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In total 2019 and projections 255 data sources from 138 countries were included in the analysis gastritis burning pain in back quality 20 mg pantoprazole. This number is expected to gastritis symptoms upper right quadrant pain generic 40mg pantoprazole otc Atlas are provided for 211 countries and territories gastritis symptoms vomiting buy generic pantoprazole on line, increase to gastritis in cats order generic pantoprazole from india 417. Full details of the methods used, including how the data sources were evaluated and processed, can be found online ( Age distribution Gender distribution Diabetes estimates for 2019 show a typically the estimated prevalence of diabetes in women increasing prevalence of diabetes by age. Similar aged 2079 years is slightly lower than in men trends are predicted for the years 2030 and 2045. Among adults aged 7579 prevalence of diabetes is expected to increase in years diabetes prevalence is estimated to be 19. The highest age-adjusted India and the United States of America, and are comparative diabetes prevalence in 2019 are in the anticipated to remain so in 2030 (Table 3. Marshall Islands is expected to in Pakistan will exceed that in the United States of have the highest age-adjusted comparative diabetes America, and will move to third place by 2045. If this trend continues, the and projections to 2030 and number of people above 65 years (6599 years) with diabetes will be 195. These data point Diabetes prevalence increases with age so the to a significant increase in the diabetes population highest estimated prevalence is in people older of the aging societies in the next 25 years and the than 65 (Figure 3. In 2019, the estimated number inevitable public health and economic challenges this will bring. The projected diabetes There are significant regional diferences in the prevalence to 2045 in this age group does not prevalence of diabetes in people older than 65 years. America ranked higher than India in the number of these estimates point to an urgent need for people older than 65 years with diabetes for 2019 prompt detection for improved global screening of and 2030. Early detection is of crucial importance; India will exceed the United States of America in the since prolonged undiagnosed diabetes can have number of people older than 65 years with diabetes negative efects, such as a higher risk of diabetes(Map 3. The undiagnosed diabetes were 136, representing 73 highest proportion of undiagnosed diabetes countries. However, globally, Mozambique has the greatest proportion of undiagnosed diabetes (86. Unfortunately, diabetes using measures of diabetes prevalence incidence is more difficult to measure than and total numbers of people with diabetes. While prevalence, as it usually requires much larger this is certainly an important way of understanding studies. Nevertheless, in recent years, adequately the impact of diabetes, it has some limitations. For sized studies, particularly those drawn from very example, a rising prevalence is typically interpreted large administrative databases. It is not yet possible to can also rise because people with diabetes are attempt country-by-country estimates of diabetes living longer as a result of improved care and incidence, as there are far too few studies. However, also the general increasing life expectancy trends a recent systematic review of studies reporting worldwide. This leads to each person staying longer trends in the incidence of diabetes among adults in the pool of people with diabetes, thus increasing has shown that between 2006 and 2014, 27% of prevalence. Therefore, it would be possible to see reported populations had a stable incidence over diabetes prevalence rising, even if obesity and time, while 36% reported a declining trend; only other risk factors are declining, as long as the care 36% reported an increasing trend in the incidence of diabetes (Figure 3. It also contrasts with diabetes is changing over time, it is necessary diabetes prevalence data, as reported elsewhere to assess the incidence of diabetes. There may diabetes are almost entirely from high-income also have been a fall in screening rates, though a countries. This is not surprising, given the cost of the study from Israel reported increasing screening infrastructure needed to collect these data (large rates at the same time as incidence fell. In such studies, it is dificult to determine falls in observed incidence reflect true reductions accurately the type of diabetes, and these reports in incidence, and may point to some success in should be seen as reflecting type 1 and 2 diabetes starting to curb the diabetes epidemic. However, since the data come from adult populations, in which the incidence of type 2 diabetes is an order of magnitude higher than the Diabetes incidence and incidence of type 1 diabetes, any trends can be prevalence in children and reasonably attributed to type 2 diabetes. It is apparent that, the number of children and adolescents with at least in some high-income countries, there is diabetes is increasing every year. In