Posterior Reversible Encephalopathy (PRES)

Posterior Reversible Encephalopathy (PRES) Posterior Reversible Encephalopathy (PRES): A Rare Presenting Feature of Pheochromocytoma Abstract Hypertension in young is mostly due to secondary causes and one of them is pheochromocytoma. These are catecholamine secreting enterochromaffin tumors causing paroxysmal hypertension. Adrenal pheochromocytoma presenting as posterior reversible encephalopathy syndrome (PRES) is very rare and has not been described in literature so far. Here, we report a case of previously healthy adolescent boy, who presented with acute onset severe headache, blurring of vision, generalized tonic clonic motor seizure and altered sensorium. His blood pressure was 234/126 mm Hg. The magnetic resonance imaging (MRI) of brain showed hyperintense signal on T2-weighted and fluid attenuated inversion recovery (FLAIR) images in bilateral parietal and occipital regions. High blood pressure and classical MRI findings were consistent with the diagnosis of PRES. Abdominal ultrasonography (USG) revealed a right adrenal mass. A diagnosis of pheochromocytoma was confirmed by abdominal triple phase contrast- computed tomography (CT) and 24-hour urinary metanephrine assay. After the blood pressure was stabilized with alpha and beta blockade, adrenal tumor was surgically excised. Histopathologic examination of tissue confirmed the diagnosis of pheochromocytoma. The MRI brain showed complete resolution of hyperintense signals (T2-weighted and FLAIR images) on two-months follow-up. He was symptom free at six months and one year follow-up. Key words: Posterior reversible encephalopathy syndrome (PRES); Reversible posterior leukoencephalopathy (RPLE); Pheochromocytoma; Hypertensive Encephalopathy; Hypertension Abbreviations: ADC: apparent diffusion coefficient; CT: computed tomography; MRI: magnetic resonance imaging; DWI: diffusion-weighted imaging; PRES: posterior reversible encephalopathy syndrome Introduction Hypertension in young is mostly due to secondary causes which include renal diseases (chronic renal failure, renal artery stenosis, polycystic kidney disease), coarctation of the aorta, systemic lupus erythematosus (SLE) and endocrinopathies. Pheochromocytomas are rare catecholamine secreting enterochromaffin tumors. The patients of pheochromocytoma usually present with spells of headache, sweating and palpitations due to excessive catecholamines. The cerebral manifestation of pheochromocytoma are uncommon. Posterior reversible encephalopathy syndrome (PRES) as a presenting feature of pheochromocytoma is rare. Case Report A 14-year-old previously healthy boy presented in emergency department with acute onset severe holocranial headache, blurring of vision, generalized tonic clonic motor seizure followed by altered sensorium. There was no previous history of nausea, vomiting, diarrhea, flushing, excessive sweating, migraine, autoimmune and connective tissue disorders, drug abuse, toxin exposure, hypertension or diabetes mellitus. He had no similar illness in past and family history was negative. His pulse rate and blood pressure were 130 beats per minute and 234/126 mm Hg, respectively. He was confused but followed simple commands. The pupillary size and light reaction were normal on both sides. Fundus examination showed bilateral papilledema. He was moving all the four limbs equally without asymmetry on painful stimulus. Plantars were bilaterally extensor. Signs of meningeal irritation (neck rigidity and Kernigs signs) were negative. Complete hemogram, serum electrolyte, renal function tests and other biochemistry including thyroid function tests were normal. Serum anti-nuclear antibodies (ANA), anti-double-stranded DNA antibody (anti-dsDNA) and ELISA test for human immunodeficiency virus (HIV) were negative. X-ray chest was normal. Electrocardiography (ECG) showed tachycardia. Magnetic resonance imaging (MRI) of brain showed hyperintense signal changes on T2-weighted and fluid attenuated inversion recovery (FLAIR) images in bilateral occipito-parietal regions. No restriction was seen on diffusion-weighted images (DWI) [Figure 1]. CT angiography of brain vessels was normal. High blood pressure and classical MRI findings were consistent with the diagnosis of PRES. On further evaluation, abdominal ultrasonography (USG) showed right adrenal mass. An abdominal triple phase contrast-enhanced CT scan revealed heterogeneous, contrast enhancing adrenal gland mass lesion measuring 32 x 26 mm suggestive of pheochromocytoma [Figure 2]. The diagnosis was confirmed by 24-hour urinary metanephrine assay. The plasma aldosterone concentration (PAC) and plasma renin activity (PRA) ratio (PAC/PRA) was 10.4. The 24- hour urinary normetanephrine was 31,572 Â µg/24 hour (normal: 63-402 Â µg/24 hour), urinary metanephrine was 1,524 Â µg/24 hour (normal: 32-167 Â µg/24 hour) and plasma noradrenaline level was 18,635 pg/mL (normal: 0-400 pg/mL). Patient was managed intensively with nitroprusside infusion to reduce blood pressure. Injectable phenytoin was administered according to body weight to control seizures. Once patient was stabilized, he was started on oral alpha-blocker prazosin (20 mg/day) followed by beta-blocker propranolol (40 mg/day). After adequate alpha and beta blockade, patient was planned for surgery and resection of adrenal mass was done. Histopathologic examination confirmed the diagnosis of pheochromocytoma without invasion of the adrenal