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Autologous tissue can be either rectus muscle or latissimus dorsi muscle myocutaneous fiap treatment for sciatica discount cefuroxime 250mg amex. If it identifies a solid plan for breast cancer and mass medications jaundice discount cefuroxime 250 mg mastercard, then it should be followed by biopsy medications peripheral neuropathy discount 250 mg cefuroxime overnight delivery. If it is diagnosed in the third trimester treatment diarrhea quality 250mg cefuroxime, lumpectomy can be done and radiation given postpartum. Males with breast cancer Breast Cancer in Males often have direct extension to the chest wall at Predisposing factors: Klinefelter’s syndrome, estrogen therapy, elevated endogenous estrogen, previous irradiation, and trauma. Infiltrating ductal carcinoma most common histologic type (men lack breast lobules). Diagnosis tends to be late, when the patient presents with a mass, nipple retraction, and skin changes. Treatment for early-stage cancer involves a modified radical mastectomy and postoperative radiation. Partial-thickness or full-thickness burns involving face, hands, feet, geniSeventy-five percent of talia, perineum, or skin over major joints. Lesser burn injury in conjunction with inhalational injury, trauma, or preexisting medical conditions. Burns in patients requiring special social, emotional, or rehabilitation Typical scenario: A assistance. Cover burns with silver sulfadiazine/clean sheet and then warm blanburned, including the ket. Insert Foley catheter in patients requiring fiuid resuscitation or with a burn center. Patients with high-voltage electrical injury require cardiac monitor, as do any intubated or otherwise unstable patients. The risk of infection is extremely high with skin loss, since the skin is our biggest immune defense. Rule of Nines for estimating body surface area burned in adults, children, and infants. Patients with acceptable social situations amenable to providing a safe and helpful environment at home. At 4 mL/ Give half of 24-hour requirement in first 8 hours from the time of burn, kg/%, 4 fi 60 fi 25 = and the remainder over the next 16 hours. Adjust fiuids when urine output is more than 33% different (in either direction) from recommended over 2–3 hours. Increase in Fluid Requirements the risk of infection of High-voltage electrical injury burned tissue is increased Inhalational injury because the wound is Delayed resuscitation protein rich and moist, and Intoxicated at time of injury is thus a good culture medium. Hypovolemia and Daily burn care in shower or tank if possible; otherwise, at bedside. Impairment of circulation in extremities Impaired ventilation No anesthesia is needed. Fasciotomy Escharotomy may fail, especially when the burn is from high-voltage the most common electrical injury or is associated with soft tissue, bone, or vascular injury. Debridement and Skin Grafting Excisional treatment is indicated for most deep secondand thirddegree burns once the patient is stabilized. Advantages: Decreased length of stay, earlier return to work, decreased incidence of infection, decreased complications, improved survival. Technique: Full-thickness burns require debridement to the investing fascial layer using the scalpel and bovie. A Goulian knife, which takes off sequential thin layers, can be used for partialand some full-thickness excisions; requires debridement until uniform capillary bleeding. The incisions are placed along the mid-medial lines of the extremities and the thorax (dashed lines). The skin is especially tight along major joints, and decompression at these sites must be complete (solid lines). If the risk of mortality is anticipated to be < 50%, first graft hands, feet, face, and joints. For pseudomonal or pediatric infections, infuse subeschar piperacillin, Infection is more likely in and plan for emergent operative debridement within 12 hours. Carbon monoxide impairs tissue oxygenation by decreasing oxygencarrying capacity of blood, shifting oxygen-hemoglobin dissociation curve to the left, binding myoglobin and terminal cytochrome oxidase. Symptoms do not correlate well with carboxyhemoglobin levels, but levels up to 10% are typically asymptomatic. V/Q scanning will demonstrate carbon particle deposition on endobronchial mucosa. More than 1000 volts—passage of current is not limited and tissue injury can continue. Duration of contact (tissue injury continues to occur as long as the agent remains in contact with the skin). Copious water lavage: Irrigation should continue for at least 30 minutes for acid burns, and longer for alkali burns (because they penetrate deeper into the tissue). Malignant hyperthermia Atracurium and cis-atracurium undergo degradation in plasma at physiological pH and temperature by organ-independent Hofmann eliminaOther special tion and so can be used in patients with hepatic and renal dysfunction. Can be used to “reverse” neuromuscular blockade of nondepolarizing agents (at end of surgery). Maintenance Nitrous oxide can diffuse into closed spaces/lumens, Involves use of inhalational agents. Patient should have full muscle strength and protective