0:00

Welcome, this is the New England Journal

0:02

of Medicine. I'm Dr. Lisa Johnson.

0:05

This week, October 19,

0:08

2023, we feature articles on enzalutamide

0:11

and luprolide in prostate cancer,

0:14

optical coherence tomography, OCT-guided

0:18

versus angiography-guided PCI,

0:21

vancomycin and cephalosline prophylaxis

0:24

in arthroplasty, and on

0:26

OCT and eye care, a

0:29

review article on the syndrome of inappropriate

0:32

antidiuresis, a case

0:34

report of a woman with recurrent hemorrhagic

0:36

pericardial effusion, and

0:39

perspective articles on Yellowjack's

0:42

potential return to the American South,

0:45

on wedding websites, free speech,

0:47

and adverse drug effects, and

0:50

on a chance to modernize health

0:52

care behind bars. Improved

0:56

Outcomes with Enzalutamide

0:58

in Biochemically Recurrent Prostate

1:01

Cancer, by Stephen Friedland,

1:04

from the Cedars-Sinai Medical Center,

1:06

Los Angeles, and colleagues.

1:10

Patients with prostate cancer who

1:12

have high-risk biochemical recurrence

1:14

have an increased risk of progression.

1:18

This study evaluated the efficacy

1:20

and safety of enzalutamide

1:22

plus androgen deprivation therapy

1:25

with luprolide and enzalutamide

1:28

monotherapy, as compared

1:30

with luprolide alone in 1,068

1:34

patients with prostate cancer who

1:36

had high-risk biochemical recurrence

1:39

with a prostate-specific antigen

1:41

doubling time of 9 months or

1:43

less.

1:44

The patients were followed for a median

1:47

of 60.7 months.

1:50

At 5 years, metastasis

1:52

free survival was 87.3% in the combination

1:54

group, 71.4% in

1:57

the end-of-life group.

1:59

the Luprolide Alone group and 80%

2:03

in the Monotherapy group. With

2:06

respect to metastasis-free survival,

2:08

Enzalutamide plus Luprolide

2:11

was superior to Luprolide

2:13

Alone, hazard ratio for metastasis

2:16

or death 0.42. Enzalutamide

2:19

Monotherapy was also superior

2:22

to Luprolide Alone, hazard ratio

2:24

for metastasis or death 0.63.

2:27

No new safety signals were

2:30

observed and there were no substantial

2:32

between-group differences in

2:35

quality of life measures.

2:37

In patients with prostate cancer

2:39

with high-risk biochemical recurrence,

2:42

Enzalutamide plus Luprolide

2:44

was superior to Luprolide

2:47

Alone with respect to metastasis-free

2:50

survival. Enzalutamide

2:52

Monotherapy was also superior

2:54

to Luprolide Alone. The safety

2:57

profile of Enzalutamide was consistent

2:59

with that shown in previous clinical

3:02

trials with no apparent

3:04

detrimental effect on quality

3:06

of life.

3:08

Anna Aparicio from the University

3:10

of Texas MD Anderson Cancer

3:13

Center, Houston writes in an editorial

3:16

that the state of biochemical recurrence

3:18

in prostate cancer is one in

3:20

which rising serum prostate-specific

3:23

antigen, PSA levels,

3:26

points to the existence of disease

3:28

that remains radiographically

3:30

invisible on CT and

3:33

technetium-99M bone scans. Because

3:37

most prostate cancers have a prolonged

3:39

natural history and largely affect

3:42

older men with many competing

3:44

causes of death, a sizable proportion

3:47

of patients will never suffer or die

3:50

from their metastases. For

3:52

such patients, cancer therapies

3:54

can only result in harm.

3:57

Still, many biochemical recurrences

3:59

are

3:59

harbingers of prostate cancer

4:02

related morbidity and mortality,

4:04

prompting some practitioners to use

4:07

androgen deprivation therapy ADT

4:10

to curtail its progression. However,

4:13

producing level one evidence

4:15

that this approach prolonged survival

4:18

has been fraught with challenges. The

4:20

heterogeneity of prostate cancer

4:23

is one such challenge. A second

4:25

challenge is that the toxic effects

4:27

from ADT, such as cardiometabolic

4:30

syndrome or loss of bone mineralization,

4:34

impair quality of life in most

4:36

patients and may even accelerate

4:38

death in some. Nevertheless,

4:41

the results of the trial by Friedland

4:43

and colleagues do support that

4:46

in a subgroup of men with biochemical

4:48

recurrence, the benefits of early

4:51

cancer control with systemic

4:53

therapy outweigh its risks.