capsule [Figure-3]. The MRI brain showed complete resolution of hyperintense signals (T2-weighted and FLAIR images) and 24-hour urine metanephrines were normal on two-months follow-up. He was asymptomatic at six months and one year follow-up. Discussion Pheochromocytomas are neuroendocrine tumors arising from chromaffin cells of the adrenal medulla or extra-adrenal paraganglia. The classical features like holocranial headache, palpitations, hypertension, hyperhidrosis, hyperglycemia and hypermetabolism are due to excessive catecholamines production in these tumors. The cardiac complications such as arrhythmias, myocardial infarction and sudden deaths are associated with cardiotoxic effects of high blood catecholamines levels. Pheochromocytoma is a rare cause of secondary hypertension and accounts for 0.5% to 2.0% of all causes of hypertension in children. The neurological complications (ischemic or hemorrhagic stroke) are related to increased platelet aggregation, hypertension and vasospasm due to high catecholamines levels. The various potential triggers of pheochromocytoma crisis leading to hemodynamic instability are stress, blood loss, surgery and anesthesia. The diagnosis of pheochromocytoma is confirmed by 24-hour urinary meta nephrine and normetanephrine levels. Clinical features of reversible posterior leukoencephalopathy syndrome (PRES) are acute onset headaches, vision loss, seizures and altered sensorium. It is mostly due to hypertension, however other common causes are chronic renal disease, uremic encephalopathy, ergot alkaloids, steroids, chemotherapy, vasculitis and tumors. Pheochromocytoma is one of the rare cause of PRES due to secondary hypertension. However, to the best of our knowledge, acute, life-threatening initial presentation of pheochromocytoma as PRES has not been described in literature. Magnetic resonance images (MRI) of brain typically shows hyperintense signal changes on T2-weighted and fluid attenuated inversion recovery (FLAIR) images due to vasogenic edema. It mostly involves the cortical and subcortical white matter of the parietooccipital, frontal and temporal regions. Cerebral hemorrhage, cytotoxic edema and contrast enhancement are atypical imaging findings of PRES. The parietooccipital cortex and subcortical w hite matter were affected in our case. Classically, these signal abnormalities are reversible on antihypertensive therapy. The pathophysiology of PRES is still poorly understood, however, various hypothesis have been proposed. Severe hypertension causes deranged autoregulation of sympathetically mediated cerebral arterioles. It leads to increased permeability in the blood-brain barrier and causes vasogenic edema. Sympathetic innervation of the vertebrobasilar system is not as extensive or as complete as that of the anterior circulation. Therefore, PRES predominantly affects parietooccipital cortex and subcortical white matter. Other possible mechanism may be endothelial dysfunction due to circulating toxins or chemotherapy agents. There may be cerebral infarction or hemorrhage due to compromise of the microcirculation by pressure from surrounding vasogenic edema. The exact etiology of the seizure remains unknown, but may result from effects of the pheochromocytoma on reducing seizure threshold via its actions on metabolic or hypertensive parameters. Our patient had high levels of circulating catecholamin es, produced autonomously by tumor. Once vasogenic edema subsided with antihypertensive therapy, all the abnormal MRI findings vanished. Clinical topography (acute onset headache, visual blurring, seizure and altered sensorium), high blood pressure and typical MRI findings suggested diagnosis of PRES. In our patient, other differential diagnosis such as thrombocytopenic thrombotic purpura (TTP), hemolytic uremic syndrome (HUS), encephalitis, systemic lupus erythematosus (SLE), brain mass lesions and drug toxicity were ruled out by appropriate clinical and laboratory investigations. In our patient, hypertension was detected for the first time on hospital admission and before that he never had any symptoms like headache, palpitations, perspiration or diarrhea. Our patient is of clinical interest as pheochromocytoma presented with life-threatening hypertensive encephalopathy. Management of pheochromocytoma requires aggressive approach including fluid resuscitation and antihypertensive therapy (both alpha and beta blockade) followed by surgical resection of tumor. Conclusion Pheochromocytomas are catecholamine secreting enterochromaffin tumors causing paroxysmal hypertension. Our patient is of clinical interest as an acute, life-threatening hypertensive encephalopathy (PRES) as a presenting feature of adrenal pheochromocytoma has not been described in literature so far. Pheochromocytoma should be ruled out in every young patient with acute hypertensive encephalopathy. Figure Legends Figure 1. Magnetic resonance imaging (MRI) of brain showing hyperintense signals on T2-weighted and fluid-attenuated inversion recovery (FLAIR) images in parieto-occipital region. No diffusion restriction is seen. [ T1-weighted axial (A), T2-weighted axial and sagittal (B,C), FLAIR (D), diffusion weighted (DWI) (E) and corresponding apparent diffusion coefficient (ADC) (F) images]. These abnormal signals completely vanished on follow-up MRI after six weeks. Figure 2. Triple phase contrast-enhanced computed tomography (CT) of abdomen showing heterogenous enhancing mass lesion measuring 32 x 26 mm in right adrenal gland. [Axial CT: Arterial phase (A,B), Venous phase (C) and Delayed phase (D)]. Figure 3. Hematoxylin and eosin (HE) stained microphotographs showing large pleomorphic nuclei, abundant basophilic cytoplasm and cell-nesting pattern (zellballen pattern). [HE stain 40x view (A), 100x view (B,C)]. 1