populations of evidence of falling incidence of diabetes, despite European origin, nearly all children and adolescents the inexorable rise in prevalence. It is not yet clear with diabetes have type 1 diabetes, but in other what is driving the observed falls in incidence. Japan) type 2 diabetes is more the data all apply to diagnosed diabetes, and so common than type 1 diabetes in this age group. The overall annual increase is estimated to have contributed, although the timing of declines be around 3% with strong indications of geographic in a number of countries do not quite match the diferences. It is estimated that around 98,200 children incidence rates (per 100,000) of type 1 diabetes and adolescents under the age of 15 years are in children and adolescents under the age of 15 diagnosed with type 1 diabetes annually and this years. In countries with limited access to insulin estimated number increases to 128,900 when the and inadequate health service provision, children age range extends to under 20 years (Table 3. With increasing 100,000 population levels of obesity and physical inactivity among Rank Country or territory per year) 014 years children and adolescents in many countries, type 1 Finland 62. It is important to note that of the prevalence of impaired glucose tolerance nearly one-third (28. Of course, this age group also has income countries, where access to antenatal care a higher prevalence of diabetes generally. Globally, there are more deaths associated with Diabetes-related mortality diabetes in women (2. This is equivalent to one are also associated with a negative economic death every eight seconds. Diabetes is estimated impact for countries, often called the indirect to be associated with 11. The other Regions spent significantly less, despite being the economic impact of diabetes is expected to home to 41. These projections Expenditure due to diabetes has a significant impact are conservative, as they assume that the mean on health budgets worldwide. The reason behind 370 the large expenditure observed in older age groups 360 is almost certainly the higher frequency of diabetes350 related complications in later stages of life. Global trends in the incidence and prevalence of type 2 diabetes in children and adolescents: indirect costs are made up. Type 2 diabetes across generations: from pathophysiology to prevention and absenteeism; and presenteeism. Saeedi P, Petersohn I, Salpea P, Malanda B, Karuranga S, enormous threat and great opportunity. The global economic burden of trends from a large population-based study in Israel. Almost three-quarters of deaths due to diabetes each year occur in people under the age of 60 years the highest proportion in this age group in the world. Only three countries (Ethiopia, Kenya and Uganda) had studies conducted within the past five years. Diabetes prevalence figures for other countries in the Region were <5% based on studies using fasting blood glucose and self-reported 5<6% diagnostic criteria. Throughout the Region, data on the incidence of 6<7% type 1 diabetes in children and adolescents are scarce. To calculate estimates for type 1 diabetes in children and adolescents, for example, 7<8% data sources from Ethiopia, Mauritius, Rwanda and Tanzania were 8<9% identified and extrapolated. Due to the small number of data sources fi9% available, estimates for the Region must be interpreted with caution, particularly mortality and health expenditure estimates. Diabetes prevalence large proportions occur in lowand middle-income is higher in urban (5. A total of 73 data sources from 39 countries were used to generate diabetes estimates among adults in the Region. Estimates for 12 countries (Georgia, Germany, Greenland, Israel, Italy, Luxembourg, Macedonia, Malta, Norway, Romania, Russian Federation and Uzbekistan) were based on studies <5% conducted within the past five years.


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I do not want to diet for gastritis sufferers order pantoprazole 20 mg be viewed as meddling outside of my role gastritis medscape buy pantoprazole master card, but sometimes I just get really concerned gastritis vs gastroenteritis purchase pantoprazole 20 mg with visa. This was managed successfully gastritis symptoms back pain buy pantoprazole with amex, but after the surgical procedure had been completed the Certifed registered nurse anesthetist (crna) decided to monitor the boy in the operating room (or) a bit longer than usual, to ensure that he was truly stable before being transferred to the post anesthesia care unit (pacu). In the course of fulflling these tasks, one of the nurses disconnected the electrical power to monitoring equipment that was still attached to the boy. While the event described above was not deemed consequential by anyone involved, it illustrates the potential for more serious consequences resulting from coordination and cross-checking defcits. These may arise when personnel do not consider how their activities and actions might impact the overall situation in which they are embedded. Such communication practices are not yet exercised as a professional standard