Lateral geniculate artery pseudoaneurysm after arthroscopic medial meniscectomy.

Vascular complications after arthroscopy are rare and generally present as transient paresthesia most likely due to nervous injury or vasospasm. Rare cases of genicular artery injuries can occur and generally involve the medial genicular artery due to proximity to the right arthroscopic knee hook. This case, however, represents a rare lateral inferior genicular artery injury resulting in a symptomatic pseudoaneurysm. In addition, during the workup, the best visualization of the pseudoaneurysm was possible using duplex ultrasound. The diagnostic information seen on ultrasound was paramount and superseded the findings from conventional angiography and computed tomography angiography, both of which were nonspecific. In brief, this case not only highlights a rare surgical complication but also emphasizes the importance of duplex ultrasound compared with angiography and computed tomography in the workup of pseudoaneurysms.

Entrepreneurial leadership, nurses' proactive work behavior, and career adaptability: a structural equation model.

BACKGROUND: Healthcare organizations with practitioners who exhibit proactive work behavior and career adaptability acquire a competitive advantage in the face of many adversities. Entrepreneurial leadership (EL) is a new leadership approach that has a huge impact on followers' behavior, although research into its theory and empirical evidence is still in its infancy. METHODS: A non-probability convenience sample methodology (n = 450) was utilized to choose study participants, who were equally dispersed among the two private hospitals in Alexandria. A cross-sectional study was carried out in all departments of the hospitals, which were chosen at random using a simple random procedure. Three validated scales were used in this study to measure the study variables and establish a structural equation model. RESULTS: The result of this study revealed that nurses perceived moderate mean scores of all variables; entrepreneurial leadership (140.84 ± 11.94), proactive work behavior (46.02 ± 5.85), and career adaptability (85.55 ± 10.35). In addition, the structured equation model revealed a goodness fit index and presents that entrepreneurial leadership significantly affects nurses' proactive work behavior with an estimated ß of 0.555, coefficient of regression C.R. of 4.006, at P value < 0.001. Also, it significantly affects career adaptability with an estimated ß of .834, a coefficient of regression C.R. of 3.491 at P value < 0.001. CONCLUSIONS: The developed structural equation model confirmed the significant impact of entrepreneurial leadership (EL) on nurses' proactive work behavior (PWB) and career adaptability (CA)". Therefore, this study offers important implications for nurse managers, staff nurses, hospital human resources management practice, and academics.

Post COVID-19 workplace ostracism and counterproductive behaviors: Moral leadership.

BACKGROUND: The wide proliferation of Covid-19 has impacted billions of people all over the world. This catastrophic pandemic outbreak and ostracism at work have posed challenges for all healthcare professionals, especially for nurses, and have led to a significant increase in the workload, several physical and mental problems, and a change in behavior that is more negative and counterproductive. Therefore, leadership behaviors that are moral in nature serve as a trigger and lessen the adverse workplace effects on nurses' conduct. AIM: this research is directed to explore the impact of post-COVID-19 workplace ostracism on nurses' counterproductive behavior and examine the role of moral leadership as a mediating factor in post-COVID-19 workplace ostracism and nurses' counterproductive behavior. ETHICAL CONSIDERATION: Ethical review and approval Was received from Ethical Committee at the Faculty of Nursing, Alexandria University, Egypt. METHODS: A cross-sectional and correlation study was implemented in all units of medical, surgical, critical and intensive care units by using three tools; moral leadership questionnaire, Workplace Ostracism Instrument (WOS), and Counterproductive Work Behaviors Questionnaire (CWBs). A convenient sample of 340 from 699 bedside nurses was granted. RESULTS: This study revealed that nurses' perceived moderate mean percent (55.49 ± 3.46) of overall workplace ostracism and counterproductive behavior (74.69 ± 6.15). However, they perceived a low mean percentage of moral leadership. There was a significant positive correlation between workplace ostracism and counterproductive behavior. Otherwise, a significant negative correlation was found between moral leadership, workplace ostracism and counterproductive behavior. Also, this study proved the mediating effect of moral leadership in decreasing workplace ostracism by 79.3% and counterproductive behavior by 36.7%. CONCLUSION: Hospital administrators need to be aware of the significance of moral leadership and apply integrity in the clinical setting to reduce the drawback of isolation on nurses' conduct and increase value for the organization as a whole and nurses in particular.

Optimization of antidote stocking, availability, and administration practices for a large multihospital organization.

