0:00

Welcome. This is the New

0:02

England Journal of Medicine. I'm Dr. Michael

0:04

Bierrer. This week, January 25,

0:08

2024, we feature articles

0:10

on Daratumumab in myeloma

0:12

therapy, the early

0:14

treatment of patent ductus arteriosus

0:17

with ibuprofen, measurable residual

0:19

disease in chronic lymphocytic leukemia,

0:22

hospital prices for physician-administered

0:25

drugs, and Asian

0:27

Americans and racial justice in

0:29

medicine, a review

0:32

article on wearable technologies

0:34

in cardiovascular medicine, a

0:36

case report of an infant with

0:39

inconsolable crying and weakness, and

0:41

perspective articles on minding the gap,

0:44

on transforming population health,

0:47

and on the heartbeat. Daratumumab,

0:53

Bortezomib, Lenalidomide, and dexamethasone

0:55

for multiple myeloma, by

0:59

Peter Sonnefeld from the Erasmus

1:01

MC Cancer Institute Rotterdam, the

1:04

Netherlands, and co-authors. Daratumumab,

1:08

a monoclonal antibody targeting CD38, has

1:10

been approved for use with standard

1:13

myeloma regimens. In this phase 3

1:15

trial, 709 transplantation-eligible patients with newly

1:21

diagnosed multiple myeloma were randomly

1:23

assigned to receive either subcutaneous

1:25

Daratumumab added to

1:28

Bortezomib, Lenalidomide, and dexamethasone,

1:31

VRD, induction, and consolidation

1:33

therapy, and

1:37

added to Lenalidomide maintenance therapy,

1:39

the Daratumumab group, or the standard regimen.

1:42

of VRD induction and consolidation therapy

1:44

and Lenalidomide maintenance therapy, alone, the

1:47

VRD group. At a median follow-up

1:49

of 47.5 months, the risk of

1:51

disease progression or death in

1:55

the Daratumumab group was lower. than

2:00

the risk in the VRD group. The

2:03

estimated percentage of patients with progression-free survival

2:05

at 48 months was 84.3%

2:07

in the daratumumab group and 67.7% in the VRD group.

2:14

The percentage of patients with a

2:16

complete response or better was higher

2:19

in the daratumumab group than in

2:21

the VRD group, 87.9% versus 70.1%.

2:26

This was the percentage of patients

2:28

with minimal residual disease, MRD

2:30

negative status, 75.2%

2:33

versus 47.5%. Death

2:37

occurred in 34 patients in

2:39

the daratumumab group and

2:41

44 patients in the VRD

2:43

group. Grade 3 or

2:45

4 adverse events occurred in most patients

2:47

in both groups. The most

2:50

common were neutropenia and thrombocytopenia.

2:53

Various adverse events occurred in 57% of

2:56

the patients in the daratumumab group and

2:58

49.3% of those in the VRD group. The

3:03

addition of subcutaneous daratumumab

3:05

to VRD induction and

3:08

consolidation therapy and to

3:10

lenalidomide maintenance therapy conferred

3:12

a significant benefit with

3:15

respect to progression-free survival

3:17

among transplantation-eligible patients with

3:20

newly diagnosed multiple myeloma.

3:24

In an editorial, Edward

3:26

Stottmauer from the University of

3:28

Pennsylvania, Philadelphia writes that the

3:31

results of this trial by

3:33

Sonnefeld and colleagues corroborate those

3:35

of the Griffin study, a

3:37

phase two study of a

3:40

similar design, and clearly show

3:42

that the addition of daratumumab

3:44

enhances the efficacy of standard

3:46

first-line therapy for transplantation-eligible patients

3:49

with newly diagnosed multiple myeloma,

3:51

and that this quadruplet therapy

3:53

appears to be safe and

3:55

feasible and did not impede

3:58

proceeding to transplantation. Several

4:00

unanswered questions remain, however.

