0:00

Welcome, this is the New England Journal

0:02

of Medicine. I'm Dr. Lisa

0:04

Johnson. This week, January 18,

0:07

2024, we feature articles on

0:10

testosterone treatment and fractures in

0:12

men, long-term resynchronization

0:15

defibrillation therapy for heart

0:17

failure, azithromycin to

0:20

prevent infant mortality in

0:22

Burkina Faso, oral

0:24

synotrilvir for adult patients

0:26

with COVID-19, understanding

0:29

liability risk from healthcare

0:31

AI tools, and

0:33

the rise of house staff unions,

0:36

a review article on syphilis

0:38

during pregnancy and congenital syphilis,

0:41

a case report of a woman with

0:43

melanoma and fever, and

0:45

perspective articles on responding to

0:48

medical errors, on looking

0:50

ahead to state global budgets

0:52

for healthcare, and on

0:55

broken both ways. Testosterone

0:58

treatment and fractures in

1:01

men with hypogonadism by

1:04

Peter Snyder from the

1:06

University of Pennsylvania, Philadelphia, and

1:08

colleagues. Testosterone

1:10

treatment in men with

1:13

hypogonadism improves bone

1:15

density and quality, but

1:17

trials with a sufficiently large sample

1:20

and a long enough duration to

1:22

determine the effect of testosterone on

1:24

the incidence of fractures are needed.

1:27

This trial examined the risk

1:29

of clinical fracture in a

1:32

time-to-event analysis. 5,204 middle-aged

1:34

and older men with hypogonadism were

1:40

randomly assigned to apply

1:42

a testosterone or placebo

1:44

gel daily. After

1:46

a median follow-up of 3.19 years,

1:49

a clinical fracture had occurred in

1:52

3.5% of

1:54

participants in the testosterone group and

1:56

2.46% of

1:59

participants the placebo group.

2:02

The fracture incidence also appeared

2:04

to be higher in the

2:06

testosterone group for all other

2:08

fracture endpoints. Among

2:11

middle-aged and older men

2:13

with hypogonadism, testosterone treatment

2:15

did not result in

2:17

a lower incidence of

2:19

clinical fracture than placebo.

2:21

The fracture incidence was numerically

2:24

higher among men who received

2:26

testosterone than among those who

2:29

received placebo. Matisse

2:32

Grossman from the University of

2:34

Melbourne, Australia and Bradley

2:36

Anewalt from the University of

2:38

Washington School of Medicine, Seattle,

2:41

write in an editorial that

2:43

in the trial by Snyder

2:45

and colleagues, the increased incidence

2:47

of clinical fractures in the

2:49

testosterone group was a surprising

2:51

finding. How do we explain

2:53

it? First, fracture

2:55

incidence increased immediately at

2:58

the onset of treatment,

3:00

a finding that would be too rapid to

3:02

be due to effects on bone. The

3:05

rapid divergence between trial groups

3:08

is more likely to be

3:10

related to behavioral changes in

3:13

the participants randomized to testosterone,

3:15

perhaps affecting behaviors such as

3:17

engaging in physical activities associated

3:20

with fracture risk. Second,

3:22

there was no substantial between-group

3:25

difference in the incidence of

3:27

typical osteoporotic clinical fractures of

3:29

the spine, hip, humerus and

3:32

wrist in this trial. Ankle

3:34

and rib fractures that are typically

3:36

associated with trauma accounted for

3:39

the majority of the excess

3:41

fractures in the testosterone group. What

3:44

are the clinical implications of the

3:46

trial? The findings do

3:49

not apply to men

3:51

with hypogonadism due to

3:53

identifiable disease of the

3:55

hypothalamic-pituitary-testicular axis who need

3:57

testosterone for normal function. However,

4:00

a potential increase in fracture

4:02

risk should be considered in

4:05

the decision-making about testosterone therapy

4:07

for men with low serum

4:09

testosterone concentrations due

4:11

to aging or obesity. Finally,

4:14

men at high risk for

4:16

fragility fracture should receive

4:19

osteoporotic drug therapy with

4:21

proven antifracture benefit independent

4:24

of any consideration of

4:26

testosterone therapy. Major

4:29

concerns about cardiovascular and

4:31

prostate risks that are associated

4:33

with testosterone therapy have been

4:36

reduced in the past several

4:38

years and in selected men,

4:41

evidence regarding potential benefits such

4:43

as diabetes prevention and improved

4:45

mobility has emerged. Ironically,

4:48

the trial by Snyder

4:50

and colleagues identified a

4:53

potential unanticipated fracture risk

4:55

with testosterone treatment which

4:57

highlights the importance of

4:59

future randomized control trials

5:02

of the effects of

5:04

exogenous testosterone on fractures.