Revisiting the NASL

It is said that we are able to see the correctness, validity and impact of our actions only after the moment we act had passed. This article looks back into the experience of the North American Soccer League. This is an attempt to revisit the rise and demise of the league.A Brief HistoryThe North American Soccer League (NASL) was established as a result of the merger of the United Soccer Association and the National Professional Soccer League. It was the culmination of the first modern attempts to create a truly national soccer league in the United States. The NASL even had franchise teams from Canada. Prior to its establishment, soccer competition in the United States was primarily on the semi-professional and amateur level.The United Soccer Association (USA) was sanctioned by the Federation of International Footbal Association (FIFA) and established itself in twelve major cities across the United States. The National Professional Soccer League (NPSL), on the other hand, was not san ctioned by FIFA. It also did not abide by FIFA player transfer rules and had ten franchise teams. Fan interest for the two leagues was initially high and attendance was not bad for the first year.The merger of the two leagues into the NASL, however, was an act of desperation. Fan interest had quickly faded, television ratings were terrible and the teams of the USA and NPSL had experienced massive financial losses. The disastrous start was such that only five teams of the original seventeen teams that started the NASL survived the first two seasons (Holroyd, 2005).Teams folded but new franchises took their place in the league. The turning points in league history took place in the 1971 to 1975 period. The New York Cosmos joined the NASL in 1971 and won the league in 1972. The entry of the Cosmos established the league’s presence in a major market and brought greater media attention to the league. The following year saw the Philadelphia Atoms joining the league. The Atoms also won the league title in their inaugural season. The team was bannered by Kyle Rote Jr., son of a former star of the National Football League’s (NFL) New York Giants. Rote also won the league’s Rookie of the Year and Most Valuable Player awards. By 1974, the NASL had grown and have fifteen teams competing (Holroyd, 2005).Before the start of the 1975 season, the New York Cosmos got Edson Arantes do Nascimento (more popularly known as Pelà ©) to play for the team. This move placed the league in the spotlight and significantly increased public interest in soccer in the United States. Pelà ©, of course, is considered possibly the greatest soccer player ever. He gained the moniker â€Å"King of Football† or simply King Pelà © during his career. The attention snowballed through 1977 and culminated with 77,691 spectators for the 1977 playoff game between the Cosmos and the Ft. Lauderdale Strikers at Giants stadium. Pelà © retired from the sport, and the league, in 1 977 after an exhibition game between the two professional football clubs he had played for — New York Cosmos and Santos FC from Brazil (Holroyd, 2005).The NASL followed its success by undergoing a major expansion, adding six teams in 1978. League competition was organized into a NFL-style divisional lineup with a 30-game season. Teams also went into an unprecedented spending spree to sign up international players in an attempt to match the Cosmos’ success or at least remain competitive in the league (Litterer & Holroyd, 2003).Seven years after Pelà ©'s farewell, the league started 1984 (its 17th season) smaller than it had been in over a decade with only nine teams. Also, four of these teams were on shaky financial ground. The league eventually closed down after the Chicago-Toronto best-of-three finals series in Toronto, Canada (Holroyd, 2006).Addressing the MistakesPolicy 1: Develop Homegrown Talents to Generate AwarenessWhat could have the league done to sustain its elf? What could have been avoided? Among the team sports played in the United States, soccer had not yet reached the level of fan interest and media attention that is given to professional baseball, basketball and football. As a result, the franchise teams that made the NASL were in shaky financial standing except for that brief golden period that spanned 1971 to 1977.In this regard, the first issue to address is generating awareness and increasing the interest of fans. Soccer was not, and is not yet, dear to the hearts of American sports spectators. It has not reached the manic-obsessive levels of fan interest outside of the United States. According to Paglia (2007), the nature of the game runs counter to the fundamental element required of a US spectator sport.A hallmark of the most popular outdoor spectator sports in America, for example baseball and football, is that fans try to anticipate the next plays, possible game outcomes and share these speculations with one another. Socc er, by its nature, is an extemporaneous sports with many improvisational plays. It is so fluid that speculating on outcomes is close to impossible.Fan interest could, however, be impacted