Timing of tracheostomy, weaning from mechanical ventilation and duration of hospitalization among a sample of pediatric patients

@#<p><strong>OBJECTIVE: </strong>To determine if there is a difference in the duration of mechanical ventilation and hospitalization between patients who underwent early compared to late tracheostomy.</p><p><strong>METHODS:</strong></p><p><strong>Design:    </strong>            Causal-Comparative (ex post facto) Chart Review</p><p><strong>Setting:    </strong>            Tertiary National University Hospital</p><p><strong>Participants:       </strong>            Records of 68 pediatric patients who underwent elective tracheostomy from January 1, 2013 to June 30, 2018 were considered for inclusion. Patients were excluded if invasive mechanical ventilation was not done prior to tracheostomy, if they underwent emergency tracheostomy or had incomplete records. Selected patients were categorized in the early tracheostomy group if the procedure was performed within 14 days of mechanical ventilation and late tracheostomy group if performed beyond 14 days. Early post-tracheostomy weaning from mechanical ventilation was defined as less than 7 days from time of tracheostomy.</p><p><strong>RESULTS:</strong> A total of 21 patients were included, 6 in the early tracheostomy group and 15 in the late tracheostomy group. Although early tracheostomy did not show significant association with shortened post-tracheostomy duration of mechanical ventilation (O.R. 6; C.I. 0.276 to 130.322; p = .476), two-sample t-tests showed the early tracheostomy group had a significantly shorter mean duration of mechanical ventilation and hospitalization compared to the late tracheostomy group (13.17 vs. 54.13 days, p = .0012; 21.17 vs. 66.67 days, p = .0032).</p><p><strong>CONCLUSION:</strong> Although early tracheostomy does not shorten post-tracheostomy mechanical ventilation support, there is a significant difference in the duration of mechanical ventilation and hospitalization between early and late tracheostomy groups and this may suggest potential benefits of performing tracheostomy earlier in children.</p><p> </p><p><strong>KEYWORDS:</strong> tracheotomy; pediatric; mechanical ventilation; hospitalization</p>

