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The Clinical Presentation

• First Online: 01 January 2013

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• Sergio V. Delgado 3 &
• Jeffrey R. Strawn 4  

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Presenting case material to colleagues requires preparation, whether the presentation is to be made casually during bedside rounds or in the formal environment of a national meeting. It is rewarding when a presentation is well received, particularly because it may prove helpful to other clinicians, allied health professionals, and researchers. Regardless of the setting, the presenter’s goal is to share their knowledge based on observations they have made and lessons they have learned from the case or cases. The most time-consuming aspect of the patient-oriented presentation is collecting and organizing as much information as possible about the patients, their families, and others who were involved in the patients’ care. Once these tasks are complete, the presenter must summarize the information and place it within the context of treatment data and consensus approaches. Tailoring the talk to the audience is also of paramount importance. Different groups will invariably come from different disciplines, and the presentation will need to be tailored to accommodate each audience’s background, interests and goals.

Make everything as simple as possible, but not simpler —Albert Einstein (1879–1955)

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Altman LK (2006) Socratic dialogue gives way to powerpoint®. New York Times, 12 Dec 2006

Google Scholar  

Blechner MJ (2012) Confidentiality: against disguise, for consent. Psychotherapy (Chic) 49(1):16–18

Article   Google Scholar  

Clifft MA (1986) Writing about psychiatric patients. Guidelines for disguising case material. Bull Menninger Clin 50(6):511–524

PubMed   CAS   Google Scholar  

Copeland HL, Hewson MG, Stoller JK et al (1998) Making the continuing medical education lecture effective. J Contin Educ Health Prof 18:227–234

Gabbard GO (2000) Disguise or consent: problems and recommendations concerning the publication and presentation of clinical material. Int J Psychoanal 81:1071–1086

Article   PubMed   Google Scholar  

Gabbard GO, Williams P (2001) Preserving confidentiality in writing of case reports. Int J Psychoanal 82:1067–1068

Article   PubMed   CAS   Google Scholar  

Hull AL, Cullen RJ, Hekelman FP (1989) A retrospective analysis of grand rounds in continuing medical education. J Contin Educ Health Prof 9(4):257–266

Lorin MI, Palazzi DL, Turner TL et al (2008) What is a clinical pearl and what is its role in medical education? Med Teach 30(9–10):870–874

Sackett DL, Rosenberg WM, Gray JA et al (1996) Evidence based medicine: what it is and what it isn’t. Br Med J 312:71–72

Article   CAS   Google Scholar  

Tuckett D (2000) Reporting clinical events in the journal: towards the constructing of a special case. Int J Psychoanal 81:1065–1069

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Delgado, S.V., Strawn, J.R. (2014). The Clinical Presentation. In: Difficult Psychiatric Consultations. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-39552-9_8

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Effectiveness of Clinical Presentation (CP) Curriculum in teaching clinical medicine to undergraduate medical students: A cross-sectional study.

Saroj adhikari yadav.

1 Patan Academy of Health Sciences, Kathmandu, 44600, Nepal

Sangeeta Poudel

Swotantra gautam.

2 B P Koirala Institute of Health Sciences, Dharan, Nepal

Sanjay Kumar Jaiswal

Samikchya baskota, aaradhana adhikari, binod duwadi, nischit baral, sanjay yadav.

3 Institute of Medicine, Kathmandu, 44600, Nepal

Associated Data

Underlying data.

Figshare: CP Curriculum Raw data updated in Excel and PDF. https://doi.org/10.6084/m9.figshare.18666410.v1 10

This project contains the following underlying data:

• - Analysis and Raw data.xlsx

Extended data

This project contains the following extended data:

• - CP Questionnaire for Faculties.pdf
• - CP Questionnaire for students.pdf
• - CP Surprise exam Questionnaire.pdf

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Peer Review Summary

Introduction:  The Clinical Presentation (CP) curriculum was first formulated in 1990 at the University of Calgary, Canada. Since then, it has been adopted at various medical schools, including Patan Academy of Health Sciences (PAHS), a state-funded medical school in a low-income country (LIC), Nepal. This study aims to evaluate the perceived effectiveness of the CP curriculum by students and faculty at PAHS, and test knowledge retention through a surprise non-routine exam administered to students. 

Method:  This is a cross-sectional study to evaluate the efficacy of the CP curriculum in teaching clinical medicine to the first batch of MBBS students of PAHS School of Medicine. Ethical approval was obtained from the Institutional Review Committee (IRC)-PAHS (Ref no std1505911069). Perceived effectiveness was evaluated using a set of questionnaires for faculty and students. A total of 33 students and 34 faculty filled the perception questionnaires. Subsequently, a questionnaire consisting of 50 Multiple Choice Questions (MCQs) from different clinical medicine disciplines was administered to test students’ knowledge retention. Out of 49 students, 38 participated in the surprise non-routine exam.  

Result:  A significantly higher number of faculty preferred the CP curriculum compared to the traditional system of teaching clinical medicine (16 vs 11, Kruskal Wallis: 0.023, ie. P-value < 0.05). A significantly higher number of the students liked and recommended CP curriculum in the clinical year of medical education (20 vs. 13 with p-value < 0.05). In the non-routine surprise exam, two thirds of the students scored 60% or above. 

Conclusion: Both faculty and students perceive that the CP curriculum system is an effective teaching and learning method in medical education, irrespective of their different demographic and positional characteristics. The students’ overall performance was good in surprise, non-routine exams taken without scheduling or reminders.

Introduction

Sir William Osler, considered the father of modern medicine, emphasized the teacher's role in helping students to observe and reason. He recommended abolishing the traditional lecture method of instruction. 1 Medical education is evolving in response to scientific advances and societal needs. 2 A well-organized comprehensive knowledge domain has practical implications in clinical problem solving, and appropriate teaching and learning methods play an important role in achieving the educational goals. 3

Clinical presentation (CP) is a relatively new and innovative approach to teaching medicine. CP engages medical students in their understanding of the disease process from clinical feature to diagnosis. Students begin studying abnormalities of complaints, examination, and laboratory findings; i.e., signs, symptoms, and laboratory investigations which a patient presents to the doctor with. Students then progress towards diagnosis. The underlying philosophy of the CP Curriculum is that: “The reaction of the human body to an infinite number of insults is always finite and stable over time”. 4 For example, if there is any attack on the respiratory system, whether infectious, inflammatory, immunological, traumatic, or iatrogenic; the respiratory system responds through coughing, cyanosis, chest pain, difficulty breathing, noisy breathing, or hemoptysis. 4 Thus, the CP Curriculum aims to help students understand the process of moving from “symptoms to diagnosis.”

The CP curriculum was first formulated in 1990 at the University of Calgary Faculty of Medicine in Canada. 5 The curriculum was adopted and redesigned based on local needs at various medical schools worldwide. Patan Academy of Health Sciences (PAHS), a state-funded medical school in Nepal, has adopted several new and innovative approaches in teaching and learning medicine. The CP Curriculum is one of the several approaches adopted by PAHS. 6

PAHS medical education team assumes that the CP curriculum is better than traditional lecture-based teaching. In this study we are testing the perceived effectiveness of students and faculty, and the level of knowledge among the students trained by the CP curriculum. The level of knowledge was assessed by marks scored by the students in a surprise non-routine exam without prior information. Perceived effectiveness was based on the thinking/perception of the students and faculty on the effectiveness of the CP curriculum. We assume the CP curriculum is at least not inferior to traditional lecture-based teaching.

Study design

This is a cross-sectional study that aims to evaluate the efficacy of the CP curriculum in teaching different disciplines of clinical medicine to undergraduate medical students of PAHS, which is currently the only medical school implementing the CP-curriculum in undergraduate medical education. A new Multiple-Choice Question (MCQ) based questionnaire was designed to evaluate the level of knowledge and two separate questionnaires were developed for faculty to evaluate perception about CP-curriculum.

Study population

All consenting medical students from 2016 of PAHS School of Medicine currently in clinical clerkship years and all clinical sciences faculty who had delivered at least one teaching-session with the CP curriculum to these students were included in the study. Consenting students were asked to fill the questionnaire together in class, whereas faculty were approached personally and asked to complete the questionnaires. Students and faculty who were part of the study team, those who didn’t provide consent, and those who participated in the pilot survey section of the questionnaire developed for this study were excluded. All 34 faculty completed the perception questionnaires, with zero non-response rate. Out of 49 students, 33 completed the perception questionnaires and 38 turned up to the surprise non-routine exam for assessment of knowledge retention.

Ethics and consent

This study was approved by the Institutional Review Committee (Ethical Committee) of Patan Academy of Health Sciences (PAHS), Kathmandu, Nepal (Ref No std1505911069). Written informed consent was obtained from all participants before completing the questionnaire. Students who gave verbal consent were asked to complete the questionnaire together in class. Faculty were approached personally and requested to complete the questionnaires. At the start of each questionnaire, a tick box was used for participants to indicate written consent. Participants were informed verbally and in writing that their names and identifiying information would be kept anonymous, and their data would only be used for research purposes.

Data collection

Three sets of questionnaires were used. The first set of questionnaires were designed to test the perceived effectiveness of the CP curriculum from the faculty perspective. It contained seven questions on background information (age, sex, job position, highest academic degree, etc) and 13 questions on perceived effectiveness.

Similarly, the second set of questionnaires for the students included 11 questions on background information and 15 questions on perceived effectiveness. The perception questionnaire had questions about effectiveness or satisfaction in regard to different aspects of the CP curriculum. Participants had to respond with a tick mark in a Likert scale ranging from one (strongly agree) to five (strongly disagree) for each question.

The third set of questionnaires tested the students' clinical knowledge and contained 50 MCQs from different clinical medicine disciplines. Based on curriculum of the university, there were seven MCQs each from surgery, medicine, pediatrics, obstetrics and gynecology, and two questions each from orthopedics, emergency medicine, general practice, otolaryngology, anesthesiology, dermatology, dentistry, psychiatry, radiology, ophthalmology, and forensic medicine. The questions were randomly selected from the question pool of the Examination section of university. The selected questions were randomly arranged, and a surprise non-routine written exam was conducted with this questionnaire. A maximum time of one hour was provided to solve these 50 questions.