airway refiexes before extubation. During emergence, patient Airway: Due to anatomy of pediatric airway, intubation can be more challengis at risk for aspiration and ing (see Table 19-4). Ways Pediatric Airway Differs from Adult resulting in the inability to ventilate the patient). Vocal cords are at a slant and more anterior Halothane hepatitis is an immune-mediated hepatotoxicity associated with use of halothane (an inhalational anesthetic). Insert needle at L3–L4 or L4–L5 (at this level cauda equina is present and spinal cord has already ended). Backache Common Common Permanent neurologic injury Very rare Very rare Epidural abscess or hematoma N/A Rare 313 Local Anesthesia Used for local infiltration of operative site, during spinal or epidural anesthesia, and peripheral nerve blocks. Obstetric patients are at Mechanism of action: Through blockade of sodium channels. Nonionized form: Needed to cross nerve sheath while the ionized form is the active form. Acidosis: Local tissue acidosis as from infection increases ionized drug form and limits anesthetic activity of the drug. Therefore, local infiltraSpinal anesthesia is tion into an area of infection may not produce adequate analgesia. Avoid epinephrine in areas with lack of colhours, since the anesthetic lateral blood fiow. Scrotum Dantrolene sodium (a calcium channel blocker considered more definPenis itive treatment, but onset of action takes about 30 minutes). Types of Arteries Elastic: Major vessels, including aorta, subclavian, carotid, pulmonary arteries. Venous Anatomy Also three layers, but adventitia is most prominent, and intima and media are generally thin. Easily palpable pulses in either lower quadrant indicate distal aortic or common iliac aneurysm. Patient should be reclining in supine position, with full exposure of ab“Scoring” of pulses: domen and legs. Therefore, you should use Other types of plethysmography (seldom used): < 200 cc of dye, and use Ocular plethysmography with caution in patients with Impedance plethysmography renal dysfunction. A pseudoaneurysm does Misleading results associated with: not contain all three layers Diabetic patients, as calcification of vessels makes them less comof the arterial wall. Arteriography Typical scenario: You are Use of contrast dye with fiuoroscopy to delineate arteries. Maintain direct Decreased pulses compared to pre-angio: If resolves within 1 hour, may be due to spasm; otherwise, consider arterial injury, clot.

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Other tumors of the esophagus are less common (including leiomyomas symptoms 3dpo cefuroxime 500mg without a prescription, melanomas treatment chlamydia cefuroxime 500 mg with mastercard, carcinoids symptoms diabetes best cefuroxime 250 mg, lymphomas) medicine cabinet cheap cefuroxime 250mg overnight delivery. Most cases occur in patients over the age of 50, but there is an increase in cases in younger patients with disease detected at an earlier stage. Over 50% of patients have unresectable or metastatic disease at the time of presentation. Five-year survival rate is poor, but increased to 14% toward the end of the 20th century. Gradual development of dysphagia (74% of patients) due to invasion esophageal lumen is of serosal layer, first for solids and later for both solids and liquids obstructed. With advanced disease, the patient will appear cachectic; supraclavicular lymphadenopathy may be present, as may signs of distant metastasis. May develop symptoms depending on local invasion (stridor, coughing, aspiration pneumonia, hemoptysis, vocal cord/recurrent laryngeal nerve paralysis). Asymptomatic patients are occasionally identified by surveillance endoscopy, especially patients with Barrett’s esophagus. Barium esophagram is the initial diagnostic test—may show stricture, ulceration, or mass. Radiotherapy for avoidance of perioperative morbidity and mortality (can shrink tumor but may predispose to local complications and not palliate dysphagia and odynophagia). Combination therapy of these three modalities is becoming increasthe 5-year survival rate for ingly common. Postoperative complications are common and include fistulae or abscesses and respiratory complications. Other options include endoscopic laser therapy, endoscopic dilatation and stent placement, or placement of a gastrostomy or jejunostomy. Some believe it to be congenital, others due to infolding of redundant esophageal mucosa, 111 and others due to stricture result from infiammation from chronic refiux. Symptoms include brief episodes of dysphagia during hurried ingestion of solid foods. Treatment ranges from dilatation (usually once) +/– antirefiux measures to incision of the ring and excision. Plummer-Vinson syndrome (Patterson-Kelly syndrome): An uncommon clinical syndrome characterized by dysphagia, atrophic oral mucosa, spoon-shaped and brittle fingernails, and chronic iron deficiency anemia. An esophageal web, which is usually the cause of dysphagia was often thought to be a main component of the syndrome, but evidence has shown that it develops as a response to ingesting ferrous sulfate for the treatment of the anemia. See Pediatric Surgery chapter