Open Access: DOAJ and Plan S, Digitization and Disruption

@#<p>"Those with access to these resources -- students, librarians, scientists -- </p><p>you have been given a privilege. You get to feed at this banquet of knowledge </p><p>while the rest of the world is locked out. But you need not -- indeed, morally, </p><p>you cannot -- keep this privilege for yourselves. You have a duty to share it </p><p>with the world."</p>Aaron Swartz1 (who killed himself at the age of 26,<p>facing a felony conviction and prison sentence</p><p>for downloading millions of academic journal articles)</p><p> </p><p>The Philippine Journal of Otolaryngology Head and Neck Surgery was accepted into the Directory of Open Access Journals (DOAJ) on October 9, 2019. The DOAJ is "a community-curated online directory that indexes and provides access to high quality, open access, peer-reviewed journals"2 and is often cited as a source of quality open access journals in research and scholarly publishing circles that has been considered a sort of "whitelist" as opposed to the now-defunct Beall's (black) Lists.3</p><p>As of this writing, the DOAJ includes 13,912 journals with 10,983 searchable at article level, from 130 countries with a total of 4,410,788 articles.2 Our article metadata is automatically supplied to, and all our articles are searchable on DOAJ. Because it is OpenURL compliant, once an article is on DOAJ, it is automatically harvestable. This is important for increasing the visibility of our journal, as there are more than 900,000 page views and 300,000 unique visitors a month to DOAJ from all over the world.2 Moreover, many aggregators, databases, libraries, publishers and search portals (e.g. Scopus, Serial Solutions and EBSCO) collect DOAJ free metadata and include it in their products. The DOAJ is also Open Archives Initiative (OAI) compliant, and once an article is in DOAJ, it is automatically linkable.4 </p><p>Being indexed in DOAJ affirms that we are a legitimate open access journal, and enhances our compliance with Plan S.5 The Plan S initiative for Open Access publishing launched in September 2018 requires that from 2021, "all scholarly publications on the results from research funded by public or private grants provided by national, regional, and international research councils and funding bodies, must be published in Open Access Journals, on Open Access Platforms, or made immediately available through Open Access Repositories without embargo."5 Such open access journals must be listed in DOAJ and identified as Plan S compliant.</p><p>There are mixed reactions to Plan S. A recent editorial observes that subscription and hybrid journals (including such major highly-reputable journals as the New England Journal of Medicine, JAMA, Science and Nature) will be excluded,6 quoting the COAlition S argument that "there is no valid reason to maintain any kind of subscription-based business model for scientific publishing in the digital world."5 As Gee and Talley put it, "will the rise of open access journals spell the end of the subscription model?"6</p><p>If full open access will be unsustainable for such a leading hybrid medical journal as the Medical Journal of Australia,6 what will happen to the many smaller, low- and middle-income country (southern) journals that cannot sustain a fully open-access model? For instance, challenges facing Philippine journals have been previously described.7 </p><p>According to Tecson-Mendoza, "these challenges relate to (1) the proliferation of journals and related problems, such as competition for papers and sub-par journals; (2) journal funding and operation; (3) getting listed or accredited in major citation databases; (4) competition for papers; (5) reaching a wider and bigger readership and paper contribution from outside the country; and (6) meeting international standards for academic journal publications."7  Her 2015 study listed 777 Philippine scholarly journals, of which eight were listed in both the (then) Thomson Reuters (TR) and Scopus master lists, while an additional eight were listed in TR alone and a further twelve were listed in Scopus alone.7 To date, there are 11,207 confirmed Philippine periodicals listed on the International Standard Serial Number (ISSN) Portal,8 but these include non-scientific and non-scholarly publications like magazines, newsletters, song hits, and annual reports. What does the future have in store for small scientific publications from the global south?