Podcasts about cedar sinai

When the resume says: Yale, Stanford, Harvard, and Cedar Sinai as past training and education, you can usually trust the opinion as it relates to their specialty. The exception is when it relates to yourself... Welcome to the Just Dumb Enough Podcast. A show that acknowledges no one is always an expert, by dispelling misconceptions with real experts.  My guest today is Andrew Kadar. Dr. Kadar is a fan of the show with over four decades of work as an anesthesiologist. Despite all of this  he missed his own heart disease diagnosis until it nearly killed him. He's with us today to explain heart disease a bit, tell us some risk factors, and ultimately prove that his situation was not as unique as you might think.     ( Www.GettingBetterDoc.Com )   ( https://a.co/d/fNLK36d will take you to: Www.Amazon.Com "Getting Better: A Doctor's Story of Resilience, Recovery, and Renewal" )  ( Www.MagicMind.Com/Dumb20 ) Let's not deny our own mortality! (Jeez, that's a dark way to start a show...)  Side note, I've had multiple family members now actually require heart surgery over the years, and even a few that have passed away from untreated conditions, so I'm trying to stay very aware of my own risk. I would hope you're all doing the same, keeping yourselves in good health for a long time to come.  In other news, September is well underway, so here's the updated rankings so far:  1. The United States, taking back first place thanks to New York, Texas, and Illinois.  2. England of the United Kingdom, rocketing back up the list.  3. Australia, with Victoria now holding a small lead over Queensland.  4. Canada, with Ontario maintaining a healthy lead.  5. Ireland... tied with Ghana! What a race!  That's it for this week! Have a great week, a great weekend, and I'll see you all back here next week for another new episode!  Until the next episode, pretty please do all the things to help the show: rate, review, like, and subscribe.  Reach out to DumbEnoughPodcast@Gmail.Com or on any social media if you want to reach me personally.  Most importantly, Stay Dumb! 

Don't Face Cancer Alone"The 6 Pillars of Healing Cancer" workshop series provides you valuable insights and strategies to support your healing journey - Click Here to EnrollCould changing what you eat dramatically improve your odds against cancer?Dr. Katie Deming sits down with radiation oncologist Dr. Hans Kim to explore how the ketogenic diet combined with radiation treatment could be the future of personalized medicine and empowered patient care.You'll learn about the science behind why cancer cells are more vulnerable when your body is in ketosis. Dr. Kim shares real-world examples from his practice, including how some patients have experienced surprising benefits from incorporating a ketogenic approach during their cancer treatment.References from episode:Trial at Cedar Sinai:  https://www.ljamaral.com/new-page-1The University of Iowa paper on ketogenic diet as an adjuvant treatment option for cancer: https://www.sciencedirect.com/science/article/pii/S2213231714000925Dr. Jethro Hu's trial on glioblastoma and ketogenic diet: https://clinicaltrials.gov/study/NCT03451799 Together, they explore how our modern diet might be at odds with our evolutionary biology. Prepare to gain a new perspective on nutrition that could influence your approach to overall health and wellness, whether you're dealing with a specific condition or simply aiming to optimize your well-being.You'll hear about ongoing clinical trials and the potential future of this innovative therapy combination. Plus, practical tips on how to safely explore ketosis.Listen and learn how the foods you eat could potentially enhance your body's ability to fight disease and support healing. Keto Mojo Blood Glucose and Ketone Meter:  Send us a Text Message.Don't Face Cancer Alone"The 6 Pillars of Healing Cancer" workshop series provides you valuable insights and strategies to support your healing journey - Click Here to Enroll MORE FROM KATIE DEMING M.D. Free Guide - 3 Things You Need to Know About Cancer: https://www.katiedeming.com/cancer-101/Work with Dr. Katie:www.katiedeming.comFollow Dr. Katie Deming on Instagram:The.Conscious.Oncologist Take a Deeper Dive into Your Healing JourneyFollow Dr. Katie Deming's Linkedin Here Please Support the Show Share this episode with a friend or family member Give a Review on Spotify Give a Review on Apple Podcast DISCLAIMER:The Born to Heal Podcast is intended for informational purposes only and is not a substitute for seeking professional medical advice, diagnosis, or treatment. Individual medical histories are unique; therefore, this episode should not be used to diagnose, treat, cure, or prevent any disease without consulting your healthcare provider.

