0:00

Welcome. This is

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the New England Journal of Medicine. I'm

0:04

Dr. Michael Beerer. This

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week, October 5,

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2023, we feature articles on siriliumab

0:11

for relapsing polymyalgia

0:13

rheumatica,

0:15

modifiable risk factors, cardiovascular

0:18

disease, and mortality, extracorporeal

0:21

life support in cardiogenic

0:23

shock, and esketamine

0:26

versus quetiapine for treatment-resistant

0:29

depression, a review article on

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stem cell aging and pre-cancer

0:34

evolution, a clinical problem

0:37

solving on digging into the histology,

0:40

and perspective articles on preventing

0:43

heat-related illness among outdoor

0:45

workers, on countering

0:47

the health disinformation machine,

0:50

and on dismantling the over-policing

0:53

of black medical trainees. Siriliumab

0:59

for Relapse of Polymyalgia

1:01

Rheumatica During Glucocorticoid

1:03

Taper by Robert Spiera

1:06

from Weill Cornell Medical College, New York,

1:09

and others. Polymyalgia

1:12

rheumatica is an inflammatory disease

1:14

of unknown cause characterized by pain and morning

1:17

stiffness of the shoulder and pelvic

1:19

girdles, with substantial effect on quality of

1:22

life and function. Glucocorticoids

1:25

have been the mainstay of treatment. More than half of patients

1:28

with polymyalgia rheumatica have a relapse

1:31

while glucocorticoid therapy is tapered. Previous

1:34

studies have suggested that

1:36

interleukin-6 blockade may be clinically useful in

1:39

the treatment of polymyalgia rheumatica.

1:42

Siriliumab, a human monoclonal

1:44

antibody, binds interleukin-6 receptor

1:47

alpha and efficiently blocks the interleukin-6

1:50

pathway.

1:51

In this phase 3 trial, 118

1:54

patients were randomly assigned to receive

1:57

a subcutaneous injection every

1:59

two weeks.

1:59

of either cerilumab plus

2:02

a 14-week glucocorticoid taper

2:04

or placebo plus a 52-week

2:07

glucocorticoid taper. At

2:09

week 52, the primary

2:11

outcome of sustained remission

2:14

occurred in 28% of patients in the cerilumab

2:18

group and in 10% of patients

2:21

in the placebo group. The median

2:23

cumulative glucocorticoid dose at 52

2:26

weeks was significantly lower

2:28

in the cerilumab group than

2:30

in the placebo group, 777 milligrams

2:32

versus 2,044 milligrams. The

2:37

most common adverse events with cerilumab

2:40

as compared with placebo were neutropenia,

2:43

15% versus 0%, arthralgia, 15% versus 5%, and diarrhea, 12% versus 2%. More

2:52

treatment-related discontinuations were

2:54

observed in the cerilumab group than in the

2:56

placebo group, 12% versus 7%. Cerilumab

3:01

showed significant efficacy in

3:03

achieving sustained remission

3:06

and reducing the cumulative glucocorticoid

3:08

dose in patients with a relapse

3:11

of polymyalgia rheumatica during

3:13

glucocorticoid tapering. Daniel

3:17

Alitaha from the Medical University

3:19

of Vienna writes in an editorial

3:21

that, together with the results of previous

3:23

trials both in similar and different

3:25

populations, the findings from

3:28

the trial by Spiera and colleagues

3:30

represent a broadening of the strategic

3:33

approach toward the management of polymyalgia

3:36

rheumatica according to the treat-to-target

3:38

principle, even beyond the definition

3:41

of remission. These additional

3:43

treatment options allow for more flexibility

3:46

in the tailoring of the right management

3:48

strategy to achieve remission and

3:51

minimize the risks of glucocorticoids.

3:54

As evidence of the efficacy of interleukin 6

3:57

receptor blockade accumulates from

3:59

the previous and the current trial,

4:02

we can conclude that this approach is effective

4:04

as second-line therapy after glucocorticoid

4:07

failure, as well as first-line

4:09

therapy in new onset disease. We

4:12

can also conclude that a shortened

4:14

period of glucocorticoid tapering is

4:16

possible and that interleukin 6 receptor

4:19

blockade is beneficial in combination

4:21

with a short-term glucocorticoid taper

4:24

as compared with a full 52-week taper.