</p><p>I previously shared my insights from the Asia Pacific Association of Medical Journal Editors (APAME) 2019 Convention (http://apame2019.whocc.org.cn) on the World Association of Medical Editors (WAME) Newsletter, a private Listserve for WAME members only.9 These reflections on transformation pressures journals are experiencing were the subject of long and meaningful conversations with the editor of the Philippine Journal of Pathology, Dr. Amado Tandoc III during the APAME 2019 Convention in Xi'an China from September 3-5, 2019. Here are three main points:</p>the <strong>real need for and possibility of joining forces</strong>- for instance, the Journal of the ASEAN Federation of Endocrinology Societies (JAFES) currently based in the Philippines has fully absorbed previous national endocrinology journals of Malaysia and the Philippines, which have ceased to exist.  While this merger has resulted in a much stronger regional journal, it would be worthwhile to consider featuring the logos and linking the archives of the discontinued journals on the JAFES website. Should the Philippine Journal of Otolaryngology Head and Neck Surgery consider exploring a similar model for the ASEAN Otorhinolaryngological - Head and Neck Federation? Or should individual specialty journals in the Philippines merge under a unified Philippine Medical Association Journal or the National Health Science Journal Acta Medica Philippina? Such mergers would dramatically increase the pool of authors, reviewers and editors and provide a sufficient number of higher-quality articles to publish monthly (or even fortnightly) and ensure indexing in MEDLINE (PubMed).the migration from cover-to-cover traditional journals (contents, editorial, sections, etc.) to publishing platforms (e.g. <strong>should learned Philippine societies and institutions consider establishing a single platform instead of trying to sustain their individual journals</strong>)? Although many scholarly Philippine journals have a long and respectable history, a majority were established after 2000,7 possibly reflecting compliance with requirements of the Commission on Higher Education (CHED) for increased research publications. Many universities, constituent colleges, hospitals, and even academic and clinical departments strove to start their own journals. The resulting journal population explosion could hardly be sustained by the same pool of contributors and reviewers.<p>In our field for example, faculty members of departments of otorhinolaryngology who submitted papers to their departmental journals were unaware that simultaneously submitting these manuscripts to their hospital and/or university journals was a form of misconduct. Moreover, they were not happy when our specialty journal refused to publish their papers as this would constitute duplicate publication. The problem stemmed from their being required to submit papers for publication in department, hospital and/or university journals instead of crediting their submissions to our pre-existing specialty journal. This escalated the tension on all sides, to the detriment of the new journals (some department journals ceased publication after one or two issues) and authors (whose articles in these defunct journals are effectively lost).</p><p>The older specialty journals are also suffering from the increased number of players with many failing to publish their usual number of issues or to publish them on time. But how many (if any at all) of these journals (especially specialty journals) would agree to yield to a merger with others (necessitating the end of their individual journal)? Would a common platform (rather than a common journal) provide a solution?</p>more radically, <strong>the individual journal as we know it today (including the big northern journals) will cease to exist</strong>- as individual OA articles (including preprints) and open (including post-publication) review become freely available and accessible to all. However proud editors may be of the journals they design and develop from cover to cover, with all the special sections and touches that make their "babies" unique, readers access and download individual articles rather than entire journals. A similar fate befell the music industry a decade ago. From the heyday of vinyl (33 and 78 rpm long-playing albums and 45 rpm singles) and 8-tracks, to cassettes, then compact disks (CD's) and videos, the US recorded music industry was down 63% in 2009 from its peak in the late 70's, and down 45% from where it was in 1973.10 In 2011, DeGusta observed that "somewhat unsurprisingly, the recording industry makes almost all their money from full-length albums" but "equally unsurprising, no one is buying full albums anymore," concluding that "digital really does appear to have brought about the era of the single.10 As McDowell opines, "In the end, the digital transforms not only the ability to disrupt standard publishing practices but instead it has already disrupted and continues to break these practices open for consideration and transformation."11<p>Where to then, scientific journals? Without endorsing either, will Sci-Hub (https://sci-hub.se) be to scholarly publishing what Spotify (https://www.spotify.com) is to the music industry? A sobering thought that behooves action.</p>