4:56

The results also confirm that in this

4:58

population, as in men with

5:00

more advanced stages, adding

5:02

an androgen receptor inhibitor

5:05

increases the efficacy of ADT.

5:08

In addition to developing more effective

5:11

drugs with fewer toxic effects,

5:13

tilting the scale to maximize

5:15

benefit will require better predictors

5:18

of prostate cancer lethality

5:21

and treatment effect. Finally,

5:23

the definition of benefit is arguably

5:26

our greatest hurdle. In

5:28

the end, because there is more

5:30

to life than death, a single

5:33

measure is unlikely to encompass

5:35

the complexity of clinical benefit

5:37

in men with biochemical recurrence.

5:41

Various carefully assessed endpoints

5:43

will need to be weighed on the risk-benefit

5:46

balance.

5:59

New York, and colleagues.

6:02

This trial evaluated the safety

6:05

and effectiveness of Optical Coherence

6:07

Tomography, OCT, Guided

6:10

Percutaneous Coronary Intervention,

6:13

PCI, as compared with

6:15

Angiography Guided PCI, in

6:18

high-risk patients and lesions.

6:23

2,487 patients with medication-treated

6:25

diabetes or complex coronary

6:28

artery lesions were randomly assigned

6:30

to undergo OCT Guided

6:33

PCI or Angiography

6:35

Guided PCI. A final

6:37

blinded OCT procedure

6:40

was performed in patients in the angiography

6:42

group.

6:43

The trial was conducted at 80 sites

6:45

in 18 countries. The

6:48

two primary efficacy endpoints

6:51

were the minimum stent area after

6:54

PCI as assessed with OCT

6:56

and target vessel failure at two

6:59

years, defined as a composite

7:02

of death from cardiac causes, target

7:04

vessel myocardial infarction, or

7:06

ischemia-driven target vessel

7:09

revascularization. The

7:11

minimum stent area after PCI

7:14

was 5.72 millimeters

7:17

squared in the OCT group and 5.36

7:20

millimeters squared in the angiography

7:23

group. Target vessel failure

7:25

within two years

7:26

occurred in 88 patients

7:29

in the OCT

7:29

group and in 99 patients

7:32

in the angiography group. Kaplan-Meier

7:34

estimates 7.4% and 8.2% respectively.

7:40

OCT-related adverse events

7:43

occurred in one patient in the OCT

7:46

group and in two patients in the

7:48

angiography group. Stent

7:50

thrombosis within two years occurred

7:53

in 0.5% of patients

7:55

in the OCT group and in 1.4% of patients

7:57

in the

7:59

angiography group.

8:01

Among patients undergoing PCI,

8:04

OCT guidance resulted in

8:06

a larger minimum stent area

8:08

than angiography guidance, but

8:11

there was no apparent between-group

8:13

difference in the percentage of patients

8:15

with target vessel failure at

8:17

two years. OCT

8:22

or angiography guidance for

8:24

PCI in complex

8:26

bifurcation lesions. By

8:28

Niels Holm from the Aarhus University

8:31

Hospital, Denmark, and colleagues.

8:35

Whether routine optical coherence

8:38

tomography, OCT, guidance

8:40

in PCI of lesions involving coronary

8:44

artery branch points bifurcations

8:46

improves clinical outcomes as

8:49

compared with angiographic guidance

8:52

is uncertain.

8:53

In this trial at 38 centers in Europe, 1,201 patients

8:55

with

8:59

a clinical indication for PCI

9:02

and a complex bifurcation

9:04

lesion identified by means of

9:06

coronary angiography were

9:08

randomly assigned to OCT-guided

9:11

PCI or angiography-guided PCI.

9:15

18.5% of patients in the

9:16

OCT-guided PCI group and 19.3% of patients in the angiography-guided

9:22

PCI group had a bifurcation lesion involving the left main

9:24

coronary artery. At

9:29

two

9:30

years, a primary endpoint

9:32

event of a composite of

9:33

major adverse cardiac events, MACE,

9:36

defined as death from a cardiac

9:38

cause, target lesion myocardial

9:41

infarction, or ischemia-driven target

9:43

lesion revascularization, had

9:45

occurred in 10.1% of patients with a coronary

9:47

artery branch.