4:27

However, even with the growing evidence

4:29

base from these trials, the future management

4:32

of polymyalgia rheumatica continues

4:34

to carry numerous questions that will

4:36

keep the field busy. The best strategy

4:39

will depend on the duration of sustained

4:41

remission, on glucocorticoid-related

4:44

side effects, and on drug

4:46

expenses. Thus, the questions

4:49

have been refined from can we manage

4:51

to how do we manage, and from is

4:54

glucocorticoid-free remission possible

4:57

to how can we achieve glucocorticoid-free

5:00

remission as fast as possible? Many

5:03

factors will influence the choice of strategy

5:06

and its consequent effects on the illness

5:08

burden, degree of glucocorticoid

5:10

exposure, burden of toxic effects,

5:13

and relative cost effectiveness. Total

5:17

effect of modifiable risk

5:20

factors on cardiovascular

5:22

disease and mortality by the global

5:24

cardiovascular risk consortium.

5:28

Five modifiable risk factors are

5:30

associated with cardiovascular disease

5:33

and death from any cause. This

5:35

study examined associations between

5:38

the risk factors, including body

5:40

mass index, systolic blood pressure,

5:42

non-high density lipoprotein cholesterol,

5:45

current smoking and diabetes,

5:48

and incident cardiovascular disease

5:50

and death from any cause using

5:52

Cox regression analysis stratified

5:55

according to geographic region, age,

5:58

and sex. Population

6:01

attributable fractions were estimated

6:03

for the 10-year incidence of cardiovascular

6:06

disease and 10-year all-cause

6:08

mortality. Among 1,518,028 participants, 54.1%

6:10

of whom were women, with a median age of 54.4 years, regional

6:21

variations in the prevalence of the five

6:23

modifiable risk factors were noted. And

6:26

cardiovascular disease occurred

6:29

in 80,596 participants during a median follow-up of 7.3 years.

6:36

And 177,369 participants died during a median follow-up

6:39

of 8.7 years. For

6:46

all five risk factors combined,

6:48

the aggregate global population

6:51

attributable fraction of the 10-year

6:53

incidence of cardiovascular disease

6:56

was 57.2% among women and 52.6% among men. And

7:02

the corresponding values for 10-year

7:05

all-cause mortality were 22.2% and 19.1%.

7:13

Philip Joseph and Salim Yousuf

7:15

from McMaster University, Hamilton,

7:18

Ontario, Canada write in

7:20

an editorial that together the risk

7:22

factors described in the study by

7:24

the Global Cardiovascular Risk Consortium

7:27

accounted for a population attributable

7:30

fraction of cardiovascular disease

7:32

events of 53% among

7:34

men and 57% among women

7:37

globally, a finding suggesting

7:39

that strategies targeting their

7:41

prevention or control could substantially

7:44

reduce the global burden of cardiovascular

7:47

disease. The challenge now

7:49

lies in how these risk factors

7:51

are tackled globally. In

7:54

the current study, the largest contributing

7:56

risk factor for cardiovascular disease

7:59

was elevated systolic blood pressure,

8:01

which accounted for a population attributable

8:04

fraction of 22% among men and 29% among

8:06

women. Elevated

8:10

non-HDL cholesterol level was

8:12

the second largest contributing risk

8:14

factor. Cholesterol management

8:16

is equally poor in middle-income and

8:19

low-income countries, with statins

8:21

being used in only 8% of

8:23

persons eligible for primary

8:25

prevention of cardiovascular disease.

8:28

A new strategy to improve the

8:30

control of these risk factors is

8:32

task shifting or task

8:35

sharing between physicians and non-physician

8:38

health workers, with the latter implementing

8:40

key components of management, such

8:42

as screening, diagnosis, medication

8:45

prescription, and lifestyle counseling.

