Loading

Fluticasone

Premedication with a corticosteroid or an antipyretic helps to prevent this problem discount fluticasone 500mcg online. Renal impairment 1216 Despite the low levels of the drug excreted in the urine purchase fluticasone line, patients may exhibit a decrease in glomerular filtration rate and renal tubular function generic fluticasone 500 mcg mastercard. Serum creatinine may increase, creatinine clearance can decrease, and potassium and magnesium are lost. Renal function usually returns with discontinuation of the drug, but residual damage is likely at high doses. Azotemia is exacerbated by other nephrotoxic drugs, such as aminoglycosides, cyclosporine, and vancomycin, although adequate hydration can decrease its severity. Sodium loading with infusions of normal saline prior to administration of the conventional formulation or use of the liposomal amphotericin B products minimizes the risk of nephrotoxicity. Hypotension A shock-like fall in blood pressure accompanied by hypokalemia may occur, requiring potassium supplementation. Care must be exercised in patients taking digoxin and other drugs that can cause potassium fluctuations. It is effective in combination with itraconazole for treating chromoblastomycosis. It is also used in combination with amphotericin B for the treatment of systemic mycoses and for meningitis caused by C. Flucytosine can also be used for Candida urinary tract infections when fluconazole is not appropriate; however, resistance can occur with repeated use. Excretion of both the parent drug and metabolites is via glomerular filtration, and the dose must be adjusted in patients with compromised renal function. Reversible hepatic dysfunction with elevation of serum transaminases has been observed. Azole antifungals Azole antifungals are made up of two different classes of drugs—imidazoles and triazoles. Although these drugs have similar mechanisms of action and spectra of activity, their pharmacokinetics and therapeutic uses vary significantly. In general, imidazoles are applied topically for cutaneous infections, whereas triazoles are administered systemically for the treatment or prophylaxis of cutaneous and systemic mycoses. The inhibition of ergosterol biosynthesis disrupts fungal membrane structure and function, which, in turn, inhibits fungal cell growth. Mechanisms of resistance include mutations in the 14-α demethylase gene that lead to decreased azole binding and efficacy. Additionally, some strains of fungi develop efflux pumps that pump the drug out of the cell or have reduced ergosterol in the cell wall. Patients on concomitant medications that are substrates for this isoenzyme may have increased concentrations and risk for toxicity. Contraindications Azoles are considered teratogenic, and they should be avoided in pregnancy unless the potential benefit outweighs the risk to the fetus. It is the least active of all triazoles, with most of its spectrum limited to yeasts and some dimorphic fungi. It is highly active against Cryptococcus neoformans and certain species of Candida, including C. Fluconazole is used for prophylaxis against invasive fungal infections in recipients of bone marrow transplants. It is the drug of choice for Cryptococcus neoformans after induction therapy with amphotericin B and flucytosine and is used for the treatment of candidemia and coccidioidomycosis. It is well absorbed after oral administration and distributes widely to body fluids and tissues. The majority of the drug is excreted unchanged via the urine, and doses must be reduced in patients with renal dysfunction. The most common adverse effects with fluconazole are nausea, vomiting, headache, and skin rashes. Itraconazole is a drug of choice for the treatment of blastomycosis, sporotrichosis, paracoccidioidomycosis, and histoplasmosis. It is rarely used for treatment of infections due to Candida and Aspergillus species because of the availability of more effective agents. The capsule and tablet should be taken with food, and ideally an acidic beverage, to increase absorption. By contrast, the solution should be taken on an empty stomach, as food decreases the absorption. Itraconazole is extensively metabolized by the liver, and the drug and inactive metabolites are excreted in the urine and feces. Adverse effects include nausea, vomiting, rash (especially in immunocompromised patients), hypokalemia, hypertension, edema, and headache. Liver toxicity can also occur, especially when given with other hepatotoxic drugs. Itraconazole has a negative inotropic effect and should be avoided in patients with evidence of ventricular dysfunction, such as heart failure. Posaconazole is commonly used for the treatment and prophylaxis of invasive Candida and Aspergillus infections in severely immunocompromised patients. Because of its broad spectrum of activity, posaconazole is used in the treatment of invasive fungal infections caused by Scedosporium and Zygomycetes. Drugs that increase gastric pH (for example, proton pump inhibitors) may decrease the absorption of oral posaconazole and should be avoided if possible. Voriconazole has replaced amphotericin B as the drug of choice for invasive aspergillosis. It is also approved for treatment of invasive candidiasis, as well as serious infections caused by Scedosporium and Fusarium species. Inhibitors and inducers of these isoenzymes may impact levels of voriconazole, leading to toxicity or clinical failure, respectively. High trough concentrations have been associated with visual and auditory hallucinations and an increased incidence of hepatotoxicity. Drugs that are substrates of these isoenzymes are impacted by voriconazole (ure 33. Because of significant interactions, use of voriconazole is contraindicated with many drugs (for example, rifampin, rifabutin, carbamazepine, and St. Isavuconazole has a spectrum of activity similar to voriconazole and is approved for invasive aspergillosis and invasive mucormycosis. Isavuconazonium has high bioavailability after oral administration and distributes well into tissues. Echinocandins Echinocandins interfere with the synthesis of the fungal cell wall by inhibiting the synthesis of β(1,3)-D-glucan, leading to lysis and cell death.