by creating awareness. In 1975, fan interest and awareness of soccer went up when Pelà © played in the league. At the time of his entry, Pelà © was famous even in the United States. This tack is being duplicated again by the Major League Soccer when the LA Galaxy contracted David Beckham to play for the team. Paglia (2007) sees that Beckham will create an impact but this alone will not â€Å"convert the curious to fans†. Furthermore, the impact may not be at the same level as when Pelà © played in the NASL. The two players are not the same whether in stature or even in playing style.Giorgio Chinaglia, the former Italian international who played alongside Pelà ©, does not think Beckham alone can promote the sport and league. Other big European names have to follow him to produce sustained success. Chinaglia even estimates that around 50 international soccer stars may be needed. (Adderley, 2007). But the NASL have already gone through this route before and it was with disastrous results.Some, even in 1978, had criticized the move to bring in more foreign players as shortsighted. They said that it was more important to develop American talent. But those voices were lonely cries in the wilderness.A lesson could be learned from 1973 when the Philadelphia Atoms won the NASL championship. Fan interest was sparked by the emergence of Kyle Rote Jr. He was considered the first â€Å"All-American† soccer star. The American spectator wants a star to relate to and follow. And it would be better if the star was homegrown. The NASL should link up with amateur, collegiate and semi-professional soccer leagues. It would even be better if it had its own developmental league.Policy 2: Cooperation and Fiscal DisciplineLooking back into the 1978 NASL spending spree, despite the i ncreased audience base and interest, more money was being spent than what was being earned. Operating a sports league is an awkward venture. The owners have to co-operate and make many business decisions collegially despite the fierce team competition. Taking a page from the National Football League’s business model, the NASL could have developed an internal incentive system that would stabilize team expenditures and â€Å"equalize† revenue generation.Two sets of incentives used by the NFL are (1) the teams' owners share roughly 70% of their revenues with each other; and (2) they stick to a strict salary cap that limits the amount each team can spend on players' salaries. As a result of these incentives, all thirty-two teams in the NFL have an even chance of being financially viable and athletically competitive despite having different market base (The Economist, 2006). Admittedly, the NASL attempted to institute a salary cap in 1984 but by then it was to little to lat e.Policy 3: Align Game to International StandardsSoccer’s World Cup is the biggest sporting event in world. The third policy that NASL could have done was to align its tournament format to that of the World Cup and international competition.By establishing a tournament format aligned to international (or globally accepted/recognized) format helps the league in two ways. One is that the American audience is educated on the mechanics of the game, and consequently increases the level of appreciation for the sport. Another is that the level of play of American players also gets aligned to that of foreign national teams.European football leagues hold inter-league competitions to determine the â€Å"continental† champion. For example, the Italian League champion plays against the French League champion. The NASL had already previously done this through friendly tours. The Ft. Lauderdale Strikers made a tour of England in February 1978. Foreign teams also toured the United St ates.Becoming competitive against foreign soccer teams could have helped in sustaining fan interest and support. Case in point is the impact of US National Team’s achievement in the 1994 World Cup. The team surpassed all expectations and reached the quarterfinals. This accomplishment sparked greater interest in the sport.ReferencesAdderley, Nigel. 2007. Beckham’s US Test. Accessed October 25, 2007 from http://news.bbc.co.uk/sport1/hi/football/6294762.stmHolroyd, Steve. 2005. The Year in American Soccer – 1984. Accessed October 25, 2007 from http://www.sover.net/~spectrum/year/1984.html2006. The Year in American Soccer – 1968. Accessed October 25, 2007 from http://www.sover.net/~spectrum/year/1968.htmlLitterer, David and Steve Holroyd. 2003. The Year in American Soccer – 1978. Accessed October 25, 2007 from http://www.sover.net/~spectrum/year/1978.htmlPaglia, Jim. 2007. A Naysayer View of Pro Soccer. Accessed October 25, 2007 from http://www.soccera merica.com/index.cfm?fuseaction=Articles.showArticleHomePage;art_aid=22406The Economist. 2006. In a league of its own. [Electronic version] Accessed October 25, 2007 from http://www.economist.com/business/displaystory.cfm?story_id=6859210

The Importance of Science to Civilization

