How to implement paid family and medical leave: A toolkit for practices.

Paid family and medical leave policies are increasingly popular in today's competitive labor market and provide well-documented advantages to all stakeholders. Implementing paid leave for radiologists can seem daunting due to overlapping legal and institutional policies, logistical challenges and call coverage, as well as industry-specific special considerations such as resident education and historical workplace attitudes. This toolkit can empower radiology leaders to implement written paid leave policies in their home institutions and demonstrate that equitable, compassionate institutional policies for paid leave are financially favorable, widely desirable, and increasingly achievable with the right tools in hand.

Malignant cerebellar edema in three-year-old girl following accidental opioid ingestion and fentanyl administration.

A three-year-old girl was found altered with an unknown timeline. Gas chromatography mass spectrometry was positive for hydromorphone, dihydrocodeine, and hydrocodone. Initial computed tomography and magnetic resonance imaging suggested a malignant cerebellar edema not confined to a vascular distribution. She received fentanyl boluses on hospital days 0 and 1 before receiving a continuous infusion on day 1. On day 3, she had an episode of acute hypertension and bradycardia. Emergent computed tomography showed an evolving hydrocephalus and similar diffuse edema throughout both cerebellar hemispheres. External ventricular drain was placed to relieve the increased intracranial pressure. Following drain placement and fentanyl discontinuation, the patient recovered, though not without fine- and gross-motor deficits at the four-month follow-up. Our case adds to a handful of case reports of opioid toxicity in pediatric patients that present as toxic leukoencephalopathy. Though the mechanism is poorly understood, it has been suggested to be a consequence of the neurotoxic effects of the drug, which has particular affinity for µ opioid receptors-the primary opioid receptor found in the cerebellum. Clinicians would do well to recognize that this syndrome is primarily caused by direct toxicity rather than ischemia. This case adds insight by suggesting that lipophilic opioid analgesics may worsen this neurotoxicity. When intervening with mechanical ventilation, clinicians should consider avoiding lipophilic opioid drugs for analgesia until the pathogenesis of cerebellar edema is better understood.

Preoperative risk factors for postoperative delirium following hip fracture repair: a systematic review.

OBJECTIVE: Systematically identify preoperative clinical risk factors for incident postoperative delirium in individuals undergoing hip fracture repair in order to guide clinicians in identifying high risk patients at admission. METHODS: This is a systematic review of prospective observational studies with estimation of association between preoperative risk factors and incident postoperative delirium in multivariate models. Electronic searches were conducted in PubMed, Embase, PsycINFO, CINAHL, Cochrane Library, Proquest Dissertations and Theses, and WorldCatDissertations. Hand searches were conducted in selected journals and their supplements. RESULTS: Search yielded 6380 titles and abstracts from electronic databases and 72 titles from hand searches, and 10 studies met inclusion criteria. The following risk factors were significant in bivariate models: cognitive impairment, age, gender, institutionalization, functional impairment, body mass index (BMI), albumin, comorbidities, American Society of Anesthesiologist classification, acute medical conditions, polypharmacy, and vision impairment. Among all of these risk factors, cognitive impairment most consistently remained statistically significant after adjusting for other risk factors in multivariate models, followed by BMI/albumin and multiple comorbidities. CONCLUSION: In our systematic review, cognitive impairment was one of the strongest preoperative risk factors for postoperative delirium after hip fracture surgery. Preoperative cognitive assessment may be one of the most useful methods of identifying those who are at high risk for postoperative delirium and prioritizing delivery of delirium prevention measures.