However order fluticasone cheap, there is a need for properly energy is generated from rapid vibrations of a blade or designed and powered comparative studies to guide sur­ shears at the tip of the instrument generic 100 mcg fluticasone with mastercard, causing water to evap­ geons regarding the most effective and safe modes of orate from the tissues at a low temperature buy discount fluticasone online. Laser energy in minimal access gynaecological surgery the other mechanism it uses is stretching of the tissue by has diminished with the advent of the newer, easier to the blade edge, causing friction and generating heat, cut­ use and cheaper energy modalities described here. The advantage of the ultrasonic scalpels compared with electrosurgery is the reduction in tissue Photo and video documentation charring, desiccation and spread of thermal energy, low­ ering the risk of inadvertent injury to other structures. The universal use of video cameras at endoscopic sur­ Devices are now also available that combine both gery lends itself to recording still images, short excerpts advanced bipolar electrosurgery with ultrasonic energy. Photographs Advanced bipolar devices and ultrasonic energy are clinical records that can be discussed with the patient appear to provide more rapid and bloodless operating as well as colleagues if a second opinion is sought. To date, recordings are excellent for teaching, and can also be 522 Basic Science used for research, to measure performance and to assess (e. Hyskon, can also help with the understanding of operative com­ which is 32% dextran 70 in dextrose) can be used. Normal plications and are increasingly useful with regard to saline is most frequently used for diagnostic hysteros­ complaints and negligence claims. The choice of fluid distension media for operative hysteroscopy depends on the type of instrumentation; physiological Equipment for hysteroscopy media, namely normal saline, should be preferred when using mechanical instruments. Resectoscopic electro­ surgery traditionally required the use of electrolyte‐free Direct imaging within the uterine cavity utilizing hyster­ oscopy requires an endoscope, outer sheath(s) for pas­ solutions such as glycine, sorbitol or mannitol because sage of distension media, a light lead and camera relaying they employed monopolar electrical circuits. An enlarged can be undertaken using rigid hysteroscopes whereas non‐compliant uterus, leakage of distension medium flexible hysteroscopes are restricted to diagnosis. Rigid through the cervix or excessive suction when using a hysteroscopes generally have a Hopkins rod‐lens optical system whereas flexible and very narrow rigid hystero­ continuous flow system will mean that a higher inflow scopes contain optical fibres. The desired distension is achieved by using gravity, pressure bags or special hysteroscopic Rigid hysteroscopes come in different sizes in terms of their outer diameter, 2. The distal lens can be straight or oblique, the most frequently used being 0° and 30° angles of view. Oblique lenses have the advantage of a wider field of view, ena­ Mechanical instruments bling diagnosis and facilitating operative procedures as instrumentation can be visualized under higher magnifi­ Miniature flexible or semi‐rigid mechanical instruments cation. Diagnostic procedures can be performed using a such as scissors, grasping and biopsy forceps can be used single outer sheath fitted around the optic to allow irri­ with operating sheaths for minor procedures such as tar­ gation of fluid or gas distension media thereby achieving get biopsy or polypectomy. Continuous flow permits simultane­ fragile because of their size, typically 7 or 5 French gauge ous irrigation/suction and tends to be used for surgery (3 Fr = 1 mm), so replacements should be available should where removal of blood and tissue debris is necessary to they break. On the plus side, they are very unlikely to maintain visualization within the uterine cavity. Most diagnostic and operative hystero­ the late 1990s; the Versapoint™ Bipolar Electrosurgery scopic set‐ups are less than 5. As these the uterine cavity is a potential space and has to be dis­ electrodes are bipolar, physiological solutions such as tended at relatively high pressure to afford a panoramic normal saline and Hartmann’s solution can be used view. Spring‐tip electrode suitable for removing polyps, and grade 0 fibroids) is shown with the electrosurgical generator. A needle‐like twizzle‐tip electrode is also available (not shown) for removing polyps, septa, and adhesions. The flow of electricity is limited to the distal tip of the electrode with current circulating between the distal active and slightly more proximal pas­ sive return surfaces. The electrodes are versatile because they can be passed down the 5 Fr working channel of any standard operative hysteroscope. Resectoscopes