4:03

For example, would the

4:05

substitution of the next-generation

4:08

proteasome inhibitor carfilzomib for

4:10

bortezomib improve outcomes? Perhaps

4:13

most importantly, when we compare first-line

4:16

therapies for myeloma, overall

4:18

survival is the standard outcome

4:20

measure rather than progression-free survival

4:23

or MRD-negative status. We should

4:25

not discount the benefits of

4:28

long progression-free survival, but

4:30

we must also consider the toxic

4:32

effects, financial burden, and quality of

4:34

life over many years of therapy.

4:37

In subsequent analyses of overall survival

4:39

in the trial by Sonnefeld and

4:42

colleagues, access to

4:44

second-line daratumumab-based therapy in the

4:46

VRD group should be reported

4:49

to inform our understanding of

4:51

whether differences in overall survival

4:53

are attributable specifically to the

4:55

use of first-line daratumumab-based therapy

4:58

or to a lack of

5:00

future access to second-line daratumumab-based

5:02

therapy. Nevertheless, it is

5:05

not realistic to wait years

5:07

for overall survival benefits to

5:09

materialize when treatment decisions are

5:11

needed now for our patients.

5:14

This is a golden age of

5:16

treatments for patients with myeloma. The

5:18

vast majority of patients with newly

5:20

diagnosed disease can expect a rapid,

5:22

deep, and durable response to

5:25

therapies with good safety profiles. A

5:28

cure requires more work, but

5:30

with the results of this

5:32

trial and the continuing development

5:34

of active targeted therapies, the

5:36

future remains bright. Trial

5:40

of Selective Early Treatment

5:43

of Patent Ductous Arteriosis

5:45

with Ibuprofen by Sameer

5:47

Gupta from Sidra Medicine,

5:49

Doha, Cutter, and Co-authors.