8:48

Such strategies can be facilitated

8:51

by the use of a polypill,

8:53

which reduces the blood pressure and

8:56

cholesterol level simultaneously,

8:58

and improves cardiovascular disease

9:00

outcomes. Reducing the global

9:03

burden of cardiovascular disease to

9:05

a large extent is feasible, but

9:08

requires fundamental changes in

9:10

the approach to cardiovascular disease

9:12

prevention by integrating public

9:14

health and clinical strategies among

9:17

policymakers, physicians, allied

9:19

health groups, and communities at multiple

9:22

levels. Such an approach could

9:24

reduce the incidence of cardiovascular

9:26

disease to a substantial extent globally

9:30

and at low cost. Extracorporeal

9:34

life support in infarct-related

9:37

cardiogenic shock by

9:39

Holger Tille from Heart Center

9:41

Leipzig, Germany, and others. Extracorporeal

9:45

life support, ECLS,

9:47

is increasingly used in the treatment of infarct-related

9:50

cardiogenic shock despite a

9:52

lack of evidence regarding its effect on

9:54

mortality. In this multi-center

9:57

trial, 417 patients with

10:00

acute myocardial infarction complicated

10:02

by cardiogenic shock for whom early

10:05

revascularization was planned were

10:08

randomly assigned to receive early ECLS

10:11

plus usual medical treatment or

10:14

usual medical treatment alone, the control

10:16

group. At 30 days, the

10:19

primary outcome of death from any

10:21

cause had occurred in 47.8% of patients in

10:25

the ECLS group and in 49% of patients

10:27

in the control group. The

10:31

median duration of mechanical ventilation

10:33

was 7 days in the ECLS

10:35

group and 5 days in the control

10:38

group. The safety outcome consisting

10:40

of moderate or severe bleeding occurred

10:43

in 23.4% of the patients

10:45

in the ECLS group and in 9.6%

10:48

of those in the control group. Unusual

10:51

vascular complications, warranting intervention

10:54

occurred in 11% and 3.8% respectively. In

10:59

patients with acute myocardial infarction

11:01

complicated by cardiogenic shock with

11:04

planned early revascularization,

11:06

the risk of death from any cause at

11:08

the 30-day follow-up was not

11:11

lower among the patients who received

11:13

ECLS therapy than among those

11:15

who received medical therapy alone.

11:19

In an editorial, Jane Leopold

11:22

and Darren Taishman, deputy editors

11:24

for the journal, write that the patients

11:27

who were enrolled in the trial by Tila

11:29

and colleagues were at high risk for adverse

11:31

outcomes and were considered to be the most

11:33

likely to benefit from mechanical circulatory

11:36

support. 77.7% received

11:39

cardiopulmonary resuscitation before

11:41

randomization. The median blood pH

11:44

was 7.2. The median

11:46

lactate level was 6.9 millimoles

11:49

per liter. And the median left ventricular

11:51

ejection fraction was 30%. According

11:55

to the Society for Cardiovascular

11:57

Angiography and Interventions, In

12:00

the shock stages, a condition of 48.4%

12:04

of all patients in the trial was categorized

12:07

as either deteriorating stage

12:09

D or in extremis

12:12

stage E, and ECLS

12:14

was initiated before or during

12:16

the revascularization procedure

12:19

in 47.7%. Nonetheless,

12:22

the lack of apparent mortality benefit

12:25

appeared to be consistent across

12:27

multiple subgroup analyses, including

12:30

those performed according to sex, age,

12:33

the presence or absence of diabetes,

12:35

STEMI or non-STEMI, anterior

12:38

myocardial infarction, a lactate

12:40

level of more than 6 millimoles per liter,

12:43

or receipt of cardiopulmonary resuscitation.

12:47

Notably, a subgroup analysis

12:49

according to shock severity stage was

12:51

not included. The lack

12:54

of a mortality benefit with ECLS

12:56

in this trial corresponds to

12:58

the findings of other randomized trials

13:00

of mechanical circulatory support devices

13:03

in patients with myocardial infarction

13:05

and cardiogenic shock. Will

13:08

the results of the trial by Tila

13:10

and colleagues change current clinical

13:12

practice? If the goal of

13:14

ECLS is to improve 30-day

13:17

mortality, these data should

13:19

steer interventional and critical care

13:22

cardiologists away from

13:24

its early routine implementation

13:26

for all or even most patients

13:28

with myocardial infarction and cardiogenic

13:31

shock. There will be some patients

13:33

in this population for whom ECLS

13:36

is necessary and life-saving, but

13:38

the results of this trial do not

13:40

tell us which ones. For

13:43

now, the best course may be to

13:45

reserve the early initiation of ECLS

13:48

for those patients with infarct-related

13:50

cardiogenic shock in whom the likely

13:53

benefits more clearly outweigh

13:55

the potential harms. nasal

14:00

spray versus quetiapine

14:03

for treatment-resistant depression

14:06

by Andreas Reif from the University

14:08

Hospital Goethe University, Frankfurt,

14:11

Germany, and colleagues. In

14:15

treatment-resistant depression commonly

14:17

defined as a lack of response to

14:19

two or more consecutive treatments during

14:21

the current depressive episode, the percentage

14:24

of patients with remission is low

14:27

and the percentage with relapse is high.