Hysteroscopic resectoscopes are used to resect or ablate the endometrium and excise focal lesions such as polyps and fibroids, remove septa and lyse adhesions. Originally the resectoscopes used a monopolar electrode but advances in technology have led to the development of equally effective bipolar resectoscopes that have the safety advantage of using isotonic distension media with reduced risks of serious complications arising from fluid overload and induced hypervolaemic hyponatraemia. The modern resectoscope consists of five components: the optic, handle mechanism, inflow and outflow sheaths. Key components include the optic, handle be active or passive in design; for hysteroscopy, a passive mechanism, inflow and outflow sheaths, and loop electrode. The vast majority of gynaecologists prefer a multi‐puncture approach with Tissue removal systems are the most recent technological instruments inserted through ancillary ports usually sited advance in hysteroscopic surgery. Ancillary to provide simultaneous mechanical cutting and tissue port sites are usually 5–15 mm depending on the diameter retrieval thereby maintaining better views during surgi­ of the instruments to be accommodated. More recently, cal procedures within the uterine cavity and avoiding the miniature surgical instruments, typically with diameters use of more hazardous thermal energy. Each tube incorporates a create a pneumoperitoneum at laparoscopy, most com­ small aperture or ‘window’ distally through which monly inserted at the umbilicus. The Veress needle is removed tissue is extracted by the application of external usually inserted transabdominally, but in obese patients suction tubing; the removed tissue is then trapped in a can be introduced through the uterine fundus or vagina tissue collector. This may reduce the incidence of major More recently, the Symphion™ (Boston Scientific, Natick, vessel injury though not bowel injury [10]. They generally con­ sist of a hollow transparent trocar in which is loaded a 0° laparoscope [11]. Equipment for laparoscopy Laparoscopes Trocars and cannulae Laparoscopes are built around a rod‐lens system that Trocars and cannulae act as conduits for the laparoscope transmits images to the camera. They come in a variety of sizes laparoscopes are also available but are more fragile and depending on the diameter of the instrumentation to be provide an inferior image. Laparoscopes come in a accommodated, with 5mm and 10–12mm ports being range of diameters (3–12mm) and various angles of the most commonly used. The 10‐mm 0° laparoscope is most widely made of steel, are reusable and are sharp‐tipped. Ambulatory Gynaecology, Hysteroscopy and Laparoscopy 525 there are a host of disposable trocars and cannulae with Laparoscopic insufflator modifications to optimize performance. A recent One of the great advantages of laparoscopy over open Cochrane review comparing visceral and vascular com­ surgery is superior visualization of the anatomy. Mini‐laparoscopy is performed used because it is odourless, non‐combustible, cheap, through 3. Insufflators control intra‐abdominal pressure satisfactory and this approach has the advantage of bet­ rather than flow, and this should be set at 12–15 mmHg ter cosmetic results and a lower incidence of postopera­ (1. This technique uses a single umbilical port that is adapted such that not only a laparoscope but additional operating Suction/irrigation pump instruments can be passed. Bespoke multi‐access ports are available with expandable retractors and even home‐ the provision of suction (negative pressure aspiration) made designs with a surgical glove attached to the port and irrigation (instillation of fluid under pressure) helps and instruments passed through small incisions in the maintain visualization within the operative field. Robotic laparoscopic surgery They can be atraumatic, suitable for holding delicate structures such as fallopian tubes, bladder and bowel, or Robotic‐assisted laparoscopic surgery has been utilized traumatic to ensure a firm grip of more robust tissue, in gynaecology as an alternative to standard ‘straight such as when performing ovarian cystectomies. The da Vinci® surgical system Sharp curved laparoscopic scissors are the other essential (Intuitive Surgical Inc. Robotic surgery may offer several advantages in gynaecology, including mag­ nified three‐dimensional vision, wristed instruments that aid dexterity and precision, and less fatigue and reduced back and shoulder injuries for surgeons because they can operate sitting down at a console [12]. There remains a lack of robust randomized controlled trial data on robotic surgery compared with standard multi‐ port laparoscopy and at present, in the absence of com­ pelling evidence of improved effectiveness, the costs associated with robotic surgery for the most part remain prohibitive [13,14].