The importance of science to civilization It is said that modern civilization is a scientific civilization. For an individual, science has rendered us great comfort nowadays. We no longer have to travel on foot; instead, we can just sit comfortably without any fatigue in cars, air-conditioned trains, buses, etc. We are free from hard labor which our uncivilized forefathers suffered from. Neither do we follow barbarous practice of having slaves, since science has provided us with slaves of a new kind, which undertake most of the work, that is, machine.On top of that, we are also free from diseases and various pains since drugs and operation techniques have been developed dramatically. Maslow's theory of hierarchy of needs suggests that the physiological needs must be met before the individual will strongly desire (or focus motivation upon) the secondary or higher level needs, which means the human that lacks food, love, esteem, or safety would consider the greatest of his/her needs to be food. And as mentioned above, it is science that satisfies our basic demands; thus, we have opportunities to pursue something higher, such as art and literature.Science also promote the development of spiritual civilization. With the advent of the internet, and extraordinary growth in information and communication technologies in recent years, more information than ever before is made freely available and easily shared. Almost all the masterpieces of artist, musicians, writers, philosophers, scientists, etc can be enjoyed at fingertips. We are not only consumers, but also producers. When Gangnam Style was released, tens of thousands people made their own versions and uploaded on the internet, which could be appreciated by millions of netizens.For a nation, science is of critical significance for the progress of its civilization. China's long history has seen some extremely important inventions emerge, most noticeably gunpowder, paper making, printing and the compass, which, in t he words of Roger Bacon, changed the whole appearance and status of things in the world and also made China among the four great ancient civilizations. However, in the nineteenth century, Europe entered into world history with immense developments in technology, which was later identified as the Industrial Revolution.From then on, China lost its advantages over the the rest of world in various aspects, and it was invaded by the great powers into a series of Unequal Treaties. Chinese civilization were, during that period, regarded inferior and the Chinese nation was referred to as â€Å"Sick Man of East Asia†. Even the Chinese people abandoned their own cultural identity and turned to the Western civilization. Therefore, science is the foundation as well as the major force behind the progress of civilization. 0101102027

Competition, Stability, And Civil Society - 958 Words

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In spite of these acts of disobedience, the Maoist party was st ill able to secure a minority in the CA (Harris, 2013b). Then there is the Marxist-Leninist part whose doctrine follows that of the leaders of Russia Marx and Lenin. In their charter, they aim to unite the lower class citizens and those of unfavorable castes and give them a political voice which has, up until recently, been overlooked (Communist Party, 2011). Finally, there is the Nepali-Congress party, who are the most central of the prominent political parties. The Nepali-Congress was alsoShow MoreRelatedThe Human Being Is A Self Seeker Of Preservation And Pleasure1641 Words   |  7 PagesThroughout history there have been many movements and great thinkers that have impacted society and the way that we perceive life and the human being. Thinkers such as Augustine, Hobbes, Aristotle, Kant, etc., have all developed theories of how they perceive the human being and their ethos as well as how a good life should be. 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Charles Darwin s Theory Of Natural Selection - 1408 Words

Over time, different species learn to adapt to their living environment in order to survive. If a genetic change of a characteristic is passed down through generations, a formation of a new species occurs (G, Linstead et. al., 2012). A variation to the characteristic of an individual can increase its survival and this provides more opportunities to reproduce. When the individual reproduces, the offspring benefit in result of the heritable genes and eventually through generations, the variants will be spread throughout the entire population (Montgomery, 2009). Charles Darwin’s theory of natural selection can be supported through both fossils and homologous structures. A technique that supports Charles Darwin’s theory of natural selection is fossils. A fossil is the remnant or imprint of a previous animal embedded in rock and preserved in petrified form (J, Castro, 2013). 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He had a theory that all species have inherited traits over time from common ancestors, and in a partnership with Alfred Russel Wallace introduced his scientific theory that this pattern of evolution resulted from an action that he called natural selection, in which the struggle for existence has a similar effect to the natural selection involved in selectiveRead MoreThe Scientific Theory Of Science And Technology1449 Words   |  6 Pageslive in today. Charles Robert Darwin was an English geologist and naturalist, best known for his significant addition to the science of evolution. He had a theory that all species have inherited traits over time from common ancestors, and in a partnership with Alfred Russel Wallace int roduced his scientific theory that this pattern of evolution resulted from an action that he called natural selection, in which the struggle for existence has a similar effect to the natural selection involved in selective

The s Theory Of The Tripartite Soul And Sigmund Freud s...

