Podcasts about brigham women

Listen to ASCO's Journal of Clinical Oncology article, "Scotch and Pizza” by Dr. Paul Jansson, who is an Emergency and Critical Care Physician at the Brigham and Women's Hospital. The article is followed by an interview with Jansson and host Dr. Lidia Schapira. Dr Jansson share his perspective as a critical care physician and how one question can serve many purposes all at once. TRANSCRIPT Narrator: Scotch and Pizza, by Paul S. Jansson, MD, MS  “Would you tell me about J?,” I asked. What was she like? I made eye contact with one of her sons, who looked back at me, somewhat puzzled.  “You mean her illness?” he asked, quizzically. Immediately, I worried that I had lost the family, all sitting shoulder-to-shoulder in the cloistered conference room. No, I responded, can you tell me about J before the illness? What was she like? J came to the intensive care unit (ICU) in the early hours of the morning, only a few hours after making her way from the emergency department to the oncology ward. Admitted with a diagnosis of failure to thrive and dehydration, her CT scans made clear the extent of her cancer's spread. Over the last few months, she had shown remarkable improvement with each serial round of palliative chemotherapy, beating the cancer back and holding it at bay, one round at a time, but it had now spread seemingly everywhere, despite medication, despite molecular testing and targeted treatment, and despite her tenacity. Overnight, she became more and more confused, her electrolytes deranged from days of poor oral intake, now admitted to an unfamiliar environment. Her lungs, bearing the brunt of her disease, had further suffered over the week as she aspirated. As her breathing became more labored, a nasal cannula progressed to positive pressure ventilation. By early morning, she was unresponsive, and the early morning phone call to her family had led to a panicked reversal of her Do Not Resuscitate/Do Not Intubate order. And so she came to me, mechanically ventilated, blood pressure supported by an armada of vasopressors, her body failing, which brought us back to that small room. We didn't have the chance to get to know her before she got sick. I looked around the room, meeting their eyes. We only know her like this. What was she like before all of this? In my first months of intern year in the ICU, I had seen this technique used in family meetings. Initially, I adopted it as a matter of routine, copying the methods I had seen used by senior residents and attending physicians. As I came into my own as a physician, developing my own style, I began to see its value. It opened my eyes beyond the Comprehensive Flowsheet and the Results Review spreadsheet that scrolled into infinity. It showed me why I was doing what I was doing and who I was doing it for. “She loved scotch and pizza.” The room was silent, and we looked around. Her oldest daughter, a nurse herself by training, had broken the silence. Together, she clarified. I know it's a weird combination, she said, but she loved scotch and pizza. It must have been something from college. We all glanced around for a moment, making bewildered eye contact, before the entire room broke into laughter.  “She made a mean coleslaw,” volunteered another brother. “And a great hot dog.” “She was a fantastic mother,” reported the next. “She was my soul.” Thus far, her husband had sat quietly in the corner, the face of stoicism. He was a retired physician, a self-described man of few words. A moment of silence as we all looked toward him, across a conference table, barren except for half-used boxes of tissues, surrounded by children on both sides. She was the best thing that could ever happen tome, he continued. Another long pause, until the words spilled forth. When I would leave her to go to work, I felt incomplete. When I returned home, I felt an immense sense of being at peace. When I was with her, I was calm. She made me whole. She was my soul. We sat in silence, the tears welling in my eyes, welling in all our eyes. She was everything that I was not. Kind. Patient. A fantastic cook. We laughed. Then, another long pause as he gathered his thoughts. And now I know what I need to do.  In his stoicism, his silence, his love, he told us what we all needed to hear. As deeply as her loss would rend his soul, there was nothing more that I could do—that anyone could do—to bring back the woman who gave such life, and further treatment would only prolong her suffering. She died that afternoon, surrounded by her family, finally at peace. A chef for the neighborhood. A mother. A friend. A wife. A soulmate. And a lover of scotch and pizza. Dr. Lidia Schapira: Hello, and welcome to JCO's Cancer Stories: The Art of Oncology, which features essays and personal reflections from authors exploring their experience in the field of oncology. I am your host, Dr. Lidia Schapira, Professor of Medicine at Stanford University. Today we're joined by Dr. Paul Jansson, an Emergency and Critical Care Physician at the Brigham and Women's Hospital and a member of the Harvard Medical School faculty in Boston. In this episode, we'll be discussing his Art of Oncology article, “Scotch and Pizza.”  At the time of this recording, our guest has no disclosures.  Paul, welcome to our podcast, and thank you for joining us. Dr. Paul Jansson: Well, thank you. It's a pleasure to be here with you.  Dr. Lidia Schapira: So first, let me ask a little bit about this essay and about your intended audience. This is a beautiful meditation, I would say, on a family meeting that takes place in the context of somebody with advanced cancer. What led you to write it? What led you to decide to share it, mostly with an oncology readership.  Dr. Paul Jansson: This is a piece that I think wrote itself and it was something that came to me as I couldn't sleep in the hospital call room. I was on call the day after this family meeting and lying in the polyester sheets and listening to the air conditioning rumble, I couldn't sleep. And it just came to me all of a sudden that I had to write it, and I had to write it in this exact way. I was working an overnight shift in the intensive care unit, and at 5:00 a.m. sat down at the computer, and this just all poured out, basically, in the method in which it appears today. I think there were very minor grammatical changes, but it really just came out. It was a story that I feel that I needed to tell. Dr. Lidia Schapira: So why do you think that this meeting and this family impacted you so deeply? I mean, there's a huge emotional connection here, and I introduced you as a critical care doctor, but you sound like a palliative care doctor to me here, sitting with a patient, basically just asking one question and then watching this loving scene unfold. And it struck me that it moved you. Did I get that right? Dr. Paul Jansson: I think you're absolutely right. Brigham and Women's Hospital is the inpatient hospital for the Dana-Farber Cancer Institute in Boston. And so, by its nature, intensive care medicine at Brigham Women's is a lot of oncology care. And so you are absolutely right in that these conversations are very routine for us. But there was something about this family, the connection, that just stuck with me. I think with many of these conversations, it's relatively routine. It's certainly not routine for the families. But as an intensive care specialist, this is a relatively routine conversation. And to get this level of detail and humor and eulogizing on the part of her husband is really quite unusual and was very profound to me, sitting in that moment stuck with me. Dr. Lidia Schapira: I was struck, Paul, by the fact that you asked one question, and immediately they're talking about her in past tense. She was. She loved. She did. Did that strike you in the moment as sort of showing that they actually knew exactly what was happening? Dr. Paul Jansson: Yeah. I think there is a moment in these conversations where the family understands what is happening and what needs to happen. And it's, I think, best if the family gets there on their own and works really well in that goals of care setting. And I think the love that they were expressing for her and the admiration and the appreciation, that was really profound to me. Dr. Lidia Schapira: One of the reasons why I love your piece is that it takes us from what we are now teaching as a goals of care discussion or a family meeting. And it brings us back more to the art of medicine, the joy of medicine, and the intimacy of these moments. This family was totally ready to accept you in their little circle and start to share things that were really very deep for them. Tell us a little bit about what it was like to be in the room with her husband, who's a retired physician, her daughter, who's a nurse, and the other family members who seem to be sort of helping one another to eulogize, as you said, in the most loving way, their almost gone mother and wife.  Dr. Paul Jansson: I am not an oncologist, and I do not have the pleasure of these longitudinal relationships that many oncologists have developed over months and years and decades for some of these patient physician relationships. And so as an intensive care physician, it's a very quick and powerful bond that we are really forced to make with the families. And so I actually never talked with this woman. She was intubated on the night shift and was brought to the intensive care unit, intubated and sedated, and I never got to meet with her. I never got to sit in the office with her and discuss her hopes and her fears and her journey and all of those things that are really more the domain of the oncologist. But in our specialty, I have to really develop this relationship very quickly, where people will trust a life and death discussion with someone whom they've only known for 15 or 20 minutes in some circumstances.  And so it really is a privilege and an honor to be granted this degree of trust and disclosure and openness about who the patient is and was in the life before I met her. And so sitting in that room, it's always very awkward to start. It's a converted conference room with some boxes in the corners, and there's only, as I wrote in the piece, a box of tissues on the table. And so very quickly, we have to go from, “Paul Jansson, I'm the intensive care doctor,” to these discussions of life and death, and how to negotiate this very fraught transition, I think is really the point that I think you're getting at in the art of medicine. And how do we go from 0 to not 0 to 60, but 0 to 100 with these really life and death decisions? And that's very difficult. Dr. Lidia Schapira: In a flash. Dr. Paul Jansson: Exactly. And far sooner than anyone wanted, I think, if any of these families. Everything is so sudden. I even wrote about this in the piece. She had a DNR, DNI in place, and they got the call at 03:00 a.m., 04:00 a.m. however early it was in the morning. And so you can really tell at that moment they were not expecting any of this. They were not ready for any of this. But unfortunately, we were in that circumstance. Dr. Lidia Schapira: You know, Paul, when I hear you speak, I remember a friend of mine who is an actor and teaches doctors communication skills, and she basically says that doctors and actors have 90 seconds to develop rapport with their audience. And basically in your field or in the emergency room, this actually plays out every day. You're absolutely right, we in oncology often build these relationships, craft these relationships over time. And we probably know the names of all the people in the room and we would know what they do. But you're just kind of walking into the scene. Now that you've had a little time to reflect, do you know what it was that led them to reverse that DNR/DNI decision? Was it panic? Was it not knowing? I think as a reader, I'm struck with the fact that they had a plan, they reversed the plan, and then they quickly just came right back to what the original plan was. Maybe they hadn't expected this to happen so quickly.  Dr. Paul Jansson: I think it's more common than we think it is, or perhaps it should be. And I think every family has a different reason for why this is. And I think for some families it's just they needed more time. And so this was for them a call that was at 04:00 a.m. and they were at home and they weren't with her. And many families just want to be there for the end. I think for some families there's a bit of denial, “Okay, sure theoretically she said do not resuscitate, do not intubate, but we're not at that point yet.” So I think for some families there's that. And for some families, it just takes more time than they're expecting. And that's not unusual in our world, as I think everyone there saw what was happening to her and what we had essentially done to her, intubating her and putting her on all the pressors and doing all these things that were somewhat against her wishes at the end of life, so we had done these things to her. And it just took a little bit more time to realize this was not what she would want and also to give them time to be there. But I think every family has a different motivation, and it's hard to say how you would react with that phone call at 02:00 a.m. It's never what you think it would be. Dr. Lidia Schapira: Yeah, it's the old president's commercial, right? “Who do you want to take this call at 03:00 a.m. when there's an emergency?” But when it's this personal, I can understand it. I wonder if you can tell us a little bit how it struck you when the family sort of very organically again reached the conclusion and her husband articulated, “I know what I need to do.” What did that feel like for you as the critical care doctor who is quickly trying to lead this family to perhaps what you would consider the most dignified or humane, compassionate denouement for them? Dr. Paul Jansson: I think the first feeling for me was relief and just knowing that the decision that they had made for her was the right decision. And it wasn't a decision that I needed to make and talk them into or negotiate with them. It was the decision that they knew was right. And I think the other thing that stuck with me so much was the love and humor that they displayed in this. And I think many, many families would cry and be sad, but how many families would sit there and make a joke about this strange food combination that she has from college and how she loves to cook from the neighborhood, and all of these just flashes of humanity and humor that I was not expecting from the family. And then in that moment, we went very suddenly from humor to this profound grief and appreciation and reflection on who she was as a woman and her personality and how well that complemented her husband. And it was just this emotional whirlwind where we go from bad news to laughing together to crying together, all in the span of what was probably 10 to 15 minutes. That really stuck with me.  Dr. Lidia Schapira: Paul, humor me here. I don't often get to interview a critical care doctor, especially on a public medium like a podcast. So speak a little bit to me and through me to our listeners. What can oncologists do to have a good rapport with the critical care docs and nurses who are actually looking after their patients? Sometimes there are all of these moments of anticipated tension, and I wonder if you can just give us a little instruction. Dr. Paul Jansson: That's a wonderful question. I think honesty and truthfulness is always incredibly important, and taking that relationship that you've built with the family over time and bringing us into that circle of trust and letting us give our perspective. And I am not the oncologist, as I said before, I do not know all of the data and all of these things that is well within your specialty, but I know that the specialty of critical care and what is and isn't achievable, and to have the oncologist team have those developed relationships and ideally some knowledge of what the patient would want and blend that with what I'm able to deliver as an intensivist. I think that the trust together and the working together for what the patient wishes and what we can actually deliver for the patient, that's really what is most meaningful in collaborating with the oncologists.  Dr. Lidia Schapira: Yeah, I say a little prayer for that. I know that I've walked into an ICU and hoped very much that my colleagues in critical care didn't see me as an oncologist in denial, somebody who wanted to be very much a sort of present for their patient. You probably have some of those stories. Dr. Paul Jansson: There's an interesting tension. Yeah, I think you exactly pointed that out, that there's this tendency to think that the oncologist is always going to offer yet another round of chemotherapy or some clinical trial that can be offered. And on the intensive care side of the fence, we're sitting and counting on our fingers and sometimes toes, how many organ systems are not working, and how we negotiate that hopefulness and optimism with who is in front of us and what we've been dealing with over the last hours and days and weeks. And I think the tension is probably more theoretical. Every time I talk to the oncologist, they're quite realistic. I think more than perhaps is in my mind. So I think there's more of a theoretical disconnect than there is in real life.  Dr. Lidia Schapira: Well, I hope our professions can coexist and work collaboratively for the sake of our patients. Talk to me a little bit about how you might use this very intimate story in your teaching, since you're part of a teaching faculty. Dr. Paul Jansson: Well, shortly after the preprint was posted, I actually received a letter by email from a faculty member at a teaching hospital affiliated with a cancer hospital, saying that he was going to start using this piece in his discussions about how to have goals of care discussions with his oncology fellows. And I think there are two different purposes of the question that I asked: “Tell me about her.” And I think they serve two distinct purposes. And the first is this humanizing and making a human connection that we talked about. It allows you to make some of that connection that you haven't had the ability to do over the last weeks and months and years. You can really see that patient as an individual person. And I think the second role that this question helps with, particularly for the intensivist, is it really helps to expectation set. And so for many people, the answer to this question will be, “Oh, well, she was running a mile a day, and she loved her pottery and she loved whatever it was that is her passion.” And for some people, the answer may be, “Well, she was having a really hard time lately, and she was spending more time in the hospital than out of the hospital.” And so that can also really help from the intensivist side of things with prognosticating and really being realistic about what we can offer at this moment. That's why I really like this question “Tell me about her,” because it really helps with everything all at once. It lets us make that human connection. It lets us gather some of the clinical information that we need, and it reminds us of why we're doing this job in the first place, and that's to take care of the patient.  Dr. Lidia Schapira: Yeah. My very last question now is this: It occurs to me that you have a lot of these moments, and as you say, you cry, you share in the human aspect of all this. And you're right there, you have a front row seat to this grief and this loss. Do you and your colleagues have any protocol or ritual to help one another and support one another and at least acknowledge the emotional load of your work?  Dr. Paul Jansson: That's an excellent question. I think from the intensivist side of things, when we have the conversation this way, it's actually a blessing to us. I think there's a lot of moral injury, particularly in critical care, and doing things to the patient that I alluded to before, that the patient wouldn't necessarily want, or unnecessarily prolonging life at the risk of suffering. And I think when patients and families realize that this is not what their loved one would want, I think for many of us, this is a relief, and it's a blessing and an honor to take care of patients at the end of life. When it goes like this, we're actually very happy. It's really a pleasure more than a cross to bear. Dr. Lidia Schapira: Yeah. Thank you so much for sharing your thoughts, your humor, your humanism, your incredible common sense, and I'm so glad that the piece just poured out and that you chose to put it in front of an oncology readership. So from our listeners, thank you so much.   And for those of you who are listening, thank you for listening to JCO's Cancer Stories, the Art of Oncology. Until next time, when we'll find you again. Don't forget to give us a rating or review, and be sure to subscribe so you never miss an episode. You can find all of the ASCO shows at asco.org/podcasts.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.   Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Like, share and subscribe so you never miss an episode and leave a rating or review.   Guest Bio: Dr. Paul Jansson is an Emergency and Critical Care Physician at the Brigham and Women's Hospital and a member of the Harvard Medical School faculty in Boston.

Bruce A. Koplan, MD, MPH, FHRS, Brigham Women's Hospital is joined by Matthew R. Reynolds, MD, MS, FHRS, Lahey Hospital & Medical Center, and Esseim Sharma, MD, University Hospitals Cleveland to discuss integrating patient-specific cardiac implantable electronic device (CIED)-detected atrial fibrillation (AF) burden with measures of health care cost and utilization allows for an accurate assessment of the AF-related impact on health care use.  https://www.hrsonline.org/education/TheLead https://www.jacc.org/doi/full/10.1016/j.jacep.2023.12.011 Host Disclosure(s): B. Koplan: Speaking/Consulting Honoraria: GE Healthcare Contributor Disclosure(s): M. Reynolds: Speaking, Teaching, and Consulting: Medtronic, Edwards Lifesciences, Philips, iRhythm Technologies, Membership on Advisory Committees: Affera, Inc. E. Sharma: Nothing to disclose. This episode has .25 ACE credits associated with it. If you want credit for listening to this episode, please visit the episode page on HRS365     https://www.heartrhythm365.org/URL/TheLeadEpisode61

Spinal cord disorders are common and frequently disabling. Despite advances in our ability to diagnose and treat patients with spinal cord disease, many are underserved by their health care systems due to gaps in knowledge and care. In this episode, Lyell K. Jones Jr, MD, FAAN, speaks with Shamik Bhattacharyya, MD, FAAN, who served as the guest editor of the Continuum® February 2024 Spinal Cord Disorders issue. They provide a preview of the issue, which publishes on February 8, 2024. Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Bhattacharyya is the Anne M. Finucane Distinguished Chair in Neurology and chief of the division of spinal cord disorders at Brigham Women's Hospital and an assistant professor of neurology at Harvard Medical School in Boston, Massachusetts. Additional Resources Continuum website: ContinuumJournal.com Subscribe to Continuum: shop.lww.com/Continuum American Academy of Neurology website: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Guest: @shamik_b Full transcript available here Transcript  Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by visiting the link in the show notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the show notes. Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum: Lifelong Learning in Neurology. Today I'm interviewing Dr. Shamik Bhattacharyya, who recently served as Continuum's Guest Editor for our latest issue, on spinal cord disorders. Dr. Bhattacharyya is a neurologist at Brigham and Women's Hospital, where he serves as Chief of the Division of Spinal Cord Disorders and as an Assistant Professor of Neurology at Harvard Medical School, in Boston, Massachusetts. Dr.  Bhattacharyya, it's great to see you - welcome. Thank you for joining us today. Dr Bhattacharyya: Good to see you, Dr. Jones. I look forward to speaking. Dr Jones: So, for our listeners who are new to Continuum, Continuum is a journal dedicated to helping clinicians deliver the highest neurologic care to their patients. We do so with high-quality clinical reviews and content in our journal and in our audio format. For our long-time listeners to Continuum Audio, you'll notice a few different things with our latest issue and our latest author interviews. For many years, Continuum Audio has been a great way to learn about Continuum articles. Starting with this issue on spinal cord disorders, I'm happy to announce that our Continuum Audio interviews will now be available to all on your favorite open podcast platforms. We'll hear some exciting new content in our interviews, and we're also going to introduce interviews with our guest editors, like Dr Bhattacharyya, who are really indispensable in putting these issues together. In this issue, specifically, Dr. Bhattacharyya is full of extremely helpful clinical descriptions and treatment strategies for patients with spinal cord disorders. As the editor, you got really a broad view of the whole range of spinal cord disease. What was the most surprising thing when you were reviewing these articles? Dr Bhattacharyya: I think as a field, neurology - the knowledge base in neurology - grows bigger and bigger and bigger each day and in fields hard to keep up and how to integrate all of it together, right? I think all of us deal with it. And that's the hope of Continuum, is that you can provide these periodic refreshers. I got refreshed myself! Even though I see the patients day in and day out, when you actually read about the advances, for example, in hereditary spastic paraplegias, or the nuances of how neoplasms in the spinal cord are now classified- you say “wow”, I didn't actually know that. The knowledge spreads and grows, and I think that's the beauty of being an editor of some of these issues - is that you get to learn yourself and maybe perhaps even apply them in the clinical situation. Dr Jones: You and I are both educators. And that's, I think, one of the secret joys of teaching is that you end up learning a lot, sometimes from the people you're teaching, right? I guess maybe that's not a surprise - that you learn something by reading it. I guess it was probably pretty nice, huh? Dr Bhattacharyya: It was very good. I think the authors all come from different geographic backgrounds, even from different training backgrounds. In spinal cord disorders, there are trials in some aspects, but in other aspects it's really opinion-based practice, right? So, it was good to also see how other institutions do it. And I imagine it's the same for readers when they see how they do it at their institution and also get a viewpoint of how it's done at other places. That's the valuable perspective piece for putting together a different of authors and see how people do it at different places. Dr Jones: Always nice to learn from others. And speaking of learning - for our clinicians who are listening to our interview today, Shamik, tell us a little bit about the basics of how spinal cord disorders present. I know as an educator, sometimes for, especially junior learners, it's a little mysterious and I'm not really sure why that is, but what are some of the basic clinical tenets of how spinal cord disorders present? Dr Bhattacharyya: I'm glad you brought this up, because in some ways, spinal cord is the orphan child of neurology, right? I think for most neurology trainees, the nervous system stops at the brainstem and then progresses again at the nerves. The spinal cord is really just viewed as this conduit of tracts up and down, and that's all it does is a big set of wires, which is not true, right? A lot of primary neurological processing happens at the level of the spinal cord, and it really is a continuation of the central nervous system. And I hope, with this issue, people get a sense of that. For spinal cord disorders (also called myelopathy; the name goes, synonymously, hand in hand), I think one of the principal functions of the spinal cord is balance. A lot of the program - the neural programming of balance on postural reflexes are hard wired into the spinal cord. I think one of the key aspects of spinal cord disorders is imbalance. I think that people should think of this as a core feature of myelopathy. If you take an example for cervical spondylotic disease, people think, is it going to be off your hands? Well, I think most patients with cervical spondylotic myelopathy actually complain of gait imbalance as one of the early features of the disease. So, imbalance, bilateral weakness, and/or bilateral numbness, tingling, paresthesia - those aspects are suggestive of spinal cord disorder. Bowel and bladder dysfunction can be, but it's not universally true. Now, there's some specific symptoms that I think are especially suggestive of spinal cord disorders I think that are kind of fun to ask about, and if true, can help you localize. One is the Lhermitte sign; you ask people to flex their neck and say, like, “Do you feel sharp, shooting thing, like, down your hands or your back?” In your legs? If true, you have something, right? That's a spinal cord disorder. The other sign that I think is clinically helpful is weakness on one leg and numbness on the other, like Brown-Séquard syndrome or hemicord syndrome. If you find that to be true - and you often see that with multiple sclerosis lesions or other traumatic lesions - that is a spinal cord disorder. I think those clues can come out in history and on exam, and can help you localize it better. Dr Jones: It's nice to know those specific features - in other words, those things that, when you do see or hear them, really should make us think about spinal cord disorders, right? Again, they might not be the most common way they present, but it's good to have those in your pocket, right? Dr Bhattacharyya: Right. Dr Jones: You mentioned this - spinal cord pathology occupies kind of an interesting place in the neurological world, right? There really aren't “myelopathists,” but you direct a division on spinal cord disorders, which is - I think is pretty uncommon. Tell us a little about that. How does that work at your institution? Dr Bhattacharyya: Maybe I can start with the history of this, right - of how this actually came about. I was graduating as a fellow and entering as a faculty in our neurology department. Initially, my interest was in autoimmune neurological disorder - it still is in autoimmune neurological disorders. And yet, when they saw patients who came in for myelitis and turned out they didn't have an inflammatory myelopathy, there really was no home for them, right? - it's a strange space. And that includes even for garden-variety, cervical spondylotic disease that's causing myelopathy - there is no good neurology home for those patients. After the first year of seeing patients, I felt that we need to do better for that. That's why we ended up opening the spinal cord disorders clinic, which was actually the only neurology-based one in our system. There are plenty run by physiatry, surgery, pain management, and other services. But the only neurology one in our system focused specifically on neurologic management of patients with any type of spinal cord pathology. Dr Jones: That's a distinctive way that it came about at your institution and in your own career. It sounds like this does need to be a team effort. Who are the other disciplines or specialists who need to be involved in the care of these patients? Dr Bhattacharyya:  Our spinal cord clinic itself is a part of the comprehensive spine center in our hospital. In that center are pain management doctors, physiatry, as well as different spine specialties, including orthopedics and neurosurgeons and interventional radiologists. So, it's kind of a multidisciplinary group effort to take care of these patients. Dr Jones: I know it'll vary according to the problem with the spinal cord, right? There's dozens or hundreds of different diseases that can affect the spinal cord. So, treatments are different for different diseases, right? But what do you see, therapeutically, as being some of the next big things on the horizon for patients with spinal cord disease? Dr Bhattacharyya: I think one of the common, unifying aspects is pain from spinal cord injury. Especially if there's interruption in the spinothalamic tracts, the pain can be a very severe thing that ranges all the way from neuromyelitis optica, the tonic spasms, to spinal cord infarcts, chronic sequelae of pain, to trauma (spinal cord trauma) - pain is such a big aspect. And our both interventional and oral neuropathic pain medicines don't do a good job with it. I think there's a wave of new medications that are in trials for neuropathic pain and I'm hopeful that they will be helpful and that they will improve pain control and quality of life for our patients. The medication approaches to pain also come with side effects that all of the medicines have. Some of our patients are on high doses of multiple medicines and have cognitive impairment, right? I think that was also the motivation behind our getting a specific section in this issue on symptomatic management of spinal cord injury. Because I think no matter where you are in the spectrum of spinal cord disorders, whether you're a vascular doctor or a family doctor, you will be prescribing gabapentin and baclofen, right - as for helping the patient, and it's good to know how to do it. The other aspect that I'm really hopeful about are sort of second-generation prosthetic devices. These are some of the electrostimulation devices where there's intelligence built into the device that detects you moving your leg and then artificially stimulates a peroneal nerve. This is much better than foot braces, for example, for foot drops. And there are now multiple companies who make these devices, and for some of our patients who have had spinal cord disorders and had difficulty walking or tripping, these have actually made a big difference. I think prosthetic and electric stimulation also has potential of helping a broad range of patients with spinal cord disorders. Dr Jones: And I'm glad you mentioned that article on the symptomatic management of the problems with spinal cord disease, regardless of the cause. And it's a wonderful article that will encourage our listeners to seek out. To go back to the pain, this is something that - many of us who care for patients with spinal cord problems - we encounter is this. And I think it's underrecognized (the pain complications of spinal cord disease). Medications on the horizon - what about devices and neuromodulation? This is another thing I get asked about a lot. Dr Bhattacharyya: Exactly. I think the - for example, spinal cord stimulators for pain management - I think it's been controversial in the sense of who are the best people for it. The history of neuromodulation in spinal pain in some senses has been unfortunate because it was first approved for so-called “failed back syndrome,” right? And the name is terrible. The patient population is heterogeneous. And it has come to a point where it was unclear who it was helping and what the right indications were. I think for neuropathic pain and, in particular, for spinal cord injury pain, I think there is now a renewed push to study neuromodulation, both implantable devices and external devices, to see if those aspects can help. I think they're part of the new wave of things. I think the question patients often ask me is, “Can you regrow my spinal cord?” - right? “Is there something on the horizon yet?” As far as I know, right at this moment, there is not, that's clinically applicable, but perhaps in the future that might be true. But I think, short of regrowing the spinal cord, we can help function and help pain in meaningful ways. Dr Jones: We'll be hopeful about cell therapies and other regenerative therapies down the road. I don't think it's in our immediate future, but we maintain hope. You know, I know this is an area that, again - spinal cord problems are common, spine disease is common - but it does kind of fall between the cracks clinically. If there were one point, Dr Bhattacharyya, that you would want to make to our listeners about the one thing not to miss, or the thing that you most commonly see being missed in the clinical evaluation and/or care of these patients, what would that one thing be? Dr Bhattacharyya: I think the time to clinical evolution of myelopathy probably has the biggest value in determining the cause of it. I think this was beautifully brought out by the article by Dr. Pardo, where he talks about an integrative approach to myelopathy, and in contrast to prior conceptions of whether it's inflammatory based on your CSF cell count or your MRI features, it's actually based on time - time from onset of symptom to nadir of symptom. Is it a few hours, is it days, is it months, right? And having that diagnostic framework is, I think - I go back to it time and time again - is key in trying to figure out, because none of the measures we use, both on imaging or CSF or laboratories, are very sensitive or specific, and actually do not outperform just categorizing by time alone, right? So, I think the one take-home message is, if you have sudden, rapid-onset myelopathy that evolves over minutes, it's probably a vascular process. Even if you find ten cells in the CSF, it's still vascular, right? If it's something that evolves over days, maybe 7, 8, 9 days, and then you find diffusion restriction in the spinal cord on imaging, it's probably still an inflammatory process rather than a sudden spinal cord infarct, right? So, I think that the time aspect cannot be ignored and should play a central role in decision making. Dr Jones: That's very helpful. And I think maybe the corollary to that is - there are chronic spinal cord disorders, right? And I think clinicians, especially if you're not familiar with spinal cord disease, it's terrifying, right? As soon as you start to think, “Wow, this patient's telling me a story and I'm worried this could be a spinal cord problem - should I send them to the emergency department?” - right? They have some bladder dysfunction; they have some gait disorder. But if it has been going on for years, the emergency department is probably not the best place to evaluate that, is it? Dr Bhattacharyya: I'm glad you mentioned it because we see that in the emergency room, right? Someone clearly has a myelopathy; you asked him how long it's going on – it going for months or even years sometimes, right? And it was first noticed and sent out. So, yes - there are multiple causes of chronic myelopathies. They range all the way from structural causes, where you can have things like, for instance, webs, of arachnoid webs, that cause slow progressive myelopathies, to vascular malformations of myelopathies, to nutritional causes (even that can cause a slow, progressive myelopathy), Not to speak of infections; I think we often think of infections as causing fast myelopathies, but especially with HTLV-1-associated myelopathy, the usual clinical progression is slow and progressive. I think across all categories of disease, there are instances of slow, progressive myelopathies that really require thoughtful workup but doesn't require an emergency workup. Dr Jones: Yeah, it's good to know that not every spinal cord problem is an emergency. I think it does terrify clinicians, right? I mean, this is the broadband connection between the brain and the body, and it's fragile, and it's unforgiving, and it's every command sent to the body - every piece of information sent back to the brain, all traveling through a billion neurons with a maximum diameter slightly larger than a dime, right? I think that's why it creates consternation. But I imagine it's also - on the clinical side - it's probably in part challenging and in part rewarding to care for these patients. When you think about what's most rewarding about the care of patients with spinal cord disorders, what comes to mind for you? Dr Bhattacharyya: I think, a couple of aspects. And just thinking back to my last clinic - I put it on Fridays, just because I get the most joy out of this clinic, right? The first is that there's no single piece of test that gives you the answer totally, right? It's usually about putting the history together, the labs, the imaging, and talking about it together, right? And I think it's that integrated piece that, as clinicians, I think that brings us joy; it's that figuring something out, that's more than saying, “Is there diffusion restriction or not on the brain MRI?” – right? The second piece that I think is helpful is that, that patients really want to learn, and for spinal cord disorders in particular, there's easy anatomic things that you can point to patients and say, like, “This is why you are weak in the arm and maybe numb in the leg, and that's causing your problem, and this is what we're going to do about it.” And I think, the ability to communicate that with the patient through images is, I think, unique in the sense that patients understand it - that this is the connection and there's something wrong here and that's why I'm having these symptoms. I think those are aspects of spinal cord disorders that I think are really neat. I will say that I also hope that, for our trainees, right, - I think their comfort with imaging stops at the brainstem, right? The moment it gets below the spine, whether looking at foraminal narrowing or canal stenosis, it's about, “Do they have a T2-hyperintense lesion or not?” And beyond that, people are hesitant. I hope that if this issue can give a different categories of spinal cord disorders, our trainees also become a little bit more facile with different aspects of spinal pathology. Dr Jones: I think a lot of neurologists are drawn to our field because of the problem-solving nature, right? Which is what you have to do before you start helping the patient. And you clearly have a lot of enthusiasm for this - I mean, it's contagious, right? There aren't a lot of myelopathists right now, but maybe after listening to your interview, Dr Bhattacharyya, reading your issue in Continuum, maybe you've created some myelopathists. Dr Bhattacharyya: And just remind, there's an AAN spine section that exists in the American Academy of Neurology, and it's very small and can use more members. Certainly, you're welcome to join. Dr Jones: Well, that's a great plug and, Dr Bhattacharyya, once again, I want to thank you for joining us and thank you for such a thorough, fascinating, engaging discussion on spinal cord disorders. Thank you for guest editing a really phenomenally well-done issue that I think is going to be really informative to our readers and our listeners. Again, we've been speaking with Dr Shamik Bhattacharyya, Guest Editor for Continuum's most recent issue, on spinal cord disease. Please check it out, and thank you to our listeners for joining today. Dr. Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, please consider subscribing to the journal. There's a link in the episode notes. We'd also appreciate you following the podcast and rating or reviewing it. Thank you for listening to Continuum Audio.