5:52

The cyclooxygenase inhibitor ibuprofen may

5:55

be used to treat patent

5:57

ductous arterioses PDA in pretrial

5:59

conditions. term infants. This

6:01

trial evaluated short-term outcomes with early

6:04

treatment, 72 hours or earlier

6:07

after birth, with ibuprofen for a

6:09

large PDA, diameter of 1.5 millimeters

6:11

or greater

6:14

with pulsatile flow, in extremely

6:17

preterm infants born between 23

6:19

weeks zero days

6:21

and 28 weeks six

6:24

days gestation. 326

6:27

infants were assigned to receive

6:29

ibuprofen and 327 to receive

6:31

placebo. A primary

6:33

outcome event of a composite

6:36

of death or moderate or

6:38

severe bronchopulmonary dysplasia evaluated at

6:40

36 weeks of

6:42

postmenstrual age occurred in 69.2%

6:44

of infants in the ibuprofen group and in 63.5%

6:46

of infants in the placebo group. 13.6%

6:53

of infants in the ibuprofen group and 10.3% of infants in

6:55

the placebo group died. Among

7:02

the infants who survived to 36

7:04

weeks of postmenstrual age, moderate

7:06

or severe bronchopulmonary dysplasia occurred

7:08

in 64.2% of

7:11

the infants in the ibuprofen group and

7:13

in 59.3% of the infants

7:16

in the placebo group. Two

7:18

unforeseeable serious adverse events occurred

7:20

that were possibly related to

7:23

ibuprofen. The risk of

7:25

death or moderate or severe bronchopulmonary

7:27

dysplasia at 36 weeks

7:29

of postmenstrual age was

7:32

not significantly lower among infants

7:34

who received early treatment with

7:36

ibuprofen than among those who

7:38

received placebo. Jill

7:41

Marron from Women and Infants Hospital

7:43

of Rhode Island, Providence writes in

7:45

an editorial that the results of

7:48

the trial by Gupta and colleagues

7:50

indicated that early targeted use of

7:52

ibuprofen offered no benefit in reducing

7:54

the risk of a primary outcome

7:57

event of death or moderate or

7:59

severe bronchopulmonary copulmonary dysplasia. Despite

8:02

its negative findings, the trial

8:04

provides important information. With

8:06

more than half of the enrolled patients born at

8:09

less than 26 weeks

8:11

gestation and in absence of

8:13

notable serious adverse events, early

8:16

parenteral administration of the drug appeared

8:18

to be safe in this high-risk

8:20

population and might ultimately

8:23

reduce the need for surgical

8:25

or transcatheter closure. The

8:27

trial also highlights the numerous

8:29

confounders that are inherently linked

8:32

to trials involving PDA closure,

8:35

even minor variations in the

8:37

timing of drug delivery, non-standardized

8:40

dosing regimens and roots of

8:42

administration, receipt of open label

8:45

treatment and exposure to

8:47

drugs that affect duct patency all

8:50

contribute to the difficulty in

8:52

interpreting results in even the

8:55

most well-designed trials. These

8:57

ongoing limitations impair our ability

9:00

to identify the appropriate therapeutic

9:02

approach, leaving neonatologists and

9:04

cardiologists to continue to grapple

9:07

with choosing among courses of

9:09

action for timely and effective

9:12

PDA closure, including

9:14

doing nothing at all. Chronic

9:19

lymphocytic leukemia therapy guided

9:21

by measurable residual disease

9:24

by Taohaa Munir from the

9:27

Leeds Cancer Center United Kingdom

9:30

and co-authors. The

9:32

combination of ibrutinib and venetoclax

9:35

has been shown to improve

9:37

outcomes in patients with chronic

9:39

lymphocytic leukemia, CLL, as compared

9:42

with chemoimmunotherapy. This

9:44

study evaluated whether ibrutinib,

9:47

venetoclax and personalization of

9:49

treatment duration according to

9:52

measurable residual disease, MRD,

9:55

is more effective than

9:57

fludarabine cyclophosphamide rituximac. FCR.

10:01

523 patients

10:03

with untreated CLL were randomly

10:06

assigned to the Abrutinib Venetoclax

10:08

group or the Abrutinib monotherapy

10:10

with FCR group. At

10:13

a median of 43.7 months, disease progression

10:16

or death had occurred in 12

10:19

patients in the Abrutinib Venetoclax group

10:21

and 75 patients in

10:23

the FCR group, hazard ratio 0.13.

10:27

Death occurred in 9 patients in

10:29

the Abrutinib Venetoclax group and 25

10:33

patients in the FCR group, hazard ratio 0.31.

10:35

At 3 years, 58% of the patients in

10:41

the Abrutinib Venetoclax group

10:43

had stopped therapy owing

10:45

to undetectable MRD. After

10:48

5 years of Abrutinib

10:50

Venetoclax therapy, 65.9% of

10:53

the patients had undetectable MRD in

10:55

the bone marrow and 92.7% had

10:59

undetectable MRD in the peripheral

11:02

blood. The risk of

11:04

infection was similar in the Abrutinib

11:06

Venetoclax group and the FCR group.

11:08

The percentage of patients with serious

11:10

cardiac adverse events was higher in

11:13

the Abrutinib Venetoclax group than in

11:15

the FCR group, 10.7% versus 0.4%.

11:21

MRD-directed Abrutinib Venetoclax improved

11:24

progression-free survival as compared

11:26

with FCR and results

11:29

for overall survival also

11:31

favored Abrutinib Venetoclax. Hospital

11:36

prices for physician-administered drugs

11:38

for patients with private

11:41

insurance by James Robinson

11:44

from the University of California

11:46

Berkeley and co-authors. Hospitals

11:49

can leverage their position

11:51

between The ultimate buyers and

11:54

sellers of drugs to retain

11:56

a substantial share of insurer

11:58

pharmaceutical expenses. Then hospitals can

12:01

reduce what they pay to

12:03

manufacturers for the drugs, especially

12:05

if they are eligible for

12:07

three forty be discounts and

12:09

ten increase what they are

12:11

paid for the drugs by

12:13

imposing markups on the reimbursement

12:15

prices they charge. the insurers.