5:08

Long-term outcomes of

5:10

resynchronization defibrillation for

5:12

heart failure by

5:15

John Sapp from Dalhousie

5:17

University, Halifax, Nova Scotia,

5:19

Canada. The

5:22

resynchronization defibrillation for ambulatory

5:24

heart failure trial, RAFFT,

5:27

showed a greater benefit

5:29

with respect to mortality

5:31

at five years among

5:34

patients who received cardiac

5:36

resynchronization therapy, CRT, then

5:39

among those who received

5:41

implantable cardioverter defibrillators, ICTs.

5:45

The investigators now report on

5:47

the effect of CRT on

5:49

long-term survival. The trial

5:52

has been reviewed by patients with a

5:54

reduced ejection fraction, a widened QRS complex,

5:56

and NYHA class 2 or 3 heart

5:58

failure. were

6:01

randomly assigned to receive either

6:03

an ICD alone or

6:05

a CRT defibrillator. 1050

6:09

patients were included in the

6:11

long-term survival trial. The

6:13

median duration of follow-up was 7.7 years

6:17

and the median duration of follow-up for

6:19

those who survived was 13.9 years. The

6:23

primary outcome of death from any cause

6:25

occurred in 76.4% of patients assigned to

6:30

the ICD group and in 71.2% of

6:33

patients assigned to the CRT

6:35

defibrillator group. The time until

6:38

death appeared to be longer

6:40

for those assigned to receive

6:42

a CRT defibrillator than those

6:44

assigned to receive an ICD.

6:48

Acceleration factor 0.8. A

6:51

secondary outcome event of a composite

6:53

of death from any cause, heart

6:55

transplantation or implantation of a ventricular

6:58

assist device occurred in 77.7% of

7:00

patients in the ICD group and

7:05

in 75.4% in the CRT defibrillator group. Among

7:11

patients with a reduced ejection

7:13

fraction, a widened QRS complex

7:16

and NYHA class 2 or

7:19

3 heart failure. The survival

7:21

benefit associated with receipt of

7:23

a CRT defibrillator as compared

7:26

with ICD appeared

7:28

to be sustained during a median

7:30

of nearly 14 years of follow-up.

