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By failing to discuss strangulation, we are failing our patients

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It would have taken him six seconds to knock me out.

Shortly thereafter, I might have lost my life.

A month before I finally found the strength to leave an abusive ex-partner, during an argument, he lunged at me with unexpected force and wrapped his hands around my neck. I desperately kicked his chest, terrified, heart racing, believing that these might be my final moments.

My memory of that attack comes in brief flashes: first I sat on the bed, then I suddenly found myself helpless on my back, staring at the silver overhead light that swayed several feet above my face. Feeling his hands around my neck and praying that this wouldn’t be the end of me. I do not wanna die. I don’t want to stop breathing. When he let go, my feet in their little gray socks were still fidgeting in the air.

I later shared the experience with a trauma doctor who listened as I downplayed the attack: “It could have been worse, I wasn’t losing airflow, he wasn’t pushing down…” I remembered what my then…my Partner then said to me: “I would never hurt you. I was just trying to scare you.” The doctor shook her head ruefully.

“No, Chloe. You could have passed out in six seconds.”

It takes between 5 and 10 seconds render a victim unconscious by strangulation. Death can occur within minutes.

Nobody unexpectedly goes for their partner’s throat with good intentions.

The Training Institute on Strangulation Prevention defines strangulation as “an obstruction of the blood vessels and/or airflow in the throat resulting in asphyxiation.” Importantly, it is caused by the external application of physical force versus gagging, an internal airway obstruction.

This definition remained an impersonal fact for me until I experienced it myself.

In a sample of 62 women from a domestic violence advocacy program, 68 percent said they had experienced strangulation in one instance Study 2001. In 93 percent of the cases, the perpetrator lived with the victim. In 78 percent of the cases, the attempted strangulation took place in the victim’s home. In the vast majority of cases, either a husband, boyfriend or fiancé was named as the perpetrator.

The adverse health consequences for victims of non-fatal strangulation in the context of intimate partner violence (IPV) cannot be overstated. Physical consequences include but are not limited to: neurological symptoms, loss of consciousness, blurred vision, difficulty speaking, difficulty swallowing (dysphagia), and shortness of breath. Psychiatric consequences include depression and PTSD.

A 2008 case-control study assessed non-fatal strangulation as a risk factor for homicide in women. It found that women who were victims of attempted or completed homicide were much more likely to have a history of strangulation compared to matched controls who had experienced IPV at any point in their lives. Shockingly, the study found that the Probability of murder increases by 750 percent for victims of domestic violence who have experienced strangulation compared to those who have not.

In other words, a woman whose partner has her hands around her neck is at an inordinately high risk of losing her life.

These data underscore a grim message: Physicians should definitely ask about strangulation when screening for IPV, especially in the ED when there is a remote question about a patient with IPV. And in order for clinicians to consider asking about strangulation, either in the highly acute environment of the emergency department or in the quieter environment of primary care, clinicians must first be educated about strangulation.

Medical education has made tremendous strides in the last few decades. For our knowledge base, we have to deal with significantly more material in 4 to 5 years of studying medicine today than previous generations of doctors. Certainly, some subjects can inadvertently be left behind.

I contend that we cannot afford to lose out on medical education on IPV and strangulation. Even a sentence or two about the risks of non-fatal strangulation would have given me a starting point as a potential victim and student. We owe it to ourselves and our patients to be fully informed about this topic.

We don’t talk about that in medical school. We must. It could literally be the difference between life and death for our patients.

A domestic violence counselor summed up my own experience with the grim statement: “I call it ‘practice killing’. He didn’t kill you in that moment. But he showed that he was ready for it.”

Chloe NL Lee is a medical student.

Photo credit: Shutterstock.com


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How to avoid holiday burnout this Christmas

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Putting yourself first isn’t a bad thing (Image: Getty)

Christmas is meant to be a magical time of family, fun and food.

But for many of us, it can be an incredibly stressful experience that makes us feel like we should always be doing more.

On this week’s episode of the Centre County Report.co.uk podcast dirt dropsMiranda Kane spoke to psychotherapist and author Nancy Collier about holiday burnout — and how to deal with it.

Nancy believes women are prone to burnout because we’ve long been taught the lesson that if you don’t do a job, no one else will.

But Nancy says it’s time to change that narrative.

She said: “This incredibly strong conditioning leads us as women to believe that our job on earth is to take care of other people’s needs… that our value is in making other people happy and in giving other people a positive experience.” Offer.”

But Nancy says it doesn’t make us think about – or know – what we want. Instead, what we are actually taught is that nurturing is in itself a need that must be met.

‘We’re taught that, right?’ says Nancy. “That our nourishment comes from their nourishment. But that’s broken. And that’s why we’re all so weary and exhausted, because we’ve lost touch with what we want and need.’

She adds that we often feel like we have only two choices: we can be selfish or selfless—neither is satisfying.

And if we end up trying too hard to cater to people’s needs, we can be labeled as “controlling.”

“We operate from this tiny sympathy box, which is really challenging,” says Nancy.

Nancy Collier offered advice on how to avoid festive burnout (Image: Nancy Collier)

It’s not hard to understand why so many women feel burnt out at the end of the year — and it can show in many different ways.

Nancy said, “Some women get physically exhausted.

“Just exhaustion where you can’t get out of bed on Saturdays. You’re just bone dry and just can’t do it.

“With other women, they tend to numb it. Maybe it’s Netflix or Chardonnay or Brownies or whatever it is.

“Other women, it’s anger and resentment … there’s a background feeling of, ‘But what about me? What about what I really need and want that isn’t for someone else?”

“I’m a really good daughter for aging parents, I’m a really good partner. I’m a devoted mother, I’m a great employee, I’m all of those things for other people.”

“It’s a loneliness and isolation.

‘We’re really moving away from ourselves. We’re really giving up.’

Knowing when you need your time (Picture: Getty Images)

So how do we start making a change? Nancy shares some tips that could radically transform your celebrations.

Ask for what you need

We must first realize how seldom we really tell the truth and how much we shape and change [w’re doing to be] this perfect person.

“We also need to have some compassion for ourselves.

“And then we start practicing in small steps.”

Nancy says it’s worth letting go of some little things you think you can “risk” elsewhere.

“Like asking, ‘Hey, do you think you could save the wrapping paper?’ or ‘Do you think you could do the wrapping this year?’

“We must make very clear what we have asked for.”

And you don’t have to justify your claims.

“I’d love for women to start being very respectful and kind and just say, ‘I want you to buy half the gifts this year,'” says Nancy. “And then put a point right there, don’t explain it away.

“This is the beginning of stepping into your own shoes. You take the risk, you break an old system.”

“should” becomes “want”

Nancy also says we should think less about what we “should” do and more about what we “want” to do.

Don’t feel like you should do anything (Picture: Getty Images)

Nancy said: ‘[Think about] What vacation do I actually want? Maybe I want it much smaller. Or maybe I want it bigger. Or maybe I want to give different kinds of gifts or celebrate spirituality more than consumerism… Take charge of your personal holiday.”

She suggests that using a mantra can help you realize the fact that your experience matters as much as anyone else’s.

She explains: “It also depends on what you want and need. And that has to start as… a mantra.

“It feels very unnatural at first, and sometimes we have to fake it … but we have to make a habit of it.”

Be authentic

It’s important to show people the real you.

She explains: “The last is [to have] that honesty. How can I go through this holiday to be real?

“And I’m going to take a big risk in trusting that this can be welcomed.

“It’s okay to feel exhausted. It’s okay to be bored. It’s okay if I feel like I’ve done enough. It’s okay to think that’s not really fun.”

It’s okay to take a step back (Picture: Getty Images)

Nancy added that by being more authentic, we can build healthier relationships.

She says, “We get these relationships where we come across as this perfect woman and everyone’s happy, but we feel a little bit lonely and isolated because we’re not really sharing our true experiences.”

She adds, “You’ll find that you feel more connected, you feel full. And you’re really doing your partner and your family and friends a favor by telling them about you.’

Do you have a story to share?

Get in touch via email Centre County [email protected] County Report.co.uk.

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Specialty Pharma’s Next Big Opportunity: It’s Time for Patient Access to Adopt an Open Protocol

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Yishai Knobel, CEO and co-founder of RxWare

In January 2020, the financial conglomerate Visaannouncedit acquired a relatively unknown startup, Plaid, for $5.3 billion. Acquisitions like this are not uncommon, but someone at the US Department of Justice took note of the announcement. Visa had a stranglehold on financial transactions. The Ministry of Justicepostponed to halt takeoverarguing that Plaid “poses a threat to that monopoly: it has developed an innovative new solution that would replace Visa’s online debit services.”

Plaid derives its power not in spite of, but from its invisibility – a visa of power that the government ultimately could not refuse. When a consumer transfers money electronically from one financial platform to another, makes a deposit, or applies for a mortgage, there’s a good chance Plaid is involved. It is the software that enables interoperability between different financial services brokers. It seamlessly stitches together transactions that would otherwise be very complicated. visa at the timeallegedly held around 70 percent of the online direct debit marketShe had every reason to feel threatened. Plaid has discovered a way to charge merchants and consumers less for the convenience of online connectivity.

Ultimately, both parties withdrew from the takeover. Visa’s target purchase price of $5.3 billion looked like a bargain at the timePlaid was valued at approximately $13.4 billion in a Series D funding roundin April 2022.

A similar turning point is now upon us for the specialty pharmaceutical industry. Along the way, specialty pharma patients interact with a number of siled institutions: clinics, specialty pharmacies, copay program providers, patient assistance programs, nurses, etc. Similar to the financial industry, these institutions still exchange patient information via fax machines. Facilitating digital interoperability between these different stakeholders is paramount. So what lessons can be learned from the story of Plaid’s meteoric rise?

To diagnose the problem that specialty pharmaceuticals face, a brief history lesson is in order. The healthcare industry began its first major digital transformation in earnest in the 1990s whenthe large-scale conversion to electronic recordsstarted. The industry’s preference for paper did not disappear overnight. Healthcare systems have been slow to digitize their filing cabinets full of charts and other patient data. The Institute of Medicine initially advocated a switch from paper-based to electronic patient records1992however, only 13 percent of US healthcare facilitieswere foundto have a fully implemented EHR system by 2004.Many are yet to make the transition.

Today sale of specialty drugsaccount for more than half of all drug expenditure. This sector of the healthcare industry has both the incentive – and the financial means – to make the patient experience as seamless as possible. However, in many ways it is more backward than the fintech industry before Plaid. When Plaid effectively forced financial institutions to adopt an open protocol approach to digital interoperability, “every bank took their five-year digitization strategy and whittled it down to a year or two,” said CEO Zach Perretsaid in an interview with Fortune magazine.

In healthcare in general, and in patient services in particular, the transition to an open protocol approach has been slow and uneven. Open protocol, put simply, is a digital language that facilitates electronic transactions between prescribers, pharmacies, patient support providers, data aggregators, insurers, and other stakeholders in the specialty pharmaceutical patient journey. Taking an “open protocol approach” means standardizing the open and shared application programming interfaces (APIs) within an industry or a sub-sector of a larger industry. The widespread adoption of these protocols allows all participants in the environment to expect a well-defined behavior when communicating digitally with each other.

The power of the open protocol approach has been recognized across many industries. Check out Twilio’s example. In 2008, the startup launched its first API to make and receive calls entirely in the cloud. Now, six years after going public, the company is worth billions. The suite of related tools includes platforms for data security, language analysis and customer relationship management.

If the healthtech and pharmatech industries can take this opportunity to standardize their most common digital tasks, the integration of records and transactions between the different parties will be lightning fast compared to today. This is the key lesson that pharmatech and healthtech companies can learn from what Plaid has done for the fintech industry.

If an open protocol approach facilitates convenience, what’s the downside? As in finance, traditional healthcare players tend not to share information very efficiently with their competitors. Interoperability has never been an explicit goal of the industry. However, for patients with specialty pharmaceuticals, interacting with stakeholders across multiple silos is the norm. Typically, these patients require at least one transaction to receive their prescriptions from the prescribing physician, then another with the office to provide their HIPAA, TCPA, and Hub consent, then interact with the Hub regarding their coverage, and then again with a specialty pharmacy regarding their shipments and out-of-pocket payments, then another to handle the co-payment, another with a patient assistance program, another to support compliance, etc. The patient journey is usually long and complicated – not to mention of his own recovery from the illness for which she is being treated.

You may be wondering: can an open protocol be HIPAA compliant? HIPAA does not specifically prohibit the use and sharing of Open Protocol-based software. “Open protocol” does not automatically mean “unsafe” either. While the industry’s reluctance to share back-end software protocols is understandable, there is nothing standing in the way of collaborative problem solving to ensure that all private healthcare data transmitted over open protocols remains secure. On the contrary, an open protocol can easily allow such monitoring of the data passed, much better than fax machines and FTP transmissions. At the moment, this reluctance is making life more complicated for patients. Your patient journey usually requires working with discreet service providers who often use outdated means of communication.

The discussion of how to integrate an open protocol approach into a complicated system governed by HIPAAhas been running for years. Yet many key players in the industry are still at the bottom: moving their primary means of communication from paper to digital.

The time to cross that bridge has passed. As Plaid’s case study makes clear, now is the time for the industry to embrace open protocols.


About Yishai Knobel

Yishai is co-founder and CEO of RxWare. Before HelpAround, Knobel was Head of Mobile at AgaMatrix Diabetes, the manufacturer of the world’s first smartphone blood glucose meter. He also served at Microsoft’s Startup Labs in Cambridge and as an officer in an elite Israeli Army R&D unit.

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When your letter to the editor is rejected or ignored

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Dear Doctor. El Dalati,

I am sorry that we are unable to publish your recent letter to the editor regarding the Chowdhury article of September 16, 2021. The space available for correspondence is very limited and we must use our judgment to present a representative sample of the material received. Many meaningful messages have to be rejected due to lack of space.

The answer from the New England Journal of Medicine (NEJM) seemed simple and straightforward enough on the surface. A closer look, however, highlighted a troubling feature of medical publishing: journals can publish virtually anything they choose, through an ambiguous peer-review process with no governing board to review the quality of the research or the validity of the claims. The only option most people have when they discover a serious error in a published article is to send a letter to the editor, the editor who published a potentially misleading manuscript.

The article highlighted above entitled “Oral versus intravenous antibiotics for endocarditis‘, was published in September 2021 and presented itself as a point-counterpoint discussing the management of endocarditis in patients with substance use disorders. One author wrote an article in favor of intravenous (IV) antibiotic therapy and the other outlined an argument for using partial oral antibiotic treatment. However, both authors excluded relevant literature and indicated a general lack of interest in the patient’s experience. The pro-IV author emphasized keeping the patient hospitalized and did not consider alternative methods to intravenous treatment, although the literature supports that people who inject drugs (PWIDs) can do so successfully complete IV therapy on an outpatient basis at home or at medical recreation facilities. There was no acknowledgment of how the healthcare system discriminates against PWIDs, including Refusal to be admitted to nursing facilities to receive antibiotics. While the author explored the need for an interdisciplinary approach to the management of endocarditis, there was no discussion as to whether the patient had access to a multidisciplinary endocarditis team. There was also no discussion as to why the patient wanted to leave the hospital. An investigation into this could have led to a safe medical solution. While the rebuttal touched on these issues in passing, it focused primarily on the medicinal value of oral versus intravenous antibiotics, rather than addressing how stigma from the healthcare system impacted patient treatment. Ultimately, both opinions placed the provider perspective ahead of the patient perspective without fully considering the available evidence. I set out all of these concerns in my letter, which conforms to the very specific standards required by NEJM, and received the response at the beginning of this article.

Fast forward a year to September 2022, when the American Heart Association (AHA) published a scientific statement entitled Circulation in its journal “Management of infective endocarditis in people who inject drugs.” The document specifically addresses the role of partial oral antibiotic therapy for patients with Staphylococcal aureus endocarditis. More specifically, the authors include a recommendation for the use of linezolid and rifampin to treat methicillin-resistant Staphylococcus aureus (MRSA) endocarditis and attribute this specific treatment to it POET study published by Iversen et al. in 2018. However, no cases of MRSA endocarditis were included in this study. Iversen et al. included patients with endocarditis caused by methicillin-resistant coagulase-negative staphylococci (MRCoNS), and linezolid and rifampin were among the antibiotics used to treat these cases. There is little evidence that using this regimen to treat MRCoNS-related endocarditis can be extrapolated to treating MRSA endocarditis. In addition, although the POET study included 201 patients in the oral therapy arm, only four patients with CoNS endocarditis were treated with linezolid and rifampin. In summary, the POET study was incorrectly cited in the most recent scientific statement and advocated the use of an antibiotic combination for the treatment of MRSA endocarditis, which was actually only examined in 4 patients with CoNS endocarditis.

In addition, recent literature has demonstrated this Staphylococcus aureus can account for up to 75 percent of cases of endocarditis associated with injecting drug use (IDU-IE), other studies have suggested so Streptococci and enterococci can be seen in about 40 percent of patients with IDU-IE. Notably, only 21.8 percent of the patients examined in POET had Staphylococcus aureus as the etiologic agent. In contrast, 73.3 percent of patients in POET had endocarditis caused by either streptococci or enterococci. However, the scientific explanation makes no comment on the role of partial oral antibiotic treatment for these pathogens, despite the larger sample size examined.

Again I wrote a letter to the editor of the AHA and the principal authors of the statement. Instead of a polite declination for publication, this time I heard nothing. In both cases, these major medical publications chose to ignore reasonable criticism of their work. In the first case, NEJM continued to promote the biases that PWIDs face through the healthcare system. In the second case, the AHA miscited existing literature and consequently made incorrect recommendations. Both NEJM and Circulation are among the most widely read medical journals in the world, and their articles have the potential to influence clinical decision-making for a large number of providers. As an infectious disease physician primarily caring for patients with substance use disorders and endocarditis, I witness daily the adverse effects of poor quality literature and guidelines that miscite existing evidence. be clear I am a proponent of oral antibiotic therapy for all patients with endocarditis and have published articles to support it. However, without the opportunity for appropriate discourse, these journals make it difficult for providers who actually care about patients to provide quality patient-centred care.

Perhaps we can start an evidence-based discourse outside the walls of these powerful institutions to transform the conversations about patient care and most importantly, put the right information in the hands of medical providers.

Sami El Dalati is a specialist in infectious diseases.

Photo credit: Shutterstock.com


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