12:18

These. Investigators analyze National Blue

12:20

Blue Claims data that included

12:23

four hundred, Four thousand, Four

12:25

hundred, Forty Three patients in

12:27

the United States who had

12:30

over four million Five hundred

12:32

thousand drug infusion visits for

12:34

Uncle Logic conditions, inflammatory conditions

12:37

or blood cell deficiency disorders.

12:39

The. Median price markup defined as

12:42

the ratio of the reimbursement

12:44

price to the acquisition price

12:46

For hospitals eligible for three

12:48

forty be discounts was three

12:50

Point zero. Eight. After.

12:52

Adjustments for drugs, patient

12:54

and geographic factors. Price.

12:57

Mark ups at hospitals eligible

12:59

for three forty be discounts

13:01

worth six point, five, nine

13:03

times as high as those

13:06

in independent physician practices and

13:08

price mark at non eligible

13:10

hospitals. Were. Four Point Three

13:12

Four times as high as those

13:15

in physician practices. Hospitals.

13:17

Eligible for Three Forty Be

13:19

Discounts retain sixty four point

13:21

three percent of insurer drug

13:24

expenditures, whereas hospitals not eligible

13:26

for Three Forty Be discounts

13:28

retained forty four Point eight

13:30

percent, and independent physician practices

13:32

retained. Nineteen. Point One

13:35

percent. This. Study showed

13:37

that hospitals imposed large price

13:39

markups and retained a substantial

13:42

share of total insurer spending

13:44

on physician administered drugs for

13:47

patients with private insurance. The

13:49

effects were especially large for

13:52

hospitals eligible for discounts under

13:54

the Federal Free Forty Be

13:56

Drug Pricing program on acquisition

13:59

costs. Paid to manufacturers,

14:03

Wearable. Digital Health Technologies

14:05

for monitoring in cardiovascular Madison

14:07

A review article by Erica

14:10

Spats from Yale School of

14:12

Medicine New Haven, Connecticut and

14:15

coauthors. Eight Real Fibrillation

14:17

affects one in twenty five adults

14:19

over sixty years of age and

14:21

one in ten adults over eighty

14:24

years of age. Eight Real Fibrillation

14:26

may go undetected for long periods

14:28

of time and may become apparent

14:30

only when symptoms develop such as

14:32

those in the context of prolonged

14:34

tech, a cardio leading to pulmonary

14:37

been is congestion and to decline

14:39

in ejection fraction, or a problem

14:41

bollixed stroke. Even after

14:43

a raid controller rhythm control

14:45

strategy is implemented and ongoing

14:47

risk for recurrent patriot fibrillation

14:49

and worsening heart failure may

14:52

affect quality of life and

14:54

survival. Ongoing. Monitoring

14:56

combined with oral anti coagulation

14:59

to prevent stroke and maintain

15:01

sinus rhythm has shown benefits

15:03

with regard to disease progression,

15:06

hospitalization, and survival. In

15:08

a traditional care model the patient

15:11

would be scheduled for regular visits

15:13

to assess her blood pressure, weight

15:16

and cardiac rhythm which would provide

15:18

single time point dated to consider

15:20

in deciding whether to adjust the

15:23

guideline. Directed Medical Therapy. Even

15:25

frequent visits may be missed

15:28

times and ineffective for identifying

15:30

disease progression and meeting medical

15:32

therapy goals. The. Goal

15:34

of Remote patient monitoring is

15:37

to use remotely collected and

15:39

transmitted health data to improve

15:42

outcomes by capturing lifestyle behaviors

15:44

that patients could change such

15:47

as sleep and activity, controlling

15:49

risk factors, and detecting clinical

15:52

deterioration or a change in

15:54

health status. Before. It

15:56

worsens. This review focuses on

15:58

the use of. The digital

16:01

wearable technology used for

16:03

monitoring of three com

16:05

and cardiovascular conditions: hypertension,

16:07

Heart. Failure and a drill

16:09

fibrillation. Clinicians are interested

16:12

in the potential for remote

16:14

patient monitoring and wearable technologies

16:16

to increase the efficiency and

16:19

efficacy of cardiovascular disease management.