for discussion of esophageal embryology and tracheoesophageal fistulas. Gastrectomy: Loss of Anterior gastric wall: Left vagus nerve (gives branch to liver). Disease or resection of Gastroduodenal pain: Sensation via sympathetic afferents from level T5 terminal ileum: Causing (below nipple line) to T10 (umbilicus). Perforation (7% incidence): Sudden, severe midepigastric pain radiating to right shoulder, peritoneal signs, free peritoneal air. A chest or abdominal film may not show presents due to 3 months free air because the posterior duodenum is retroperitoneal. Think: Gastric outlet Obstruction: Due to scarring and edema; early satiety, anorexia, vomitobstruction. Secretin stimulation test: Secretin (a gastrin inhibitor) is delivered parenterally (usually with Ca2+) and its effect on gastrin secretion is measured. Antacids: Over the counter, good for occasional use for all causes of dyspepsia, but better drugs are available for active ulcer disease. Surgery is indicated when ulcer is refractory to 12 weeks of medical treatment or if hemorrhage, obstruction, or perforation is present. Truncal vagotomy and selective vagotomy are not commonly performed anymore due to associated morbidity (high rate of dumping syndrome) despite good protection against recurrence. Procedure of choice is highly selective vagotomy (parietal cell vagotomy, proximal gastric vagotomy) (see Figure 8-2). The terminal branches to the pylorus and antrum are spared, preserving pyloroantral function and thus obviating the need for gastric drainage. Common complications Preferred due to its lowest rate of dumping; however, it does have the specific to surgery for highest rate of recurrence. Afferent loop syndrome Laparoscopic option: A posterior truncal vagotomy coupled with an anMarginal ulcer terior seromyotomy is being done laparoscopically. Occasionally, when focus of tumor canPostvagotomy diarrhea not be found, a total gastrectomy may be considered in severe cases refractory to medical management. Can be caused by refiux of duodenal contents (pyloric sphincter dysfunction) and decreased mucus and bicarbonate production. V + A Bleeding from the Back (posterior duodenal aUnless the patient is in shock or moribund, a definitive procedure should be considered. CusHing’s ulcer (think: Curling’s ulcers: Gastric stress ulcers in patients with severe burns. Pernicious anemia (decreased production of intrinsic factor from gastric parietal cells due to idiopathic atrophy of the gastric mucosa and subsequent malabsorption of vitamin B12). Symptomatic treatment with motility-reducing agents (kaolin-pectin, loperamide, or diphenoxylate). Refractory cases may respond to cholestyramine (bile-salt binding Two types of chronic agent). Achlorhydria, Symptoms typically occur 5–15 minutes postprandially (early dumping Autoimmune disease. Treated by dietary modification: Small, multiple low-carbohydrate/fat meals; avoid excessive liquid intake. Severe cases (1%) that do not respond to dietary modifications can be treated with octreotide (synthetic somatostatin—helps delay gastric emptying time and transit through small intestine). Typical scenario: A Surgical management: Roux-en-Y gastrojejunostomy with a long (~5058-year-old woman who is cm) Roux limb. Bilious vomiting may improve, but symptoms (early sa6 days postop from a tiety, bloating) may persist. Treatment: Endoscopic balloon dilatation or surgical revision of loop if that fails. Hypochloremic, hypokalemic metabolic alkalosis with paradoxical aciBoerhaave syndrome: duria. Nasogastric decompression is necessary to normalize the size of the diCoffee grounds is the term lated stomach. Bleeding varices are ligated, or sclerosed via endoscopy (see Hepatobiliary System chapter). Bleeding is controlled by undersewing the vessel on either side of the hemorrhage. Medical conditions Prerequisite: Participation in supervised dietary program without success. Malabsorptive: Limit nutrient absorption by bypassing duodenum and small intestine. Linitis plastica: 7–10%, “leather bottle” type, involves all layers, extremely poor prognosis. Late: Anorexia/weight loss, nausea, vomiting, dysphagia, melena, hematemesis; pain is constant, nonradiating, exacerbated by food. Chemotherapy: Sometimes used palliatively for nonsurgical candidates; no role for adjuvant chemotherapy. Location: Proximal gastric cancer has less favorable prognosis than distal lesions. Prognosis depends on completeness of resection, presence of metastases, and the mitotic index. Are the only ones with any real malignant potential; others are mostly asymptomatic and uncommon. Mucosal thickening secondary to hyperplasia of glandular cells replacing chief and parietal cells. May consist of hair (trichobezoar), vegetable matter (phytobezoar) (especially in patients who may have eaten persimmon), or charcoal (used in management of toxic ingestions). The primitive gut tube, formed from the endoderm, begins to develop into the foregut, midgut, and hindgut. This communication narrows by Intestine elongates and midgut loop herniates through umbilical ring. Consists of four parts: Superior (first) part—duodenal bulb: 5 cm long; site of most ulcers.