7:36

In an editorial, Lynn

7:38

Warner-Stevenson and Jay Montgomery

7:40

from Vanderbilt University Medical

7:42

Center, Nashville, write

7:45

that the improved clinical trajectory for

7:47

patients with mild heart failure at

7:49

a median of nearly 14 years

7:52

after CRT implantation in the

7:55

RAFT trial is remarkably similar

7:57

to the benefits observed in

7:59

the cohort of asymptomatic patients

8:02

who received enalapril in

8:04

the previously reported landmark

8:06

SOLVED, Studies of Left

8:09

Ventricular Dysfunction, trial. Although

8:12

survival among patients with heart

8:14

failure symptoms was longer with

8:16

enalapril than with placebo during

8:18

the initial SOLVED trial period,

8:21

survival at 12 years

8:23

among those assigned to receive enalapril

8:25

had declined to approximately that of

8:28

patients who were assigned to receive

8:30

placebo. In contrast,

8:32

among the patients who were

8:34

asymptomatic, survival was not longer

8:37

in the enalapril group than

8:39

in the placebo group during

8:41

the 3-year trial period, but

8:43

survival was significantly longer among

8:46

these patients for the duration

8:48

of the 12-year follow-up period,

8:50

despite the widespread use of

8:52

ACE inhibitors after the trial

8:55

period ended. On

8:57

the basis of the results

8:59

of SOLVED and other landmark

9:01

trials in patients with heart

9:03

failure, the multiple medications recommended

9:05

for patients who have symptomatic

9:07

heart failure with reduced ejection

9:10

fraction are now recommended

9:12

also for patients with

9:14

pre-heart failure, stage B,

9:17

before symptom onset. Despite

9:20

the fact that the patients in raft

9:22

had only mild heart failure symptoms at

9:24

the time of their enrollment in the

9:26

trial, almost 80% had died by 15

9:28

years. Because

9:33

CRT offers remarkable improvements

9:35

in functional capacity, quality

9:37

of life, and survival,

9:40

the principles of providing

9:42

earlier treatment for heart

9:44

failure might now include

9:47

CRT, particularly as technology

9:49

improves. CRT Initiation could

9:52

be accelerated after a diagnosis

9:54

of left bundle branch block

9:56

is made in patients with

9:58

a low left ventricular. Ejection

10:00

fraction. Which. Is less likely

10:02

to increase with the use of medical.

10:05

Therapy alone. With. Increasing

10:07

use of biomarkers screening to

10:09

identify patients with asymptomatic left

10:11

ventricular dysfunction. We should also

10:14

advance our use of effective

10:16

therapies with the hope that

10:18

we will see. More time

10:21

with good quality survival.

10:25

As isro my son during

10:27

routine well in sent visit

10:29

to prevent death. By.

10:31

Ali Ca from the Salsa

10:33

do plus sales on Sunday

10:35

dinner. Burkina, Faso

10:37

and colleagues. Mass.

10:40

Distribution of a zipper a

10:43

my since two children one

10:45

to sixty nine months of

10:47

age has been shown to

10:49

reduce childhood all cause mortality

10:51

in some Sub Saharan African

10:53

regions, with the largest reduction

10:55

seen among infants younger than

10:57

twelve months of age. This.

11:00

Trial evaluated whether the administration

11:02

of is it real nice

11:04

and at routine infant health

11:06

care visits would be effective

11:08

in preventing through. The

11:11

trial involved thirty two thousand,

11:13

eight hundred, seventy seven incense

11:15

from three regions of Burkina

11:18

Faso, and compared a single

11:20

dose of his if throw

11:22

my son with placebo administered

11:24

during infancy five to twelve

11:27

weeks of age. The. Primary

11:29

endpoint was death before six

11:31

months of age. Eighty

11:34

two incense in the As If

11:36

Throw My Son group and Seventy

11:38

five incense in the Placebo group

11:40

died before six months of age.

11:43

Hazard Ratio: One point Zero Nine.

11:45

The. Absolute difference in mortality

11:47

was zero point. Zero four

11:50

percentage points. There was no evidence

11:52

of an effective as if throw

11:54

my cents on mortality in any

11:56

of the pre specified sub groups.

11:59

And know. The evidence of a difference

12:01

between the two trial groups any

12:04

incidents of adverse events. In.

12:06

This trial conducted in Burkina

12:08

Faso, The investigators found that

12:10

administration a visit from I

12:12

sent to Incense through the

12:14

existing health care system did

12:16

not prevent death. Or.

12:20

A Sim natural the Or for

12:22

adult patients with mild to moderate

12:24

cove it nineteen. By been

12:26

tell. From. The China

12:28

Japan Friendship Hospital Beijing

12:31

China and colleagues. Sim.

12:34

Nutshell, the Air is an

12:36

oral three climber trips and

12:38

like protease inhibitor said has

12:40

been found to have in

12:42

vitro activity against Sars. Cozy

12:44

to and potential efficacy in

12:46

a phase one be trial.

12:49

In. This Phase two three trial

12:51

one thousand two hundred eight

12:53

patients who had mild to

12:55

moderate cove it nineteen and

12:58

onset of symptoms within the

13:00

past three days were randomly

13:02

assigned to receive some next

13:04

year plus return of here

13:06

or Placebo twice daily for

13:08

five days. Among patients

13:10

in the Modified Intention To

13:12

Treat population who received the

13:14

first dose of trial drug

13:17

or placebo within seventy two

13:19

hours after symptom onset, the

13:21

time to sustained resolution of

13:23

Covert Nineteen symptoms was significantly

13:25

shorter in the same Naturals

13:27

Here group then in the

13:29

placebo group. One. Hundred eighty

13:32

point one hours versus two

13:34

hundred sixteen hours. On. Day

13:36

five: the decrease in viral load

13:39

from baseline was greater in the

13:41

same naturals the or group then

13:43

in the placebo group. Mean difference

13:46

minus one point five One blog

13:48

ten copies per milliliter. The.

