Today physicians and scientists have a detailed understanding of human biology and have developed diagnostic and therapeutic tools that were unimaginable a century ago. Yet physicians have provided ...care and counsel for more than 3000 years. Some, such as Hippocrates and Osler, remain exemplars of the excellent physician. They did not have our scientific knowledge or tools, but they knew something important and performed some task of great value to their patients. What did they know and what did they do? This article explores the questions every ill patient asks, the timeless nature of patient as person, and the forms of non-factual knowing (described as know-how, know-what, know-who, and know-how-it-feels) that are essential to patient care. From this, it is suggested that the combination of understanding, insight, and judgment used for practical action, what Aristotle called "phronesis," is the core competency of excellent physicians which has remained unchanged across the centuries.
Background
Specific data are needed regarding the impact of transfusion on operative complications in pancreatectomy. The objectives of this study were to determine risk factors for transfusion and ...to evaluate the potential association between transfusion and operative complications in elective pancreatectomy procedures.
Study Design
We reviewed our institution’s pancreatectomy and ACS-NSQIP databases. Multivariate analysis was used to determine clinicopathologic risk factors predictive of transfusion, and then a transfusion propensity score was developed to evaluate the impact of transfusion on post-pancreatectomy complications.
Results
Of the 173 patients who were treated from September 2007 to September 2011, 78 patients (45 %) were transfused ≥ 1 unit of blood (median, 3.0 units; range, 1–55). Risk factors for transfusion included increasing Body Mass Index (BMI), smoking, increasing mortality risk score, preoperative anemia, intraoperative blood loss, and benign pathology. After controlling for these risk factors using a transfusion propensity score, transfusion was an independent predictor of increased complications, infectious complications, and hospital costs.
Conclusions
Multiple factors are predictive of transfusion in pancreatectomy, including increasing BMI and smoking. When controlling for transfusion propensity based on these risk factors, RBC transfusion is associated with worse operative outcomes including infectious complications. Development of protocols and strategies to minimize unnecessary transfusion in pancreatectomy are justified.
A renewed emphasis on clinical competence and its assessment has grown out of public concerns about the safety, efficacy, and accountability of health care in the United States. Medical schools and ...residency training programs are paying increased attention to teaching and evaluating basic clinical skills, stimulated in part by these concerns and the responding initiatives of accrediting, certifying, and licensing bodies. This paper, from the Residency Review Committee for Internal Medicine of the Accreditation Council for Graduate Medical Education, proposes a new outcomes-based accreditation strategy for residency training programs in internal medicine. It shifts residency program accreditation from external audit of educational process to continuous assessment and improvement of trainee clinical competence.
Ongoing examination of Panicum sensu lato in the grass tribe Paniceae (Poaceae) has resulted in the need to provide new combinations in Dichanthelium for four species previously assigned to Panicum: ...P. bicknellii Nash, P. filiramum Ashe, P. malacon Nash, and P. pinetorum Swallen. The four species have either been treated as synonyms of other Dichanthelium taxa in recent manuals and monographs, or not treated at all. The new combinations are: Dichanthelium bicknellii (Nash) LeBlond, D. filiramum (Ashe) LeBlond, D. malacon (Nash) LeBlond, and D. pinetorum (Swallen) LeBlond. El examen en curso de Panicum sensu lato en la tribu Paniceae (Poaceae) ha dado como resultado la necesidad de hacer nuevas combinaciones en Dichanthelium para cuatro especies previamente asignadas a Panicum: P. bicknellii Nash, P.filiramum Ashe, P. malacon Nash, y P. pinetorum Swallen. Las cuatro especies han sido tratadas como sinónimos de otros taxa de Dichanthelium en recientes manuales y monografias, no han sido tratadas en absoluto. Las nuevas combinaciones son: Dichanthelium bicknellii (Nash) LeBlond, D. filiramum (Ashe) LeBlond, D. malacon (Nash) LeBlond, y D. pinetorum (Swallen) LeBlond.
Two new species of Dichanthelium are described: Dichanthelium appalachiense from shale woodlands in the mountains of Virginia, with a historical population from Pennsylvania; and Dichanthelium ...harvillii from a mafic region in the Piedmont of Virginia.