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The six generation delay was 18 taken to treatment 4 hiv cefuroxime 250 mg sale imply that normal senescence symptoms 4dpiui generic cefuroxime 250 mg line, of the type that occurs in a single generation treatment with cold medical term purchase cefuroxime 250 mg amex, must 34 involve important undiscovered factors medicine 54 357 cheap cefuroxime 500 mg otc. The connection among telomeres, Hayflick limits, and the phenomenon of senescence is important whether telomeres are the primary mechanism or just one of several. But, telomere regulation has significance beyond the issue of our gradual decline with age. Activation of telomerase appears to be a necessary step in most transformations of 26,28 normal tissue into tumors. The connection of cancer and senescence to the same mechanism is not serendipity, it is a window into a fundamental trade-off, the balance of which we may find difficult to improve. Juxtaposing an evolutionary perspective on senescence, with the gerontological and oncological view of telomeres, it appears that limits on the proliferative capacity of somatic cells (Hayflick limits) evolved as tumour suppressors that rein in runaway cellular proliferation, but that these same limits preclude indefinite somatic maintenance, causing gradual degradation of function. It seems the telomere/telomerase system is an 1 antagonistic pleiotropy of the type Williams predicted. Only when senescence is recognised as an inherent consequence of design trade-offs can we fully understand the nature of ageing. We will use reserve capacity to refer to the remaining quantity of population doublings that a differentiated 19 cell can undergo (in vivo) before reaching its Hayflick limit. When a cell is damaged such that it begins to over-proliferate, it ultimately reaches its Hayflick limit and proliferation ceases. The greater the reserve capacity of the progenitor cell, the larger the resultant mass of growth-arrested daughter cells will be. We regard this mass of cells as a proto-tumour, each cell possessing the first of several mutations necessary for tumorigenesis and cancer. Because cells will tend to retain more proliferative potential early in an organism’s life, younger individuals should tend to produce larger proto-tumours than older individuals. Since each cell in a proto-tumour presents an equivalent opportunity for the acquisition of telomerase activating mutations, we predict that proto-tumours produced early in life carry a proportionally higher risk of becoming mature tumours than proto-tumours generated late in life. This effect will be exacerbated by the fact that prototumours formed at an early age will tend to have more time in which to accumulate further genetic changes. The risk from any particular proto-tumour should diminish with time, as growth-arrested cells expire and are lost. Risk reduction may be accelerated if apoptosis is triggered by proto-tumour formation, but this would accelerate the exhaustion of the neighbouring lineages that ultimately replace the lost cells. To our knowledge, no explicit mechanism linking Hayflick limits to the phenomenon of vertebrate ageing has been proposed. Development continually increases histological differentiation and specialisation, which are maximal when an organism becomes a reproductively capable adult. Throughout life, damage and programmed cellular turnover result in cells being lost from the soma and replaced. When cellular lineages exhaust their reserve capacity and are lost, they must be replaced by neighbouring lineages, if they are replaced at all. We propose that the uncompensated loss of some cellular lineages, coupled with the replacement of other lineages by neighbours (adapted to slightly different roles), 20 diminishes the optimal arrangement of cell types. By our model, body-wide senescence results from the combined effect of (a) uncompensated cellular attrition and (b) increases in what might be called histological entropy, both of which will diminish an organism’s efficiency at accomplishing whatever tasks differentiation initially evolved to address. Senescence of this type should progress at a non-linear rate, accelerating with age as fewer cellular lineages maintain and repair an ever larger proportion of the body. Skin 39 thickness decreases approximately 25% between the fourth and eighth decade of life, and entropy increases: “The epidermis of older individuals exhibits a marked variation in thickness (often in the same histologic section) and a disparity in the size, shape and staining quality of the basal cell nuclei under light microscopy. There is also a loss of the orderly alignment of cells along the basement membrane and a disruption of the gradual upward uniform differentiation present in the epidermis of younger individuals Electron microscopic studies show that the basal cells of the flattened epidermis of old individuals lack villi Deletion and derangement of small blood vessels is found in aged skin, with sun-damaged 40 skin being the most severely affected. Cells in portions of the vascular system that sustain relatively high levels of wear and tear have short 41 