Authorship Controversies: Gift, Guest and Ghost Authorship

@#<p>Authorship, "the state or fact of being the writer of a book, article, or document, or the creator of a work of art,"1 derives from the word author, auctor, autour, autor "father, creator, one who brings about, one who makes or creates," from Old French auctor, acteor "author, originator, creator, instigator," directly from the Latin auctor "promoter, doer; responsible person, teacher," literally "one who causes to grow."2  It implies a creative privilege and responsibility that cannot be taken lightly.  In the biomedical arena, the International Committee of Medical Journal Editors (ICMJE) "recommends that authorship be based on the following four criteria: 1. Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND 2. Drafting the work or revising it critically for important intellectual content; AND 3. Final approval of the version to be published; AND 4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved."3</p><p> </p><p>Thus, all persons designated as authors should qualify for authorship, and all those who qualify as authors should be so listed.3 The first of these general principles means that all persons listed as authors should meet the four ICMJE criteria for authorship; the second principle means that all those who meet the four ICMJE criteria for authorship should be listed as authors.3 The first part of the statement disqualifies honorific "gift" authors, complementary "guest" authors, and anonymous "ghost" authors from being listed as authors. The second part ensures the listing of all those who qualify as authors, even if they are no longer part of the institution or group from which the work emanates (such as students who have graduated or residents and fellows who have completed their postgraduate training).</p><p> </p><p>Honorific or "gift" authorship takes place when a subordinate (or junior) person lists a superior (or senior) person as an author, even if that person did not meet the four ICMJE authorship criteria.4,5 Bestowing the gift on a Chief, Chair, Department Head, Director, Dean, or such other person is often done in gratitude, but carries an unspoken expectation that the favor will be returned in the future. It can also be bestowed under coercive conditions (that may overlap with those of guest authorship discussed next).4.5 It is unethical because the gifted person does not qualify for authorship when at most only acknowledgement is his or her due. In the extreme, such a person can be put in the uncomfortable and embarrassing situation of being unable to comment on the supposedly co-authored work when asked to do so. Moreover, the unqualified co-author(s) may actually attempt to wash their hands of any allegations of misconduct, claiming for example that the resident first author "plagiarized the material" or "fabricated or manipulated the data" but "I/we certainly had nothing to do with that" - - hence the fourth criterion for authorship came to be.3 Reviewers and Editors may suspect "gift" authorship when for instance, a resident listed as first author writes the paper in the first person, using the pronoun "I" instead of "we" and thanks the consultant co-author under the "acknowledgements" section. The suspicions are further reinforced when the concerned co-author(s) do not participate in, or contribute to revising the manuscript critically for important intellectual content during the review and editing process.</p><p> </p><p>Guest authorship takes place when influential or well-known individuals "lend" their name to a manuscript to boost its prestige, even though they had nothing to do with its creation.6,7 They may have been invited to do so by one or more of the actual authors, but they willingly agree, considering the arrangement mutually-beneficial. Thus, a student or resident may knowingly invite an adviser or consultant to be listed as co-author, even if the latter did not meet authorship criteria. The former perceives that having a known co-author increases the chances of a favorable review and publication; the latter effectively adds another publication to his or her curriculum vitae. It is not difficult to see how such symbioses may thrive in the "publish or perish" milieu of academe. Research advising alone, even if editing of the research paper was performed, do not qualify one for authorship (Cf. "gift" authorship). This is not to say that a research, thesis or dissertation adviser may not be listed as co-author - as long as he or she meets the 4 ICMJE criteria for authorship.3 A related misconduct is the practice by certain persons with seniority of insisting their names be listed first, even if more junior scholars did all the innovative thinking and research on a project. Indeed, the order of authorship can be a source of unhappiness and dispute. Authors be listed in the order of their contributions to the work - the one who contributed most is listed first, and the order of listing should be a joint decision of all co-authors at the start of the study (reviewed periodically).</p><p> </p><p>Ghost authorship usually pertains to paid professional writers who anonymously produce material that is officially attributed to another author.7,8 They may operate out of establishments that manufacture term papers, theses, and dissertations for the right price (such as the infamous C.M. Recto district in downtown Manila, now replaced by numerous online services). They may also be employed by the pharmaceutical industry to write promotional, favorable studies that will list well-known persons (professors, scientists, senior clinicians) as authors, often with consent and adequate compensation.8 Examples include "a professor at the University of Wisconsin" being paid "$1,500 in return for putting his name" on "an article on the 'therapeutic effects' of their diet pill Redux (dexfenfluramine)," that was "pulled from the market" a year later "as doctors began reporting heart-valve injuries in as many as one-third of patients taking the drug" and the drug "later linked to dozens of deaths."9 Similar cases involved the "deadly drug" rofecoxib (Vioxx) "eventually blamed for some 60,000+ deaths," that "was also linked to a number of shameful scandals relating to fraudulent studies and the use of ghostwriters to boost sales."9 The costs involved are not meager; Parke-Davis paid "a medical education communication company (MECC) to write articles in support of the drug" Neurontin (gabapentin) "to the tune of $13,000 to $18,000 per article. In turn, MECC paid $1,000 each to friendly physicians and pharmacists to sign off as authors of the articles."9 Pfizer (who acquired Neurontin form Parke-Davis) "was found guilty of illegally promoting off-label uses of Neurontin," and "fined more than $142 million in damages."9 Whether or not morbidities or mortalities ensue from the practice, both ghosts and beneficiary-authors should be held liable in such situations.</p><p> </p><p>Clearly, the practice of "gift," "guest," and "ghost" authorship should not be entertained by authors or tolerated by editors and reviewers. Authorship should be based on the ICMJE authorship criteria. Our editors and reviewers vigilantly strive to uphold and protect the rights and welfare of our authors and the integrity and soundness of their research. We call on all fellows, diplomates and residents in training to do the same.</p>

Can modified laryngosternopexy (Laryngoclaviculopexy) project the larynx anteriorly?