16:22

Yet. To date. The. Uptake

16:24

has been limited. An.

16:28

Eight week old male infant

16:30

with in consolable crying and

16:32

weakness A case record of

16:34

the Massachusetts General Hospital by

16:36

Adam Burke with and coauthors.

16:39

An eight week old male incident

16:41

was admitted to the pediatric. I

16:43

see you with irritability. Seven.

16:46

Days earlier, irritability and

16:48

frequent crying developed. One.

16:50

Day before the current presentation, the

16:52

episodes of crying increased in duration

16:55

and the patience grandmother noticed that

16:57

he cried more intensely when the

16:59

right side of his abdomen was

17:01

touched. The patient was

17:03

evaluated at a pediatric primary care

17:06

clinic. The vital signs and physical

17:08

examination were reportedly normal, and a

17:10

diagnosis of discomfort due to gastrointestinal

17:13

gas was considered. After the patient

17:15

returned home, he had a crying

17:18

episode that lasted for multiple hours

17:20

while he was awake. That.

17:22

Night the crying continued and the

17:24

patient became in consolable. He had

17:26

frantic movements of the arms and

17:29

legs and slept only one our.

17:31

The. Patient was brought to the

17:33

emergency department where he remained

17:35

irritable and did not attain

17:37

a com awake state after

17:40

admission to the hospital. Lethargy,

17:42

hypoxia and hypo Tonia rapidly

17:44

developed. Despite. The use

17:46

of a systematic approach. there was

17:48

no obvious cause of irritability on

17:50

the basis of the initial patient,

17:52

his street and the findings on

17:55

physical examination, laboratory testing and imaging.

17:58

infant botulism is

18:01

a disease of the neuromuscular

18:03

junction that fit very well

18:05

with this patient's presentation. He

18:07

had many of the associated

18:09

signs and symptoms, including irritability,

18:11

constipation, features of bulbar palsies,

18:14

a weak cry, ptosis in

18:16

both eyes, and poor feeding,

18:18

lethargy, weakness, and respiratory

18:20

difficulties. Testing

18:22

of a stool specimen for

18:24

botulinum neurotoxin confirmed the diagnosis.

18:27

In further interviewing, the patient's

18:29

family members reported that when

18:32

the infant appeared to have

18:34

abdominal discomfort, honey was

18:36

given to try to soothe him. Asian

18:41

Americans and Racial Justice in

18:43

Medicine, a medicine and

18:45

society article by Michelle Koh

18:47

from the University of California,

18:49

Davis, and co-authors. In

18:52

the past three years, the

18:54

renewed racial justice movement in

18:56

the U.S. has prompted medical

18:58

leaders to take long overdue

19:00

steps toward recognition of racism

19:03

in our profession and institutions.

19:06

Recent developments from the rise

19:08

of anti-Asian violence, including violence

19:10

against healthcare professionals, to the

19:13

recent U.S. Supreme Court ruling

19:15

against affirmative action in Students

19:17

for Fair Admissions, SFFA versus

19:20

Harvard, and SFFA versus University

19:22

of North Carolina have highlighted

19:24

the need to advance discussions

19:27

specifically about the positionality one's

19:29

individual social identities and the

19:31

intersection of those identities and

19:33

statuses with systems of privilege

19:36

and oppression of Asian Americans

19:38

within the medical profession and

19:41

their roles and responsibilities in

19:43

disrupting the racialized hierarchy within

19:45

American medicine. Asian

19:48

Americans account for approximately one-fifth

19:50

of all U.S. physicians, academic

19:53

medical faculty, students, and trainees.