In this episode we address the recent media focus on the pros and cons of popular weight loss drugs with guest expert Dr. Pichamol Jirapinyo from Brigham & Women's Hospital. As a gastroenterologist who specializes in bariatric endoscopy and works closely with patients struggling with obesity, Dr. Jirapinyo shares her experience with treating her patients with weight loss medications such as semaglutide. We discuss your most pressing questions such as How much weight should patients realistically expect to lose? What are these medications actually doing to our digestive system? What GI side effects should patients be aware of and when to see a doctor?  Dr. Jirapinyo also offers some tips and guidance for patients considering these weight loss medications. This episode is brought to you in collaboration with the American College of Gastroenterology's Patient Care Committee.

The 16:9 PODCAST IS SPONSORED BY SCREENFEED – DIGITAL SIGNAGE CONTENT Lifers in this industry have been watching the slow but steady evolution and maturity of electronic paper products. and are now seeing them get to a state that they start to make sense for certain display applications, while also looking good enough to satisfy marketers. Taiwan-based E Ink is by a large margin the best known company developing and marketing this technology. While the big volume is in simple black and white displays for e-readers and electronic shelf labels, E Ink has been steadily improving its capabilities with color. There are now premium e-paper displays that arguably look as good as what comes off a conventional four-color printing press. And there are also now larger format single and multi-color displays that won't get anywhere near matching a specific Pantone color, but can do the job of adding green to a parking sign, to better indicate availability of spaces. E-paper products are particularly attractive for some applications these days because they nicely address concerns about sustainability and energy usage. A lot of information signs that get printed and shipped to site can get replaced by e-paper versions that are updated over networks, and use a fraction of the power of more conventional public information displays. In this episode, I have a great update chat with Tim O'Malley, or Tim O as he says he's most known. He leads commercial activities for E Ink in the US market. Subscribe from wherever you pick up new podcasts. TRANSCRIPT Tim, thanks for joining me. In the context of digital signage, what would you see as the main applications for e-paper displays, E Ink displays? Tim O'Malley: Yeah, great question. So, the e-paper display has two main characteristics that we leverage into those applications. The first is that it's paper-like and it's reflective. It's not creating light, it's reflecting the light around it, and it's very low power; it does not use any power when the image is not changing. We really want to look at applications that have been using paper traditionally, and improve that experience, create new functionality, and create more sustainability instead of replacing that paper all the time but enabling it to change. So, a big one for us is in retail applications, whether that's shelf tags on the shelves next to the product or even some of the slightly larger ones that are indicating sales and special promotions about the product.  Right, so the ESL market. Tim O'Malley: Yes, the ESL market. In many cases, you'll go into a store, and you'll see they all look like paper. But they're not, they're actually E Ink enabled shelf tags. And in that sense, there are a lot of installed signs, over 900 million tags installed in the world, and most people don't even know they're seeing it. Similarly, most of the out-of-home signs that are installed on street corners and bus stations are actually paper. All of the attention, of course, goes to the digital ones that you can update and show the latest movie posters, but there's still a lot of paper out there and if we can bring more sustainability but also run on renewable power and the ability to update it remotely, that's an improvement. So, those are the types of applications.  If you set aside ESLs and digital fact tags, that sort of thing, and then the e-reader market, what would commercial displays represent in the overall business for E Ink. I would imagine it's still pretty small.  Tim O'Malley: It's relatively smaller, that's correct. Our two big applications are the ones that you identified. That means to me of course, that's our growth opportunity, that's a big area that we can help the world, but also grow the company. As we introduce our new color platforms, we have a color that has high saturation and looks like a 4 pass printing press color, and we have color that's perhaps more muted, but it's faster and easier to use and has wider temperature.  We're coming out with a range of products that can go into those different configurations and be more appropriate for larger installations of digital signage. Yeah, I remember, God! It was probably like 13 years ago, going to Computeex in Taiwan and seeing one of the first E Ink color posters. It was like a 32-inch poster or something like that, and I thought that's pretty cool, but it had a color filter, so the colors were quite muted and over the years, those color filters have gotten a lot better, and as you mentioned, you have E Ink products that look like 4 pass color printing.  Tim O'Malley: Right, the color filter approach does have physics limitations, the lights pass through the color filter, and so you do lose some. We still take that approach, and that's still great for some installations like a lower lift in terms of scalability in order to make a display like that…  And more cost, I would imagine.  Tim O'Malley: There's extra process stuff, so it's the same. The material difference for us was taking those colors, those particles of cyan, magenta, yellow or red, green blue, and moving them into the electronic ink material so that we could move away from adding this filter on top, and that's where if you print on paper, you get the full saturation. If we use the same particles and move them, then we get full saturation. There was a material challenge in 2013, we hadn't solved it yet. But some of the stuff that we've shown in the last couple of years, and certainly this year in the Society of Information Display Conference, people would sit in front of it and just stare at it for 10 minutes, and then they would say, “How do you do that? It's pretty good.”  Although I haven't seen it in person, it looks like a very rich, detailed, fully saturated color.  Tim O'Malley: It does. We need to get you to see one in person. We can probably send something that you could look at and send back. Oh! Do I have to send it back? Damnit.  So, what is the status of that thing? Is it still what you're showing at SIT and things like that, or is it a commercially available product now? Tim O'Malley: So, in April this year, we announced that the product will be commercially available to purchase early next year. So at this point, it's getting partners and downstream ecosystems on board to be able to support that. So that should basically say the technical risk is in a reasonable place, and it's more about scaling and configuration than it is about solving any technical problems.  So, we started with black and white, as you noticed, so we added red, so it was black, white, red. We added yellow, so then it was black, white, red, and yellow, and now this gets into full color. So it's been a progression for us over the last decade, and that progression has given us the tools and confidence to say the platform has come together in a very reliable way. Would that be something in fixed sizes, or would it be like custom manufacturing according to whatever the end user needs?  Tim O'Malley: Yeah. So that gets into the business model and how we approach it. The right way to think about it is that most of what we make is a meter wide and a kilometer long, so we make it by a role process. Then it gets cut down to the appropriate size. However, we're all familiar with the mother glass and the gen fabs that go through on this TFT. So there are efficiencies by different sizes, and that's where you get this 16:9 cut. So, we are typically selling sheets of this that someone else downstream from us can cut to size. But then they're still limited by efficient cuts of glass, or we're making modules ourselves, buying in TFTs where again we look at the efficiency of the cuts of glass. So technically any size is possible, practically most people coalesce around standard sizes. Okay. So it would be the same kind of sizing range that you might find for a flat-panel LCD display? Tim O'Malley: Yes! I guess what I'm angling towards is trying to get an understanding of this premium full-color e-paper display. If it was a 55-inch e-pap er display reflective display versus a 55-inch QLED or OLED display, what would be the cost difference? Would they be comparable, or would you be paying a lot more because the volumes are smaller?  Tim O'Malley: So we try to characterize the cost into total cost of ownership.  Yeah, I understand, it's a salesy thing to do, but I get it. Tim O'Malley:. Yeah. So straight up, It's typically more upfront, but the installation costs are typically much less. So a lot of our installations are running off solar panels. So, there is no digging up of the concrete or running a power line in order to supply it. You put a pole on the ground, you put a solar panel on top, and it works. So that's where even on the installation side, just the cost of the display itself isn't the only factor, and then if we're using 1% of the energy over the lifetime of the display, or if it's renewable, practically zero because it's not drawing energy then we want to be able to factor that in as well. That's why I try to characterize it as looking at the total cost of ownership because we do want to factor in installation and renewal.  Fair enough. It just becomes a sticker shock issue if you're just selling completely on MSRP or something.  Tim O'Malley: And I also said at the outset that we're looking at paper primarily as our way to improve things, and it turns out that paper's kind of cheap. So yeah, the people who are used to paper pricing will get a sticker shock as well, but the value is there. We think it makes a big difference. That's an education project for us. I was thinking more of this premium fully saturated color, E Ink displays being indoor products, but you're saying they could go for digital out-of-home applications. Tim O'Malley: Right now, the highest saturation color is primarily indoor. So again, that's part of our progress to continue adding the capability to do outdoor activities. In the outdoor signs, there are both low and high temperatures and a little bit of the rugged UV side of things. But UV is not that bad, as you can add filters. Low temperature is relatively easy because heating is small and easy to put in. But cooling is a pain and so making sure that we get the high-temperature right, which we're working on and is very close. It will unlock even more locations for us outside. We do have other products, like we've announced Spectra Six, which is the highest saturation and mostly indoor. Kaleido 3 Outdoor, which is the color filter we talked about, is our other product that was announced in April, and that really is giving us the temperature range for the outdoors that does get into match the configuration of the application.  What's the refresh rate on that? If it's a transit schedule and it's showing that the next bus is in three minutes when it goes to two minutes, is it pretty snappy, or does the image get a little wobbly for a few milliseconds? Tim O'Malley: A little wobbly, interesting choice of words.  To use the kid's term spazzes out for a few milliseconds. I've certainly seen that in demos of e-paper displays.  Tim O'Malley: Sure. But I'll take a little wobbly over spazzed out. So the Kaleido 3 Outdoors is built on our black and white platform, which switches very fast. We only have to move white or black particles up or down. So, that's typically a second, let's say. Maybe up to five seconds depending on temperature and other factors. So, it's pretty quick.  The higher saturated sets that we talked about, that's more like 15 seconds to update, and obviously, if you're standing in front of it, 15 seconds is longer enough to notice. So again, we still talk about fitting the configuration to the application. It can be faster, or it can be up to 10 or 15 seconds.  I'm perhaps weird, but I think it's actually interesting in a way of attracting viewers in certain respects when it's going through this change, because you're looking at it going thinking, what the hell's going on there, and then you see what turns into and it's almost like you want to see that happen again.  Tim O'Malley: Yeah. So, you've got a lot of experience in the industry, and you know that motion attracts attention. So there certainly is an element to it, you can use that motion, and in some cases we've tried to add that into the retail application where not just showing that static, say, price of the product, but sparkling a little bit or highlighting a little bit in order to draw somebody's attention as they're walking by in order to attract them to that product. So that is something that can be done, and it's an advantage of moving from paper to a display but still keeping five-year life on the coin cell battery instead of having to connect it to power.  How important was going to color filters for your transit or municipal displays?  Was that something that the end user said, “We like this, but we need to show a no parking sign or whatever with a red filter on it?” Tim O'Malley: Yeah, it was important feedback from the market and consumers, whether that's a public transportation subway line where you want to be able to show each of the line colors with red, green, blue, et cetera, appropriately, or the bus lines often have colors associated with them as well, or red means no parking, is a common thing. Red is used to indicate something of special importance. That was definitely based on the feedback.  That's where we started with the color filter because that was the integration and that was the easier technical challenge and then moved to built-in particles in order to make the color more saturated over time. Is that where you're at now with the, I think you said, Kaleido 3 or something like that?  Tim O'Malley: The Kaleido platform is the color filter platform, and then Spectra is our higher saturation, has traditionally mostly been for retail platform, right? And with the reaching of full color, we're looking to expand that into broader markets. Is there still R&D work going on to introduce video?  I saw low frame rate E Ink displayed at Touch Taiwan about four or five years ago and thought, that's interesting, but it's got a long way to go before that's commercially viable. Tim O'Malley: Yeah, so there's a couple of things there. Recently we showed, again at that same conference in LA, a display running a video. I think it was around 15 frames per second just to showcase that it was possible to have a display running a video and that was using a color filter on the display to do it.  In general, however, the main advantage of replacing paper with an e-paper display is the low power when the image is not changing. So most of the applications that make sense aren't using video because they want low power savings. Like I mentioned, the shelf tags are five to seven years on a pair of coin cells. You could shorten that to three months if you did video on the coin cells. But why would you?  So if someone wanted to try and do video, it would lose some of the key benefits of low power. It could technically be done, but that's probably not the best fit for the technology stream that we've been focused on, and the application we are focused on.  It turns out there's a really good solution in the world for video. As you mentioned, QLED or OLED. So that's a fine choice for that application and for paper replacement, and for things like that, we're developing a differentiated approach. So you can go down that path with R&D, but it's not a core focus, and you stay in your lane, so to speak? Tim O'Malley: That's a great rephrasing. Little shorter. That was good. You're hired.  I was in Europe a couple of weeks ago for a conference, a digital signage conference, and Europe's very different from North America in a whole bunch of ways, but particularly when it comes to the mindset and the requirements around energy conservation and sustainability.  When I was asked, while I was over there, “What's the mindset in North America?” And I would say they're starting to talk about it, but it's nothing like it is over here. I know your company talks a lot about energy savings and sustainability. Is it more of a discussion in other parts of the world than perhaps in North America?  Tim O'Malley: Yes, absolutely. I agree with your impression of Europe. There was a regulation passed in Germany, and I think one also in France, limiting the amount of time that a digital display for non-public information, so an advertising display can be operated during the day. So I think it's six hours.  Primarily that regulation is intended to save energy. My general observation from looking at the retail market where we were working in shelf tags, it started in Europe. They were maybe leading the thoughts on the benefits that you can get with low power displays, particularly on labor savings because the labor situation in Europe is a little bit different than in Asia and North America. But the trend to use e-paper displays in retail migrated from Europe, then to Asia, and from Asia over to North America. You might have seen earlier this year Walmart announced they were adopting it. I expect the same thing to happen with this type of focus on sustainability and energy usage, and signage. We will see that Europe will lead, and then eventually, as the configurations are more mature and the benefits are clearer, it'll start to migrate around the world. So I do expect that the stuff that you saw at that conference will be a trend.  Is the mindset around being socially responsible and environmentally responsible, or is it more calculated that this is going to save us money, or is it simply they're doing it because regulations are forcing our hand? Tim O'Malley: I expect that when it turns into a trend, which I think it will be all of the above. I mentioned that the initial push to put shelf tags in retail was primarily for labor savings, and it was primarily in Europe. But now, if you look at the recent interview that the Walmart CFO did, there's a return on investment by making these changes; we can update prices easier, we can compete online, can do supply management, and it helps us with logistics. Also, we still have the labor savings, and it looks better.  When the configurations start to mature and come online, it'll still be about sustainability, but there'll be other aspects that are beneficial as well. We can use it for communicating with the public during emergency situations. That will also lend to the trend. Right now, it's a lot about sustainability and energy savings. I think as it gets better, more and more attributes will start to be recognized and feed the trend.  I'm curious again about mass transport. I've seen and written about a number of pilots and initial deployments of e-paper displays as real-time transit schedule information signs at bus stops, and so on. I'm curious whether you see those turn into full deployments or, for the most part, they are still early-stage pilots? Tim O'Malley: Most installations we've been working with today are city by city, shall we say? Each city is typically doing a pilot before moving to a larger installation. So we're in the process of that earlier stage. In some cases, there are signs hanging from handles in subway cars in China. That's an installation.  Late stage pilot is maybe a reasonable answer, but also it's part of the process of getting it through these stages of government bureaucracy approval, figuring out how they want to make infrastructure investment, and validating that these different applications and new cases make sense. So bus stations, bus signs, and bus shelters are a strong category for us, but it's still early days.  Yeah. Is there any mass transport system globally that has fully deployed?  Tim O'Malley: There's not a fully deployed global system that I'm aware of, but there's a number of, especially cities, that are interested in what could be done with the right configurations, and this is where we are getting to a full-color product is also helpful to those installations. Instead of talking about it being limited to black, white, and red, it can do everything. Let's figure out how we adapt that in a way that makes sense. So it turns the conversation from talking about potential limitations to talking about potential solutions.  Yeah, I think Sydney, Australia, and transport for London and the UK have both done pretty substantial pilots, right?  Tim O'Malley: Yes. Very impressive.  There you go. I haven't lost all my marbles yet.  Tim O'Malley: You have been in the industry for a while. You must follow it.  Yeah, that's what I get up in the morning and do. What about the medical market? I think that's an area that's really got a lot of opportunity in big healthcare institutions for information displays, like outside of patient rooms, at the nursing stations, on and on, and I know on your website that's talked about. I'm curious, what stage of adoption is that? I suspect early. Tim O'Malley: It's the earliest stage, a fine description. We identified that opportunity and started working towards it. It's a little bit ahead in Asia. Right at the time when Covid was starting, it turned out not to be a great strategic moment to really be focusing on healthcare. The worldwide healthcare hospital industry started to focus on something else at that time, and it has taken a little bit of a reset for us to engage in those conversations.  Nevertheless, whether it's an information board in the patient room where it's displaying key statistics that are relevant to the patient, such as their doctor's name or their schedule for the day. And we've done a pilot with Brigham Women's Hospital in Boston, where there's positive feedback on that type of board in the room. It's nice in the sense that it's not giving off light at night, it's not like keeping you awake as if your TV showing the same information, and it's unobtrusive if you decide you did want to watch TV, it just sits on the side of the room with the information if and when you want it. Yeah, I suspect, though, it's an incredibly long sales cycle.  Tim O'Malley: Everyone tells me healthcare is extremely lucrative and extremely hard to break into. We're working on the break into it at the moment.  Yeah, I don't think there's any deal that you do in a couple of meetings.  Tim O'Malley: But there's real value there. We think it's a potential solution. We are starting to see the conversations change now that the world is getting back to more normalcy.  We might be seeing a little bit of adoption on the inventory management front first, where you take the same shelf tags that are being used in retail and bring them into those stock rooms in the hospitals and connect that to the inventory management system. So if something starts to run low, you push a button on the tag, or maybe it's even automated by a scale, you can have a significant savings by managing your inventory better. So we're seeing in the back room, maybe not seen by all the patients, that might be a pretty good application. So, we're still exploring ways to add value there. Yeah, I chatted with a company called Freshwater Digital in Michigan and their digital signage solutions company, but they also do ESLs, and they were describing how they were seeing some activity around things like e-paper fact tags in research labs for the cages for and trying different medications on lab rats or monkeys or whatever, and I thought that's interesting.  Tim O'Malley: Exactly. I've also heard and seen some of that. It's leveraging that combination of this cloud communication infrastructure and the fact that you don't need to connect the tag to power. It can sit there, it can be in communication, it can update when it needs to, but it can also go for a year plus on a coin cell. That's enabling us to go into places that might have been more difficult for traditional solutions.  There's been a lot of noise the last couple of years coming out of CES with, I think it was a BMW that had E Ink, some sort of an E Ink overlay that would make the car changeable. Is that like trade show bling or something that's real and one day might be out there?  Tim O'Malley: Absolutely real, and one day might be out there, but also a little trade show bling. So working with BMW has been awesome. They're great designers, and taking a technical mindset and engineering and matching it up with some design thinking created what was really a wow concept car. And so, the goal was to create a concept car to show what's possible, and what was shown at CES this year was a car covered in E Ink material that could switch between 32 different colors and show different patterns and different segments and create a lot of wow factor.  Ideally, over time we'll start to work this into some simpler parts of the car, maybe inside the car. We also have some integration with the front lights and with the headlights and then work towards that full-color car covering; the exciting thing about that is it's moving away from what we think of as digital information into something that's more like personalization. Now, you can change your clothes every day or from one venue to another depending on whether you're at a barbecue or a formal dinner, and you could change your car too in order to reflect either location. Hyper personalization seems to be a trend. That was part of what BMW was leaning into we have a sustainable solution, but also a digital solution for personalization.  What about building materials? I think it was near San Diego airport, or at the airport, they had a parking garage that was collided in another E Ink material. Tim O'Malley: Yeah, that was based on an old battleship design from World War II called Dazzle, where it would break up the lines. So you didn't have quite an outline on the horizon, and they wanted to bring that same feeling into the rental car center, because they have the naval base out there. And we did have a whole bunch of signs on the outside of the building that could change and pre-programmed patterns. You said it did that. Is that no longer active? Tim O'Malley:  Oh, it's still there. Architecture is not a primary focus, so if we start from that first principle of looking at places where people use paper and then bringing added benefit. Paper isn't widely used on the outside of buildings as a material. You might have some signs or some advertisements, and we did talk about that.  Architecture, there's a lot of it. It might be interesting over time, but it wouldn't be my first step from where we're today.  That's also a very long sales cycle.  Tim O'Malley: It's also a very long sales cycle, yes, and it's not traditionally an easy way to bring a high-tech material in. You really need to make the configuration simple to bring onto the site for people to install and use.  This flew by. Just one last question. What can we expect to see what kind of announcements can you hint out over the next six to twelve months for E Ink? Tim O'Malley: We're heavily leaning into applications that are color, and we want to bring full color into all of our product lines. So the thing that I would be looking for is more announcements by customers and partners that have E Ink displays that are upgrading them to those full color solutions and in many cases I think that will help us unlock another round of excitement as consumers become aware of what can be possible, and hopefully, smart cities start to look at that and adopt it as well.  So full color in more places is those type of announcements that I'm looking for. Alright. Thank you very much for spending some time with me. 