These questionnaires were compiled and discussed in the research group and reviewed by the research advisors to establish content validity. Copies of all three questionnaires can be found under Extended data. 10 They were administered to randomly selected 15 students and 15 faculty in a pilot study to establish the face validity and feasibility. The students and faculty randomly selected for the pilot study were administered the questionnaires to complete. Then they were asked in detail about the questionnaire and any suggestions for revisions or editing needed. The pilot survey was not powered for statistical comparisons. Only a few grammatical corrections were made after review and feedback from the pilot study. Subsequently, the final study was conducted.

The faculty participants were also involved in the development of the CP curriculum at PAHS, hence, responder bias in favor of CP curriculum may be present in this study.

The data collected were digitalized using Epi-Info version 7 software. These raw data were exported to MS-Excel. The excel sheet is made available in the public domain for readers. 10 SPSS version 13.0 was used for statistical test and analysis. Shapiro-Wilk test was used first to test the normality. Non-parametric tests (Mann-Whitney and Kruskal Wallis) was used for normal distribution. Classical ANOVA for equal variance and Welch ANOVA for unequal variance were used after testing the homogeneity of variance, and post-hoc/tukey test was used for significant classical ANOVA results.

In this study, we calculated the total score via forced Likert scale, ranging from 1 (strongly agree) to 5 (strongly disagree) for each respondent determined as the dependent variable, and compared it with other variables i.e., background information. The total score of all the Likert scale questions was calculated, and the normality test was performed, keeping “total score” as the dependent variable. The full dataset can be found under Underlying data. 10

Response from faculty on perceived effectiveness of the CP curriculum

The data of the total score did not follow a normal distribution (Shapiro-Wilk Test, p < 0.05), so a non-parametric test was used to compare the dependent variable. We used Mann-Whitney and Kruskal Wallis tests for the variables containing two groups and more than two groups, respectively.

Among the 34 respondents from the faculty group, 24 (70.59%) were male, and 10 (29.41%) were female. 20 (58.82%) of the faculty respondents were lecturers, and the remaining 14 (41.18%) were senior professors, associate professors, and assistant professors. Out of the 34 respondents, 31 (91.18%) were involved in developing the CP curriculum at PAHS. However, 3 (8.82%) were involved in teaching the curriculum but not in developing the CP curriculum.

As many as 15 (44.12%) respondents favored the CP curriculum system over the traditional system, 11 (32.35%) preferred the traditional teaching system, and 8 (23.53%) preferred both. Overall, the faculty liked the CP curriculum more than the traditional system of teaching clinical medicine (Kruskal Wallis = 0.023, p-value < 0.05). The majority of faculty, 27 (79.41%), would suggest future students to join a medical school that implemented the CP curriculum system rather than the traditional system. Only 12 (35.29%) of them thought that the CP curriculum system should be the sole leading teaching and learning system in clinical medicine, meaning more faculty preferred a hybrid system of both the CP curriculum and the traditional system. However, these differences were not statistically significant (p-value > 0.05).

As shown in Table 1 , a significant number of faculty (p values > 0.05) perceive the CP curriculum to be more effective than the traditional system for teaching clinical medicine to undergraduate medical students. There is no significant difference in the perception of the effectiveness of the CP curriculum among faculty based on academic rank, gender, highest academic degree, or the institution of their residency training (p-value > 0.05). The median number of faculty who perceive the CP curriculum system to be more effective and suggest future students to study medicine in this system rather than the traditional system is higher. But, the difference was not statistically significant (p > 0.05). There was no significant difference in faculty foreseeing the CP curriculum as the leading method of teaching and learning medical education in the future (p > 0.05).

Response from students on perceived effectiveness of the CP curriculum

The normality test shows that the total score data follows a normal distribution (Shapiro-Wilk, p > 0.05) with a mean value of 50.57 with a standard deviation of 8.17. Therefore, we used a parametric test to compare the test variable with others. We subsequently tested for homogeneity of variance: we used classical ANOVA for equal variance, and Welch ANOVA for unequal variance. Finally, if significant classical ANOVA results were obtained, we used the post-hoc/tukey test.

There were 33 respondents, among which 23 (69.70%) were males, and 10 (30.30%) were females. The age group of respondents was between 20 to 30 years. A significantly higher number (20 i.e., 60.61%) of the respondents recommended studying in a medical school implementing CP curriculum (p < 0.05). No significant differences were seen between educational or geographical backgrounds and scholarship categories (p > 0.05) as shown in Table 2 .

Assessment for knowledge retention of the students

An hourly surprise non-routine written exam was conducted to test the knowledge of the students. A copy of this exam can be found under Extended data. 10 The exam included 50 MCQs from different disciplines of clinical medicine. The surprise test was conducted without prior reminders, and 38 out of 49 students participated. The findings, as outlined in Table 3 , show that 24 out of 38 (65.79%) of the students scored 60% or higher. The results demonstrate that approximately two-thirds of the students passed the surprise test, indicating good test performance.

The current study shows a higher preference for the CP curriculum by undergraduate medical students and faculty at PAHS for teaching and learning clinical medicine in medical school. These findings further substantiate previous reviews on the principles of teaching methods and the acceptability of the curriculum.

This curriculum was chosen in part because of confidence in the comprehensiveness of the knowledge it encompasses. Equally important was the organization of medical knowledge that this curriculum engenders: each clinical presentation is organized according to a variable number of causal diagnostic categories. Each of these categories is identified by a prototype. Exhaustive lists of diagnoses belonging to a given category are avoided. As students' clinical experiences increase and they encounter more diagnoses, the students can add them to the appropriate causal categories stored in their memories. How the diagnostic prototypes are presented allows students to identify the discriminating features within and between each. The process by which students can compare and contrast the distinctive features of each disease is facilitated. It is so because the CP curriculum is well organized and comprehensive. 3 , 7 Since the CP curriculum is simple to follow and to organize the learning content, students in the CP curriculum also reported less stress due to the volume and complexity of study materials and examinations. 7

Prior studies at the University of Calgary demonstrated a substantial effect size on students’ retention of basic science knowledge while participating in the CP curriculum. 8 Our study conducted on clinical clerkship year participants showed that two-thirds of students achieved 60% (passing scores) or more in the surprise non-routine exam, signifying a high retention of clinical discipline knowledge. Findings from the current study expand on the effectiveness of the curriculum across medical school years with respect to knowledge retention.

A study done among medical students utilizing the CP curriculum showed a favorable response to the use of schema in the CP curriculum. 9 In our study, we could not evaluate the use the schemas of CP to perform clinical assessment in order to reach the appropriate diagnosis. We recommend further studies in this respect. Additionally, long-term knowledge retention was not tested in our study, which could be another important area of investigation.

This study has several other limitations as well. The study was conducted at a single institution, thereby potentially reducing the overall generalizability of the findings. The faculty members recruited as participants for assessing the perceived effectiveness of the curriculum were also involved in the adaptation and development of curriculum at PAHS, hence, potentially increasing responder’s bias in the study by some degree. The cross-sectional nature of the study provides only a limited understanding of the effects of the curriculum over the long term.

Based on this study, we can conclude that both faculty and students perceive the CP curriculum system as an effective teaching and learning method in medicine, irrespective of their demographic and positional characteristics. The findings suggest higher knowledge retention in knowledge by implementing the CP curriculum during clinical clerkship years. Since the 1990s, CP Curriculum has been established as a multidimensional teaching-learning method in many medical school systems. In the evolving medical education world with rapid digitization, massive turnover of medical and education data, and increased use of remote learning methods, a deeper understanding of influencing variables will help effectively utilize this highly valued curriculum.

Data availability

Authors' contributions.

SAY, SKJ, AA, and BD conceptualized and designed the study. All 9 authors; SAY, SJ, SP, SG, SB, AA, BD, NB, and SY contributed to data analysis and interpretation. SAY and SP wrote the first draft of the article. All 9 authors, SAY, SP, SG, SJ, SB, AA, BD, NB, and SY critically revised the manuscript and approved the final version of manuscript for publication.

Acknowledgements

We thank Prof. Dr. Kedar Prasad Baral and Prof. (Associate) Shital Bhandary for their immense help during this research. We thank all respondent faculty and medical students of PAHS for participating in the study.

[version 1; peer review: 1 approved

Funding Statement

The author(s) declared that no grants were involved in supporting this work.

Reviewer response for version 1

1 Health Action and Research, Kathmandu, Kathmandu, Nepal

2 International Agency for Research on Cancer, Lyon, France

Dear author(s),

Thank you for your hard work on this research manuscript. Please find my comments/ queries below.

The research article deals with the effectiveness of Clinical Presentation (CP) curriculum in teaching clinical medicine to undergraduate medical students. CP curriculum is yet to be adopted in many low- and middle-income countries. The results show that the medical students and the faculty were satisfied with the CP curriculum and believed CP as a stand-alone method of teaching as well as in conjunction with traditional methods of teaching could benefit medical students.

Study design:

“This is a cross-sectional study that aims to evaluate the efficacy of the CP curriculum in teaching different disciplines of clinical medicine to undergraduate medical students of PAHS, which is currently the only medical school implementing the CP-curriculum in undergraduate medical education.”

• Is PAHS the only medical school implementing the CP-curriculum in Nepal or worldwide?

Ethics and consent:

“Students who gave verbal consent were asked to complete the questionnaire together in class.”

• Please elaborate on this sentence.
• Was any faculty member present in the class?
• Was the test compulsory or optional?
• Did the students have the right to refuse the test or leave the test in between?

Data collection:

• Was the questionnaire in English?
• How long did the questionnaire take to complete?
• How much time were the respondents given to complete the questionnaire?
• What were the minimum and maximum possible scores (total or based on questionnaire sets)?

I hope the comments are useful and would enable the author(s) to strengthen this study.

Is the work clearly and accurately presented and does it cite the current literature?