in healthcare. The nurse who had prematurely disconnected the monitoring equipment later explained: We have to turn those rooms around, quick. If cases get backed up it hurts the hospitals bottom line and surgeons get upset because it hurts their bottom line, too. We are very concerned with patient safety here, I just hadnt thought about the impact of what I was doing on anyone else. What we are held to account for strongly infuences what we attend to (Woods 2004). Being held to account for individual fulfllment of tasks, rather than the performance of tasks in close coordination with other care providers, remains a powerful source of fragmentation and patient harm (Brown 2005b; patterson, render and ebright 2002). And while many clinical units have check-ins on patient needs and care plans called interdisciplinary or multidisciplinary rounds, these vary greatly in terms of participation and rigor. Hospitals are very busy and while members of each discipline are expected to go to discharge rounds, they are not accountable for attendance; they are accountable for fulflling their assigned tasks with patients, which is pretty time-pressured. For example, you can look at the physical therapy notes but they are all in the code-talk of physical therapy. Discharge rounds are driven by pressure to get the patient out of the hospital with very little consideration of what happens to that patient upon discharge. Because of this incoherence in discharge planning we are probably a bigger reason than anyone realizes for the existence of so many frequent fyers. We do not assemble all of the minds necessary to do discharge rounding well, and we do not have the organizational structure and incentives to do so. Consequently, no matter how much we may want to, we never fully understand how our role fts into the overall process of care experienced by the patient. Although the current picture may seem bleak, the good news is that clinical environments are rich in diverse intellectual resources which, if harnessed through team processes, may yield signifcant improvements in the safety and quality of care (lawrence 2002; leonard, graham and Bonacum 2004; uhlig et al. The Importance of Harnessing Intellectual Variety in Clinical Care the ability to detect and diagnose problems or anomalies, and adapt activity to avert failure, has been discussed by numerous researchers as instrumental to safety and reliability (Hollnagel, Woods and Leveson et al. Teams comprised of members with diverse expertise and perspectives may be especially capable of problem detection, analysis, and resolution (Bolman 1980; Klein 2006; Sarter and Alexander 2000; Woods, OBrien and Hanes 1987). Per Karl Weick (2001): When technical systems have more variety than a single individual can comprehend, one of the few ways humans can match this variety is by networks and teams of divergent individuals Whether team members differ in occupational specialties, past experience, gender, conceptual skills, or personality may be less important than the fact that they do differ and look for different things when they size up a problem. If people look for different things, when their observations are pooled they collectively see more than any one of them alone would see. Weick also points out that as team members become more alike, or homogenous, their collective observations are less distinguishable from their individual observations, and they are likely to gain little advantage in understanding a problem collectively rather than individually. Harnessing the intellectual variety represented by the many disciplines that care for patients requires fattening of hierarchy and creating a context in which clinical personnel feel safe to express concern, inquire, or advocate for another perspective, without fear of repercussion. While desirable and admirable, this sense of responsibility remains rooted in the view that errors are de facto evidence of incompetence, if not moral failure (Brown 2005a). Interprofessional and intra-professional shaming continues to dampen the willingness of physicians, nurses, and other personnel to ask questions or voice concerns with any but their most trusted colleagues (Coiera 2000; Fuedtner, Christakis and Christakis 1994; Hafferty and Franks 1994; Hicks et al. But, it is especially hard to do this with a physicianto suggest that something might not be rightthat they could have missed something. The development of an environment in which team processes such as cross-checking may thrive requires freedom from concern about being shamed or censured as a consequence of engaging in inquiry and advocacy (argyris and schon 1974; Bolman 1980; edmondson 2003; Helmreich 2000). Edmondson (1999 and 2002) used the term psychological safety to describe the extent to which people view their work environment as enabling them to engage in the interpersonal risk of pointing out their own mistakes, voicing a concern, or speaking up to intervene in anothers erroneous action or inaction. In psychologically safe environments people believe that they will not be rebuked for identifying a problem, asking assistance, or