13:50

Incidence of adverse events during treatment

13:52

was higher in the Sim natural,

13:55

the or group then in the

13:57

placebo group. Twenty nine percent versus

13:59

twenty one. Point: Six percent.

14:01

Most. Adverse events were mild

14:03

or moderate. Early. Administration

14:05

of same nutshell the or

14:08

plus return of here shortened

14:10

to the time to the

14:12

resolution of symptoms among adult

14:14

patients with Cozad nineteen without

14:16

evidence Safety. Concerns. Syphilis,

14:20

Complicating pregnancy and

14:22

congenital syphilis. A

14:25

review article by Irene. Staff heard

14:27

from Nyc Govern Medical School

14:29

at U T Health Houston

14:31

and colleagues. Congenital.

14:34

Syphilis was first described by

14:36

guest star to Rayleigh in

14:39

Fourteen Ninety Seven, and continues

14:41

to cause major negative consequences

14:44

worldwide. After. A steady decline

14:46

in U S. cases of primary

14:48

and secondary syphilis after Nineteen Ninety,

14:51

which led to hopes of it's

14:53

elimination rates hidden Nader in two

14:55

thousand and one. Unfortunately,

14:57

the rates have subsequently increased among

15:00

men and women of reproductive age

15:02

as well as among incense, And

15:04

in Twenty Twenty One, the rate

15:07

of congenital syphilis in the United

15:09

States was the highest it has

15:11

been in nearly thirty. Years.

15:14

Congenital. Syphilis usually results

15:16

from trance placenta passage of

15:19

trapping him a pallidum to

15:21

the cetus during disseminated maternal

15:23

inception. Less frequently

15:25

neo Natal insects. And occurs

15:28

through exposure to sit on lytic. Genital

15:30

lesions at the time of

15:32

delivery. The. Only anti

15:34

microbial agent proven to be

15:37

both safe and efficacious for

15:39

the treatment of syphilis during

15:42

pregnancy is parental Benzene Penicillin

15:44

t administered intra muscular li

15:46

according to the clinical stage.

15:49

Ultra. Scenography is the most commonly.

15:52

Used message to examine a

15:54

cetus for evidence of congenital

15:56

syphilis. Ultrasound a graphic

15:58

evidence. Of intrauterine. Infections can

16:00

be detected after eighteen weeks

16:02

of gestation, when a see

16:04

is able to mount an

16:06

immune response to T Pallidum

16:08

infection. Elimination. Of

16:11

Perry Natal syphilis is possible

16:13

with timely diagnosis and treatment

16:15

during pregnancy. New diagnostic approaches

16:18

that are capable of detecting

16:20

T Pallidum, insects and in

16:22

the new are need. The.

16:25

Impact of and treated syphilis

16:27

on maternal and neonatal health

16:30

outcomes is profound. This.

16:32

Review discusses the manifestations and

16:34

a sense of his syphilis

16:36

during pregnancy and mother to

16:39

child transmission. Of.

16:42

Fifty seven year old woman

16:44

with melanoma and seaver. A

16:46

case record of the Massachusetts

16:48

General Hospital by a mere

16:51

mohamed and colleagues. A.

16:53

Sixty seven year old woman

16:55

with respected stage three see

16:57

cutaneous melanoma was admitted to

17:00

the hospital. Because of seaver.

17:02

Four months earlier, bleeding developed from a

17:05

leash and on the right side of

17:07

the scalp. A. Diagnosis of

17:09

stage three seat melanoma had

17:11

been made. Molecular. Profiling

17:14

had identified the Be Wrath

17:16

the six hundred He mutation.