@#<p style="text-align: justify;">Laryngosternopexy is a suturing method between the thyroid lamina and sternal ligament in order to relieve tension from the anastomosis when performing segmental resection of the airway.  A thick absorbable monofilament suture is passed through thyroid lamina and the interclavicular ligament of the sternum in a figure of eight fashion as described by Castellanos.1,2 In laryngosternopexy, the suture support is ventral to the anastomotic site in the midline. However, this places the "pexy" sutures in the way, making a tracheotomy and second stage decannulation difficult. We describe a modified laryngosternopexy (laryngoclaviculopexy) that can be performed with the "pexy" sutures out of the way to allow access to the trachea, and our initial experience with three patients.</p>

A dozen years, a dozen roses

@#<p style="text-align: justify;">Twelve years have passed since my first editorial for the Philippine Journal of Otolaryngology Head and Neck Surgery, on the occasion of the silver anniversary of our journal and the golden anniversary of the Philippine Society of Otolaryngology - Head and Neck Surgery (PSO-HNS).1 Special editorials have similarly marked our thirtieth (pearl)2 and thirty-fifth (coral or jade)3 journal anniversaries, punctuating editorials on a variety of themes in between. Whether they were a commentary on issues and events in the PSO-HNS or Philippine Society, or on matters pertaining to medical research and writing, publication and peer review, I have often wondered whether my words fell on deaf ears. But write, must I-- despite my writer's doubt.</p><p style="text-align: justify;"> </p><p style="text-align: justify;">What then, do a dozen years symbolize? As a baby boomer, I am all too familiar with what "cheaper by the dozen" meant in daily life, outwardly displayed in the matching attire my siblings and I wore on special occasions -- such as Yuletide when we would sing the carol "twelve days of Christmas."4 We read the comedy "Twelfth Night"5 in school, although I admittedly enjoyed "The Dirty Dozen"6 more than Shakespeare. College ROTC introduced me to the "Daily Dozen" and the grueling Navy count- 1,2,3, ONE! One, two, three, TWO! (One, two, three, four! I love the Marine Corps!) And that is as far as my list of memorable dozens goes, covering five dozen years of life.</p><p style="text-align: justify;"> </p><p style="text-align: justify;">Of these, one fifth or 20% of my life has been devoted to our journal. From that perspective, I cannot help but wonder whether, or how it mattered. After 12 years, the day-to-day routine has hardly changed; neither have the periodic problems that precede the birth of each issue. I still find it difficult to solicit and follow-up reviews, and I still burn the midnight oil on weekends and holidays, patiently guiding authors in revising their manuscripts. Nevertheless, our journal has come a long way from where it was when we started (although it has not reached as far and as quickly as I would have wanted it to). Much depends on our authors and the caliber of their contributions, and our reviewers and the quality and timeliness of their reviews. However, despite our efforts to conduct education and training sessions on Medical Writing and Peer Review, the new batch of submissions and reviews each year evinces the need to repeat these regularly. In this regard, the increasing response-ability of our associate editors and continuing support of our society are needed to ensure our progress.</p><p style="text-align: justify;"> </p><p style="text-align: justify;">This year, we welcome Dr. Eris Llanes as our new Managing Editor as we thank and congratulate Dr. Tony Chua (who retains his position as Associate Editor) for serving in that role for the past 12 years. We have finally migrated from our previous platform to the Public Knowledge Platform - Open Journal Systems (PKP-OJS) available from https://pjohns.pso-hns.org/index.php/pjohns/index. The PSO-HNS has become a member of the Publishers International Linking Association (PILA), which manages and maintains, deposits and retrieves, Metadata and Digital Identifiers inclusive of associated software and know-how. This will enable us to register Digital Object Identifiers (DOIs) for all our content using the Crossref® system (https://www.crossref.org/about/), making our "research outputs easy to find, cite, link, and assess."7 We are also subscribing to the Crossref® Similarity Check plagiarism detection software service powered by iThenticate® (https://www.crossref.org/services/similarity-check/)7 and are exploring ways and means of converting all our articles to eXtensible Markup Language (XML) format. These steps reflect our continuing efforts to comply with the requirements for indexing in the Directory of Open Access Journals (DOAJ)8 and our re-application for indexing in Scopus®.9 These steps would not have been possible without the full support of the PSO-HNS Board of Trustees under the leadership of our President, Dr. Aggie Remulla, for which we are truly grateful.</p><p style="text-align: justify;"> </p><p style="text-align: justify;">Indeed, the past 12 years may represent a complete cycle (such as 12 hours on a clock, or months in a year, or 12 signs of the zodiac), the first steps in the rebirth of our journal. Although they may not count among the "memorable dozens" of my life, each of these years may be likened to a rose (with its attendant thorns) - a bouquet of a dozen roses that I offer to all of you.</p><p style="text-align: justify;">"for there's no rose without a thorn,</p><p style="text-align: justify;">no night without the morn,</p><p style="text-align: justify;">no gain without some meaningful loss ..."10</p>