Moral Compass Navigation helps individuals arrive to a given destination, but the human life also requires of such navigation. Some individuals unconsciously seek directions when challenged with a given issue and know which way to steer because of their moral compass. Furthermore, the moral compass is the soul that guides the personal self, but it is also the non-material aspect of a human being that is immortal. Although, the soul’s existence is in question, there is evidence that validates that the soul is real. Such evidence includes Plato’s theory of the tripartite soul and Sigmund Freud’s psychodynamic theory, which reevaluates Plato’s theory. Both theories address that the soul’s existence is the personality of a human being. On the other hand, many critics claim that the soul does not exist since it is beyond our knowledge; therefore we cannot demonstrate such existence. Hume a philosopher during the Enlightenment affirms this claim under the branch of empiricism, which states that true knowledge, arises from our five senses: touch, smell, sight, taste, and hearing. Therefore, to determine if something exists at least one or all of the senses have to be applied since the material aspects of something demonstrates its existence. Moreover, the reasoning behind empiricism is an addition to Hume’s theory of sense perception. The theory is composed of two elements, which are impressions and ideas. Impressions are immediate sensations or perceptions such as touch or

Leadership in Health Care for Texas Hospital- myassignmenthelp

Question: Discuss about theLeadership in Health Care for Texas Hospital. Answer: Introduction The present paper aims to highlight the role of leadership in bringing about positive change within a healthcare system that fosters better service delivery. It undertakes a critical analysis of the approach taken by a healthcare leader for establishing a sustainable change in the healthcare setting so that better patient outcomes are achieved. The present paper considers the extent to which the applied strategies were successful in achieving the proposed change pertaining to the service delivery concerned. In addition, it also identifies the challenges emerging while implementing the change process at different levels. The manner in which these challenges were addressed would be mentioned in the paper. While writing this paper, strategies that would have been more beneficial in the selected context would also be highlighted based on literature search. Justifications for decision taken around the poposed change would be another part of the paper. Recommendations would be provided for future directions pertaining to leadership demonstration. The paper would end with a logical conclusion provided to the comprehensive discussion. Background Working as a healthcare leader at a reputed Texas Hospital of USA, a professional is expected to demonstrate key competencies and skills that are suitable for the welfare of the organisation. The aim of a healthcare leader is to foster positive changes in the care setting that are in alignment with the mission, vision and values of the healthcare system. One such initiative taken for better patient care delivery services was the implementation of Cyber Security For Medical Devices (CSFMD) at the Texas hospital. The idea encompassed installation of firewalls for enriching the health-related services given. The potential benefit of this system included transparency in working systems, protection from medical device misuse through better security, safeguarding of patients and superior health services provided to patients by medical staffs who are trained and competent. A planned change was considered that was decided in collaboration with other health care professionals, namely physicia ns, nurses and other staffs of the medical team. Though the proposal for change was a collaborative decision, it was the responsibility of the healthcare leader to act as the vehicle for change. For successful implementation of the change, it was ideal to demonstrate suitable leadership skills that guide the complete process of change. Leadership strategies utilised relevant to the planned change For healthcare professionals holding a high position in a healthcare setting, it is logical to demonstrate key leadership skills that promote changes in the setting for the betterment of all stakeholders. Leadership is known to guide such changes holding the potential to transform the manner in which a certain operation is functional within the care organisation (). The leadership style utilised relevant to the planned change of CSFMD implementation was transformational leadership. While implementing the proposed plan for CFSMD, different leadership qualities were brought into practice such as positive attitude, excellent communication, integrity, honesty, empathy, flexibility, courage, accountability, confidence, team management skills, creativity and mentoring ability. According to Richter et al., (2016) transformational leadership is a form of flexible and adaptive leadership. Through this form of leadership the leaer creates an environment of shared responsibility influencing novice methods of knowing. Transformational leadership is known to act as a motivating factor that enables followers to set up higher ideas as well as moral values. The leader is responsible for setting in deep ideas and notable vaues. This encourages the followers to sustain the change that they perceive to be good and let go of personal interest. Supportive environments are created under such form of leadership (Bansk et al., 2016). As opined by Mitchell et al., (2014) transformational leadership theory has provided its worth in a wide range of healthcare settings across the globe. This form of leadership fosters the development of capacity that brings in increased level of personal commitment towards organisational objectives. As stated by Birasnav (2014) transformational leadership facilitates a redefinition of vision and mission of individuals that is marked by a renewal of their level of commitment towards goal fulfilment. Spano-Szekely et al., (2016) in this regard has stated that leaders abdiign by such leadership style engender admiration, trust and respect among the followers. Characteristics of a transformational leader are enthusiastic, persistent, role model, continual learner, risk-taking communicator, visionary, risk-sharing, courageous and mentoring. A leader is expected to have the ability to deal with highly complex situations and ambiguity. Challenges addressed While implementing the change pertaining to CSFMD at the Texas hospital a