19:56

Asian Americans In the general:

19:58

U.S. Population trace their art

20:00

regions to more than thirty

20:02

four countries, and their socio

20:04

economic status varies more widely

20:06

than that of any other

20:08

racialized group. Asian American

20:11

physicians and trainees in

20:13

conjunction with high representation

20:15

face high levels of

20:17

harassment and discrimination from

20:19

peers, supervisors, staff, and

20:21

patients. The rise in

20:23

anti Asian violence specifically

20:25

targeting health care workers

20:27

and the lack of

20:29

systematic responses represents an

20:31

escalation of pre existing

20:33

trends. Organized. Medicine

20:36

has not offered adequate

20:38

opportunity for Asian Americans

20:40

to acknowledge and heal

20:42

from interpersonal and structural

20:44

racial trauma. Within. The

20:46

Profession Asian Americans are

20:49

the exemplars for diversity

20:52

without inclusion. Mind.

20:55

The Gap. Machine. Learning dataset

20:58

shift and history in the

21:00

age of clinical algorithms. A

21:02

perspective by Andrew Leave from

21:04

Brigham and Women's Hospital and

21:06

David Jones from Harvard Medical

21:09

School, both in Boston. A

21:12

A P Help was one

21:14

of the first computerized diagnostic

21:16

programs created during the mainframe

21:18

era of the Nineteen sixties

21:20

to Nineteen seventies. British.

21:22

Surgeon S. T. De Dum

21:25

Ball and is University of

21:27

Leeds colleagues developed a P

21:29

Help to assist in the

21:31

diagnosis of patience with acute

21:33

abdominal pain. They used a

21:35

mathematical formula that had attracted

21:37

substantial interest in the postwar

21:39

period phase theorem. De. Dum

21:41

Balls team collected data on thousands

21:44

of patients who presented with acute

21:46

abdominal pain. The. researchers used

21:48

date on clinical symptoms such

21:50

as pain severity location and

21:53

quality and physical science like

21:55

pulse and abdominal guarding to

21:57

derive probabilities for the computer

22:00

system. When the resulting computer algorithm

22:02

was tested on roughly 300 patients

22:05

who presented to the general

22:07

infirmary in 1971, the program

22:09

dazzled. According to the team's

22:12

report, AAP help generated the

22:14

correct diagnosis in 91.8% of

22:16

cases, surpassing the performance of

22:21

senior clinicians. Then,

22:23

De Dambal introduced it to

22:25

hospitals outside leads.

22:28

But when his group teamed up

22:30

with researchers at Bispebieg Hospital in

22:32

Copenhagen in 1976 to test the

22:37

system in a fresh clinical

22:39

environment, its overall accuracy plummeted

22:41

to 65%. The problem wasn't

22:46

the system's hardware or software.

22:48

Instead, it was its data.

22:51

The population used to develop AAP

22:53

help differed in critical ways from

22:55

the population in which it was

22:58

subsequently implemented. The

23:00

incongruities meant that the

23:02

conditional probabilities underlying AAP

23:04

help were inaccurate

23:07

for patients in Copenhagen.

23:09

De Dambal's troubled efforts to

23:11

bring his computerized system across

23:14

the North Sea led him

23:16

to a powerful conclusion. Databases

23:19

don't travel. The

23:21

non-transferable nature of the

23:23

leads data prefigured current

23:25

challenges related to dataset

23:27

shift as machine learning

23:30

algorithms spread throughout clinical

23:32

practice. The training

23:34

data used to create AI

23:36

algorithms from early machine learning

23:38

models for diagnosing diabetic retinopathy

23:41

to newer generative AI models

23:43

have a past and

23:45

a specificity. History

23:48

illuminates the persistent challenge of

23:50

dataset shift in medicine and

23:53

offers tools for contextualizing

23:55

data and anticipating and

23:58

mitigating dataset shift. today.

24:03

Transforming population health. ARPA-H's

24:06

new program targeting broken incentives.