purchase fluticasone mastercard

Abnormal (Vaccinium macrocarpon) preparation in reducing sensitivity to intravesical potassium in interstitial asymptomatic bacteriuria in patients with an ileal cystitis and radiation cystitis buy fluticasone with paypal. Ask about any other skin affect the vulva and to refer for dermatological advice problems cheap fluticasone 500mcg without a prescription, either past or present buy 500mcg fluticasone visa, and also specifi­ and management appropriately. Do they have multidisciplinary team have been established to provide any known allergies? If the patient has been problems that affect the vulva and the basic principles of pregnant, were deliveries straightforward or compli­ initial management. The history relating to cervical smears and any abnormalities or treatment is important, particularly in patients with vulval intraepithelial neoplasia, where cervical intraep­ History‐taking ithelial neoplasia is frequently associated. A clear method of history‐taking should be used, Loss of libido is common with any dermatological con­ and a proforma can be helpful to ensure that the key dition of the vulva, and psychosexual factors frequently areas are covered. The interview should take place in a sympathetic envi­ ● General medical history: underlying medical conditions ronment and it is often helpful to enquire about the gen­ can be relevant to some vulval problems, i. Patients may report ‘irritation’ but this should always be qualified, as irritation is not always synonymous with itching. It is Examination helpful to ask if they want to scratch to alleviate the symptoms, as if they say no, then itch is not the problem. The examination should always be carried out with a Is the itching constant or intermittent and are there any trained chaperone present. The vulva can be adequately Dewhurst’s Textbook of Obstetrics & Gynaecology, Ninth Edition. The vulva is first examined overall but the labia majora need to be separated in order to adequately visualize the internal structures of the vulva. An examination of the skin at extragenital sites will often give valuable diagnostic information and inspection of the oral mucosa, eyes, scalp, nails and other flexural sites is important. Normal variants There are some very common and important normal variants seen on examination of the vulva. They are a normal variant and do keratinized epithelia of the labia minora and vestibule, not require any treatment. Fordyce spots These are small sebaceous papules found on the inner Vestibular papillae surfaces of the labia minora. They can be very A common finding is the presence of tiny filiform projec­ prominent in some women and may also be seen on the tions on the inner labia minora and vestibule. Benign Diseases of the Vulva 797 Normal physiological changes Childhood In the first few weeks of life, the vulva is under the influ­ ence of maternal hormones. The clitoral hood and labia minora are relatively prominent and may be seen with­ out separation of the labia majora. Puberty Deposition of fat increases the size of the labia majora and mons pubis, and pubic hair appears. Post menopause the labia majora become less prominent and there is a reduction in hair growth. Biopsy This is a very simple procedure that can be performed in the outpatient clinic under local anaesthesia. Clinicopathological correlation is vital in all cases of vulval dermatoses, and review by a dermatopathologist is very helpful. In cases where an autoimmune bullous disorder is suspected, a biopsy should also be taken for direct immunofluorescence. Microbiological investigation Appropriate swabs and transport media for bacterial, yeast and viral culture may be needed. In children, constipation is a frequent fea­ Patch testing ture if the perianal area is affected. This is performed where an allergic contact dermatitis is the early lesions are white ivory papules that may suspected, either as a primary problem or where it is a coalesce to form plaques. Ecchymosis due to rupture secondary phenomenon caused by an allergy to treat­ of dermal vessels is common, as is oedema. Patients need to be referred to a dermatologist for Ecchymosis is common in children and often leads to the these tests, which should include specific allergens that erroneous diagnosis of sexual abuse. As the disease progresses, scarring occurs with loss of the labia minora, which become fused to the labia Inflammatory diseases of the vulva majora. Introital narrowing can lead to Lichen sclerosus difficulties with intercourse and dyspareunia if the skin splits. The vagina is not involved in lichen sclerosus and Lichen sclerosus is an inflammatory dermatosis with a this may be a useful distinguishing feature from lichen predilection for the anogenital skin [2]. The only exception to this is where there is a sig­ more common in women than men. Extragenital lesions nificant vaginal prolapse, where the epithelium becomes may be seen in about 10% of women with genital involve­ keratinized and lichen sclerosus can then develop on this ment. Aetiology