With organizations heavily focused on EHR rollouts and optimizations, the “critically important” administrative systems took a back seat, said Craig Kwiatkowski. In this interview, he talks about the “major overhaul” Cedar-Sinai has undergone to centralize services, the keys to success with its Accelerator program, and his interesting career background. Source: Cedars-Sinai CIO Craig Kwiatkowski Talks Overhauling ERP, AI Governance & Immersive Learning on healthsystemcio.com - healthsystemCIO.com is the sole online-only publication dedicated to exclusively and comprehensively serving the information needs of healthcare CIOs.

Chaz N Schatz genuflect and give a heartfelt "We're Not Worthy!!" to Billy Alexander & Tim Starace from YYNOT. We were so thrilled to have YYNOT join us that we dumped name checking (beyond the usual suspect What No Way Guy) in favor of chatting up the band and going deep with YYNOT and Rush music analysis and organized chaos. We got the scoop on the 2024 Bubba Bash, Billy's new release Alpha Rhythm, and holy shit - a fuck-ton whole lot more than we bargained for!! (The language...these guys...) Fast Facts: - Tim doesn't dream. - Billy's had nightmares about performing with Rush. - The 2023 Bubba Bash raised over $100K for the Neil Peart wing at Cedar Sinai! - Schatz bollocks up the vote...(whose Shatz is hanging now??) We share a special Mental Health Day message from the home office at Danforth & Pape, deep dive on how YYNOT came to be, the band, their life on the road, gear choices in the studio versus the stage, traveling preferences, male-oriented wipe preferences (Tim's preferences...), the evolution of the Bubba Bash, and so much more...we're really gonna blow your drawers out with a pants-load of YYNOT coverage. So grab whatever it is you sanitize with, don't look at your fingers, and join us for our best behavior episode - one that would have made Dad proud. Welcome to the sweet-spot baybee...cacao! Cacao!! We're also announcing Schatz's Effin' Pre-show Meet Up at The Dark Bullet in NYC near the Beacon Theater on November 13th - come out and hang out with Schatz and other Rush Rashers making their way to the Effin show!! Rush news, general nonsensical disorderly conduct, lack of regard for correctness or truth, and reckless endangerment of your whole-brain. This is the only podcast that is dedicated to increasing opioid release in your anterior insula, your anterior cingulate cortex (ACC), and your posterior cingulate cortex (PCC), in addition to the basal ganglia and the thalamus...and all that that implies.  Some thick North Jersey accents and they give you some royalty-free sound effects and movie clips too - what more do you need to indulge your urge to scratch?!  Join us - you know where to scratch - blah, blah...RushRash.

We are joined today by Dr. Barry Brock, aka “The King of VBAC” along with one of his VBAC-hopeful patients, Kara. Kara and Meagan ask Dr. Brock VBAC-related questions similarly to how we hope you interview your providers during your VBAC preparation. Dr. Brock touches on topics such as gestational diabetes, big babies, preparing for your VBAC, induction, placenta previa, preeclampsia, HELLP syndrome, VBAC after multiple Cesareans, and vaginal breech delivery. Additional LinksNeeded WebsiteHow to VBAC: The Ultimate Prep Course for ParentsThe VBAC Link Facebook CommunityFull Transcript under Episode DetailsMeagan: Hello, everybody. Welcome, welcome. We have a really cool episode for you today, an episode that we have been really anxiously waiting for and so honored to be having. We love having birth professionals on the podcast and today we are so honored to have Dr. Barry Brock chatting with us today about birth and VBAC and all of the things. And then we have an extra special cohost today, Kara Sutton, who is actually one of Dr. Brock's patients. Hello! Kara: Hi guys. I'm so excited to be here. Meagan: So excited to have you guys. I just wanted to share a little bit about the amazing Barry Brock before we get going into all of these amazing questions that this community has asked. Dr. Barry Brock has been a doctor for over 30 years and has experience in obstetrics and gynecology. He has been attending as a doctor at Cedars and I believe Dr. Barry Brock, you had your residency there, right? Dr. Brock: I did. Meagan: That's really cool so you've been there for a while. Dr. Brock is amazing and takes pride in giving quality care to all of his patients. Seriously, one of the coolest things—I mean there are a lot of cool things—but especially with me in the VBAC world, one of the coolest things to me is that you have an outstanding Cesarean rate. It's very low. I think that's one of the things that you are very well known for along with helping people have vaginal breech deliveries which we know is kind of trickling out in the world and vaginal twin deliveries and of course, VBACs. So welcome, Dr. Brock, and thank you so much for being here with us. Dr. Brock: It's my pleasure. Meagan: Oh my gosh. Yes, and as I mentioned, we've got Kara who is a patient of Dr. Brock. Kara, tell us how it is to be a patient. Kara: I am a mom of two. I had an emergency and I had a planned C-section due to PTSD from that first emergency C-section. Now I am four months pregnant with my third baby girl and Dr. Brock is my doctor. I'm excited to try and achieve a vaginal