24:08

A perspective by Darshak Sangavi

24:10

from the Department of Health

24:13

and Human Services and Dawn

24:15

Alley from George Washington University,

24:18

both in Washington DC. Despite

24:22

spending more per capita on

24:24

health care than any other

24:26

country, the United States lags

24:28

behind other high-income countries on

24:30

crucial health outcomes including life

24:32

expectancy and maternal mortality. In

24:35

addition, disparities based on race,

24:37

ethnicity, and income persist. Although

24:40

nearly half the burden of

24:42

disability and death in the

24:44

United States may be associated

24:47

with modifiable risk factors, misaligned

24:49

economic incentives in the U.S.

24:52

health system lead to an

24:54

emphasis on individually focused interventions

24:57

that respond to acute needs

25:00

rather than community-based

25:02

prevention. There is

25:04

currently no mechanism that provides

25:06

incentives or rewards for improving

25:08

population health in entire communities.

25:10

To address this need, the

25:13

Advanced Research Projects Agency

25:15

for Health, ARPA-H, recently

25:18

announced its first program focused

25:21

on innovation in the area

25:23

of population health. Health care

25:25

rewards to achieve improved outcomes,

25:28

heroes. Authorized in 2022,

25:30

ARPA-H has received

25:33

2.5 billion in funding

25:35

and has invested approximately

25:38

1 billion in various

25:40

moonshot projects. Contracts have

25:42

focused principally on high-tech

25:45

programs such as accelerated

25:47

vaccine development, new

25:49

approaches to regrowing joints in

25:52

people with osteoarthritis, and augmented

25:54

imaging for improving cancer surgery.

25:57

The authors hope that here

26:00

Heroes will demonstrate the value

26:02

and feasibility of

26:04

realigning incentives to

26:06

focus on population-wide

26:08

illness prevention. Heartbeat,

26:13

a perspective by Marsha Glass

26:15

from Tulane University School of

26:17

Medicine, New Orleans. Dr.

26:21

Glass had felt constantly nauseated and

26:23

could feel her body changing as

26:26

it went through the first stages

26:28

of pregnancy. On the

26:30

day of her first pregnancy ultrasound,

26:32

the doctor, friendly and efficient, pulled

26:34

down her drape and applied gel

26:37

to her abdomen. Dr.

26:39

Glass watched on the screen next to her

26:41

as the images came up. She

26:43

waited to hear a heartbeat. But

26:46

instead, her doctor said carefully,

26:49

Let me see if I can get a better

26:51

look with a transvaginal. Something

26:54

wasn't right. Dr.

26:56

Glass was far enough along that the doctor should

26:58

have been able to get a good look. Dr.

27:01

Glass suddenly felt freezing cold. Her

27:04

doctor's response was pitch perfect.

27:07

She sat with Dr. Glass for almost

27:09

an hour. Dr.

27:11

Glass decided that night to shake it all

27:13

off. She took the mesoprostol

27:16

tablets and waited for everything to bleed

27:18

and cramp its way out. The

27:21

pain of all the bits coming out of

27:23

her was sinister. And she

27:25

figured it would be over soon. She

27:27

didn't ask for time off from work. In

27:30

four years of medical school and three

27:32

years of internal medicine residency, she had

27:35

had a total of zero

27:37

discussions about trauma-informed care, breaking

27:40

bad news, resilience training, grief

27:43

support, or personal wellness.

27:45

Instead, she felt pressured to

27:47

push her physical and psychological

27:49

reactions aside and always

27:52

put the job first. At

27:54

some point, this ethos stuck. After

27:57

the weekend, Dr. Glass picked up a

28:00

full panel of consults at her

28:02

busy hospital. She told

28:04

no one what she was going through. One

28:07

of the patients on her list was a woman

28:09

in her thirties like Dr. Glass, but

28:11

who had had a massive seizure while

28:14

awaiting surgery for a brain tumor. The

28:17

patient was in the ICU in their

28:19

large teaching hospital, suddenly unable

28:21

to talk to anyone or respond in

28:23

any way. She was

28:26

also in her third trimester of

28:28

pregnancy. Dr. Glass shrugged

28:30

off the idea that her case might be

28:32

too much for her on her first day

28:34

back. She had spent years

28:37

witnessing other people's trauma and supporting them

28:39

and their families through it. She

28:41

hurried over to the neural ICU, washed her

28:44

hands and quickly slid open the glass door.