number of challenges were faced that influenced the success of the initiative and the outcome of the same. The key challenge was, however, the fear and apprehension that the team members showcased. The individuals were reluctant to move from the present position to a new position that demanded a new set of roles and responsibilities. They also feared the loss of their job if the complex technology was being implemented in practice. Lack of coordination was also a prime concern. The members did not support regular meetings held and had a negative attitude towards the leader. A lack of positive attitude was evident as the individuals had a rude behaviour and showed less concern for driving the change. It was challenging on the leaders part to address this scenario. For addressing the barriers cropping up, it was advantageous to apply transformational leadership style in adjunct with Kurt Lewins change management model. The change management model was divided into three stages known as Unfreezing, Management of change and Refreezing. The unfreezing step was beneficial in making the team understand the importance of the implementation of CFSMD technology in the setting. The team was explained that the manual working systems at the hospital were not efficient enough to give adequate output. In addition, it was a time-consuming process and outdated process. The concern of patient safety was also put forward in terms of security management. The reduced revenue generation because of poor services was also brought into notice. The unfreezing stage was further valuable in challenging the beliefs and values of the team members. The advantages of using CSFMD was outlined in details in the manging change phase. At this juncture, the professionals had to be empowered and involved in the team. The third stage of refreezing was marked by initiatives for sustaining the change. This stage witnessed offering reward systems, engaging in feedback provision and celebration of success. This was beneficial for overcoming all barriers in relation to change in practice. Sharing of information was also fostered in this regard. Throughout the process of applying change management model of Kurt, transformational leadership was integral part of it. While demonstrating such leadership, it is the responsibility of the leader to communicate the need for implementing robust technological advances in the setting. The motivational factor driving change was rewards for achieving the newly set target. This step can be criticised and opposed on ethical and humanitarian grounds. In contrast to considering rewards system for successful implementation of change, other motivational aspects should have been relevant, mainly focusing on morales and values (Weib Suib, 2016). Mullen et al., (2017) have criticised transformational leadership and stated that there remains an un-clarity of the components of the leadership style; namely inspirational, intellectual, idealized, and individualized. While a group of scholars support rewards as an ethical inspirational factor, others oppose that gains and benefits coming from rewards are not suitable as inspirational factors. Further, the leader in the present context should have come up with individualistic approaches that suit the temperament and decision-making process of stakeholders. In addition, impression management is also criticised to a considerable extent. Manipulation of the ideas and thoughts of the stakeholders might not have been the appropriate method of bringing about the change (Hillen et al., 2017). It would have been better if the decision was more of a concerted effort of all stakeholders rather than only of the leader. Ethical implications Ethical implications were not considered at the core while bringing about the proposed change in service delivery. There was an absence of adequate consultation with the relevant stakeholders before determining the best possible method of implementing the change. The healthcare consumers, other healthcare professionals and the wider community were not consulted before finalising on the change process of CFSMD. According to Schmitt et al., (2017) a leader is supposed to act in an ethical manner while bringing about a change in the system. This incorporates the valuable input from all stakeholders, both the service users as well as service providers. Pinck and Sonnentag (2017) in this context had stated that decision making process of a healthcare leader must be resting upon the insights provided from perceptions and opinions of stakeholders who would be ultimately effected by the change. Informing the individuals about the proposed change prior to its implementation would not serve th e purpose of being ethical and justified. Outcomes The outcome of the leadership style was in alignment with the objectives of the proposed change. The leader was enabled to overcome the issues regarding change management process. The team members could be encouraged to cover up for the gaps generated in service performance. The team members could also be motivated to have a collaborative approach towards work. The leader was also successful in being ethical and linking the change with the needs of the hospital. The flexible approach was efficient in moving away from the manual system to a better and advanced technology implementation. Problems arising within the team were solved through mutual understanding. Analysis of decisions around the planned change At the core of the change management process lay transformational leadership. Kellly (2012) attacked transformational leadership for being elitist and having disproportionate focus on the heroic aspects of this leadership style. As condemned by the authors, the success of such leadership is always at the expense of the concerns and distress of the followers. Contained in this disparagement is the conception that transformational leaders possess particular traits which others do not have access to. Subsequently, the fate of followers is undeniably fixed to the aspirations of leaders who might be dominant. Northouse (2015) put forward a strong criticism of transformational leadership in the context of organisational settings. In their article, the authors have commented that transformational leaders are much charismatic and it is this aspect that makes leadership mythologizing. The base of this leadership style is not strong as the foundational stone is composed of mere trust and expectations. Taylor (2012) in this ground stated that transformational leadership might not be responsible in a direct manner for increasing the self-efficacy of the individuals in the realm of