0:00

Welcome, this is the New England Journal

0:02

of Medicine. I'm Dr. Lisa Johnson.

0:05

This week, August 17,

0:08

2023, we feature articles on voracidinib

0:11

for IDH mutant low-grade

0:13

glioma, a trial of dietary

0:16

intervention for cognitive decline,

0:19

omitting radiotherapy after breast

0:21

conserving surgery in luminal A

0:23

breast cancer, gene therapy

0:26

for the Krigler-Najjar syndrome, and

0:29

on abortion counseling, liability,

0:32

and the First Amendment, a review

0:34

article on community acquired pneumonia,

0:37

a case report of a man with fever and

0:39

foot pain, and perspective

0:41

articles on prioritizing mental

0:44

health in the HIV-AIDS response

0:46

in Africa,

0:48

on reducing healthcare's climate

0:50

impact, and on free

0:52

and charitable clinics. This

0:55

week, we also feature a new clinical

0:58

decisions on the participation

1:00

of children in American football.

1:03

This feature about a young boy who wants

1:05

to participate in American football

1:07

offers a case vignette, accompanied

1:10

by two essays, one supporting

1:12

the boy's participation in the sport

1:15

and the other recommending that he

1:17

not participate.

1:19

We want to know what you decide. Visit

1:22

NEJM.org to vote.

1:26

Voracidinib in IDH1

1:29

or IDH2 Mutant

1:32

Low-Grade Glioma by

1:34

Ingo Mellinghoff from Memorial

1:36

Sloan Kettering Cancer Center, New

1:39

York.

1:40

Isocitrate dehydrogenase,

1:43

IDH mutant grade 2

1:45

gliomas, are malignant brain

1:48

tumors that cause considerable

1:50

disability and premature

1:52

death.

1:53

Voracidinib, an oral brain

1:56

penetrant inhibitor of mutant

1:58

IDH1 and IDH2.

1:59

and IDH2 enzymes

2:02

showed preliminary activity

2:05

in IDH mutant gliomas.

2:08

In this phase 3 trial, 331

2:11

patients with residual or recurrent

2:14

grade 2 IDH mutant

2:17

glioma who had undergone no

2:20

previous treatment other than surgery

2:22

were randomly assigned to receive

2:25

either oral vorocidinib

2:27

or matched placebo in 28 day

2:30

cycles.

2:32

At a median follow-up of 14.2 months, 226

2:34

patients, 68.3%, were continuing to receive vorocidinib

2:42

or placebo.

2:44

Progression-free survival was

2:46

significantly improved in

2:49

the vorocidinib group as compared

2:51

with the placebo group.

2:53

Again, progression-free survival, 27.7

2:55

months versus 11.1 months.

3:00

The time to the next intervention

3:03

was significantly improved in

3:05

the vorocidinib group as compared

3:07

with the placebo group.

3:09

Hazard ratio 0.26.

3:12

Adverse events of grade 3 or higher

3:15

occurred in 22.8% of the patients who received vorocidinib

3:20

and in 13.5% of those who received placebo.

3:25

An increased alanine amino

3:27

transferase level of grade 3

3:29

or higher occurred in 9.6% of the patients

3:34

who received vorocidinib and

3:36

in no patients who received placebo.

3:40

In patients with grade 2 IDH

3:42

mutant glioma, vorocidinib

3:45

significantly improved progression-free

3:48

survival and delayed the time

3:51

to the next intervention.

3:54

writes

4:01

that approximately 2,500 persons

4:04

in the US receive a diagnosis

4:06

of IDH-mutated grade 2

4:08

glioma each year. These

4:11

patients tend to be young with

4:13

a median age of 40 years.

4:16

Most have tumor-related epilepsy

4:18

and grapple with a tumor that may affect

4:21

cognition, employment, and other

4:23

aspects of life. These tumors

4:26

typically become refractory to

4:28

treatment and are eventually fatal,

4:30

belying their designation as low-grade

4:33

gliomas.

4:35

Both fractionated radiotherapy

4:37

and alkylating agent-based

4:40

chemotherapy help control

4:42

these tumors but convey a substantial

4:45

risk of permanent toxic effects.