the aetiology remains unclear but it is thought that it is mediated by a lymphocyte reaction. Immunohistochemical alterations of the epidermis and dermis support an auto­ immune cause and circulating IgG antibodies to extracel­ lular matrix proteins have been demonstrated. There is an association in both the patient and their first‐degree relatives with other autoimmune diseases, particularly thyroid disorders. Flat showing rubbery oedema of labia minora and clitoral hood and white lesions which can coalesce into plaques. This may present as a small persistent erosion or ulcer, a hyperkeratotic area or fleshy friable papule or nodule. Here the squamous cell carcinoma presents as a fleshy Treatment nodule, but persistent erosion should also prompt biopsy. Ongoing treatment may be required by some patients to Surgery is only required to treat the scarring complications 800 Benign Gynaecological Disease or if there is neoplastic or pre‐neoplastic change. Topical calcineurin inhibitors are increasingly popular but should not be used first line as there are concerns about their long‐term safety in relation to the development of malignancy. In those with resistant symptoms, it is important to exclude an allergic contact dermatitis to treatment, irri­ tant dermatitis due to urinary incontinence, or an addi­ tional problem such as herpes simplex or candidiasis. A proportion of patients will develop vulvodynia after their lichen sclerosus is well controlled. Treatment must be targeted at this rather than increasing the use of topical steroids. These may occur in isolation without the presence of dis­ ● Any resistant areas, ulcers or hyperkeratotic lesiors ease at other sites. The char­ the vulva, vagina and gingival margins [7], with specific acteristic cutaneous lesions are small purplish papules, genetic associations. The lacrimal duct, external audi­ which may exhibit a fine lace‐like network over their sur­ tory meatus and oesophagus can also be involved and face known as Wickham’s striae. These can also be seen disease at these sites needs a multidisciplinary approach on mucosal lesions. The vulval lesions mainly affect the inner labia minora the nails can show pterygium formation and scalp and vestibule where erythema and erosions occur lesions can result in a scarring alopecia. A lacy white edge is seen and this is the Histology shows irregular acanthosis with a saw‐ best site for a confirmatory biopsy.

generic 250mcg fluticasone otc

In the initial evaluation period fluticasone 100mcg without a prescription, it is important to evaluate respiratory status as well as peripheral perfusion cheap fluticasone american express. Poor oxygenation can be a sign of frankly restrictive respiratory physiology secondary to a burned torso order fluticasone 100mcg without prescription, and acute limb ischemia can also develop from a badly burned limb. Torso escharatomies will improve excursion of the chest wall, and limb escharatomies alleviate the functional venous tourniquet of a significant burn, equivalent to a fasciotomy for acute compartment syndrome. On the torso, escharotomy incisions are made along the anterior axillary line and connect at the level of the second rib and the xyphoid. In rare situations, orbital pressures can be elevated secondary to retro-orbital edema, necessitating lateral canthotomies. Abdominal Compartment Syndrome the inflammatory cascade and changing oncotic pressures in a patient with an acute burn undergoing resuscitation can lead to abdominal compartment syndrome. Abdominal hypertension is typically first identified by decreased urine output and restrictive airway dynamics. Transurethral bladder pressures in a chemically paralyzed patient greater than 20 cm H O are considered diagnostic for abdominal hypertension. Low-voltage (less than 1,000 V) injuries create thermal burns, injuring tissue from the outside in, whereas high voltage (greater than 1,000 V) can initially be deceiving in their devastation because a significant portion of the injury is not cutaneous but rather to the underlying muscle and bone. Very high-voltage injuries will have both extensive deep tissue injury and obvious cutaneous injury [37]. Immediate life-threatening conditions related to electrical injuries include cardiac dysrhythmias and spinal cord injury, either from direct injury, fall, or because of tetany resulting in spinal column fracture and cord injury. Exit and entry wounds should be identified when possible, because this will help identify potentially affected tissue. Compartment syndrome from myonecrosis is common, especially in the upper extremity, and patients should be monitored closely for this complication in the first 24 hours. Limbs injured by electricity with resultant compartment syndrome require fasciotomies rather than simple escharotomies [38]. Aggressive fluid resuscitation should be initiated quickly to limit the renal effects of myonecrosis and myoglobinuria. Maintaining high urine output can help prevent kidney injury associated with myoglobin crystallization in the renal tubules. Acids