal management of anaphylaxis (ANX) in the emergency department (ED). To evaluate the recorded diagnosis and management of patients who presented with ANX at our university hospital ED and to assess how the management correlated with the severity of the case and the training level of the ED staff. A descriptive study that involved reviewing the electronic medical records of patients who presented with ANX at the ED during a period of 4 years. When reviewing 1341 charts of potential cases, 60 met the criteria for ANX, but only 23% were correctly coded. Inaccurate coding was noted in 77%, mainly as an "allergic reaction." Systemic corticosteroids were administered in the ED to 85% of the patients and H1-antihistamines to 73%; only 20% received epinephrine. Ten patients required hospital admission, and, on discharge, only four patients (40%) were given epinephrine autoinjector prescriptions. Of the 50 who were discharged home, 48% were given epinephrine autoinjector prescriptions and 16% were given a referral for allergy evaluation. The observed low rates of appropriate diagnostic coding of ANX, of epinephrine administration, epinephrine autoinjector prescribing at discharge, and referral for allergy evaluation call for more education on these issues. Some of these pitfalls can be partly attributed to the setting in a university ED where health providers are usually busy in rendering urgent care.

Severe Asthma: Challenges and Pitfalls in Management.

A small but significant subset of asthmatic children show a lack of response to standard management, resulting in further intensification of therapy to optimise symptom control and may remain symptomatic despite maximal therapy. Severe asthma results in increased risk of adverse outcomes whilst contributing significantly to the economic burden on the nation's health resources. The ERS / ATS guidelines were published in 2014 and form the basis of identifying, evaluating and managing severe asthmatic children. However, much of this evidence is extrapolated from adult studies and may be inappropriate in children as unlike adults, children have a more atopic phenotype. Severe asthma is an umbrella term and may represent several overlapping heterogeneous wheezing entities. This chapter aims at discussing the strategies employed in managing severe asthmatic children with particular focus on diagnostic challenges and management pitfalls. Particular emphasis is put into the logical and systematic approach to a child with severe asthma and describes the multidisciplinary approach to manage these children. Finally, this chapter describes the novel therapies available in children and in adults in managing this challenging condition.

Consensus guideline: Pre-hospital management of decompression illness: expert review of key principles and controversies

(Mitchell SJ, Bennett MH, Bryson P, Butler FK, Doolette DJ, Holm JR, Kot J, Lafère P. Pre-hospital management of decompression illness: expert review of key principles and controversies. Diving and Hyperbaric Medicine. 2018 March;48(1):45е.doi.10.28920/dhm48.1.45-55.) Guidelines for the pre-hospital management of decompression illness (DCI) had not been formally revised since the 2004 Divers Alert Network/Undersea and Hyperbaric Medical Society workshop held in Sydney, entitled "Management of mild or marginal decompression illness in remote locations." A contemporary review was initiated by the Divers Alert Network and undertaken by a multinational committee with members from Australasia, the USA and Europe. The process began with literature reviews by designated committee members on: the diagnosis of DCI; first aid strategies for DCI; remote triage of possible DCI victims by diving medicine experts; evacuation of DCI victims; effect of delay to recompression in DCI; pitfalls in management when DCI victims present at hospitals without diving medicine expertise and in-water recompression. This was followed by presentation of those reviews at a dedicated workshop at the 2017 UHMS Annual Scientific Meeting, discussion by registrants at that workshop and, finally, several committee meetings to formulate statements addressing points considered of prime importance to the management of DCI in the field. The committee placed particular emphasis on resolving controversies around the definition of "mild DCI" arising over 12 years of practical application of the 2004 workshop's findings, and on the controversial issue of in-water recompression. The guideline statements are promulgated in this paper. The full workshop proceedings are in preparation for publication.

Pre-hospital management of decompression illness: expert review of key principles and controversies.

Guidelines for the pre-hospital management of decompression illness (DCI) had not been formally revised since the 2004 Divers Alert Network/Undersea and Hyperbaric Medical Society workshop held in Sydney, entitled "Management of mild or marginal decompression illness in remote locations". A contemporary review was initiated by the Diver's Alert Network and undertaken by a multinational committee with members from Australasia, the USA and Europe. The process began with literature reviews by designated committee members on: the diagnosis of DCI; first aid strategies for DCI; remote triage of possible DCI victims by diving medicine experts; evacuation of DCI victims; effect of delay to recompression in DCI; pitfalls in management when DCI victims present at hospitals without diving medicine expertise and in-water recompression. This was followed by presentation of those reviews at a dedicated workshop at the 2017 UHMS Annual Meeting, discussion by registrants at that workshop and finally several committee meetings to formulate statements addressing points considered of prime importance to the management of DCI in the field. The committee placed particular emphasis on resolving controversies around the definition of "mild DCI" arising over 12 years of practical application of the 2004 workshop's findings, and on the controversial issue of in-water recompression. The guideline statements are promulgated in this paper. The full workshop proceedings are in preparation for publication.