PURPOSE: Inadequate hospital antidote inventory is a widely documented international issue due to high medication costs, lack of emphasis on antidote importance, variable international standards, hospital size, and drug availability. A large health system underwent process and policy implementation for antidote stocking, availability tracking, and administration strategies to ensure appropriate inventory and improve patient safety. SUMMARY: Process and policy implementation occurred over a 12-month period across the health system's 11 acute care hospitals with emergency department services. Opportunities for optimization were identified following data capture surrounding institution-specific antidote inventory and usage across the health system. Specifically, minimum par levels at each institution were determined from 2018 expert recommendations for both the central pharmacy and automated dispensing machines within the emergency department. These quantities ensured the availability of an antidote within a specific timeframe contingent on the acquisition acuity for at least one 100-kg patient. Entries for order sets, order statements, and smart pump drug libraries were modified or formulated to facilitate standardized practices and minimize safety errors before a system-wide electronic health record transition. CONCLUSION: It is prudent for all institutions, independent or within a health system, to identify areas of improvement for antidote inventory and management. Implementation of a similar process for antidote stocking, sharing, and delivery at other institutions is feasible and necessary to mitigate issues with drug acquisition and timely administration.

Maxillary sinus volume in patients with canted occlusal plane: A cone-beam computed tomography study.

OBJECTIVES: To compare the maxillary sinus volume between both sides in adult patients with upper occlusal canting (>2 mm cant) and a control group (≤2 mm cant) using cone-beam computed tomography scans. MATERIALS AND METHODS: This retrospective study included a total of 84 scans (42 scans per group) according to predetermined selection criteria. OnDemand 3-D™ software was used for volumetric and linear measurements of the maxillary sinus. Maxillary occlusal canting was determined at the level of the maxillary first molars. It was defined as the vertical difference between right and left sides relative to the Frankfort horizontal plane. Non-parametric tests were applied. RESULTS: The median difference in the maxillary sinus volume between the sides was statistically significant between the control and cant groups (P < 0.001). Also, the median difference in the maxillary sinus craniocaudal height and apex sinus distance between the sides was statistically significant between the control and cant groups (P < 0.05 and P < 0.001, respectively). CONCLUSION: In adult patients, maxillary occlusal canting of more than 2 mm was associated with asymmetric maxillary sinus volumes. In the cant group, maxillary first molars on the canted-down side were in close proximity to the sinus floor, which suggests a limited leeway for molar intrusion.

Crisis, ethical leadership and moral courage: Ethical climate during COVID-19.

BACKGROUND: The global COVID-19 pandemic has challenged nurse leaders in ways that one could not imagine. Along with ongoing priorities of providing high quality, cost-effective and safe care, nurse leaders are also committed to promote an ethical climate that support nurses' moral courage for sustaining excellence in patient and family care. AIM: This study is directed to develop a structure equation model of crisis, ethical leadership and nurses' moral courage: mediating effect of ethical climate during COVID-19. ETHICAL CONSIDERATION: Approval was obtained from Ethics Committee at Faculty of Nursing, Alexandria University, Egypt. METHODS: A cross-sectional design was used to conduct this study using validated scales to measure the study variables. It was conducted in all units of two isolated hospitals in Damanhur, Egypt. A convenient sample of 235 nurses was recruited to be involved in this study. RESULTS: This study revealed that nurses perceived a moderate mean percent (55.49 ± 3.46) of overall crisis leadership, high mean percent (74.69 ± 6.15) of overall ethical leadership, high mean percent (72.09 ± 7.73) of their moral courage, and moderate mean percent of overall ethical climate (65.67 ± 12.04). Additionally, this study declared a strong positive statistical significant correlation between all study variables and indicated that the independent variable (crisis and ethical leadership) can predict a 0.96, 0.6, respectively, increasing in the dependent variable (nurses' moral courage) through the mediating impact of ethical climate. CONCLUSION: Nursing administrators should be conscious of the importance of crisis, ethical leadership competencies and the role of ethical climate to enhance nurses' moral courage especially during pandemic. Therefore, these findings have significant contributions that support healthcare organizations to develop strategies that provide a supportive ethical climate. Develop ethical and crisis leadership competencies in order to improve nurses' moral courage by holding meetings, workshops, and allowing open dialogue with nurses to assess their moral courage.

Urinary excretion after transcaval renal penetration of a fragmented Bird's Nest filter.

Permanent inferior vena cava (IVC) filters are used to prevent venous thromboembolic events in select populations of patients. The Bird's Nest filter (BNF; Cook Medical, Bloomington, Ind) is an IVC filter that has been associated with various complications including filter strut fractures, migration, caval wall perforation, visceral perforation, and vascular injury. We report a case of a BNF that eroded transmurally through the IVC into the right kidney parenchyma. The patient underwent operative intervention with removal of the BNF with an uncomplicated postoperative course. In patients with symptoms and local filter perforations, we advocate for safe filter removal when possible to avoid long-term damage.

Key articles and guidelines for the emergency medicine clinical pharmacist: 2011-2018 update.