Episode 142: Tirzepatide IIFuture Dr. Beuca explains that tirzepatide has shown benefits in patients with obesity that go beyond its weight-reducing effects and includes reduction of blood pressure, among others. Dr. Arreaza explains that Wegovy (semaglutide approved for weight loss) is also very beneficial for weight loss and explains.  Written by Maria Beuca, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Maria: Hello everyone, today is June 2, 2023, and we want to re-visit our discussion about the drug Tirzepatide from our May 19th, 2022. A little re-cap for those of you who don't know, tirzepatide, also known by the brand name Mounjaro, is a drug that was approved by the FDA a year ago for the treatment of type 2 Diabetes. It is similar to the drug Semaglutide, also known by the brand name Ozempic which many of you may be more familiar with, thanks to the Kardashians and other celebrities making it popular as a “weight loss” drug. Arreaza: The brand name for weight semaglutide is Wegovy.Maria: Both of these drugs are injected once a week and mimic the effect of the incretin hormone GLP-1 by binding to its receptor. Incretin hormones are a group of hormones that cause insulin to be released from the pancreas after eating to help lower blood sugar levels.  These incretin hormones also help suppress the appetite, causing you to eat less and lose weight. Tirzepatide is different because it is the first drug to mimic the action of two hormones, both GLP-1 and GIP. In our last episode, we also discussed the SURPASS-2 study that showed tirzepatide to be superior to semaglutide because of this dual incretin action, with greater weight loss, lower HA1c levels, and lower triglyceride and VLDL levels. At that time, we also mentioned the SURMOUNT-1 Phase 3 clinical trial that was ongoing at the time. Well, it is now complete, and the results are in. There were 2,539 obese or overweight participants without diabetes in the study who lost between 16-22.5% of their starting weight on Tirzepatide. On 15 mg dose, participants lost about 52 lbs (24 kg), on 10 mg 49 lbs (22 kg) and on 5 mg about 35 lbs (16 kg), but those on the placebo lost only 2.4% or about 5 lbs (2 kg). As you can see there is very little difference in weight loss between the 10 mg dose and the 15 mg dose, although a big difference is seen compared to the 5 mg dose. It's important to note that they took Tirzepatide for 72 weeks or a year and a half. Arreaza: That's very significant weight loss. It is important to emphasize that these patients did NOT have diabetes. Maria: These weight loss results have proven to be comparable to bariatric surgery. The study also showed improvement in cardiovascular and metabolic risk factors such as lower blood pressure, fasting insulin, lipid levels and even aspartate aminotransferase levels in comparison to the placebo. By the end of the study, more than 95% of the participants who had pre-diabetes had converted to normal glucose levels. This study was so impressive that it was presented at the 82nd Scientific Sessions of the American Diabetes Association and was also published in The New England Journal of Medicine. Arreaza: It seems like tirzepatide is ahead of the game for weight loss.Maria: Although it is approved as a drug for diabetes, the next step is to approve it for weight loss and to begin treating obesity as a chronic disease that needs to be treated. Maria: And this makes sense. Currently, more than 4 in 10 American adults have obesity, and obesity is the cause of many other conditions. Just yesterday, I was seeing patients in the orthopedic clinic and I had several patients being seen for knee pain due to obesity, and they are postponing surgery because they have been losing weight on tirzepatide and are already feeling better. I think avoiding knee surgery alone is a pretty good reason to approve these drugs for weight loss, but there are many other conditions that are improved by weight loss. Arreaza: My anecdotes are related to semaglutide, but I can imagine that this may also apply to tirzepatide. I had a patient who was able to stop all antihypertensive medications because of 40-lb weight loss. Maria: Dr. Caroline Apovian, director of the Center for Weight Management and Wellness at Brigham Women's Hospital, states that “If everybody who had obesity in this country lost 20% of their body weight, we would be taking patients off all these medications for reflux, for diabetes, for hypertension. We would not be sending patients for stent replacement.”Maria: Last month, officials from Eli Lilly, the company that makes tirzepatide, stated that they are hoping to have a fast-track approval to sell it for chronic weight management by sometime this year. The problem is that many of these patients who were prescribed Tirzepatide have not been able to get it because it has been out of stock for the last few months in all the local pharmacies. They get the prescription, start taking Tirzepatide and begin to lose weight or improve their blood sugar levels and then it is out of stock and now you have people with Diabetes who have gotten off insulin because Tirzepatide worked so well and suddenly they can't get it and are at risk for getting pretty sick without it. Arreaza: The manufacturer of Wegovy announced this, “we will only be able to supply limited quantities of 0.25 mg, 0.5 mg, and 1 mg dose strengths to wholesalers for distribution to retail pharmacies which will not meet anticipated patient demand. We anticipate that many patients will have difficulty filling Wegovy® prescriptions at these doses through September 2023. We do not currently anticipate supply interruptions of the 1.7 mg and 2.4 mg dose strengths of Wegovy®”. Why is this happening? Maria: The problem is that this drug was not meant for the masses, for all these young girls wanting to lose a few pounds for aesthetic reasons. It was meant for people with a BMI 30 or with a BMI 27 plus another comorbidity such as hypertension. Celebrities have brought attention to these drugs for weight loss, for example Ozempic has over 433 million views on TikTok. It has gotten so bad that people are turning to questionable sources online to purchase these drugs, where it is given cute names like “skinny shots.” And if your insurance does not cover Tirzepatide, it is still expensive, starting at around $1000 per month. Some of the insurers who used to cover the cost stopped covering it or placed new restrictions on who qualifies. Another downside is that tirzepatide and other drugs of this class have not been on the market that long, so the long-term effects are still not known. So far, early evidence shows that most people gain the weight back as soon as they stop taking it, so are the weight loss benefits sustainable at this high cost? Maria: We talked about the adverse effects in the last episode, but it's important to go over them again. Patients can have diarrhea, nausea, vomiting, constipation, and abdominal pain that can often bring these patients into the clinic or even the Emergency room thinking they are ill, when in fact it is an adverse effect of their medication, especially the first few days of starting or increasing the dose. So, educating patients is very important before they start this new drug. There is also a small risk of pancreatitis or gallbladder problems, so it is important to have blood work done to check the pancreas and gallbladder prior to starting tirzepatide. There is also a warning to avoid using it if you have a family or personal history of thyroid cancer. Arreaza: Reminder, MEN type 1. I would like to mention the so-called “Ozempic face”. It is the face you get with rapid weight loss, making you look a little older due to fat loss on the face. As a summary, tirzepatide is a very effective medication for weight loss, pending FDA approval. It is not free of side effects, so we still need to follow the recommendations from FDA and other reputable sources to prescribe it responsibly. There is room for further research on these medications. Currently, there are no clear guidelines regarding labs before starting treatment (lipase?) or labs for monitoring after treatment. The evidence regarding these medications continues to evolve and we should stay up to date with the changes. _______________________Conclusion: Now we conclude episode number 142 “Tirzepatide II.” Future Dr. Beuca came back almost one year later to shed more light on the use of tirzepatide in the treatment of obesity. Dr. Arreaza provided some insight into the management of side effects and the potential harm of this novel medication. Overall, tirzepatide is effective and safe and may be the answer to many of our patients with diabetes and obesity. This week we thank Hector Arreaza and Maria Beuca. Audio editing by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________References:Brownie, Grace. “The Problematic Arrival of Anti-Obesity Drugs.” Wired, 25 January 2023. https://www.wired.com/story/anti-obesity-drugs/Dockrill, Peter. “Experimental Drug Breaks Record for Weight Loss in Latest Clinical Trial Results.”ScienceAlert, 9 May 2022, https://www.sciencealert.com/experimental-drug-breaks-record-for-weight-loss-in-latest-clinical-trial-results.Frías, Juan P., et al. “Tirzepatide versus Semaglutide Once Weekly in Patients with Type 2 Diabetes.”New England Journal of Medicine, 5 August 2021, https://www.nejm.org/doi/full/10.1056/NEJMoa2107519.Jastreboff, Ania  M., et al. “Tirzepatide Once Weekly for the Treatment of Obesity.” New England Journal of Medicine, 21 July 2022, www.nejm.org/doi/full/10.1056/NEJMoa2206038.“Label as Approved by FDA. - Pi.lilly.com.”Mounjaro Prescribing Information, Lilly USA, LLC, May 2022, https://pi.lilly.com/us/mounjaro-uspi.pdf.Mounjaro. Prescribing Information. Lilly USA, LLC.  May 2022. https://pi.lilly.com/us/mounjaro-uspi.pdf?s=pi“Surmount-1 Study Finds Individuals with Obesity Lost up to 22.5% of their Body Weight when Taking Tirzepatide.” 4 June 2022. https://diabetes.org/newsroom/press-releases/2022/surmount-1-study-finds-individuals-%20with-obesity-lost-up-to-22.5-percent-body-weight-taking-tirzepatide.Royalty-free music used for this episode: "Happy-Go-Lucky." Downloaded on October 13, 2022, from https://www.videvo.net/ 

Do YOU get migraines? headaches? They are literally... THE WORST. Don't worry, you are not alone. Migraines affects ~28 million adults in the U.S, with 85% of chronic migraine sufferers being women. Today, I am in conversation with a NYC based Neurologist, Dr. Huma Sheikh who is here to breakdown the difference between headaches and migraines, potential triggers you should know about, when you need to see a doctor ASAP and holistic ways to prevent and treat them! Send this episode with anyone who is a part of the #migrainesufferers gang. LISTEN UP! The Flourish Heights Podcast was made for women, by women. To be empowered in health starts with a true connection with your body. Join Valerie Agyeman, Women's Health Dietitian as she breaks through topics surrounding periods, women's nutrition, body awareness, and self-care.  About Dr. Huma Sheikh Dr Huma Sheikh is a board-certified Harvard-trained Headache Specialist and Neurologist. She graduated from UMDNJ- Rutgers Medical School and completed a Neurology residency at Montefiore Medical Center in Bronx NY.  She then completed a Vascular Fellowship followed by another fellowship in "Headache and Facial Pain," at Brigham & Women's Hospital- Harvard Medical School. She now has over 6 years of clinical experience treating complex headaches and takes a holistic approach. Dr. Sheikh is involved in research and started the "Migraine and Vascular Committee," at the American Headache Society (AHS). You can find her on TikTok or in the media spreading awareness and education. Connect with Dr. Sheikh: Websites: https://www.headachesnyc.com/ IG: @headachesnyc TIKTOK: @headachesnyc Stay Connected: Let's Flourish! BOOK your 1:1 Virtual Nutrition Coaching session: www.flourishheights.com/nutrition-counseling Is there a topic you'd like covered on the podcast? Submit it to hello@flourishheights.com Say hello! Email us at hello@flourishheights.com Subscribe to our quarterly newsletters: Flourish Heights Newsletter Visit our website + nutrition blog: www.flourishheights.com Women's Nutrition Counseling: www.flourishheights.com/nutrition-counseling Follow us on social media: Instagram: @flourishheights Facebook: @flourishheights Twitter: @flourishheights Want to support this podcast? Leave a rating, write a review and share! Thank you!

I am bringing back the IMG Roadmap live program; this is an intensive but fast bootcamp to get you ready for the 2024 match cycle. If you want to be informed once we launch click here https://www.aceyourclinicals.com/2023! ***** Have you ever heard that International Medical Graduates (IMGs) can't secure spots in top programs and competitive specialties? Dr. Rhanderson Cardoso, a successful cardiologist at Harvard Medical School at the Brigham Women's Faulkner Hospital, is here to prove otherwise! Background: Currently working at Harvard Medical School Attended Medical school in Brazil Completed Internal Medicine residency at University of Miami, where he served as a chief resident Cardiology Fellowship at Johns Hopkins followed by Imaging Fellowship at Harvard Medical School Stays on as faculty and performs research and teaches residents Match Journey: Dr. Cardoso's dream was always to complete medical residency in the US ECMFG provided the opportunity for him to do so Completed Step 1 in his 5th year of medical school and had observerships in the US Despite the lack of people taking the same path, he applied for residency just after graduation Mistakes in application: no publications and applied to too few programs Matched at University of Miami and was able to secure better programs in the future Challenges: Matched and completed residency on J1 Long residency (3 years of medicine, 1 year of chief residency, and 3 years of fellowship) Had to apply for extension for additional training in cardiac imaging Took on a position in academic institution after residency and now has an O visa Research Difficulty: As a 1st-year resident, he had limited time to do research He learned systematic review and meta-analysis to become more appealing to collaborators and mentors Barriers for IMGs: Financial expenses English language proficiency Difficulty in getting meaningful research done Webinar: Dr. Cardoso is hosting a webinar on February 28th on the publication roadmap. You can find more information on his Instagram @rhandersoncardoso.md and @metaanalysis.academy. ***** Follow us on Instagram for supportive content and download our targeted planner from our website! Subscribe to our podcast and newsletter and consider joining our program in the spring to kick start your IMG journey in 2023. As always you can click on the following links to listen to more episodes of our podcasts on Apple podcasts, Google podcasts and Spotify. --- Support this podcast: https://anchor.fm/ninalum/support

In this re-aired episode, we produce a conversation that is both informative and enjoyable to listen to, with a colleague from my time at Georgia Tech.

According to the National Association of Anorexia Nervosa and Associated Disorders, eating disorders are among the deadliest mental health illnesses in the United States. What's more, these disorders can go undiagnosed for years, making treatment and recovery even more challenging. In this interview, Gregory Hundemer, MD, an associate scientist with the Ottawa Hospital Research Institute and Assistant Professor at the University of Ottawa, provides an overview of eating disorders and discusses new research he was involved with that could help with early diagnosis and intervention. About the Expert   Gregory Hundemer, MD, is an associate scientist in the Clinical Epidemiology Program at the Ottawa Hospital Research Institute, an assistant professor of medicine at the University of Ottawa, and a staff nephrologist at the Ottawa Hospital. He received his medical doctorate from Vanderbilt University and Master of Public Health degree from Johns Hopkins University. After medical school, he served 4 years as a flight surgeon in the United States Air Force. He then completed his internal medicine residency at Massachusetts General Hospital and nephrology fellowship at the combined Massachusetts General Hospital and Brigham & Women's Hospital Joint Nephrology Fellowship Program.

Dr. Eben Alexander spent over 25 years as an academic neurosurgeon, including 15 years at the Brigham & Women's Hospital, the Children's Hospital and Harvard Medical School in Boston. Over those years he personally dealt with hundreds of patients suffering from severe alterations in their level of consciousness. Many of those patients were rendered comatose by trauma, brain tumors, ruptured aneurysms, infections, or stroke. He thought he had a very good idea of how the brain generates consciousness, mind and spirit.In the predawn hours of November 10, 2008, he was driven into coma by a rare and mysterious bacterial meningo-encephalitis of unknown cause. He spent a week in coma on a ventilator, his prospects for survival diminishing rapidly. On the seventh day, to the surprise of everyone, he started to awaken. Memories of his life had been completely deleted inside of the coma, yet he awoke with memories of a fantastic odyssey deep into another realm – more real than this earthly one! His older son advised him to write down everything he could remember about his journey, before he read anything about near-death experiences, physics or cosmology. Six weeks later, he completed his initial recording of his remarkable journey, totaling over 20,000 words in length. Then he started reading, and was astonished by the commonalities between his journey and so many others reported throughout all cultures, continents and millennia. His journey brought key insights to the mind-body discussion and to our human understanding of the fundamental nature of reality. His experience clearly revealed that we are conscious in spite of our brain – that, in fact, consciousness is at the root of all existence.He has been blessed with a complete recovery that is inexplicable from the viewpoint of modern Western medicine.

  Vidcast:  https://youtu.be/Hx6vlbgavIc   MIT engineers in collaboration with Harvard's Brigham & Women's investigators are developing surgically-implantable materials that can be literally dissolved when no longer needed.  Metals including aluminum become brittle and disintegrate when exposed to gallium.  The research team has shown that aluminum staples will dissolve within minutes when coated with a gallium-indium liquid.  The gallium compound is non-toxic.  This same concept could be used to develop dissolvable stents and medication-carrying capsules.   https://onlinelibrary.wiley.com/doi/10.1002/adma.202208227   #staples #stents #metal #embrittlement #galliumindium #aluminum  

What is Breast Density? How dangerous is it for women? What happens if a mammogram identifies dense breast tissue? These and many more critical questions for Dr. Pamela Habib Head of US Medical Affairs at Bayer Radiology.BIO ~PAMELA HABIB Dr. Habib leads the US Medical Affairs team at Bayer Radiology and oversees engagement with healthcare professionals, communication of scientific data, and various educational and research initiatives. Dr. Habib is a Breast Radiologist, who completed her breast imaging fellowship at Harvard Medical School's Brigham & Women's Hospital. In clinical practice she focused on mammography, MRI, ultrasound, and breast interventional procedures.

What is Breast Density? How dangerous is it for women? What happens if a mammogram identifies dense breast tissue? These and many more critical questions for Dr. Pamela Habib Head of US Medical Affairs at Bayer Radiology.BIO ~PAMELA HABIB Dr. Habib leads the US Medical Affairs team at Bayer Radiology and oversees engagement with healthcare professionals, communication of scientific data, and various educational and research initiatives. Dr. Habib is a Breast Radiologist, who completed her breast imaging fellowship at Harvard Medical School's Brigham & Women's Hospital. In clinical practice she focused on mammography, MRI, ultrasound, and breast interventional procedures.

