Syphilis and Private Equity
Two different topics today—even if the latter is basically the former, just in a suit.
QUESTION: What Happens When Private Equity Buys Hospitals?
Source: Kannan, S., Bruch, J. D., Zubizarreta, J. R., Stevens, J., & Song, Z. (2025). Hospital Staffing and Patient Outcomes After Private Equity Acquisition. Annals of internal medicine, 178(11), 1529–1538. [pubmed]
Private equity (PE) continues to buy hospitals across the US. When PE takes over, their priority is simple: cut costs to extract profit. For EM and ICU clinicians, this study finally gives rigorous national data on what those cuts actually do to staffing and patient outcomes.
Short version: PE hospitals staff less, spend less, transfer more, and their ED patients die more.
Key Findings
1. Massive staffing cuts in the most staffing-sensitive areas
After acquisition, PE hospitals slashed salary expenditures by:
18 percent in the ED
16 percent in the ICU
Hospital-wide reductions included:
11.6 percent fewer full-time employees
16.6 percent reduction in total salary spending
Control hospitals (non-PE) increased staffing over the same period.
This is the playbook: maximize investor profit by shrinking the labor force that actually delivers care.
2. ED mortality goes up
After PE acquisition:
ED mortality increased by 13.4 percent from the pre-acquisition baseline.
Equivalent to 7 additional deaths per 10,000 ED visits.
Meanwhile, mortality in control hospitals improved over the same timeframe.
The kicker: No increase in patient acuity, demographics, or comorbidities.
This is not sicker patients. This is worse resourcing and staffing.
3. More patients get shipped out
Transfers to other acute care hospitals rose:
ED transfers: up 4.2 percent
ICU transfers: up 10.6 percent
And the transferred patients were, unsurprisingly, sicker. They were older, with more comorbidities, more intubations, more dialysis, more blood products etc.
When your ICU staffing is chopped and bed availability decreases, sending critically ill patients elsewhere becomes necessary.
4. ICU length of stay falls
ICU LOS dropped by 0.2 days (a 4.8 percent reduction).
Shorter LOS sounds good until you see it paired with staffing cuts and higher transfer rates. This is not efficiency. It’s capacity strain pushing early or external disposition.
The bottom line:
This study confirms what clinicians have been feeling for years. Private equity ownership is a structural extraction model that strips staff, reduces clinical capacity, and leads to higher ED mortality.
Now, Let’s talk Syphilis.
Check out this new JAMA review article on Syphilis. A good read for the EM physician.
Source: Chevalier, F. J., Bacon, O., Johnson, K. A., & Cohen, S. E. (2025). Syphilis: A Review. JAMA, 334(21), 1927–1940. [pubmed]
Some highlights below:
1. Epidemiology
Syphilis is very much back. It shows up across all demographics—keep it in your differential.
US cases up 61 percent from 2019 to 2023, including 112 percent in women. Congenital syphilis doubled.
MSM still account for a big proportion of male primary and secondary cases, but infections in women are driving congenital spikes.
Transmission: direct contact with infectious lesions; vertical spread any trimester. Up to 40 percent fetal demise if untreated.
2. Clinical Stages
Primary (early)
Painless chancre, often unnoticed.
Regional lymph nodes.
Secondary
Diffuse maculopapular rash especially on palms and soles in 70 to 90 percent.
Condyloma lata.
Fever, malaise, lymphadenopathy.
Can see: hepatitis (cholestatic pattern), nephrotic presentations.
Latent
No symptoms. Diagnosed only by serology.
Early latent = acquired within past 12 months; late latent = >12 months.
Neurosyphilis (any stage)
Meningitis, uveitis, cranial nerve palsies, hearing loss, stroke presentations.
Ocular or otic disease can be treated without LP unless other neuro findings exist.
3. Diagnostic Testing: RPR / VDRL / Treponemal Tests
Nontreponemal tests: RPR & VDRL
These detect antibodies to lipoidal antigens released during tissue damage.
Key points:
Reactive 1 to 2 weeks after chancre appears.
Peak sensitivity in secondary syphilis; can fall in late disease.
Titers are quantitative (1:4, 1:8, 1:32).
A higher number = more active infection. The titer is the highest dilution that which the sample is still reactive. More syphilis=More dilutions.
Use for disease activity and response to treatment.
Fourfold change (two dilutions) is clinically meaningful (e.g., 1:64 → 1:16).
Treponemal tests: TP-EIA, TPPA, FTA-ABS
Detect antibodies specific to T. pallidum.
Stay positive for life in almost everyone.
NOT useful for treatment monitoring or distinguishing new vs old infection.
Testing Algorithms: “Reverse Sequence” is more common these days (and performed at my institution).
Adapted from Figure 3 in Chevalier et al. 2025
Reverse Screening Algorithm.
Key Interpretations
History of syphilis diagnoses, treatments, titers, and physical examination is needed to differentiate between previously treated and untreated syphilis and for accurate staging and treatment.
Treponemal positive + RPR positive → active or previously treated syphilis; look at prior titers to determine new vs old infection
Treponemal positive + RPR nonreactive → prior treated infection, very early primary, late latent
4. Treatment
First-line for essentially everyone: Benzathine Penicillin G
Primary, secondary, early latent → 2.4 million units IM x 1
Late latent or unknown duration → 2.4 million units IM weekly x 3
Neuro / ocular / otic syphilis → Aqueous crystalline penicillin G IV q4h or continuous infusion for 10 to 14 days
Alternatives (nonpregnant only)…[but also penicillin shortages]
Doxycycline 100 mg PO BID × 14 days (early) or 28 days (late)
Ceftriaxone 1 g IV/IM daily × 10–14 days
Scenario: Treponemal test positive on routine STI panel; patient has no symptoms. What stage do you treat?
Treponemal positive + RPR positive → treat as late latent unless clinical or history data indicate infection <1 year prior. Again, if no documented prior tests and you cannot establish the duration → treat as late latent/unknown duration (3 weekly shots or 28 days of doxycycline).
Treponemal positive + RPR negative → Could be previously treated syphilis, late latent, very early infection, or false-positive TT
Next step is history + repeat RPR in 1 to 2 weeks if early infection is possible.
If no known prior syphilis history and no recent negative serology…You must assume late latent → BPG weekly × 3 or doxy for 28 days
If recent (< 1 year) syphilis testing is negative, then treat as early latent → BPG x 1 or doxy for 14 days
This review is only a smidge of the info in this review article. It goes into a lot more depth about clinical management, including with patients with serologic nonresponse, neurosyphilis, and congenital syphilis. Here is the link again for your convenience!
Cheers,
Dillon