If applicable, is the statistical analysis and its interpretation appropriate?

Are all the source data underlying the results available to ensure full reproducibility?

Is the study design appropriate and is the work technically sound?

Are the conclusions drawn adequately supported by the results?

Are sufficient details of methods and analysis provided to allow replication by others?

Reviewer Expertise:

Global health, gerontology, cancer

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Jayadevan Sreedharan

1 Department of Community Medicine, Gulf Medical University, Ajman, United Arab Emirates

Title: Effectiveness of Clinical Presentation (CP) Curriculum in teaching clinical medicine to undergraduate medical students: A cross-sectional study.

This study aimed to assess the perceived effectiveness of students and faculty and the level of knowledge among the students trained by the CP curriculum. The authors assume the CP curriculum is not inferior to traditional lecture-based teaching.

Are sufficient details of methods and analysis provided to allow replication by others?: 

It is not clear why the authors have given MCQ to the faculty (their score is given and statistical test done).

If applicable, is the statistical analysis and its interpretation appropriate?:

The authors mentioned in the article that "Classical ANOVA for equal variance and Welch ANOVA for unequal variance were used after testing the homogeneity of variance, and post-hoc/Tukey test was used for significant classical ANOVA results", where they have used this test is not clear in the manuscript.

The p-value is given in exact value; the importance of p-value is to check whether to accept the null or alternate hypothesis. In the methodology, they mentioned that p-value >0.05 is not significant. Then what more information do the readers get if they include the actual p-value? 

The sample size of this study is very small and the conclusion from this study can not be generalised to the entire population. 

The authors mentioned in the conclusion that "The findings suggest higher knowledge retention in knowledge by implementing the CP curriculum during clinical clerkship years" . How the authors reach this conclusion is unclear.

Epidemiology, Biostatistics, Medical education, Public health

Priyanka Panday

1 California Institute of Behavioral Neurosciences & Psychology, Fairfield, CA, USA

This article focuses on the importance of the clinical presentation (CP) curriculum in a particular institute (Patan Academy of Health Sciences (PAHS)) among medical students and faculty in terms of their preference and performance on a surprise non-routine exam. 

• Cross-sectional study is appropriate as a study design for this article.
• Relevant articles from 2020, 2019, and 2004 have been appropriately cited as references.
• The methods used for data collection, as well as the result of the study has been elaborated in detail to ensure accuracy.
• Results are presented in a tabular form and the conclusion derived coincides with the results indicating the effectiveness of the CP curriculum system as an effective teaching and learning method in medicine.
• As far as the statistical analysis is concerned, it is not my area of expertise. However, p< 0.05 for response of effective implementation of the CP curriculum and the response from faculty is statistically significant.

I cannot comment. A qualified statistician is required.

Endocrine disorders, Heart conditions, Medications, COVID-19, Obstetric conditions, Epilepsy, HIV, etc.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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How to present patient cases

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• Mary Ni Lochlainn , foundation year 2 doctor 1 ,
• Ibrahim Balogun , healthcare of older people/stroke medicine consultant 1
• 1 East Kent Foundation Trust, UK

A guide on how to structure a case presentation

This article contains...

-History of presenting problem

-Medical and surgical history

-Drugs, including allergies to drugs

-Family history

-Social history

-Review of systems

-Findings on examination, including vital signs and observations

-Differential diagnosis/impression

-Investigations

-Management

Presenting patient cases is a key part of everyday clinical practice. A well delivered presentation has the potential to facilitate patient care and improve efficiency on ward rounds, as well as a means of teaching and assessing clinical competence. 1

The purpose of a case presentation is to communicate your diagnostic reasoning to the listener, so that he or she has a clear picture of the patient’s condition and further management can be planned accordingly. 2 To give a high quality presentation you need to take a thorough history. Consultants make decisions about patient care based on information presented to them by junior members of the team, so the importance of accurately presenting your patient cannot be overemphasised.

As a medical student, you are likely to be asked to present in numerous settings. A formal case presentation may take place at a teaching session or even at a conference or scientific meeting. These presentations are usually thorough and have an accompanying PowerPoint presentation or poster. More often, case presentations take place on the wards or over the phone and tend to be brief, using only memory or short, handwritten notes as an aid.

Everyone has their own presenting style, and the context of the presentation will determine how much detail you need to put in. You should anticipate what information your senior colleagues will need to know about the patient’s history and the care he or she has received since admission, to enable them to make further management decisions. In this article, I use a fictitious case to …

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Osteoporosis

Definition and clinical presentation.

Glaser, David L. MD * ; Kaplan, Frederick S. MD *†

From the Departments of * Orthopaedic Surgery and † Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.

Acknowledgment date: June 17, 1997.

Acceptance date: June 17, 1997.

Device status category: 1.

Address reprint requests to: Frederick S. Kaplan, MD; Department of Orthopaedic Surgery: Silverstein Two; Hospital of the University of Pennsylvania; 3400 Spruce Street; Philadelphia, PA 19104.

Osteoporosis is a skeletal condition characterized by decreased density (mass/volume) of normally mineralized bone. The reduced bone density leads to decreased mechanical strength, thus making the skeleton more likely to fracture. Postmenopausal osteoporosis (Type I) and age-related osteoporosis (Type II) are the most common primary forms of bone loss seen in clinical practice. Secondary causes of osteoporosis include hypercortisolism, hyperthyroidism, hyperparathyroidism, alcohol abuse, and immobilization. In the development of osteoporosis, there is often a long latent period before the appearance of the main clinical manifestation, pathologic fractures. The earliest symptom of osteoporosis is often an episode of acute back pain caused by a pathologic vertebral compression fracture, or an episode of groin or thigh pain caused by a pathologic hip fracture. In the diagnostic process, the extent and severity of bone loss are evaluated and secondary forms of bone loss are excluded. A careful diagnostic work-up that includes clinical history, physical examination, laboratory evaluation, bone densitometry, and radiographic imaging will allow the clinician to determine the cause of osteoporosis and to institute medical interventions that will stabilize and even reverse this frequently preventable condition.

Osteoporosis is a skeletal condition characterized by decreased density (mass/unit volume) of normally mineralized bone. The reduced density impairs the mechanical strength of the bone, thus making it more vulnerable to fracture.

The World Health Organization has established diagnostic criteria for osteoporosis that are based on bone density measurements determined by dual-energy x-ray absorptiometry (DXA). A patient is classified as having low bone mass if the bone mineral density measures between 1 and 2.5 standard deviations below the mean value in a young reference population. The diagnosis of osteoporosis is made if a patient's bone density is 2.5 standard deviations or more below the mean for young normal people 2 ( Table 1 ).

In this definition, it is recognized that there is a strong association between bone mineral density and the likelihood of fracture. 4,22,28 According to the criteria, approximately 0.6% of young women have osteoporosis and approximately 16% have low bone mass. By age 75, an estimated 38% of white women will have osteoporosis and 94% will have low bone mass. 20,21,25,26 Although the definition is useful for establishing the prevalence of osteoporosis, it is inadequate as a guide to treatment, because other factors influence bone quality and fracture risk. Treatment should be determined for each patient after consideration of these other factors in addition to bone density. Because the risk of osteoporotic fracture during the remaining lifetime of many elderly patients is sufficiently low, aggressive treatment is usually not needed. Conversely, many patients who do not meet the World Health Organization's criteria for osteoporosis might have other risk factors and circumstances that justify treatment. Therefore, the World Health Organization's criteria has made physicians aware of the prevalence of osteoporosis but should not be used to dictate absolute thresholds for diagnosis and treatment.

Osteoporosis has been classified into two categories, primary and secondary. Primary osteoporosis is further divided into three types- postmenopausal osteoporosis (Type I), age-related osteoporosis (Type II), and idiopathic osteoporosis. Postmenopausal (Type I) osteoporosis develops in women who have estrogen deficiency, whereas age-related (Type II) osteoporosis occurs in men and women as their bone density decreases with aging. Secondary osteoporosis refers to those patients in whom a causative factor or disease process is identifiable. 18

Osteoporosis is less common in men than in women, probably reflecting that men have greater bone mass than women at all ages, and experience no physiologic equivalent of menopause. 24 Nonetheless, severe Type II (age-related) and idiopathic osteoporosis occurs in men. Secondary osteoporosis caused by excessive alcohol in-take, hypogonadism, hypercortisolism, and hyperthyroidism also occur in men and can lead to varying degrees of clinically significant osteoporosis. 7,9,12,13,16

Clinical Signs and Symptoms

In osteoporosis, as in hypertension, there is often a long latent period before clinical symptoms or complications develop. The most prevalent sequelae are compression fractures of the vertebral bodies and fractures of the ribs, proximal femurs, humeri, and distal radiuses.

Pathologic fractures are among the most obvious clinical manifestations of osteoporosis. 14,17 In patients with osteoporosis, as well as in older persons, fractures are often the result of a fall. 11,29 Results reported in recent studies on falls in the elderly have identified numerous predisposing factors. Intrinsic causes include neurologic and musculoskeletal disorders, cardiovascular disorders, and visual disturbances, all common in this population. Extrinsic factors that increase the risk of falls are the use of sedatives, excessive use of prescription medications, dim lighting, cluttered floors, and various other obstructions (scatter rugs, curbs, and stairs). 21,23,29-31 Reduced resistance to trauma caused by a decrease in soft tissue padding that can help absorb and deflect the kinetic energy at sites of impact, as well as low bone mass, may contribute to the high incidence of fracture. Hip fractures in thin patients are probably related to decreased resistance and low bone mass. Therefore, persons with ample body fat or well-developed muscles are less likely to sustain a fracture during a fall. 14

Vertebral Compression Fractures

The earliest symptom of osteoporosis is often an episode of acute back pain occurring when the person is at rest or during such routine activity as bending, standing from a seated position, lifting a heavy object, or opening a window. Although most compression fractures are painless, pain can occur suddenly. Most patients can recall the exact moment the pain began but may have difficulty identifying the vertebral site involved. Spinal movement is severely restricted, with flexion reduced more than extension. Pain intensifies with sitting or standing and is relieved by bed rest in the fully recumbent position. Coughing, sneezing, and straining to move the bowels can exacerbate the pain. Sitting or standing for prolonged periods may be impossible because of severe pain. The patient walks slowly, but the gait is otherwise normal.