delivery with this one. Dr. Brock has the LA rep as the go-to VBAC doctor if you're trying to achieve VBAC so that is why I am seeing him. I switched doctors specifically for this pregnancy which I think is super important to find the right doctor. I feel really excited and comfortable with Dr. Brock for this particular delivery, especially after the trauma from the first two. For those of you guys who don't know, Cedar Sinai is a really famous hospital in LA. We're in Beverly Hills here today. Everyone from Kylie Jenner allegedly and Jay-Z and Beyonce and all of the people have delivered there so he's kind of a rockstar. So I'm excited. Meagan: Yes. Oh my gosh. It is such an honor. Such an honor so thank you both for being here.Kara: Yeah, so I kind of wanted to jump in right away and wanted to ask Dr. Brock, why do you think the national average C-section rate is so high and why do so many doctors just schedule a C-section? Dr. Brock: Well, the docs are very concerned about a healthy baby and a healthy mother. It takes the stress off of the doctor if there are any problems getting the baby out, but there's no evidence that we've improved the Cesarean section. We have massively increased the Cesarean section rate and we have not improved the fetal outcome. So obviously the system that we're going with here needs to be tweaked a little bit. But they also need experience. To do a vaginal breech delivery, you have to have the skill and expertise to be able to do that and if you're not doing that, you don't have the skills so for a lot of doctors, for them, it's safer to do the Cesarean section than to do a vaginal breech delivery. I understand that. You're not skilled. Among the criteria that the American College of OBGYN recommends is that if you're doing a vaginal breech delivery, you have to know how to do it. Of course, if you don't do it, you don't get it done. Another thing is that doctors are very concerned with fetal monitor tracing and they are concerned about the baby's health and well-being. So when the baby comes out, the other side of the coin is that we do lots of Cesarean sections for fetal distress but most of those babies come out screaming. Well, you can say that we saved this baby from getting in trouble or we did an unnecessary Cesarean section. Remember there is also the mother's health and the baby's health. There's a higher risk to the mother's health– ten times greater having a C-section than a vaginal delivery– but extremely rare. So that's not a major factor. You say ten times greater but the incidence is so low. It's much greater that you walk outside when it's raining and get hit by lightning. But still, in LA, it's a very rare thing so I'm not concerned about that. Doctors want the best for the baby. It seems like this. A lot of the time they can get away with a Cesarean section. Some insurance companies pay for more Cesarean sections. You don't have to go ahead and spend hours and hours in labor. My philosophy is a little different. But you need the skill and expertise. That's when obstetricians can deliver a healthy baby vaginally. Meagan: Yeah. Wow, I love that. I feel like we could do a whole podcast just on this question alone because it is such a big question. Like you said, I love that you touched on what if we've got a Cesarean but the baby comes out screaming? We've had people say, “I've had this emergency C-section but then my baby had an 8/9 APGAR so was my baby in distress?” So thank you so much for touching on that. Another big question that we have that a lot of people ask is the big baby question. What if I'm being told that my baby really is too big to give birth vaginally? Is that really a thing? What's the accuracy on that and how would I know if choosing a Cesarean is the right choice versus going for a vaginal birth after a Cesarean? What's the safety there for the baby?Dr. Brock: Well, a major concern is– the American College addressed that. It is with mothers that are diabetic and have gestational diabetes. If the baby's over 4500 grams, which is a very big baby, then consideration should be for Cesarean section for the risk of shoulder dystocia. But that's it. At 5000 grams, if you do not have gestational diabetes, that's a huge baby. Kara: What is that in pounds? Meagan: It's like 9 pounds. Is it 9?Dr. Brock: 12 pounds or something like that? It's a huge baby. Meagan: Yeah, anything over 11 is an extra large baby, and then at 9 pounds, 15 ounces is where they start paying attention, right? Dr. Brock: Yeah, but the biggest problem with shoulder dystocia is if you have a very large baby and you do a mid-vacuum or forceps, then the incidence of having shoulder dystocia is very high, like 25%. But most of the time, mother nature goes ahead and plants the hat and wants a vaginal delivery. It'll tell you. Maybe it's stuck or something like that. But to me, it's always worth a try because basically, you're saying that mothers who are diabetic would have died in labor. Mother Nature knows what to do. When you give it a chance to prove it, I've seen it all. I've had a mother who had two Cesarean sections for a 6-pound baby so she really wanted a vaginal delivery. I waited and waited and waited and she delivered her 9-pound baby.  