Nutritional support for the patient with pancreatobiliary disease.

Critically ill patients with severe pancreatobiliary disease exhibit multiple nutritional alterations compounded by the stress response. Acute pancreatitis may present as a life-threatening illness; patients are likely to be hypermetabolic and may have hyperglycemia and hypocalcemia. Nutritional support from parenteral or enteral feeding will probably be required in patients presenting with three or more positive risk factors as determined by Ranson criteria. Nutritional therapies for liver disease vary according to the specific disorder manifested. Patients with fulminant hepatic failure need to be monitored for profound hypoglycemia. Encephalopathy may develop in patients with acute-on-chronic liver disease, necessitating a protein restriction. Patients undergoing liver transplant are a perioperative challenge due to the combination of preoperative malnutrition, an extensive surgical procedure, and postoperative stress. Such patients require individualized assessment and management.

Evaluating borderline students.

While it was difficult for our faculty to face the disparity which arose in deciding whether or not to pass Anne, many important points were raised which strengthened the evaluation process particularly in the case of the borderline student. Newer faculty members related uneasiness in being specific and directive with "borderline" students. Experienced faculty offered suggestions on overcoming this fear and finding support among peers. Open discussion provided a forum for the exchange of ideas and philosophies. Though no definitive solutions were uncovered we judged this workshop to be a valuable learning experience with broad appeal across a very diverse faculty.