14:30

This phase 3B study evaluated

14:33

the efficacy and safety of eschatamine

14:35

nasal spray as compared with extended-release

14:38

quetiapine augmentation therapy,

14:41

both in combination with ongoing

14:43

treatment with a selective serotonin

14:45

reuptake inhibitor, SSRI,

14:48

or a serotonin norepinephrine

14:50

reuptake inhibitor, SNRI. In 676

14:55

patients with treatment-resistant depression,

14:58

more patients in the eschatamine

15:00

group than in the quetiapine group had

15:03

remission at week 8, 27.1% versus 17.6% of

15:05

patients, which was

15:10

the primary endpoint. More patients

15:12

in the eschatamine group than in the quetiapine

15:15

group also had no relapse

15:18

through week 32 after remission at week 8, 21.7% versus 14.1% of

15:20

patients, which was the

15:26

key secondary endpoint. Over 32

15:30

weeks of follow-up, the percentage of

15:32

patients with remission, the percentage

15:34

of patients with a treatment response, and

15:37

the change in the score from baseline

15:39

on the Montgomery-Asberg Depression

15:41

Rating Scale favored eschatamine

15:44

nasal spray. The adverse

15:46

events were consistent with the established

15:49

safety profiles of the trial treatments.

15:52

In patients with treatment-resistant

15:54

depression, eschatamine nasal

15:57

spray plus an SSRI

15:59

or SNRI was superior

16:01

to extended-release quetiapine

16:04

plus an SSRI or SNRI

16:06

with respect to remission at week

16:09

eight. Rupert

16:11

McShane from the University of Oxford,

16:14

United Kingdom writes in an editorial

16:16

that in the trial by Reif and colleagues,

16:19

neither drug did particularly well

16:21

with respect to the primary endpoint, although

16:24

esketamine nasal spray was more

16:26

efficacious than extended-release quetiapine

16:29

and was associated with fewer adverse

16:31

events that led to discontinuation

16:33

of the trial treatment. The benefit

16:35

gradually increased over time

16:38

with both drugs. Real-world

16:40

experience with esketamine nasal

16:42

spray has been reassuring. Cystitis

16:45

and cognitive impairment remain

16:48

theoretical rather than actual

16:50

risks. Similarly, overuse

16:53

is prevented because the nasal spray

16:55

has to be administered in the clinic, which

16:57

also enhances the opportunity for

17:00

regular review. If the

17:02

only determinants about which antidepressant

17:05

to prescribe after the failure of two

17:07

drug treatments were efficacy and

17:09

safety, then the rational conclusion

17:12

from the present trial would be that esketamine

17:14

nasal spray should start to be used

17:17

as a third-line therapy. However,

17:20

weekly or twice-weekly clinic

17:22

visits are the norm for maintenance

17:24

treatment with esketamine nasal spray. Cost

17:27

and inconvenience are therefore likely

17:29

to be decisive factors in its use. Esketamine

17:33

nasal spray will not be the only

17:35

glutamate antagonist to find

17:37

its way into clinical practice. A

17:39

recent meta-analysis suggested

17:42

that intravenous racemic

17:44

ketamine may be more efficacious

17:46

than esketamine, and two large

17:48

head-to-head trials support the

17:51

use of intravenous racemic ketamine

17:53

later in the treatment pathway as an

17:55

option for people who would otherwise

17:58

need electroconvulsive therapy.

18:00

Nevertheless, the trial by Reif

18:03

and colleagues supports the radical

18:05

and disruptive idea that esketamine

18:08

nasal spray has a place early

18:10

in the sequence of antidepressant treatment.

18:12

It seems to help prevent depression

18:15

from consolidating its grip.

18:20

Stem cell aging and pathways

18:22

to pre-cancer evolution. A

18:25

review article by Catriona Jamison

18:27

from the University of California at San

18:29

Diego, La Jolla, and

18:31

Irving Weissman from the Stanford University

18:34

Medical Center, California. What

18:37

is it that always is, but

18:40

never comes to be? And

18:42

what is it that comes to be, but

18:45

never is? PLATO.