Mother Nature knows what to do. Meagan: Right. So for gestational diabetes, maybe if they are controlled and everything is looking good and the baby doesn't look like it's 12-13 pounds or a really large baby, you still feel that it's reasonable to go for a vaginal birth? Dr. Brock: I practically always think it's better for a vaginal birth. I mean, there are exceptions. I do VBACs after two Cesareans. I don't do it after three. The incidence for you to rupture after one Cesarean is 0.5-1% which is very small. For two Cesarean sections, it's 5% but then it climbs dramatically after that so I don't do that. Obviously, you have to look at if the placenta is implanted properly. If the patient is of an abnormal presentation of the placenta with placenta previa or accreta. Accreta is when the surface of the placenta digs itself into the wall of the uterus and that presents a major problem. That's a good idea to get a good center who knows how to handle it. Meagan: Absolutely. Dr. Brock: But Mother Nature– give it a chance. Meagan: Give it a chance. Kara: I'm interested. So why won't all doctors induce VBACs? What's the best method for induction and what should I do if my doctor refuses? Dr. Brock: I induce for medical reasons. When someone has a previous Cesarean section, we don't give prostaglandins because that has shown an increased chance of rupture. I much prefer all my patients to go into labor spontaneously. I sign for a lot more testing after 40 weeks. It depends if we find medical problems but they'll test twice a week to make sure the fluid's normal, the Doppler flows are normal, and the NST are non-stress tests where we see baby's heartbeat. I consider 42 weeks as normal. If someone's, like I said, diabetic, I'll do 40 weeks unless there are other problems. But I prefer them to go into labor naturally because I think it's easier on the mother and it's a higher success for a vaginal delivery. But saying that, this week, I've had a mother who had a baby who was abnormal and it was going to be fine. He needed heart surgery. She had two previous Cesarean sections. We induced her and she had a vaginal delivery. The baby, thank God, is doing fine. We will do heart surgery probably in 3 or 4 months. Each person's different and we have to take everything into consideration. Right now, I like to wait for Mother Nature to do its thing. Keep an eye on Mother Nature, but let mother nature do its thing. Meagan: I love that. Keep an eye on mother nature, but let Mother Nature do its thing. Because we do, we have so many people writing in saying, “My doctor says I have to have a baby by 39 weeks spontaneously or my chances of VBAC are completely out the window and I have to schedule a Cesarean.” It puts people in a fight or flight mode where they are out there trying to do all of the things to try to be induced but it's not working because their body is not ready when really what we need to do is step back and let Mother Nature do its thing. Dr. Brock: Well, there are exceptions. Obviously, someone who is sitting in my office and is 3-4 centimeters dilated and she's 39 weeks then she's an easy induction. If you're closed and high, then don't rush to an induction. Meagan: Right. Right. Dr. Brock: For each person's safety, individually you have to do that.  Meagan: And that is one of the most important things I think any provider out there should view is that everyone is an individual. I'm not the same as Cara and Cara's not the same as this mom that just had her VBAC after two Cesareans. We're all individuals and have different situations. So one of the big questions is breech. If we have someone that is having a breech baby or their baby is breech and not turning, a lot of people just have these repeat Cesareans and we know that you are really big in supporting that. Obviously, there are again, things that have to pan out. But why do you think breech is really going away? If someone is having a breech baby, what can they do to help avoid that C-section if they don't have a provider like you that's maybe more supportive of having a breech delivery?Dr. Brock: Well obviously, because in today's society of birth, people don't have the skills to do a breech delivery. You can't have a breech delivery unless your provider knows how to do it. The first thing I want to do is try to turn the baby. At 37 weeks, we will schedule you. We do it at 37 weeks because statistically if the baby hasn't turned at 37 weeks, there is less chance that he will do that. Also, the fact that if something happens in a version– I've done hundreds of them and I've never had a problem but theoretically if something happens and we do a Cesarean section, baby is at term at 37 weeks. That's the first thing I would do. With the breech delivery, I treat a breech delivery– I don't care if it's a first-time mother or a second. I do the same thing. Just like Kara, when she gets around 6-7 centimeters dilated, which means the active phase of labor– she can labor at home or wherever, but once she gets to 6 or 7 centimeters, I want everything to go quickly. What I mean is that I want her to dilate quickly. I want the butt to settle down quickly and I want to push her out quickly. You're not going to push for 3 or 4 hours. I'll do that for first-time mothers or with any mother head-down but not with a breech. I want it to go quickly. A lot of babies don't do that, but that's where I stay safe because if it flies out, it flies out. The biggest problem with breech delivery is that the head