bringing about change. Trust and respect are to sole two components that drive the followers to act in a manner as desired by the leader. The outcomes of the process might be as per the needs of the leaders, but they are not as per the views of the followers under certain circumstances. Mitchell et al., (2014) further highlighted that undermining transformational leadership is justified. The reason for this is that leaders of this genre might abuse power depending on situations. In light of this, it is also to be highlighted that a section of the followers might be dependent characters forming bonds with the leaders that are not suitable. Further, as the authours note, the leadership lacks the balances of countervailing interests and power effective for avoiding dictatorship. Hillen et al., (2017) argued that the effectiveness of transformational leadership is to be questioned, more specifically the morality of the leadership style. The authors had to opined that leaders with this leadership style motivate the followers through appealing to stronger emotions and the ultimate impact on the followers is not adjudged. Such leaders are to exert a powerful influence over the other individuals who are to offer respect and dignity. Thriving on manipulation and power is not suitable. The manner is which the leadership style is executed is crucial for its success in different settings. Future directions Though transformational leadership have been applied in different healthcare contexts, its suitability is to be adjudged depending on the context in which it is to be applied. In health care settings, transformational leadership might be more of negative outcomes than positive. The followers might be playing a passive role where they would act as dependent variable. Any healthcare professional implementing this leadership style must stick to the essence of the leadership approach. This implies that only positive insights from the leadership style are to be considered (Barr Dowding, 2016). Communication, transparency and ethics are an integral part of the leadership style it is to be made successful. Rather than focusing on the perceptions of the leadership style, the outcomes of the process are to be analysed. Lastly, a healthcare leader might apply transformational leadership in combination with other leadership style to get desired results (Gopee Galloway, 2014). Conclusion Transformational leadership has been successful in diverse range of settings and professions; the health care sector being one. Transformational leadership and its core principles of idealised influence and intellectual stimulation are applicable to healthcare organisations for bringing about change. It is to be highlighted that transformational leaders are responsible for elevating individuals from low levels of need to higher levels while maintaining focus on the need for survival. Collective purposes for all individuals lies at the core of such practice. Such form of leadership when applied to a healthcare setting must consider proper communication between leaders and followers. The success of change proposed on the degree of transparency and clarity maintained while implementing the change through leadership. Collaboration among individuals is only possible when individualised consideration, inspirational motivation and charisma are considered. At a healthcare setting such as Tex as hospital, transformational leadership must look beyond promoting performances and effecting huge changes through traditional methods. The capacity for organizational transformation must be accompanied by moral responsibility, for transformational leaders to outline influential institutional cultures. References Banks, G. C., McCauley, K. D., Gardner, W. L., Guler, C. E. (2016). A meta-analytic review of authentic and transformational leadership: A test for redundancy.The Leadership Quarterly,27(4), 634-652. DOI: https://doi.org/10.1016/j.leaqua.2016.02.006 Barr, J., Dowding, L. (2016). Leadership in health care (3rd ed.). London: Sage. Birasnav, M. (2014). Knowledge management and organizational performance in the service industry: The role of transformational leadership beyond the effects of transactional leadership.Journal of Business Research,67(8), 1622-1629. DOI: https://doi.org/10.1016/j.jbusres.2013.09.006 Gopee, N., Galloway, J. (2014). Leadership and management in health care (2nd ed.). London: Sage. Hillen, H., Pfaff, H., Hammer, A. (2017). The Association between transformational leadership in German hospitals and the frequency of events reported as perceived by medical directors.Journal of Risk Research,20(4), 499-515. DOI: https://dx.doi.org/10.1080/13669877.2015.1074935 Kelly, P. (Eds.). (2012). Nursing leadership management (3rd ed.). Clifton Park, NY: Delmar/Cengage. Mitchell, R., Boyle, B., Parker, V., Giles, M., Joyce, P., Chiang, V. (2014). Transformation through tension: The moderating impact of negative affect on transformational leadership in teams.Human Relations,67(9), 1095-1121. DOI: https://doi.org/10.1177/0018726714521645 Mullen, J., Kelloway, E. K., Teed, M. (2017). Employer safety obligations, transformational leadership and their interactive effects on employee safety performance.Safety science,91, 405-412. DOI: https://doi.org/10.1016/j.ssci.2016.09.007 Northouse, P. G. (2015). Leadership: Theory and practice. U.S.: Sage Publications Pinck, A. S., Sonnentag, S. (2017). Leader Mindfulness and Employee Well-Being: The Mediating Role of Transformational Leadership.Mindfulness, 1-13. DOI: https://doi.org/10.1007/s1267 Richter, A., von Thiele Schwarz, U., Lornudd, C., Lundmark, R., Mosson, R., Hasson, H. (2016). iLeada transformational leadership intervention to train healthcare managers implementation leadership.Implementation Science,11(1), 108. DOI: https://doi.org/10.1186/s13012-016-0475-6 Schmitt, A., Den Hartog, D. N., Belschak, F. D. (2016). Transformational leadership and proactive work behaviour: A moderated mediation model including work engagement and job strain.Journal of Occupational and Organizational Psychology,89(3), 588-610. DOI: 10.1111/joop.12143 Spano-Szekely, L., Griffin, M. T. Q., Clavelle, J., Fitzpatrick, J. J. (2016). Emotional intelligence and transformational leadership in nurse managers.Journal of Nursing Administration,46(2), 101-108. DOI: 10.1097/NNA.0000000000000303. Taylor, V. (Ed.). (2012). Leading for health and wellbeing. London: Sage. Weib, E. E., Sb, S. (2016). The relationship between transformational leadership and effort-reward imbalance.Leadership Organization Development Journal,37(4), 450-466. DOI: https://doi.org/10.1108/LODJ-08-2014-0146