PURPOSE: To summarize recently published research reports and practice guidelines on emergency medicine (EM)-related pharmacotherapy. SUMMARY: Our author group was composed of 14 EM pharmacists, who used a systematic process to determine main sections and topics for the update as well as pertinent literature for inclusion. Main sections and topics were determined using a modified Delphi method, author and peer reviewer groups were formed, and articles were selected based on a comprehensive literature review and several criteria for each author-reviewer pair. These criteria included the document "Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009)" but also clinical implications, interest to reader, and belief that a publication was a "key article" for the practicing EM pharmacist. A total of 105 articles published from January 2011 through July 2018 were objectively selected for inclusion in this review. This was not intended as a complete representation of all available pertinent literature. The reviewed publications address the management of a wide variety of disease states and topic areas that are commonly found in the emergency department: analgesia and sedation, anticoagulation, cardiovascular emergencies, emergency preparedness, endocrine emergencies, infectious diseases, neurology, pharmacy services and patient safety, respiratory care, shock, substance abuse, toxicology, and trauma. CONCLUSION: There are many important recent additions to the EM-related pharmacotherapy literature. As is evident with the surge of new studies, guidelines, and reviews in recent years, it is vital for the EM pharmacist to continue to stay current with advancing practice changes.

Sexually Transmitted Infection Review for the Acute Care Pharmacist.

PURPOSE: Review selected sexually transmitted infections (STIs) and treatment recommendations for pharmacists and providers practicing in the acute care setting. SUMMARY: In 2015, the Centers for Disease Control and Prevention (CDC) published an updated guideline on the treatment of STIs with an emphasis on prevention and new diagnostic strategies to combat the growing problem of STIs in the United States. Despite this guidance, the incidence of infection has continued to grow. In October 2016, an in-depth analysis reported that 20 million new infections occur annually in the United States. With this growing burden of disease, it is pertinent that health-care providers optimize their treatment strategies to improve upon the management of STIs. Focusing on identification of asymptomatic- and symptomatic-infected persons, treatment, education, effective follow-up, and counseling for patients and sexual partners, emergency medicine pharmacists and providers can help minimize the negative long-term health consequences of STIs. CONCLUSION: In the emergency department setting, clinical pharmacists and providers can play a crucial role in preventing and treating STIs and should continue to expand and keep current their knowledge of this topic.

Relationship between ethical ideology and moral judgment: Academic nurse educators' perception.

BACKGROUND: Ascertaining the relationship between ethical ideology, moral judgment, and ethical decision among academic nurse educators at work appears to be a challenge particularly in situations when they are faced with a need to solve an ethical problem and make a moral decision. PURPOSE: This study aims to investigate the relationship between ethical ideology, moral judgment, and ethical decision as perceived by academic nurse educators. METHODS: A descriptive correlational research design was conducted at Faculty of Nursing, Alexandria University. All academic nurse educators were included in the study (N = 220). Ethical Position Questionnaire and Questionnaire of Moral Judgment and Ethical Decisions were proved reliable to measure study variables. ETHICAL CONSIDERATIONS: Approval was obtained from Ethics Committee at Faculty of Nursing, Alexandria University. Privacy and confidentiality of data were maintained and assured by obtaining subjects' informed consent. FINDINGS: This study reveals a significant positive moderate correlation between idealism construct of ethical ideology and moral judgment in terms of recognition of the behavior as an ethical issue and the magnitude of emotional consequences of the ethical situation (p < 0.001; p = 0.031) respectively. Also, there is a positive significant moderate correlation between relativism construct of ethical ideology and overall moral judgment (p = 0.010). Approximately 3.5% of the explained variance of overall moral judgment is predicted by idealism together with relativism. DISCUSSION: The findings suggest that variations in ethical position and ideology are associated with moral judgment and ethical decision. CONCLUSION: Organizations of academic nursing education should provide a supportive work environment to help their academic staff to develop their self-awareness and knowledge of their ethical position and promoting their ethical ideologies and, in turn, enhance their moral judgment as well as develop ethical reasoning and decision-making capability of nursing students. More emphasis in nursing curricula is needed on ethical concepts for developing nursing competencies.

Can ethanol intoxication secondary to docetaxel be predicted based on dose administered using a point-of-care saliva ethanol test?