Se describen dos especies nuevas de Dichanthelium: Dichanthelium appalachiense de bosques de lutita en las montañas de Virginia, con una población histórica de Pennsylvania; y Dichanthelium harvillii de una región máfica en el piedemonte de Virginia.
OBJECTIVE:
To report a case of international normalized ratio (INR) elevation resulting from the administration of topical methyl salicylate in a patient whose INR was previously stable while she ...received warfarin anticoagulation.
CASE SUMMARY:
A 22-year-old white woman presented with an INR of 12.2 after applying a topical pain-relieving gel to her knees daily for eight days. The potentiation of the warfarin anticoagulation was attributed to the low-dose methyl salicylate contained in the product.
DISCUSSION:
Methyl salicylate is systemically absorbed through the skin in measurable amounts, and may increase warfarin action by affecting vitamin K metabolism or by displacing warfarin from protein-binding sites. While several investigators have reported this interaction with use of high-dose methyl salicylate, this case indicates that a significant interaction can occur with the use of lower topical doses of methyl salicylate as well.
CONCLUSIONS:
Healthcare providers and patients taking warfarin must be aware of the potential hazard of using topical methyl salicylate in combination with warfarin.
Resolution of the systematic relationships of the New England Boneset, Eupatorium novae-angliae, has been elusive. This rare species, known from only 15 sites in Massachusetts and Rhode Island, has ...been demonstrated to be male-sterile and agamospermous, and thus inferred to be polyploid, but its progenitor diploids have not been identified clearly. In a study that hinged on a combination of fieldwork and morphological study together with molecular analysis, we have demonstrated that E. novae-angliae contains ITS repeats characteristic of two sexual diploid species of the genus. One is the widespread E. perfoliatum, the second is a previously unrecognized endemic to clay-based Carolina bay and depression meadow habitats in the Carolinas, that had been included in E. leucolepis and is now recognized as a separate species, E. paludicola. The molecular data highlight the distinctiveness of E. novae-angliae and underscore the need for efforts to continue to protect it in its native habitat.
As part of ongoing work on the Flora of the Southeastern United States (Weakley & Southeastern Flora Team 2023) and related projects, as well as for general floristic, conservation, and scientific ...work in eastern North America, it is essential to document taxonomic and nomenclatural changes and significant distribution records. Here, we propose six new species of graminoids (two Rhynchospora, three Dichanthelium, and one Anatherum)—five from fire-maintained pine savannas and embedded wetlands of the southeastern Coastal Plain and one from the floristically and ecologically related fire-maintained pine savannas of North Andros Island in The Bahamas. We provide rationale and documentation for the “taxonomic resurrection” of Vaccinium ashei, an economically important member of Vaccinium sect. Cyanococcus, based on morphology, estimation of ploidy level with flow cytometry, and phylogenomic analysis based on high-throughput DNA sequencing. We make four new combinations in Convolvulus to accommodate the inclusion of Calystegia in Convolvulus to resolve paraphyly. We also make six new combinations necessary to recognize sect. Leptopogon of Andropogon at generic rank, as Anatherum, based on the phylogenetic work of other researchers and the previously incomplete transfer of recognized species to Anatherum, providing the needed names to recognize this group of species in genus Anatherum in North American floristic treatments. We document the surprising discovery of Carex lutea, previously believed to be endemic to two counties in eastern North Carolina, in two counties in the panhandle of Florida, and a county in eastern South Carolina—discoveries aided by iNaturalist and Facebook. We document new states as being within the distribution ranges of additional species: Quercus similis (Florida), Juncus brachycephalus (Arkansas and Missouri), Rhexia mariana var. mariana (Ohio), Asarum acuminatum and Elionurus tripsacoides (Alabama), and Mecardonia procumbens (Georgia). Other important distributional records, many representing rediscoveries of conservationally significant, extant populations of plants previously considered of only historical occurrence in a state, are also reported: Alabama (Arnica acaulis, Asclepias connivens, Berberis canadensis, Bulbostylis warei, Ctenodon viscidulus, Parnassia grandifolia, and Pinguicula pumila) and Georgia and Florida (Lobelia boykinii).
PDF