9:53

At two years, a primary endpoint event of a composite of major

9:55

artery branch points were

9:59

reported. patient's angiography-guided PCI group.

10:04

Procedure-related complications

10:06

occurred in 6.8% of patients in the OCT-guided

10:09

PCI group and

10:11

in 5.7% of patients in

10:13

the angiography-guided PCI

10:16

group. Among patients

10:18

with complex coronary artery

10:20

bifurcation lesions, OCT-guided

10:23

PCI was associated with

10:26

a lower incidence of MACE

10:28

at two years than angiography-guided

10:31

PCI. In

10:34

an editorial,

10:34

Harold Dowerman from the University

10:37

of Vermont Larner College of Medicine,

10:40

Burlington, asks,

10:42

Does the negative result in the trial

10:44

by Ali and colleagues indicate

10:46

that a foundation of interventional

10:49

cardiology, that larger

10:51

acute coronary lumen gains,

10:53

improve patient outcomes, may

10:56

no longer broadly apply

10:58

in the era of contemporary

11:00

drug-eluting stents and pharmacology?

11:04

Is this theory only valid when

11:06

the more macroscopic assessment

11:08

of luminal changes assessed

11:10

by angiography is used?

11:13

Is the disconnect between improved

11:15

mechanistic luminal gain and clinically

11:18

measurable outcomes caused by

11:20

a threshold that is currently reached in

11:22

the majority of patients undergoing

11:24

PCI with angiographic

11:27

guidance alone? We have

11:29

learned from OCT imaging that

11:31

the pathophysiology of coronary

11:33

artery disease is

11:35

far more complex than

11:37

we previously thought.

11:38

Although the findings from the trials by

11:41

Ali and colleagues and Holm and

11:43

colleagues may be broadly interpreted

11:46

as adding momentum to intercoronary

11:49

imaging-based PCI for patients with

11:52

complex coronary artery lesions,

11:54

these two trials may also shine

11:57

a new light on the complexity

11:59

involved. in further optimizing

12:01

percutaneous coronary revascularization.

12:05

Given the power of OCT to illuminate

12:08

the nuanced details of a common

12:10

disease, perhaps that complexity

12:13

is exactly what we should have expected.

12:18

Optical Coherence Tomography

12:20

and Eye Care,

12:22

a clinical implications of basic research

12:24

by Cynthia Tote from Duke University,

12:27

Durham, North Carolina. For

12:30

imaging of the neurovascular tissue

12:32

of the retina since the late 19th

12:35

century, physicians have relied

12:37

on the ophthalmoscope and camera,

12:40

until 1991, that is, when David Huang, Eric Swanson,

12:45

and James Fujimoto and their

12:47

colleagues described the use of

12:49

coherence properties of light

12:51

waves to perform non-invasive

12:54

imaging of the eye of a cadaver

12:57

and of the vascular lamina of a

12:59

coronary artery, thus initiating

13:02

the field of optical coherence

13:04

tomography, OCT, and

13:06

a revolution in patient care.

13:09

The importance of this work is recognized

13:12

through the 2023 Lasker-DeBakey

13:15

Clinical Medical Research Award.

13:18

OCT uses a low coherence

13:20

light source that illuminates a

13:23

Michelson interferometer at its

13:25

core to detect the interference

13:28

between reflected light from

13:30

scatterers at multiple depths

13:32

within tissue and a reference

13:34

reflector in order to extract

13:37

information about their depth location

13:40

and reflectivity. OCT

13:42

is sensitive to very low levels

13:45

of returned light, which reduces

13:47

the exposure of sensitive tissues

13:49

to high intensity light. The

13:52

axial resolution of imaging is several

13:54

microns, which allows for in vivo

13:56

visualization

13:57

of cellular and even some

13:59

subcellular layers at a depth

14:02

of a millimeter or so in most

14:04

tissues.

14:05

The use of light in the near-infrared

14:08

range results in incoming

14:09

light that is comfortable for patients,

14:12

unlike the white light of ophthalmoscopes

14:15

and ocular cameras.