BACKGROUND: The Food and Drug Administration issued a drug safety alert highlighting the potential association of docetaxel infusion with signs and symptoms of alcohol intoxication. This concern is significant because patients treated with docetaxel often have comorbidities and are prescribed concomitant centrally active medications. As a result, these patients may be at risk for iatrogenic events. OBJECTIVE: The objective of this study was to identify a correlation with docetaxel infusion and saliva ethanol concentration using a point-of-care ethanol test. METHODS: In this pilot study, ethanol concentrations were measured using a validated saliva ethanol test in patients receiving intravenous docetaxel as part of their chemotherapy regimen. Both ethanol dose and infusion rate were calculated based on the amount of the specific docetaxel product administered. Saliva ethanol concentrations were measured at baseline, immediately after infusion completion, and at 30 and 60 min postinfusion. RESULTS: A total of 17 patients were included in the analysis. The mean ethanol dose administered was 2.6 ± 0.5 g of ethanol per infusion of docetaxel with a mean infusion rate of 3.2 ± 0.7 ml of ethanol per hour. At baseline, immediately after infusion, and 30 and 60 min postinfusion, all patients had a saliva ethanol test result of 0 mg/dl. CONCLUSION: Based on this small pilot study, the prediction of patients who will experience ethanol intoxication using a point-of-care saliva ethanol test based on the docetaxel dose administered is challenging. This observation requires confirmation in larger and more heterogeneous populations.

Multidisciplinary Approach to Treatment of Soft Tissue Sarcomas Requiring Complex Oncologic Resections.

BACKGROUND: To review the experience and outcome of utilizing a multidisciplinary team, including vascular surgery and orthopedic surgery, in the operative treatment of soft tissue sarcomas (STSs) at an academic, tertiary care hospital. METHODS: A retrospective review was performed of all patients who underwent elective STS resection between July 1, 2012 and January 31, 2015, since the addition of a specialized cancer treatment center and a dedicated oncologic division of orthopedic surgery. Surgical cases performed in conjunction with both orthopedic and vascular surgery were reviewed. RESULTS: Sixty-three patients underwent 66 surgical resections for STS during the study period. There were no perioperative deaths. Fifty-two lower-extremity resections (78.8%), 6 upper-extremity resections (9.1%), and 8 pelvic resections (12.1%) were performed. Sixteen cases required a vascular intervention (24.2%). These interventions included bypass in 2 patients (12.5%), primary repair of a named vessel in 4 patients (25%), and ligation of a named vessel in 10 patients (62.5%). Three patients had local recurrence of their tumor (4.5%), requiring further resection during the follow-up period. Seven patients required a primary amputation (10.6%). The average size of the tumor removed was 1,776 mL, ranging from 5 mL to 36,300 mL. CONCLUSIONS: The quality of surgical resection is paramount in optimal treatment of STS; however, wide resection of STS can result in prolonged operative times, significant blood loss, vascular complications, and functional deficits. A multidisciplinary surgical team including orthopedic and vascular teams may improve the treatment by optimizing complex resections that may require involved vascular control or reconstruction.

Relative value unit-based compensation incentivization in an academic vascular practice improves productivity with no early adverse impact on quality.

OBJECTIVE: Given the increased pressure from governmental programs to restructure reimbursements to reflect quality metrics achieved by physicians, review of current reimbursement schemes is necessary to ensure sustainability of the physician's performance while maintaining and ultimately improving patient outcomes. This study reviewed the impact of reimbursement incentives on evidence-based care outcomes within a vascular surgical program at an academic tertiary care center. METHODS: Data for patients with a confirmed 30-day follow-up for the vascular surgery subset of our institution's National Surgical Quality Improvement Program submission for the years 2013 and 2014 were reviewed. The outcomes reviewed included 30-day mortality, readmission, unplanned returns to the operating room, and all major morbidities. A comparison of both total charges and work relative value units (RVUs) generated was performed before and after changes were made from a salary-based to a productivity-based compensation model. P value analysis was used to determine if there were any statistically significant differences in patient outcomes between the two study years. RESULTS: No statistically significant difference in outcomes of the core measures studied was identified between the two periods. There was a trend toward a lower incidence of respiratory complications, largely driven by a lower incidence in pneumonia between 2013 and 2014. The vascular division had a net increase of 8.2% in total charges and 5.7% in work RVUs after the RVU-based incentivization program was instituted. CONCLUSIONS: Revenue-improving measures can improve sustainability of a vascular program without negatively affecting patient care as evidenced by the lack of difference in evidence-based core outcome measures in our study period. Further studies are needed to elucidate the long-term effects of incentivization programs on both patient care and program viability.

Glucagon for refractory asthma exacerbation.

Glucagon, a hormone secreted by pancreatic alpha cells, causes bronchial smooth muscle relaxation by activating the synthesis of cyclic adenosine monophosphate. It was studied in the 1980s and 1990s as a treatment option for the management of asthma but has since not been evaluated. Data to support its use are limited, but it may serve as a last-line agent for refractory asthma exacerbation. Here we describe 4 cases in which intravenous glucagon was used to manage severe, refractory asthma exacerbation in the emergency department.