Towards a multiscale crop modelling framework for climate change adaptation assessment.

Predicting the consequences of manipulating genotype (G) and agronomic management (M) on agricultural ecosystem performances under future environmental (E) conditions remains a challenge. Crop modelling has the potential to enable society to assess the efficacy of G × M technologies to mitigate and adapt crop production systems to climate change. Despite recent achievements, dedicated research to develop and improve modelling capabilities from gene to global scales is needed to provide guidance on designing G × M adaptation strategies with full consideration of their impacts on both crop productivity and ecosystem sustainability under varying climatic conditions. Opportunities to advance the multiscale crop modelling framework include representing crop genetic traits, interfacing crop models with large-scale models, improving the representation of physiological responses to climate change and management practices, closing data gaps and harnessing multisource data to improve model predictability and enable identification of emergent relationships. A fundamental challenge in multiscale prediction is the balance between process details required to assess the intervention and predictability of the system at the scales feasible to measure the impact. An advanced multiscale crop modelling framework will enable a gene-to-farm design of resilient and sustainable crop production systems under a changing climate at regional-to-global scales.

The ethics of dysfunctional professional relationships.

Dr N, the chief surgeon at a large private hospital who has been practicing there for decades, has noted recent changes in the administration that are troubling. Multiple advertisements proclaim awards that have not been achieved and various ads employed actors pretending to be patients experiencing miracle cures. Pressures on medical staff to practice more efficiently have become overbearing. Changes in bundling Medicare postoperative care have raised questions about future patient selection. There is a lack of transparency with minimal physician input. The much respected chief-of-staff has moved into the administrative side and no longer advocates for the professionalism of the staff. When Dr N meets with the chief-of-staff and objects to these changes, the chief of staff calls Dr N a complainer and tells him to forget about it. Nothing is done.

The ethics of insurance limiting institutional medical care: It's all about the money.

Dr F. Inest practices surgery at a renowned medical center but is concerned because increasing numbers of medical insurers are excluding his institution from coverage. Many of his former referring physicians are beginning to send their patients elsewhere for this reason. The marketing people have been busy increasing their advertising buys and exploring new business models. There is even talk about reducing expensive clinical trials. However, regardless of his affiliation, he has little control over these and other organizational decisions that directly impact his practice clinically and fiscally. What should he do?

Fiduciary disparity clarity: Ethics of divided allegiances.

An experienced senior vascular surgeon, Dr H. O. Nest, at a university medical center is asked to evaluate a patient with a rare complex vascular problem. The patient is a high-ranking university official, Mr N. Otable, well known to all in the university setting. Dr Nest has had very limited experience with the condition. He has viewed presentations about it but is aware of a world expert at another institution. He discusses transfer with the patient, who agrees on that approach. Later that day, when Dr Nest receives a visit from the Chief-of-Staff and the hospital CEO asking about Mr Otable, they are very concerned that transfer will reflect badly on the medical center's reputation. Dr Nest is strongly requested to reconsider his recommendation--almost at gunpoint. What should he do? A. If he believes that the outcome will be satisfactory, he should schedule the operation. B. He should explain the situation to the patient and let him choose where he wishes to have his surgery. C. He should continue with the plan to refer the patient to another center. D. He must understand his limits and base his decision accordingly. E. He should arrange a conference with the surgeons in the vascular division and the administrators.

Is medical advertising always unethical, or does it just seem to be?

Dr C. Lever is the undisputed expert in a new endovascular procedure he developed and brought to fruition over the years. Other professionals publishing their results call it by his name, although he has strictly avoided that nomenclature. Lever is at a medical center with several participating hospitals, which boast aggressive ultracompetitive marketing departments. His hospital wants to concentrate on him as proof that the best care is available at their facility. A successful campaign certainly would add to Lever's and perhaps to his group's referrals. He looks at the first advertisement and a Greek god would have been less vaunted but nothing said is untrue. What should he do? A. Ask that all advertising identifying him be discontinued immediately. B.Tell them to hype it up. C. Ask that marketing stick to the facts completely sans hype. D. Check with the Ethics Committee of the hospital. E. Check with the Ethics Committee of the American Medical Association (AMA) or American College of Surgeons or the appropriate surgical subspecialty professional association.

Obligations and frustrations with high-risk patients: ethics of physicians' evaluations.

A surgeon, Dr A. Droit, has been following a 97-year-old male with a type IV thoracoabdominal aneurysm, which became symptomatic this morning and is leaking. The patient is frail but active with no important comorbidities. The anatomy demands an open procedure. The patient is a former renowned physician who has been a longtime family friend of Dr Droit-like a grandfather. He presented incoherent with sagging blood pressure. A complicating factor is that Dr D. Rag, the chief anesthesiologist, decided that neither he nor any of his staff would provide anesthesia. Dr Droit knows an anesthesiologist who handles high-risk patients at another hospital in the medical center. The patient has worsened over the last hour, is becoming more unstable, and is unable to respond but his wife wishes to consent for surgery. What should Dr Droit do?

Publishing corruption discussion: predatory journalism.

Dr Spock is a brilliant young vascular surgeon who is up for tenure next year. He has been warned by the chair of surgery that he needs to increase his list of publications to assure passage. He has recently had a paper reviewed by one of the top journals in his specialty, Journal X-special, with several suggestions for revision. He received an e-mail request for manuscript submission from a newly minted, open access, Journal of Vascular Disease Therapy, which promises a quick and likely favorable response for a fee. What should be done? A. Send the paper to another peer reviewed journal with the suggested revisions. B. Resubmit the paper to Journal X-special. C. Submit to the online journal as is to save time. D. Submit to the online journal and another regular journal. E. Look for another job.