Anterior compression fractures in the thoracic spine may cause thoracic kyphosis (dowager's hump), the stooped posture characteristic of osteoporosis. Loss of vertebral height is usually insidious and painless and is accompanied by loss in height of the intervertebral discs. Involvement of the lumbar spine may lead to progressive loss of the normal lumbar lordosis. Axial height decreases after each fracture, and there is a discrepancy between the standing height and arm span. Patients with severe, progressive spinal compression may have an acquired short trunk and short stature. This is easily identified with the patient in the standing position. Normally the finger tips should come to the mid thigh. In advanced osteoporosis, with loss of axial height, the finger tips come to the lower thigh or knee when the patient is standing. Once the spine has collapsed to the point at which the lower ribs rest on the iliac crest, height remains stable, although bone density may continue to diminish.

After acute vertebral fractures, spasms of the paravertebral muscles are palpable and often visible. The spine and paravertebral muscles may be tender to deep palpation and to percussion at the level of the fracture.

Acute fractures are usually not associated with abnormal neurologic findings, in that they are usually stable injuries. When present, radiculopathy, can cause unilateral or bilateral pain that radiates along the costal margin of the affected spinal nerve. Involvement of the spinal cord or cauda equina is extremely uncommon, and should suggest other conditions, including infection, metastatic or primary bone tumors, myeloma, Paget's disease, or lymphoma.

During intervals between compression fractures, most patients remain pain free. However, some patients continue to be plagued by dull, aching back pain, especially with prolonged standing. This pain can often be relieved with intermittent bed rest throughout the day.

It is important to distinguish chronic back pain from the incapacitating pain of temporally clustered fractures. For a significant number of patients with cluster fractures, the severe pain initiated by the first vertebral compression fracture barely subsides before the occurrence of equally severe pain with the next fracture. Typically, these patients will have multiple fractures in a period of months, followed by gradual recovery. Such patients are able to recall each exacerbation and tend to have more severe pain of longer duration than those with isolated compression fractures. When cluster fractures are suspected in a patient, evaluation for secondary causes of osteopenia is warranted. Exacerbation of a preexisting chronic illness in a severely osteopenic, steroid-dependent patient, or an increase in the glucocorticoid medication often precipitates temporal clustering of fractures. 15

Some permanent side effects of progressive vertebral compression fractures are related to decreases in the size of the thoracic and abdominal cavities. Postural changes diminish exercise tolerance. After ingesting even small amounts of food, the patient often feels full and bloated. Severe vertebral collapse in the lumbar spine causes the abdomen to protrude. Circumferential pachydermal skin folds may develop at the rib and pelvic margins as the spinal deformity progresses.

Appendicular Fractures

In some persons, osteoporosis is first manifested by a pathologic fracture of the proximal femur or distal radius, sustained after a fall. The incidence of fractures of the femoral neck increase with age. 19 Fractures of the proximal femur are among the most feared complications of osteoporosis and are solely responsible for catapulting the disease into the category of a life-threatening disorder. These fractures often occur in patients with several preexisting comorbidities that contribute to more complicated postoperative recovery, including pneumonia, deep vein thrombosis, and fat embolus syndrome. Although reduced bone density is a critical component leading to a fractured hip, other intrinsic and extrinsic factors-cardiac disease, neurologic disorders, and medications that cause dizziness-may be equally important.

Patients typically complain of hip pain and the hip's inability to bear weight. Physical examination reveals a shortened, externally rotated leg. In cases of occult fractures, the patient complains of severe pain when the hip is in a weight-bearing position. Occult hip fractures can be observed in patients who have risk factors for osteoporosis and tend to be more active. Magnetic resonance imaging or a bone scan is often useful in diagnosing occult fractures.

Diagnostic Evaluation

The diagnostic work-up of osteoporosis focuses on evaluating the cause and magnitude of bone loss and on excluding secondary causes of bone loss. In many patients, the diagnosis of osteoporosis is made only after a pathologic fracture has occurred. To avoid the potentially devastating effects of osteoporosis, it may be clinically warranted and cost-effective to assess bone density in patients at high risk before fractures or deformities occur. These low-cost, usually available techniques are valuable diagnostic tools. Serial bone density measurements are extremely useful for monitoring the effectiveness of therapy or preventive interventions.

History and Laboratory Studies

Postmenopausal osteoporosis in women and age-related osteoporosis in men and women are the most common forms of symptomatic bone loss seen in clinical practice. A detailed history, however, may suggest that the low bone density is secondary to hyperthyroidism, primary hyperparathyroidism, hypercortisolism, myeloma, or osteomalacia ( Tables 2 and 3 ).

Risk factors for low bone density have limited value in estimating a person's actual bone density. 27 However, determining risk factors for fracture can be useful in identifying those at high risk, and treatment can be initiated to reduce the risk. 6 In women, several common, important, and clinically useful risk factors have been identified recently in the Study of Osteoporotic Fractures. These include low bone mineral density; history of a fracture after age 40; history of a fracture of the hip, wrist, or vertebra in a first-degree relative; or current cigarette smoking. 5

Obtaining a thorough history facilitates selection of appropriate baseline tests. Routine laboratory tests include complete blood count with leukocyte differential measurement; a 24-hour urine collection to measure calcium and creatinine excretion; and determination of serum levels of calcium, albumin, phosphorus, alkaline phosphatase, blood urea nitrogen, and creatinine ( Table 2 ). In asymptomatic postmenopausal osteoporosis, results of routine laboratory tests are normal and do not assess the extent or rate of bone loss or indicate the prognosis. Even in severe postmenopausal osteoporosis, the serum levels of calcium, inorganic phosphorus, and alkaline phosphatase are usually normal, although alkaline phosphatase levels may rise transiently for several weeks after a fracture. Measurement of biochemical markers appears helpful in assessing bone turnover and aids in monitoring therapy. Total alkaline phosphatase, osteocalcin, Type I collagen propeptides, urinary collagen cross-links, and collagen telopeptides are several markers that may be useful. A complete description of these tests is summarized by Erye in this issue. 1,3,8,10

Additional tests are warranted if bone loss caused by conditions other than aging and menopause is suspected. Diagnosis of primary or iatrogenic hyperthyroidism requires measurement of serum triiodothyronine resin uptake (T 3 RU), and thyroxine (T 4 ) levels, and calculation of the free thyroxine index (FTI). Serum thyroid-stimulating hormone (TSH) levels are markedly suppressed in all forms of hyperparathyroidism and are a sensitive indicator of thyroid status. Serum protein electrophoresis, urinary immunoelectrophoresis and bone marrow aspirate may be needed to detect multiple myeloma. In patients who have hypercalcemia, parathyroid hormone levels must be determined. The serum level of 25-hydroxyvitamin D, an excellent indicator of total body reserves of vitamin D, may be measured to evaluate a possible vitamin D deficiency, the most common biochemical abnormality associated with hip fractures. All men with osteopenia or osteoporosis should have an evaluation of serum testosterone level, in that asymptomatic hypogonadism is a common cause of osteopenia in men.

Differential Diagnosis

Osteoporosis and osteomalacia are commonly confused osteopenic conditions in adults. Whereas osteoporosis is characterized by a decreased density of normally mineralized bone matrix, osteomalacia is a qualitative rather than a quantitative disorder of bone metabolism. In osteomalacia, bone density may be increased, normal, or (most commonly) decreased, and bone matrix is insufficiently mineralized.

Unlike its more easily recognized childhood counterpart, rickets, adult osteomalacia may be difficult to diagnose clinically. The incidence is evenly distributed throughout all age groups. The most common causes are chronic renal failure, malabsorption, vitamin D deficiency, abnormalities of the vitamin D pathway, and hypophosphatemic syndromes. Rarer causes are renal tubular acidosis, aluminum intoxication, and hypophosphatasia.

In contrast to osteoporosis, which does not become evident until fractures occur, osteomalacia may cause generalized bone pain, tenderness, and generalized myopathy. Osteomalacia caused by vitamin D deficiency is suggested by bone pain or pathologic fracture in a patient taking anticonvulsants, by a history of malabsorption syndrome in a patient, or by a femoral neck fracture in an older patient. The levels of 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D must be determined when osteomalacia is suspected. The diagnosis can be confirmed with fluorescent microscopic examination of nondecalcified trabecular bone tissue obtained by transiliac bone biopsy after administration of time-separated double tetracycline labeling.

Although the radiographic features of osteoporosis and osteomalacia may be similar, axial changes predominate in osteoporosis, whereas appendicular changes predominate in osteomalacia. Osteomalacia is suggested by symmetric pathologic fractures and traumatic fractures. Pseudofractures (Looser zones) are characteristic of osteomalacia. These small, incomplete cortical fractures develop perpendicular to the long axis of a bone and are often bilaterally symmetric. Common areas of involvement include medial borders of the scapulas, ribs, ischiopubic rami, femoral necks, lateral borders of the femur, and distal radiuses.

Results of routine laboratory studies, typically normal in osteoporosis, may be abnormal in osteomalacia. Osteomalacia should be suspected when the product of the serum calcium level and serum phosphate level is chronically below 25 (with normal serum albumin), especially if accompanied by an elevated bone-specific alkaline phosphatase level and a urinary calcium excretion of less than 50 mg per 24 hours.

Conclusions

The effectiveness of current treatment methods for osteoporosis relies on the accurate diagnosis and classification of the disease process that results in low bone density and fractures. A careful diagnosis that is based on clinical history, physical examination laboratory evaluation, bone densitometry, and radiographic imaging will allow the clinician to enact preventive measures and medical interventions that can even reverse this frequently preventable disorder.