17:19

Three. Months later the patient was

17:21

evaluated in the oncology clinic for

17:23

initiation of treatment with a combination

17:26

of the breath and have a

17:28

be wrath inhibitor and term that

17:30

nib a mech inhibitor as targeted

17:32

therapy for melanoma. The patient

17:35

felt well and the surgical wound had

17:37

healed. One. Day after the

17:39

initiation of treatment with de bras and

17:41

a of and term that nib fever

17:44

and nausea developed. Be. Raf Neck

17:46

inhibitor therapy. Was temporarily

17:48

discontinued and treatment with

17:50

acetaminophen and ibuprofen was

17:53

started. Fever. And nausea

17:55

resolved after one day. Once.

17:57

The patient had one day without the

17:59

current season. after the antipyretic

18:01

medications had been stopped, treatment

18:04

with dibraphenib and trimetinib was

18:06

resumed. Two weeks

18:09

later, another episode of fever

18:11

occurred that rapidly resolved after

18:13

brief discontinuation of treatment with

18:15

the BRAF-MEC inhibitors. At

18:18

the time of the current

18:20

admission, the patient had high

18:22

fevers that persisted for four

18:24

days after discontinuation of treatment

18:26

with the BRAF-MEC inhibitors. Children

18:30

and laboratory results revealed hypotension,

18:32

acute kidney injury, and

18:34

acute liver injury. Among

18:37

all the possible diagnoses

18:39

in this patient, drug-induced

18:41

liver injury was the

18:43

most important consideration, given

18:45

the mixed colostatic and

18:47

hepatocellular pattern of liver

18:50

injury. In addition,

18:52

there was an absence of

18:54

evidence supporting an alternative diagnosis,

18:56

such as infection or sarcoidosis.

18:59

The most likely cause of

19:01

this patient's syndrome was drug-induced

19:04

liver injury, resulting from BRAF-MEC

19:06

inhibitor therapy. What

19:10

do trainees want? The

19:13

Rise of House Staff Unions, a

19:16

Medicine and Society article on

19:18

medical training today by Lisa

19:20

Rosenbaum, a national correspondent for

19:22

the journal. In

19:25

December 2020, when brand

19:27

new COVID vaccines were in

19:29

limited supply, Stanford University Medical

19:32

Center created an allocation system

19:34

for its employees. Their

19:36

plan had an unfortunate omission. Despite

19:39

trainees' critical frontline service, only

19:42

seven of the 1,300 employees

19:44

who were included

19:46

in the first phase were house

19:49

staff. The allocation algorithm

19:51

turned out to have a glitch

19:53

that was quickly corrected, allowing most

19:55

residents to be vaccinated in the

19:58

first phase, although none of the employees were before

20:00

the House staff staged a

20:02

lunchtime walkout. Philip Sussenheimer,

20:05

a resident, now a fellow

20:07

in palliative care, who helped

20:09

lead ensuing unionization efforts, noted,

20:12

people realized that collective

20:14

action can work. Although

20:17

Dr. Rosenbaum suspects that Stanford

20:19

made an innocent mistake that

20:22

it would have corrected regardless

20:24

of the walkout, leaders couldn't

20:26

comment during contract negotiations. The

20:29

error catalyzed unionization. Trainees

20:31

wanted salaries that were commensurate with

20:33

the cost of living, access

20:36

to on-call rooms for residents

20:38

with disabilities, more lactation

20:40

space, and vouchers for

20:42

post-call rides. But

20:45

for Sussenheimer, unionization was less

20:47

about any specific demand than

20:49

about a formal process for

20:51

negotiating with management to begin

20:53

with. Traditionally, trainees relied

20:56

on program directors to

20:58

advocate for them. Sussenheimer and

21:01

his peers wanted a seat

21:03

at the table. Although

21:05

broader unionization is escalating

21:08

nationally, trainees efforts reflect

21:10

medicine specific concerns with

21:13

unknown consequences for education

21:15

and patient care. What's

21:18

driving this movement? Can

21:20

unions meaningfully address trainees

21:23

concerns? And what's at stake

21:25

in the process? Understanding

21:30

liability risk from using health

21:32

care artificial intelligence tools. A

21:34

health law ethics and human

21:37

rights article by Michelle Mello

21:39

and Neil Guha from Stanford

21:42

Law School, California. Optimism

21:45

about the explosive potential of

21:47

artificial intelligence to transform medicine

21:49

is tempered by worry about

21:51

what it may mean for

21:54

the clinicians being augmented.