Peer review and the PJOHNS: principles, problems, and promise

The Philippine Journal of Otolaryngology Head and Neck Surgery (PJOHNS) is the official refereed journal of the Philippine Society of Otolaryngology Head and Neck Surgery (PSOHNS). What does it mean for our journal to be refereed or peer reviewed? According to the World Association of Medical Editors (WAME),1"A peer-reviewed biomedical journal is one that regularly obtains advice on individual manuscripts from reviewers who are not part of the journal's editorial staff. Peer review is intended to improve the accuracy, clarity, and completeness of published manuscripts and to help editors decide which manuscripts to publish. Peer review does not guarantee manuscript quality and does not reliably detect scientific misconduct." Who are peer reviewers? Integral to the whole system, they are experts in their chosen field who are expected to provide an unbiased opinion on the quality, timeliness, and relevance of a submitted manuscript.2 They are responsible to the editor and journal, their specialty and/or subspecialty, study participants and/or subjects, and authors, to "make sure rubbish does not get published."2As editors, we understand that peer review (also called refereeing) is not a perfect antidote to poor science, and we need to carefully evaluate manuscripts themselves for quality and validity.3  Prior to review, we carefully review submissions for suitability to our journal and ensure that all important elements of the manuscript are included, in accordance with our instructions to authors.4  Manuscripts are subjected to a double blinded external peer-review process, guided by the "Responsibilities and Rights of Peer Reviewers" contained in the Editorial Policy Statements approved by the Council of Science Editors Board of Directors.5  For participants in the PSOHNS research contests, this review process is facilitated by pre-judging of anonymized manuscripts by blinded judge-reviewers. Manuscripts are further reviewed by editors and other experts in the field and may be proofread, content- and form- edited and returned for revision. The revision process is often tedious, particularly when authors fail to adequately address the concerns, comments, and corrections of editors and reviewers (or referees).  In this regard, authors have much to learn from research protocol and medical writing workshops. It is also in the best interests of editors and their journals to improve peer review, and ways to do so have been identified by systematic reviews.6,7Double-blind review (blinding both author and reviewer to each other's identity and anonymizing manuscripts before review) supposedly reduces the likelihood of bias for or against authors based on name, affiliation or country of origin, and is perceived as more fair.3,8  Unless they are able to guess the identity of authors, reviewers only discover such identities if the manuscript is finally accepted and published.7,9 On the other hand, lack of transparency may be considered a limitation of double-blind review, although the cultural-appropriateness of transparency may be argued in collective cultural contexts such as ours. To minimize bias, and manage and assure the quality of the peer review process, we try to select peer reviewers who possess the appropriate expertise needed to review a manuscript thoroughly and identify and exclude peer reviewers with potential conflicts of interest.10 In cooperation with the PSOHNS, we conduct 1-day introduction to basic medical writing workshops, and 2-day advanced workshops for peer reviewers every year, as well as mini-workshops during our annual convention. Unfortunately, it seems that those who would benefit most from our courses are not the ones who participate in them. Very few consultants have attended either workshop, evinced by the quality of co-authorship of their own papers, or their reviews of other papers. There are many instances where senior colleagues perpetuate inappropriate research and writing practices, contradicting what would have been the correct work of their junior co-authors (the latter merely applying what they learned from our workshops). Worse, some of these consultants insist on their way (as research supervisors, co-authors or reviewers), undoing our corrections and misguiding residents in the process. Things would be different if they opened themselves to acquiring the knowledge, skills, and attitudes of good referees, and contribute to the ongoing history of scholarship in our field. Meanwhile, regardless of the recommendations they make, the ultimate decision and responsibility is the editor's.We aim to publish original work of value to the intellectual community in the best possible form and to the highest possible standards, and expect similar standards from our reviewers and authors. Our journal follows the "Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals" of the International Committee of Medical Journal Editors (ICMJE), and is proudly listed as such.11  Honesty, originality and fair dealing on the part of authors, and fairness, objectivity and confidentiality on the part of editors and reviewers are among the critical values that enable us to achieve our aim. To this end, we also endorse and uphold the Ethical Guidelines for Peer Reviewers established by the Committee on Publication Ethics (COPE).12  We hope that our efforts are well worth the hardships and heartaches we endure with each manuscript we process. Guided by our principles, we painstakingly search for solutions to current problems as the promise of a better tomorrow beckons. We invite you to partner with us as peer reviewers and participate in our future.