When money and principles clash: the ethics of a surgical teaching service.

During your preoperative visit, a very wealthy patient, Gill Bates, who donated a wing to the large teaching hospital in which you practice, has an unusual request: He does not want any residents involved with his care. He is scheduled for an open infrarenal aneurysmectomy. He explains that his decision is based on the experience of a relative many years ago who was harmed by a resident's error. You clarify that you will do the procedure but that this is a teaching hospital and residents provide excellent assistance and postoperative care. He is resolute in demanding that only grown-up surgeons provide his care.

Medicine versus religion in the surgical intensive care unit: who is in charge?

The chief of surgery at a large academic medical center is approached by a vascular surgical faculty member. After a repair of an aortic dissection, an elderly man has remained comatose and has worsened over several weeks, developing multiple system organ failure. Statistically, his chance of leaving the hospital alive is <1%. The family is deeply religious, and the minister and various elders, deacons, and members of their church have been vigilant in constant prayerful attendance. The attending's tactful suggestions that the time is coming when nature should be allowed to take its course was not well received. The family and their support group are convinced that their fervor will summon a miracle. A large group complained to patient affairs and was taken to the medical center director's office. Today, the director told the attending that the hospital would absorb the overall cost until the patient dies and that the unfavorable press from stopping care is unacceptable. The chief of surgery should:

When is medical industry backing lacking?

A sales representative from Megastint approached Dr A. Krasia with an offer to financially support future educational conferences and allow his institution to be a training center if he participates in a new study comparing an old product to a recently approved and more expensive one. Dr Krasia and his department currently use Megastint's products. The medical center's utilization committee must approve the addition of more expensive pharmaceuticals, devices, or equipment, and Dr Krasia is the chair. How should Dr Krasia respond to Megastint's offer of financial support and to become a training center?

Business dealings with a patient: money never sleeps.

Mr M.O. Gul returned for his postoperative visit today after you successfully repaired a leaking abdominal aortic aneurysm. Mr Gul owns most of the cable networks in the state, making him a billionaire. He realizes that he met the bearded reaper and walked away because of your skills. He is pioneering a new technology that will make current Wi-Fi obsolete. Unexpectedly, he offers you the opportunity to invest with the expectation of huge returns. M.O. personally guarantees you will not lose money. What should you do? A Invest. No questions asked. B Do not invest. It is unprofessional. C Do not invest without consulting with your attorney. D Do not invest. You have already been paid for services rendered. E Invest provided you forego future medical relationships with M.O. as the attending physician.

Conflict of credentialing: accolade or unfair trade.

The newly appointed chief of surgery at an open-staff hospital received an application for vascular privileges from a senior general surgeon who took a period of additional fellowship in vascular surgery at a nonacademic regional medical center. The fellowship does not make him board eligible in vascular surgery, but he has maintained his general surgery board certification and the pertinent bylaws do not specifically state which certification is required, only that the surgeon must be board certified and have additional training in vascular surgery. He is a member of a large politically powerful group practice that apparently wants to refer their substantial number of vascular cases internally. The chief of surgery finished vascular surgery training locally 3 years ago. The applicant has a checkered past, with multiple lawsuits and in-house investigations of cases with poor outcomes. The credentialing procedure is that the chief of service makes a recommendation to the chief of staff who makes a recommendation to the board of directors for approval. The chief of staff, who will make the final recommendation to the hospital board of directors, is a member of the applicant's group practice. What recommendation should the chief of vascular surgery make to the chief of staff?

Surveys of rodent-borne disease in Thailand with a focus on scrub typhus assessment.

The epidemiology of many rodent-borne diseases in South-East Asia remains ill-defined. Scrub typhus and lep-tospirosis are common and medically significant, while other zoonotic diseases, such as spotted fever group Rickettsiae have been identified, but their overall medical significance is unknown. Rodent surveillance was conducted from June 2002 to July 2004 in 18 provinces from Thailand. Traps were set up for one to three nights. Blood and serum samples and animal tissue samples (liver, spleen, kidney and urinary bladder) were collected. Chiggermites, ticks and fleas were removed from captured rodents. A total of 4536 wild-caught rodents from 27 species were captured over two years of animal trapping. Rattus rattus was the dominant species, followed by Rattus exulans and Bandicota indica. Almost 43 000 ectoparasites were removed from the captured animals. Approximately 98% of the ectoparasites were chigger-mites, of which 46% belonged to the genus Leptotrombidium (scrub typhus vector). Other genera included Schoengastia and Blankaartia. Tick and flea specimens together comprised less than 1% of the sample. Among the five species of ticks collected, Haemaphysalis bandicota was the predominant species caught, followed by Ixodes granulatus other Haemaphysalis spp., Rhipicephalus spp. and Dermacentor spp. Only two species of fleas were collected and Xenopsylla cheopis (rat flea) was the predominant species. Using both commercial diagnostic kits and in-house molecular assays, animal tissue samples were examined and screened for zoonotic diseases. Seven zoonotic diseases were detected: scrub typhus, leptospirosis, murine typhus, tick typhus, bartonella, babesiosis and trypanosomiasis. Most samples were positive for scrub typhus. Other zoonotic diseases still under investigation include borrelosis, ehrlichiosis, the plague, and other rickettsial diseases. Using geographic information systems, global positioning systems and remote sensing technology, epidemiological and environmental data were combined to assess the relative risk in different biotopes within highly endemic areas of scrub typhus in Thailand.