telomeres, implying a history of cellular replacement and likely attrition of cellular lineages. These areas fail to produce a protective layer of cells characteristic of younger tissue, and consequently have an increased propensity to develop atherosclerotic 41 plaques. Vertebrates use reserve capacity in growth, maintenance, and repair; each process erodes telomeres, reducing proliferative potential. Though antagonistic pleiotropy and accumulated damage hypotheses have traditionally been 21 viewed as alternative explanations for senescence, the finite reserve capacity approach integrates them. Damage, even if it is functionally repaired, will accelerate the ageing of tissue by limiting the capacity for future maintenance and repair. The liver of a heavy drinker, for instance, may function essentially as well at 40 as it did at 25, but should fail more rapidly than the liver of a non-drinker, even if alcohol consumption ends before damage is evident. Any factor that damages tissue, including mutagens, pathogens, mechanical wear or trauma, oxidative stress and free radicals, will promote a local increase in that tissue’s rate of senescence. Selection should tend to optimise reserve capacities based on a species’ timing of reproduction and the typical rate of cellular repair and turnover as well as the extrinsic risk of mortality. Although telomere erosion begins at whatever point in ontogeny telomerase is inactivated in the soma, selection should adjust reserve capacities so the loss of cellular lineages does not begin before the usual age of first reproduction. In iteroparous species, selection should further act to co-ordinate reserve capacities among tissues so that senescence is synchronised throughout the body, thus minimising the fitness cost that would accompany early senescence in any particular organ (as per refs. But, because of the stochastic nature of environmental insults, past selection cannot predict the reserve capacity needs of individuals nor the organs on which they depend. An otherwise healthy individual may die from the premature senescence of a particular tissue (despite the synchronising force of selection) if the tissue has had an unusual history of damage. Because rates of damage differ between conspecific individuals, we should also expect dissynchrony of senescence rates between individual animals, even in populations that are genetically homogeneous. Selection can adjust telomere lengths based on species’ averages for parameters such as the number of cells in each tissue of the body and typical rates of damage and mortality. But selection based on averages will not produce ideal telomere lengths for individuals. The optimal telomere length on a chromosome passed from a 5’6” father to his 6’1” son will necessarily be a compromise (longer than optimal for the father and shorter than optimal for the son). This constraint may explain why the positive interspecific correlation between body size and longevity (addressed in ref. For example, even when the effects of obesity are controlled for, larger 43,44 45,46 humans and dogs tend to be comparatively short lived. The extra cell divisions required to become larger, by diminishing reserve capacity at maturity, may shorten lifespan by reducing the capacity of larger individuals to maintain and repair their tissues. We expect smaller individuals to suffer a greater per cell risk of developing tumours due to longer-than-optimal telomeres at maturity. At the same time they should show an increased resistance to other senescent effects. Since smaller individuals are composed of fewer cells, we do not expect their increased per-cell tumour risk to fully counteract their decreased rate of senescence. Reinterpreting experimental results: Senescent cellular phenotypes: misregulation or adaptive responsefi Upon reaching a Hayflick limit, many cell types begin expressing genes that were previously 47 untranscribed, and cease expression of previously active genes. Several workers have conjectured that somatic senescence of individuals results from the progressive 48-50 accumulation of cells with “senescent phenotypes”. To our knowledge no one has proposed a mechanistic connection between these phenotypes and organismal ageing. The implicit assumption is that expired cellular lineages accumulate late enough in life that selection lacks the power to regulate their function to the benefit of the organism. He went on to argue that selection would then produce modifiers that would minimise the harm caused by these late effects. We suggest that “senescent cellular phenotypes” are actually adaptations that limit the harm caused by the expiration of cellular lineages. The hypothesis that changes in gene expression associated with ageing are the result of misregulation is apparently falsified by the very data used to support it. They found that 50% of the genes whose expression is altered in ageing (both accelerated and normal) belonged to two classes, mitosis initiation and progression genes. If transcriptional changes were the result of misregulation then we should expect a random pattern of changes reflecting a lack of stabilising selection on gene regulation.