18:48

TEMEUS. Like Plato's

18:50

description of the enigma of human

18:52

existence, stem cells may

18:54

remain dormant for a person's lifespan

18:57

and never fulfill their potential. That

19:00

is, never come to be. Or may

19:02

differentiate into other cell types

19:04

and thus come to be, but

19:06

no longer exist as stem cells.

19:09

Perhaps the most unique property of stem

19:12

cells is that they can divide without

19:14

differentiating. This property,

19:17

called self-renewal, allows

19:20

perpetual generation of all cells

19:22

in the tissue while maintaining a stem

19:25

cell pool.

19:26

However,

19:27

deregulation of self-renewal

19:30

during aging and in response to

19:32

microenvironmental and macroenvironmental

19:34

stressors, such as inflammation

19:37

and environmental exposures, can

19:39

lead to cancer. All

19:42

cells in the body can acquire mutations,

19:44

but without self-renewal, they

19:47

cannot become the roots of cancer. Cumulative

19:50

data suggests that pre-cancer

19:53

stem cells arise from clonally

19:56

mutated tissue stem cells that

19:58

disrupt normal tissue homeostasis

20:01

as exemplified by hematopoietic

20:03

stem cell deregulation in pre-leukemic

20:06

bone marrow disorders. Specifically,

20:09

in myeloproliferative neoplasms

20:11

and myelodysplastic syndromes, pre-leukemia

20:15

stem cells acquire resistance

20:17

to apoptosis and programmed

20:20

cell death, have assurance of

20:22

longevity, and evade innate

20:25

and adaptive immune responses, ultimately

20:28

leading to the generation of

20:30

self-renewing leukemia

20:32

stem cells that fuel therapeutic

20:35

resistance in secondary acute

20:37

myeloid leukemia, in part by

20:40

becoming dormant in protective

20:42

microenvironments. Digging

20:47

into the histology, a clinical

20:49

problem solving by Raghavendra

20:51

Paknakar from University of Chicago

20:54

Medicine and colleagues, a

20:56

33-year-old man with ulcerative colitis who

20:59

was receiving treatment with tofacetinib,

21:01

a Janus kinase inhibitor, presented

21:04

to the hospital with worsening fatigue

21:06

and bloody diarrhea. During

21:08

the four months before presentation, he

21:10

had had fevers in the late afternoon

21:12

and evening, drenching night sweats,

21:15

and an unintentional weight loss of 23 kilograms.

21:19

Two weeks before presentation, he began

21:21

to have six to nine episodes of liquid

21:23

stools per day that were associated with

21:26

urgency, the passage of blood, and

21:28

nocturnal awakenings. The patient

21:30

worked as a grain elevator operator

21:33

in the upper Midwestern U.S. and

21:35

continued to work until his symptoms worsened

21:38

two weeks before presentation. Laboratory

21:41

evaluation revealed a high ferritin

21:43

level and low total iron binding

21:46

capacity, which were consistent with

21:48

anemia associated with chronic disease.

21:51

A chest x-ray showed diffuse

21:53

reticular nodular opacities. On

21:56

the morning of the third hospital day,

21:58

the patient had a such change in his clinical

22:01

presentation with the development of diffuse

22:03

abdominal pain, distension, and

22:06

guarding. CT findings

22:08

were consistent with a bowel perforation.

22:11

Urgent colectomy was performed. Examination

22:14

of colon specimens showed well-demarcated

22:17

areas of ulceration with granulomas

22:20

along with perforation in the rectum.

22:23

Brocote-Gomorri methenamine silver

22:25

staining highlighted clusters

22:27

of small ovoid yeast

22:30

forms that were consistent with histoplasma

22:33

capsulatum. Most patients

22:35

with histoplasmosis are asymptomatic

22:38

or have mild symptoms with a self-limited

22:40

disease course. However, patients

22:43

with a high inoculation burden

22:45

or those who are immunosuppressed

22:47

are at risk for severe or

22:49

disseminated disease. Preventing

22:54

heat-related illness among outdoor

22:56

workers, opportunities for clinicians

22:59

and policy makers, a perspective

23:01

by Rosemary Sokas from Georgetown

23:04

University, Washington, D.C., and

23:06

Emily Siney from the Icahn School

23:08

of Medicine at Mount Sinai, New York.