seeking additional information. Common Ground psychological safety is necessary for the development of common ground: the shared beliefs, values, and assumptions among team members that serve interpredictability and support a climate in which team members may develop the norm of assisting each other in avoiding or mitigating missteps (Klein 2006; Klein et al. Inquiry and discourse enable the development of a teams tacit if not explicit compact to cross-monitor and cross-check (Edmondson 2003; Helmreich 2000; Klein et al. Developing a collaborative social context characterized by psychological safety and common ground requires time, space, and dialogue. In hospital-based care, opportunities for the development of psychological safety and the emergence Nemeth Book. The Impact of Productivity and Effciency Pressure on Collaboration the united states healthcare system is under intense and escalating societal pressure to provide healthcare that is accessible, equitable, safe, reliable, and cost effective (Kohn, Corrigan and Donaldson 2000; Corrigan et al. Coupled with personnel shortages in key patient care roles such as nursing, hospitals are increasingly operating near the limits of their capacity (JcaHo 2004). He asked us to each share our thoughts on the patients care needs from our professional perspective, aloud. When one of the nurses mentioned that the patient was to be taken for a radiological procedure later in the morning the social worker revealed that the patient already had that procedure the day before. The patient said he knew he was going to have a radiological procedure that day, but hadnt realized it would have been an unnecessary repeat. It turns out that we had some kind of problem with our computer system that sometimes led to patients being collected and transported for radiological procedures more than once. Two other people spoke up and said that this had happened with other patients before, but at the time they thought it was just a fuke and had never mentioned it. It made me and others wonder how many things like this go on that we never make visible because we dont get together as a team with all the disciplines to talk about the whole process of care. We only came together as a team that one time; the hospitalist couldnt make it routine given the many different department managers he had to win over. And he couldnt fnd a way to pay for the time of some of the disciplines so that they could be there. But it was a really rich experiencefrom that one time I learned things about what members of the other disciplines thought was important to note about patients that I had been unaware of. I suspect that there are lots of expensive ineffciencies that operate in our organization that Nemeth Book. Through interdisciplinary discourse regarding patients needs and plans of care, clinical process problems and other patient care issues may be revealedwhether they have roots only in the clinical setting or across multiple functional areas of the hospital. Finally, this quote also suggests that learning about how ones role fts into the larger processes of patient care does not occur automatically. In other industries, such as aviation, there has been substantial exploration of how to structure communication and interaction to limit error and promote learning (Bolman 1980; Helmreich 2000; Mudge 1998; Patankar and Taylor 1999). Cultivating Collaborative Practice: A Tale of Doing and Undoing there follows the story of a multidisciplinary group of care providers that utilized lessons from aviation and other industries to become a high performing interdisciplinary team. Collaborative cross-checking and other team processes emerged and prospered for over three years. During that time the quality and safety of patient care provided by the team, while already highly rated against national benchmarks, improved signifcantly and the team was recognized in the United States for its innovative approach to clinical teamwork (Uhlig et al. The story of the team, eventually known as the Cardiac Surgery Care Team, reveals how they created time and space for collaboration and how collaborative cross-checking and other team processes may serve the improvement of patient care. Yet, despite their success, the team was ultimately disbanded in the face of powerful cultural push-back. Their experience underscores the diffculty of sizing up both medical staff and hospital readiness for change and the challenges faced by change agents in navigating the development of new organizational forms in healthcare. In late 1999, health professionals caring for open heart surgery patients at a midsized community hospital began re-thinking care processes for their patients. The provision of care for open heart surgery patients is socially and technically complex. Surgeons, therapists, nurses, pharmacists, social workers, and other disciplines must coordinate their assessments and therapeutic actions with one another and with patients and families. For the past 100 years, the patients medical record has been cast as the primary coordination medium for role-based task fulfllment in hospital care.