14:17

Thus, the OCT research team

14:19

rapidly translated their findings

14:22

to in vivo high-resolution

14:24

diagnostic visualization of

14:26

ocular tissue layers, such as

14:29

the cornea, lens, and retina

14:31

in the eye of a living patient. In

14:34

some, OCT has

14:36

changed the modern eye examination.

14:41

Trial of vancomycin and cephasilin

14:44

as surgical prophylaxis in

14:47

arthroplasty

14:48

by Tricia Peel

14:50

from Monash University, Melbourne,

14:52

Victoria, Australia, and

14:54

colleagues.

14:56

The addition of vancomycin to

14:58

beta-lactam prophylaxis in

15:00

arthroplasty may reduce

15:03

surgical site infections. However,

15:05

the efficacy and safety are

15:08

unclear. In this trial, adult

15:10

patients without known methicillin-resistant

15:13

Staph aureus, MRSA colonization,

15:16

who were undergoing knee, hip, or

15:18

shoulder arthroplasty, were

15:20

randomly assigned to receive 1.5 grams

15:24

of vancomycin or normal

15:26

saline placebo, in addition

15:29

to cephasilin prophylaxis. Among 4,113

15:34

patients in the modified Intention

15:36

to Treat population,

15:38

surgical site infections occurred

15:40

in 4.5% of patients in the vancomycin group and in 3.5% of patients

15:43

in the placebo

15:48

group.

15:49

Among patients undergoing knee

15:51

arthroplasty, surgical site infections

15:54

occurred in 5.7% of

15:56

patients in the vancomycin

15:57

group and in 3.7% of patients in the vancomycin group.

15:59

percent of patients in the placebo

16:02

group.

16:03

Among patients undergoing hip arthroplasty,

16:06

surgical site infections occurred in 3%

16:09

of patients in the vancomycin

16:11

group and in 3.1% of

16:13

patients in the placebo group.

16:16

Adverse events

16:17

occurred in 1.7%

16:18

of patients in

16:20

both the vancomycin and the placebo

16:23

group, including hypersensitivity

16:25

reactions in 1.2% and 0.5% of patients respectively,

16:31

and acute kidney injury in 2.1% and 3.6% of

16:33

patients respectively.

16:38

The addition of vancomycin to spheseulin

16:41

prophylaxis was not superior

16:43

to placebo for the prevention of

16:46

surgical site infections in arthroplasty

16:49

among patients without known

16:52

MRSA colonization. The

16:56

Syndrome of Inappropriate Antidiuresis,

16:59

a review article by Horacio

17:02

Adregui from Baylor College of Medicine,

17:04

Houston and Nicolaus Medias

17:07

from Tufts University School of Medicine,

17:10

Boston. Hyponatremia

17:13

is the most common electrolyte abnormality

17:16

and affects approximately 5% of adults overall

17:18

and 35% of hospitalized patients. The

17:24

condition is usually caused by a water

17:26

excess relative to sodium and potassium

17:29

content. In the Syndrome of

17:31

Inappropriate Antidiuresis, which

17:34

is a frequent cause of hyponatremia,

17:37

increased secretion of antidiuretic

17:40

hormone in the absence of osmotic

17:42

and hemodynamic stimuli, leads

17:45

to water retention by the kidneys

17:48

and water excess. Manifestations

17:50

of the Syndrome of Inappropriate Antidiuresis

17:53

depend on the rapidity of development

17:56

and the severity and duration of

17:58

the condition. Symptoms range

18:01

from mild and nonspecific, such

18:03

as weakness and headache, to severe

18:06

and life-threatening, such as seizures

18:08

and coma. Causes of the

18:10

syndrome of inappropriate diuresis

18:13

include cancer, medications,

18:16

pulmonary conditions, disorders

18:18

of the central nervous system, postoperative

18:21

state, severe nausea, and

18:23

stress. Frequently, the cause

18:26

is undetermined. Urgent

18:28

treatment is required for patients with

18:30

this syndrome who have severe symptoms,

18:33

in which case worsening of cerebral

18:35

edema could be catastrophic. Traditional

18:38

treatment has been the administration

18:40

of 3% sodium chloride

18:43

by means of slow, continuous infusion

18:46

to reverse cerebral edema. However,

18:49

consultation with a specialist is

18:51

warranted in such situations.