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Wound Infection Clinical Presentation

• Author: Hemant Singhal, MD, MBBS, MBA, FRCS, FRCS(Edin), FRCSC; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
• Sections Wound Infection
• Pathophysiology
• Epidemiology
• Definition and Classification
• History and Physical Examination
• Laboratory Studies
• Ultrasonography
• Approach Considerations
• Antibiotic Prophylaxis
• Risk Assessment
• Perioperative Recommendations
• Surgical Care
• APSIC Guidelines for Prevention of Surgical-Site Infection
• WHO Guidelines on Surgical-Site Infection
• CDC Guidelines for Prevention of Surgical-Site Infection
• IDSA Guidelines on Surgical-Site Infection
• Medication Summary
• Antibiotics
• Questions & Answers
• Media Gallery

Surgical-site infection (SSI) is a difficult term to define accurately because it has a wide spectrum of possible clinical features.

The Centers for Disease Control and Prevention (CDC) has defined SSI to standardize data collection for the National Nosocomial Infections Surveillance (NNIS) program. [ 8 , 16 ] SSIs are classified into incisional SSIs, which can be superficial or deep, and organ/space SSIs, which affect the rest of the body other than the body wall layers (see the image below). These classifications are defined as follows:

• Superficial incisional SSI - Infection involves only skin and subcutaneous tissue of incision
• Deep incisional SSI - Infection involves deep tissues, such as fascial and muscle layers; this also includes infection involving both superficial and deep incision sites and organ/space SSI draining through incision
• Organ/space SSI - Infection involves any part of the anatomy in organs and spaces other than the incision, which was opened or manipulated during operation

Superficial incisional SSI is more common than deep incisional SSI and organ/space SSI. Superficial incisional SSI accounts for more than half of all SSIs for all categories of surgery. The postoperative length of stay is longer for patients with SSI, even when adjusted for other factors influencing length of stay.

A report by the NNIS program [ 17 ] cited particular clinical findings as characteristic of the different types of SSI.

Superficial incisional SSI is characterized by the following:

• Occurs within 30 days after the operation
• Involves only the skin or subcutaneous tissue
• Includes at least one of the following: (a) purulent drainage is present (culture documentation not required); (b) organisms are isolated from fluid/tissue of the superficial incision; (c) at least one sign of inflammation (eg, pain or tenderness, induration, erythema, local warmth of the wound) is present; (d) the wound is deliberately opened by the surgeon; (e) the surgeon or clinician declares the wound infected
• Note: A wound is not considered a superficial incisional SSI if a stitch abscess is present; if the infection is at an episiotomy, a circumcision site, or a burn wound; or if the SSI extends into fascia or muscle

Deep incisional SSI is characterized by the following:

• Occurs within 30 days of the operation or within 1 year if an implant is present
• Involves deep soft tissues (eg, fascia and/or muscle) of the incision
• Includes at least one of the following: (a) purulent drainage is present from the deep incision but without organ/space involvement; (b) fascial dehiscence or fascia is deliberately separated by the surgeon because of signs of inflammation; (c) a deep abscess is identified by direct examination or during reoperation, by histopathology, or by radiologic examination; (d) the surgeon or clinician declares that a deep incisional infection is present

Organ/space SSI is characterized by the following:

• Involves anatomic structures not opened or manipulated during the operation
• Includes at least one of the following: (a) purulent drainage is present from a drain placed by a stab wound into the organ/space; (b) organisms are isolated from the organ/space by aseptic culturing technique; (c) an abscess in the organ/space is identified by direct examination, during reoperation, or by histopathologic or radiologic examination; (d) a diagnosis of organ/space SSI is made by the surgeon or clinician

Examples of wound infections are shown in the images below.

Breasted D. The Edwin Smith Surgical Papyrus . Chicago: University of Chicago Press; 1930.

Bryan PW. The Papyrus Ebers . London/Washington DC: Government Printing Office; 1883.

Cohen IK. A Brief History of Wound Healing . Yardley, PA: Oxford Clinical Communications; 1998.

Lister J. On a new method of treating compound fractures. Lancet . 1867. 1:326-9, 387-9, 507-9.

Qvist G. Hunterian Oration, 1979. Some controversial aspects of John Hunter's life and work. Ann R Coll Surg Engl . 1979 Jul. 61 (4):309-11. [QxMD MEDLINE Link] .

Helling TS, Daon E. In Flanders fields: the Great War, Antoine Depage, and the resurgence of débridement. Ann Surg . 1998 Aug. 228 (2):173-81. [QxMD MEDLINE Link] .

Krizek TJ, Robson MC. Evolution of quantitative bacteriology in wound management. Am J Surg . 1975 Nov. 130 (5):579-84. [QxMD MEDLINE Link] .

National Nosocomial Infections Surveillance (NNIS) System. National Nosocomial Infections Surveillance (NNIS) report, data summary from October 1986-April 1996, issued May 1996. A report from the National Nosocomial Infections Surveillance (NNIS) System. Am J Infect Control . 1996 Oct. 24 (5):380-8. [QxMD MEDLINE Link] .

Hsiao CH, Chuang CC, Tan HY, Ma DH, Lin KK, Chang CJ, et al. Methicillin-resistant Staphylococcus aureus ocular infection: a 10-year hospital-based study. Ophthalmology . 2012 Mar. 119 (3):522-7. [QxMD MEDLINE Link] .

Cruse PJ, Foord R. The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. Surg Clin North Am . 1980 Feb. 60 (1):27-40. [QxMD MEDLINE Link] .

Emori TG, Gaynes RP. An overview of nosocomial infections, including the role of the microbiology laboratory. Clin Microbiol Rev . 1993 Oct. 6 (4):428-42. [QxMD MEDLINE Link] .

Mayon-White RT, Ducel G, Kereselidze T, Tikomirov E. An international survey of the prevalence of hospital-acquired infection. J Hosp Infect . 1988 Feb. 11 Suppl A:43-8. [QxMD MEDLINE Link] .

Nosocomial Infection National Surveillance Service (NINSS). Surgical site infection in English hospitals: a national surveillance and quality improvement program. Public Health Laboratory Service . 2002.

Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol . 1999 Apr. 20 (4):250-78; quiz 279-80. [QxMD MEDLINE Link] .

Kirkland KB, Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol . 1999 Nov. 20 (11):725-30. [QxMD MEDLINE Link] .

Di Leo A, Piffer S, Ricci F, Manzi A, Poggi E, Porretto V, et al. Surgical site infections in an Italian surgical ward: a prospective study. Surg Infect (Larchmt) . 2009 Dec. 10 (6):533-8. [QxMD MEDLINE Link] .

National Nosocomial Infections Surveillance System. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 to June 2002, issued August 2002. Am J Infect Control . 2002 Dec. 30 (8):458-75. [QxMD MEDLINE Link] .

Mahmoud NN, Turpin RS, Yang G, Saunders WB. Impact of surgical site infections on length of stay and costs in selected colorectal procedures. Surg Infect (Larchmt) . 2009 Dec. 10 (6):539-44. [QxMD MEDLINE Link] .

Haley RW, Schaberg DR, Crossley KB, Von Allmen SD, McGowan JE Jr. Extra charges and prolongation of stay attributable to nosocomial infections: a prospective interhospital comparison. Am J Med . 1981 Jan. 70 (1):51-8. [QxMD MEDLINE Link] .

Eagye KJ, Kim A, Laohavaleeson S, Kuti JL, Nicolau DP. Surgical site infections: does inadequate antibiotic therapy affect patient outcomes?. Surg Infect (Larchmt) . 2009 Aug. 10 (4):323-31. [QxMD MEDLINE Link] .

[Guideline] Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis . 2014 Jul 15. 59 (2):147-59. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] Berríos-Torres SI, Umscheid CA, Bratzler DW, et al, Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg . 2017 Aug 1. 152 (8):784-791. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] Global guidelines for the prevention of surgical site infection, 2nd ed. World Health Organization. Available at https://www.who.int/publications/i/item/global-guidelines-for-the-prevention-of-surgical-site-infection-2nd-ed . January 3, 2018; Accessed: March 16, 2023.

[Guideline] Ling ML, Apisarnthanarak A, Abbas A, Morikane K, Lee KY, Warrier A, et al. APSIC guidelines for the prevention of surgical site infections. Antimicrob Resist Infect Control . 2019. 8:174. [QxMD MEDLINE Link] . [Full Text] .

Burke JF. The effective period of preventive antibiotic action in experimental incisions and dermal lesions. Surgery . 1961 Jul. 50:161-8. [QxMD MEDLINE Link] .

Barchitta M, Matranga D, Quattrocchi A, Bellocchi P, Ruffino M, Basile G, et al. Prevalence of surgical site infections before and after the implementation of a multimodal infection control programme. J Antimicrob Chemother . 2012 Mar. 67 (3):749-55. [QxMD MEDLINE Link] .

Gupta R, Sinnett D, Carpenter R, Preece PE, Royle GT. Antibiotic prophylaxis for post-operative wound infection in clean elective breast surgery. Eur J Surg Oncol . 2000 Jun. 26 (4):363-6. [QxMD MEDLINE Link] .

Platt R, Zucker JR, Zaleznik DF, Hopkins CC, Dellinger EP, Karchmer AW, et al. Perioperative antibiotic prophylaxis and wound infection following breast surgery. J Antimicrob Chemother . 1993 Feb. 31 Suppl B:43-8. [QxMD MEDLINE Link] .

Woodfield JC, Beshay N, van Rij AM. A meta-analysis of randomized, controlled trials assessing the prophylactic use of ceftriaxone. A study of wound, chest, and urinary infections. World J Surg . 2009 Dec. 33 (12):2538-50. [QxMD MEDLINE Link] .

Woods RK, Dellinger EP. Current guidelines for antibiotic prophylaxis of surgical wounds. Am Fam Physician . 1998 Jun. 57 (11):2731-40. [QxMD MEDLINE Link] .

Culver DH, Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med . 1991 Sep 16. 91 (3B):152S-157S. [QxMD MEDLINE Link] .

American Society of Anesthesiologists. New classification of physical status. Anesthesiology . 1963. 24:111.