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Rowe leads the MacArthur Foundation’s Network on An Aging Society and chairs the Institute of Medicine’s Committee on the Future Health Care Workforce for Older Americans medicine mart order 500 mg cefuroxime overnight delivery. He has served as president of the Gerontological Society of America and recently chaired the Committee of the Institute of Medicine of the National Academy of Sciences on the Future Health Care Workforce Needs of An Aging Population 10 medications doctors wont take 500mg cefuroxime free shipping. Rowe was elected a Fellow of the American Academy of Arts and Sciences and a member of the Institute of Medicine of the National Academy of Sciences where he is involved in the Evidence Based Roundtable treatment urinary retention discount 500mg cefuroxime free shipping. Rowe serves on the Board of Trustees of the Rockefeller Foundation and is Chairman of the Board of Trustees at the Marine Biological Laboratory in Woods Hole medicine plies safe 500 mg cefuroxime, Massachusetts. Shurin was professor of Pediatrics and Oncology at Case Western Reserve University; director of Pediatric Hematology-Oncology at Rainbow Babies and Children’s Hospital; director of Pediatric Oncology at the Case Comprehensive Cancer Center; and vice president and secretary of the Corporation at Case Western Reserve University in Cleveland, Ohio. Shurin received her education and medical training at Harvard University and the Johns Hopkins University School of Medicine. Her laboratory research focused on the physiology of phagocyte function, recognition and killing of pathogens; mechanisms of hemolysis; and iron overload. She has been active in clinical research in many aspects of pediatric hematology-oncology, including participation in the Children’s Cancer Group, Children’s Oncology Group, multiple studies in sickle cell disease and hemostasis. The Foundation is an independent philanthropy with assets of more than $700 million, headquartered in Oakland, California and dedicated to improving the health of the people of California through its program areas: Better Chronic Disease Care, Innovations for the Underserved, Market and Policy Monitor, and Health Reform and Public Programs Initiative. He has been elected to the Institute of Medicine and serves on the board of the National Business Group on Health. Prior to joining the California HealthCare Foundation, Smith was Executive Vice President at the Henry J. He has served on the Performance Measurement Committee of the National Committee for Quality Assurance and the editorial board of the Annals of Internal Medicine. Steele previously served as the dean of the Biological Sciences Division and the Pritzker School of Medicine and as vice president for medical affairs at the University of Chicago, as well as the Richard T. Widely recognized for his investigations into the treatment of primary and metastatic liver cancer and colorectal cancer surgery, Dr. His investigations have focused on the cell biology of gastrointestinal cancer and pre-cancer and most recently on innovations in healthcare delivery and financing. A prolific writer, he is the author or co-author of more than 476 scientific and professional articles. Steele received his bachelor’s degree in history and literature from Harvard University and his medical degree from New York University School of Medicine. He completed his internship and residency in surgery at the University of Colorado, where he was also a fellow of the American Cancer Society. Steele serves on several boards including Bucknell University’s Board of Trustees, Temple University School of Medicine’s Board of Visitors, Premier, Inc (Vice Chair), Weis Markets, Inc. Steele is currently Honorary Chair of the Pennsylvania March of Dimes Prematurity Campaign, served on the Healthcare Financial Management Association’s Healthcare Leadership Council, the Northeast Regional Cancer Institute, the Global Conference Institute, and previously served on the Simon School of Business Advisory Board (University of Rochester) 2002 2007. He was recognized by “Modern Healthcare’s 100 Most Powerful People in Healthcare” in 2009 and 2010. Marilyn Tavenner is currently the Acting Administrator for the Centers for Medicare & Medicaid Services. Tavenner served as the agency’s second-ranking official overseeing policy development and implementation as well as management and operations. Tavenner, a life-long public health advocate, manages the $820 billion federal agency, which ensures health care coverage for 100 million Americans, with 10 regional offices and more than 4,000 employees nationwide. Tavenner served for four years as the Commonwealth of Virginia’s Secretary of Health and Human Resources in the administration of former Governor Tim Kaine. In this top cabinet position, she was charged with overseeing 18,000 employees and a $9 billion annual budget to administer Medicaid, mental health, social services, public health, aging, disabilities agencies, and children’s services. By 1993, she began working as the hospital’s Chief Executive Officer and, by 2001, had assumed