Hubris, humility and healing

@#<p class="MsoNoSpacing" style="text-align: center; margin: 0in -3.5pt .0001pt .25in;" align="center">"<i>Pride goeth before destruction, and an haughty spirit before a fall.</i></p><p class="MsoNoSpacing" style="text-align: center; margin: 0in -3.5pt .0001pt .25in;" align="center"><i>Better it is to be of an humble spirit with the lowly, </i></p><p class="MsoNoSpacing" style="text-align: center; margin: 0in -3.5pt .0001pt .25in;" align="center"><i>than to divide the spoil with the proud.</i>"</p><p class="MsoNoSpacing" style="text-align: center; margin: 0in -3.5pt .0001pt .25in;" align="center"> </p><p class="MsoNoSpacing" style="text-align: center; margin: 0in -3.5pt .0001pt .25in;" align="center">- Proverbs 16:18-191</p><p class="MsoNoSpacing" style="text-align: center; margin: 0in -3.5pt .0001pt .25in;" align="center"> </p><p class="MsoNoSpacing" style="margin: 0in -3.5pt .0001pt .25in;">      </p><p class="MsoNoSpacing" style="text-align: justify; text-justify: inter-ideograph; text-indent: .25in; margin: 0in -3.5pt .0001pt .25in;">There is justifiable pride in completing the arduous journey: the 4- to 5-year post-baccalaureate Doctor of Medicine degree capped with a grueling year of internship, passing the professional licensure examinations, obtaining a 3- to 7-year post-graduate residency training, hurdling Diplomate specialty board examinations, perhaps even completing a 1- to 2-year clinical and/or research fellowship subspecialty qualification and becoming a full-fledged Fellow of a specialty society, college, or academy after a 2-year probation or initiation period. A full 15 to 20 years after High School, you are finally on your own. Armed with encyclopedic knowledge and cutting-edge skills, you confidently (even cockily) set out to conquer case after clinical case as you "exercise awesome power over life and death."2 You may even succeed in your campaign for some time, and pride can easily bloat out of proportion into hubris -- "excessive pride toward or in defiance of the gods, leading to nemesis."3 Thus was the weaver Arachne transformed into a spider after challenging (and being defeated by) the goddess Athena.4</p><p class="MsoNoSpacing" style="text-align: justify; text-justify: inter-ideograph; text-indent: .25in; margin: 0in -3.5pt .0001pt .25in;"> </p><p class="MsoNoSpacing" style="text-align: justify; text-justify: inter-ideograph; text-indent: .25in; margin: 0in -3.5pt .0001pt .25in;">Unfortunately, Arachne was oblivious to her web. You would not be where you are were it not for the countless people who directly or indirectly supported you throughout your journey. Your parents and family, clan and community, teachers and classmates were certainly there. But more than them, the nameless--even faceless-- others whose lives and services (yes, including the cadaver you dissected in anatomy) made yours possible were also there. Ultimately, many others had to die, figuratively and literally, so that others-- you included-- may live. The very persons you now perceive as patients represent the collective people (living and dead) who made your becoming a physician possible. You owe them. </p><p class="MsoNoSpacing" style="text-align: justify; text-justify: inter-ideograph; text-indent: .25in; margin: 0in -3.5pt .0001pt .25in;"> </p><p class="MsoNoSpacing" style="text-align: justify; text-justify: inter-ideograph; text-indent: .25in; margin: 0in -3.5pt .0001pt .25in;">If you still have not learned by now, patients are not cases to be solved, but persons to serve. Engaging whole but broken people, people in pain or dis-ease, entails more than expert knowledge and sharply honed skills. As Sir William Osler said, "To know the