18:54

Management strategies of less severe

18:56

illness include reversal or

18:58

amelioration of the underlying disorder

19:01

when possible, fluid restriction,

19:03

supplementation with sodium chloride,

19:06

often with furosamide, and treatment

19:08

with urea or tolevaptin.

19:12

A 62-year-old woman with recurrent

19:15

hemorrhagic pericardial effusion,

19:18

a case record

19:18

of the Massachusetts General Hospital

19:21

by Evan Yujil and colleagues.

19:25

A 62-year-old woman was evaluated

19:28

for recurrent hemorrhagic pericardial

19:31

effusion. Three months earlier,

19:34

pleuritic pain and tightness in

19:36

her chest developed suddenly while

19:38

she was eating.

19:39

The chest pain persisted and began

19:42

to radiate to the neck and back.

19:45

She was unable to take a full

19:47

breath and had dizziness with exertion.

19:50

She presented to the emergency department

19:52

of another hospital. CT

19:55

of the chest revealed a moderate

19:57

circumferential pericardial

19:59

effusion.

19:59

with an attenuation level

20:02

of 34 to 50 Hounsfield units. Protamine

20:07

sulfate was administered.

20:09

The patient was transferred to the emergency

20:11

department of a second hospital.

20:14

A transthoracic echocardiogram,

20:16

TTE, showed a small to

20:18

moderate circumferential pericardial

20:21

effusion, primarily abutting

20:23

the right atrium and right ventricle

20:26

with right atrial inversion and

20:28

intermittent diastolic inversion

20:31

of the right ventricle. Pericardio-centesis

20:34

was performed and 200 milliliters of bloody

20:37

fluid was drained. On

20:40

the third hospital day, no pericardial

20:43

effusion was detected on TTE. Four

20:45

days before the

20:46

current admission, the

20:49

patient was evaluated by her cardiologist

20:52

and reported ongoing cough

20:54

and dyspnea. A TTE

20:57

showed recurrence of a moderate pericardial

20:59

effusion.

21:01

Her presentation was subacute with

21:03

evidence of the physiologic characteristics

21:06

of tamponade on TTE.

21:09

Fourteen years earlier, the patient

21:11

had undergone transcatheter

21:14

closure of an atrial septal defect. This

21:17

patient was evaluated for

21:19

erosion of the atrial septal defect closure device,

21:23

and the device was surgically

21:24

removed.

21:26

Device erosion is a very

21:28

rare but serious complication

21:31

of percutaneous transcatheter

21:33

closure of atrial septal defects.

21:38

Yellow Jack's potential return

21:41

to the American South. A perspective

21:44

by Peter Hotez from Baylor

21:46

College of Medicine, Houston, Texas, and

21:49

Angel Deseré-LaBote from

21:51

Stanford University School of Medicine,

21:53

California.

21:55

Tasked with coordinating U.S. readiness

21:57

for our next big global pandemic, global

22:00

infection threats, the new White

22:02

House Office of Pandemic Preparedness

22:05

and Response will emphasize emerging

22:08

coronavirus infections, zoonotic

22:11

influences, and infections

22:13

caused by filoviruses and

22:15

other highly lethal pathogens.

22:18

But mosquito-transmitted virus,

22:21

arbovirus infections, are equally

22:24

important,

22:24

and their spread has begun accelerating

22:27

in the American South. Yellow

22:30

fever, in particular, has a concerning

22:32

legacy. During

22:35

the 1800s, yellow fever caused

22:37

highly lethal and economically

22:39

devastating urban epidemics

22:42

in southern U.S. coastal cities

22:44

and those on the Mississippi River. It

22:46

was sometimes known as yellowjack,

22:49

from the name of a nautical flag hoisted

22:52

from ships arriving from the Caribbean

22:54

that were quarantined because of

22:56

suspected cases of the disease.

22:59

The last major U.S. yellow

23:01

fever epidemic occurred in New

23:04

Orleans in 1905, with an estimated 5,000 cases

23:07

and 1,000 deaths. But

23:10

environmental and socioeconomic

23:12

conditions in the U.S. South, especially

23:15

in Gulf Coast cities, may

23:17

permit sharp increases in

23:19

the

23:20

incidence of serious arbovirus

23:22

infections, and yellow fever

23:24

is of particular concern.