23:12

Mortality from heat stroke among outdoor

23:15

workers has risen over the

23:17

past two decades as temperatures

23:20

have climbed. Approximately 32 million

23:23

people in the U.S. work outdoors

23:25

in industries such as construction,

23:28

transportation, sanitation, agriculture,

23:31

groundskeeping, and emergency

23:34

and protective services. Some

23:36

workers in particular are 35

23:39

times as likely as the general

23:42

population to die of heat

23:44

exposure. Many other workers

23:46

face serious heat exposure inside

23:48

buildings, including warehouses, bakeries,

23:51

and foundries, yet federal and state

23:54

data substantially underestimate

23:57

heat-related mortality owing to

23:59

underrepresented health. recognition, misclassification,

24:02

and failure to capture heat-associated

24:05

exacerbations of underlying

24:08

conditions and increases in traumatic

24:10

injuries. Clinicians can help

24:13

support patients who may be at risk

24:15

for heat-related illness. All clinicians,

24:17

but especially those in primary care,

24:20

could identify patients whose work may expose

24:22

them to heat, review medical histories

24:25

for risk factors, and educate patients

24:27

on how to recognize and respond

24:30

to heat exhaustion. Patients

24:33

should understand the need for a buddy

24:35

system to recognize signs of heat

24:38

stroke in others. The person is either

24:40

hot and dry to the touch, or

24:42

continuing to sweat but confused,

24:45

and understand that heat stroke is a

24:47

life-threatening emergency requiring

24:50

rapid cooling with ice and transportation

24:53

to a hospital. For clinicians at

24:55

safety net clinics that often care for

24:57

low-income or immigrant workers, the

24:59

Migrant Clinicians Network

25:02

provides extensive resources for

25:04

both providers and patients. Most

25:07

important, clinicians could work with

25:09

their member organizations to advocate

25:12

for meaningful regulatory and legislative

25:14

action to protect workers amid

25:17

the escalating climate crisis. Entering

25:22

the Health Disinformation Machine,

25:24

a perspective by Alex

25:26

Keroglian from the Fenway Institute,

25:29

Boston. Since 2016,

25:33

Harvard Medical School has offered an advanced

25:35

course called Caring for Patients with

25:38

Diverse Sexual Orientations, Gender

25:40

Identities, and Sex Development, a

25:43

clinical and scholarly elective. As

25:46

its director for six years, Dr.

25:48

Keroglian had encountered no

25:51

resistance or objections. On

25:53

January 10th of this year, the

25:56

College Fix, an online

25:58

outlet that engages college

26:00

students to write for right-wing

26:03

media published an article

26:05

entitled Harvard med class

26:07

focuses on LGBTQIA

26:11

plus infants and older

26:13

course is directed by LGBT

26:16

activist within 24 hours

26:19

Britain's daily mail had picked up the

26:21

narrative and published an article that claimed

26:23

that HMS medical students are

26:25

being taught how to care for infant

26:28

patients who identify as LGBTQIA

26:31

plus and included a large

26:33

headshot of dr. Corogelian Also

26:36

that day Fox News published

26:39

Harvard Medical School offers course

26:41

about healthcare for LGBTQIA

26:44

plus infants The

26:47

initial coverage of the course illustrates

26:49

the capacity of a far-reaching systematic

26:53

disinformation machine that cross links

26:55

written press social media and broadcasting

26:59

outlets to amplify and

27:01

disseminate falsehoods around

27:03

the world at dizzying speed This

27:06

media ecosystem enables

27:08

the advancement of an anti LGBTQIA

27:12

plus political agenda with devastating

27:15

consequences Including proliferation

27:17

of legal restrictions on necessary

27:19

care for transgender and gender-diverse

27:22

young people and threats against clinicians

27:25

and educators in the field in

27:28

this instance the ability to withstand

27:31

and counter the health disinformation

27:34

campaign hinged on several

27:36

key advantages principled

27:39

support for academic freedom from medical

27:41

school and hospital leaders unwavering

27:44

commitment from funders Communication

27:47

staff who heeded strategic guidance

27:50

from an LGBTQIA plus

27:52

community organization responsive

27:55

security services and law

27:57

enforcement agencies diligent

28:00

fact-checking by journalists, and

28:02

a social media platform's policy

28:05

of flagging and removing

28:07

disinformation. Defending

28:10

against this harm demands the same

28:12

degree of coordination involved in

28:14

the machine that caused it. Such

28:17

efforts require subject matter experts

28:20

to vocally denounce falsehoods,

28:22

institutions to stand with faculty

28:25

who are under attack, and media leaders

28:27

to ensure information integrity.