responsibility for 20 hospitals as President of the company’s Central Atlantic Division. Tavenner holds a bachelor’s of science degree in nursing and a master’s degree in health administration, both from the Virginia Commonwealth University. She has worked with many community and professional organizations, serving as a board member of the American Hospital Association, as president of the Virginia Hospital Association, as chairperson of the Chesterfield Business Council, and as a life-long member of the Rotary Club. Her contributions also include providing leadership in such public service organizations as the March of Dimes, the United Way and the Juvenile Diabetes Research Foundation. Tavenner has been recognized for her volunteer activities, including the 2007 recipient of the March of Dimes Citizen of the Year Award. He is currently the Executive Vice President and Chief of Medical Affairs at UnitedHealth Group, a Fortune 25 diversified health and well-being company. Tuckson is responsible for working with all the company’s diverse and comprehensive business units to improve the quality and efficiency of the health services provided to the 75 million members that UnitedHealth Group is privileged to serve worldwide. Drew University of Medicine and Science in Los Angeles; and he is a former Commissioner of Public Health for the District of Columbia. He is an active member of the prestigious Institute of Medicine of the National Academy of Sciences. He is immediate past Chair of the Secretary of Health and Human Services’ Advisory Committee on Genetics, Health and Society. Tuckson has also held other federal appointments, including cabinet level advisory committees on health reform, infant mortality, children’s health, violence, and radiation testing. Tuckson currently serves on the Board of Directors for several national organizations including the National Hispanic Medical Association; the Alliance for Health Reform; the American Telemedicine Association; the National Patient Advocate Foundation; the Macy Foundation; the Arnold P. In the 1990s, she served as chief of staff to two North Dakota senators: Kent Conrad (D) and Quentin Burdick (D). She also has served as director of the Center for Health Policy, Research and Ethics at George Mason University in Fairfax, Va. She has a bachelor of science degree in nursing from the University of Mary in Bismarck and master’s and doctoral degrees in nursing from the University of Texas at Austin. Woodson ensures the effective execution of the Department of Defense (DoD) medical mission. He oversees the development of medical policies, analyses, and recommendations to the Secretary of Defense and the Undersecretary for Personnel and Readiness, and issues guidance to DoD components on medical matters. Woodson co-chairs the Armed Services Biomedical Research Evaluation and Management Committee, which facilitates oversight of DoD biomedical research. Army Reserve, and served as Assistant Surgeon General for Reserve Affairs, Force Structure and Mobilization in the Office of the Surgeon General, and as Deputy Commander of the Army Reserve Medical Command. Woodson is a graduate of the City College of New York and the New York University School of Medicine. He received his postgraduate medical education at the Massachusetts General Hospital, Harvard Medical School and completed residency training in internal medicine, and general and vascular surgery. He is board certified in internal medicine, general surgery, vascular surgery and critical care surgery. He also holds a Master’s Degree in Strategic Studies (concentration in strategic leadership) from the U. In 1992, he was awarded a research fellowship at the Association of American Medical Colleges Health Services Research Institute. He has authored/coauthored a number of publications and book chapters on vascular trauma and outcomes in vascular limb salvage surgery. His prior military assignments include deployments to Saudi Arabia (Operation Desert Storm), Kosovo, Operation Enduring Freedom and Operation Iraqi Freedom. He has also served as a Senior Medical Officer with the National Disaster Management System, where he responded to the September 11th attack in New York City. Woodson’s military awards and decorations include the Legion of Merit, the Bronze Star Medal, and the Meritorious Service Medal (with oak leaf cluster). In 2007, he was named one of the top Vascular Surgeons in Boston and in 2008 was listed as one of the Top Surgeons in the U. He is the recipient of the 2009 Gold Humanism in Medicine Award from the Association of American Medical Colleges. Filart is a physician boarded in the field of Physical Medicine and Rehabilitation and Spinal Cord Medicine. She graduated from the Johns Hopkins Carey Business School with a Master’s in Business of Medicine and earned a Lean Six Sigma Green Belt. The Cost Institute identifies and disseminates best practices and promising solutions to cost, quality, patient safety, and employee engagement challenges with a focus on implementation and actionable information for employers.

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