4:48

Thus, even though it is well recognized

4:50

that these tumors grow continuously

4:53

when untreated, the watch-and-wait

4:56

strategy is sometimes considered

4:58

as an initial approach. The

5:00

results of this trial by Melinghoff

5:03

and colleagues support a role

5:05

for voracidinib therapy that

5:07

permits the deferral of more

5:09

toxic interventions. Nonetheless,

5:12

this trial represents only a first

5:15

step toward better treatment of

5:17

patients with IDH mutant

5:19

glioma. The

5:20

anti-neoplastic activity of

5:23

voracidinib should be interpreted

5:25

in the context of other active

5:28

interventions.

5:29

Progression-free survival with

5:32

fractionated radiotherapy alone

5:34

as initial therapy for grade 2

5:37

IDH mutant gliomas exceeds

5:40

four years.

5:41

The corresponding progression-free

5:43

survival with temozolomide chemotherapy

5:47

is three years among patients

5:49

with astrocytoma and 4.5 years

5:52

among those with oligodendroglioma.

5:56

The median progression-free survival

5:58

with a combination

5:59

radiation therapy and chemotherapy

6:02

is 8 to 10 years.

6:05

From this perspective, the single

6:07

agent activity of vorocidinib

6:10

is modest.

6:11

As Mellinghoff and colleagues note,

6:13

molecularly targeted agents

6:16

have the greatest potential when

6:18

used early.

6:20

Analyses on important questions

6:22

remain forthcoming. But

6:25

regardless of the answers, this

6:27

trial has put a nail in the

6:29

coffin of the watch and wait

6:32

approach.

6:34

In a science behind the study editorial,

6:37

Elizabeth Closs from Yale University,

6:40

New Haven, Connecticut, writes that

6:42

existing treatment options for grade 2

6:45

glioma include surgery,

6:47

chemotherapy, and radiotherapy.

6:50

Most patients undergo surgery

6:52

in which the goal is to achieve gross

6:55

total resection.

6:57

However, the anatomical location

6:59

and growth pattern of the tumor can

7:02

be deterrence to complete resection.

7:05

The timing of adjuvant therapy

7:07

after surgery remains controversial

7:10

and varies across healthcare facilities.

7:13

A watch and wait strategy is

7:16

often used in patients with a low

7:18

risk of early disease progression,

7:21

as was the case for patients in the

7:23

trial by Mellinghoff and colleagues.

7:26

Radiotherapy alone prolongs

7:28

the time to recurrence but does not

7:31

increase overall survival

7:33

and may be associated with a reduction

7:35

in neurocognitive function.

7:38

However, radiotherapy is

7:40

generally administered with adjuvant

7:42

therapy, in which case it adds

7:44

a survival benefit. Regardless

7:47

of the type of chemotherapy used, recurrence

7:50

generally occurs, as well as

7:52

a risk of DNA hypermutation,

7:55

which is associated with tumor progression.

7:58

Vorocidinib ennates the tumor.

7:59

enables a treatment strategy wherein

8:02

the use of adjuvant therapies

8:04

and their associated decline in quality

8:07

of life may occur later in

8:09

the patient's disease trajectory.

8:12

Because current adjuvant treatments

8:14

for grade 2 glioma can lead to

8:16

considerable physical and cognitive

8:19

impairments, the ability to delay

8:21

tumor progression and the time to the

8:23

next intervention, as well as to

8:26

maintain or improve quality

8:28

of life, is a step forward.

8:30

Vorocidinib is the first treatment

8:33

method in many years to show

8:35

improved progression-free survival

8:38

and a relatively low side effect

8:40

profile in persons with IDH

8:43

mutant grade 2 glioma, independent

8:46

of 1p19q co-deletion status.

8:50

The results with respect to overall

8:52

survival will be eagerly awaited.

8:57

Trial of the Mind Diet for

8:59

Prevention of Cognitive Decline

9:02

in Older Persons

9:03

by Lisa Barnes from the Rush University

9:06

Medical Center, Chicago. Findings

9:10

from observational studies suggest

9:12

that dietary patterns may offer

9:15

protective benefits against cognitive

9:17

decline, but data from clinical

9:20

trials are limited.

9:22

The Mediterranean DASH intervention

9:24

for Neurodegenerative Delay, known

9:27

as the Mind Diet, is a

9:29

hybrid of the Mediterranean diet

9:31

and the DASH dietary approaches

9:34

to stop hypertension diet,

9:37

with modifications that include foods

9:39

that have been putatively associated

9:41

with a decreased risk of dementia.

9:45

In this trial, involving 604 older

9:48

adults without cognitive impairment,

9:51

but with a family history of dementia,

9:54

a body mass index greater than 25, and

9:57

a suboptimal diet, as determined

9:59

by mean.