Pearson ML. Guideline for prevention of intravascular device-related infections. Part I. Intravascular device-related infections: an overview. The Hospital Infection Control Practices Advisory Committee. Am J Infect Control . 1996 Aug. 24 (4):262-77. [QxMD MEDLINE Link] .

Mermel LA, Farr BM, Sherertz RJ, Raad II, O'Grady N, Harris JS, et al. Guidelines for the management of intravascular catheter-related infections. Clin Infect Dis . 2001 May 1. 32 (9):1249-72. [QxMD MEDLINE Link] .

Dettenkofer M, Wilson C, Gratwohl A, Schmoor C, Bertz H, Frei R, et al. Skin disinfection with octenidine dihydrochloride for central venous catheter site care: a double-blind, randomized, controlled trial. Clin Microbiol Infect . 2010 Jun. 16 (6):600-6. [QxMD MEDLINE Link] .

Latham R, Lancaster AD, Covington JF, Pirolo JS, Thomas CS Jr. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Infect Control Hosp Epidemiol . 2001 Oct. 22 (10):607-12. [QxMD MEDLINE Link] .

Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med . 1996 May 9. 334 (19):1209-15. [QxMD MEDLINE Link] .

Belda FJ, Aguilera L, García de la Asunción J, Alberti J, Vicente R, Ferrándiz L, et al. Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA . 2005 Oct 26. 294 (16):2035-42. [QxMD MEDLINE Link] .

• Wound infection due to disturbed coagulopathy. This patient has a pacemaker (visible below right clavicular space) and had previous cardiac surgery (median sternotomy wound visible) for a rheumatic mitral valve disorder, which was replaced. The patient was taking anticoagulants preoperatively. Despite converting to low-molecular weight subcutaneous heparin treatment and establishing normal coagulation studies, she developed a postoperative hematoma with subsequent wound infection. She had the hematoma evacuated and was administered antibiotic treatment as guided by microbiological results, and the wound was left to heal by secondary intention.
• Abscess secondary to a subclavian line.
• Definitions of surgical site infection (SSI).
• Factors that affect surgical wound healing.
• Large ulceration in a tattoo. A 33-year-old man presented with a superficial ulceration about 4 weeks after a red tattoo on his forearm. Microbial swabs remained negative. His medical history was uneventful and he was in good general health. No reason for this uncommon reaction could be identified. Image courtesy of the National Institutes of Health.
• Table 1. Pathogens Commonly Associated with Wound Infections and Frequency of Occurrence [ 8 ]
• Table 2: Surgical Wound Classification and Subsequent Risk of Infection (If No Antibiotics Used) [ 8 , 10 ]
• Table 3. Recommendations for Prophylactic Antibiotics as Indicated by Probable Infective Microorganism Involved [ 8 , 30 ]
• Table 4. Predictive Percentage of SSI Occurrence by Wound Type and Risk Index* [ 31 ]
• Table 5. American Society of Anesthesiologists (ASA) Classification of Physical Status [ 32 ]
• Table 6. Data Support Recommendations

Contributor Information and Disclosures

Hemant Singhal, MD, MBBS, MBA, FRCS, FRCS(Edin), FRCSC Consultant Breast Surgeon, Clementine Churchill Hospital; Consultant Breast Surgeon, Harley Street Breast Clinic, UK Hemant Singhal, MD, MBBS, MBA, FRCS, FRCS(Edin), FRCSC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada , Royal College of Surgeons of Edinburgh Disclosure: Nothing to disclose.

Kanchan Kaur, MBBS, MS (GenSurg), MRCSEd Consulting Breast and Oncoplastic Surgeon, Medanta, The Medicity, India Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association , American Physiological Society , American Society of Nephrology , Association for Academic Surgery , International Society of Nephrology , New York Academy of Sciences , Society for Surgery of the Alimentary Tract Disclosure: Nothing to disclose.

Amy L Friedman, MD Professor of Surgery, Director of Transplantation, State University of New York Upstate Medical University Amy L Friedman, MD is a member of the following medical societies: American College of Surgeons , American Medical Association , American Medical Women's Association , American Society for Artificial Internal Organs , American Society of Transplant Surgeons , American Society of Transplantation , Association for Academic Surgery , Association of Women Surgeons , International College of Surgeons , International Liver Transplantation Society , New York Academy of Sciences , Pennsylvania Medical Society , Philadelphia County Medical Society , Society of Critical Care Medicine , Transplantation Society Disclosure: Nothing to disclose.

Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma , Eastern Association for the Surgery of Trauma , Southern Surgical Association , American College of Chest Physicians , American College of Surgeons , American Medical Association , Association for Academic Surgery , Association for Surgical Education , Shock Society , Society of Critical Care Medicine , Southeastern Surgical Congress , Tennessee Medical Association Disclosure: Nothing to disclose.

Charles Zammit, MD Senior Specialist Registrar, Department of Surgery, Breast Unit Charing Cross Hospital of London, UK

Disclosure: Nothing to disclose.

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Osteoporosis. Definition and clinical presentation

Affiliation.

• 1 Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, USA.
• PMID: 9431639
• DOI: 10.1097/00007632-199712151-00003

Osteoporosis is a skeletal condition characterized by decreased density (mass/volume) of normally mineralized bone. The reduced bone density leads to decreased mechanical strength, thus making the skeleton more likely to fracture. Postmenopausal osteoporosis (Type I) and age-related osteoporosis (Type II) are the most common primary forms of bone loss seen in clinical practice. Secondary causes of osteoporosis include hypercortisolism, hyperthyroidism, hyperparathyroidism, alcohol abuse, and immobilization. In the development of osteoporosis, there is often a long latent period before the appearance of the main clinical manifestation, pathologic fractures. The earliest symptom of osteoporosis is often an episode of acute back pain caused by a pathologic vertebral compression fracture, or an episode of groin or thigh pain caused by a pathologic hip fracture. In the diagnostic process, the extent and severity of bone loss are evaluated and secondary forms of bone loss are excluded. A careful diagnostic work-up that includes clinical history, physical examination, laboratory evaluation, bone densitometry, and radiographic imaging will allow the clinician to determine the cause of osteoporosis and to institute medical interventions that will stabilize and even reverse this frequently preventable condition.

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Depression ranges in seriousness from mild, temporary episodes of sadness to severe, persistent depression. Clinical depression is the more-severe form of depression, also known as major depression or major depressive disorder. It isn't the same as depression caused by a loss, such as the death of a loved one, or a medical condition, such as a thyroid disorder.

To diagnose clinical depression, many doctors use the symptom criteria for major depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

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Symptoms are usually severe enough to cause noticeable problems in relationships with others or in day-to-day activities, such as work, school or social activities.

Clinical depression can affect people of any age, including children. However, clinical depression symptoms, even if severe, usually improve with psychological counseling, antidepressant medications or a combination of the two.

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Interim Guidance for Health Departments on Testing and Reporting for Oropouche Virus Disease

At a glance.

This document provides current testing guidance for patients with suspected Oropouche virus disease (Oropouche), an interim case definition, and guidance for case reporting to ArboNET. Updates to the guidance will be made, as needed, based on new information about Oropouche virus.

CDC currently offers both surveillance and clinical diagnostic testing for patients meeting the suspect case definition for Oropouche. Surveillance testing consists of non-CLIA validated tests. Because the assays are not clinically validated, surveillance testing results can be used for surveillance purposes only, and CDC will not be providing results to patients, clinicians, or otherwise for clinical decision making. Surveillance testing for Oropouche virus currently includes molecular testing. Clinical diagnostic testing consists of CLIA-validated neutralizing antibody testing of serum or CSF. More details on both testing options are provided in the sections below.

Suspect case definition

Patient with travel within two weeks of initial symptom onset (as patients may experience recurrent symptoms) to an area with documented or suspected Oropouche virus circulation* and the following:

• Abrupt onset of reported fever, headache, and one or more of the following: myalgia, arthralgia, photophobia, retroorbital/eye pain, or signs and symptoms of neuroinvasive disease (e.g., stiff neck, altered mental status, seizures, limb weakness, or cerebrospinal fluid pleocytosis); AND
• No respiratory symptoms (e.g., cough, rhinorrhea, shortness of breath); AND
• Tested negative for other possible diseases, in particular dengue†.

*If concern exists for local transmission in a non-endemic area, consider if the patient shared an exposure location with a person with confirmed Oropouche virus infection, lives in an area where travel-related cases have been identified, or has known vector exposure (e.g., mosquitoes or biting midges).

†If strong suspicion of Oropouche virus disease exists based on the patient's clinical features and history of travel to an area with virus circulation, do not wait on negative testing before sending specimens to CDC.

Specimen requirements

For serum or CSF collected within the first 10 days of illnes s , a minimum of 1.0 ml is preferred as this will allow for both Oropouche virus clinical diagnostic and surveillance testing (for volumes <0.5 ml contact [email protected] for guidance).

• All specimens should be submitted to CDC through state health departments. For after-hours contact information for health departments please visit: https://www.cste.org/page/EpiOnCall .

The local jurisdiction should split the specimen before sending to CDC. This approach to splitting of specimens will be used until a CLIA-validated PCR assay is available at CDC. Revised guidance for use of the CLIA-validated PCR assay will be released on this website at that time.

• One half should be submitted for clinical diagnostic testing according to CDC's routine arboviral testing submission protocol .
• The other half should be submitted for surveillance testing using an anonymous local specimen ID and must not include the patient demographic or clinicians' details. Surveillance specimens should be sent using the same shipping instructions (i.e., temperature, packaging, etc.) as for other arboviral diagnostic specimens.

For serum or CSF collected after the first 10 days of illness , a minimum of 0.5 ml is preferred to allow for Oropouche virus serologic testing and any other necessary testing for other circulating arboviruses (for volumes <0.5 ml contact [email protected] for guidance).

• Since the convalescent specimen will only be tested for antibodies using the clinical diagnostic test, it should be submitted according to CDC's routine arboviral testing submission protocol . Please note on the 50.34 Specimen Submission Form dates and results of commercial and state laboratory testing for other arboviruses, in particular dengue.