in turn burn by coagulation necrosis and as such are typically more superficial in their penetration of tissue [40]. Self-immolation accounts for only 4% of burn admission; however, these patients present complex patient care problems, because there is typically significant psychopathology that may hinder recovery [43]. Adequate pain control during their hospitalizations and during dressing changes has been shown to limit the long-term psychiatric effects of burn trauma [44]. Once the burn has been treated, wounds closed, and shock resolved, tapering of sedatives and narcotics can be initiated such that the patient may be weaned from the ventilator and avoid withdrawal symptoms. Among patients with extremity burns, long-acting regional anesthetics may be beneficial for pain control and permit better burn care and therapy. Khatib M, Jabir S, Fitzgerald O’Connor E, et al: A systematic review of the evolution of laser Doppler techniques in burn depth assessment. Peeters Y, Vandervelden S, Wise R, et al: An overview on fluid resuscitation and resuscitations endpoints in burns: past, present and future. Lawrence A, Faraklas I, Watkins H, et al: Colloid administration normalizes resuscitation ratio and ameliorates “fluid creep. Tao L, Zhou J, Gong Y, et al: Risk factors for central line-associated bloodstream infection in patients with major burns and efficacy of the topical application of mupirocin at the Central Venous Catheter Exit Site. Peeters Y, Lebeer M, Wise R, et al: An overview on fluid resuscitation and resuscitation endpoints in burns; past, present and future. Part 2- avoiding complications by using the right endpoints with a new personalized protocolized approach. Schmauss D, Rezaeian F, Finck T, et al: Treatment of secondary burn wound progression in contact burns-a systematic review of experimental approaches. Hu S, Liu W-W, Zhao Y, et al: Pyruvate-enriched oral rehydration solution improved intestinal absorption of water and sodium during enteral resuscitation in burns. Nunez-Villaveiran T, Sanchez M, Millan P, et al: Systematic review of the effect of propanolol on hypermetabolism in burn injuries. Breederveld R, Tuinebreijer W: Recombinant human growth hormone for treating burns and donor sites (Review). Li H, Guo Y, Yang Z, et al: the efficacy and safety of oxandrolone treatment for patients with severe burns: a systematic review and meta-analysis. Kurmis R, Greenwood J, Aromataris E: Trace element supplementation following severe burn injury: a systematic review and meta-analysis. Wise R, Jacobs J, Pilate S, et al: Incidence and prognosis of intra- abdominal hypertension and abdominal compartment syndrome in severely burned patients: pilot study and review of the literature. Saracoglu A, Kuzucuoglu T, Yakupoglu S, et al: Prognostic factors in electrical burns: a review of 101 patients. Wang X, Zhang Y, Ni L, et al: A review of treatment strategies for hydrofluoric acid burns: current status and future prospects. Sveen J, Ekselius L, Gerdin B, et al: A prospective longitudinal study of posttraumatic stress disorder symptom trajectories after burn injury. Entirely new therapies are possible for grave diseases, such as low tidal volume strategies for acute lung injury or early antimicrobial therapy for sepsis [3–5]. Meanwhile, a designated credentialed provider always must be responsible for the overall care plan and occasionally adjudicate differences of opinion regarding difficult decisions, or reconcile conflicting recommendations from key team members. The conflicts arise not only from uncertainties about outcomes but also about what is understood as success. The American College of Critical Care Medicine has described three levels of hospital-based critical care centers to optimally match services and personnel with community needs [7]: 1. They require the continuous availability of sophisticated equipment, specialized nurses, and physicians with critical care training. The combination of caring for acutely ill patients, end-of-life decision- making, and coordination of large interprofessional teams can lead to frustration, communication breakdown, and discord among members of the health care team. Conflict has been associated with lower quality patient care [12,13], higher rates of serious medical errors [14], staff burn out [15,16], and greater direct and indirect costs of care [17]. Two dominant mechanisms were also described and categorized in their analysis as “the perception of ownership” and the “process of trade. Individual ownership is also a dominant issue and includes instances where members recognized their own or other’s skill; this recognition is part of the smooth collaborative functioning of the team. When ownership is not attended to, or one commodity is not offered in trade for another, tensions accumulate and collaboration is compromised [9]. The Surgeon’s Perspective the qualities that define a surgical personality have been described by anthropologist Joan Cassell [18] as decisiveness, control, confidence, and certitude.

By W. Reto. Jamestown College.

Jaga