This week, please join author Michelle O'Donoghue and Associate Editor Parag Joshi as they discuss the article "Long-Term Evolocumab in Patients With Established Atherosclerotic Cardiovascular Disease." Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts, Dr. Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, Associate Editor and Director of the Poly Heart Center at VCU Health in Richmond, Virginia. Well, Carolyn, very interesting feature this week. Evolocumab, another application for that in patients with established atherosclerotic cardiovascular disease. But before we get to that feature discussion, how about we grab a cup of coffee and discuss some of the other very interesting articles in this issue? Dr. Carolyn Lam: Oh, I'd love that. And I'd like to go first, because Craig, have you heard of hybrid debranching repair? I know, I know. I had that same look, and can I tell you about it? Because I found it so interesting. Dr. Greg Hundley: Absolutely. Dr. Carolyn Lam: Now, the management of complex aortic aneurysmal disease involving the visceral vessels is challenging due to its very high morbidity and mortality. After four decades of experience in open repair, only a few centers worldwide report laudable results. And numerous factors limit total endovascular repair, including the access to devices, experience in deploying them, and several anatomical restrictions. So, hybrid debranching procedures were introduced for those patients who are unfit for the open or endovascular excluded patients. And while these have been developed, small series have only been done and revealed a wide range of short term results. So, today's paper is very important, and it's from Dr. Oderich from UT Memorial Herman Texas Medical Center and colleagues. It's a large multi-institutional study, which contains the five year outcomes in 200 patients offering greater clarity in the usefulness and limitations of these hybrid debranching repair procedures. What they found was that hybrid aortic debranching had a low early mortality when done in lower risk patients, but mortality remained very elevated in high risk patients. And so, this suggests that deep branching could be a good alternative in patients adequate for traditional open repair, although pulmonary complications are quite common. The bypass grafts to the visceral vessels had very good patency with a five year primary patency of 90%. Permanent spinal cord injury occurred in 6%, suggesting that deep branching in experienced centers may offer outcomes comparable to centers of excellence for open thoracoabdominal aortic aneurysm repair. Dr. Greg Hundley: Wow, Carolyn, very nice and so beautifully explained. Dr. Carolyn Lam: You know what, Greg? I'm on a roll and I'd like to tell you about one more, this time a preclinical study. First, a little bit about the background. You see, transplantation with pleuripotent stem cell derived cardiomyocytes, as we know, represents a very promising therapeutic strategy for cardiac regeneration. We even have first clinical studies in humans, but yet little is known about the mechanism of action underlying graft induced benefits. So in this paper from Dr. Weinberger from University Medical Center Hamburg in Germany and colleagues, they explored whether transplanted cardiomyocytes actually actively contribute to heart function by injecting these cardiomyocytes with an optogenetic off on switch in a Guinea pig cardiac injury model. Dr. Greg Hundley: Wow, Carolyn, this is so interesting. So what did they find? Dr. Carolyn Lam: So, light induced inhibition of endo-grafted cardiomyocyte contractility resulted in a rapid decrease in left ventricular function in about 50% of the animals that was fully reversible with the offset of photo stimulation. So in conclusion, this optogenetic approach demonstrated that transplanted cardiomyocytes can actively participate in heart function, supporting the hypothesis that the delivery of new force generating myocardium can serve as a regenerative therapeutic strategy. Dr. Greg Hundley: Oh wow, Carolyn. That was just fascinating. Such incredible preclinical science in our journal. Well, Carolyn, this next paper comes to us from the world of myocarditis. And Carolyn, it involves a population based cohort of 336 consecutively recruited patients with acute myocarditis enrolled in both London and Maastricht. And the authors, led by Dr. Sanjay Prasad from Royal Brompton Hospital, investigated the frequency and clinical consequences of dilated cardiomyopathy and arrhythmogenic cardiomyopathy genetic variants in this population based cohorts of patients with acute myocarditis. Now, Carolyn, all participants underwent targeted DNA sequencing for well characterized cardiomyopathy associated genes and their comparison to healthy controls, of which they had 1,053 that were sequenced on the same platform. Case ascertainment of their outcomes in England was assessed against their national hospital admission data, and the primary outcome was all cause mortality. Dr. Carolyn Lam: So what did they find, Greg? Dr. Greg Hundley: Right, Carolyn. So these authors identified for dilated cardiomyopathy or arrhythmogenic cardiomyopathy associated genetic variants in 8% of patients with acute myocarditis. This was dominated by the identification of desmoplakin truncating variants in those with normal LVF, and then titin truncating variants in those with a reduced LVF. So Carolyn, importantly, these variants have clinical implications for treatment, risk stratification, and family screening. Genetic counseling and testing would be considered in patients with acute myocarditis to help reassure the majority of individuals that don't have one of these genes, while improving the management of those that do have one of the underlying genetic variants. Very interesting findings from the world of myocarditis. Dr. Carolyn Lam: Great. And a great clinical take home message. Thank you, Greg. Well, this next paper sought to investigate the influence of age on the diagnostic performance of cardiac troponins in patients presenting with suspected myocardial infarction. Dr. Atul Anand from the BHF Center for Cardiovascular Science and University of Edinburgh and colleagues did this by performing a secondary analysis of the high stakes stepped wedge cluster randomized control trial that evaluated the implementation of a high sensitivity cardiac troponin ISA in consecutive patients presenting with suspected acute coronary syndrome. Dr. Greg Hundley: Oh wow. Carolyn. Super interesting, and very applicable clinically. So what did they find here? Dr. Carolyn Lam: In older patients presenting with suspected MI, the majority of cardiac troponin elevations are explained by acute or chronic myocardial injury or type two MI. The specificity and positive predictive value of high sensitivity cardiac troponin to identify myocardial infarction decreases with age and is observed, whether applying sex specific or age adjusted 99th percentile diagnostic thresholds or a rolling threshold for the triage of patients at high probability of myocardial infarction. Serial troponin testing incorporating an absolute change in troponin concentration increased the discrimination for myocardial infarction in older adults. Dr. Greg Hundley: Oh wow, Carolyn. Such clinically applicable findings in this particular study, particularly when managing our aging population. Well, Carolyn, how about we discuss some of the other articles in this issue. And there's a very nice In-depth piece by our own Sami Viskin entitled “Arrhythmogenic Effects of Cardiac Memory.” And then, there's an exchange of letters by Drs. Giannitsis and Mueller regarding the article, “Unexpected Sensitivity Issue of Three High Sensitivity Cardiac Troponin I-Assays in Patients with Severe Cardiac Disease and Chronic Skeletal Muscle Diseases.” Dr. Carolyn Lam: Nice. There's also a Research Letter by Dr. Szendroedi on “Impaired Mitochondrial Respiration in Humans with Prediabetes: A Footprint of Prediabetic Cardiomyopathy.” And there's a CV case series by Dr. Kalra on very high cholesterol mimicking homozygous familial hypercholesterolemia. Interesting case. Well, I suppose that wraps it up. Let's go on to the feature discussion, shall we, Greg? Dr. Greg Hundley: You bet. Evolocumab. Welcome listers to this feature discussion on October 11th, and we're very fortunate today. We have with us Dr. Michelle O'Donoghue from Brigham Women's Hospital and Dr. Parag Joshi from UT Southwestern, the Associate Editor for this paper. Well, Michelle, can you describe for us some of the background information that went into the preparation of your study, and then what was the hypothesis that you wanted to address?   Dr. Michelle O'Donoghue: Sure. Happy to do so, and thank you for having me. So by way of background, the Fourier study, which was previously published in the New England Journal, compared Evolocumab to placebo in 27,000 plus patients with established atherosclerotic cardiovascular disease, and Evolocumab significantly reduced the risk of major adverse cardiovascular events. But, the follow up duration was relatively short. Median follow up was 2.2 years. So this was now an open label extension study to Fourier known as the Fourier OLE study that allowed an additional median follow up time of five years, during which time all patients were now treated with open label Evolocumab. T. He primary hypothesis that we were testing in this extension study was primarily to look at long term safety. We had limited data to really assure us of the safety of PCSK9 inhibitors over the course of several years. And so, safety was the primary hypothesis that we were testing, but also of course of key interest, during the parent Fourier study, we know that the benefit for cardiovascular risk reduction appeared to grow over time. So this was also an opportunity to see that pattern and to see whether or not there was in fact legacy effect for patients who were treated earlier with Evolocumab versus placebo. Dr. Greg Hundley: Very nice, Michelle. And so, sounds like we have a substudy of the Fourier trial. Can you describe for us a little bit more, for this substudy, your study population and your study design? Dr. Michelle O'Donoghue: Sure. So the patients enrolled in the open label extension were a subset of those who participated in the parent study. So as I previously mentioned, more than 27,000 participated in Fourier. It was a global study. For the open label extension, it was more than 6,500 patients who participated, and those were patients who were at sites in Europe and United States. And so, those patients were then followed on average for a meeting of five years. So that means that all together, patients who had been randomized to Evolocumab in the parent study had potentially more than eight years of drug exposure for us to examine safety. Dr. Greg Hundley: Very nice. And so, what did you find? Dr. Michelle O'Donoghue: Well, first, looking at the first hypothesis of safety, we saw no evidence that there was any increased risk of any adverse events of interest when it comes to PCSK9 inhibitors as a drug class, or achieving very low levels of LDL cholesterol. So there was no uptick in terms of neurocognitive events, the risk of diabetes. We do know that there was an increased risk of injection site reactions with the PCSK9 inhibitors, but not one that appeared to persist over time. So first was the safety, but importantly, I think that the more interesting results perhaps were those for MACE, for cardiovascular risk reduction. So we saw, even though all patients were being treated with open label Evolocumab during the extension phase, the benefit that was seen during the parent study persisted. So there was a 15% reduction in the primary outcome, a broad composite of cardiovascular events. There was also a 20% reduction in the triple composite of cardiovascular death, MI, or stroke. And then perhaps of the most interest to your listeners is that there was a 23% reduction in cardiovascular mortality, and that was not something that was seen in the parent study. It really took time for that mortality benefit to emerge. Dr. Greg Hundley: Very nice. Michelle. Just a couple quick clarification points. Did you see these effects in both men and women? And then was there any impact of age on those results? Dr. Michelle O'Donoghue: Great questions. Some of those subgroup analyses are still ongoing, but no, we did not see any evidence of effect modification at first pass. But again, we'll be continuing to dig into all potential subgroups. Dr. Greg Hundley: Very nice. Parag, I know you have many papers come across your desk. What attracted you to this particular manuscript? Dr. Parag Joshi: Yeah, thanks. And congratulations again, Michelle. It's a really phenomenal study, and the findings, as you highlighted, are just really impactful for the field. I think for our journal at circulation, this is a really high impact finding in terms of extending out, giving us a rigorous way to look at long term follow up for people on PCSK9 inhibitors and really reassure that there is safety there. And as you highlighted, a sustained reduction in LDL cholesterol, other compounds in the space, Bococizumab in particular, that there were induced antibodies against the monoclonal antibody, and that sustained response was not there. So I thought that was also really reassuring, that over the course of eight years, we see sustained LDL reduction. And with that, really reaffirming the idea that the longer you can reduce LDL, there's an associated reduction in events. And as you highlighted, the initial Fourier, there was some question about why there wasn't a CV death mortality signal while there was in the Odyssey outcome study and slightly different patient populations of course, but just really needed more time to start to tease that out. So all of this, I think this is the first that we're seeing this kind of long-term data on this impactful class of medications that really made this a fantastic manuscript for us at Circulation. Dr. Greg Hundley: Wow. Boy, Parag, I don't know that you could have stated that any better. So Michelle, looking forward, what is your group thinking? And then maybe just as your comment on the field in general, what do you think is the next study or series of studies that needs to be performed in this sphere of research? Dr. Michelle O'Donoghue: Well, I think he started to touch upon the areas of interest to us, is that I think that there are still many opportunities to answer more questions even within this existing data set. In particular, there was a dedicated neurocognitive substudy that was built into the parent study. And we also have that now through the extension period. So, that was a sort of more rigorous assessment of neurocognitive outcomes. And so, that's another analysis that we're going to be pursuing in the near future and I think is of potential key interest. And then beyond that, I think that the PCSK9 inhibitor class in general is just so interesting. There are additional compounds that are under study, such as small interfering RNA, so different mechanisms of getting to the PCSK9 protein. And I think it'll be reassuring to see whether or not they are consistent results, regardless of how you lower PCSK9, whether it translates into similar types of clinical benefit. So I think it's an exciting field. And then stay tuned. I think there'll be more to come. Dr. Greg Hundley: Parag, do you have anything to add? What do you see really as the next series of studies that might be performed here in this area of research? Dr. Parag Joshi: Yeah, I think Michelle hit the nail on the head that seeing confirmatory evidence here would be great. And then really, what's so exciting about this space is there's so much interest in ways to address this protein, including gene editing, vaccination against it. And now you're getting the necessary evidence that, hey, you can really suppress these levels in patients for years without concerning safety signals, at least from what we've seen so far. So that's more excitement as to long term ways to address cardiovascular risk. Dr. Greg Hundley: Wow. Well, listeners, we've been very fortunate today to have with us Dr. Michelle O'Donaghue from Brigham and Women's Hospital, and Dr. Parag Joshi from UT Southwestern as the Associate Editor of Circulation to really bring us these exciting results, highlighting that long term LDL-C lowering with Evolocumab was associated with persistently low rates of adverse events over eight years that did not exceed those observed in the original placebo arm during the parent Fourier study, and led to further reductions in cardiovascular events compared with delayed treatment initiation. Well, on behalf of Carolyn and myself, we want to wish you a great week and we will catch you next week on the run. Dr. Greg Hundley: This program is copyright of the American Heart Association 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

Does obesity increase your likelihood of certain cancers? A new study might surprise you…Dr. Scott Shikora, Director of Metabolic and Bariatric Surgery at Brigham & Women's Hospital and Professor of Surgery at Harvard Medical School joined Dan to discuss a new JAMA (Journal of the American Medical Association) study that analyzed the connection between obesity and cancer.

Proof of Heaven with Eben Alexander   Cynthia Sue Larson talks with Eben Alexander about his Near-Death Experience (NDE), Shared Death Experiences (SDE), After Death Communication (ADC), Artificial Intelligence (AI), and the nature of reality.  Eben describes how it is becoming increasingly evident from his experience and experiences of others that the mind creates the brain, and not the other way around.  Eben shares some profound insights for how we can best live our lives with awareness of the meaning and value of relationships, free from the false sense of separation imbued in the very foundation of reductive material realism.  Dr. Eben Alexander was an academic neurosurgeon for over 25 years, including 15 years at the Brigham & Women's Hospital, Children's Hospital, and Harvard Medical School in Boston. He experienced a transcendental Near-Death Experience (NDE) during a week-long coma from an inexplicable brain infection that completely transformed his worldview. A pioneering scientist and modern thought leader in the emerging science that acknowledges the primacy of consciousness in the universe, Eben is author of the New York Times #1 bestseller Proof of Heaven, The Map of Heaven and Living in a Mindful Universe. http://ebenalexander.com Learn more about Cynthia Sue here: http://www.realityshifters.com

Dr. Pamela Habib, head of US Medical Affairs at Bayer Radiology and Dr. David Schacht, Breast Radiologist at Northwesterern's Lynne Sage Breast Center discuss the all-important topic of Breast Cancer and the issue of 'Dense Breasts' and its impact on breast cancer risk.About Dr. Pamela Habib:   Dr. Habib leads the US Medical Affairs team at Bayer Radiology and oversees engagement with healthcare professionals, communication of scientific data, and various educational and research initiatives. Dr. Habib is a Breast Radiologist who completed her breast imaging fellowship at Harvard Medical School's Brigham & Women's Hospital. In clinical practice, she focused on mammography, MRI, ultrasound, and breast interventional procedures. About David Schacht:   Dr. David Schacht is a breast radiologist at Northwestern's Lynne Sage Breast Center at Prentice Women's Hospital.  He has been an attending physician both at Northwestern, and previously at the University of Chicago.  He obtained his undergraduate, medical, and public health degrees all from Northwestern before pursuing his radiology residency and breast imaging fellowship at the University of Chicago. His academic interests include understanding new uses of MRI to detect breast cancer and the use of case-based learning to improve the performance of radiologists.    For more information please visit: https://radiologyresources.bayer.com/dense-breast-resources

Dr. Pamela Habib, head of US Medical Affairs at Bayer Radiology and Dr. David Schacht, Breast Radiologist at Northwesterern's Lynne Sage Breast Center discuss the all-important topic of Breast Cancer and the issue of 'Dense Breasts' and its impact on breast cancer risk.About Dr. Pamela Habib:   Dr. Habib leads the US Medical Affairs team at Bayer Radiology and oversees engagement with healthcare professionals, communication of scientific data, and various educational and research initiatives. Dr. Habib is a Breast Radiologist who completed her breast imaging fellowship at Harvard Medical School's Brigham & Women's Hospital. In clinical practice, she focused on mammography, MRI, ultrasound, and breast interventional procedures. About David Schacht:   Dr. David Schacht is a breast radiologist at Northwestern's Lynne Sage Breast Center at Prentice Women's Hospital.  He has been an attending physician both at Northwestern, and previously at the University of Chicago.  He obtained his undergraduate, medical, and public health degrees all from Northwestern before pursuing his radiology residency and breast imaging fellowship at the University of Chicago. His academic interests include understanding new uses of MRI to detect breast cancer and the use of case-based learning to improve the performance of radiologists.    For more information please visit: https://radiologyresources.bayer.com/dense-breast-resources

Imagine having a telescope that could allow you to see whether a syndrome will manifest in the future. Imagine being able to use it to cure diseases before they can even occur. For Dr. Thomas McElrath, MD-PhD in the Division of Maternal-Fetal Medicine at the Brigham & Women's Hospital, this telescope exists and is called LIFECODES. The LIFECODES Biobank is an extensive biobank of samples collected for over 14 years with data on over 6,000 pregnancies. It is used to look at biomarkers associated with pregnancy complications and the effects of environmental exposures on pregnancy outcomes. In this episode, we have interviewed Dr. McElrath to talk about his recent work published in Nature. He has leveraged these data to shed light on normal pregnancy progression to uncover new biomarkers that can be used to diagnose syndromes months before clinical presentation.  “Zenyatta is my Spirit Animal and Hyacinths'' music composition administered by Rukudzo © 2022 Rukudzo Kanyemba. All rights reserved.

In this podcast episode, host Dr. Steven H. Linder talks with three other expert physicians who are leaders in the fight against the opioid epidemic: Dr. Casey Grover, Dr. Don Stader, and Dr. Scott Weiner. The panel explores the power of naloxone, the emergency intervention that has saved countless people after accidental overdose with fentanyl, the illicit drug now appearing in pill form and in illegal drugs of all kinds. The physicians give a moving inside look at the actual situation on the front lines, as healthcare professionals and communities join forces to save their loved ones. With opioid-related deaths at an all-time high in 2022, the panelists explore how we can make a difference, whether by carrying naloxone personally, raising awareness of fentanyl's dangers, or advocating for much-needed investment in addiction medicine. The podcast begins with a 4 minute introduction and background to the subject, followed by the panel discussion at 4:00. Featuring: Steven H. Linder, MD, FCCP, American Board of Internal Medicine, American Board of Pulmonary Medicine, Staff Physician, VA Medical Center Palo Alto, California Casey Grover, MD, FACEP, Chair of the Division of Emergency Medicine, Community Hospital of the Monterey Peninsula and Physician Champion of the Monterey County Prescribe Safe Initiative. Don Stader, MD, FACEP, Founder & President, Stader Opioid Consultants and Chair of the Colorado Naloxone Project. Physician, Swedish Medical Center and Lincoln Health in Colorado. Scott Weiner, MD, MPH, Director, Brigham Comprehensive Opioid Response and Education Program, Brigham Women's Hospital

Dr. Eben Alexander spent over 25 years as an academic neurosurgeon, including 15 years at the Brigham & Women's Hospital, the Children's Hospital and Harvard Medical School in Boston.  Over those years he personally dealt with hundreds of patients suffering from severe alterations in their level of consciousness. Many of those patients were rendered comatose by trauma, brain tumors, ruptured aneurysms, infections, or stroke. He thought he had a very good idea of how the brain generates consciousness, mind and spirit.In the predawn hours of November 10, 2008, he was driven into coma by a rare and mysterious bacterial meningo-encephalitis of unknown cause. He spent a week in coma on a ventilator, his prospects for survival diminishing rapidly. On the seventh day, to the surprise of everyone, he started to awaken. Memories of his life had been completely deleted inside of the coma, yet he awoke with memories of a fantastic odyssey deep into another realm – more real than this earthly one!His older son advised him to write down everything he could remember about his journey, before he read anything about near-death experiences, physics or cosmology. Six weeks later, he completed his initial recording of his remarkable journey, totaling over 20,000 words in length. Then he started reading, and was astonished by the commonalities between his journey and so many others reported throughout all cultures, continents and millennia.His journey brought key insights to the mind-body discussion and to our human understanding of the fundamental nature of reality. His experience clearly revealed that we are conscious in spite of our brain – that, in fact, consciousness is at the root of all existence.His story offers a crucial key to the understanding of reality and human consciousness. It will have a major effect on how we view spirituality, soul and the non-material realm. In analyzing his experience, including the scientific possibilities and grand implications, he envisions a more complete reconciliation of modern science and spirituality as a natural product.He has been blessed with a complete recovery that is inexplicable from the viewpoint of modern Western medicine.His latest book on the subject of consciousness and reality, Living in a Mindful Universe: A Neurosurgeon's Journey into the Heart of Consciousness, co-authored with Karen Newell, will be released in Fall 2017 by Rodale Books.His first book, Proof of Heaven: A Neurosurgeon's Journey into the Afterlife (2012), debuted at #1 on the New York Times Bestseller list and remained in the top ten for over a year. His second book, The Map of Heaven: How Science, Religion and Ordinary People are Proving the Afterlife (2014), explores humankind's spiritual history and the progression of modern science from its birth in the seventeenth century, showing how we forgot, and are now at last remembering, who we really are and what our destiny truly is.His story was featured in a series of peer-reviewed medical articles about near-death experiences (NDEs) in Missouri Medicine(2015), now published as the book The Science of Near-Death Experiences (edited by John C. Hagan III, 2017). It concludes with his chapter, “Near-Death Experiences, The Mind-Body Debate, and The Nature of Reality.”A graduate of the University of North Carolina at Chapel Hill, Dr. Alexander received his medical degree from Duke University School of Medicine in 1980. He taught neurosurgery at Harvard Medical School in Boston for fifteen years, and has performed over 4,000 neurosurgical operations. During his academic career he authored or co-authored over 150 chapters and papers in peer reviewed journals, authored or edited five books on radiosurgery and neurosurgery, and made over 230 presentations at conferences and medical centers around the world.Since Proof of Heaven was released in 2012, he has been a guest on The Dr. Oz Show, Super Soul Sunday with Oprah Winfrey, ABC-TV's 20-20 and Good Morning America, FOX-TV's FOX & Friends, and his story has been featured on the Discovery Channel and the Biography Channel. He has been interviewed for over 400 national and international radio and internet programs and podcasts.  His books are available in over 40 countries worldwide, and have been translated into over 30 languages.Since his NDE, Dr. Alexander has dedicated himself to sharing information about near-death experiences and other spiritually-transformative experiences, and what they teach us about consciousness and the nature of reality.He continues to promote further research on the unifying elements of science and spirituality, and together with Karen Newell, regularly teaches others ways to tap into our greater mind and the power of the heart to facilitate enhancement of healing, relationships, creativity, guidance, and more.Enjoy my conversation with Dr. Eben Alexander.

The Epstein-Barr virus (EBV) causes multiple sclerosis based on a new monumental study in young adults serving on active duty in the US military. The study found that the risk of developing MS increased 32-fold after infection with the Epstein-Barr virus. EBV causes infectious mononucleosis, spreads through saliva and infects B immune cells.  Alberto Ascherio MD DrPH shares his group's recent findings, published in Science. Epstein-Barr virus treatments in clinical trials reviewed including vaccination studies with the goals of stopping disease progression and preventing MS from ever occurring. The impact of vitamin D, smoking, and obesity on the risk of developing multiple sclerosis is reviewed.  Howard Weiner MD details the genetic risk factors for developing multiple sclerosis such as human leukocyte antigen (HLA) and risks of passing the disease onto children. The role of gut organisms, known as the microbiome, in both potentially causing multiple sclerosis and protecting people with the disease is explored. Strategies for a multiple sclerosis cure are highlighted. Barry Singer MD, Director of the MS Center for Innovations in Care, interviews: Howard Weiner MD is the Robert L. Kroc Professor of Neurology at the Harvard Medical School, where is has been on faculty since 1976. He is the Director and Founder of the Partners Multiple Sclerosis Center as well as the Co-Director of the Center for Neurologic Diseases at the Brigham & Women's Hospital in Boston. He is also a film writer, director and author. Dr. Weiner is the author of “Curing MS.” His latest book is “The Brain Under Siege: Solving the Mystery of Brain Disease, and How Scientists are Following the Clues to a Cure.” Alberto Ascherio MD DrPH is Professor of Epidemiology & Nutrition at the Harvard Chan School of Public Health. Dr. Ascherio obtained his medical degree at the University of Milan in 1978.  His research group focuses on identifying causes, risk factors and biomarkers of susceptibility and early diagnosis of multiple sclerosis including key research on Epstein-Barr virus and vitamin D. Season 4 MS Living Well podcast is sponsored by Octave. Visit www.mslivingwell.org for more information.

Dr. Natalie Dattilo's approach to her work is straightforward, practical, and rooted in science.Dr. Natalie Dattilo's approach to her work is straightforward, practical, and rooted in science. She takes the ‘woo' out of wellness and teaches us how to cultivate a personalized self-care practice for “real life.”Dr. Dattilo is a licensed clinical & health psychologist who specializes in the treatment of depression, anxiety, stress, insomnia, and other health conditions. She has over a decade of experience helping people overcome a wide range of issues using a personalized, structured, and scientifically backed approach, and currently, she provides psychological evaluation and treatment at Brigham & Women's Hospital and is an Instructor of Psychiatry at Harvard Medical School. This episode focuses on gratitude. You've probably heard a million times by now the importance of gratitude and mindfulness. But that's because they work! Listen as we discuss building your own daily gratitude practice, how gratitude affects our physical and mental health, how to get started, and how you know it's working.