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Administration Life >5% Amylin analogues (Injectable) Pramlintide Synthetic analog ~0 gastritis diet discount pantoprazole 20 mg without prescription. Effcacy and safety of canaglifozin monotherapy in subjects with type 2 diabetes mellitus inadequately controlled with diet and exercise gastritis gastroenteritis cheap 20 mg pantoprazole amex. Effcacy and Safety of the Dipeptidyl Peptidase-4 Inhibitor Alogliptin in Patients With Type 2 Diabetes and Inadequate Glycemic Control gastritis diet buy pantoprazole 40mg low cost. Association of B12 defciency and clinical neuropathy with metformin use in type 2 diabetes patients gastritis symptoms heart attack 20mg pantoprazole. This document is intended for educational purposes only as a quick reference guide to commonly used diabetes drugs. Please refer to full prescribing information and additional reference materials for detailed information on a specifc drug or drug use, dosing in special populations and drug use in patients with specifc medical conditions. When Electrolytes, lipid panel, renal detemir (dose de(dose needed10 colorless10 given twice daily administer function10 pendent)10 depen12 hours from morning (Levemir) 10 dent) dose or with the evening meal10 70% insulin 101-4hrs11 18-24hrs11 ~8No adjustments Cloudy or No11 Usually twice daily. Electrolytes11 aspart 20min11 9hrs11 needed11 milky11 Administer within 15 protamine minutes before or after a meal. Vial should be rolled suspension between the palms to 30% insulin achieve proper aspart injecconsistency11 tion (Novolog 70/30) 75% 0. Vial protamine calculatshould be rolled between ed13 the palms to achieve proper 25% insulin 12 consistency lispro (Humalog 75/25) Mixed 50% 0. Vial lated15 should be rolled between 30% insulin the palms to achieve proper regular 14 consistency (Humulin 70/30, Novolin 70/30) Initial Dosing Guidelines Start low, and go slow16 Multi-dose Insulin Therapy: starting dose: 0. This document is not intended to override a clinicians judgment in individual patient management. Delmarva Foundation would like to thank the following students for their assistance in the creation of this reference: John Taktajian, Frederick Frimpong, Duyen Nguyen, Desiree Massari, Quyen Tran, Amy Chen, Christie Dunton. Wa l l ac e Wa de Sta di u m Duke University Durham, North Carolina Notes on Academic Dress Academic dress had its origin in the Middle Ages. When the European universities were taking form in the thirteenth and fourteenth centuries, scholars were also clerics, and they adopted robes similar to those of their monastic orders. Caps were a necessity in drafty buildings, and copes or capes with hoods Mace and Chain of Ofce attached were needed for warmth. As the Again at commencement, ceremonial use control of universities gradually passed from is made of two important insignia given to the church, academic costume began to take Duke University in memory of Benjamin N. Both the mace and chain of ofce are in cut and color of gown and type of headdress. They were States has been continuous since Colonial designed and executed by Professor Kurt J. The Mace, the symbol of authority of the the bachelors gown is relatively simple with University, is made of sterling silver long pointed sleeves as its distinguishing mark. It is thirty-seven inches long the gown for the masters degree has an Signifcance of Colors and weighs about eight pounds. At the oblong sleeve with the rear part cut square Colors indicating felds of lower end of the hammered shaft is a gilt and the front part with a cutaway arc. The upper end of most elaborate academic costume is the some of the universities the shaft displays the inscription Universitas doctoral gown with velvet panels down the represented by members Dukiana 1838. This inscription is surmountfront and three bars of the same material of the faculties of the ed by a short, hammered neck followed by across the sleeves. The velvet is usually black, University are: the head which has eight futings alternating but it may be a color designating the feld of with eight gilt ribs. The gown Arts, Letters, Humanities: mace, a band carries the motto of Duke itself, usually black like those of the lower white Business Administration: University: Eruditio et Religio. The upper end degrees, may be of a color distinctive of a drab of the mace is a crown of gilt laurel leaves particular university. Dentistry: lavender which carries the seal of Duke University Divinity, Theology: scarlet the hood bears a still larger symbolic burden: surrounded by the three symbols of the Economics: copper the width of its velvet trimming designates Trinity to indicate that Duke University Education: light blue the level of the degree; the color heralds the Engineering: orange emerged from Trinity College. University is symbolized by a lining of Duke Medicine: green It is four feet long and is also made of blue with a white chevron. The main part Nursing: apricot the cap, originally round, is usually a square consists of nine silver pine cones alternating Philosophy: dark blue mortarboard and is the same for all degrees. In the front hangs the gilt medallion cap worn with the doctoral robe may have a Science: golden yellow with the official seal of Duke University gold tassel. The Duke doctoral gown is in the surrounded by a laurel wreath into which authentic Duke blue. With this gown there may be worn Duke family with the motto In Adversis Idem a black velvet, four-pointed, soft tam with a set in a sterling wreath of laurel leaves and square top and a gold metallic bullion