21:57

One question is especially problematic because it needs

21:59

to be addressed. may chill AI

22:01

adoption. When AI

22:03

contributes to patient injury, who

22:05

will be held responsible?

22:08

Some attorneys counsel healthcare

22:10

organizations with dire warnings

22:12

about liability and dauntingly

22:14

long lists of legal

22:16

concerns. Unfortunately, liability

22:19

concern can lead to

22:21

overly conservative decisions, including

22:23

reluctance to try new

22:26

things. Yet older

22:28

forms of clinical decision support

22:30

provided important opportunities to prevent

22:33

errors and malpractice claims.

22:35

Given the slow progress

22:37

in reducing diagnostic errors,

22:39

not adopting new tools

22:42

also has consequences and

22:44

at some point may

22:46

itself become malpractice. Liability

22:48

uncertainty also affects AI

22:51

developers' cost of capital

22:53

and incentives to develop

22:55

particular products, thereby influencing

22:57

which AI innovations become

23:00

available and at what

23:02

price. To help

23:04

healthcare organizations and physicians weigh

23:06

AI-related liability risk against the

23:09

benefits of its adoption, these

23:11

authors examine the issues that

23:13

courts have grappled with in

23:16

cases involving software error and

23:18

what makes them so challenging.

23:21

Because the signals emerging from

23:23

case law remain somewhat faint,

23:25

the authors conducted further analysis

23:27

of the aspects of AI

23:30

tools that elevate or

23:32

mitigate legal risk. Drawing

23:35

on both analyses, the authors

23:37

provide risk management recommendations focusing

23:40

on the uses of AI

23:42

in direct patient care with

23:44

a human in the loop

23:47

since the use of fully

23:49

autonomous systems raises additional issues.

23:53

Responding to medical errors, implementing

23:57

the modern ethical paradigm.

24:00

Perspective on the Fundamentals of

24:02

Medical Ethics by Thomas Gallagher from

24:04

the University of Washington Medicine,

24:06

Seattle and Alan Caciella

24:08

from Johns Hopkins Medicine,

24:11

Baltimore. Responding

24:13

to a medical error is daunting.

24:16

Clinicians may experience the emotions

24:18

every human feels when something

24:20

has gone wrong. Remorse

24:22

frustration, embarrassment and

24:24

fear. Traditionally, recommendations

24:27

regarding responding to medical

24:29

errors focused mostly on

24:31

whether to disclose mistakes

24:33

to patients. Over

24:36

time, empirical research, ethical

24:38

analyses and stakeholder engagement

24:40

began to inform expectations

24:43

which are now embodied

24:45

in communication and resolution

24:48

programs, CRPs, for

24:50

how health care professionals and organizations

24:53

should respond not just to

24:55

errors, but any time patients

24:57

have been harmed by medical

24:59

care. Adverse events. CRPs

25:02

require several steps, quickly

25:05

detecting adverse events, communicating

25:08

openly and empathetically with patients

25:10

and families about the event,

25:14

apologizing and taking responsibility for

25:16

errors, analyzing events

25:18

and redesigning processes to

25:20

prevent recurrences. Supporting

25:23

patients and clinicians and

25:25

proactively working with patients

25:27

toward reconciliation. In this

25:30

modern ethical paradigm, any time

25:33

harm occurs, clinicians

25:35

and health care organizations

25:37

are accountable for minimizing

25:39

suffering and promoting learning.

25:42

However, implementing this ethical

25:44

paradigm is challenging, especially

25:47

when the harm was due to an error.

25:50

Today, in the wake of

25:53

all harmful errors, bioethical principles

25:55

require that clinicians and health

25:58

care organizations demonstrate. Currency

26:00

Compassion and Accountability and pro

26:03

actively meet patient needs. These

26:05

steps would not only increase

26:08

trust in the healthcare system

26:10

but would also help it

26:13

improve. Looking.

26:16

Ahead to state: Global

26:18

Duchess. For healthcare. A

26:21

perspective by Sue has Gandhi

26:23

from Brigham and Women's Hospital

26:25

Boston and colleagues. Fourteen.