28:47

Like all the thousands of ICU

28:49

patients she had seen, the patient

28:51

had wires everywhere, connected to beeping

28:53

monitors. The patient's young

28:55

husband sat nearby, hypervigilant, searching

28:58

her constantly for signs of

29:00

consciousness. Dr. Glass stood

29:02

quietly, taking it all in, maintaining

29:05

her professional composure. But

29:09

suddenly she realized the low beating

29:11

sound wasn't her patient's monitor. It

29:14

was the patient's fetus's heartbeat. Badum,

29:17

badum, badum. Dr.

29:20

Glass stood there paralyzed, utterly

29:22

without words, impotent. Feeling

29:25

dizzy and confused, Dr.

29:27

Glass walked behind the patient's bed and

29:29

pretended to examine the photos near the

29:32

window as she tried to compose herself.

29:35

It all just hit Dr. Glass

29:37

at once, and she was smacked

29:39

with a physical grief so excruciating

29:41

that she wasn't sure she could

29:44

stay upright. But

29:46

she wasn't the patient that day, and

29:48

this wasn't the time to work through

29:50

what had happened to her. So

29:53

she took a deep breath and walked

29:55

back around to The side of

29:57

the patient's bed. In

30:01

our images in Clinical medicine

30:03

a nine year old boy

30:05

who had recently emigrated from

30:07

Brazil presented with a three

30:09

week history of next swelling,

30:11

fevers and weight loss. On

30:13

examination there was fixed tender

30:15

Cervical Lymphadenopathy. History: Pathological

30:18

examination of a biopsy specimen

30:20

of a lymph node in

30:22

the deep left Cervical region

30:24

showed tissue ios in a

30:26

Celia granule, ominous formations and

30:28

conspicuous round structures and clusters

30:30

of yeast forms. A Pc

30:32

Our Ass A of lymph

30:34

node tissue was positive for

30:36

Para Cox C, O These

30:38

Brasilia insists. A diagnosis

30:40

of para cox to the oil my

30:42

closest was made. Treatment. With

30:45

eight, Recognizance was initiated, but was

30:47

later changed to flu console owing

30:49

to adverse side effects. Two

30:52

months after presentation, the patient's

30:54

symptoms had evaded. In

30:57

another image of fifty one year

31:00

old man presented to the emergency

31:02

Department after he had sustained blunt

31:04

force trauma to the face in

31:06

a fight. He received nasal

31:08

packing. One. Hour after

31:10

discharge, he returned with bloody

31:13

tears, blurry vision and I

31:15

pay. On. Physical examination

31:17

blood oozed from the upper

31:19

and lower lack from a

31:21

punk.on both sides and accumulated

31:23

along the margins of the

31:26

lower eyelid of finding known

31:28

as hemo lack Korea see

31:30

the video at any J

31:32

M .org A diagnosis of

31:34

chemo lack Korea resulting from

31:36

retrograde blood flow through the

31:38

nasal lack formal system after

31:40

nasal tampa not for episode

31:42

axis was made. To

31:44

treat the ongoing epa, Sachs's the

31:46

nose was repacked and topical up

31:49

enough for him was applied to

31:51

the left nasal cavity. A half

31:53

hour later, the bloody tears had

31:55

resolve. This.

31:57

Concludes our scenery. Let. us

31:59

know what you think about our podcast. Any

32:03

comments or suggestions may be sent

32:05

to audio at

32:07

nejm.org. Thank

32:10

you for listening.