Submitting for surveillance testing

Specimens for surveillance testing should be shipped to:

ATTN: Virology Team (Aaron Brault, Holly Hughes)

3156 Rampart Road

Fort Collins, CO 80521

In advance of sending specimens for surveillance testing, please notify the Arboviral Diseases Branch clinical team at [email protected] . Please email the following information in advance of sending specimens for surveillance testing (see Excel spreadsheet template ):

• ID number (no link to patient identifiers can be provided to CDC)
• State of residence
• Symptom onset date (please include date of onset of initial symptoms if patient experienced a recurrence).
• Symptoms (please list all known symptoms associated with this illness. If patient experienced a recurrence, please list date of initial symptom resolution and date of recurrence).
• Immunocompromising conditions or medications
• Travel location(s)
• Travel dates
• Specimen type(s)
• Specimen collection date(s)
• Dates and results of commercial and state laboratory testing for other arboviruses, in particular dengue

Clinical diagnostic testing

Patients meeting the suspect case definition should have clinical diagnostic testing, if possible. At this time, clinical diagnostic testing at CDC can only be completed on serum or CSF using a CLIA-validated plaque reduction neutralization test (PRNT). To confirm a recent infection in a patient, paired specimens are needed to demonstrate a 4-fold or greater change in Oropouche virus-specific quantitative neutralizing antibody titers between acute- and convalescent-phase serum specimens collected optimally ≥2 weeks apart. If paired specimens cannot be obtained, detection of neutralizing antibodies in a single specimen is considered laboratory evidence of infection, but since timing cannot be determined, clinical correlation is needed for interpretation.

Given the evidence indicating a risk of vertical transmission of Oropouche virus from a gestational parent to their fetus, paired acute and convalescent specimens collected optimally ≥2 weeks apart are needed to confirm recent infection in a pregnant person.

Clinical diagnostic test results will be sent to public health partners in the jurisdictional health department where the case resides. These results can be shared with the treating physician and can be used for clinical decision making.

Clinical diagnostic testing algorithm

• Clinical diagnostic testing should be considered for patients meeting the suspect case definition.
• At this time, antibody kinetics have not been well defined for Oropouche virus infections. Until more is known, CDC recommends collecting acute and convalescent samples.
• Samples obtained during the initial illness phase (e.g., when the patient presents with their first symptoms) are considered acute. Samples obtained after recovery from the initial illness, including during the recurrence of symptoms, are considered convalescent samples.
• A 4-fold change in 90% plaque reduction neutralizing antibody titers (PRNT 90 ) is considered confirmatory laboratory evidence of recent infection.
• A PRNT 90 titer of ≥10 is considered laboratory evidence of infection, but since timing of infection cannot be determined, clinical correlation is needed for interpretation (e.g., timing of travel and potential vector exposure in relation to symptom onset, clinical features, absence of other etiologies of symptoms).

Surveillance testing

Surveillance testing is performed to allow for the detection, response, and control of emerging and re-emerging arboviruses, such as Oropouche virus. Results of the surveillance testing will be shared with public health partners in the jurisdictional health department where the patient resides to allow for awareness and public health action. The results will have a cover letter noting a non-validated CLIA assay was used for the purpose of surveillance and are not to be shared with the patient or clinical team caring for the patient. Results will be conveyed using local sample ID only and will not include any patient or clinician identifiers.

Surveillance testing algorithm

• Oropouche virus surveillance testing should be considered for individuals meeting the suspect case definition and for whom serum and/or CSF specimens have been collected up to 10 days after symptom onset.
• Specimens will be tested in duplicate using a modified Oropouche virus real-time reverse transcription-polymerase chain reaction (rRT-PCR).

Reporting cases to ArboNET

Oropouche virus disease is not currently a nationally notifiable condition. However, CDC encourages voluntary reporting to ArboNET, the national arboviral surveillance system. Jurisdictions can report cases using condition code 10072 (Other arboviral disease, not otherwise specified) and 'Oropouche' for arbovirus. If you cannot report the arbovirus variable as 'Oropouche' then please report as 'Other Arbovirus'. The criteria below should be used for classification of Oropouche cases. For questions or further guidance on reporting, please contact [email protected].

Interim case definition

Current testing is limited to the assays described above, however the interim case definition incorporates additional assays and testing on specimen types that may become available in the future.

Confirmed case

A case that meets the suspect case definition* and one or more of the following laboratory criteria:

• Isolation of virus from, or demonstration of specific viral antigen or nucleic acid in, tissue, blood, CSF, or other body fluid
• Four-fold or greater change in virus-specific quantitative antibody titers in paired sera
• Virus-specific IgM antibodies in CSF or serum with confirmatory virus-specific neutralizing antibodies in the same or a later specimen

Probable case

A case that meets the suspect case definition* and one of the following laboratory criteria:

• Virus-specific IgM antibodies in CSF or serum
• Virus-specific neutralizing antibodies in a single CSF or serum specimen

*Absence of a more likely clinical explanation.

Oropouche virus is spread primarily by midges. Learn about areas at risk, the illness it causes, and ways to prevent becoming infected.

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Does your research study meet the National Institutes of Health (NIH) definition of a clinical trial? Watch this webinar recording to find out!

Experts from the National Institute of Mental Health (NIMH) provided an overview of NIH clinical trial classifications, with a particular focus on global mental health research. Their insight will help you correctly identify whether a study is considered a clinical trial so you can:

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Sri Lanka Successfully Conducts Capacity Building Program in Clinical Management of Dengue– For Bangladeshi Health Staff

Dengue is a public health problem in Sri Lanka with over 50 000 cases reported each year in the recent past. The country has been successful in bringing down the Case Fatality Rate (CFR) over the last two decades which was around from 5% in 1996 to 1% in 2009 and has declined gradually over time to 0.07% in 2023. It shows the resilience and high capacity of the curative sector in managing of dengue patients. However, the country experiences rising cases during the rainy seasons in June-July and October-December every year. During the last quarter of 2023, almost all districts of the country have reported dengue cases, with Colombo, Gampaha and Kalutara districts in the Western Province having the highest case detection rates during this year.

Sri Lanka’s achievement is due to multiple factors such as the availability of evidence-based clinical guidelines, continuous capacity building of clinical staff, and regular organization of dengue death review processes, which were streamlined from 2009 onwards. However, dengue continues to be a challenge for Sri Lanka.

National Institution of Infectious Diseases (NIID) which was established in 1926 is the pioneer infectious disease hospital in Sri Lanka. NIID rendered its valuable service during recent major events, notably during the Dengue 2017 epidemic and COVID-19 (2020-2021) pandemic. The hospital has modern treatment facilities (including a specialized dengue treatment unit), a highly skilled and dedicated staff, and a national level training facility for clinical management of dengue.

In 2022 and 2023 around 500 doctors and nurses were trained by NIID on clinical management of dengue. These programmes were conducted in collaboration with the National Dengue Control Unit (NDCU). The World Health Organization (WHO) has always given technical and financial support when requested for these training.   

The National Institute of Infectious Diseases in collaboration with the National Dengue Control Unit of the Ministry of Health, Sri Lanka, conducted the first international training on dengue case management from 22 to 28 July 2024. This training was designed for a group of selected doctors and nurses nominated by the Ministry of Health and Family Welfare, Bangladesh. In addition to the hands-on training, the participants also learnt on how health facilities need to be set up for treatment and monitoring of dengue patients and also gained an understanding on the leading roles of nurses in dengue case management and monitoring. The training comprised of presentations/lectures, discussions, hands-on training, clinical training, field visits and interactive sessions. Moreover, a symposium composed of knowledge sharing sessions was held with the Ministry of Health top officials, renowned clinicians, academicians, research staff and provincial and district level officials. 

This initiative is set to significantly enhance the dengue case management in Bangladesh and strengthen healthcare ties between two countries in years to come.

Nepal, Bhutan and Myanmar have expressed their interests in receiving the training on dengue case management in Sri Lanka through NIID. Therefore, national efforts will continue to introduce regular capacity building programs for countries that showed interests.

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Clinical trials exclude disabled Americans because federal agencies failed them, new report finds

Federal agencies implicitly and explicitly exclude people with disabilities from clinical trials.

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By Timmy Broderick

Aug. 15, 2024

Disability in Health Care Reporting Fellow

People with disabilities are largely excluded from clinical trials that could benefit them because federal agencies have failed to update rules that govern how trials are conducted or neglected to enforce existing laws that protect disabled Americans against discrimination, a new report has found.

The National Council on Disability, an independent federal agency, released the report this week detailing how several federal agencies implicitly and explicitly exclude people with disabilities from clinical trials. The report singled out several agencies including the Food and Drug Administration, National Institutes of Health, Health and Human Services and Department of Justice.

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While health practitioner biases worsen this problem, the council’s research highlights how the federal apparatus encourages this exclusion. This is, however, not the first time disabled Americans’ participation in clinical trials have been identified as a problem. A non-affiliated 2022 study of 97 clinical trial protocols found startling levels of exclusion for various disability groups — e.g., eligibility criteria removed 68% of people with psychiatric disabilities and 53% of people with HIV or hepatitis. 

As disabled people have fought for more political power , the cost of such exclusion from clinical trials — i.e., the poorer health outcomes for people with disabilities — has become more visible in recent years. In one of the starkest examples of this exclusion, 90% of people with Down syndrome develop Alzheimer’s during their lifetimes. However, the population is routinely excluded from trials for Alzheimer’s treatments, even though self-advocates with Down syndrome have been pivotal for securing better funding for treatments .

“How can this population benefit from these potentially life-changing treatments if they’re excluded from the trials? And how can anyone know what these therapeutics’ efficacy and safety is on this population – and one of the populations most affected? Exclusion exacts too high a price,” said the council’s Vice Chair Emily Voorde in a press release.

The authors’ recommendations fall into four buckets: codifying eligibility parameters, developing funding mechanisms that prioritize more inclusive trials, making trial documents and trial participation more accessible and beefing up oversight and enforcement of existing laws that would ensure trial sponsors abide by these guidelines. 