9:59

of a 14-item questionnaire

10:02

were randomly assigned to follow

10:04

the MIND diet with mild caloric

10:07

restriction or a control diet

10:09

with mild caloric restriction.

10:12

Participants followed the diets for

10:14

three years.

10:15

The trial was completed by 93.4% of

10:17

the participants. From baseline to year three, improvements

10:25

in global cognition scores were

10:27

observed in both groups with

10:29

increases of 0.205 standardized

10:33

units in the MIND diet group and 0.17

10:36

standardized units in

10:39

the control diet group.

10:41

Changes in white matter hyperintensities,

10:44

hippocampal volumes, and total

10:46

gray and white matter volumes on

10:48

MRI were similar in the two

10:51

groups. Among cognitively

10:53

unimpaired participants with

10:55

a family history of dementia, changes

10:58

in cognition and brain MRI

11:01

outcomes from baseline to year

11:03

three did not differ significantly

11:06

between those who followed the MIND

11:08

diet and those who followed the

11:11

control diet with mild caloric

11:13

restriction.

11:16

Omitting radiotherapy after

11:19

breast conserving surgery in

11:21

luminal A breast cancer

11:24

by Timothy Whelan from McMaster

11:26

University, Hamilton, Ontario,

11:29

Canada. Adjuvant

11:31

radiotherapy is prescribed

11:33

after breast conserving surgery

11:35

to reduce the risk of local recurrence.

11:39

However, radiotherapy is

11:41

inconvenient, costly, and

11:43

associated with both short-term and

11:45

long-term side effects.

11:48

Improving care by omitting

11:50

radiotherapy is a goal in

11:52

the treatment of patients in whom the

11:54

risk of local recurrence is

11:57

minimal,

11:57

thereby avoiding the short

11:59

and long-term side effects of

12:02

radiotherapy.

12:03

Clinicopathologic factors alone

12:06

are of limited use in the identification

12:09

of women at low risk for local

12:11

recurrence in whom radiotherapy

12:13

can be omitted. Molecularly

12:16

defined intrinsic subtypes

12:18

of breast cancer can provide additional

12:21

prognostic information. A

12:24

prospective cohort design was

12:26

chosen for the study because the research

12:29

question focused on prognosis

12:31

rather than on treatment efficacy targeted

12:34

to a very low risk group. The

12:37

study included women who were at least 55

12:39

years of age had undergone

12:41

breast conserving surgery for T1N0,

12:45

tumor size less than two centimeters

12:48

and node negative, grade one or

12:50

two, luminal A subtype

12:52

breast cancer, defined as

12:55

estrogen receptor positivity of

12:57

greater than or equal to 1%, progesterone

13:00

receptor positivity of greater

13:02

than 20%, negative human

13:04

epidermal growth factor receptor

13:06

two, and a KI67

13:09

index of less than or equal to 13.25% and

13:13

had received adjuvant endocrine

13:15

therapy. The KI67

13:18

index, the percentage of cells that

13:20

are positive for KI67

13:23

as determined by immunostaining

13:26

of the primary tumor is a marker

13:28

of cellular proliferation that

13:30

distinguishes luminal A from

13:33

higher risk ER positive

13:35

luminal B breast cancer.

13:38

500 patients with a KI67

13:40

index of 13.25% or less were

13:45

enrolled and did not receive

13:47

radiotherapy.

13:49

The primary outcome was local

13:52

recurrence in the ipsilateral breast.

13:55

In consultation with radiation

13:57

oncologists and patients

13:59

with...

13:59

breast cancer. The investigators

14:02

determined that if the upper boundary

14:04

of the two-sided 90% confidence

14:07

interval for the cumulative incidence

14:09

at 5 years was less than 5%,

14:11

this would represent

14:13

an acceptable risk of local recurrence

14:16

at 5 years. At 5 years

14:19

after enrollment, recurrence

14:21

was reported in 2.3%

14:24

of the patients, a result that

14:26

met the pre-specified boundary.

14:29

Breast cancer occurred in the contralateral

14:31

breast in 1.9% of the patients and recurrence

14:35

of any type was observed in 2.7%.

14:37

Among women who were at least 55 years of age and had

14:39

T1N0,

14:45

grade 1 or 2 luminal A

14:47

breast cancer that were treated with

14:50

breast conserving surgery and

14:52

endocrine therapy alone, the

14:54

incidence of recurrence at 5 years

14:57

was low with the omission

14:59

of radiotherapy.