23:27

For example, outbreaks in humans

23:29

of viral infections caused by Aedes

23:32

mosquitoes, primarily Aedes

23:34

aegypti and Aedes albopictus,

23:37

have already begun to occur in

23:39

Florida and Texas.

23:41

Although these have generally been small,

23:44

their mere presence, together with

23:46

new predictions of increases

23:48

in Aedes habitats throughout the

23:50

South attributable to climate

23:52

change and urbanization, suggests

23:55

that suitable conditions

23:57

for future epidemics will

23:59

become present.

23:59

These authors

24:02

believe yellow fever should be

24:04

prioritized as part of

24:06

our national pandemic preparedness

24:09

efforts given that the conditions

24:11

are now in place for Yellowjack

24:13

to return and sicken many

24:16

people in southern U.S. cities.

24:20

Wedding websites, free speech,

24:23

and adverse drug effects.

24:25

A perspective by Jerry Avorn

24:28

from Brigham and Women's Hospital, Boston. In

24:31

its June 2023 decision

24:34

in 303 Creative LLC

24:37

versus Elenis, the U.S. Supreme

24:39

Court upheld the right of

24:41

a wedding website designer to

24:44

refuse to provide services for

24:46

a same-sex marriage. In

24:48

its 6-3 decision, the

24:50

court ruled that the designer's First

24:53

Amendment rights would be violated

24:55

by a requirement that she provide

24:57

such services, since that would

25:00

represent a form of

25:01

compelled

25:02

speech.

25:03

This decision could well legitimize

25:06

denials of services to people who

25:08

are members of sexual or gender minority

25:11

groups, and potentially to many

25:13

other marginalized groups. But

25:16

the principles underlying it could

25:18

also have surprisingly far-reaching

25:20

implications, possibly affecting

25:23

the ability of physicians and patients

25:25

to learn about the side effects of the

25:27

drugs we use. The 303

25:30

Creative case was obviously not

25:33

about medicine, and some observers

25:35

believe it relates only to protecting

25:37

a company's right to avoid compelled

25:40

expressive speech. But

25:42

it is the latest of several decisions

25:44

that trace a potentially ominous

25:47

trend eroding the regulation

25:49

of corporate statements. The

25:51

argument is sometimes linked to religious

25:54

liberty, but other cases barring

25:56

compelled speech had nothing to do

25:58

with religion. For example,

26:01

in 2019, the American

26:03

Beverage Association prevailed

26:05

in a case against San Francisco,

26:08

which had tried to require that statements

26:10

be added to the packaging of high-sugar

26:13

beverages to indicate that drinking

26:15

them contributes to obesity,

26:18

diabetes, and tooth decay.

26:20

The Ninth Circuit Court ruled that

26:22

such labels would represent compelled

26:25

speech imposed by the government

26:27

on soda manufacturers.

26:29

The implications of the 303 Creative

26:32

Decision for vulnerable groups extend

26:34

far beyond same-sex couples

26:37

seeking to commission a wedding website. When

26:40

it comes to understanding the risks

26:42

of the medications we use, all

26:45

prescribers and patients could now

26:47

become vulnerable groups.

26:49

It's not too early to wonder whether

26:51

the power that Congress has vested

26:53

in the FDA to ensure that drugmakers

26:57

accurately describe their products' side

26:59

effects might before long also

27:01

be limited by the courts as a form

27:04

of prohibited, compelled

27:06

speech.

27:08

A Chance to Modernize Health Care

27:11

Behind Bars, Section 1115

27:14

Medicaid Inmate Exclusion Waivers.

27:17

A perspective

27:18

by Brendan Saloner from Johns

27:20

Hopkins Bloomberg School of Public

27:22

Health, Baltimore.

27:25

In 2023, California

27:27

and Washington became the first states

27:30

to receive waivers from the Centers

27:32

for Medicare and Medicaid Services

27:34

regarding the Medicaid Inmate

27:37

Exclusion Policy, a federal

27:39

provision that generally prohibits

27:42

Medicaid from paying for health

27:43

care for people who are incarcerated.

27:47

Roughly 2 million Americans

27:48

were incarcerated

27:49

on any given day in 2020 and 2021.