26:28

Years after the passage of the

26:30

Affordable Care Act, the value based

26:32

care movement is facing hard. Truths.

26:35

And evaluation of forty nine

26:37

of the first payment and

26:39

care delivery models implemented by

26:41

the Center for Medicare and

26:43

Medicaid Innovation see: Mm. I

26:46

showed that the vast majority

26:48

haven't achieved that goal of

26:50

reducing health care spending. The.

26:52

Congressional Budget Office reported that.

26:54

Despite it's initial projects and

26:57

that these models would result

26:59

in nearly three billion dollars

27:01

in net savings between Twenty

27:04

Eleven and Twenty Twenty. Cm

27:06

am I actually increased federal

27:08

spending by five point, Four

27:10

billion dollars over his first

27:13

decade. Although. This analysis

27:15

excluded the Medicare Shared

27:17

Savings Program, a signature

27:19

initiative that has produced

27:21

moderate say things. The

27:23

findings are sobering. In.

27:25

The wake of these disappointing

27:28

results, see Mm I is

27:30

advancing. New Approaches. In.

27:32

September Twenty Twenty three, The

27:34

Centers For Medicare. And Medicaid

27:37

Services announced an ambitious

27:39

model. The state's advancing

27:41

all payer health equity

27:44

approaches and development ahead.

27:47

The. Ahead model moves toward

27:49

population based payment at

27:51

the state level and

27:53

has three goals: curbing

27:55

cost growth, improving population

27:57

health, and advancing health.

28:00

Equity. Stake. Can

28:02

now apply to participate

28:04

in this voluntary model.

28:06

Ahead will employ several

28:08

strategies to achieve it's

28:10

goals, each of which

28:12

has both promising features

28:14

and limitations. First ahead

28:16

will use global budgets

28:18

as the primary strategy

28:20

for curbing cost growth.

28:23

Second ahead seeks to

28:25

improve population health by

28:27

elevating primary care. Third,

28:29

a Heads strategy for

28:31

advancing health equity includes

28:33

requirements for hospitals to

28:36

develop health equity plans,

28:38

collect demographic data, and

28:40

screen for social needs.

28:44

Broke in both ways. A

28:46

perspective by Samuel Slaven from

28:48

Brigham and Women's Hospital Boston.

28:52

Tiny. Shards of glass littered

28:54

Stella's ex boyfriends basement apartment

28:57

and she still sell them

28:59

all. Over her skin, even

29:01

behind her ears, Most.

29:03

Of her doctors thought it was psychosis,

29:06

a byproduct of crystal. Meth now

29:08

hardened into a sixty to lose

29:10

and. But it could have been

29:12

true for X would smash light bulbs

29:14

out of rage. Yet whether it

29:17

was true or delusion might not

29:19

matter. Stella. Had lived

29:21

with pain since high school. I

29:23

got it in the head point

29:25

blank. She said it was one

29:28

of those seriously hard hitting nineteen

29:30

eighties paintball guns already vintage in

29:33

Ninety Nine. Before.

29:35

The Accident: she was preparing for

29:37

Olympic trials in field hockey. Overnight,

29:40

these aspirations disappeared as

29:42

he desperately sought. Relief.

29:45

By the time Doctor Slave and met

29:47

her, Stella's six was no longer the

29:49

oxy or the heroin that she had

29:51

kicked or even the mess. Which is

29:54

he hadn't. It. Was the act

29:56

of injecting itself? It was

29:58

about taking. Control. Cutting

30:00

she said and it was injecting

30:02

that sent staff or as. To

30:05

her heart causing and oh car died.

30:07

Us and eating holes in

30:09

her mitral and aortic valve.

30:11

Stella. Was told she would die without

30:14

heart surgery but no one would operate.

30:16

On an active drug user. A

30:19

few weeks later, Doctor Slaven met

30:21

her in the clinic as her

30:23

cardiologist. She sat on the exam

30:25

table slender. In a loose fitting

30:27

orange Etti. What? Had happened

30:29

in the hospital was still a blur

30:31

so doctors slave and drew pictures of

30:34

the heart showing the whole and Stella's

30:36

aortic south and even larger tear in

30:38

her mitral valve. So. Now

30:40

she said now I can say

30:43

my hearts broken. Both. Ways.

30:46

Afterwards. Doctor. Slate and

30:48

held onto the pieces of Stella's

30:50

story, finding himself looking at his

30:53

phone each morning expecting to learn

30:55

that she was admitted overnight and

30:57

needed. Surgery. Many.

30:59

Public Health advocates now

31:01

endorse decriminalization of all

31:04

drugs when possessed in

31:06

quantities intended for personal.

31:09

Use. Yet. Even if we

31:11

change our laws, we will

31:13

still need to confront the

31:15

criminalization that we have internalised

31:17

the widespread idea that someone

31:19

like Stella is morally different

31:21

from the active smoker who

31:24

need surgery for lung cancer

31:26

or the daily sugary soda

31:28

drinker with diabetes listed for

31:30

a kidney transplant. Patients.

31:32

Are not present for the conversations

31:34

of the undercard died his team,

31:36

but they are. Stories and voices

31:39

need to be represented. We'll

31:41

human narratives might make us

31:43

question what we mean when

31:45

we say get clean might

31:47

make us ask what is

31:49

so unclean about injecting through

31:52

alcohol swab skyn with sterile

31:54

needles? Why? Do we reserve? Clean

31:56

for total. Abstinence. And when

31:58

we do so. Are we making

32:01

a medical judgment or a moral

32:03

one? Just. A few

32:05

pieces of a life story might

32:07

be enough to make us question

32:09

the diocese we learned in medical

32:11

school. On the wards or out

32:13

in the world. In.

32:16

Our images and clinical medicine. A sixty

32:18

five year old woman presented with a

32:21

one year history. Of Skyn darkening

32:23

on her face. Two years earlier,

32:25

she had started. Applying a skin

32:27

lightening cream containing hydroquinone to

32:30

her face daily to treat

32:32

my last map. On. Physical

32:34

examination bluish brown patches with

32:36

background era sema and he

32:39

lands at tasers. Were observed

32:41

on the Cheeks Nasal Bridge

32:43

and Perry Oral region. With

32:45

lesser involvement on the forehead.

32:48

Their. Mask he of the affected

32:50

areas revealed Hyper Crow make

32:52

pinpointed Mac tools. Skyn

32:54

biopsy revealed extra cellular

32:56

deposition of yellow brown

32:58

pigments in the dermis.

33:01

A diagnosis of exhaustion is

33:03

okra know sisk was made.

33:06

Okra Noses is a

33:08

hyper pigmentation disorder that

33:10

results from the accumulation

33:12

of oprah colored deposits

33:14

in tissue. It. Is deemed

33:16

endogenous when related to our

33:18

captain area. And exogenous

33:20

when related to the use

33:22

of skin lightening agents. Exile

33:25

genus okra know is challenging

33:27

to treat and may not

33:29

be. Reversible. In.

33:31

Another image of fifty nine year

33:33

old man presented with a four

33:35

week history of severe itching in

33:38

his pubic region. On physical

33:40

examination, small brown nets and

33:42

mobile crabs saved lives we've

33:45

seen attached to the shafts

33:47

and bases respectively. Of

33:49

pubic hairs. Dermis. Gop

33:51

examination showed nits that had

33:54

a cap or oh, purchase

33:56

them on one end and

33:58

six legged lice ingesting. Would

34:00

see the video at any

34:02

durham.org A diagnosis of pubic

34:05

lice was made. Pubic.

34:07

Lice are parasites that are

34:09

most commonly transmitted through sexual

34:12

contact. The life cycle of

34:14

the organism involves stages as

34:16

a knit or egg nymphs

34:18

and adult loves. An adult

34:21

Laos will die within forty

34:23

eight hours without a blood

34:25

seeding. Treatment. With topical

34:27

lindane, the only lice killing

34:30

medication available locally was given.

34:33

This. Concludes our summary: Let us

34:35

know what you think about our

34:38

podcast. Any comments or suggestions may

34:40

be sent to audio at any

34:43

J M .org. Thank.

34:45

You for. Listening.