patient that has the disease is more important than to know the disease that the patient has."5 Head and hands are worthless without heart. Competence needs to be motivated by compassion and enabled by communication. It has little place for pride, and none for hubris. On the contrary, its primary stance is one of humility-- true concern for others as opposed to self-concern: 6 </p><p class="MsoNoSpacing" style="text-indent: .25in; margin: 0in -3.5pt .0001pt 1.0in;"><i>"Do not imagine that if you meet a really humble man he            will be what most people call 'humble' nowadays: he will not              be a sort of greasy, smarmy person, who is always telling you          that, of course, he is nobody. Probably all you will think about          him is that he seemed a cheerful, intelligent chap who took a            real interest in what you said to him. If you do dislike him it              will be because you feel a little envious of anyone who seems               to enjoy life so easily. He will not be thinking about humility:              he will not be thinking about himself at all."</i></p><p class="MsoNoSpacing" style="margin: 0in -3.5pt .0001pt .25in;"> </p><p class="MsoNoSpacing" style="text-align: justify; text-justify: inter-ideograph; margin: 0in -3.5pt .0001pt .25in;">      This concern for others, rather than for the self, may mark the so-called "sweet spot between hubris and humility" where one feels "small and insignificant but empowered at the same time."7 Being confronted by, and surmounting the tension between life and death with each patient encounter (some more than others) redefines and reinforces this spot over and over again -- but not without taking its toll. After so many years, a part of me still dies with each patient's death. I suppose that one cannot deal with wellness and illness, and living and dying, without sustaining collateral damage in the process-- far beyond the inevitable wear and tear that accompany our own aging process. And this is a truly humbling realization. </p><p class="MsoNoSpacing" style="text-align: justify; text-justify: inter-ideograph; margin: 0in -3.5pt .0001pt .25in;"> </p><p class="MsoNoSpacing" style="text-align: center; margin: 0in -3.5pt .0001pt .25in;" align="center"> </p><p class="MsoNoSpacing" style="text-align: justify; text-justify: inter-ideograph; text-indent: .25in; margin: 0in -3.5pt .0001pt .25in;">We can choose to wallow in self-pity, and even despair. Or we can bracket our pains and concerns, and practice the compassion of the wounded healer, where "in our own woundedness, we can become as source of life for others."8 Compassion is enabled and concern communicated when we ourselves embrace pain, dis-ease and brokenness--ours, as well as that of our patients. It is not easy, but we fully begin to serve as worthy instruments of healing when with each death, we die; and with each life, we live again.</p>

Oral hemorrhage in a 3-year-old boy caused by self-mutilating behavior

A 3-year-old boy referred for persistent tongue bleeding was diagnosed with a rare self-mutilating disease that had also affected his lip and fingers. He underwent multiple odontectomy and partial glossectomy and continues to undergo behavior therapy and on-demand splints and restraints. He has stopped self-biting and has gained appetite and weight. Lesch-Nyhan Syndrome can cause significant morbidity including self inflicted oral hemorrhage and emergent measures are not easily decided. The long-term management of its neurobehavioral symptoms is problematic and multidisciplinary, and health providers remain challenged to find the best treatment, prolong lifespan and improve quality of life within their respective contexts