How to grow without going broke

Growing a business without killing it with debt is an ongoing challenge for business owners. Too often, leaders have taken a shortsighted approach that involves buying expensive equipment, hiring additional employees, or acquiring new facilities to meet a fickle uptick in demand—only to further deplete organizational resources. Learning from the mistakes that some well‐known firms have made in their growth efforts can help business leaders avoid the pitfalls of poor change management, stagnation, and sloppy expansion. As the experiences of one high‐tech engineering firm show, even a failing company can become profitable again by cutting expenses, engaging customers as partners, and judiciously shoring up cash flow to take advantage of industry developments. Managers at companies of all sizes can apply these lessons to ensure that short‐term gains are not made at the expense of their organization's long‐term viability.

Stroke in sickle beta thalassemia - a case report highlighting pitfalls in management in a low prevalence country

Stroke in Sickle cell disease is a devastating complication. As Sickle cell disease is uncommon in Sri Lanka many clinicians may be unfamiliar with management of the disease and its complications. A 10-year-old boy presented with a transient ischaemic attack. He has had a silent large parietal infarct previously. He had been managed with transfusions and had undergone a splenectomy. However, he had not received hydroxyurea or undergone trans-cranial Doppler assessment.

Cerebral Pathophysiology in Extracorporeal Membrane Oxygenation: Pitfalls in Daily Clinical Management.

Extracorporeal membrane oxygenation (ECMO) is a life-saving technique that is widely being used in centers throughout the world. However, there is a paucity of literature surrounding the mechanisms affecting cerebral physiology while on ECMO. Studies have shown alterations in cerebral blood flow characteristics and subsequently autoregulation. Furthermore, the mechanical aspects of the ECMO circuit itself may affect cerebral circulation. The nature of these physiological/pathophysiological changes can lead to profound neurological complications. This review aims at describing the changes to normal cerebral autoregulation during ECMO, illustrating the various neuromonitoring tools available to assess markers of cerebral autoregulation, and finally discussing potential neurological complications that are associated with ECMO.

Faecal transplantation for IBD management-pitfalls and promises.

Faecal microbiota transplantation (FMT) as a potential treatment for inflammatory bowel disease (IBD) is an area of active current research, having been stimulated by the remarkable efficacy of FMT in treatment of Clostridium difficile-associated colitis. This review is based on data from numerous case series on FMT in IBD since 1989 and results of four RCTs in ulcerative colitis (UC); three fully published. Early signals of short to medium-term efficacy of FMT for UC are promising. Methodology, underlying mechanisms and questions regarding safety of FMT remain controversial. Many trials of FMT in adults and children are currently recruiting. Future trials of FMT will likely revisit Crohn's disease and patients undergoing pouch surgery. Advances in microbial culture complementing genetic sequencing and investigations into the virome and mycobiome in IBD will be of great future interest.

6.6 Medications for Insomnia

The goals of this session are as follows: 1) to provide an update on current pharmacologic prescription options available for the treatment of pediatric insomnia; 2) to review the data supporting safety and efficacy of over-the-counter (OTC) medications, including melatonin; and 3) to present an outline to assist the child mental health professional in developing a practical and rational approach to using sedative hypnotic drugs in clinical practice, including patient and medication selection and potential pitfalls in management.

Maternal Empowerment - An Underutilized Strategy to Prevent Kernicterus?

Kernicterus is a common cause of death and morbidity in many Low- Middle-income Countries (LMICs) and still occurs in affluent nations. In either case, the immediate cause is delayed treatment of severe hyperbilirubinemia. In the West, a provider driven "systems approach" has been widely adopted to identify babies at risk prior to discharge from birthing centers with follow up monitoring based on the serum bilirubin level at time of discharge. The situation is more complicated in regions of the world where kernicterus is endemic, especially in LMICs where Glucose-6-phosphate Dehydrogenase Deficiency (G6PDd) is common and the system of jaundice management is often fragmented. To examine reasons for errors in jaundice management leading to kernicterus and the potential beneficial role of enlisting more parental participation in management decisions. We searched world literature related to pitfalls in jaundice management including deficiencies in providers' and parents' knowledge and behavior. Perspectives from mothers of children with kernicterus supplemented the literature review. System failures contributing to kernicterus in affluent countries include a lack of follow up planning, bad advice by providers, and a delay in care seeking by parents. In many LMICs, the majority of births occur at home with unskilled attendants. Traditional practices potentiate hemolysis in G6PDd babies. The danger of severe jaundice is frequently underestimated both by parents and care providers, and cultural and economic barriers as well as ineffective therapies delay care seeking. The failure to provide parents information about identifying severe jaundice and knowledge about the risks and treatment of hyperbilirubinemia has contributed to delayed treatment in both affluent and low-middle-income countries. A recent non-randomized clinical trial, supports teaching all parents skills to monitor jaundice, signs of early neurotoxicity, the importance of breast feeding, avoidance of ineffective or dangerous practices, and when/where to seek help. Empowering parents allow them to participate more fully in care decisions and to confront obstacles to care when provider services fail.

A Behavioral Decision Making Perspective on Organizational Inefficiencies

This symposium uses a behavioral decision making perspective to uncover previously unrecognized pitfalls in management. Three presentations document novel shortcomings of managers' decision making ...

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.&#x0D; 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.&#x0D; 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%.&#x0D; 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.