In this week's edition of Circulation on the Run, Dr. Amit Khera introduces the new Social Media Editors to our Circulation listeners. Please welcome Dr. Vanessa Blumer, Dr. Pishoy Gouda, Dr. Xiaoming (Ming) Jia, Dr. Peder Langeland Myhre, and Dr. Sonia Shah to Circulation. Dr. Amit Khera: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Amit Khera, Associate Editor from UT Southwestern Medical Center in Dallas, and Digital Strategies' Editor for Circulation. And today I have the privilege of sitting in for your usual host, Dr. Carolyn Lam, and Dr. Greg Hundley. Well, two times a year, we really have a special issue, there's no print issue for Circulation in the summer and here in that holiday time. So, fortunately, we get to use this for really whatever we want to do. Dr. Amit Khera: And today we have a very special issue. A few months ago, we transitioned over from a prior social media editor team that was Jainy Savla Dan Ambinder, and Jeffrey Hsu. We were able to recruit a fantastic group of new social media editors. You probably have seen their work behind the scenes, but you've not gotten to meet them personally. So, today I have the privilege of introducing you to our new social media editors. This group of five, that's been working for several months and we get to know them a little bit. Get to hear a little bit about their perspective on social media from fellows in training, and also what they've learned so far in their few months in working with Circulation. So, I'm going to go one by one and introduce you. And first I want to introduce you to Dr. Vanessa Blumer. Vanessa, tell us a little bit about yourself. Dr. Vanessa Blumer: Thank you so much, Dr. Khera, it is such an honor to be here. And I've had so much fun the months that I've been working for Circulation, it's truly just a privilege to work alongside this talented group. So I'm Vanessa Blumer. I am originally from Caracas, Venezuela, born and raised there, did all of my medical training back home. That included medical school, a year of rural service, or rural medicine. Then I actually did residency training in Venezuela as well. It wasn't really in my plans straight away to come to the US, but a little bit due to the political situation that we all know that Venezuela's going or suffering, I decided to come to the US. Dr. Vanessa Blumer: I did residency in the University of Miami, Jackson Memorial hospital, which I loved. Stayed there for a chief year. And then after that came to Duke University to do cardiology fellowship. I'm currently a third year cardiology fellow at Duke, doing a year of research at the DCRI, which I am enjoying a lot, and will be doing heart failure next year. I will be going to Cleveland Clinic for a year of advanced heart failure. Dr. Amit Khera: Well, you've had quite a journey, Vanessa, and congratulations, I think your match was relatively recently. So, we're excited to see where your career takes you from here and appreciate your contribution so far. Now I'm going to introduce you to Pishoy Gouda. Pishoy Tell us a little bit about yourself.     Dr. Pishoy Gouda: Morning, Dr. Khera. My name is Pishoy. I have had the privilege of doing my medical trading all over the world. I was born here in Toronto and moved to Edmonton where I mostly grew up. Since then, I traveled to Galway Ireland where I spent six years to do my undergraduate medical training. Hopped over a short flight and did my Masters in Clinical Trials in the London School of Hygiene and Tropical Medicine before returning to Canada to start my residency training. Got to work with some amazing people in Calgary while I completed my internal medicine training, and then finally returned home to Edmonton where I am in the last few months of my adult cardiology training. Dr. Pishoy Gouda: Next year, I'm really excited to start my interventional cardiology training, which is going to be really exciting. Some of my interests, working with social media, wearable technology so working with this great group has been really awesome. Dr. Amit Khera: Thank you Pishoy. Obviously lots of travels from you as well, and we definitely appreciate your expertise and interest in social media and in technology. It's been very valuable. Next someone who's closer to my backyard. Ming Jia. Ming, welcome. Dr. Xiaoming (Ming) Jia: Hello from Houston, and thank you Dr. Khera. So, it's been a great opportunity to be involved as a social media editor for Circulation. So I'm a current cardiology fellow at Baylor College of medicine in Houston, Texas. Was originally born in China, and grew up in sunny Florida. I did my medical training in Florida as well, and then moved over to Houston, Texas for residency, and now wrapping up my last year in general fellowship. Next year, I'll be staying in Houston at Baylor for interventional fellowship. Then, hopefully after that career in interventional cardiology, but as well as preventional cardiology as well, I tended to actually interest in both interventional and preventional cardiology. Dr. Amit Khera: Very cool. I know you and I were talking about this right beforehand, how that nexus of the two fields and just some of your interest in a lot of the research you've done so far. So again, offering a unique and different perspective, which we appreciate so, welcome, Ming. Next, Peder Myhre. Peder, welcome. Dr. Peder Langeland Myhre: Thank you so much, Dr. Khera. This is Peder Myhre from Norway, all the way across the pond. And it's such a great honor to be part of this podcast, which I've been a big fan since it started a couple years ago and where Carolyn Lam has been doing with it, it's been really amazing. And I've actually been promoting it to everyone I know with any kind of interest in cardiology. My position in training right now is that I'm in the last year of cardiology training and I'm also doing a 50% post-doc at the University of Oslo with Professor Torbjørn Omland as a mentor. And as a part of my training, I was one year at Harvard University at Brigham Women's Hospital to do research with Professor Scott Solomon's group a couple of years ago. Dr. Amit Khera: Well, we appreciate your affinity and now you get to be on the podcast. That's pretty exciting as well. I should say, each of you is linked to an outstanding Associate Editor at your home institution. And so we're glad you have that mentorship as well there too. And speaking of someone at home institution, someone who I've known for a very long time, Dr. Sonia Shah. Sonya, introduce yourself, please.   Dr. Sonia Shah: Thank you, Dr. Khera. No, just to echo what everyone has said already, it truly has been an honor and a privilege to work with this awesome team. And it's been a lot of fun along the way. So I'm Sonia Shah. I'm a third year cardiology fellow at UT Southwestern in Dallas, Texas. Originally from Central Florida, actually. And then did my undergrad medical school training in Chicago and then went out to the West Coast for my residency training was out at Stanford and now I'm loving being in Dallas. So it's been a lot of fun. So I particularly have an interest in women's cardiovascular health and advanced imaging. And so currently looking for jobs now. Dr. Amit Khera: Well, I can say you've been a star fellow and have a really incredible and unique skillset. And, so we look forward to seeing what your career brings and certainly you've brought a lot to our podcast. And we'll talk more about that in just a bit, since you are longest standing social media editor currently. Well, I want to now dig in a little bit and you all again, I want to thank you for what you've done for the last several months. I certainly have learned a lot from you. We've had some discussions as a group about, thoughts about social media and how social media works. Dr. Amit Khera: And so maybe we'll start with the sort of existential question about, why social media? What is the value for journals, if you think about Circulation, but really any journal. What does social media bring? And again, you all have a unique perspective as largely fellows in training and Vanessa, maybe I'll go back to you a little bit about, why social media? What's the point of relevance about all this work that you're doing? Dr. Vanessa Blumer: Yeah. Thank you so much, Dr. Khera. I think that's a great question. And I do think that that's a question that we ask ourselves every day as we're doing this. I think the way that the medical literature has been evolving, it's been evolving in a way of social media and people are consuming more and more social media daily. I think in my own daily life, I discover articles that I'm interested in through social media a lot more than I used to before. And I also discover that I'm interested in particular articles, the way that they are transmitted in social media or the way that they're presented in social media. Dr. Vanessa Blumer: So I think we're reinventing ourselves and reinventing the way that we present to the public, the articles that we have in Circulation, so that people want to read our articles or want to read the articles that authors are doing such a great job at putting together. So I think, we are coming up with creative ideas every day and it's part of what we discuss as a group of how do we present this so that people want to read the articles and discover all the hard work that authors are putting together through different social media platforms. Because we know that people consume not just one social media platform, but several. So I think there's huge potential in social media if we use it in the right way. Dr. Amit Khera: Yeah. I think your points well taken. I know we're going to talk a lot about Twitter today, but as you pointed out, there are other media as well. That's just in the sort of main, I guess, currency and in the medical and cardiovascular literature. And you mentioned value to authors and one thing you mentioned, which I'll transition a little is about the way things are presented, help you get interested in them. And so that gets to the art of the tweet. Something we've talked about a little bit and, there's a little bit of on the job training, if you will. And we've talked about is there a gold standard in terms of what makes a good frankly, a medical journal tweet. Well, Ming, what do you think? You've been toiling over this for a few months now and tell us what you think is helpful in a medical journal tweet in terms of achieving the goals that Vanessa mentioned. Getting an audience interested in reading these articles is really doing justice for the authors to transmit their research. Dr. Xiaoming (Ming) Jia: Great question, Dr. Khera, and this is something that, as a social media editor, I'm still learning. So for me, writing a concise tweet is very important. Trying to get that essence of a entire study into a very limited number of characters. Obviously having a great figure that highlights the key findings of a study is also very important as well. Now at the same time, I think the most effective posts though, are those that serve as a hook for the paper. So, while we want are tweet to stand on their own. I think the most effective tweets helped to entice the audience to want to read a little bit more and go and read the entire manuscript. So certainly there is a art and skillset in terms of writing these effective posts. Dr. Amit Khera: Yeah. You certainly bring up some key points, right? So being concise, one by definition and but two is, there are tweets that sometimes can go on and on and that comes into using some interesting hashtags and some shortcuts. But I think your point about innuendo, enticing, not giving away the whole story, but just enough to get people to want to read more. And I think that that is an art. Dr. Amit Khera: And I've certainly seen as you all have done this more and more about how your own writing and tweets have evolved. Pishoy, we've talked a little bit about, all of you are researchers, you've all done some great research, about thinking about social media, sort of a research area. Again, since there's no gold standard about what's a great tweet, just thinking about it more of a discipline as we do any other area that we want to explore scientifically. What are your thoughts about, how do we figure out more, learn more about what makes a great tweet? Dr. Pishoy Gouda: Yeah. Evidence based tweeting is something that I've been interested in. Everything that we do, we want to make sure that we do it well and that we do it effectively and the same goes with social media posts. So what works, what raises interactions with our content. And that's something that other disciplines and advertising have been doing all the time and we should be doing the same as well. If our goal is to increase interactions with our content, then we want to make sure that we are doing it in the most evidence based way. And we've learned a few things. We know that cardiologists and individuals in medicine in general have been using Twitter much more frequently as a way to consume in both your medical and research content. Dr. Pishoy Gouda: So what makes a post great and what increases its interaction and the bottom line is we don't really know. We have a few studies and a few small randomized controlled trials that have been done that give us some insight. We know that vigor, that tweets that include images might pull readers to them a little bit more. But you know what exactly works. We have a lot of observational data, but we don't have a lot of high quality data that gives us the answer to this question. So what we've learned so far is use images, use links. If you can use graphical abstracts, that seems to help as well. But, it's something that we're continuously looking at and we're really excited to put together some new evidence coming up soon in the future. Dr. Amit Khera: Evidence based tweeting. I like it. As you and I have discussed, my predecessor Carolyn Fox had a randomized trail called Intention-to-Tweet using Circulation and then a follow-up study to that. So we hope to do also some good high quality research about social media and what works. Well, that gets to who's your audience, right? I always like to think about when you start something, who's your audience. And there could be lots of people. I think probably our strike zone is researchers, scientists, clinicians, of course, there's lots of lay individuals too, that are paying attention on social media. One thing that's different about Circulation than some other journals is this melding of basic science and clinical science. Some journals are all basic science and all clinical science and Circulation's both. Dr. Amit Khera: And I mean, frankly, that's posed an interesting challenge for this group. None of you are, including myself, are card carrying basic scientists, if you will. So we've had to translate those articles. And I would consider that both a challenge, but also an opportunity because, if we're speaking to a basic science audience, of course we may have one tone we use, but we want this basic science. I think that's the purpose of Circulation is basic science applicable to the clinician and clinical researchers. So, translating that's been a real opportunity. And Peta, maybe I can ask you about that opportunity of translating basic science for clinical researchers and clinicians. Dr. Peder Langeland Myhre: Yes. I completely agree. And I've learned so much from this job as a social media editor to really try to get the essence out of a basic science paper and the translational outlook for clinicians. Because all of the papers that are basic science that at least I came across in Circulation also have a clinical implication and a translational side of it. And I think when we read these papers and try to sum it up in one tweet, we want to keep the most important essentials of the basic science, but also extend it to clinicians so that they understand in what setting and what this can potentially mean in the future. So for me, that's the biggest challenge when we review basic science papers, but it's also perhaps the part of this job that I learn the most. Dr. Amit Khera: Yeah. I agree. I think we're all learning a lot. I've certainly learned a lot by delving in deeper into the basic science papers and figuring out how to translate them appropriately. And I think this really highlights, as you mentioned, what Dr. Hill our Editor in Chief, his feeling is basic science papers in Circulation all have to have important clinical implications. That's the benchmark, if you will. So I think we've seen that shew in terms of what papers have come across for you all. Dr. Amit Khera: Well, I'm looking now at our longest standing social media editor, Sonya Shaw, she started a few months before as sort of a transition because we certainly wanted someone in place that could help bridge between the old and the new. And Sonya, you've had a decent amount of experience now with two editorial teams. Tell us what you've learned so far by working as a social media editor at Circulation. What are some of the observations you've had and some of the things you've learned in this space? Dr. Sonia Shah: Yeah, certainly. So I think a couple things. I think my ability to accurately and concisely convey the important key points from each journal has definitely improved. But I think the other unique thing, unique perspective that we gain as social media editors is getting to actually see the behind the scenes workings of how the journal works and how papers are put together and accepted. And so I think it's been interesting to see how papers are being analyzed and the teamwork that's required by the Associate Editors and the Editors and making sure to do each paper justice and properly evaluate it. So I think that's been a really cool experience. It certainly has improved my ability to write when I try to think of, what are the key points I want to include. And how to convey information in a way that will be appealing to journals. Dr. Amit Khera: Well, thank you for that. We take this job very seriously, as you all have in that point about doing each paper justice, because you've seen, one, from the author's perspective about how much work they put in and you've been an author before and want to make sure that we appropriately appreciate that. And then also the Associate Editors, there are hours and hours of work for each paper. So even though it comes out, maybe in a few characters in a tweet, we appreciate all that's going behind it. And I'm glad you've gotten to see that process through. Ming, maybe I can come back to you. What have you learned so far by working in Circulation for the last few months? Dr. Xiaoming (Ming) Jia: I do want to echo what Sonya just said in terms of really getting a glimpse of the behind the scenes work is quite amazing. The amount of work and coordination it takes to get a paper from publication to promotion. And, we don't really get that exposure as a author for a manuscript or even as a peer reviewer. So, that part has definitely been a great learning experience. On the other side, I do find it interesting that ever since taking on this role as a social media editor, my way of writing has changed as well. So, trying to be more efficient, getting key points across and really being concise and focused in my manuscript writing. So that's been very helpful from a personal level as well. Dr. Amit Khera: We're very thankful for that. I think we always want this to be bidirectional where you all are contributing in meaningful ways. But that the goal here with fellows in training in this role, social media editors. But for you all to be learning something as well. So I'm glad that that has occurred. And we'll talk more about that in just a few minutes. Dr. Amit Khera: Well, we have a couple of international social media editors and this is my intention. We want to make sure we have a diverse group of social media editors. By background, by thought, by location. And, one way that the beauty of that is again, we get different perspectives. I guess the downside is time zones. We were just joking before, as we were starting this podcast about some of us are very early in the morning and one of our social media editors unfortunately is always late at night when we have our meetings. Peta, tell us a bit about unique observations from an international perspective. You said you've been following Circ for a while, but tell us, from your perspective in Europe, the social media process and how you see it. Dr. Peder Langeland Myhre: Thank you so much. And it's actually been a really transformation for me from before I spent my year in Boston to after. Because I really learned the potential of using social media and especially Twitter to stay updated and get the latest papers and thoughts from experts in the field. And I remember before I went there, I was often very frustrated that it was so inconvenient to get across important papers that was within my field of interest. Because all the journals were not longer sent in paper to our hospital and the websites were confusing. Dr. Peder Langeland Myhre: So when Dr. Vaduganathan at the Brigham & Women's Hospital introduced me to Twitter, that really was an eye opener for me. And, ever since that, 90% of the papers that I read I first see on Twitter. Because that's the first place, the people that are within my field, publish it or tweet it. And also I'm able to, you follow a certain amount of scientists and physicians and they have the same interest as you. So it's also, most of it is relevant for what I want to read. So it's really been a revolution for me to start to use Twitter and social media for medical and scientific purposes. And not only for friends and family. Dr. Amit Khera: Yeah. I think it's some great points. One, is even simplistically just be able to access articles, which we don't always appreciate, from people from around the world. And then obviously what many can, is follow people that have similar interests and amazing to see sort of how different people consume the literature. And for you Twitter being your entry point, I guess, for how you do that, which is I'm sure many, many people do the same. And we have another international editor you met earlier. Pishoy, tell us your perspective. And obviously you're in Canada now and have moved many places. What's your perspective from an international perspective, looking at social media? Dr. Pishoy Gouda: Coming to work at Circulation, I expected a very niche editorial board, but what I'm really finding out is boy, does it take a village. And it is people from all over the world. And it really hits home that collaboration and research has become a global phenomenon. And to be able to do art well and to appropriately represent researchers from across the world. We have an editorial board and team that is global and it really does take a village to take a paper from submission all the way through the publication team, starting from the authors to the peer reviewers, editors. But then the entire post-production team, which is behind the scenes and don't get a lot of glory, but they do a lot of the heavy lifting to make sure that, the research that's submitted gets in front of readers. And that's something that I hadn't really thought of before. And it's been really interesting to see how that process unfolds. So that's definitely been eye opening for me. Dr. Amit Khera: Well, I appreciate what you said about, when it takes a village and I would be remiss if I don't always call out Augie Rivera, who is the engine and mastermind behind Circulation, who's helping us do this podcast today and every week. But the other part is the international workings I think many may not appreciate. We have editorial board meetings every other week at very different time zones on purpose because we have people in Europe and in Asia and in Africa. And as you know, Dr. Lam who's the main podcast editor is in Singapore. Dr. Amit Khera: So, this is by intention. It really gives us a wonderful international perspective. And so we're so glad to have you two as part of our international team. Well, I think that's a great transition, a little bit to just talking about fellows in training and involvement in journals for Circulation perspective, and from the AHA, I should say, getting fellows in training involved in cardiovascular research, the editorial process, this is something that's really important to us and something we continually strive to find new ways to do. So, Vanessa, I'm going to come back to you. I know, not just at Circulation, but I know at other journals you've had some responsibilities. Tell us a little bit of what you tell other fellows in training about getting involved in journal activities. How to, and what's the benefit. Dr. Vanessa Blumer: Thank you so much Dr. Khera. I think this is such an important question. First my recommendation is, get involved in one way or another. I think there's different ways of getting involved as simple as just start reviewing articles. And the reason I say this is as I aspire to become an academic, a well-rounded academic cardiologist, I think my involvement with journals has just made me a much better researcher, a much better academic cardiologist. It's made me, I think, Sonya said this so well, it's made her a better author. It's made me a better writer. So I think it compliments what you do just so much better. I think you're better at what you do when you see the behind the scenes and you understand what happens in scholarly publishing. So I think there's different ways of getting involved. I know that Circulation has many and then probably a good way is to reach out. Dr. Vanessa Blumer: I know that people can reach out to us and we can probably guide them along the way, but different journals have different ways of getting involved. But I think if you want to start, one way is start reviewing. You learn a lot through the review process in itself on how an article is structured. And there's some journal that have a little bit more of a mentorship approach towards reviewing. And, that's also a good way starting out. When we start off as residents, we get some papers get in our inbox to review and we really don't necessarily know how to approach it. So maybe a mentorship approach to it is a good way to start. But overall, I would just say, start getting involved. I think it's a great experience. Personally, I have learned so much from it and I think I'm just a better academic cardiologist because of it. Dr. Amit Khera: Thank you for that. And I think your point about just find ways to get involved. And I think our challenge is to continue to facilitate ways for trainees, fellows in training and others to get involved. But I think that that first step in finding maybe a mentor of your institution that could help guide you would be important. And I'm going to finish with Sonya. I'm going to come back to you. You've not only had the social media editor window for quite some time. Being at Circulation, you get to see behind the curtain perhaps more than others because, Circulation is such a big part of what we do at UT Southwestern. And, we've had this Fellow Reviewer Program where you've been able to participate in reviews and things like that. From your perspective, maybe telling the fellows in training, listening out there about getting involved in journal activities, the value that you've seen and how to do so. Dr. Sonia Shah: Yeah, I think that's a really important question. At the end of the day, the ability to read and interpret and take away the major conclusions and properly interpret a study is a skill. And so I think the more you do it, certainly the better you get at it. And being part of a journal being on the reviewer end, being on the end where you're creating social media posts is really an opportunity to develop and refine that skill. And so to all the fellows out there who are interested, regardless of whether you want to do academic cardiology or not, it is an important skill, even in the future, to be able to read and properly interpret studies. So I highly recommend it. I find for me, I've definitely learned a lot through the process and have certainly improved. Dr. Amit Khera: Well, there you have it, our five social media editors. First, I want to thank you all for your contributions to Circulation. You're an incredibly bright group as everyone learned about. I have future leaders in cardiology. And we're very fortunate to have you contributing to Circulation and to our authors and readers. So thankful to have you as part of Circulation and look forward to working with you and innovating and coming up with some creative, new ways to think about social media and ways to transmit research for journal. Dr. Amit Khera: Well, I think there you have it. Again, I'm Amit Khera. I'm associate editor and standing in this week for Carolyn Lam and Greg Huntley, who will join you again next week. So thank you for joining us for Circulation on the Run. Dr. Greg Hundley: This program is copyright of the American Heart Association 2021. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more visit ahajournals.org.

For this week's podcast, we had a special interview with Kerry Bannigan, Executive Director of The Fashion Impact Fund, and Lucie Brigham, Chief of Office at the United Nations Office for Partnerships. Together Ms. Bannigan and Ms. Brigham have coordinated their efforts to help the global fashion industry to be more sustainable. During our not-to-be-missed interview, we examine a wide range of issues facing today's textile and apparel industries including the importance of sustainability from both the practical level industry production, supply and distribution, to policy initiatives to help guide the industry to better, more equitable ways of conducting business. Additionally, we discuss their joint initiative at the Conscious Fashion and Lifestyle Network to bring about positive change in the textile and apparel industry around the world and to help the industry to be better stewards of the planet's environment. Hosted by Jennifer Crumpler, Fiber Development Manager and Manager of the e3 Sustainable Cotton Program from BASF, and interviewed by industry consultant Bob Antoshak.

I had the opportunity to speak on a panel for the development of a new chronic pain app. There were three of us that were practitioners on that panel. It was myself, a social psychologist and our guest, Dr.Natalie Dattilo. We were fielding questions both from people living with pain as well as practitioners. I had the opportunity to get to know Natalie and I wanted to share her with you and introduce you to her because I found her approach to be very refreshing. For me, it was refreshing even though we know that mental health is finally getting the attention it deserves both in pain care and other aspects of illness.   What I like about her approach is that she focuses on well-being and resilience. Instead of focusing on what's wrong, she's focusing on what can we improve and how can we improve someone's resiliency so that they can cope and overcome whatever physical or mental health challenge that they're facing.   She is a licensed Clinical and Health Psychologist who specializes in the treatment of depression, anxiety, stress as well as insomnia. She provides psychological evaluation and treatment at Brigham Women's Hospital and is an Instructor of Psychiatry at Harvard Medical School. In this episode, we discuss the intersection between self-care and resiliency, when it comes to living with chronic pain or another challenging health condition.   We discuss why self-care is important and how self-care is related to resiliency, how to build resiliency, as well as the barriers that might show up as you start to engage in a self-care routine. The rates of depression, anxiety as well as chronic pain skyrocketed during the COVID-19 pandemic. This is an important episode to share with your friends, family as well as the patients that you treat. There's no time like a depressant to take stock of how you're doing mentally, physically as well as emotionally and to develop a self-care routine that will contribute to resiliency. Without further ado, let's begin and meet Dr. Natalie Dattilo.   Love the show? Subscribe, rate, review, and share! Here's How »   Join the Healing Pain Podcast Community today: integrativepainscienceinstitute.com Healing Pain Podcast Facebook Healing Pain Podcast Twitter Healing Pain Podcast YouTube Healing Pain Podcast LinkedIn Healing Pain Podcast Instagram

Guest: Muthiah Vaduganathan, MD, MPH What do we currently know about the cardiac consequences of the COVID-19 vaccines? Dr. Muthiah Vaduganathan, cardiologist and investigator at Brigham Women's Hospital at Harvard Medical School, addresses the cardiac concerns surrounding the vaccines and how we can talk to patients about them.

Despite pain being one of the first attempts at "medicine" by early humans, pain as a medical discipline is relatively young.  Today on Health Is On The Way we are joined by pain physician Dr. Mihir Kamdar from Massachusetts General Hospital's Cancer Pain Clinic to discuss: What pain is. The important role pain plays as an alarm system for injuries to our body. Why pain is connected to our fear and anxiety centers in our brains. How mood impacts pain for patients. Why for some people pain can become chronic or persistent, even after the underlying injury has healed. How multi-modal treatment models address not just the physical but also the  psycho-social needs of pain patients. The fact that true multi-modal pain care is inaccessible to most Americans and how digital health programs like Fern Health can scale to help solve that. How medical professionals have shifted the focus from patient pain scores to quality-of-life metrics in response to the Opioid crisis. The ripple impact unresolved pain can have on patient's familes, social circles, employers and society. About Our Guest Dr. Mihir Kamdar graduated from the Emory University School of Medicine, then completed an Internal Medicine Residency at Brigham & Women's Hospital. From there, Dr. Kamdar completed a fellowship with Harvard Palliative Medicine and a Massachusetts General Hospital (MGH) Anesthesia Pain Medicine fellowship. Following these experiences, Dr. Kamdar became a Staff Attending, Palliative Care and Anesthesia Pain Medicine at Massachusetts General Hospital (MGH) where he is now an Associate Director, Palliative Care Division, Department of Medicine, and Director of Cancer Pain Clinic and Attending, Palliative Care and Anesthesia Pain Medicine at MGH. In addition, Dr. Kamdar is an Instructor in Medicine at Harvard Medical School.   This episode is not medical advice nor does MGH or Dr. Kamdar endorse any treatment or program like Fern Health mentioned in the episode.  Please consult your own medical professional for your medical needs.

In this session host Stephen Wood speaks with Dr Louis Nguyen and Dr Liz Yates, surgeons and researchers at the Brigham and Women's Hospital in Boston discuss the impact of climate change on healthcare and patient outcomes. Dr Yates and Dr Nguyen discussed the large carbon footprint of the healthcare industry, especially in developed nations. This includes the large amount of waste that stems from pre-made kits as well as other disposables. Similarly, the amount of energy that is dedicated to healthcare accounts for a large carbon footprint among industries. This leads to a discussion on the impact of climate change on patient accounts. The focus was on surgical patients and how issues like heat islands and lack of access to air conditioning can result in higher morbidity and mortality. This extends to other patient populations including OBGYN patients, pulmonary patients as well as the vulnerable young and elderly. More concerning is how this impact seems greater for marginalized and underserved populations. The group spent the remainder of the conversation discussing how everyone can make an impact with even small, local actions. Louis Nguyen Bio: Dr Louis Nguyen is a vascular and endovascular surgeon at Brigham & Women's Hospital and Associate Professor of Surgery at Harvard Medical School. Within the Department of Surgery, he serves as the Vice-Chair for Digital Health Systems; and within the Division of Vascular & Surgery, he is the Director of Clinical and Outcomes Research, as well as the Director of Quality, Safety, and Value. His interest in Environmental Sustainability focuses on minimizing the environmental impact from healthcare through education and implementation programs Liz Yates Bio: Elizabeth Yates, MD, MPH is a general surgery resident at Brigham and Women's Hospital.  She has completed three years of clinical training and is currently completing a research fellowship at the Center for Surgery and Public Health, focusing on sustainable surgical care delivery and the impact of climate change on surgical outcomes. Show Notes: Matthew J. Eckelman, Kaixin Huang, Robert Lagasse, Emily Senay, Robert Dubrow, Jodi D. Sherman. Health Care Pollution And Public Health Damage In The United States: An Update. Health Affairs, December 2020 Rizan C, Steinbach I, Nicholson R, Lillywhite R, Reed M, Bhutta MF. The Carbon Footprint of Surgical Operations: A Systematic Review. Ann Surg. 2020 Dec;272(6):986-995.

Caroline McGuirk is an inflammatory breast cancer patient at Dana Farber.  Caroline was experiencing some skin changes on her right breast beginning in September 2020. While it wasn't overly alarming, she thought she had an infection, which the Web told her often clears itself.  She underwent 20 weeks of chemotherapy, followed by modified radical mastectomy and then 6 weeks of radiation. Dr Fliipa Lynce received her medical degree from the Universidada Nova de Lisboa, Portugal in 2004. In 2020 she joined the staff of Dana-Farber Caner Institute and Brigham Women's Hospital, where she is a medical oncologist and clinical investigator in the Breast Oncology Center  See omnystudio.com/listener for privacy information.