15:02

Gene Therapy in Patients with

15:05

the Krigler-Najjar Syndrome

15:07

by Lorenzo D'Antiga

15:09

from the hospital Papa Giovanni

15:12

23rd,

15:13

Bergamo, Italy.

15:16

Patients with the Krigler-Najjar Syndrome

15:18

lack the enzyme UGT1A1,

15:22

the absence of which leads to severe

15:25

unconjugated hyperbilirubinemia

15:27

that can cause irreversible neurologic

15:30

injury and death. Prolonged

15:33

daily phototherapy partially

15:35

controls the jaundice, but the only

15:37

definitive cure is liver transplantation.

15:41

These investigators report the results

15:44

of a dose escalation portion

15:46

of a Phase 1-2 study

15:49

evaluating the safety and efficacy

15:52

of a single intravenous infusion

15:54

of an adeno-associated virus

15:57

0-type 8 vector

15:59

encoded

15:59

UGT1A1

16:02

in patients with the Krigler-Najjar syndrome

16:04

that were being treated with phototherapy.

16:07

Five patients received a single

16:10

infusion of the gene construct,

16:12

GNT0003.

16:15

No serious adverse events

16:18

were reported.

16:19

The most common adverse events were

16:21

headache and alterations in liver

16:23

enzyme levels.

16:25

In addition, amino transferase increased

16:28

to levels above the upper limit of the

16:30

normal range in four patients,

16:33

a finding potentially related to

16:35

an immune response against the infused

16:38

vector.

16:39

These patients were treated with a course of glucocorticoids.

16:42

By week 16, serum bilirubin

16:45

levels in patients who received the

16:47

lower dose of GNT0003 exceeded

16:53

300 micromoles per liter. The

16:55

patients who received the higher dose

16:57

had bilirubin levels below 300

16:59

micromoles per liter

17:02

in the absence of phototherapy at

17:04

the end of follow-up, mean

17:06

baseline bilirubin level 351

17:10

micromoles per liter, mean level

17:12

at the final follow-up visit week 78

17:14

in two patients and week 80

17:17

in the other 149 micromoles per liter. These

17:22

preliminary findings provide evidence

17:25

that liver-directed gene transfer

17:27

with GNT0003 in

17:30

five patients with Krigler-Najar

17:33

syndrome was not associated

17:35

with serious adverse events and

17:37

corrected bilirubin levels, allowing

17:40

for discontinuation of phototherapy.

17:45

Community Acquired Pneumonia, a

17:47

review article by Thomas Fyle

17:50

Jr. from Summa Health, Akron,

17:52

Ohio.

17:54

Community Acquired Pneumonia in a Patient

17:57

is an acute pulmonary parenchymal

18:00

infection acquired in the community,

18:02

as distinguished from an infection acquired

18:05

in a hospital.

18:06

In the US, community-acquired

18:08

pneumonia is one of the leading causes

18:11

of hospitalization and death, with

18:13

approximately 6 million cases

18:16

reported each year. The

18:18

development of pneumonia is influenced

18:20

by a combination of factors, including

18:23

host susceptibility, pathogen

18:26

virulence, and the inoculum of microorganisms

18:29

reaching the lower airways. Respiratory

18:33

pathogens must overcome several

18:35

defense mechanisms of the respiratory

18:37

system before reaching the alveoli.

18:41

Pathogens can reach the alveoli by means

18:44

of micro-aspiration, aspiration

18:46

of small amounts of oropharyngeal

18:49

secretions that often occurs during

18:51

sleep.

18:52

Inhalation, macro-aspiration,

18:55

aspiration of a large amount of oropharyngeal

18:58

or upper gastrointestinal contents,

19:01

or hematogenous spread.

19:04

If pathogens overcome the alveolar

19:06

defense mechanisms, they will multiply

19:09

and cause local tissue damage.

19:12

Injured host cells then produce

19:14

damage-associated molecular patterns

19:17

that further stimulate alveolar

19:19

macrophages to produce cytokines

19:22

and chemokines, triggering a

19:24

local inflammatory response.

19:27

The inflammatory responses explain

19:30

most of the host patients' signs

19:32

and symptoms, as well as laboratory

19:35

and imaging abnormalities.