28:30

Only with this dedicated collaboration

28:32

can we preserve the truth

28:35

on which our patients' lives depend.

28:40

Dismantling the over-policing

28:43

of Black residents, a perspective

28:45

by Joshua Ellis from Beth Israel

28:48

Deaconess Medical Center, Boston, and

28:51

colleagues. Black

28:53

residents training in the United States

28:55

face higher rates of both remedial

28:58

interventions and dismissal from

29:00

their programs than do their white counterparts.

29:03

This disproportionality raises

29:06

concern that Black trainees

29:08

are being over-policed in medical

29:10

education. According to the

29:12

Accreditation Council for Graduate Medical

29:15

Education, Black trainees accounted

29:17

for only 5 percent of

29:19

all residents in 2016, but 20 percent of those

29:22

who were dismissed

29:24

from a residency program. Over-policing

29:28

in the academic setting and workplace refers

29:30

to aggressive and unnecessary

29:33

scrutiny, discipline, and dismissal.

29:36

These actions affect the mental health of trainees

29:38

as well as their careers. Deliberate

29:41

attention is required if we are

29:43

to reduce these actions and the resulting

29:45

psychological injuries. These

29:47

authors have developed a framework

29:50

for supporting Black trainees instead

29:52

of resorting to disciplinary action.

29:55

First, transparency is

29:58

critical in providing residents with

30:00

feedback and individual plans.

30:03

Effort should be made to ensure that the

30:05

trainee fully understands the evaluation

30:08

and remediation processes, including

30:10

the potential for their dismissal. In

30:12

addition, foster an inclusive

30:15

learning environment. Approach

30:17

trainees with sensitivity, including

30:20

incorporating trauma-informed or

30:22

trauma-sensitive practices. Provide

30:24

support. Use objective

30:27

measurements such as clinical metrics

30:29

and exam scores. Avoid

30:31

punitive measures and provide a safe

30:34

space for learning. Engage

30:36

in collaborative design of remediation

30:38

plans. Ensure confidentiality.

30:42

And understand the environment. Recognize

30:45

institutional demographics. In

30:49

our images in clinical medicine, a

30:52

55-year-old man presented with progressive

30:54

handwriting impairment and rapid, slurred

30:57

speech. In his 30s, he

30:59

had worked as a welder without

31:02

access to personal protective equipment.

31:04

Neurologic examination was notable

31:06

for reduced facial expression, blepharospasm,

31:10

and cluttered dysarthric speech. An

31:13

MRI showed non-enhancing,

31:15

hyper-intense signal in the basal

31:17

ganglia on both sides. On

31:20

the basis of the patient's welding history

31:23

and neurologic syndrome, a diagnosis

31:25

of manganese poisoning was

31:28

made. Serum and urine manganese

31:30

levels were not obtained, since these

31:32

values are often normal in cases

31:34

of chronic or previous exposure.

31:37

Treatment with intravenous EDTA

31:39

was administered for six months, and

31:42

the patient's symptoms subsequently

31:45

abated. And the abnormal findings

31:47

on MRI resolved.

31:51

In another image, a young woman in

31:53

the Philippines presented with a one-day

31:56

history of an itchy rash, fevers,

31:58

chills, myalgae, and other things. nausea,

32:01

anorexia, and a retro-orbital

32:03

headache had developed five days earlier

32:06

and lasted four days. On

32:08

presentation, she had a maculopapular

32:11

erythematous rash surrounding patches

32:13

of unaffected skin. Results

32:16

of rapid and serologic testing for

32:19

dengue were positive. Dengue

32:21

infection is classified into three

32:24

phases, febrile, critical,

32:26

and convalescent. In the convalescent

32:29

phase of infection, a confluent

32:31

erythematous rash with small areas

32:33

of unaffected skin that look like

32:36

islands in a sea of red, as

32:38

seen in this patient, may be present.

32:41

The patient was reassured that her condition

32:43

would continue to improve. Three

32:45

days later, her rash had completely

32:47

resolved. This

32:50

concludes our summary. Let

32:52

us know what you think about our podcast. Any

32:55

comments or suggestions may be sent

32:57

to audio at NEJM.org.

33:01

Thank you for listening.