is coming last. The cord is beside the head so you've got to get the baby out quickly. Using those criteria, I've had very good success and no problems, but I've done many Cesarean sections because obviously, I remember one patient who came in. She was 9 centimeters. It was fantastic. She was doing great. She started pushing and all that came down was the testicles. So I sectioned for a 10-pound baby. So mother nature is telling you, “Just because you're committed to a vaginal delivery, you don't drag the kid out.” The idea is to let the baby do its thing. The reason we want butt down, especially in first-time mothers, is that if it's not his feet coming out, the cervix may dilate to 6-7 centimeters and the feet come out and the body comes out and the cervix is not fully dilated when it gets to the head and it gets trapped. The cervix never clamps down. It just never fully dilates. That's why we usually don't do footling breech. We don't do vaginal delivery. There are exceptions, but rare exceptions. If a multiparous patient comes in and the feet are there and the cervix is completely dilated, the baby just falls out. That's really an exception to the rule. The other concern with a footling breech is especially if the mother is dilated, that patient is concerning because if the water breaks and she's dilated and just the feet are there, the cord may fall out. It's called a cord prolapse. That's a contraindication to try to do something at home. If someone is dilated and footling breech, that's the kind of patient I would bring to the hospital and do a C-section for cord prolapse. Meagan: Yeah, which makes sense. There are not a lot of you out there that will support or is trained and educated in vaginal breech delivery and from what we're gathering is that it's not really being taught a ton in medical school anymore. Is that correct? Dr. Brock: Well, not in my residency. I mean, I may offer to do that but it's easier. I mean, you schedule a C-section. You walk in. It's an hour. You're done versus spending 8, 10, or 12 hours laboring this patient. So the incentive isn't there to do that. So the skills are disappearing. I mean, I've offered to come in and assist anyone who wants to do a breech delivery and I've done that but not that often. The residents are always invited. They can do that but just because they do it in residency, it's a big staff to get through. They may do one or two breech deliveries but they don't feel comfortable to keep on going out in the private practice. It is dying out. Meagan: Yeah. It makes me sad. It makes me sad. Kara: I have a question because I have had two C-sections. How long should somebody wait to conceive after a C-section? I've heard mixed things about this. I've been told mixed information about this and I just would love to hear your point of view on that. Dr. Brock: Well, there's some data to show that ideally it is two years apart but everybody's facts come into play. For someone who is much older and has trouble getting pregnant, if someone had a baby at 40 and wants another child if she is waiting until 42, she may never get pregnant. I've not found it to be a big factor but statistically, it does seem to be safe. I would do psychologically what's better for you how far apart you want to have your kids. Besides, mother nature does help. It takes some time to get pregnant as you get older. Kara: Great. Is the thought that the longer you wait, the more healed your C-section scars are and your uterus is stronger or is that not real? Meagan: Like is there less chance of rupture that way? Dr. Brock: Literature is in my mind, not that clear. Statistically, it's probably true but it's like saying you're at a greater chance of dying if you're driving at 58 miles an hour instead of 55. It's true, but statistically, is it really a factor? Meagan: It's not substantial. It's not anything that's a concrete yes or no. Okay, and talking about VBAC after two Cesareans or more, what are the complications surrounding a C-section or even a repeat C-section? We talk here a lot about the risks of VBAC– rupture and things like that– but we don't talk a lot about complications, especially even years later. Are there complications for people who have had Cesareans even years later? Dr. Brock: Years later, I don't know much about that. I do know the higher the Cesarean section rate, you're going to have an increase of abnormal implantation of the placenta from accreta or things like that. It goes up. Instances of rupture with more Cesarean sections go up. I've done Cesarean sections, 5, 6, and 7 Cesarean sections. It depends. The doctor who goes in there with all of the scarring, while it's very, very difficult and dangerous, it may pass on to the next time, but most of the time, it's not a problem at all. I have no limitations per se on how many Cesarean sections someone can have. I have a patient right now. She had a Cesarean section then I did a VBAC. Now she's pregnant again but she wants a repeat Cesarean section because she had anal problems and she had surgery so her surgeon recommended that she doesn't try for a vaginal delivery. I'm not 100% in agreement but I have no problem respecting her wishes and we set her up for a Cesarean section. Each case has to be individual. There are no absolute rules for anything. As far as consequences, most of the time for later on, there is