19:37

Most outpatients with mild

19:40

community-acquired pneumonia can be

19:42

treated empirically without diagnostic

19:45

testing for bacteria. However,

19:47

testing for SARS-CoV-2 and

19:49

influenza should be considered.

19:52

A comprehensive approach to microbiologic

19:55

testing for hospitalized patients

19:57

is recommended for determining the appropriate

19:59

appropriate pathogen-directed therapy.

20:03

The choice of antimicrobial therapy

20:05

for community-acquired pneumonia varies

20:08

according to severity, coexisting

20:11

conditions, and the likelihood of

20:13

antimicrobial-resistant

20:15

organisms.

20:18

An 18-year-old man with fever

20:21

and foot pain. A case record

20:23

of the Massachusetts General Hospital

20:25

by Daniel Roush and colleagues.

20:29

An 18-year-old man with the

20:31

Dravet syndrome, which is characterized

20:34

by epilepsy starting in infancy

20:36

or early childhood that can include

20:38

a spectrum of symptoms ranging from

20:40

mild to severe, began to

20:43

have fever and increased seizure

20:45

activity.

20:47

Two weeks before the current admission,

20:49

amoxicillin treatment was begun

20:52

because of mucosal thickening in

20:54

the paranasal sinuses and

20:56

secretions seen on imaging. In

20:58

the absence of clinical symptoms

21:01

of sinusitis,

21:02

the patient also had a two-month

21:05

history of progressive swelling,

21:07

pain, and ultimately bruising

21:10

of his left foot and there was MRI evidence

21:13

of marrow edema in multiple

21:15

bones of the foot. In the five

21:17

days before admission, the patient

21:20

was noted to be less interactive

21:22

than usual. He had intermittent

21:24

diaphoresis and tachycardia.

21:27

Other frequency increased from one

21:29

every two to three days to two

21:31

or three seizures daily.

21:34

The patient was evaluated again

21:36

in the emergency department.

21:38

Subsequent radiography revealed

21:40

diffuse bone demineralization

21:43

and multiple fractures.

21:45

Laboratory evaluation revealed

21:48

anemia, an elevated blood level

21:50

of CRP, and an elevated

21:52

erythrocyte sedimentation rate.

21:55

The parents reported that during the

21:57

two weeks before this admission,

21:59

the patient was The patient had new bleeding

22:01

from the gums and the nose. The

22:04

patient was on a ketogenic diet

22:06

as adjunctive treatment for seizures.

22:09

Because of multiple food allergies,

22:12

the ketogenic formula was administered

22:14

through a gastrostomy tube.

22:16

Vitamin C deficiency

22:19

was the best explanation for this

22:21

patient's constellation of symptoms

22:24

and was thought to be due to inadequate

22:27

intake. It consisted

22:29

of repletion with monitoring

22:31

for symptom resolution and improved

22:34

blood levels.

22:37

Abortion counseling, liability,

22:40

and the First Amendment, a Medicine

22:42

and Society article by Katie

22:44

Watson from Northwestern University,

22:47

Chicago.

22:49

When a clinician tells pregnant patients

22:51

that they can't have an abortion because

22:54

state law prohibits it, what's

22:56

the clinician's next sentence?

22:59

In the 16 US states that

23:01

have banned all or most abortion

23:04

provision, clinicians may feel

23:06

compelled to say nothing.

23:09

Consider the case of Deborah Dorbert,

23:12

who asked to end her pregnancy

23:14

after learning that her fetus had Potter's

23:17

syndrome

23:18

and was sure to die.

23:20

Her doctor told her she was too

23:22

late for Florida's ban, so

23:24

she endured agony-filled months

23:27

before delivering a baby who

23:29

died within minutes.

23:31

Why didn't her doctor refer

23:33

her to a free legal helpline

23:35

such as If When How, whose

23:38

attorneys would have confirmed that

23:40

travel posed no legal

23:42

risk to Dorbert?

23:44

Why didn't her doctor provide information

23:47

about funds such as the National

23:49

Abortion Federation's Hotline

23:51

Fund, which helps patients pay

23:53

for abortion care?

23:55

Dorbert's doctor is not alone.

23:58

One year after Roe v. Wade was

24:00

reversed. KFF, formerly

24:03

the Kaiser Family Foundation, reported

24:05

that in states that ban abortion

24:07

provision, 78%

24:08

of OBGYNs

24:12

don't make out-of-state referrals

24:15

and 30% don't inform their

24:17

patients about online resources

24:20

that explain their abortion options.

24:23

In states that ban abortion provision

24:26

after a designated point in gestation,

24:28

ranging from 6 to 22 weeks, 44% of

24:31

OBGYNs don't refer and 10% don't offer information.

24:39

Clinicians have long been duty-bound

24:42

to provide all options counseling,

24:45

and today's complex legal landscape

24:48

for abortion care increases

24:50

patients' need for clinicians'

24:52

guidance.

24:53

Clinicians know that their patient's

24:55

health and well-being require

24:58

access to accurate information,

25:00

yet those practicing in restrictive

25:03

states may worry that providing

25:05

abortion counseling puts them

25:08

in legal jeopardy.

25:10

These authors believe clinicians

25:12

must resist the fear-driven

25:15

impulse to refrain from providing

25:17

abortion information. At

25:19

the same time, professional organizations

25:22

and hospitals should support clinicians

25:25

by developing explicit patient

25:28

counseling requirements, affirming

25:30

that these health-protective discussions

25:33

and referrals are standard-of-care

25:36

medicine.

25:37

In this article, the authors assess

25:39

the small legal risks of sharing

25:42

abortion information and aim

25:44

to help clinicians right-size

25:46

their fears and adopt an informed

25:49

approach that maximizes

25:52

patient well-being.

25:55

Prioritizing mental health

25:57

in the HIV-AIDS response

25:59

in a

25:59

Africa. A perspective

26:02

by Catherine Godfrey from the Department

26:04

of State, Washington, D.C.

26:07

Mental health conditions occur at

26:09

higher rates among people living

26:12

with HIV than among people

26:14

without HIV.

26:16

In both North America and

26:18

Africa,

26:19

mental health is often neglected

26:21

in clinical practice, however, despite

26:24

associations between mental

26:26

conditions and poor health outcomes.

26:29

One clinic in Nigeria documented

26:32

that 20 percent of patients with

26:34

HIV had a missed diagnosis

26:37

of depression, for example.

26:39

These authors believe that there

26:41

are several steps that could help address

26:44

mental health programming gaps among

26:47

people living with HIV in

26:49

Africa.

26:50

First, screening tools that can

26:52

identify co-existing mental health

26:55

conditions and can be used by

26:57

community health workers could be

26:59

rolled out on a broad scale.

27:02

Effective and validated short

27:04

cognitive behavioral interventions

27:06

tailored to the cultural context

27:09

and delivered by various healthcare professionals

27:12

will need to be disseminated.

27:14

Outcomes related to both mental

27:16

health and HIV should be measured

27:19

to determine which interventions are

27:21

effective and the benefit associated

27:23

with each component of an intervention.

27:26

Modern electronic and other remote

27:29

solutions could be adopted and

27:31

adapted for mental health interventions

27:34

in Africa, which would support

27:36

efficient utilization of higher-level

27:39

clinicians.

27:40

Community clinicians and health workers

27:43

will also need training to provide

27:45

mental health care within a framework

27:47

that makes effective use of higher-level

27:50

clinicians and existing structures.

27:52

Finally, data

27:55

could be analyzed in a way that permits

27:57

refinement of screening and intervention.

28:00

tools and facilitates broader

28:02

understanding of the effects of coexisting

28:05

conditions on both individual people

28:08

and the community.

28:11

Reducing health care's climate

28:14

impact.

28:15

Mission critical or extra

28:17

credit. A perspective by

28:19

Alexander Raben from the Veterans

28:21

Affairs Ann Arbor health care system,

28:24

Ann Arbor, Michigan.

28:26

The news broke that the Joint Commission

28:28

would relegate its hospital sustainability

28:31

standards originally proposed as

28:34

mandatory to the optional

28:36

category. A collective groan

28:39

emerged from the community of health professionals

28:42

working to address the global climate

28:44

emergency.

28:45

In making the standards extra credit,

28:48

has the accrediting body strayed

28:50

from its mission?

28:52

Health care delivery is responsible

28:54

for 8.5% of

28:57

total U.S. greenhouse gas

28:59

emissions, as well as emissions of

29:01

other pollutants. To address

29:04

this conflict between health care operations

29:07

and healthy outcomes, in March 2023, the

29:10

Joint Commission announced proposed

29:13

requirements for minimizing

29:15

hospitals' greenhouse gas emissions

29:18

and waste. However, in late

29:20

April 2023, reportedly

29:22

in response to feedback from hospitals,

29:25

health systems and the health care industry

29:28

after the proposal was released for public

29:30

comment, the Commission backtracked.

