Tracheal agenesis

Tracheal agenesis (also known as tracheal atresia) is a rare birth defect with a prevalence of less than 1 in 50,000 in which the trachea fails to develop, resulting in an impaired communication between the larynx and the alveoli of the lungs. Although the defect is normally fatal, occasional cases have been reported of long-term survival following surgical intervention.
The disease was first described in 1900 by Payne. To this date, it is estimated that about 200 cases have been reported and published worldwide. Several types of the disease have been described and the slight anatomical variations have resulted in the establishment of different classification systems. There are three main types of tracheal agenesis, designated Types I, II and III.
In 2013, a South Korean child, Hannah Warren, born with tracheal agenesis, was successfully treated at Children's Hospital of Illinois, after having been kept alive in an intensive care unit for the first two and a half years of her life. An artificially created trachea was implanted, that had been created by tissue engineering, by using a nanofiber mesh, coated with her own stem cells. Although the transplant was successful, she died three months later from other health issues.
The disease has been more frequently observed in males than in females, at a ratio of 2:1.
Signs and symptoms.
Observable signs and symptoms of the disease differ depending on whether the observation in done in utero or after parturition. Only the signs and symptoms of the embryo are described, due to the lack of research in maternal symptoms.
In utero.
The classic in-utero symptoms of tracheal agenesis are an absence of the trachea leading to congenital high airway obstruction syndrome, lung distention, polyhydramnios, heart malformations, heart displacement and hydrops fetalis. Other congenital malformations such as genitourinary, gastrointestinal and musculoskeletal anomalies are common and occur in 80% of the reported cases.
Tracheal agenesis may lead to a distention of the foetus’ lung due to a build-up of pulmonary fluid within them. In this case, ultrasound scans show bilaterally enlarged and homogeneously echogenic lungs as well as the inversion of both hemidiaphragms. Although lung distention has been described as a classic symptom, hypoplasia or complete aplasia of the lungs can also occur, in an estimated 26% of cases. In some cases, normal lung development was also reported in neonates with tracheal agenesis.
The abnormal development of the foetus’ lungs leads to cardiovascular abnormalities. Distention of the lungs results in a compressed and displaced heart, hindering the normal growth and development of the organ. Depending on the severity of the compression of the heart, normal venous return to the organ would correspondingly be hindered, resulting in a condition known as hydrops fetalis (also known as fetalis ascites), in which oedema form in the developing foetus. Hydrops fetalis can be observed in utero via ultrasound scan.
Polyhydramnios occurs in embryos presenting with a tracheoesophageal fistula as the liquid produced by the lungs supposedly pass to the stomach, in the amniotic fluid.
At birth.
More than half of the recorded cases of tracheal agenesis have led to premature deliveries and in almost all reported cases, infants die shortly after birth due to lack of oxygenation. Neonates with tracheal agenesis present with symptoms characteristic to congenital high airway obstruction syndrome with no audible cry after birth, respiratory insufficiency, respiratory distress and cyanosis. No trachea is palpable below the cricoid cartilage.
Causes.
The exact causes of tracheal agenesis remain unknown. Different embryological theories have arisen to explain the congenital development of the disease.
Embryological causes.
The relative similarities between the different subtypes of the disease suggest that there is a common stage at which the development is hindered.
In normal embryogenesis, the trachea differentiates from the foregut during the fourth week of gestation. The respiratory diverticulum, a ventral projection formed from the foregut, appears. Eventually, the tracheoesophageal ridges will fuse to form a septum. The laryngotracheal tube will then fully separate from the foregut. Two primary bronchial buds form at the end of the tube, which then elongates to form the trachea. The buds then branch to form the bronchi, lungs and alveolar tissue. The development of the respiratory tract is closely associated to that of the oesophagus. Both organs regulate each other’s growth via molecular interactions.
In tracheal agenesis, a delay in the development of the primary bronchial buds causes a transient arrest in the growth of the laryngotracheal tube, hindering the normal development of the trachea. The failure of the lung buds to develop from the primitive foregut leads to tracheoesophageal malformations. The development of the buds occurs after the elongation of the oesophagus, causing a dissociation in the growth of the two organs. Due to this dissociation, the buds directly develop to form the lungs, without forming the trachea, resulting in tracheal agenesis. Different degrees of this malformation result in different types of tracheal agenesis.
Genetic determinants.
No clear genetic pattern or karyotype has been established to support the development of tracheal agenesis. The genes that have been postulated to influence the development of the disease are all associated to the congenital development of the lungs, trachea and oesophagus. These are BMP-4, BMPR1A and BMPR1B, Gli2 and Gli3, sonic hedgehog and NK2 homeobox 1. It is highly likely that tracheal agenesis results from the mutation of several of these genes.
BMP-4 is an important signalling molecule in the early development of the embryo. BMP-4 null mutations in the foregut endoderm and in its surrounding mesoderm results in atresia of the trachea and under developed lungs. The Bmp family restricts the site of formation of lung buds as well as to induce cell proliferation via the suppression of Sox2.
Gli2 and Gli3 null mutations were also found to result in delayed lung, tracheal and oesophageal development. The two signalling molecules are implicated in the mediation of Sonic hedgehog signalling, which regulates the proliferation and differentiation of the oesophagus, trachea and lungs.
In mice, NK2 homeobox 1 null mutation results in a significantly shorter trachea, connected to the oesophagus via a tracheoesophageal fistula. In embryos with a homozygous mutated NK2 homeobox 1 locus, the tracheoesophageal ridges fail to fuse and form a septum.
Diagnosis.
The diagnosis of the disease is dependent on observable signs and symptoms and on the stage of gestation. There are two ways to diagnose tracheal agenesis: early in utero, or later at birth. Recognisable clinical patterns are associated with tracheal agenesis.
Most commonly, the in-utero diagnosis of the disease requires using radiography and ultrasound scans.
At birth, the diagnosis is suspected clinically through the observations of characteristic signs and symptoms of the disease. Tracheal agenesis should be suspected when tracheal intubation is impossible. The confirmation of the diagnosis relies on results of endoscopic laryngoscopies and oesophagoscopies at birth. X-ray studies are necessary to determine the class and the severity of the disease. CT scans remain an option to provide more information if required.
Classification.
Tracheal agenesis is classified according to anatomical subtypes. Different classifications exist but the universally accepted one, by Floyd and colleagues in 1962, distinguishes three anatomical subtypes: type I, II and III.
Type I.
Type I is described as tracheal atresia, rather than tracheal agenesis. The trachea is absent proximally but there remains a short normal segment of the distal trachea. A tracheoesophageal fistula links the distal segment of the proto trachea to the oesophagus. It is estimated that 13% of cases of the disease are of type I.
Type II.
Type II tracheal agenesis is the most common form of the disease, estimated to appear in 60% of cases. Type II is characterised by a complete absence of the trachea. The bronchi are normal and fuse at the carina. In most cases, the oesophagus and the carina are joined by a fistula.
Type III.
In type III tracheal agenesis, the trachea is completely absent and the bronchi develop individually, originating from the oesophagus directly and without joining at the carina. No tracheoesophageal fistula is present in this case as the trachea is completely absent. It is estimated that 27% of all cases are type III.
Other classifications.
In 1979, Faro described seven types of tracheal agenesis (A-G). This classification system differs from Floyd’s early propositions as it encompasses a more detailed description of the disease, including the surrounding organs such as the larynx and the lungs. The importance of this more detailed classification system is that the presence of surrounding organs, such as the larynx, might alter the observed symptoms of the traditionally defined tracheal agenesis. For example, neonates with a larynx might emit a faint cry at birth, while those with complete agenesis of the trachea and of the larynx will not. Acknowledging these different anatomical subtypes allows for a more comprehensive diagnosis and better management of the disease.
Faro type A describes a total pulmonary agenesis, in which none of the respiratory organs are present. Type B is comparable to Floyd’s type III and describes complete agenesis of the trachea, with no joining of the bronchi. Faro type C describes total agenesis of the trachea with normal bronchi fusing at the carina. A tracheoesophageal fistula is present and links the carina to the oesophagus. In Faro type D, the larynx is joined to the distal trachea and a tracheoesophageal fistula links the carina to the oesophagus. Faro type E is comparable to Floyd’s type I, as the distal trachea is present and joined to the oesophagus via a fistula. Faro type F describes the proximal absence of the trachea but the normal presence of the distal trachea. In this case, the trachea is not attached to the oesophagus. In Faro type G, a segment of the trachea is absent, defining it as partial tracheal agenesis.
Management.
In patients with tracheal agenesis, surgical correction is required to allow for a relatively temporary survival of the neonate. Tracheal intubation is proven to be impossible in almost all cases. In most cases, if surgery is unsuccessful, severe asphyxia results in the death of the neonate, on average two days after birth. The longest survival ever reported was six years.
See also.
Children's Hospital of Illinois Transplant surgery on Hannah Warren


Whitehead Institute

Whitehead Institute for Biomedical Research is a non-profit research institute located in Cambridge, Massachusetts, United States that is dedicated to improving human health through basic biomedical research. It was founded as a fiscally independent entity from the Massachusetts Institute of Technology (MIT), where its 18 members all hold faculty appointments in the MIT Department of Biology or the MIT Department of Bioengineering. Two members (Rudolf Jaenisch, 2010, and Robert Weinberg, 1997) are National Medal of Science recipients; ten have been elected to the National Academy of Sciences; and four have been elected to the National Academy of Medicine; six are Howard Hughes Medical Institute Investigators.
On September 2019, Ruth Lehmann was announced as the new Director of the Whitehead Institute for Biomedical Research, commencing July 2020 and succeeding David Page.
History.
Whitehead Institute was founded in 1982 by industrialist and philanthropist Edwin C. “Jack” Whitehead (1920–1992), who sought to establish a research institute "dedicated to improving human health through basic biomedical science". Whitehead believed that while such an institution should be closely affiliated with an academic institution, it should remain wholly independent and self-governing. In David Baltimore (1975 Nobel Laureate in Physiology or Medicine), Whitehead found a partner who agreed that this approach would create an "optimum environment for basic research". As Whitehead Institute's Founding Director, Baltimore handpicked Harvey Lodish, and Robert Weinberg from MIT, Gerald Fink from Cornell University, and Rudolf Jaenisch from University of Hamburg, Germany, to be Whitehead Institute's Founding Members. This group then identified promising younger scientists to be the first generation of Whitehead Members; and they established the Whitehead Fellows Program as a vehicle for accelerating the careers of highly promising young investigators.
Less than a decade after its founding, the Institute for Scientific Information in Philadelphia identified Whitehead as the top research institution in the world in molecular biology and genetics, based on the impact of its scientific publications. Whitehead Institute's Center for Genome Research became the single largest contributor to the Human Genome Project, and reportedly contributed one-third of the human genome sequence announced in June 2000.
In the early 2000s, the CGR formed the independent Broad Institute of MIT and Harvard, of which then-Whitehead Member Eric Lander was named Founding Director and President.
Whitehead Institute's influence continues. Over a 10-year period, papers published by Whitehead scientists had more impact in molecular biology and genetics than those from any of the 15 leading research universities and life sciences institutes in the United States. Training and education is integral to Whitehead Institute's mission and approximately 300 undergraduates, graduate students, post-doctoral researchers, and visiting scientists are integrally engaged in its research programs. Four times since 2009, the Whitehead Institute has been ranked first as the Best Place to Work for Postdocs in USA by "The Scientist" magazine.
Today, Whitehead scientists run research programs in cancer biology, developmental biology, genetics and genomics, metabolism, neurodevelopment and neurodegenerative disease, and regenerative medicine. In addition, numerous biotech companies have been launched by Whitehead Members or based on intellectual property developed at the Institute, such as Alnylam Pharmaceuticals, Sanofi Genzyme, Ironwood Pharmaceuticals, Rubius Therapeutics, and Verastem.
In 2019, according to the NACUBO report, Institute had an endowment of $527.9 million.
Faculty.
The Whitehead faculty currently comprises 18 members whose laboratories focus on biology's most fundamental questions. The Members, who are all also MIT faculty members, are:
Fellows Program.
The Whitehead Fellows Program provides an opportunity for highly accomplished recent PhDs to direct their own labs, rather than work in a senior researcher's lab as a traditional postdoctoral researcher. Fellows receive dedicated lab space and funds for equipment, lab operations, salary, and core staffing. They also receive mentoring from Whitehead Faculty Members, who serve as resources and integrate the Fellows into the Institute's collaborative culture.
Past Whitehead Fellows include George Q. Daley, Dean of Harvard Medical School; Angelika Amon, MIT professor and cancer researcher; Eric Lander, President and Founding Director of Broad Institute; Kathleen Rubins, NASA astronaut and space biologist; David C. Page, Whitehead Institute Director; and Peter S. Kim, former President of Merck Research Laboratories.


Donald W. Black

Donald W. Black (born February 15, 1956) is an American psychiatrist and professor of psychiatry at the University of Iowa. He is the editor-in-chief of the "Annals of Clinical Psychiatry". A noted researcher on gambling disorder, he received the Scientific Achievement Award from the National Center for Responsible Gaming in 2016.


Angela Thomas

Angela Eleine Thomas is a consultant paediatric haematologist and former director of the haemophilia centre, Royal Infirmary of Edinburgh.
Biography.
Angela Thomas qualified in medicine in 1980 from Barts and The London School of Medicine and Dentistry. She trained in adult haematology, subsequently specialising in paediatric haematology.
She is on the National Emergency Stockpile Quality Panel
She is vice-chair of the Commission on Human Medicines and chairs the Clinical Trials, Biologicals & Vaccines Expert Advisory Group.
She is a Scientific Committee Member and expert with the European Medicines Agency.
She was awarded an OBE for services to the regulation of public health in the 2018 New Years Honours.
She was appointed as Acting President of RCPE in June 2020.


William Truban

William Andonia Truban (October 6, 1924 – February 3, 2007) was a veterinarian who served more than two decades as a Republican in the Virginia Senate, representing Shenandoah, Clarke, Frederick and Loudoun Counties and the city of Winchester, Virginia, and sometimes Fauquier and Warren counties as well. Dr. Truban was then Senate minority leader of what was then a small party as the Byrd Organization disintegrated.
Early life.
William Truban was born in the unincorporated town of Gormania in Garrett County, Maryland on October 6, 1924 to Joseph Truban and his wife May Parks. He was single and classified as a gardener or groundskeeper when he registered for the draft upon turning 18. Truban was inducted into the U.S. Army in Baltimore, Maryland, on March 15, 1943. He served in the U.S. Army Air Force in the Asian Theater during World War II,
He used the G.I. Bill at West Virginia Wesleyan College in Buckhannon, West Virginia from which he received a bachelor's degree. He earned his veterinary degree (V.M.D.) from the University of Pennsylvania School of Veterinary Medicine in Philadelphia, Pennsylvania. He married Mildred Jean Hayes and was a member of the United Methodist Church.
Career.
Truban established Shenandoah Animal Hospital in Woodstock, Shenandoah County, Virginia and was active in the Veterinary Medical Association as well as the Woodstock Rotary Club. His son Thomas S. Truban later took over the veterinary practice.
Political career.
Truban won a special election in 1970 after J. Kenneth Robinson, who had represented the then-rural 27th District in the Virginia Senate as a Republican, won election to the U.S. House of Representatives. Dr. Truban won 61% of the votes cast in that election and handily defeated Democrat Robert Smalley. Four years later, he defeated Democrat Thelma T. Ore by a similar margin, although in 1979 Truban won re-election with a mere 56.9% of votes cast while running against Democrat Donald W. Patterson Jr. Dr. Truban faced no opposition in his 1983 nor 1987 campaigns for re-election and announced his retirement before the 1991 primary.
Dr. Truban served as the sole Republican on the Senate Finance Committee and as Senate minority leader until November 1991. While he was the Republican floor leader, his party held no more than 10 of the Senate’s 40 seats; Republicans later became the majority party. Dr. Truban helped establish a veterinary school at Virginia Tech, which became the Virginia-Maryland Regional College of Veterinary Medicine. A fiscal conservative as had been both his long-serving predecessor Democrats Harry F. Byrd Sr. and Harry F. Byrd Jr., Truban sat on the Joint Legislative Audit and Review Commission (JLARC) which in 1990 proposed establishing a state cash reserve to protect Virginia’s bond rating and keep the state on firm financial footing during economic downturns. Although the proposal initially failed, voters ratified the Virginia Revenue Stabilization Fund, better known as the rainy-day fund, in 1992, and it became law in 1993.
Later years.
Truban continued his veterinary practice, but when health issues accumulated, he entered an assisted living facility in Woodstock, Virginia. There he died on February 3, 2007, survived by his widow and six children, as well as grandchildren. One of his sons, William A. Truban Jr. became a lawyer and established legal practice specializing in elder law.


Danielle Spencer (American actress)

Danielle Spencer (born June 24, 1965) is an American actress and former child star best known for her role as Dee Thomas on the ABC sitcom "What's Happening!!", which ran from 1976 to 1979. She would later reprise the role on the series' sequel, "What's Happening Now!!"
Life and career.
Spencer was born in Trenton, New Jersey to writer Cheryl Pelt, who separated from her husband when Spencer was very young. Spencer considered her mother's next husband, Tim Pelt, to be her father. The family relocated to the Bronx, New York. Spencer became an actor around the age of eight and began taking acting classes. In 1976, Spencer was cast as younger sister Dee Thomas on the show "What's Happening!!", which was loosely based on the film "Cooley High". The show was a summer mid-season replacement, but performed so well in its time slot that a full second season was ordered.
On September 7, 1977, during the second season of the show, Spencer and her stepfather Tim Pelt were involved a severe car accident that left Spencer in a coma for three weeks. Pelt was killed, and his fatal injuries were caused by trying to protect Spencer during the crash. Spencer has no memories of the accident and spent six months recuperating in arm and leg casts.
After the cancellation of the show in 1979, Spencer and her mother relocated to Africa for a time. Upon her return, she attended the University of California-Davis to earn a degree in veterinary medicine, a pursuit that was encouraged by her late stepfather. As syndicated reruns of the 65 "What's Happening!!" episodes had done well, in some markets eclipsing the show's ratings during its network run, in 1985 a sequel series was created called "What's Happening Now!!". Spencer played Dee in various episodes over the sequel's three-season run while attending college. While in her sophomore year, she pledged and became a member of Delta Sigma Theta sorority. After "What's Happening Now!!" was canceled in 1988, Spencer attended Tuskegee University Veterinary School in Tuskegee, Alabama. She became a veterinarian in 1996.
Spencer considers herself to be in semi-retirement from show business, but still acts occasionally. In 1997, she portrayed a veterinarian in the hit film "As Good as It Gets" and appeared in "Peter Rabbit and the Crucifix" in 2001. She continues to act in small roles in film and television when it does not conflict with her veterinary practice.
The cast of "What's Happening!!" was honored at the 2006 TV Land Awards, where Spencer was the co-winner (along with "Little House on the Prairie" actress Alison Arngrim) of the "Character Most in Need of a Time-Out" award.
Spencer released a book about her life as a child star entitled "Through the Fire: Journal of a Child Star". The book led to renewed interest in Spencer's life and career, and led to appearances on shows such as "The Wendy Williams Show", TV One's hit series "Life After" and "Unsung Hollywood" with her former cast members.
Personal life.
Spencer married Garry Fields, a marketing manager and her publicist and manager, in Marina Del Rey, California in 1999. The couple divorced in 2013.
In 2004, Spencer experienced balance and chronic pain issues and was diagnosed with spinal stenosis as a result of the injuries from her 1977 car accident. A surgery to correct the problem left her partially paralyzed for eight months. Spencer received treatment at the Kessler Institute for Rehabilitation in New Jersey; she credits the institute for giving her life back to her.
Spencer has been a veterinarian in California for more than 25 years. In an interview with "People", Spencer credited her own battle with spinal injury and paralysis for changing her perspective on the treatment of animals from simply alleviating their pain to finding the underlying cause of their problems.
In 2014, Spencer was inducted as part of the permanent exhibition of the new National Museum of African American History and Culture. She is the only former child actor who holds this honor. She also became involved in fashion design and debuted her "Dani Collection" line, which was patterned after her own style of dress.
Spencer was diagnosed with breast cancer in September 2014. Speaking out for Breast Cancer Awareness Month, Spencer told "Black America Web" that her diagnosis took her by surprise. "With everything that I've been through with the spinal cord injury, I said I know God is not going to give me another affliction," she said, "so I was completely shocked when the doctors told me." Though the news came as a surprise, Spencer said the disease runs in her family. "I have a lot of help and support around me," she said. Spencer stated that she was considering her treatment options, with surgery at the top of the list. "I'm trying to get as many opinions as possible but it does look like that is what I’m going to do," she said. "Hopefully after that there won’t be any chemotherapy or radiation involved."
Spencer makes appearances as a motivational speaker. She told "Ebony" Magazine in 2012, "I’ve made peace with the fact that surgeries, back pain and walking with crutches will be part of my life forever. Some days are good, some days are difficult. Yet, despite the challenges, there are reasons to celebrate. My life includes volunteering with a charity that feeds the homeless; providing care for animals through my work as a vet."


Robert Derzon

Robert Alan Derzon (December 30, 1930 – June 17, 2009) was an American health care professional who served as the first director of the Health Care Financing Administration (HCFA), the arm of the US federal government responsible for administering Medicare and Medicaid.
Early life and education.
Derzon was born in Milwaukee, Wisconsin. He received his undergraduate education at Dartmouth College, graduating in 1953. He was awarded a master's degree from Dartmouth's Amos Tuck School of Business Administration in 1955, and earned a Master of Public Health in 1956 from the University of Minnesota.
Professional career.
Derzon served as associate director of New York University Medical Center from 1960 to 1966. Derzon was appointed as first deputy hospital commissioner in the New York City Department of Hospitals by Mayor of New York City John Lindsay, serving under lawyer and hospital administrator Joseph Vincent Terenzio, the first non-physician to serve as Hospitals Commissioner. Derzon served as the department's acting commissioner in 1970 after Terenzio's resignation. He testified to a legislative committee of New York State in 1969, stating that hospitals in New York City were "on the brink of fiscal disaster" due to reductions in Medicaid funding and calling the system of paying for hospital and medical care "a disaster" in which the majority of people statewide could not get affordable and accessible health care.
Derzon was named as administrator of the University of California, San Francisco Medical Center in 1970, serving in the position until 1977.
President of the United States Jimmy Carter appointed Derzon to serve as the first head of the Health Care Financing Administration (HCFA, later called the CMS), an agency created in March 1977 with the responsibility for overseeing both Medicare, which provides health insurance for those over age 65, and Medicaid, which provides health insurance for the poor. The two programs had both been established in 1965, but had been operated independently until that point. Derzon's task was to address the soaring costs of hospital care by reducing abuse and fraud in the two programs, implementing efforts to reduce costs that were controversial.
As part of a series of recommendations to United States Secretary of Health, Education, and Welfare Joseph A. Califano, Jr. sent in June 1977, Derzon supported the nationwide implementation of living will laws that had been enacted in California, suggesting that Federal aid be withheld to states that did not pass such laws. Derzon estimated that living will laws, which would allow doctors to end life support in cases where recovery is deemed unlikely, could cut $1 billion by 1978 in costs related to the 20% of annual Medicare expenses spent caring for patients in their last year of life. The memorandum also raised concerns about the growth in the number of physicians, estimating that the 85,000 additional doctors added by 1980 would generate $5 billion in revenue while increasing costs for hospital care, suggesting that cuts in the number of new doctors might be necessary and might well be supported by the American Medical Association. Derzon's memo advocated for Medicaid funding of abortions for poor women, citing $1,000 in annual savings in welfare expenditures on each unwanted child as well as $100 in reduced Medicaid expenses.
Secretary Califano fired Derzon from his post heading the HCFA in September 1978, citing Derzon's failure to progress quickly enough with the restructuring of Medicare and Medicaid. Derzon was willing to stand up to Califano's proposals and tell him what wouldn't work, a stance that Califano did not like and that led to what were described as "fiery clashes" between the two. Leonard D. Schaeffer was named as Derzon's replacement.
Personal.
A resident of Mill Valley, California, Derzon died of swine flu at age 78 on June 17, 2009, while visiting a friend in Orangeville, Ontario. He is survived by one daughter and two sons and nine grandchildren. His wife had died in 2002 after 46 years of marriage.


John Crighton Bramwell

John Crighton Bramwell (1889–1976) was a British cardiologist, professor of medicine, and one of the founders of cardiology as a specialist subject in the UK.
Education and career.
After education at Cheltenham College, J. Crighton Bramwell matriculated in 1907 at Trinity College, Cambridge, graduating BA in 1910. There he was influenced by the physiologist Keith Lucas. In 1911 Bramwell started clinical medical training at the Manchester Royal Infirmary. At the start of WWI he joined the 1st East Lancashire Territorial Field Ambulance in Egypt. In 1915 he was granted leave for two months to take his final examination at the University of Manchester, where he graduated MB CHB. After his return to active duty, he was posted to the 23rd Division, 12th Army Corps in France and then in Italy as part of the Italian Expeditionary Force. He served first with a Field Ambulance and later as Deputy Assistant Director of Medical Services (DADMS) to GHQ, Italy.
At the Manchester Royal Infirmary, Bramwell became in 1919 a house physician under G. R. Murray and a medical and cardiographic registrar. At the University of Manchester in 1920 Bramwell was put in charge of the newly established electrocardiographic department. At the University of Manchester's department of physiology from 1919 to 1923 Bramwell collaborated with Archibald Hill on several papers on pulse wave velocity and arterial elasticity and taught clinical medicine.
In 1923 Bramwell graduated MD from the University of Manchester and was elected one of the first four Rockefeller Travelling Fellows of the Medical Research Council. From 1923 to 1925 he worked at Washington University in St. Louis and the Rockefeller Institute of Medical Research in Manhattan and also visited about 18 of the leading medical schools in the United States and Canada.
He was appointed in 1925 an assistant lecturer in experimental physiology at the University of Manchester. He was appointed in 1926 a physician at the Manchester Royal Infirmary and later entered consulting practice as a cardiologist. From 1940 to 1946 he was part-time Professor of Systematic Medicine in the University of Manchester. In 1946 he resigned that professorship so that Robert Platt could become full-time professor of medicine. From 1946 to 1954 Bramwell was professor of cardiology and then retired as professor emeritus.
He was elected FRCP in 1929 and honorary FRCP (Edin.) in 1960. He gave in 1937 the Lumleian Lectures on "Arterial pulse in health and disease" and in 1956 the Harveian Oration on "Practice, teaching and research". For many years he was an editor for the "Quarterly Journal of Medicine". He was in 1955–1956 the president of the Association of Physicians and the president of the British Cardiac Society. He was for many years a member of the editorial board of the "British Heart Journal", which in 1956 dedicated a special issue to him. In that issue, J. Maurice Campbell wrote an appreciation of Bramwell's contributions to cardiology.
Family.
J. Crighton Bramwell's father Byrom Bramwell and eldest brother Edwin Bramwell were elected FRCP. In 1929 Crighton Bramwell married Elsa Violet Risk. Her father James Risk was a whisky distiller, who owned the Bankier Distillery in Banknock, Scotland. Crighton and Elsa Bramwell had two sons, one of whom became a physician, and one daughter, who worked in medical publishing.


Mediastinal shift

Mediastinal shift is the deviation of the mediastinal structures towards one side of the chest cavity, usually seen on chest radiograph. It indicates a severe asymmetry of intrathoracic pressures. Mediastinal shift may be caused by volume expansion on one side of the thorax, volume loss on one side of the thorax, mediastinal masses and vertebral or chest wall abnormalities. An emergent condition classically presenting with mediastinal shift is tension pneumothorax.
Mediastinal shift may be detected on antenatal ultrasound in certain fetal conditions.


Center for Personalized Education for Physicians

The Center for Personalized Education for Physicians (CPEP) is a non-profit organization, headquartered in Denver, Colorado, and it specializes in physician competency assessment and educational intervention. The organization was established in 1990 as a collaborative effort of seven Colorado healthcare organizations: the Colorado Alliance for CME, the Colorado Foundation for Medical Care, the Colorado Hospital Association, the Colorado Medical Society, the Colorado Physician Health Program, the Colorado Society of Osteopathic Medicine and the University of Colorado School of Medicine.
CPEP provides assessment and education for physicians re-entering practice. Its approach is based on the idea that education should be directed by an evaluation of the individual's educational needs and that traditional continuing medical education conferences alone may not be effective in improving practice. This is consistent with the approach of remediation programs both in the United States and internationally. Physicians take part in CPEP programs for medical ethics education and training, to address performance evaluation issues and concerns, and to help them reinstate their medical licenses.
CPEP collaborates with the University of Colorado Schoolof Medicine and is led by faculty and other physician consultants who are board certified in their respective specialties. CPEP is one of five programs nationwide that have been accepted as members of the Coalition for Physician Enhancement, the primary U.S. organization representing programs that provide physician assessment and education.
CPEP receives no funding from medical licensure fees or state sources. Instead, the organization is supported by participant fees and donations from the Colorado medical community, including the COPIC Companies.
Assessment Testing
Doctors are referred to CPEP for competency assessments from different organizations, including hospitals, medical groups and state medical boards. The CPEP approach to physician competency evaluation and assessment has three major components: clinical competence assessment, educational intervention, and post-educational evaluation.
The assessment is individualized based on the physician’s practice and the concerns of the referring organization. The actual assessment includes structured clinical interviews, simulated patient encounters and written testing. This testing is overseen by a board-certified physician who acts as an associate medical director (AMD). This AMD then compiles a final report, and the physician receives recommendations for education based on their needs.
ProBE
The ProBE (Professional/Problem-Based Ethics) Program started in 1992 in New Jersey as collaboration between the New Jersey State Board of Medical Examiners and The Ethics Group, LLC. The program started as a way to provide educational intervention to physicians who were identified by the Board and had received ethical infractions.
By 1996, the ProBE Program had been endorsed by 45 licensing boards and sub-specialty boards throughout the United States. In 2007, CPEP acquired The Ethics Group, LLC, and began offering the program.
The ProBE Program provides education for healthcare professionals, and it focuses on ethics violations and unprofessional conduct secondary to boundary violations in the practice of healthcare. These violations can include financial irregularities, misrepresentation, sexual misconduct, disruptive behavior and substance abuse. The class is offered in Denver, Colorado and Newark, New Jersey in the United States, and Toronto, Ontario, Canada.
Other Programs
CPEP offers a Clinical Practice Reentry Program for physicians who wish to reenter the field after a voluntary absence to enhance a physician's practice, and/or restore a physician's clinical capabilities. This program evaluates the physician’s clinical skills, including structured clinical interviews and a one-day comprehensive evaluation. Physicians are then given a reentry plan, which includes supervised clinical experience to update skills and knowledge and a detailed reporting of progress. To enter this program, physicians must have left the medical field in good standing, and they must want to reenter in the same clinical practice for which they were trained.
The Patient Care Documentation Seminar teaches physicians how to identify basic documentation guidelines, understand the legal issues associated with poor documentation and overcome barriers to good documentation. Physicians can receive up to eight continuing medical education credits and up to two Experience Rating System points for taking the class.
The Personalized Implementation Program is the follow-up class to the Patient Care Documentation Seminar. Physicians submit three sets of charts to CPEP at two, four and six months, and they receive feedback via checklists from a medical consultant on their progress at two and four months. Physicians then contact CPEP for a telephone conference with a medical reviewer and receive a final report of their progress after the last chart is submitted.


Cryptic shock

Pre-shock is also known as compensated shock, or cryptic shock describes the state in which the human body is still capable of offsetting the abnormally reduced tissue perfusion by exerting compensatory mechanism.
For instance, in a solely hypovolemia without formally entering "shock" state, the body is able to constrict peripheral vessels, accelerate heart rate, and boost myocardial contractility to compensate for the negative impacts out of a certain percentage reduction in total effective arterial blood volume. Thus, the person, particularly for those non-elderly who have higher physical reserve, might not be symptomatic of such blood loss accounted for certain amount of total blood volume in the body and might even manifest a normal systolic pressure as well as diastolic pressure. Taken together, tachycardia, a modest change in "overall" blood pressure in either trend—increase or decrease--, or hyperlactatemia that is not deemed to be "moderate to severe", are the likely only early signs of clinical shock.
Clinical shock aka uncompensated shock is termed "overt" shock.


Dan Krewski

Daniel Krewski is an Academic who is Professor of Medicine and Professor of Epidemiology and Community Medicine at the University of Ottawa, where his focus is health risk assessment in the Institute of Population Health.


Knut-Olaf Haustein

Knut-Olaf Haustein (20 September 1934 – 10 February 2006) was a German physician best known for his work studying the effects of tobacco smoking.


William Newman (American football)

William S. "Dusty" Newman (c. 1882 – July 11, 1964) was an American football player and coach. He was a first-team All-American center for Cornell University in 1906. He later coached football at the Carlisle Indian Industrial School as an assistant to Pop Warner in 1907 and at Georgetown University as the school's head coach from 1908 to 1909.
Playing career.
Newman played at the center position for Cornell University from 1904 to 1906. He was selected as a first-team All-American by Caspar Whitney in 1906. Newman played for the Cornell football team during all three years in which Glenn "Pop" Warner was the head coach. Newman also rowed in the bow seat on Cornell's varsity crews from 1906 to 1907 that won Intercollegiate Rowing Association championships. In 1927, Newman was selected as the second-team center on Cornell's all-time football team. In supporting the selection, the "New York Sun" wrote: "Although Bill Newman never weighed 170 pounds, he had the reputation of being the strongest man physically who ever attended Cornell. ... Although he attained his greatest fame as an oarsman, Newman was a bull on the gridiron with a punishing drive that carried opponents back to China." For his contributions to championship teams in both football and rowing, Newman was tapped for the Quill and Dagger society and the "Cornell Alumni News" in 1933 called him "one of Cornell's all time athletic heroes."
Coaching career.
Newman graduated from Cornell in 1907. That fall, Warner took over as the head football coach of the Carlisle Indian Industrial School. Warner hired Newman as his line coach at Carlisle. Newman was an assistant coach at Carlisle in 1907. Newman later served as head coach at Georgetown in 1908 and 1909. Newman was inducted into the Cornell University Hall of Fame in 1978. In 1913, Newman returned to Cornell as an assistant football coach.
Late life and death.
Newman was a veterinarian and worked for the Bureau of Animal Husbandry. He spent time in the Western United States treating American bison in Yellowstone National Park. Newman was reassigned in 1924 to New York State, where he worked on the eradication of tuberculosis in animals. Newman was found dead at his home of a self-inflicted gunshot, on July 12, 1964. He was estimated to have died the previous evening.


James Harlan Steele

James Harlan Steele was an American veterinarian recognized as “the father of veterinary public health” who led some of the first efforts to prevent the spread of disease from animals to humans.
Steele’s professional career spanned more than 70 years. It began in 1938 when he worked in a brucellosis testing laboratory for the Michigan State Department of Agriculture while studying veterinary medicine at Michigan State University. Brucellosis developed in many of his veterinary colleagues, and he wanted to learn how the causative pathogen and other pathogens were transmitted from animals to humans. This marked the beginning of his lifelong vocation of studying and controlling zoonotic diseases.
In 1941, Steele received a doctorate of veterinary medicine from Michigan State University, and in 1942, he earned a master of public health degree from Harvard University. In 1943, he was commissioned as a sanitarian in the Public Health Service (PHS). He spent most of World War II in Puerto Rico and the Virgin Islands, where he coordinated milk and food sanitation programs, evaluated zoonotic threats to the islands, and conducted research on brucellosis, bovine tuberculosis, rabies, and Venezuelan equine encephalitis.
References.
"This article incorporates public domain text from the CDC as cited"


Peter Ball (physician)

Peter Ball or Balle, M.D. (died 1675), was an English physician.
Ball was the third son of Sir Peter Ball of Mamhead Devon and his wife Anne Cooke, daughter of William Cooke. In 1652 he was admitted to the Middle Temple, London and called to the bar in 1657. Peter was entered as a medical student at Leyden on 13 January 1659, at the age of 20, but went on to Padua, where he took the degree of doctor of philosophy and physic with the highest distinction on 30 December 1660. To celebrate the occasion verses in Latin, Italian, and English were published at Padua, in which Ball, by a somewhat violent twist of his Latinised names, Petrus Bule, is made to figure as 'alter Phœbus.'
Ball was admitted an honorary fellow of the Royal College of Physicians in December 1664. He was one of the original fellows of the Royal Society, one of the council in 1666, and in the following year was placed on the committee to organise the cataloguing of the library and manuscripts of Arundel House, which had been presented to the society by Henry Howard, Esq., afterwards Duke of Norfolk.
While at Mamhead in October 1665, Ball and his elder brother William observed the Rings of Saturn as a band (or "fascia") upon the planet when they had apparently disappeared from being seen edge-on from Earth.
Ball died in July 1675 and was buried on 20 July in Temple Church.


Spina vestibuli

Below the opening of the orifice of the coronary sinus they fuse to form a triangular thickening—the spina vestibuli.Spina Vestibuli is a mesechymal condensation which extends from the mediastinum of the heart and covers the leading edge of the primary atrial septum; its origin is outside of the heart.


Charles McNeil (physician)

Charles McNeil FRCPE FRCP RSE (21 September 1881 – 27 April 1964) was a physician specialising in paediatrics, in particular neonatal paediatrics. He was a Fellow of the Royal College of Physicians of both London and Edinburgh, and was President of the Royal College of Physicians of Edinburgh from 1940-1943.
Life.
At the outset of World War I, he was commissioned as a Major in the Royal Army Medical Corps attached to the Scottish Branch of the British Red Cross Society, and from 1915-1918 was in command of the military hospital at Rouen.
After World War I, McNeil returned to the Royal Hospital for Sick Children, and also conducted a lectureship in children's diseases at the University of Edinburgh. On his retirement, Professor McNeil was given the honorary degree of LL.D by the University. In 1932 he was elected a Fellow of the Royal Society of Edinburgh. His proposers were James Watt, Sir Edward Albert Sharpey-Schafer, Sir David Wilkie and Arthur Logan Turner. He resigned from the Society in 1948.
Family.
In 1919, Charles McNeil married Alice Hill Workman, daughter of Thomas Workman, a company director. They did not have any children.


Anterior superior iliac spine

The anterior superior iliac spine (abbreviated: ASIS) is a bony projection of the iliac bone, and an important landmark of surface anatomy. It refers to the anterior extremity of the iliac crest of the pelvis. It provides attachment for the inguinal ligament, and the sartorius muscle. The tensor fasciae latae muscle attaches to the lateral aspect of the superior anterior iliac spine, and also about 5 cm away at the iliac tubercle.
Structure.
The anterior superior iliac spine refers to the anterior extremity of the iliac crest of the pelvis. This is a key surface landmark, and easily palpated. It provides attachment for the inguinal ligament, the sartorius muscle, and the tensor fasciae latae muscle.
A variety of structures lie close to the anterior superior iliac spine, including the subcostal nerve, the femoral artery (which passes between it and the pubic symphysis), and the iliohypogastric nerve.
Clinical significance.
The anterior superior iliac spine provides a clue in identifying some other clinical landmarks, including McBurney's point, Roser-Nélaton line, and true leg length (see unequal leg length). It is also an important surface landmark for various surgical approaches, such as treatment of hernia. The severity of symptoms of damage to the iliohypogastric nerve can show whether damage occurred above or below the anterior superior iliac spine.
Bone may be harvested from the nearby iliac crest for use elsewhere in the body. As the subcostal nerve lies close to the anterior superior iliac spine, this is put at risk of damage.
The iliotibial tract may be irritated where it passes over the anterior superior iliac spine in iliotibial band syndrome.


John Carr Badeley

John Carr Badeley (1794–1851) was an English physician.
Biography.
After education at King Edward VI Grammar School, Chelmsford and at Charterhouse, he matriculated on 16 March 1812 at Gonville and Caius College, Cambridge. He graduated there MB (Cantab.) in 1817 and MD in 1822.
Badeley was physician to Chelmsford Dispensary for twenty years. He was also inspecting physician to the lunatic asylums in Essex. He was elected FRCP in 1825. He gave the Harveian Oration in 1849 and the Lumleian Lectures in 1851.
On 9 April 1835 he married Althea Faithfull Fanshawe. They had five sons and six daughters. Among their five sons was Captain Henry Badeley, who was the father of Henry John Fanshawe Badeley, 1st Baron Badeley.


Interventional radiology

Interventional radiology (IR) is a medical subspecialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs both diagnostic and therapeutic procedures through very small incisions or body orifices. Diagnostic IR procedures are those intended to help make a diagnosis or guide further medical treatment, and include image-guided biopsy of a tumor or injection of an imaging contrast agent into a hollow structure, such as a blood vessel or a duct. By contrast, therapeutic IR procedures provide direct treatment—they include catheter-based medicine delivery, medical device placement (e.g., stents), and angioplasty of narrowed structures.
The main benefits of interventional radiology techniques are that they can reach the deep structures of the body through a body orifice or tiny incision using small needles and wires. That decreases risks, pain, and recovery compared to open procedures. Real-time visualization also allows precision guidance to the abnormality, making the procedure or diagnosis more accurate. These benefits are weighed against the additional risks of lack of immediate access to internal structures (should bleeding or a perforation occur), and the risks of radiation exposure such as cataracts and cancer.
Types of interventional radiology.
Common elements.
Interventional radiology is a set of techniques that allows access to the internal structures of the body through body orifices or very small incisions and guidance with medical imaging. Regardless of the reason for the intervention, the procedure will likely use common elements such as a puncture needle (to pass through the skin), guidewires (to guide through structures such as blood vessels or the biliary or urinary systems), a sheath (which slides over the guidewire and hold the path open without injuring it), and catheters (that allow fluids to be pushed through them).
Also common to all intervention radiology procedures are the medical imaging machines that allow the healthcare provider to see what is occurring within the body. Some use x-rays (such as CT and fluoroscopy) and some do not (such as ultrasound and MRI). In each case, the images created may be modified by computer to better visualize the structures as is in the case with digital subtraction angiography, CT and MRI, or the display of the images improved with virtual reality or augmented reality presentation.
Therapeutic interventional radiology.
"Vascular"
"Biliary intervention"
"Catheter placement"
"Ablative"
"Genitourinary"
Techniques for specific disorders.
Biliary intervention.
Gastrointestinal Bleeds.
The treatment of a gastrointestinal bleed can range anywhere from monitoring an asymptomatic bleed to supporting and maintaining the hemodynamic function of the patient. The role for the interventional radiologist is to offer patients an image-guided, minimally invasive procedure to alleviate a condition that could be otherwise be potentially life-threatening.
The avenue for the interventional radiologist to dictate the clinical course of a GI bleed is largely influenced by location of bleed, overall patient health and other conditions the patient may have, most notably heart and liver functions. For most cases, collaboration between the gastroenterologist and interventional radiologist optimizes patient outcome but again, is largely dictated by anatomical location of the GI bleed. If a patient is evaluated and determined to be a candidate for an interventional procedure, then the bleed is often treated by embolization. Embolization is a process in which the interventional radiologist accesses the culprit bleeding vessel via a small catheter and interrupts blood flow to the site of bleeding via various mechanisms. Side effects of this procedure are minimal but there is a risk of bleeding and infection—though much less than the equivalent surgical procedure. When successful, the procedure often eliminates the bleed and patients can walk after a few hours of rest.
Hepatobiliary.
A transjugular intrahepatic portosystemic shunt (TIPS) is a procedure an interventional radiologist performs to create a shunt (essentially, a new conduit allowing for blood flow) between the hepatic inferior vena cava and the portal vein, a vessel that returns blood from the intestines to the liver. The portal vein is the site where hypertension (high blood pressure) can produce a myriad of deleterious effects throughout the liver and small or large intestine.
Primarily, a TIPS functions to alleviate two different conditions: an emergent/life-threatening GI bleed or ascites (excessive abdominal fluid) caused by too high of blood pressure in the portal vein that is otherwise uncontrolled by diet and medications.
The workup for the procedure is straightforward and the interventional radiologist performing the procedure often orders several tests to assess how well the patient will tolerate the procedure. These are often simple blood tests, and an ultrasound of the heart and liver. The procedure is often well tolerated and can result in a permanent reduction or elimination of symptoms. The procedure can take anywhere between 15 minutes to an hour and has lower risks of bleeding or infection compared to an equivalent surgical procedure.
A TIPS may cause temporary confusion or worsening of liver/heart function. The degree of these two side effects largely depend on the health of the patient's heart and liver prior to the procedure and the risk-benefits of the procedure must be thoroughly discussed with their interventional radiologist before beginning. If the post-procedural consequences are more troublesome to the patient than their initial symptoms the artificial conduit created by the procedure can be reversed if the post-procedural side effects outweigh those caused by the prior conditions.
Biliary disease.
In addition to normal normal liver tissue, the liver has three main vessels traversing it: arteries, veins and bile ducts. While bile is made in the liver and stored in the gallbladder, the bile eventually passes into the GI tract through the hepatic, cystic and common bile ducts. Any condition that prevents the normal flow of bile from the liver, through these bile vessels and into the GI tract can cause a condition called jaundice.
While jaundice can be caused by a few viruses that the human body can naturally clear, jaundice in the setting of an obstruction is usually caused by a cancer and can result in intolerable itching and a worsening of liver function that can be life-threatening. Depending on a patient's condition, this type of obstructive jaundice can be alleviated with surgery or chemotherapy but if these measures fail to restore proper flow of bile, an interventional radiologist can perform a procedure called a percutaneous transhepatic cholangiography (PTC).
A PTC is an outpatient procedure lasting anywhere from 15 minutes to an hour where an interventional radiologist accesses the patient's bile duct system with a needle through the skin and liver under imaging guidance. Using fluoroscopy (essentially an Xray camera) to guide a wire (followed by a catheter over the wire) through the bile duct system and into the GI tract, essentially restoring the normal flow of bile. If the patient's GI tract cannot be accessed due to the obstruction, the catheter can be placed to drain the bile duct system into a bag that the patient can wear during daily activities. Risks of this procedure include bleeding and infection but these are much lower than an equivalent surgical procedure.
Genitourinary diseases.
Benign prostatic hyperplasia.
Benign prostatic hyperplasia, or BPH, is a noncancerous condition that commonly affects men over the age of 50. The prostate gland enlarges and compresses the adjacent urethra, making it difficult for men to control frequency and/or urgency of urination. First line therapy involves medication, though long-term treatment for symptoms that are persistent despite medical optimization typically involves transurethral resection of the prostate (TURP) as the "gold standard" of care. However, TURP can lead to urinary incontinence or permanent male infertility and may not be the ideal procedure for a certain subset of patients. For those reasons, a physician may recommend undergoing a treatment known as prostate artery embolization (PAE).
Patients typically go home the same day as the procedure and can expect to feel some symptom relief in a matter of days. Though rare, risks of PAE include unintentional embolization of nearby blood vessels, which can result in loss of blood flow to surrounding areas of the bladder or rectum.
Data suggests that TURP may have higher rates of symptom resolution at 1 and 6 months, but PAE appears to provide lower risks of complications more commonly associated with surgery, such as infection.
Kidney stone disease.
Kidney stones can be present along any part of the course of the urinary tract from the kidneys to the urethra. The most common symptoms, whether in men or women, are sudden onset, intense flank pain accompanied by blood in the urine. Most kidney stones pass spontaneously, but larger ones (greater than 5 mm) are less likely to, and can cause severe pain or infection.
The interventional radiologist plays a large clinical role in the treatment of kidney stones that are unlikely to pass on their own. The gold standard of treatment for these types of stones is surgical removal. However, some patients have an infected stone and are simply too ill for an operative surgical removal. In these instances, the mainstay of IR treatment is a percutaneous nephrostomy tube. This is a procedure where a small caliber catheter is placed through the skin and into the urinary collecting system upstream of the stone. This procedure not only drains any infection, often bringing about a precipitous improvement in the patient's symptoms but also diverts urine—thus giving the patient more time to recover before definitive surgical treatment.
Varicocele.
A varicocele is defined as an enlargement of the veins within the scrotum, most commonly occurring on the left side due to anatomical reasons. When this happens, blood can stagnate within these dilated veins and cause temperature fluctuations within the testicle itself. The exact cause to this condition remains unknown and an ill-favored sequela can be male infertility.
The mainstay of treatment for this condition within the field of interventional radiology is varicocele embolization. An embolization, within the context of this procedure, results in the interruption of venous blood flow. The interruption of blood flow abates venous dilation of blood that can lead to impaired testicular temperature regulation and theoretically improve infertility. The physician accesses the dilated scrotal veins with a small catheter via a vein in the groin and embolize the varicocele. Patients often tolerate this procedure well and are able to return home the same day.
Neurological intervention.
Acute ischemic stroke.
About 87% of all strokes are ischemic strokes, in which blood flow to the brain is blocked. A clot-busting medication such as tissue plasminogen activator (t-PA) can be used in a controlled hospital setting to dissolve the clot and help restore blood flow to the damaged area of the brain. Certain patients who are suffering from an acute ischemic stroke may be candidates for endovascular therapy. Endovascular therapy is a procedure performed by neurointerventionalists to remove or dissolve the thrombus (clot) and restore blood flow to parts of the brain. Using a catheter that is directed through the blood vessels in the arm or leg up to the brain, the interventionalist can remove the thrombus or deliver drugs to dissolve the thrombus. These procedures are referred to as mechanical thrombectomy or thrombolysis, and several factors are considered before the procedure is completed.
People who may be eligible for endovascular treatment have a "large vessel occlusion", which means the thrombus is in an artery that is large enough to reach and there are no contraindications such as, a hemorrhagic stroke (bleeding in the brain), greater than six hours since onset of symptoms, or greater than 24 hours in special cases. Hospitals with comprehensive stroke centers are equipped to treat patients with endovascular care.
Long-term care after an ischemic stroke is focused on rehabilitation and preventing future blood clots using anticoagulant therapy. Patients work with specialists from fields such as physical therapy, occupational therapy, and speech therapy to complete recovery.
Intracranial aneurysm.
Although there are no clearly defined recommendations on treatment of asymptomatic aneurysms, all symptomatic unruptured brain aneurysms should be treated. Endovascular therapy is an effective treatment for select cases. During this treatment, an interventional radiologist inserts a catheter into the patient's leg and uses it to guide a coil through blood vessels to the site of the aneurysm. The coil induces clotting within the aneurysm, which reduces the risk of rupture. Multiple coils may be used depending on the size. Imaging studies (DSA, CTA, or MRA) help characterize the aneurysm to decide the best course of treatment, whether endovascular coiling or surgical clipping. Endovascular coiling is associated with a reduction in procedural morbidity and mortality over surgical. For cases of ruptured aneurysms, emergent treatment is based on the type of aneurysm, and may use a combination of techniques. Conservative therapy focuses on minimizing modifiable risk factors with blood pressure control and smoking cessation.
Cerebral arteriovenous malformation.
Arteriovenous malformations (AVMs) are abnormal blood vessel structures in which an artery connects to a vein via an abnormal channel. This creates a high flow system that puts the vessel at risk of rupture. Ruptured AVMs require emergency management of the patient; unruptured AVMs require expert consultation to discuss the risks and benefits of treatment. Current treatment options include conservative management, surgical resection, stereotactic radiosurgery, endovascular embolization, or combinations of these treatments. Endovascular embolization is a technique used by neurointerventionalists in which particles, glue, or coils are lodged inside the AVM to prevent blood flow through the abnormal channel. During this treatment, an interventional radiologist guides a catheter through a blood vessel accessed from the patient's leg to the site of the AVM. The particles, glue, or coils induce clotting within the malformation, which reduces the risk of rupture.
Pain management.
Joint and local injections.
Utilizing image guidance, local anesthetics and/or long-acting steroid medications can be directly delivered to localized sites of pain. The use of image guidance helps to confirm appropriate needle placement. This includes common imaging modalities used in joint injections: ultrasound, fluoroscopy and computerized tomography (CT).
Vertebral augmentation.
Vertebral augmentation, which includes vertebroplasty and kyphoplasty, are similar spinal procedures in which bone cement is injected through a small hole in the skin into a fractured vertebra to try to relieve back pain caused by a vertebral compression fractures. It was found ineffective in treating osteoporosis-related compression fractures of the spine. The people in both the experimental and placebo groups reported improvement in their pain, suggesting that the benefit is related to the placebo effect. , routine use is thus not recommended.
Interventional oncology.
Diseases treated.
Interventional oncology (IO) procedures are commonly applied to treat primary or metastatic cancer. IO treatments may be also offered in combination with surgery, systemic chemotherapy/immunotherapy, and radiation therapy to augment the therapeutic outcome. A variety of interventional oncological treatments for tumors arise:
Vascular disease.
Vascular Disease refers to disorders of the vasculature or circulatory system, most commonly involving the arteries, veins and lymphatics. The symptoms related to vascular disease can range from asymptomatic, bothersome symptoms or limb and/or life-threatening conditions.
Vascular and Interventional Radiologists are at the forefront of treating a wide variety of vascular diseases.
Basics of vascular intervention.
Since its development by Charles Dotter when he did a percutaneous peripheral vascular revascularization procedure for the first time on January 16, 1964 on Laura Shaw, Vascular & Interventional Radiology (commonly Interventional Radiology or IR) distinguished itself from earlier approaches to vascular disease by the use of medical imaging to guide endovascular therapies (fixing this from inside the vessel). The Seldinger technique is the basic principle that underlies endovascular procedures. Briefly, this involves using a needle to puncture a target vessel, then using a series of small medical guidewires and catheters to pass various tools inside for treatment. When these minimally-invasive techniques can be used, patients avoid the need for larger surgical exposure to treat diseased vessels. Though numerous factors can affect patient's post-operative course, in general an endovascular approach is associated with a more rapid recovery time compared to a traditional open vascular surgery.
Over the past few decades, many endovascular procedures have been developed and refined. Numerous tools are at the disposal of modern Vascular and Interventional Radiologists to perform these procedures, and developing new tools is a burgeoning focus of international research.
While some Interventional Radiology endovascular procedures are highly specialized, a few standard techniques apply to most:
The goal of endovascular therapy is to revascularize an affected or diseased vessel.
Arterial disease.
Arteries are the component of the circulatory system that carry oxygenated blood away from the heart to the vital organs and extremities. Arteries have relatively thick, muscular walls, composed of multiple layers, because they transport freshly oxygenated blood through the body at relatively high pressures. Arterial diseases can affect one or multiple layers of the artery wall.
The aorta is the largest artery in the body, and the major aortic branches continue to divide multiple times, giving way to smaller arteries, muscular arterioles and thin-walled capillaries. In contrast to arteries, capillaries have thin single-layered walls, so oxygen and nutrients can be exchanged with tissues in capillary beds before the de-oxygenated blood is carried away by the venous system.
Perfusion refers to the flow of oxygen and nutrient rich blood into the capillary beds of the muscles and organs, this is critical for their function. The lack of adequate perfusion is referred to as ischemia and is typically the cause of symptoms related to vascular disease. The goal of revascularization therapies, whether endovascular or surgical, is to re-establish or optimize perfusion and stop ischemia.
Atherosclerosis refers to a progressive narrowing of the arteries due to atheroma, derived from the Greek word for gruel or porridge. Atheromatous plaque is a mixture of fat and inflammatory debris that sticks to the inner walls of an artery. Plaque can be soft or become firm as it accrues layers of calcium, a byproduct of chronic inflammation. Atherosclerosis has no single cause but many recognized risk factors. Some risk factors are modifiable, and others are not. Age and genetic predispositions are an example of "non-modifiable" risk factors. Medical management of atherosclerosis aims to address the many other known "modifiable" risk factors, such as smoking, diet, exercise as well as blood sugar levels in patients with diabetes. Using medications to control blood pressure and cholesterol have also been shown beneficial.
Atherosclerosis is described, evaluated, and treated differently depending on the affected artery, as described below. However, multiple studies have shown strong correlations between the different types of atherosclerosis. In particular, patients with Peripheral Arterial Disease have an increased risk of Coronary Artery Disease, and severe Peripheral Artery Disease symptoms can be a predictor of cardiac related mortality. The majority of patients begin to develop symptoms from ischemia around middle age, even though vessel narrowing can develop silently and slowly over decades. Unfortunately, sudden cardiac death or stroke can be a patient's first sign of vascular disease. Therefore, controlling risk factors is crucial in those with known atherosclerosis to prevent progression of disease, and screening is recommended by some Vascular Disease Specialists for those at increased risk, such as those with diabetes, smoking or a strong family history of cardiovascular disease.
Screening tests typically use the non invasive evaluation called the Ankle-Brachial Index, which compares the blood pressure between the arm and the ankle. This can help detect narrowing in the major vessels of the chest, abdomen, pelvis, and legs. CT scans of the heart with evaluations of coronary artery calcium are also used in some instances to stratify risk of coronary artery disease.
Historically, open vascular surgical approaches were required for all critically advanced atherosclerotic disease. An endarterectomy is a large operation, where blood flow is temporarily stopped using clamps, the vessel is cut open, the plaque removed and then the vessel resealed. If an occlusion is too dense or complex, a bypass could also be performed, where two segments of vessel are bridged by an additional vein or synthetic graft.
Modern endovascular approaches to treating atherosclerosis can include combinations of angioplasty, stenting, and atherectomy (removal of plaque).
Peripheral Arterial Disease (PAD, sometimes PVD or “Peripheral Vascular Disease”) is most often a result of atherosclerosis and affects the arteries of the lower extremities, those below the aortic bifurcation. A hallmark symptom is claudication, or progressive pain in a limb associated with activity, due to ischemia. As the perfusion to a limb diminishes further pain in the foot can occur even at rest and in fact the tissues of the foot can even die.
There are several systems for staging PAD, but an often used scale is the revised Rutherford Classification. Plaque and blood flow can be evaluated using ultrasound, CT Angiography, MR angiography and catheter based angiography to establish anatomic segments of disease. The severity of ischemia can be evaluated by correlating symptoms and non-invasive physiologic vascular studies including toe pressures, TCPO2, and skin perfusion studies.
Certain monitored exercises, such as walking regimens, have been shown to significantly improve walking distance especially when used consistently for at least 6 months. When medical management fails, Vascular Interventional Radiologists can attempt to restore blood flow to extremities using angioplasty and stenting. Sometimes repeat interventions are required. The goal of therapy is to maintain perfusion, avoid amputation and preserve the limb structure and function.
Aneurysm refers to pathologic dilation of an artery to greater than 1.5 times its normal size. True vascular aneurysms are due to degenerative processes in the wall of the artery. Aneurysms can be solitary or multiple and are sometimes found in association with various clinical syndromes, including forms of vasculitis or connective tissue diseases. Aneurysms are typically classified by major shapes, either fusiform (tubular) or saccular (eccentric). Ectasia is another broad term for an enlarged vessel, but is not necessarily pathological. Rupture is a dreaded complication of aneurysms that can lead to extensive, difficult to control bleeding. Aneurysms can also clot, or thrombose, and rapidly occlude the involved vessel, leading to acute distal ischemia.
A variety of endovascular grafts are available, and each has advantages and disadvantages depending on the characteristics of the aneurysm and patient (RFS EVAR/TEVAR webinar: https://www.youtube.com/watch?v=rjRClHP1dEc)
Dissection refers to a tear in the inner layer of the arterial wall. Blood pumps into this defect and dissects its way between the layers in the wall of an artery, creating a false channel separate from the true arterial lumen. Dissections can develop due to trauma, spontaneously due to high blood pressure and native vascular disease, or in some cases as a complication of prior surgical or endovascular treatment.
When an arterial dissection expands, it can restrict normal flow through the affected artery or potentially block the origin of a branch vessel- this can compromise distal perfusion in either case. When acute and symptomatic, this is an emergency that requires prompt treatment.
However, as medical imaging has improved, chronic, asymptomatic dissections have also been discovered, and in some cases these may be safely managed with blood pressure control, follow-up imaging and proper counseling for the warning signs of potential ischemia.
Dissections can occur in any artery and are named for their vessel of origin. Aortic dissections can be further classified and treated depending on whether they involve the thoracic aorta, the abdominal aorta or both. Classic pain related to acute aortic dissections is described as “tearing” or “ripping” and possibly radiating to a patient's back. Acute aortic dissection can be difficult to diagnose but is more common than aortic aneurysm rupture.
Thoracic aortic dissections are further characterized with the Stanford classification. Type A dissections involve the root and ascending aorta. These require prompt treatment, which currently is mostly surgical in nature. Type B dissections begin in the distal aortic arch beyond the left subclavian artery origin, and may often be addressed with pain medication and blood pressure control. If the type B aortic dissection results in poor circulation to the intestines, kidneys or legs it often requires urgent endovascular repair with endografts and/or fenestrations. If a type B aortic dissection has ruptured, or has features that indicate impending rupture, they are urgently repaired too.
Dissections can also arise in virtually any other artery. Carotid artery Dissection, for example, places patients at increased risk for stroke and may extend further into the blood vessels within the brain. Vertebral Artery Dissection are less common but also dangerous for similar reasons. Mesenteric Artery Dissection may limit the blood supply to the intestines. Renal Artery Dissections can decrease blood flow to the kidneys and contribute to hypertension. Peripheral Arterial Dissections can be found elsewhere in the arms and legs. These dissections can occur primarily due to focal traumas, underlying vascular disease, or as an extension of a larger, complex aortic dissection that tears further into these smaller branches.
Treatment of dissections depends on several factors, including the location, extent, how long it has been developing (acute or chronic) and whether it is limiting perfusion. Surgical approaches to dissections can include reconstructing the aorta, surgical bypass and surgical fenestration. Like other arterial disorders, endovascular approaches to dissection such as stent-grafting and percutaneous fenestration can be utilized- either primarily or in combination with surgery depending on the complexity of the dissection.
Penetrating Aortic Ulcer (PAU)is an advanced focal form atherosclerosis, most often encountered in the aorta. It starts as a small plaque in the inner-most layer of the aorta called the intima, but the inflammatory process ulcerates and penetrates through this layer into the media. While PAU is considered a distinct entity, many think this is a precursor lesion to dissection or aneurysm. Along with Intramural Hematoma, Aneurysm and Dissection, PAU is recognized as one of several Acute Aortic Syndromes—a spectrum of related conditions correlated to potential aortic rupture. They thus have a high potential morbidity and mortality, and should at least be followed closely.
Acute or Active Bleeding can occur throughout the human body due to a variety of causes. Interventional Radiologists can address bleeding with embolization, usually with small plastic particles, glues or coils. Traumatic rupture of a blood vessel, for example, may be addressed this way if a patient is at risk of fatal bleeding. This has revolutionized medicine and interventional radiologists commonly treat refractory nose bleeds, excessive coughing of blood, intestinal bleeding, post-pregnancy bleeding, spontaneous intra-abdominal on intra-thoracic bleeding, bleeding related to trauma and post-surgical bleeding. In some instances where severe bleeding is anticipated, such as in complex surgery or the excision of a highly vascular tumor, Interventional Radiologists may embolize certain target blood vessels prior to the operation to prevent major blood loss.
Transplant Organs rely on healthy blood supply to survive. In some instances, the arteries that feed a transplant may narrow, typically where the donor vessel is sewn to the recipient. Interventional Radiologists evaluate the blood supply of these patient's and may use balloons or stents to open narrowed vessels and keep the transplant organ functional.
Venous disease.
The veins of the human body are responsible for returning de-oxygenated blood back to the heart. Like a rock rolling down a hill, blood flows from the highest pressure (the blood in the aorta) to the lower venous pressure (the blood in the vena cava as it empties back to the heart.) Unlike arteries, veins are thin walled and distensible, allowing them to accommodate large volumes of blood without significant changes in pressure. In fact, the venous system is so low pressure that veins have valves to keep blood from flowing backward. The motion of the human body helps pump blood through the veins- squeezing leg muscles while walking, for instance, helps push venous blood back up to the heart against the pull of gravity. Unfortunately, without this extra push some blood can sit stagnant in veins, leading to a multitude of clinical problems. The largest vein in the body is the vena cava. The superior vena cava (SVC) drains blood from the top half of the body while the inferior vena cava (IVC) drains blood from below the diaphragm. Elsewhere in the body, veins can be categorized into superficial, primarily associated with the skin and soft tissues, or deep veins, which drain muscles and organs.
Venous access.
Chronic Kidney Disease (CKD or Chronic Renal Disease) is a condition in which there is a progressive loss of kidney function. It has numerous recognized causes and risk factors. CKD affects approximately 14% of the world population, and over 600,000 people in the United States alone. There are five recognized stages of CKD, the fifth stage is also called End-Stage Renal Disease (ESRD) and invariably requires some form of renal replacement therapy.
Around the turn of the 20th century, breakthroughs in our understanding of renal physiology led many to believe that dialysis using artificial kidneys was a potential cure for renal disease. Over 100 years later, the only available curative, renal replacement therapy for CKD is kidney transplantation. However, many patients can live for decades utilizing dialysis.
Dialyzer technology initially outpaced the ability of clinicians to apply it to patients. In the 1920s, the first dialysis catheter was created using thin fragile glass tubes. Early methods required surgical incision to reach large vessels, which carried a large risk of major bleeding. The first somewhat permanent, reliable dialysis access, the Scribner Teflon Shunt, was invented nearly 40 years later and allowed a patient with kidney failure to survive 11 more years. As medicine and surgery have grown more sophisticated, more patients now live with chronic renal disease than ever before. The most common type of dialysis in the United States is hemodialysis, which can be performed through several types of vascular access. The Arteriovenous Fistula (AVF) is the preferred method. [Arteriovenous Fistula] (AVF) are created surgically by directly connecting an artery and a vein, most commonly in the arm. An Arteriovenous Graft (AVG) relies on the same principle but bridges the gap between the artery and vein with a medical-grade prosthetic shunt. Over time, altered flow mechanics can result in changes within the involved vessels. Vascular narrowing, thrombosis, aneurysms and pseudoaneurysms are commonly encountered complications over the life of an AVF or AVG. Interventional radiologists can use angiography to evaluate these structures (commonly called a Fistulogram) and treat dysfunctional access with angioplasty, stenting, and thrombectomy. Most patients require regular evaluation and treatment to keep their access working. When possible, AVFs are preferred to AVGs due to their relatively lower complication rate and longer patency. The Fistula First initiative works to promote physician and patient awareness about the benefits of first attempting hemodialysis through a fistula. There are a few devices (endo AVF) that are being utilized by interventional radiologists to percutaneously create fistulas in a minimally invasive fashion.
Dialysis Catheters include temporary and tunneled large-bore central venous access lines placed for administering hemodialysis. When possible, these catheters are placed in the right internal jugular vein, but the left internal jugular and femoral veins may also be utilized. Temporary dialysis lines may be placed when patients are hospitalized and either too sick or at a high risk of bleeding. Permanent hemodialysis catheters are longer overall but a segment is tunneled through the skin of the chest, which lets the catheter lie flat and lowers the risk of infection.
Central Venous Access refers to a variety of intravenous catheters placed in patients requiring certain long-term medications. These are much smaller in diameter than dialysis lines, but are larger and longer than a standard intravenous line (IV.) Examples include Hickman Catheters, Peripherally Inserted Central Cathethers (or PICCs), Tunneled small bore central venous catheters and Mediports. These lines differ in where they are inserted but are all placed under imaging guidance and adjusted so the end of the catheter sits in the vena cava adjacent to the heart. These catheter are designed to deliver strong medications, such as chemotherapy or prolonged courses of antibiotics, which are either dosed too frequently to keep placing new IVs or too irritating to small veins be injected through a standard IV.


Guillaume de Baillou

Guillaume de Baillou (Latin: Ballonius) (1538–1616) was a French physician born in Paris. He was a member of the Baillou family, one of the oldest aristocratic families in Europe.
He studied at the University of Paris, where he was a pupil of Jean Fernel (1497–1558). He attained his Bachelor of Arts degree in 1568, and his medical doctorate in 1570. He was an instructor in Paris for 46 years, and eventually became dean of the Faculty of Medicine. For a period of time he was personal physician to Henry IV (1553–1610).
Guillaume de Baillou is considered to be the first epidemiologist since Hippocrates, and is credited as the founder of modern epidemiology. He did extensive studies of epidemics that plagued Paris, and is additionally credited with providing the first clinical description of pertussis (whooping cough) in 1578. He also provided the first modern descriptions of rheumatism and arthritis of which he defined in the treatise "Liber de Rheumatismo et Pleuritide dorsali".
Guillaume de Baillou is an ancestor of (1684-1758) whose famous geology collection provided the basis for today's Natural History Museum of Vienna, Austria.
Descendants of Guillaume de Baillou live in Germany, Austria and the United Kingdom.


USMLE Step 2 Clinical Skills

Step 2 Clinical Skills (Step 2 CS) of the United States Medical Licensing Examination (USMLE) was an exam administered to medical students/graduates who wish to become licensed physicians in the U.S. It is similar to the COMLEX-USA Level 2-PE exam, taken by osteopathic medical students/graduates who seek licensure as physicians in the U.S. For US medical students, the exam fee is $1,300 (as of 2020). For medical students at non-US medical schools, the tests cost is higher—currently $1,535. These fees do not include costs associated with travel and lodging to take the test. Historically, US students have taken Step 2 CS late in their senior year, prior to graduation. However, now that more residency programs require students to record a passing score, many US medical schools recommend students take Step 2 CS in the fall of their senior year.
On May 26, 2020, in response to the COVID-19 pandemic, the USMLE "suspended Step 2 CS test administrations for the next 12-18 months."
On January 26, 2021, the USMLE announced that the work to relaunch a modified form USMLE Step 2 CS had been discontinued citing rapidly evolving medical education and changes in other standardized exams, like computer-based simulations in Step 3, that would supplement medical students' education in place of Step 2 CS.
Structure.
The USMLE Step 2CS exam consists of a series of patient encounters in which the examinee must see standardized patients (SPs), take a history, do a physical examination, determine differential diagnoses, and then write a patient note based on their determinations. The topics covered are common outpatient or Emergency Room visits which are encountered in the fields of internal medicine, surgery, psychiatry, pediatrics, and obstetrics and gynecology. Examinees are expected to investigate the simulated patient's chief complaint, as well as obtain a thorough assessment of their past medical history, medications, allergies, social history (including alcohol, tobacco, drug use, sexual practices, etc.), and family history. Usually, examinees have one telephone encounter, speaking to an SP through a microphone during which there is no physical exam component.
Examinees are allowed 15 minutes to complete each encounter and 10 minutes for the patient note for a single patient encounter. The patient note is slightly different from a standard SOAP note. For the exam note, the examinees will document the pertinent facts relating to the history of present illness as well as elements of the past medical history, medication history, allergies, social history, family history, and physical exam. The examinees will then state up to 3 differential diagnoses relating to the simulated patient's symptoms, and tests or procedures to investigate the simulated patient's complaints. The examinees should also list pertinent positive and negative findings to support each potential diagnosis. The examinees will not recommend any specific treatments in the note in contrast to a true clinic SOAP note (i.e., IV fluids, antibiotics, or other medications). Over the course of an 8-hour exam day, the examinees complete 12 such encounters. Examinees are required to type patient notes on a computer.
USMLE Step 2 CS replaced the former ECFMG Clinical Skills Assessment (CSA) effective June 14, 2004. The last administration of the ECFMG Clinical Skills Assessment (CSA) took place on April 16, 2004. When the CSA first started it was strictly for Foreign Medical Graduates while US graduates were not required to do it. That was considered a double standard in the US medical licensing process. Later the CSA was replaced with the USMLE step 2 CS and became inclusive to all medical graduates.
Grading.
The test is graded on a pass/fail basis, without any numerical score associated with it (as opposed to the other parts of the USMLE series). Examinees are scored on three separate subcomponents: Communication and Interpersonal Skills (CIS), Spoken English Proficiency (SEP), and Integrated Clinical Encounter (ICE). Each of the three subcomponents must be passed in a single administration in order to achieve a passing performance on Step 2 CS.
Exam centers.
This exam can be taken in the U.S. at five Clinical Skills Evaluation Centers (CSEC), located in:
Controversy.
The Step 2 CS exam was added to the USMLE series in 2004 by the NBME and FSMB. However, the test garnered criticism for its high exam fee and need to travel to one of five testing sites. Even before the exam was rolled out, the American Medical Association raised serious concerns with the exam, both because it failed to provide students feedback and room for remediation and because there was no proof the exam actually accomplished its mission of protecting the public.
Beginning in 2004, the USMLE program undertook a comprehensive review of the USMLE, referred to as the Comprehensive Review of USMLE (CRU). The review was overseen by the committee to Evaluate the USMLE Program (CEUP), which was composed of students, residents, clinicians, and members of the licensing, graduate, and undergraduate education communities. The goal of the committee was to determine if the mission and purpose of USMLE were effectively and efficiently supported by the current design, structure, and format of the USMLE. This process was to be guided, in part, by an analysis of information gathered from stakeholders, and was to result in recommendations to USMLE governance. The CEUP worked from 2006 to early 2008. The CEUP's final report states that "none of the feedback (received from other stakeholders) seemed to indicate that USMLE is broken, but there was considerable interest in enhancing and improving the program." Additionally, the report states that "there appeared to be very strong reactions to Step 2 CS, and CEUP felt that survey and stakeholder meeting data on this component needed to be interpreted in a special way by attempting to separate (but still be attentive to) issues related to the mechanics and costs of Step 2 CS versus the value of what the exam is intended to measure. On the issue of mechanics and costs, CEUP recognized that USMLE must be very attentive to the burden put on examinees by this testing format and that the impact on examinees must be considered when proposing future directions. Concerning the skills measured by Step 2 CS, there seemed to be legitimate concerns about content. Many people wanted to see the exam begin to assess whether the examinee can detect and interpret abnormal findings and handle challenging communication issues. There was a frequently expressed sentiment that this exam was ripe for enhancement and that many of the more advanced communication skills and other competencies could be assessed through this vehicle." In response to the feedback gathered, the CEUP recommended that "the assessment of clinical skills remain a component of USMLE, but that USMLE consider ways to further enhance the testing methods currently used, in order to address additional skills im-portant to medical practice. It is also recommended that the administrative challenges and costs to examinees as-sociated with related testing formats be given substantial weight in the consideration of future changes."
In 2013, an article published in the New England Journal of Medicine raised concerns about the value of the exam. The authors calculated that the test fee alone cost students $36 million annually, and that the cost of detecting a single student who failed the exam on back-to-back attempts was $1.1 million. A letter to the editor from the leadership of the NBME and the FSMB in response to the article highlighted the need to view the value of the Step 2 CS in terms other than just cost; specifically, they state that, "Although (the authors') interest in cost is consistent with the current climate in health care, the 'value' referenced in their title is a function of quality as well as cost. They fail to fully consider the long-term effect of this assessment program on patient safety and satisfaction, societal expectations, and effective medical education." They also note that inclusion of Step 2 CS in the USMLE "brought the USMLE closer to meeting the expectations of the public that physicians exhibit competence in communicating with and examining patients."
In February 2016, a group of students at Harvard Medical School launched a national petition calling for an end to Step 2 CS. Since the petition opened, it has collected over 20,000 signatures from medical students and physicians from all over the country.
In May 2016, the Massachusetts Medical Society and the Michigan State Medical Society have passed resolutions calling for the elimination of Step 2 CS.
In June 2016, the Arizona Medical Association and the AMA - Medical Student Section passed resolutions also calling for the elimination of Step 2 CS. All four resolutions were introduced to the American Medical Association's 2016 Annual House of Delegates meeting, and were combined and adopted as a substitute, single resolution by a unanimous voice vote on 6/15/2016. The adopted language calls for the AMA to work with the FSMB, NBME, state medical societies, and state medical boards to pursue the transition from the Step 2 CS exam to a school-administered clinical skills exam as a licensure requirement.
March 16, 2020, USMLE cancelled all appointments for the USMLE STEP 2 CS exam due to the COVID-19 pandemic. Scheduling functionality for the exam has also been cancelled. It remains to be seen what actions will be taken by the respective authorities given the fluid nature of the pandemic and the person-to-person nature of this exam.
On May 26, 2020, USMLE has "decided to suspend Step 2 CS test administrations for the next 12-18 months."
The USMLE announced on January 26, 2021, that "[they] have decided to discontinue Step 2 CS."


Josef Arneth

Josef Arneth (13 October 1873, in Burgkunstadt – 1955) was a German physician and haematologist known for naming the Arneth count.
He studied medicine at universities in Munich, Heidelberg and Würzburg, qualifying in 1897. He subsequently worked in Würzburg before becoming professor of medicine in Münster in 1907, a position he held until 1944. He published several books on haematology, and produced research on neutrophils and their changes in reaction to infection for which he is remembered.