The NIH recognized people with disabilities as a population with health disparities in 2023, but federal agencies have a long way to go to fix this “alarming reality,” said Claudia Gordon, who heads the council. 

“To effectively address health disparities, HHS must prioritize this issue as a connected policy matter across the entire department,” said Gordon.

The council recommended that Congress require the FDA to ask clinical trial sponsors to report their efforts to enroll people with disabilities, as well as demand that diversity action plans include ways to increase the participation of people with disabilities in clinical trials.

The report suggested that HHS and DOJ increase their oversight and enforcement of Section 504 of the Rehabilitation Act of 1973 and section 1557 of the Affordable Care Act at health care facilities to ensure that programs and services are accessible. Those rules prohibit entities, such as providers and health insurers that receive federal funding, and federal agencies from discriminating against Americans with disabilities.

About the reporting

STAT’s investigation is based on interviews with nearly 100 people around the country, including incarcerated patients and grieving families, prison officials, and legal and medical experts. Reporter Nicholas Florko also filed more than 225 public records requests and combed through thousands of pages of legal filings to tell these stories. His analysis of deaths in custody is based on a special data use agreement between STAT and the Department of Justice.

You can read more about the reporting for this project and the methodology behind our calculations.

The series is the culmination of a reporting fellowship sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund.

Timmy Broderick

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Demolition to begin this fall for Mayo’s $5B Rochester buildout

Mayo Clinic’s Ozmun complex will be torn down to make way for one of two new clinical buildings in downtown Rochester.

By Sean Baker

ROCHESTER - Mayo Clinic will begin demolition of the Ozmun complex this fall in the first wave of redevelopment as part of its $5 billion buildout of its downtown campus.

The Ozmun complex, located a block west of Mayo’s Gonda Building, is the planned site of one of two new clinical buildings to be developed as part of Mayo Clinic’s “Bold. Forward. Unbound. in Rochester” initiative.

Mayo plans to start with the dismantling of the Ozmun West building in September with construction on the new clinical building to begin in mid-2025, said Doug Holtan, Mayo’s chair of facilities.

“We are excited to begin this stage of visible construction that will set the stage for transformation of our downtown campus,” Holtan said during a virtual press conference on Friday.

Mayo has also submitted a demolition permit for the former Lourdes High School building on W. Center Street. The site, which Mayo purchased in 2013, will be used to construct a new logistics center to support the expanded campus.

Earlier this year, the Rochester City Council voted to remove the old Lourdes site from a list of potential landmarks , paving the way for Mayo to demolish the building. Dr. Katie Arendt, a physician leader on the so-called Unbound project, said there are plans, however, to include artifacts of the building in a park alongside the west side of the new building.

Demolition of the Lourdes site is expected to begin in the next couple of months, with construction slated for 2025.

In all, Mayo’s plans call for five new buildings to be built downtown within the next six years. Much of the 2.4 million square feet of space will be centered in its two new clinical buildings, to be constructed on the Ozmun and Damon Parking Ramp sites. Holtan said he expects the Damon ramp to close in the middle of next year.

Both clinical buildings will stretch nine floors above ground, with a two-story skyway connecting the structures with the Gonda Building. Mayo officials say the expanded spaces will allow the clinic to offer more services to patients in one location, rather than having them navigate from building to building.

Also included in Mayo’s plans are renovations to the east entrances of the Mayo and Gonda buildings. Mayo plans to begin work in the coming months to extend a temporary street through what is now Annenberg Plaza for patients to access the buildings during construction.

To support its redevelopment, Mayo plans to build two new parking ramps with a total of 1,300 spaces. Holtan said those projects are still in the design phase, adding it was too early to offer a timeline on when they would open.

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Sean Baker is a reporter for the Star Tribune covering southeast Minnesota.

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The White House 1600 Pennsylvania Ave NW Washington, DC 20500

Remarks: National Cyber Director Coker Opening Remarks at DEF   CON

Las Vegas, NV

August 10, 2024

Remarks As Prepared for Delivery

Thank you, Jay.  It’s a pleasure to be here for the first time on the DEF CON stage. And, as a whiskey drinker myself, I’m a bit disappointed that more of my speeches don’t start that way!

I’m looking forward to our conversation, Jay, where we will dig into memory safety, BGP security, firmware vulnerability, and open-source software – all of the nuanced, technical topics that make Hacker Summer Camp such a draw, even in this new venue. 

But before we get into the hard problems that really define our work at the White House Office of the National Cyber Director, I want to say a few words about the importance of this community to our efforts to make our Nation more cyber secure, innovative, and prosperous.

This is my first DEF CON – I guess you already know that from my baptism by bourbon. But while I have been thoroughly impressed by the people, presentations, and even policy proposals I have seen over the past couple days, I cannot say I’m surprised.

From my early exposure to coding as a graduate student to my time at NSA to arriving at the White House, I’ve known how special the security researcher community is. Special, but often misunderstood.

As a society, we are predisposed to celebrate builders – inventors, engineers, and the titans of industry: all are lauded for what they’ve designed and constructed.

So it can be quite jarring to hear about a culture where tinkering is turned toward breaking things. Where rather than synthesis and cohesion, we talk about de-compiling code to find its weaknesses. Where manipulating people in the form of social engineering is venerated as a way of finding the weak points in a system.

And if there’s one place in the world where those concepts are particularly foreign, it’s Washington, DC. Our elected officials and civil servants swear an oath to protect and defend the Constitution – and it is far from intuitive to many of them as to how “hacking” could possibly be in that interest.

I can see where they’re coming from. But I also challenge them to look deeper.

To understand that, for the folks in this community, the desire to take things apart is rooted in a hope that they will be made stronger. To recognize that the Internet – decentralized, governed largely by a simple set of rules written decades ago – is a miracle of human ingenuity. And that, miraculous as it may be, the Internet also needs protecting.

That ethos – of trying to make the Internet a safer place – is what makes this community so important and vital to our way of life. It’s why it’s so important to me that I made the pilgrimage out to the desert, along with so many of our cybersecurity colleagues. And I’ve got good news for you. My voice is not alone in Washington, and the chorus is growing.

Jay, I know that when you were on the National Security Council staff two decades ago, you weren’t even allowed to come to DEF CON. Today, not only are the Feds here in force to learn from and celebrate your work, they’re recruiting!

Vulnerability disclosure policies used to be a pipe dream at Federal agencies. Today, they’re required – and they’ll soon be required for Federal contractors as well.

One of the first projects we launched at ONCD after I arrived was a white paper focused on memory safety, titled “Back to the Building Blocks.”

I will admit to being a bit surprised to see such a technical product coming out of a White House Office. Yet, after reviewing the report and learning about the research and consultation underlying it, I was completely convinced that it was vital that the White House shine a spotlight on the need to adopt solutions for the most critical vulnerabilities around.

The White House endorsing formal methods is now a bit of a meme – and I couldn’t be happier.

These are outward signs of progress. At least as important, though, is the cultural change happening in Washington.

For the first time, we are seeing policymakers consider how to leverage the unique aspects of the security research community to solve some of the very hardest problems in cybersecurity. Some of that is manifesting at the operational level as collaboration, not simply information sharing, increasingly becomes the norm at NSA’s Cybersecurity Collaboration Center and CISA’s Joint Cyber Defense Collaborative.

And it extends to more strategic proposals too. Yesterday, ONCD and our partners in the government’s Open Source Software Security Initiative released a report summarizing key findings from the request for information we announced at last year’s DEF CON. Importantly, we also describe actions we are taking in response to the feedback from the community.

Some of those actions are inherently governmental. For instance, as part of the Bipartisan Infrastructure Law, the Department of Homeland Security is investing over $11 million in open-source software security.

Today, I am proud to announce the launch the Open Source Software Prevalence Initiative, which will take advantage of that investment in America. Along with partners at our National Labs, the initiative will assess the prevalence of open-source software in operational technology used by critical infrastructure owners and operators. We know that open-source underlies our digital infrastructure, and it’s vital that, as a government, we contribute back to the community as part of our broader infrastructure efforts.

But many more of the recommendations go beyond what government can do alone and that’s where you all come in.

More than that: these policy proposals rely on the dedication of researchers and their willingness to freely share their findings in order to work. In our conversations on developing a software liability regime, too, we are increasingly aiming to leverage this unique community as part of novel policy solutions.

Our reliance on all of you does, however, come with a commensurate increase in responsibility.

In the President’s National Cybersecurity Strategy, we call for more of the responsibility for cybersecurity to fall upon the more capable actors in the ecosystem. That means technology producers, yes, and certainly the Federal Government. But it also means all of you.

I know you all are up for it.

I know that the same value set that drives responsible vulnerability disclosure will lead you to continue to step up for the protection of the Internet.

I know the Internet is a safer place today because of all of your efforts.

But I challenge you to have empathy for those of us in Government who are trying to tackle the hard problems in cyberspace. They may seem easy to some of you, but the President can’t issue an order and solve them.

We’ve known about vulnerabilities in the Border Gateway Protocol for decades; still, much of U.S. Internet traffic is subject to hijacking.

Memory-safe programming languages have similarly been around for years; still, critical software that underlies our society is written in C simply because that’s what’s convenient. The “tragedy of the commons” around open-source software development is a well-understood phenomenon; still, vital packages are maintained by tiny bands of volunteers operating on a less-than shoestring budget.

Policy can help address these problems. No, I’ll go further – policy is needed to address these problems. But policy takes time.

The people of the United States have entrusted their Government with awesome authorities. As we work to use them to improve our cybersecurity posture, we must ensure that we do so responsibly with an eye toward outcomes that preserve the innovation and decentralization that have made the Internet the miracle it is today.

Most important, though, is that we do so together.

At the core of our approach at ONCD is partnership. I prioritize hearing and learning from a diverse array of stakeholders, and you all are key constituents of ours.

I know that Jay and I will dig into some more of the details of our various initiatives, but I will also continue to seek feedback from all of you throughout the weekend.

So thank you again for everything you’re doing every day to passionately protect our digital ecosystem.

And thank you, again, for welcoming me to DEF CON.

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