29:33

These authors hope and expect

29:35

that the Joint Commission will return

29:37

to the drawing board, engage with

29:40

member hospitals and find ways

29:42

to enact climate-healthy

29:44

policies that will improve outcomes

29:47

and staff morale

29:49

while saving money. These

29:51

authors know such action

29:53

is possible because their health

29:55

systems have shown the way.

29:57

The Department of Veterans Affairs has

29:59

put forth a Climate Action Plan

30:02

and, in accordance with Executive Order 14057,

30:04

catalyzing clean energy

30:08

industries and jobs through federal

30:11

sustainability, aims to reach 100%

30:13

zero-emission vehicle

30:17

acquisition by 2035.

30:20

Meanwhile, Mass General Brigham

30:22

has reduced the intensity of energy

30:24

consumption in its facilities by 20%

30:27

since 2008, which resulted in decreased greenhouse

30:32

gas emissions and has yielded

30:35

savings of tens of millions

30:37

of dollars in utilities spending.

30:42

Rediscovering the importance of

30:44

free and charitable clinics,

30:47

a perspective by Mark Hall

30:49

from Wake Forest University, North

30:52

Carolina.

30:53

Free and charitable clinics are

30:55

one of the most enduring, yet least

30:58

studied features of the U.S.

31:00

health care safety net.

31:02

Such clinics have played key roles

31:05

throughout the history of medicine in the U.S.,

31:07

adapting in various ways to

31:10

the broader economic and social

31:12

environment.

31:13

Before the establishment of the Medicaid

31:15

and Medicare programs, free clinics

31:18

were a primary source of care for people

31:20

who couldn't afford to purchase

31:22

private coverage or pay for

31:25

services.

31:26

When the Affordable Care Act substantially

31:29

expanded insurance access, free

31:31

clinics took on added roles

31:33

related to helping people navigate insurance

31:36

enrollment and addressing social

31:38

determinants of health. There

31:40

are currently about 1,400 free

31:43

and charitable clinics in the U.S.,

31:46

serving 2 million patients

31:48

per year,

31:49

which accounts for a substantial portion

31:51

of low-income, uninsured people

31:54

who seek care.

31:56

These clinics take various forms

31:58

and operate in a regular way.

31:59

of settings.

32:01

Federal support for safety net clinics

32:04

remains focused on conventional

32:06

community health centers, but

32:08

at the state and local levels, free

32:10

clinics are increasingly being seen

32:12

as an important and complementary component

32:15

of the safety net, meriting government

32:18

support. Many state associations

32:21

of free clinics report an ongoing

32:23

need for stable and predictable

32:25

funding, both for operating expenses

32:28

and to support key infrastructure.

32:31

More paid staff are needed

32:33

to complement the sizable ranks of

32:35

clinical volunteers. Funding

32:38

is also needed for the expensive equipment

32:40

that clinics require. Data

32:43

are lacking, however, on exactly what

32:46

resources are needed and where.

32:48

In part, because they vary in structure

32:51

and are relatively informal, free

32:53

clinics haven't been the focus of

32:55

systematic study.

32:59

In our images in clinical medicine, a three-year-old

33:02

girl had dark urine and jaundice

33:05

after an upper respiratory tract infection.

33:08

Laboratory studies were consistent

33:10

with hemolysis. A peripheral

33:12

blood smear showed varied sizes

33:15

and shapes of red cells that included

33:17

reticulocytes and spherocytes,

33:20

as well as erythrocyte agglutination.

33:23

Many neutrophils were coated with

33:25

agglutinated erythrocytes, forming

33:27

rosettes.

33:28

Phagocytosis of erythrocytes in

33:30

macrophages and neutrophils was

33:33

also seen. Rare findings

33:35

in autoimmune hemolytic anemia.

33:38

A direct antiglobulin test was

33:41

positive for C3D and

33:43

weakly positive for IgG.

33:46

The cold agglutinin titer was 1 to 1024.

33:49

A

33:51

diagnosis of autoimmune

33:53

hemolytic anemia from cold

33:55

agglutinin syndrome associated

33:58

with an upper respiratory infection.

33:59

was made.

34:02

In another image, a 20-year-old

34:04

man presented with a three-month history

34:07

of itchiness,

34:08

a sexual