27:55

People who are incarcerated are disproportionately

27:58

poor and

27:58

members of American health care.

27:59

marginalized racial or ethnic

28:02

groups and they have elevated rates

28:04

of mental illness, substance use

28:06

disorders, and other chronic diseases.

28:09

Engaging members of this population in

28:12

better coordinated care as they leave

28:14

jail or prison could improve post-release

28:17

use of preventive and chronic disease

28:19

care at safety net clinics and

28:22

support improved health outcomes.

28:25

The California waiver, for example,

28:27

covers various reentry

28:29

related health services for an estimated

28:33

200,000 people per year during the 90 days

28:35

before release from jail or prison.

28:39

At least 13 additional states

28:41

are seeking inmate exclusion waivers.

28:44

To support applications for such waivers,

28:47

CMS released guidance in April 2023

28:49

outlining broad

28:52

programmatic goals. The

28:54

guidance lays out three required

28:57

benefits.

28:58

Comprehensive case management, pre-release

29:00

provision of medication for substance

29:03

use disorder, referred to by CMS

29:05

as medication assisted treatment,

29:08

and provision of a 30-day supply

29:10

of all prescribed medications to

29:12

people at the time of release.

29:15

The recent inmate exclusion waivers

29:17

granted to California and Washington represent

29:20

a meaningful step toward greater

29:23

care integration for people

29:24

who are incarcerated.

29:26

The waivers could be a stepping stone

29:29

to the partial or complete repeal

29:31

of the Medicaid inmate exclusion policy,

29:34

a proposal with bipartisan

29:36

support that is under serious

29:38

consideration in Congress. In

29:42

our images in clinical medicine, a 44 year

29:45

old man

29:45

with diabetes mellitus and end-stage

29:48

kidney disease presented to the emergency

29:51

department with a two-week history

29:53

of pain and blurry vision in his

29:55

left eye, fevers, and back

29:57

pain.

29:58

An ophthalmologic example was

30:01

notable for conjunctival injection

30:03

and corneal clouding in the left

30:05

eye.

30:06

Visual acuity was 2060

30:09

in the right eye and was reduced to

30:11

minimal light perception in the left

30:14

eye. Slit lamp examination

30:16

revealed a hazy edematous cornea

30:19

and a small hypopyon in the left

30:21

eye.

30:22

Cultures of vitreous fluid and

30:24

blood grew methicillin sensitive

30:27

Staph aureus. A diagnosis

30:30

of bacterial endogenous endopthalmitis

30:33

was made. Endopthalmitis

30:36

is a vision threatening infection of

30:38

the vitreous and aqueous fluids

30:41

of the eye. The infection is deemed

30:43

to be endogenous when it results from

30:45

hematogenous spread.

30:47

Systemic antimicrobial agents

30:49

alone will not adequately treat

30:52

endogenous endopthalmitis. Intravitrial

30:56

antimicrobial therapy is warranted

30:58

and vitrectomy is indicated in

31:01

cases of severe vision loss

31:03

or progression of infection

31:05

despite antimicrobial

31:06

therapy.

31:09

In another image a 36 year

31:11

old woman presented with a three-week

31:13

history of swelling and bluish

31:16

discoloration of her left arm and

31:18

hand that occurred when she raised

31:21

her arms. The symptoms

31:23

started after she had spent 10 days

31:26

typing at a desk. On the left

31:28

side blood flowed through an anatomical

31:31

variant of the subclavian vein

31:33

that connected to the jugular

31:35

veins.

31:36

When the patient's arms were elevated

31:38

blood flow through the subclavian

31:40

veins on both sides was limited

31:43

by compression between the first

31:45

rib and the clavicle.

31:47

Blood drainage from the left side was

31:50

slower owing to smaller collateral

31:52

vessels which accounted for the patient's symptoms

31:55

on the left side. A

31:57

diagnosis of venous thoracic

31:59

outlast. syndrome was

32:01

made. Venous thoracic outlet

32:04

syndrome occurs when the subclavian

32:06

vein has thrombosis or

32:09

is compressed in the costoclavicular

32:11

space. This concludes

32:14

our summary. Let us know what you think

32:16

about our podcast. Any comments

32:18

or suggestions may be sent to

32:21

audio at NEJM.org.

32:24

Thank you

32:24

for listening.