tassel. Price, President of the University When the Duke Wind Symphony sounds the fanfare for the entrance of the faculty, the audience and candidates will rise and remain standing through the invocation. Processional March Flourish for Wind Band Ralph Vaughan Williams (1872-1958) Candidates for Degrees Members of the Faculty Members of the University Administration Members of the Board of Trustees Members of the Platform Party National Anthem Lisa Ishigame He Candidate for the Degree of Bachelor of Science in Engineering Invocation Luke A. Powery, Dean of Duke Chapel Welcoming Remarks Remarks by a Student Deeksha Malhotra Candidate for the Degree of Bachelor of Science Conferring of Honorary Degrees Introduction Jack O. And though on lifes broad sea To thee our voices raise, well raise, Our fates may far us bear, To thee our anthems ring Well ever turn to thee in everlasting praise. As supply chain, sales activities, and service and chief executive, support in all markets and countries. Prior to joining Apple, the introduction of innovative new products and Cook was vice president of corporate materials at services including iPhone X, Apple Watch, iPad Compaq and chief operating offcer of the Reseller Pro, HomePod, AirPods, Apple Pay, Apple Music, Division at Intelligent Electronics. Under his leadership, Apple initiated a program to match employee donations to charitable In April, Cook was named to Fortunes Worlds organizations, is advancing inclusion and diversity 50 Greatest Leaders list. Apple has ranked #1 efforts, and supports underserved schools in the on Fortunes Worlds Most Admired Companies U. She is the author of three goes on to say that her own defnition has become acclaimed novels that embody realism for our a man or a woman who says, Yes, theres a problem global 21st century: Purple Hibiscus (2003), which with gender as it is today, and we must fx it; we was awarded the Commonwealth Writers Prize for must do better. She such as the New Yorker, Adichie reaches a global received a MacArthur Fellowship in 2008, and audience as a feminist activist and speaker. The was elected as a foreign honorary member into both novelist Dave Eggers wrote of Adichie, She is the the American Academy of Arts and Letters and the rare novelist to become a public intellectual American Academy of Arts and Sciences in 2017. Barras career advice for of General Motors young women is to seize opportunities in order to Company. In April, Barra was named #11 on Board of Trustees for Detroit Country Day School. Mary and supply chain; and as senior vice president for Barra and her husband Tony are the parents of two global product development. Bell Bell was a member of the Durham County Board forged a partnership with Duke that resulted in of Commissioners from 1972 to 1994 and from the building of the Durham Performing Arts 1996 to 2000; he served as the chairman from Center and the renovation of the American 1982 to 1994. President Obama appointed him to today, Philip the National Commission of Fine Arts. Freelon led the team of architects on the design of the $500 million Smithsonian National Museum Freelon holds a bachelor of environmental design of African American History and Culture in degree in architecture from North Carolina State Washington, D. The new University and a master of architecture degree from museum on the National Mall was immediately the Massachusetts Institute of Technology. He celebrated for its striking beauty and symbolic also received a Loeb Fellowship and spent a year impact; Freelon has stated that he aimed to infuse of independent study at the Harvard University African American and African infuences into the Graduate School of Design. William Kaelin at the Johns Hopkins Hospital, where he served as is a cancer biologist chief medical resident. He was a clinical fellow who is a professor in medical oncology at the Dana-Farber Cancer in the Department Institute, during which time he was a McDonnell of Medicine at Scholar. A Howard Hughes Medical the Albert Lasker Basic Medical Research Award Investigator since 1998, Dr. Kaelin conducts sometimes called the American Nobel because research to understand how mutations affecting 87 of the honorees have gone on to win the Nobel tumor-suppressor genes cause cancer in order to Prize. His work has Gairdner International Award, the Grand Prix of produced new insights into how cells detect and the Fondation Lefoulon-Delalande from the Institut respond to changes in oxygen, which may prove de France, and the Wiley Biomedical Research Prize. Willis Smith Award for graduating first in the class, and serving as Editor-in-Chief of the Duke From 1987 to 2017, Robinson served as a trustee Law Journal. He later served as a member of the of the Duke Endowment, the private foundation Board of Visitors of the Law School. Russell Robinsons wife, Sally Dalton Robinson 55, He also served as a member and chair of the Board was a trustee of Duke University from 1995 to 2004 of Trustees of the University of North Carolina and co-chaired Dukes Financial Aid Initiative from at Charlotte from 1987 to 1997; as chair he was 2005 to 2008. Together, they have received the the lead advocate for the campus to gain research Duke Alumni Associations Distinguished Alumni university status and award doctoral degrees. Award in 2006, the North Carolina Humanities He was the general counsel for the John Motley Council John Tyler Caldwell Award in 2013, and the Morehead Foundation for 42 years, and he served North Carolina Order of the Long Leaf Pine in 2013.


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