Dr. Hayes interviews Dr. Sarah Donaldson and her pioneering work in pediatric radiation oncology.   TRANSCRIPT SPEAKER 1: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. [MUSIC PLAYING] DANIEL HAYES: Welcome to JCO'S Cancer Stories: The Art of Oncology, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insights into the world of cancer care. You can find all of these shows, including this one, at podcast.asco.org. Today my guest on this podcast is Dr. Sarah Donaldson. Dr. Donaldson has really been instrumental in much of the development of both, in my opinion, modern radiation oncology and especially related to pediatric radiation oncology. Dr. Donaldson was raised in Portland, Oregon. She received an initial undergraduate and nursing degree at the University of Oregon in Eugene and ultimately in Portland. After a few years working as a nurse with Dr. William Fletcher, who I hope we'll get a chance to talk about later, she elected to go to medical school and spend her first two years at Dartmouth and then finished with an MD from Harvard. She was planning to do a surgery residency at the Brigham Women's in Boston but then elected to do an internal medicine internship at the University of Washington and ultimately then a residency in radiation oncology at Stanford. After a residency and a few side trips along the way, she joined the faculty at Stanford and has remained there since. Dr. Donaldson has authored nearly 300 peer-reviewed papers, probably more than that by now. That was when I last looked at her CV a couple of weeks ago, and it seems like she brings them out every week. She has served as president of the American Board of Radiology, the Radiology Society of North America, and the American Society of Therapeutic Radiation Oncology, ASCO's sister organization, of course-- ASTRO. And she also served on the board of ASCO, the board of directors, from 1994 to 1997 and, in my opinion, perhaps as importantly, on the board of directors of the ASCO Foundation for over a decade. She has way too many honors for me to lay out here, but a few that caught my eye. Named after a distinguished scientist in the past, the Marie Curie award for the American Association of Women Radiologists, the Janeway Award from the American Radiation Society, and the Henry Kaplan Award for Teaching from Stanford. And she was the inaugural recipient of the Women Who Conquer Cancer Award from our own Foundation, the Conquer Cancer Foundation. Dr. Donaldson, welcome to our program. SARAH DONALDSON: Thanks so much, Dan. It's a privilege to be talking with you today. DANIEL HAYES: I hope I got all that right. It's pretty tough to cram the distinguished career you've had into about a minute. [LAUGHS] Anyway, I'm going to start out. So I've interviewed a lot of the luminaries and the people who really started our fields or even the subfield within our field, and you yourself had quite a journey. I know you started out as a nurse. Can you just give us some background about going to nursing school and then who and what influenced your decision to become a physician? SARAH DONALDSON: Yes, I did. I can, Dan, and it's an interesting story. Because when I grew up, girls that wanted to go on to college-- and it wasn't all girls didn't go to college, but I did. The three areas that one could do in that era were become a teacher or maybe a librarian or a nurse. And so I elected to become a nurse, and I went to nursing school. And I loved nursing school. I had a terrific time in nursing school, and along the line, I met the house officers and such and ultimately got to know a surgical oncologist. That was before surgical oncology was a field, but a young man from the Boston City Hospital training program, which was a very good surgical training program at the time, who was recruited to the University of Oregon to start a cancer program. His name was Bill Fletcher-- William S. Fletcher. And when I graduated from nursing school, Bill Fletcher was looking for a right arm assistant. He was looking for somebody to help him develop a cancer program. And he offered me a job, and the job was to work with him in the operating room, either scrubbing or circulating, to run his tumor board-- and that meant just scheduling it and taking notes and such-- and working with him in his tumor clinic. And in the tumor clinic, he was at that time beginning clinical trials, and Oregon was part of something that was called the Western Cancer Chemotherapy Group, which ultimately merged with SWOG. But at that time, his helper-- me-- filled out the forms, and we sent them to patients that were entered onto the study and got consents and measured lesions and that sort of thing. And I worked hand in hand with him. In addition to working with him in those clinical parameters, he gave me a little laboratory project, and so I worked with him in the lab and learned a little bit about small animal oncologic research, et cetera. And after a couple of years working with him, he suggested that I would be a better employee if I took some additional courses, and he suggested that maybe I should take physics because at that time he was doing isolation perfusion. I was running his pump oxygenator. He asked me what I would do if there was a pump failure. I didn't know. And he said, well, I think it would be good if you took physics. Well, the prerequisite to physics was organic. I hadn't had organic, and he was also working with radioisotopes in the lab. And he said, you could really be more helpful to me if you could work in the lab. That meant I had to take organic, and the prerequisite to organic was inorganic. To make a long story short, I took these series of classes in night school while I was working for Dr. Fletcher in the daytime. And then one night, I was working on my hamster project, and he said, I think you should go to medical school. I said, I can't go to medical school. And the long and the short of it was Dr. Fletcher thought I should go to medical school, and he made that possible for me. It's a very, very interesting story, but what it means is that I was mentored by somebody who was a visionary, and he could see a lot more than I could see. And he got me excited about medical school and everything that I knew about medical school is what he had taught me, so I of course wanted to be a cancer surgeon. And then after I went to medical school and I went to the same medical school he did, I just followed his advice. Every time I needed some guidance along the way, I asked Dr. Fletcher what I should do, and he told me what I should do, and I applied. And that's what I did. And so when I came time to choosing a specialty, I decided I would train in surgery, and I applied at the Brigham and was accepted into their surgical program. It was run by Francis Moore at the time. And that was a big deal because they hadn't had women in their surgical field, and I was very excited about all of that but feeling totally inadequate because I didn't think I knew enough medicine. And so I went to Dr. Moore and said, I think I'd be a better house officer if I knew some medicine. He says, OK, well, go take a medical internship, and we'll hold you a spot. So I went to the University of Washington and took general medicine, which was a very vibrant program, a really exciting program, and I just came alive in my internship. I loved everything about it. And then I decided I wanted to be an internist. So at this point, I was offered a position in Washington, and I had already accepted Dr. Moore in Boston. And I didn't know what to do, and I asked Dr. Fletcher what I should do. And he said, Sarah, the world of-- he called it radiotherapy at the time, but what we would call radiation oncology-- needs more surgically oriented physicians. I think you should go down and talk to my friends at Stanford. So I came down to Stanford. I met Henry Kaplan and Malcolm Bagshaw and the leaderships in the department, and including Saul Rosenberg, who was one of the people who interviewed me, and I left that day visiting at Stanford making a commitment that I would come to Stanford as a radiation oncologist. So I wanted to do everything, and I met some very inspiring people along the way, perhaps like you have in your own career. And it's for that reason that I am now excited about mentoring because it's a little bit of payback because somebody opened the door for me and made it possible for me to have a most gratifying professional career, and I would like to do that for as many people as I could. DANIEL HAYES: I love that story. And there were two things about it that came out. One is I normally don't like people who namedrop, but when you can namedrop the names you just dropped-- Bill Fletcher, who I consider really one of the early surgical oncologists, Henry Kaplan, Saul Rosenberg, Franny Moore. I was in Boston of 15 years, and he was a legend. He was not the chair anymore by any means. In fact, he passed away. But it was legendary. You should be doing these interviews instead of me. [LAUGHS] You've been there. SARAH DONALDSON: Well, it's all about where you are at the time you are and meeting the right people. I think so much of my gratifying career is just because I happened to be at the right place at the right time and met the right people. DANIEL HAYES: Well, the other thing I want to say is I always believed I don't trust people I interview who say they know exactly what they want to do. And the reason I say it that way is I have a young woman who's been a technician in my lab that just got into med school, and she sat with me and said, now, when I go there, should I tell them I know exactly what I want to do? Because she's interested in the oncology. Or should I go through my rotations and see what I like? And I said, I forbid you from going there knowing what you want to do. Go to your rotation. See what you like. You're going to run into somebody who just inspires you beyond words who-- I don't know-- maybe selling shoes. But whatever it is, become like her, and you'll be extraordinarily successful. So if there are young people listening to this, I think that your story, Dr. Donaldson, is a classic for that, the way you kicked around. And actually, you didn't tell us, but I'm going to have you tell us about your trip to Paris and that experience too and how that influenced you. SARAH DONALDSON: Oh, that was another wonderful opportunity. When I finished my training, it was 1972, and that's when America was in the Vietnam War. All of my classmates were being recruited to a mandatory draft and were having to go to Vietnam, and I felt like I too should be just like all of my best friends and I too should join the military and go to Vietnam. But that wasn't possible. Women couldn't do that. So I looked for things that I could do where I could do something useful, and I thought about joining the ship Hope and all sorts of fanciful things, but basically I was lost, and I didn't know what I wanted to do. And at that time, there wasn't a carve-out of pediatric oncology as a specialty. It hadn't been defined, but there were people that were doing pediatrics. And as a resident, I had had a little rotation at the M.D. Anderson, and when I was in medical school, I had spent a fair amount of time at the Boston Children's, so I kind of knew a little bit about those institutions. But the thing was at Stanford, I knew that I wanted to be at Stanford. But Stanford didn't have a cancer program either. And so again, I went to Henry Kaplan and Malcolm Bagshaw-- at that point, Kaplan was head of the department, and Malcolm was his associate director. But they changed positions about a year after that. So I trained under both of them, really, but I went to Dr. Kaplan and said, I'm interested in pediatrics. And I said that because we didn't have a program at Stanford and that was like a carve out that nobody had addressed yet. And he said, oh, well, if you want to study pediatric cancer, you have to go to the Institute Gustavo Roussy and train under Odile Schweisguth. And I said, no, I don't speak French. I can't do that. I'd like to go to London because I like the theater. And he said, no, no, no, no, no, that's not the way it is. If you want to be a pediatric doctor, you have to go learn pediatrics and learn to think like a pediatrician, and that means you have to go and train under Odile Schweisguth. She was at the Grand Dame of pediatric oncology. She took care of all the children in Western Europe. And so I went to Institute Gustavo Roussy to be a fellow in pediatric oncology, although I did spend some time on the radiotherapy unit as well. But that's where I learned pediatric cancer because I learned from Odile. And in French, there's a formal and an informal, and I never understood the formal because when you talk to kids, you talk in the familiar form. So I was just talking to and not [SPEAKING FRENCH]. I would just say, [SPEAKING FRENCH] and such. [INAUDIBLE] French. And that's how I learned French. More importantly, I learned the biology of cancer from Odile. It was largely observational. And I learned a lot of late effects of children who were cancer survivors. So when I came back to Stanford, at that time Mal Bagshaw was chair, and he said, well, why don't you work on starting a cancer program? We'd like to have a cancer program. So I worked with the pediatric cancer doctor at Stanford. His name was Dan Wilber, and he had just come from the M.D. Anderson. And the two of us started a cancer program at Stanford. And so I've been kind of doing that ever since, of doing pediatric cancer. So I would say my skill set came along just because the right people told me where to go at the right time. DANIEL HAYES: Were the pediatricians welcoming, or did they resent the fact that you'd never been a pediatrician? SARAH DONALDSON: Malcolm Bagshaw gave me the clue to that by saying the only way the pediatricians will accept you is by having them accept you is one of their own. So you have to learn to think like a pediatrician, and then they will accept you onto their team as one of theirs because pediatric doctors are very possessive about their patients, and pediatric cancer doctors are possessive about their patients. So it worked for me. But it worked because I had had this special training under Odile Schweisguth, who was a general pediatrician, and so I was accepted because I was at that point thinking like Odile thought because that's what she taught me how to do. So I always felt like I was accepted by the pediatric cancer doctors who then became the pediatric oncologists because that field didn't really open up for a couple of years later. DANIEL HAYES: For our listeners, Dr. Donaldson and I have not met before, and I certainly have never worked with her. But she's talking, she's glossed over that when you work with the French, you really have to speak French. When you work with the pediatricians, you really have to speak pediatrician. And you've managed to do both of those. I don't know anybody who's been that successful. I should take a sabbatical and come work with you. [LAUGHS] SARAH DONALDSON: Well, I'll tell you, Dan, there was one wonderful thing that happened because shortly after I was working at Stanford doing pediatrics, our dean wanted to recruit some more people and buff up our pediatric cancer unit. And he recruited Michael Link, who had just come out of his training at the Dana Farber. And so Michael and I started working together his first day as an assistant professor at Stanford, and pediatric oncology is a team sport. Pediatric radiation oncology is a team sport. And I had a wonderful teammate, Michael Link, with whom I worked very well, and we became very fast friends. And we did pediatric lymphoma and sarcoma, bone sarcoma, and soft tissue sarcoma, and all sorts of stuff. And I had a wonderful, wonderful colleague working with Michael Link. So one of the keys to my most gratifying part of my career at Stanford has been working with Michael Link and his associates. DANIEL HAYES: As an aside, by the way, Michael and I overlapped just a little bit at Harvard, but then he proceeded me as president of ASCO by two years, and we got to be pretty close friends during that period of time. And I echo your fondness for him. He's just an amazing human being, as far as I was concerned. And he's one of the-- he may be-- I'm trying to think, has there other pediatricians that have been president of ASCO? I'm not-- SARAH DONALDSON: No, he was the first. Yeah, he's the only one to date. DANIEL HAYES: Yeah. And he left a big stamp on the society in terms of-- we always had some pediatrics involved-- you, especially-- during the years, but as president, he was able to leave a big footprint of what we do. So he was terrific. I'd also like you to talk a little bit about the early days of the co-operative groups. You threw out that you were in the Western Group that became part of SWOG, and what were the hurdles and obstacles to getting all these folks to work together? And what do you see the pros and cons of the cooperative groups in the country? SARAH DONALDSON: I know the cooperative groups mainly through the lens of the pediatric cooperative groups. I mean, I can tell you about the adult ones, but I really know the pediatric ones. And at the beginning, there was one, and then there were two. And we worked competitively, and then ultimately the pediatric doctors learned early on that the children they took care of had rare tumors, and no one physician had a whole lot of experience with any cancer. For example, this tells the story well. When Hal Maurer was chairman of Pediatrics at Virginia, he had a child with rhabdomyosarcoma. And he called his friend Ruth Hein, who was at Michigan, and said, Ruth, I've got this child with rhabdomyosarcoma. Have you ever treated a child like this? And Ruth said, oh, I had one patient, but I think you should call Teresa because Teresa, I think, had a patient. And so Teresa Vietti was at Washington University, and so Hal Maurer and Teresa Vietti and Ruth Hein and a few other really, really pioneers started to throw their lot together and decided that the way they could answer a question about these rare tumors is by deciding what was the question of the day and working collaboratively. And then Hal Maurer became the first chair of what was then called the Innergroup Rhabdomyosarcoma Study, which has now been merged into the other pediatric groups. But that same process that worked for rhabdomyosarcoma was then employed for Wilms tumor, and then subsequently down the line, brain tumors and all the other solid tumors. And of course, St. Jude was doing this with their leukemia studies and Dan Finkel, and then Joe Simone did it with leukemia. They got everybody to join in on their team, decide together around the table by consensus what is the question that we want to have an answer for, and then just treat all the patients in a consecutive fashion, analyze those, and then take that step and go on and build to the next step. That's how the pediatricians have done it because their cancers are so rare that one person doesn't have very much experience. They have to throw their lot together and work collaboratively. So they don't work competitively. They work collaboratively. DANIEL HAYES: This is very similar to the stories I of course heard from Drs. Frei and Holland that they came ultimately to CALGB to be after a couple of mis-starts. But it's one of the things I worry about COVID. It's not the same Zooming with somebody or talking on the phone as it is sitting around dinner and just saying, maybe we could do this and make it work. So I'm hoping young people are listening to this and saying, OK, maybe we can start something new that a bunch of us work together and get things done. That's a really great story. You were early on and ended up taking both diagnostic and therapeutic radiology boards, correct? When they were combined? SARAH DONALDSON: No, no I didn't. Radiology was combined at that time, but Stanford was one of the few institutions that had a carve-out for radiation oncology without diagnostic training, and I wasn't in the first class. I was in the fourth or fifth class, so my formal training was only in what was called radiation therapy, now called radiation oncology. So it was one department, and I worked collaboratively with a diagnostic radiologist because I knew nothing about image interpretation-- nothing at all. So I'd see an X-ray. I didn't know how to interpret it, and I'd have to go and ask for some help. But they were like our best friends. But the diagnostic people could take the picture, but the therapists had access to the patients. So that made all the difference in the world because we really had access to the material, the clinical material or the blood or the bone marrow or the biopsy specimens or whatever it was, and allowed us to do studies. But to clarify, no, I was not. I do not have formal training in diagnostic radiology, although I have worked with them so closely now that I feel like they're all my brothers because you cannot do radiation oncology without collaborating closely with the imagers. DANIEL HAYES: And my first interview was with Sam Helman. This has been three or four years ago. And he was still lamenting the split because he thought it was to learn both-- and for the reasons you just said. If you don't know where it is to shoot your bean, you can't shoot your bean. That's not exactly what he said but something like that. On our side, they team hematology and oncology. Like you, I never got trained in hematology. I only trained in solid tumor oncology, which has not hurt me in any way. In fact, in many respects, I focus my efforts on things I seem to know about and let somebody else worry about blood clotting. Of all the things you're well known for-- and again, it was hard for me to get it all into a minute or two, but probably teaching and mentoring. And in this conversation, I see why. Tell me how you think that's evolved in your field, especially in radiation oncology, teaching and mentoring, and the importance of the things you've done-- and perhaps some of the people you have trained yourself and you're proud of. SARAH DONALDSON: Well, when I think of all the things that I love about my professional career, I love taking care of patients. And I've had very joyous experiences of watching pediatric cancer patients grow up and watching them in their process and treating them when they're toddlers and then getting invitations to graduations and wedding invitations and baby announcements and following through that. That's very, very gratifying. But the single most important and most gratifying part of what I do is the volumetric feedback and gratification from training residents because one patient is one patient, but one trainee then goes into academic medicine and that person has 30 or 300 or 3,000 trainees. And you see your impact is just explosive. And Stanford has had a training program in radiation oncology from the very, very beginning. It was one of the first programs that did train in radiation oncology, so a lot of talented people have come through Stanford. They need to have what Bill Fletcher did for me, which was open doors and help them with networking and giving them an opportunity and giving them some guidance and being their new best friend. When your trainees trust you like that, then you can really, really have a relationship, and you can really help them. And so I am very, very, very proud of our trainees that are now all over the place as cancer center directors or directors of departments or divisions that are doing what they're doing. You just meet the best of the best. That is the most gratifying part of-- maybe it's because that's what I'm doing now, but it's the most gratifying part of medicine that I've experienced. DANIEL HAYES: This is the third time I've said this on this call-- I hope there are young people listening, and I hope they're looking for a mentor and they can find someone as generous and trusting and helpful as you have been. SARAH DONALDSON: Dan, let me just say one little thing. DANIEL HAYES: Yeah. SARAH DONALDSON: It was extremely helpful to me-- and wonderful recognition for ASCO-- to provide the opportunity that I received the Women Who Conquer Cancer Mentoring Award. Because when I won that award, I was the inaugural-- but when I won that, all of a sudden people thought that I knew something about mentoring. I'm not certain I did know anything about mentoring, but I was asked to talk about it and asked to give advice, et cetera. And it gave me a carve out that was quite novel at the time, and now, of course, it's a mandated requirement in every training program, et cetera, but it wasn't then. And for me, it was just to return what Bill Fletcher did for me. The only way I can say is that it's a pay out, and it's so gratifying. It just makes you happy to get out of bed every morning and interact with the people you do interact with. DANIEL HAYES: He was pretty young when he began to mentor you. And I think having seen and been mentored and mentored other people, I always worry about a young person trying to mentor because you've got your own career to worry about, and it's hard not to be selfish when you're building a career in academics. He must have been a remarkable-- is he still active? Is he still around? He must have been a remarkable guy. SARAH DONALDSON: He was a remarkable guy, and no, he passed away. But that was true. And that is true because junior faculty are busy making their own professional career, and they don't have time. They're busy on their own path, and it's a hard path to go on. So most junior faculty don't really have very much time to do formal mentoring. But in Bill Fletcher's case, we worked hand in hand as sort of partners. And so I think, in some ways, I was helpful to him because I could do literature searches for him. I could write the first draft of his paper. I could write the first draft of his grant. I filled out the forms. I did a lot of things that were labor saving for him, but for me, what was he doing for me? He was teaching me to suture. He was teaching me how to resect normal [INAUDIBLE]. He was teaching me lymph node drainage from cancers. He was teaching me about drug metabolism, methotrexate, and phenylalanine mustard. And 5-FU was an experimental agent. So was vincristine-- those kinds of things. So I learned a lot from him just in the ordinary practice of taking care of the patients. DANIEL HAYES: By the way, two stories I read about you-- one is how you met Henry Kaplan, and the second is the first paper you wrote with him. Can you give us those two? And then I think we've got to sign off. SARAH DONALDSON: Well, let me tell you about the first paper I wrote with him because the other one is too funny. Everybody will laugh at me. The first paper I wrote with Henry Kaplan, I worked really, really hard on it. It had to do with bacterial infections in patients with Hodgkin's disease because we were doing splenectomies on everybody, and they were getting pneumococcal bacteremias and meningitis. And I was running the ward at that time. I was taking care of a lot of patients that were sick. So I was writing up this experience. And I wrote what I thought was the perfect paper because, see, Kaplan had a high bar, and you didn't want to disappoint him. So I wrote the paper that I thought was perfection. I had gone through a lot of drafts. And I gave it to him, and he returned it to me the next day. He read it that night. But I only looked at the first page because the first page looked like a blood bath. Everything he wrote, he wrote with a red pen. And there was red writing all over the first page. I couldn't see any white paper. It was all red comments. DANIEL HAYES: [LAUGHS] SARAH DONALDSON: And I went through-- I don't know-- 24 different drafts of that paper finally being published. And so one of the things I try to do with residents now is to teach them, you have to have a hypothesis. You have to make certain you have a database. You have to have a long term follow up. You have to understand statistics, and you have to write a paper knowing what you're doing. You don't just start writing. You do a section and a section and you build it with evidence. So I enjoy doing editing, and I think I can help some trainees focus their thinking in terms of writing a grant proposal or a manuscript that's worthwhile publishing. My introduction to Henry Kaplan-- there are many, many funny stories about them, but to end them all, I will have to say that he was very, very, very good to me. He provided a lot of opportunities and was a huge role model. He taught by scarification. We were all scared to death of him, but he was absolutely a wonderful, wonderful huggable person, if you felt like you could hug him. We didn't do that very often. We might have hugged Saul Rosenberg, but we didn't hug Henry Kaplan. But they were both helpful to me, especially in understanding lymphomas. DANIEL HAYES: For those of you listening who don't know who Henry Kaplan was, I think it's fair to say he was one of the first people to prove you could cure Hodgkin's disease with radiation. Do you agree? Is that a fair statement? SARAH DONALDSON: Yes, that's where his name came. But of course, what Kaplan did was he recruited Saul Rosenberg, and the two of those worked hand in hand, and they brought to Stanford what we call the Lymphoma Staging Conference, which was a combined modality conference where we talked together over each patient. And together, they wrote clinical trials that were institution-based clinical trials. So what Kaplan did was he did a lot of technical work with the linear accelerator, but that was just a tool. My way of thinking is his most important contribution was the importance of combined modality therapy and understanding what your colleagues can contribute and what you can contribute in doing it as a team. DANIEL HAYES: And I will encourage anyone who's listening to this to go back to the website and listen to my interview with Dr. Rosenberg who laid that out in spades. And the first few patients he treated, he had a chair outside his exam room. He would examine the patient, take them out, put them in the chair, start the IV himself, go mix the chemotherapy, hang it up, and then see the next patient in the room while the first patient was getting chemotherapy. It's a little different now. [LAUGHS] Anyway, thank you so much. By the way, I have a copy of Dr. Kaplan's book on Hodgkin's disease, which was the Bible when we were training. You can't see it because it's on my bookshelf behind my camera, but I still open it up quite a while, even for a breast cancer guy. It was a classic. I also want to say, it's very clear to me you're a nurse at heart. You've been a fabulous physician and researcher and mentor, but your love for people shines through, so congratulations. I think that's terrific. SARAH DONALDSON: Thank you so much. DANIEL HAYES: Thanks for taking your time to speak with me today. I'm sure people are going to be thrilled to listen to this, and thanks for all you've done to feel. It's just really remarkable-- and what you've done for ASCO and the Foundation, which is a big, big, payback. Thanks for everything. SARAH DONALDSON: Thank you. DANIEL HAYES: Until next time, thank you for listening to this JCO's Cancer Stories: The Art of Oncology Podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple Podcasts or wherever you listen. While you're there, be sure to subscribe so you never miss an episode. JCO's Cancer Stories: The Art of Oncology Podcast is just one of ASCO's many podcasts. You can find all the shows at podcast.asco.org. [MUSIC PLAYING]

Rules for the regulation of medical devices, such as hip prostheses and implantable defibrillators, are complex and differ from those for drugs. Aaron Kesselheim, MD, JD, MPH, and Jonathan Darrow, SJD, LLM, JD, MBA, both faculty members in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham & Women's Hospital, review device classes and approval pathways used by the US Food and Drug Administration (FDA), and prospects for improvements and reform in the agency's processes. Related Content: FDA Regulation and Approval of Medical Devices

In this interview, Pranav discusses his work as a computational cardiac research fellow, and also provides advice on what has complemented to his academic success thus far.

Dr Carolyn Lam: Welcome to Circulation on the Run! Your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts, I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: I'm Greg Hundley, Associate Editor, Director of the Pauley Heart Center, VCU Health in Richmond, Virginia. Dr Carolyn Lam: Greg, we got double features today. Now, the first one's all about fruit and vegetables. Now, before you switch off, this is a very important one, okay? So, listen on. And the second is on the EMBRACE heart failure trial. Now, this was a late breaker, very important, more data on empagliflozin, that SGLT2 inhibitor. So really, really fun discussions coming right up. But first, can I dig into one of the papers that I'm really dying to tell you about? Dr. Greg Hundley: Absolutely. Dr Carolyn Lam: Okay. This is all about the diagnostic performance of high-sensitivity cardiac troponin T strategies, that super hot topic. We know that European data support the use of low high sensitivity troponin measurements or a 0/1 hour algorithm for myocardial infarction or to exclude MACE among emergency department patients with possible acute coronary syndrome. However, there's really very modest U.S. data to validate these strategies. This study today from Dr. Allen and colleagues from University of Florida, really evaluated the diagnostic performance of an initial high sensitivity cardiac troponin T measure below the limit of quantification. And that is six nanograms per liter, a 0/1 hour algorithm, and their combination with heart scores for excluding MACE in a multi-site U.S. cohort. And this is the largest prospective multi-site U.S. study of high sensitivity troponin T strategies to date. Dr. Greg Hundley: Wow, Carolyn you've really piqued my interest. So what did they find? Dr Carolyn Lam: Okay. And initial high sensitivity, cardiac troponin T below that level of quantification of six nanograms per liter was associated with a negative predictive value of 98.3% for 30-day MACE. Okay. That was that value itself. Now the 0/1 hour algorithm rolled out 57.8% of patients with a negative predictive value of 97.2% for 30-day MACE. The addition of a low-risk heart score to that initial high sensitivity troponin T level below that six nanogram per liter and the 0/1 hour algorithm improved the negative predictive value for 30-day MACE to 99% and 98.4% respectively. Dr. Greg Hundley: Wow. Carolyn, it looks like a really comprehensive analysis of the high sensitivity troponin. So tell us what are the clinical implications of this study? Dr Carolyn Lam: So these data seem to imply that when used without a risk score and initial high sensitivity troponin T below six nanograms per liter, or a 0/1 one hour algorithm, may not have sufficient sensitivity or negative predictive value to exclude 30-day MACE in the U.S emergency department patients. But the addition of that low-risk heart score to those measures improves the negative predictive value, but rolls out fewer patients. And so in totality, these results suggest that in the U.S. Emergency departments, adding a risk score to either of these strategies really increases their safety. Dr. Greg Hundley: Boy, great new information in our journal. Well, Carolyn, I'm going to switch to the world of basic science and start to evaluate in this next paper, the regulation of cellular signatures in children with dilated cardiomyopathy, and the work comes to us from Dr. Stephanie Dimmeler from Goethe University in Frankfurt. So Carolyn, Stephanie's team performed single nuclei RNA sequencing with heart tissues from six children with dilated cardiomyopathy. One was age 0.5, 1.75 and another at 5, 6, 12, and then 13 years of age. And they did this to gain insight into age and disease-related pathophysiology, pathology, and molecular fingerprints. And the goal was to gain further insight into dilated cardiomyopathy, which is a leading cause of death in children with heart failure. Dr Carolyn Lam: Cool. So what did they find Greg? Dr. Greg Hundley: Right, Carolyn. So, the number of nuclei in fibroblast clusters increased with age in dilated cardiomyopathy patients, a finding that was consistent with an age-related increase in cardiac fibrosis quantified by cardiovascular magnetic resonance imaging. Dr. Greg Hundley: Now Carolyn, fibroblast of the dilated cardiomyopathy patients over six years of age showed a profoundly altered gene expression pattern with enrichment of genes encoding fibrillary collagens, modulation of proteoglycans and a switch in thrombospondin isoforms and signatures for fibroblast activation. Additionally, Carolyn, a population of cardiomyocytes with a high pro-regenerative profile was identified in infant dilated cardiomyopathy patients, but was absent in those children that were greater than six years old. And this cluster in these infants showed high expression of cell cycle activators, such cyclin D family members increased glycolytic metabolism and any oxidative genes and alterations in beta adrenergic signaling genes. Dr Carolyn Lam: Wow. That sounds like a magnificent and elegant study. Could you boil it down to the take home messages? Dr. Greg Hundley: You bet. Carolyn. Great question. So two points first, infants with a predominantly regenerative cardiomyocyte profile, may preferentially receive treatment strategies to support cardiac regeneration while patients with a pattern associable with cardiac fibrosis may benefit from an early anti-fibrotic therapy to avoid diastolic dysfunction. And second, despite the impracticality of performing these large cohort studies in children with dilated cardiomyopathies, tailored pharmacological treatment is possibly realistic. For example, based on the expression of beta adrenergic signaling genes. Dr Carolyn Lam: Oh wow. That is super cool. That's Circulation for you, publishing these amazing basic science papers with very big clinical implications. Well, I've got another basic science paper for you and this time I've learned a new word actually. It's called O-GlcNAcylation. I should get you to say it after me. I had to get our editor-in-chief Joe Hill to teach me to say that, O-GlcNAcylation. So, cardiomyopathy from diverse causes is marked by increased O-GlcNAcylation. Now, in this paper, co-corresponding authors, Dr. Anderson and Umapathi from Johns Hopkins University provide a new genetic mouse model to control myocardial O-GlcNAcylation independent of pathological stress. Their data actually provided evidence that excessive O-GlcNAcylation caused cardiomyopathy, at least in part due to defective energetics. Enhanced O-GlcNAcase activity was well-tolerated. And conversely, attenuation of O-GlcNAcylation was beneficial against pressure overload induced pathological remodeling in heart failure. Dr. Greg Hundley: Interesting, Carolyn. So what are the clinical implications of these findings? Dr Carolyn Lam: Well, the data really provide new proof of concept that excessive O-GlcNAcylation is sufficient to cause cardiomyopathy, and they also suggest that attenuation of this excessive O-GlcNAcylation may represent a novel therapeutic approach for cardiomyopathy. Dr Carolyn Lam: Shall we go on and sort of wrap up on what else is in this issue? Because I'd like to talk about highlights from the Circulation family of journals that Sarah O’Brien really beautifully summarizes, talking about everything from Circulation: Arrhythmia & Electrophysiology, to [Circulation:] Cardiovascular Quality & Outcomes. It's just a beautiful piece where we get all the highlights. Must read. There's also a Perspective piece by Dr. Gillis on Rhythm Control in Atrial Fibrillation: Is Earlier the Better?, and that discusses the EAST-AFNET 4 and early AF trials. Dr. Greg Hundley: Very good, Carolyn. Well, from the mailbox, professors Pan and Liu exchange letters regarding a prior response to a letter regarding the article Genetic Architecture of Abdominal Aortic Aneurysm in the Million Veteran Program. Also, Dr. Arbus-Redondo has an EKG challenge entitled, Dual Chamber Pacemaker after Sinus Node Dysfunction and an Enlarged Right Atrium. Is it what it seems? Dr. Greg Hundley: And then finally, Dr. Corrado has a very nice Research Letter, entitled, Serial versus Single Cardiovascular Screening of Adolescent Athletes. Dr. Greg Hundley: Well, Carolyn, I'm dying to hear about fruits and vegetables. How about we get onto those featured discussions? Dr Carolyn Lam: Cheeky, cheeky, Greg. Here we go. Dr Carolyn Lam: Oh, I'm so excited about today's featured discussion because it's about my favorite thing, fruits and vegetables. Okay, wait a minute, everybody. Before you start rolling your eyes, this is a really important one. Have you ever asked yourself, what is the optimal intake levels of fruit and vegetables for maintaining long-term health? Well, guess what? We're about to find out and I'm so pleased to have the first author of today's feature paper, Dr. Wang Dong, and he's from Harvard medical school and Brigham Women's Hospital. We also have our Associate Editor, Dr. Mercedes Carnethon from Northwestern University and our Associate Editor who is also the editorialist to this paper, Dr. Naveed Sattar from University of Glasgow. So welcome, everyone. Dr. Wang, please tell us what you did in this study and what were your main results? Dr. Wang Dong: Thank you, Carolyn. So, basically, in this study, we analyzed the data from two long running cohort study. That is the Nurses' Health Study and Health Professional Follow-Up Study. So these two study includes more than 100,000 participants who had been followed for up to 30 years. And we also include a meta-analysis that includes in total 26 studies and about two million participant from 29 countries, and had countries around the world. So, basically, the major finding from this study is, of course, the intake of fruits, vegetable is inversely associated with the risk of death from all cause and the different kinds of cause-specific mortality. And we have a very interesting finding that is intake of about five servings per day, that can be translated into two serving of fruits and three servings of vegetables per day, was associated with the lowest risk of total mortality. So that's an optimal intake level for fruits and vegetable. Dr. Wang Dong: And another important finding from this study is, not all foods that some people consider to be fruits and vegetables can offer the same health benefits. For example, in this study, we found that starch vegetables such as peas and corn, and some fruits juice and potatoes are actually not associated with any benefit in terms of longevity. On the other hand, if you look at green living vegetables such as spinach, kale, and fruits that's orange color fruits and vegetables, that's rich in beta-carotene and vitamin C such as citrus fruits and berries, carrots they're associated with a substantial reduction in the risk of total mortality. That's a major finding from this paper. Dr Carolyn Lam: Oh, I just love it. I mean, just like such wholesome, beautiful findings from a wonderful study. Now, if I could ask you, cause I think the first thing everyone's going to say is, okay, these are associations. I mean, what'd you do about the residual risks? Could you maybe describe how you try to address some of these things like, is taking in fruits and vegetables just a surrogate for people who, I don't know, exercise more, for example? Dr. Wang Dong: Yeah. So in original data analysis, we actually have extensive data collection of all kinds of foods, lifestyle, risk factors, medication use, any health-related variables. So we carefully adjust for a large number of confounding factors. So actually another thing I want to point out, most all of these health-related lifestyle factors actually are inverse confounding factors in this kind of analysis. So when you adjust for other confounding factors, it's tend to attenuated your inverse association. So the review from confounding actually wouldn't be a major explanation for this association. Dr Carolyn Lam: Oh, that's great. And by the way, I think I misspoke. I'm not sure if I said residual confounding or residual risk just now, but you absolutely read me right, that I meant residual confounding. So thanks. Now that we've got that out of the way, if I could ask Mercedes, please. I mean, ah, another fruits and vegetables paper, I mean, what made this one different that we said we have to have it at Circulation. Dr Mercedes Carnethon: Well, thanks so much, Carolyn. And thank you Dong, for your team's outstanding work. I know what excited me about it was the demonstration of something that we have adopted into our lexicon, that one needs five fruits and vegetables. So I was excited to see you quantify it. In particular, the question I have for you is, did you see that these patterns of association of fresh fruit and vegetable intake were consistent across the age range and in both sexes? Dr. Wang Dong: Yes, of course. In total, this acts as a stratification variable. So basically, in our original data analysis, we did the analysis in the Nurses' Health Study, which all the participants are women, and in the Health Professional Follow-Up study, in which all the participants are men, would be analyzed separately and we found very consistent results in both cohorts. Then will be the meta-analysis to meta-analyze the results from these two cohorts. It comes out age, actually if you look at the paper, I think in one of the supplemental table, with the age stratified analysis, to look at the a better association if it still holds in different age group. And we did found that the results is pretty consistent in different age groups. And also, I would point out this meta-analysis provides further support to show that this results is generalizable in different people with different social economic status, demographics status also from different background. Dr Mercedes Carnethon: Thank you so much, Dong. it brings me to what Naveed wrote about in his editorial, that food is medicine and I just really loved that and loved the implications of that. So, I don't know, Naveed, if you've got some comments to make? Questions? Dr Naveed Sattar: Yeah, thanks Mercedes. No, I really love this as well because clearly the cardiovascular community, we do lots of trials. Lots of us are nihilists and just look at trials, but actually it's hard to do trials in the food and the dietary area, but these data are very consistent. I think there are multiple potential mechanisms that may explain this. We all have to eat every day, so it's a big part of our lives. Increase fiber intake, increase potassium, micronutrients, food displacement, the more fruit and veggies you eat, the less you'll eat of other things that perhaps are not as protective. And actually, part of the motivation to write an editorial was to put all that into context in terms of mechanisms. And particularly fiber, I think we underestimate the importance of fiber, but then it was also to discuss, well, if this is true, how do we help people make the changes? Dr Naveed Sattar: And at the level of policy, at the level of high risk groups, and my own particular favorite is really communicating dietary change in the clinic. And one of the things I often try, and we put this in a kind of headline figure in the editorial, was actually getting people to try to undergo the palate test or the retraining their palates. I have lots of patients, who, would you believe, in the west of Scotland, never really eat fruit and veg, and I really pushed them to say, "Look, would you please try? And it might take a few weeks for you to retrain your palate". And lots of people come back saying, "Ah, you're correct. And my God, now I like banana and I now like salad." Dr Naveed Sattar: So actually, there's lots of tips that we can do to help people increase from their average of two to three intake, which is the vast majority of population, to four to five, but it's a gradual process and it requires good communication with our patients and to compel them that these changes might take time, but that if they make these changes, they can get to a point where they really enjoy eating fruit and veg and all the multiple health benefits that come, which this paper has now showed, Mercedes. Dr Naveed Sattar: I think for me, that was the real nub of this. Dr Carolyn Lam: Naveed, I just love the way you express it. And indeed, everyone take up that editorial and look at that beautiful figure. I love the colorful fruits and vegetables on top because it also reminds us, and this paper shows, we are not talking about potato chips, and was it those, corn and peas. But, you know, we're talking about nutrition and fiber and the good stuff. Oh, this is just amazing. I wish we could go on forever, but we have a double feature this issue. And I just want to end by saying, thank you, thank you all of you, for being on the show today. It was such an important topic and I really loved the discussion as I'm sure the audience did. Thank you. Dr Mercedes Carnethon: Thank You. Dr Naveed Sattar: Thanks very much. Dr. Wang Dong: Thank you so much. Dr Carolyn Lam: I am so pleased to have with us today, a friend, a deeply admired colleague and the corresponding author of today's feature discussion, Dr. Mikhail Kosiborod from Saint Luke's Mid America Heart Institute. Dr Carolyn Lam: Welcome, Mikhail. And thank you for publishing this beautiful paper on EMBRACE heart failure with us. I know that this was presented as a late-breaking trial at the Heart Failure Society of America meeting, and it's a very much anticipated paper, but maybe I could start with it's all about SGLT2 inhibitors these days. So please tell us how does EMBRACE add to this accumulating knowledge that we have on SGLT2 inhibitors and heart failure? Dr. Mikhail Kosiborod: Well, first of all, Carolyn, thanks so much for publishing our trial in Circulation. And you're right, SGLT2 inhibitors have been taking the world of cardiometabolic medicine and heart failure by storm over the past few years. EMBRACE is a very unique trial because it really, took this world of rapidly developing technology in heart failure and heart failure monitoring, and coupled it with one of the hottest topics in heart failure today in terms of drug management, which is the advent of SGLT2 inhibitors and the emergence SGLT2 inhibitors as a efficacious therapy, not just for prevention of heart failure, but also treatment of heart failure. Because as you know, pulmonary artery pressure and hemodynamic status are one of the strongest predictors of patient outcomes, both in terms of symptoms, hospitalizations, and deaths in heart failure. And we know actually that monitoring and intervening on elevated pulmonary pressure in this patient population may lead to hospitalizations and possibly even death. Dr. Mikhail Kosiborod: But up until recently, it's been very difficult to monitor pulmonary pressures and to use them as an outcome in heart failure trials, because you will have to use invasive monitoring, essentially a right heart catheterization to get that data. Well, now we can actually have this implanted sensors like CardioMEMS, which are the sensors that we use in EMBRACE-HF trial. So, the question we wanted to ask is, we know SGLT2 inhibitors in DAPA-HF and EMPEROR-Reduced trials, clearly reduce the risk of cardiovascular death and hospitalization for heart failure, worsening heart failure, but the mechanisms have been hotly debated. Is there a possibility these agents can actually have an impact on hemodynamic status and pulmonary pressures? And that's the key central question that we tried to address and EMBRACE-HF trial by using this novel technology at the time, now it's been around for a few years, to noninvasively measure pulmonary pressures and use it as a primary outcome in our trial. Dr Carolyn Lam: Mikhail, first of all, hats off, it was a very, very clever idea to look at these patient populations who already have CardioMEMS right, and then perform this randomized trial. I mean, when I saw this, I was like, "Aw, man, how come I didn't think of that? That's just like so clever, but it's just so Mikhail to be ahead of the curve." But I'd like to remind the audience, this was a prospective randomized trial, the pre-specified outcomes, right? So maybe you could describe that in a greater detail and then the results. Yeah. Dr. Mikhail Kosiborod: Absolutely. Well, Carolyn, first of all, once again, thank you very much. You're being very kind. We do think it was a very novel clever idea and that you're absolutely correct, as this was very rigorously designed, randomized, double blind placebo controlled investigating trial within this study and 10 sites in United States. And the patients had to have heart failure, either with reduced or preserved ejection fraction, about half-and-half actually, as it turned out to be once it's all said and done with the trial. Because they had to have implanted CardioMEMS for clinical indication previously, they were quite advanced in terms of their heart failure. So more than half of the patients were in NYHA class III or IV, they had elevated brain natriuretic peptide levels, they had hybrid symptoms as you would expect. And essentially the patients were screened, and if they were eligible, randomized to use a empagliflozin-placebo in a double-blind fashion. Dr. Mikhail Kosiborod: And they were monitored actually for a couple of weeks prior to randomization to get a baseline pulmonary artery diastolic pressure. They were then treated for 12 weeks with empagliflozin, 10 milligrams a day, or a matching placebo. And we were measuring pulmonary pressure twice a day, every day for the 12 week treatment period, and then at the end of the treatment period, the treatment was stopped, but we actually continued to measure pulmonary pressure for one additional week again, twice a day, every day. So we actually saw what happened for one week after the treatment was stopped. And, as I mentioned before, the patient population was quite advanced from a heart failure standpoint. These were patients that were adequately managed with guideline-directed medical therapy for heart failure. Of course, about half of those patients have, have HFpEF. Did I mention before was the standard of care is not a thoroughly defined? Dr. Mikhail Kosiborod: And essentially what we observed was quite remarkable, which is average pulmonary artery diastolic pressure at baseline was about 22 millimeters of mercury across the patient population, and in patients treated with empagliflozin, there was quite a rapid reduction in pulmonary artery diastolic pressure that we saw almost immediately within one week as compared with placebo. And that divergence of curves in terms of pulmonary artery diastolic pressure continued over the entire 12-week treatment period. And by the end of the treatment period, there was nearly two millimeter of mercury difference in favor of empagliflozin, with lower pulmonary artery diastolic pressure in patients with empagliflozin compared with placebo. And also interestingly, even after the treatment was stopped for an additional week, those curves continued to diverge, with even greater lowering of pulmonary artery diastolic pressure in patients that received empagliflozin. So, I think to our knowledge, this is the first evidence from a randomized clinical trial, randomized double blind placebo controlled clinical trial, that SGLT2 inhibitors, in this case, empagliflozin, have essentially direct the congestion effect towards a lower pulmonary artery pressure rapidly and with effect amplified over time. Dr Carolyn Lam: Yes. Congratulations and beautifully present it there. Now, if I could ask a few more questions now, because the things will come up there. What happened to the diuretic dose? Is this depend on diuretic dose? Are there any subgroups that appeared to benefit more? Dr. Mikhail Kosiborod: No, excellent question, Carolyn. So first of all, we monitored average daily furosemide equivalent dose continuously throughout the trial, and what we observed was that there was no difference in diuretic dose, essentially, between the two groups from a loop diuretic management standpoint. Now, remember this patients are getting frequent pulmonary pressures with diuretics being adjusted all the time. But if you look at what happens over time, that's one of the figures in the paper you see essentially the flat lines in both groups. And coupling that with the fact that pulmonary pressures continue to diverge for another week after the treatment was stopped, at least in my mind, suggests that this hemodynamic benefits as we observed with empagliflozin as compared with placebo was lowering of pulmonary pressures is likely not simply due to diuretic effect. It just cannot be explained only by diuretic effect. I think these findings are very much in line with the analysis that we had in DAPA-HF trial with the analysis that recently were published from EMPEROR-Reduced, showing that you just can't explain what you see with heart failure benefits with SGLT2 inhibitors simply by diuresis. Dr Carolyn Lam: Fascinating. Well, how about the question of diabetes? Dr. Mikhail Kosiborod: Yes. So in terms of subgroups, that you mentioned, we did do subgroup analysis. Now I will say that the subgroup analysis have to be interpreted with a great deal of caution in this trial, because the entire trial had about 65 patients, so it's a small trial. It was really powered to look at the entire patient population and look at the primary end point of the diastolic pressure. Nevertheless, as I mentioned before, we had half-and-half reduced and preserved EF and we did not see a statistically significant heterogeneity in the treatment effect when we look at patients with reduced to preserved EF, so that hopefully both for outcome trials in preserved EF heart failure, we'll see, of course, what happens with that. And in terms of diabetes we saw a bit greater effect in patients with diabetes as compared to patients without diabetes, in terms of pulmonary artery pressure reduction. Dr. Mikhail Kosiborod: But again, I would just strongly caution interpretation of those subgroups because certainly when we look at clinical outcomes in those DAPA-HF and EMPEROR-Reduced, we see no such difference. We see that the benefits, right, the hard clinical outcomes, benefits, are quite consistent regardless of diabetes status. I will say one other thing, which I think is really important. If you look at the pulmonary artery pressure trajectory in patients treated with placebo in EMBRACE-HF, you see that they actually go up over time. And this is in patients that have frequent monitoring of blood pressures, our own guideline-directed medical therapy are closely watched by predominantly heart failure cardiologists and their teams to make sure that they're well-managed. And despite that, you see this increase in pulmonary pressure over time, and that's just another reminder to us that heart failure is a progressive disease despite best available therapy. Dr. Mikhail Kosiborod: These patients deteriorate over time, which is why treatment, novel advancements, treatments like SGLT2 inhibitors and their effective implementation is just so important because we know the benefits occur very early. We saw one week here, when we start seeing separation of curves, certainly see a significant difference by 12 weeks with pulmonary pressure. But of course we know with clinical outcomes, we see within a few weeks of randomization, already a significant benefit in reducing CV death and hospitalization for heart failure, both in DAPA-HF and EMPEROR-Reduced trials. So I think that's a critical point for clinicians to keep in mind at the time of the death. Dr Carolyn Lam: Mikhail, those are just such important and practical take-home messages. Thank you again. In the last minute though, I just really, really have to go back to that very clever method. Could I just pick your brain? I mean, it's like a very clever population. This CardioMEMS population that maybe what's in the future plans? Give us a sneak peek! Dr. Mikhail Kosiborod: Well, Carolyn, very insightful as always. I really think of it as a novel platform for drug development and heart failure. I think this is the proof of concept. This is really the first time we did something in the heart failure space was with monitoring of pulmonary pressures that shows that drugs that work for hard clinical outcomes actually do something meaningful on hemodynamics. We've struggled for such a long time in heart failure to have a good surrogate endpoints that would be reflective of clinical outcomes. This may be it. It may be one of them. And I think EMBRACE-HF is a good concept proving study that can say, if you have a compound and you think that compound may be effective for heart failure. So of course the congestion is so important that we know correlates so well with clinical outcomes Dr. Mikhail Kosiborod: When we started to trial all the way back to late 2015, very few patients had this device. It's not lots of patients have this device. And testing novel treatments to try to understand will there promise in heart failure, and even making go-no-go decisions, in terms of drug development, I think is starting to become a potential future development, which we should at least seriously consider in the heart failure space. Dr Carolyn Lam: Wow, Bravo. And Mikhail, I mean. Okay, audience, listen, you heard it right here. This is amazing. Thank you once again for publishing with us and congratulations on the beautiful paper. Dr Carolyn Lam: And from Greg and I, thank you audience for joining us again today, you've been listening to Circulation on the run. Tune in again next week. Dr. Greg Hundley: This program is copyright of the American Heart Association 2021.  

David Bernstein, Elisabeth Bloxam & Caroline Mirkes were all recent Fulbright alumnae to / from Luxembourg. They share their transformative experiences. If you go through the who's who of Luxembourg's heavy-hitters and glitterati, there will be a number who were Fulbright Scholars to America. This cultural and educational scholarship offers strong candidates an outstanding opportunity to live and study in America at any point in life after a Bachelor's degree. And it's not just for Luxembourg passport holders (although your statistical chances of getting a place with one may be higher); the Fulbright programme operates between 160 countries. Fulbrighters talk of the life-long relationships they build both personally and professionally in this evermore interconnected world. You will hear in this conversation the ‘high value return on investment', as David likes to put it, and believes it might be the greatest form of local citizen diplomacy. My guests Elisabeth Bloxam, herself a Fulbright alumna, is the Director of Programs at the Commission for Educational Exchange between the United States, Belgium and Luxembourg, the Fulbright Commission in Brussels - your go-to person if you're interested in this scholarship. Elisabeth spent her Fulbright year in Luxembourg as an English Teaching Assistant, and has been with the Fulbright Commission in Brussels since 2016. Prior to that she studied European Studies and French & Francophone Studies from the College of William & Mary in Virginia (2015). David Berstein was a Fulbright Research Awardee in 2013 in Luxembourg, when he studied towards a Master in Entrepreneurship and Innovation from the University of Luxembourg. He also spent time working with Silicon Luxembourg and the US Embassy during that academic year, and harbours a hope to return as US Ambassador to Luxembourg one day! David has an MD and MBA from the University of Rochester School of Medicine & Dentistry and Simon Business School. He spent a year at the Institute For Strategy & Competitiveness at Harvard Business School. Currently, David is a PhD student at the University of Leiden in The Netherlands and an orthopaedic surgery resident physician at the Harvard Combined Orthopaedic Residency Program (HCORP), providing musculoskeletal care to patients at Massachusetts General Hospital, Brigham & Women's Hospital, Beth Israel Deaconess Medical Center, and Boston Children's Hospital. David is passionate about “fixing” America's healthcare system. Caroline Mirkes is a composer, actress, cellist and pianist from Luxembourg. The Fulbright programme took her to New York University for a Masters, but she also became a part-time student at the Lee Strasberg Institute where she began to study acting. Prior to that, Caroline studied Cello Performance at Maastricht Conservatorium, the Koninklijk Conservatorium of Brussels and Escola Superior de Barcelona. Now based in Vienna, Caroline continues to create global projects and concerts, which include Performers.lu, Cello Octet Luxembourg and art creations. Recently, her short film Criminal Eyes is selected for the Lee Strasberg Film Festival in NYC and nominated for Best Supporting Actress. She continues acting at the Schauspiel schule Wien. And aside from that, finds time for dance, acrobatics and aerial silk lessons! Origins of the Fulbright Program Just after the Second World War in September 1945, a freshman senator from Arkansas, J. William Fulbright, introduced a bill in the U.S. Congress that called for the use of proceeds from the sales of surplus war property to fund the “promotion of international good will through the exchange of students in the fields of education, culture and science.” One year later, President Harry S. Truman signed the Fulbright Act into law. Senator Fulbright saw an opportunity for good in the wake of the Second World War and proposed a program whose aim was to create the kind of mutual understanding and people-to-people relationships that would prevent such global conflict from happening again. The Fulbright Program has blossomed to become the flagship international educational exchange program of the U.S. Department of State. International educational and cultural exchange In Luxembourg, the Fulbright Program provides scholarships for Luxembourgish citizens who wish to conduct research or pursue graduate study in the USA and for American citizens to come study and teach in Luxembourg. The Fulbright Commission in Brussels administers the Fulbright Program for citizens of Belgium and Luxembourg as well as participants in the Fulbright Schuman Program, but the program operates in over 160 countries worldwide and awards approximately 8,000 grants annually. Roughly 1,900 U.S. students, 4,000 foreign students, 1,200 U.S. scholars, and 900 visiting scholars receive awards, in addition to several hundred teachers and professionals. Information about grants for Belgian and Luxembourgish citizens, educational and cultural exchanges offered by the U.S. Embassy to Luxembourg can be found via my article on RTL Today. https://www.fulbright.be/awards/grants-for-belgian-and-luxembourgish-citizens/ https://lu.usembassy.gov/education-culture/

Experts from Banner Health, Brigham & Women’s Hospital, Highmark, Insignia Health and UPMC Health Plan share success stories and best practices on how increasing activation not only helps consumers become better managers of their health but utilization and costs decline and consumer/patient satisfaction improves. Learn how you can implement their innovative ideas in your organization. This episode is sponsored by Insignia Health Insignia Health empowers healthcare organizations and health professionals around the world to assess patient activation and develop strategies for the efficient application of healthcare resources. As activation increases and individuals become better managers of their health, utilization costs decline and patient satisfaction improves. The Patient Activation Measure® (PAM®) and over 15 years of health activation research form the cornerstone of a complementary suite of solutions that help clinicians, coaches and population health providers improve health outcomes and lower costs. Today, Insignia Health supports the health activation efforts of more than 250 organizations touching the lives of millions of patients in dozens of countries.

With Samia Mora and Zareen Farukhi, Brigham Women's Hospital, Boston - USA Link to paper Link to editorial

Wellness is a proactive approach to living with multiple sclerosis. Wellness complements routine neurological care, which is often reactive to new relapses, symptoms and disease progression. Nutrition reviewed including diets such as intermittent fasting, paleo and Wahls Protocol. Great physical health relies on keeping up with routine cancer screenings and vaccinations. Options for protecting cognitive health and improving mental health are highlighted. Ways to improve social and spiritual connections are shared. Successful exercise strategies presented for an array of MS disability levels. Information given on how to balance the need for increased muscle strength with concerns of overexertion and fatigue. The role of physical, occupational and speech therapy for people with MS reviewed. The latest and future technology explored including zero-gravity treadmills, electronic foot braces, robotic exoskeletons and implantable microstimulators. Barry Singer MD, Director of The MS Center for Innovations in Care, interviews: Riley Bove MD is an Assistant Professor of Neurology at the University of California-San Francisco. Her multiple sclerosis research focuses on hormones and digital medicine. Dr. Bove started her studies in anthropology at Harvard and then global studies on a Fulbright scholarship. She returned to Harvard for medical school and then completed her residency at Massachusetts General Hospital and Brigham Women’s hospital in Boston. She completed a clinical research fellowship at the Partners MS Center and a Master’s Degree through Harvard Medical School’s Clinical Investigator Training Program. Ben Thrower MD is the medical director of the Andrew C. Carlos MS Institute at Shepherd Center, a leading rehabilitation hospital in Atlanta. He completed his medical degree at University of Florida and neurology residency at the University of Texas in San Antonio. Dr. Thrower is a Clinical Instructor of Neurology at Emory University and participates actively in clinical research. He serves on the board of directors of the Georgia Chapter of the National MS Society and has served on the board for the Consortium of Multiple Sclerosis Centers. In 2005, he was the first physician inductee into the Georgia Chapter of the National MS Society Volunteer Hall of Fame. Visit www.mslivingwell.org for more information. Share your MS story on https://ICanWithMS.org

Richard Bucala, MD is the Waldemar Von Zedtwitz Professor of Medicine, Professor of Pathology, Epidemiology & Public Health, and Chief of Rheumatology, Allergy & Immunology at Yale School of Medicine. Dr. Bucala completed his Medical school at Weill Cornell and Residency at Brigham & Women's Hospital. He pursued a Fellowship in Rheumatology from the Hospital for Special Surgery. He studies the mechanisms by which protective immune responses lead to immunopathology and his lab is leading multidisciplinary efforts to develop immunotherapies. Dr. Bucala also is credited with the discovery of the fibrocyte, which is being targeted therapeutically in different fibrosing disorders. He is a co-founder of Cytokine Networks and of MIFCOR, a biotechnology startup. He is the Editor-in-Chief of Arthritis & Rheumatology and has served on numerous advisory boards for the NIH, the pharmaceutical industry, academia, and private foundations. The buzzword usually is ‘goals': We are often asked - what are your goals? Often told to dream big and make lofty goals. Not much is said about the path we should follow to achieve our goals. Today, Dr. Richard Bucala reflects on his journey and shares how the path is more valuable than the end point. Medicine is a long educational path, but if pursued with honesty, integrity and diligence, forms us into the person we aspire to become. Focusing on these virtues while traversing this path helps us develop our professional character and ultimately determines our professional success in the long term. Pearls of Wisdom: 1. The path is more valuable than the goal. The way we achieve our goals – with honesty, integrity, ad character – is more important for the long-term, than short-term successes. 2. Honesty is knowing one's limitations; : realizing that no one person has all the answers, gives us the humility to be a great team player. But even more important than honesty is courage. Without courage, we cannot be honest. 3. Embrace the complexity and multidimensionality of medicine. It's what makes medicine so gratifying.

Even TIME magazine featured a cover in 2004, blaming inflammation for heart attack, stroke, Alzheimer's cancer, and other chronic diseases. Dale Bredesen in his book END OF ALZHEIMER'S, Brad Bale and Amy Doneen in their book BEAT THE HEART GENE, and others have their recommendations for biochemical tests for inflammation. Paul Ridker, MD at Brigham & Women's, is considered by many to be the father of chronic inflammation. He recently made headlines with the CANTOS trial. He looks simply at hsCRP. Bredesen adds albumin amounts and ratios. So do Bale and Doneen. Both added TNF alpha and IL6 previously. Both have also looked at Omega6:3. Bredesen looks at glutathione as well.For more information, contact us at 859-721-1414 or myhealth@prevmedheartrisk.com. Also, check out the following resources: PrevMed's article on inflammation testsPrevMed's websitePrevMed's YouTube channelPrevMed's Facebook page

“In order to rise to the challenge of addressing the global emergency known as climate change, we need to access and build a relationship with our higher soul. This connection fosters a life where we truly take stewardship of the planet and our relationship with other beings, and to the best of our ability, manifest love, kindness, and compassion for self, others, and the world. This leads us all to a better life.” Dr. Eben Alexander spent over 25 years as an academic neurosurgeon, including 15 years at the Brigham & Women’s Hospital, the Children’s Hospital and Harvard Medical School in Boston.  Over those years he personally dealt with hundreds of patients suffering from severe alterations in their level of consciousness. Many of those patients were rendered comatose by trauma, brain tumors, ruptured aneurysms, infections, or stroke. He thought he had a very good idea of how the brain generates consciousness, mind and spirit. In the predawn hours of November 10, 2008, he was driven into coma by a rare and mysterious bacterial meningo-encephalitis of unknown cause. He spent a week in coma on a ventilator, his prospects for survival diminishing rapidly. On the seventh day, to the surprise of everyone, he started to awaken. Memories of his life had been completely deleted inside of the coma, yet he awoke with memories of a fantastic odyssey deep into another realm – more real than this earthly one! His older son advised him to write down everything he could remember about his journey, before he read anything about near-death experiences, physics or cosmology. Six weeks later, he completed his initial recording of his remarkable journey, totaling over 20,000 words in length. Then he started reading, and was astonished by the commonalities between his journey and so many others reported throughout all cultures, continents and millennia. His journey brought key insights to the mind-body discussion and to our human understanding of the fundamental nature of reality. His experience clearly revealed that we are conscious in spite of our brain – that, in fact, consciousness is at the root of all existence. His story offers a crucial key to the understanding of reality and human consciousness. It will have a major effect on how we view spirituality, soul and the non-material realm. In analyzing his experience, including the scientific possibilities and grand implications, he envisions a more complete reconciliation of modern science and spirituality as a natural product. He has been blessed with a complete recovery that is inexplicable from the viewpoint of modern Western medicine. In this episode… The story of Dr. Alexander’s near-death experience and the subsequent journey into the nature of reality, the mind-brain connection, free will, and debunking conventional science’s denial of the existence of consciousness Dr. Alexander’s most powerful lesson since coming out of his coma has been the power of going within. Meditation is the first step to putting the little “ego-mind” in time-out, and helps us get in touch with aspects of ourselves that are more connected with other beings, and connected with the universe at large. That’s the best way to manifest the loftiest world of the dreams of our higher soul. The Life Review: a common feature of reported Near-Death Experiences where boundaries of self disappear and your life is presented to you from the emotional perspective of those around you (reinforcing the Golden Rule) Past-life accounts from children have been validated through historical research This material world is where our souls actually make progress, not the in-between spiritual realm Reincarnation was very accepted in the early days of Christianity, but the concept was written out by Constantine at the Council of Nicaea Several examples of people having NDEs and making miraculous full recoveries from deadly traumas and illnesses Darwinian concepts of evolution through competition (ideas that bled into our social and economic systems) versus evolution via collaboration and cooperation Meditation as a technique to get in touch with our higher souls, as well as a scientifically proven tool to lower stress and blood pressure, improve sleep and productivity, enhance the immune system, generate inner peace and assist with interpersonal conflict Pierre Teilhard de Chardin’s vision—echoed by those from the NDE world and the meditating community— of the evolution of all consciousness toward a higher level of oneness and connectedness and love, a utopian world for all of life on Earth—shifting the focus from the “ego-mind” toward the universal higher good It’s time to shift our identification away from individual nation-states and toward a global vision focused on the highest good of all beings; it’s time for us to wake up and care for each other and realize that a polarized society isn’t healthy and will sooner or later collapse under its own weight Resources http://ebenalexander.com/ Proof of Heaven: A Neurosurgeon's Journey into the Afterlife by Eben Alexander The Map of Heaven: How Science, Religion, and Ordinary People Are Proving the Afterlife by Eben Alexander Living in a Mindful Universe: A Neurosurgeon's Journey into the Heart of Consciousness by Eben Alexander and Karen Newell Seeking Heaven: Sound Journeys into the Beyond Audio CD by Eben Alexander and Karen Newell of Sacred Acoustics https://galileocommission.org/ The Untethered Soul: The Journey Beyond Yourself by Michael Singer https://www.sacredacoustics.com/ University of Virginia Division of Perceptual Studies Inner Sanctum Center (One Mind: United in Hope and Healing) Why Jesus Taught Reincarnation by Herbert Bruce Puryear Autobiography of a Yogi by Paramahansa Yogananda Dying To Be Me: My Journey from Cancer, to Near Death, to True Healing by Anita Moorjani My Stroke of Insight: A Brain Scientist's Personal Journey by Jill Bolte Taylor The Phenomenon of Man by Pierre Teilhard de Chardin The Science of Near-Death Experiences by John C. Hagan III Efficacy of Binaural Beat Meditation Technology for Treating Anxiety Symptoms: A Pilot Study (abstract)

Joseph Hill MD is a Professor of Medicine & Molecular Biology, the James Willerson Distinguished Chair in Cardiovascular Diseases, the Frank Ryburn Jr Chair in Heart Research, the Director of the Harry Moss Heart Center and the Chief of Cardiology at UT Southwestern Medical Center.  Dr. Hill graduated from Medical school at Duke with an MD-PhD, worked as a postdoctoral fellow at the Institut Pasteur in Paris for 5 years before pursuing residency in Internal medicine from Brigham & Women's Hospital, where he stayed on to pursue a Fellowship in Cardiovascular Disease. Dr. Hill worked at the University of Iowa before joining UT Southwestern in 2002. His Research focuses on remodelling in cardiac hypertrophy & failure and has published over 160 articles and contributed to 14 books. He is the editor-in-chief of Circulation. His many honors include serving as the President of the Association of University Cardiologists, election to the Alpha Omega Alpha Honor Medical Society and the Association of American Physicians, and being named an American Heart Association's Established Investigator. “Being a physician is an incredibly high calling,” says Dr. Joseph Hill, as he reflects on the tremendous privilege we have as physicians to help people who have entrusted their well-being into our hands. Yet, he reminds us all today to not stop there. “You owe it to this profession to give something back.” Whether it be in advancing the body of knowledge through research or mentoring the next generation as an educator or improving healthcare delivery as an administrator, he encourages us to think beyond our clinical encounters and proactively give back to the profession out of gratitude for the privilege it has bestowed upon us. Pearls of Wisdom: 1. Be mentorable. You may not hear what you want to hear from your mentors, but the best mentees keep an open mind and reflect on the advice given to them. 2. True success is holistic : family is just as if not more important than our profession and therefore we need to carve out time for our family. It will only help us in advancing our careers. 3. In the clinical encounter, make sure to acknowledge the patient's family members who accompany them.

In this episode, Dr Vonda Wright is joined by Interventional Radiologist, Dr John Lipman, founder of the Atlanta Fibroid Center as they talk about the hidden impact of uterine fibroids and the non-surgical way, he is saving women from hysterectomy and restoring their quality of life. Uterine fibroids are an incredibly common diagnosis for women. In fact, out of every four women in America, three of them usually have fibroids during their lifetime. Only one in three women usually experiences symptoms, so it can easily go undiagnosed. Atlanta Fibroid Center. and Dr John Lipman treats fibroids without surgery and saves the U.  Dr. John Lipman is a nationally recognized fibroid expert who has made it his life’s goal to educate and treat women who suffer from uterine fibroids. He is most known for his pioneering work in the non-surgical UFE procedure, Uterine Fibroid Embolization. Dr. Lipman attended Georgetown University School of Medicine. He served as chief resident at Brigham & Women’s Hospital at Harvard Medical School. Dr. Lipman was awarded the Vascular & Interventional Radiology Fellowship at Yale New-Haven hospital, at the Yale School of Medicine, the Fellowship of Society of Interventional Radiology and the Fellowship in American College of Radiology. His current academic appointment is as an Adjunct Clinical Assistant Professor in the Department of Obstetrics & Gynecology at the Morehouse School of Medicine.

This whole story has got the medical world completely at odds with itself. It has not been able to grasp the situation at all. Eben Alexander, MD, was an academic neurosurgeon for over 25 years, including 15 years at the Brigham & Women’s Hospital, Children’s Hospital, and Harvard Medical School in Boston, - with a passionate interest in physics and cosmology. He is the author of the New York Times #1 bestseller Proof of Heaven and The Map of Heaven. His third book, co-authored with Karen Newell, Living in a Mindful Universe, was released in October 2017. http://ebenalexander.com/   Listen to this latest interview but also do a youtube search and do some binge watching - you will find that he is proof that you can transcend death - but more so - finally recognises that all people who have a NDE and a OBE - are able to remember what they see, hear and experience - even as they look down from the ceiling where they have ‘floated’ - as they see the doctors and surgeons frantically working to stabilise their body and keep it alive - remembering exactly what they say, what they do, even if it is to go out of the theatre, beyond the hospital - everyone and everything is carefully noticed. That when finally they find themselves mysteriously returned to their body again - they recall EVERYTHING that transpired. That their spiritual body - ‘essence’ - call it what you wish - can still remember everything - even without a body. Scientists like Rupert Sheldrake and others have stated that our memory is not stored in our brain or our body. That our spiritual body that oscillates at a far higher frequency has the capacity to be far more knowing, than what present day science can measure within the limitation of its instruments. This is where the new paranormal science is taking us. This is evolutionary science taking us to the next level - to the unseen. It is opening the door to the new paradigm that we have been entering for the last 40 years, but have been too reluctant as a Western civilisation to fully embrace it - due to the mind set, or should we say set mind - of the scientific establishment. Who as a body of hard nosed skeptics - emphatically state that the universe and the big bang happened all by fluke or chance. That we are all a pure accident and that somehow lightening and chemistry and water, warmth and light coincidentally brought life into being and we wriggled our way out of the swamp onto horses and carts and up to the moon - that is all somehow held together in ‘a vacuum’ and we are born to reproduce and to die and that’s it - game over … This is so far from the truth and like the 10 million people in the USA over the last century who have experienced OBE and ND Experiences - and the compelling-ness of all these occurrences that have been at many levels ‘censored’ by the MSM, or if not censored, in many cases made fun of and been put down as hallucinations or delusions. That MSM has been part of an orchestrated campaign to keep the human experience locked down and keep us trapped in our bodies to basically die an ignominious death and be forgotten. What Dr Eben has done, is parted the veil or even obliterated the silkiest of shrouds beyond death to reveal and uncover the magnificence of the universe (and God) in all its dimensions, dominions, and realms of high frequency colour, sound, geometry and ordered splendour. So unimaginable and profound - that the vastness of existence within the inner planes and realms - is beyond our faculties to comprehend … He says that right now there is a revolution happening between science and spirit that is occurring and is quickening and we are near a gigantic breakthrough … and the science of consciousness - that in essence, our souls are eternal. That we are Love and are Loved. His Message: The message he was given in his journey was … You are deeply loved and cherished forever - you have nothing to fear - you are taken care of … the lessons being, of kindness - compassion and unconditional love … also mercy, acceptance and forgiveness - these deep and profound principles … that are to govern our choices … Also covered is experiencing our life review - 20% to 50% of people have a life review - where they go back to main events in their life where we harbour residual lessons to be taught and learned … and the interesting thing is when you talk to near death experiencers in this situation - they do not describe about experiencing their life review from their own viewpoint - but from the perspective of those around them who were affected by their actions and even their thoughts. Listen it is important … especially in understanding karma. He was told that he would be taught many things … ‘but you will be going back …’ Reincarnation comes up as an important lesson in soul growth - this may shake out those who have had an orthodox upbringing in their own particular Abrahamic religion - however there are so many cycles in life - from the carbon cycle to the nitrogen cycle, the sulphur and the potassium and oxygen cycles including seasonal cycles, moon cycles and cycling constellations to the Galactic Cycle and beyond …. So why not a cycle of the soul? - Plato and Pythagoras were aware of this and it is far more predominant in the Western world than is commonly known. That our souls come back again and again in a process of refinement -  until we can release ourselves from the ‘wheel of rebirth’ … Other Topics Covered. Indra's net = Eastern traditions … reincarnation. https://en.wikipedia.org/wiki/Indra%27s_net  Listen to Eben mention the power of Prayer … If you are a skeptic and atheist and a non believer - just take one hour out of your valuable life today and have a listen to this man - as his experience totally flips the medical version of life and confounds the naysayers in science too. Yet, he says he is more of a scientist today than he has ever been. That his memories have become more complex (detailed) after the coma than they were before … That memories are not stored in the brain - see Sheldrake.org and others … Briefly covered were: Telepathy, precognition, psychokinesis - the ability to manipulate matter at a distance - distance healing are all mentioned though quickly - and shared death experiences … Uvadops.org - University of Virginia - PAST LIFE research with children and reincarnation - Started by Dr Ian Stevenson and he says with reincarnation - this is where the world is heading (I heartily agree - Tim) …. it’s the science of consciousness. He mentions Captain Edgar Mitchell 6th Man on the moon and https://noetic.org/  Eben states that the days of scientists saying that NDE’s are nonsense and don’t occur are over … Because the only scientists who make such statements are the ones who don’t study or research any of the voluminous evidence that is available - globally. Eben, says the Elisabeth Kubler-Ross with her lifetime research and 20,000 interviews of NDE and OBE experiences - was absolutely essential in helping him connect the dots in relationship to his experience and he gives her kudos for the mapping of the territory that she did all those years ago. Now there are 100’s of scientists who are fully onboard following up on consciousness and the invisible realms today. https://www.ekrfoundation.org/elisabeth-kubler-ross/  He says https://galileocommission.org/ - is a very good resource … Meditation is big with him - going within … https://www.sacredacoustics.com/ Karen Newell, co-author with him on his new book. This is all about Understanding the Destiny of Humanity … We have to let go of the false sense of separation We are all in this together - and it is truly all about Love … He stresses Pierre Teilhard de CHARDIN - and his book The Phenomenon of Man - (1881–1955), French Jesuit philosopher and palaeontologist. He is best known for his theory, blending science and Christianity, that man is evolving mentally and socially towards a perfect spiritual state. The Roman Catholic Church declared his views were unorthodox and his major works (e.g. The Phenomenon of Man, 1955) were published posthumously. He was basically shunned by the Roman Church. Yet, humanity is converging on the Omega Point and the Cosmic Christ and that humanity is still tracking on Teilhard’s timeline. http://teilharddechardin.org/index.php/biography  Love and compassion and kindness … He mentions all the planetary challenges we face within the biosphere - pollution, war, deforestation, climate, avarice - - you name it … The Golden Rule - treat others like you would like to be treated Treating animals humanely is important - because they too, have a very rich spiritual existence. Towards the end of the interview I asked Dr Eben: “There are no accidents in the universe?” He paused and said in relationship to him - “no, there are no accidents” I then posited - “therefore what happened to you has to be part of the plan to waken up humanity - ‘Gods plan if you will'' - “that what happened to you and how you are today assisting hugely in the awakening of humanity could be seen as a dispensation for humanity? - Or that in fact this was your assignment - this was your mission, to go through this journey and share your profound story that we are all eternal beings …’ I did not get to complete this below piece as we became engaged in talking about the above. “That you, Eben incarnated into our world - studied the body and brain function, become an expert in this field and that in this age of modern medicine have medical science show on the screens and high tech apparatus that in this ND experience your brain had been predominantly destroyed - that you were basically clinically dead - yet you can have a miraculous recovery - and come back today in full consciousness, sharing joy and goodwill.” “That this event had to BE” - and that this wonderful interview today could come as an extension of your mission.” We also briefly mentioned that humanity ‘has to remember their inner candle, and keep it alive.’ This interview is a very important message for all souls on earth that live within the biosphere. That we all share the invisible breath that keeps our sacred bodies alive. That this invisible breath is shared by all biota - humans and all animals and - especially trees, vegetation and plankton that convert our breathed out C02 back to Oxygen in a magnificent loop of connectivity. Anima mundi - Latin for World Soul     Next week we will have the last interview of the year - one that will interest everyone.

Sons of the Flag Ryan “Birdman” Parrott, Founder, President & CEO served eight years as a U.S. Navy SEAL, attached to Team SEVEN, completing three combat tours to Iraq. In 2005, Ryan was riding atop a Humvee manning the turret gun in enemy territory, when his vehicle was hit by an improvised explosive devise (IED), causing a flash fire and throwing him from the vehicle. Ryan regained composure with his face and arms on fire, and witnessed his fellow team members suffer devastating burn and blast injuries. After completing his service, Ryan moved to Dallas. Meeting other Veterans in the area, some of whom suffered serious burn injuries, Ryan became discouraged that Veteran Burn Survivors were not benefitting form advancements in the area of burns in the same way that amputees benefit from incredible advancements in prosthetics. Searching for better answers, Ryan realized that traumatic burns significantly impact not only the military community, but fire fighters, first-responders and civilians as well. Feeling called to help, Ryan established Sons of the Flag. Sons of the Flag, a non-profit organization, founded in 2012, is vigilantly committed to supporting military and first responder survivors by providing funding for innovative research, Fellowships for doctors to further their training in treating burn survivors, and support for those impacted by a traumatic burn. To that end, Sons of the Flag brings together passionate community leaders, pioneering physicians, experienced military service members, dedicated first responders and purposeful civilians to complete the mission. To date, Sons of the Flag has funded Medical Fellowships at Brigham & Women’s Hospital in Boston and UT Southwestern in Dallas, supported Burn Units and the staff who work there all over the country, financially supported Pediatric Burn Camps all over the country, established a Fire-Fighter led National Task Force, and funded many individual Burn Survivor requests for help. The need is immense, the injuries are life-long, and our commitment is unwavering.

Miami Book fair author: Dr. Daniela Lamas, a Harvard University Fellow, Pulmonary & Critical Care Physician at Brigham & Women’s Hospital, medical reporter for The Miami Herald, writer of medical drama “The Resident” and Author of: “You Can Stop Humming Now; A Doctor’s Story of Life, Death and In Between” shares her patients’s experiences- and her of position of keeping them alive at all costs, or not? @danielalamasmddoctors@massgeneralbrgham.org617-278-1000

21 May 2020 The #COVID19 series continues.: Resa speaks with Ashish Jha MD MPH and Miriam Laufer MD MPH.  They discuss the Atlantic magazine article ‘How Could the CDC Make That Mistake?', Hydroxychloroquine, Vaccines, Summer Camps, and opening institutions of higher learning (see NYTimes Op Ed by Christina Paxson) Dr. Ashish K. Jha is the K.T. Li Professor of Global Health at the Harvard TH Chan School of Public Health and Director of the Harvard Global Health Institute (HGHI). He is a practicing General Internist and is also Professor of Medicine at Harvard Medical School. Dr. Jha received his MD from Harvard Medical School and trained in Internal Medicine at the University of California in San Francisco. He completed his General Medicine fellowship at Brigham & Women's Hospital and received his MPH from the Harvard TH Chan School of Public Health. Dr. Jha is a member of the Institute of Medicine at the National Academies of Sciences, Engineering, and Medicine. In September, Dr. Jha will begin work as the Dean of the Brown University School of Public Health. Dr. Miriam Laufer is Professor of Pediatrics, Medicine, Epidemiology and Public Health, and Faculty of the graduate program in Microbiology and Immunology at the University of Maryland School of Medicine. She received her medical degree at the University of Pennsylvania and completed her residency in pediatrics at Babies and Children's Hospital of New York (now New York Children's Hospital) of Columbia University. She completed fellowships in pediatric infectious diseases at Johns Hopkins University and in malaria research at the Center for Vaccine Development at the University of Maryland. She received her MPH from the Bloomberg School of Public Health at Johns Hopkins University.

I am thrilled and honored to introduce you to Akhtari Alam, a women full of life and amazing experiences that an average person might not be able to imagine. Her journey of migration from Asian Sub-continent to the nation of immigrants has heart wrenching ebb and flows. I had the privilege to speak with her in Urdu, you can use the caption to convert it into Urdu where ever it is available.  Akhtari Alam did her MS from Dacca University,East Pakistan  (now Bangladesh ) in microbiology with top position. She came to USA in the end of 1970. Worked at Brigham & Women's Hospital, Boston in microbiology department for over 43 years. She worked for last 23 years as lead person in Mycology, which included routine mycology and teaching technologists and interns. Alam Has done many workshops in mycology. Retired four years ago and enjoying it very much.  Enjoy! 

Dr. Eben Alexander III has been an academic neurosurgeon for the last 25 years, including 15 years at the Brigham & Women's and the Children's Hospitals and Harvard Medical School in Boston. Over his academic career he authored or co-authored over 150 chapters and papers in peer reviewed journals, and made over 200 presentations at conferences and medical centers around the world. He thought he had a very good idea of how the brain generates consciousness, mind and spirit. In the predawn hours of November 10, 2008, he was driven into coma by a rare and mysterious bacterial meningitis-encephalitis of unknown cause. He spent a week in coma on a ventilator, his prospects for survival diminishing rapidly. On the seventh day, to the surprise of everyone, he started to awaken. Memories of his life had been completely deleted inside of coma, yet he awoke with memories of a fantastic odyssey deep into another realm - more real than this earthly one! His older son advised him to write down everything he could remember about his journey, before he read anything about near-death experiences, physics or cosmology. Six weeks later, he completed his initial recording of his remarkable journey, totaling over 20,000 words in length. Then he started reading, and was astonished by the insights his journey brought to the world's literature on near-death experiences, and to all phenomena of extended consciousness. His experience clearly revealed that we are conscious in spite of our brain - that, in fact, consciousness is at the root of all existence. His story offers a crucial key to the understanding of reality and human consciousness. It will have a major effect on how we view spirituality, soul and the non-material realm. In analyzing his experience, including the scientific possibilities and grand implications, he envisions a more complete reconciliation of modern science and spirituality as a natural product. He has been blessed with a complete recovery and shares his most powerful, life-changing story in his book, Proof of Heaven: A Neurosurgeon's Journey into the Afterlife, which debuted at #1 on the New York Times Bestseller list.