but it's more related to how many times you get pregnant, not how you deliver. Bladder dropping and things like this, each pregnancy puts a toll on that. I think mother nature plans for you to have your first kid when you get through puberty. I think it's a very bad idea for 13-year-old kids to have kids. But mother nature, that's the whole plan. That's the animal kingdom. That's what we do. Of course, for millions of years, you were dead at 20 but that's a different story. Meagan: So kind of piggy-backing off of that question too, we had someone write in talking about how she had a Cesarean and then they went in for a second Cesarean but they didn't use the same incision so she's got two incisions which I had never actually heard of, in her uterus. In the uterus, they cut a different spot is what she said. She's asking– okay, so now she's got two incisions in her uterus. Is that something that would be suggested for her to VBAC because she'd really like a vaginal birth? Dr. Brock: No, that's fine. First of all, the patient doesn't know about the scar on the uterus. It's the doctor. When I go in there unless someone had a vertical incision and there's no such thing as a classical. They call it a classical incision, but that was done 100 years ago and they went up and down incision on the belly and they went up and down incision on the uterus. The top of the uterus is the fundus is what we never do. That's at a much higher instance of uterine rupture. We used to do that. Somebody added, “Once a section, always a section.” That's where that falls. I would say 95% of Cesarean sections are low-transverse. They are very low on the uterus. But when I go down and do that, I see the bladder there. I don't know where the last Cesarean section was. I can't see. I just tape down the bladder and make an incision so I have no idea in the uterus. But we do know that, like I said, during Cesarean sections and repeat, it's not a problem. We do know that.I've given it to patients that had previous fibroid surgery. The American College recommends, what is the indication for the surgeon? Does he recommend you for vaginal? He should tell you that. My philosophy is when I do that, it depends on if I enter the cavity of the uterus and whether I would recommend a Cesarean section. Sometimes the fibers outside of the cavity, I have no problem recommending a vaginal delivery. I've done vaginal deliveries after another doctor did multiple fibroids laparoscopically. They sewed it up and I asked him. He said, “Well, it should be fine. We did multiple scars and she did great.” Yeah, individuals.Meagan: Exactly, yeah. Thank you. Kara: I have a question. I did not have supportive providers in regard to my first two deliveries. I had an emergency C-section and then a planned C-section and nobody brought up that I could deliver vaginally or any of that. I just felt like I had a C-section so I had to have one the second time around. So I wanted to know what are the ways to really help someone find a provider who actually tries for that? I think a lot of women can't find the right doctor who can do that. Meagan: Yeah. Dr. Brock: It's hard to say. Some hospitals publish the C-section rates of their doctors. That's one way to look into it. But blogs and things like this, you have to talk to your doctor and see what's comfortable. You can't force your doctor to do something he's not comfortable with. Many years ago, one of the doctors, an old-time doctor, refused someone to do a VBAC because he had a bad outcome with a baby. Your personal experience comes in. Everyone's trying to do the best thing. They're trying to do what's safe for you and your baby. You just have to find a match that works for you. Kara: When you're interviewing your doctor, what are the types of questions you can ask to get a sense of his or her skill level with it or comfort level with VBAC? Dr. Brock: Well, I've had a patient come in. She had three previous Cesareans sections. She wanted me to do a vaginal birth. I said, “Don't. My limit is two.” They have it out to think that it's the same but it's not. It's about talking to your doctor and asking them personally. “I'm thinking about having a VBAC. What do you think about it?” You want to be comfortable with your doctor and listen to his advice, but there are different opinions out there. If you're comfy with your doctor and you trust your doctor, I have no problem if he feels that he did a section and recommends another section, I understand that. We do know that certain things that change behaviors. They talk about measuring the thickness of the scar, of the uterus, and things like this. A study just came out that found no correlation whatsoever. Meagan: I was going to ask that. That is a huge question too. “My doctor said I can't because my thickness isn't thick enough.”Dr. Brock: Well, there was no correlation. It made me nervous. I had one who had a scar. They said she had a window in the ultrasound. She had two previous Cesarean sections. I delivered her baby vaginally no problem. After that article came out saying there was no correlation, and my experience showed there was no correlation but each case is individualized. I may have a previous rupture and that's a different story. There is no good literature on that and it's probably not worth the risk. Meagan: Right. What about single and double sutures?Dr. