How Might we Build an Equitable Future? Design Justice, a Counternarrative to Dominant Approaches in Medical Education.

PHENOMENON: Marginalized individuals in medicine face many structural inequities which can have enduring consequences on their progress. Therefore, inequity must be addressed by dismantling underlying unjust policies, environments, and curricula. However, once these injustices have been taken apart, how do we build more just systems from the rubble? Many current strategies to address this question have foundational values of urgency, solutionism, and top-down leadership. APPROACH: This paper explores a counternarrative: Design Justice. As a set of guiding principles, Design Justice centers the experiences and perspectives of marginalized individuals and communities. These principles include mutual accountability and transparency, co-ownership, and community-led outcomes, and honoring local, traditional, Indigenous knowledge. FINDINGS: Rooted in critical scholarship and critical design, Design Justice recognizes the interconnectedness of various forms of marginalization and works to critically examine power dynamics that exist in every design process. These co-created principles act as practical guardrails, directing progress toward justice. INSIGHTS: This paper begins with an overview of Design Justice's history in critical scholarship and critical design, providing foundational background knowledge for medical educators, scholars, and leaders in key concepts of justice and design. We explore how the Design Justice principles were developed and have been applied across sectors, highlighting its applications, including education applications. Finally, we raise critical questions about medical education prompted by Design Justice.

Dealing with large-scale supply lines when introducing new regimens.

PURPOSE OF REVIEW: As programs plan the introduction of a new antiretroviral as part of a regimen for HIV treatment, supply chain considerations need to be taken into account. The key to success is balancing the introduction of a new regimen with the phasing out of an old regimen in a manner that does not result in either a shortage or an excess supply of either product while ensuring that patients continue receiving their medications. This necessitates that country programs, donors, and procurement entities possess an appreciation of the global antiretroviral market and understand the dynamics that the manufacturing of new antiretrovirals will have on the transition. RECENT FINDINGS: Supply, demand, and financial considerations affect the capacity of the supply chain to facilitate a successful antiretroviral transition. Although this commentary draws on United States Agency for International Development experiences under the President's Emergency Plan for AIDS Relief from earlier antiretroviral treatment shifts, the approaches are applicable to other institutions and to future transitions. Three approaches were employed: ensuring the engagement of all key stakeholders in transition planning and execution, including clinicians, advocacy groups, supply chain professionals, ministry, and donors; conducting and updating regularly the national quantification and supply plans for all regimens; and introducing antiretroviral products into programs from regional warehouses based on firm orders. SUMMARY: Extensive planning and accounting for supply chain factors is essential to ensuring a smooth transition to a new regimen and to enable the global antiretroviral market to respond adequately.

Internal thoracic artery grafts for the entire heart at a mean of 12 years.

BACKGROUND: There is consensus today that the long-term results of bypassing the left anterior descending artery with an internal thoracic artery (ITA) graft are superior to those of a saphenous vein graft. Our hypothesis for this study was that three-vessel revascularization with only ITA grafts would also give excellent results. METHODS: Using our previously described techniques to enhance the length of ITA grafts by skeletonization and high mediastinal mobilization, we were able to perform tension-free, three-vessel revascularization using only ITA grafts in 125 (83%) of a consecutive series of 150 patients with three-vessel occlusive coronary disease. We followed 100% of these 125 exclusive ITA graft patients (average of 3.9 anastomoses per patient) to their time of death (59; 47.2%) or current living status (66; 52.8%). RESULTS: Combined intraoperative graft flows averaged 225 mL/min. Of the 125 patients in this study (average age, 63.5 years), 121 (96.8%) lived beyond 40 days. Of these 121 patients, 55 (45%) died at a mean of 7 years postoperatively and 66 (55%) are still living at a mean of 12.1 years. Of these 121 patients, 112 (93%) had angina at baseline. Of these 112, 92 (85%) were angina free at a mean of 9.1 years postoperatively. Freedom from infarction was 100% at 5 years and 97% at 10 years. Freedom from reintervention was 90% at a mean of 9.8 years. CONCLUSIONS: Use of ITA grafts for three-vessel coronary revascularization provides excellent results and is both practical and appropriate for many patients.

Liquefaction - caused ground failure during the February 4, 1976, Guatemala earthquake

Seismically induced liquefaction (the transformation of granular materials to a liquefied state due to increased pore - water pressure) caused ground failures in the February 4, 1976, Guatemala earthquake. Failures occurred predominantly in areas of recent deposition such as deltas and stream channels, and around some small ponds and wet areas in the highlands. Water - laid saturated pumiceous sand deposits were highly susceptible to liquefaction. Lateral - spreading landslides with more than 9.6 m horizontal displacement and a meter of subsidence occurred on slopes as gentle as 3.2 percent on the youngest part of the delta in Lake Amatitlan (14 km south of Guatemala City) due to liquefaction of a shallow (1 m deep) layer of pumice sand and gravel. Associated ground cracks and sand boils formed as much as several hundred meters from the lake shore and were generally oriented parallel to the lake shore or to river banks. Lateral spreading across these cracks destroyed some well - built reinforced brick houses that appeared to have suffered no direct shaking damage. At the Rio panajachel delta on lake Atitlan, 65 km west of Guatemala City, cracking and associated subsidence due to lateral spreading caused moderate damage along the lake shore. In the swampy lower Motagua River Valley, bank collapses were common and ground cracks and sand boils were noted as far as 100 meters from river banks. Liquefaction effects were also reported from Lake Izabal, Guatemala; from Puerto Cortés, Omoa, and the San Pedro Sula area in Honduras; and from Lake Ilopango, El Salvador. The ground failures at Omoa affected houses built on sand dunes. There were ground cracks and damage to shoreline structures at a delta in Lake Ilopango about 240 km from the fault rupture (AU)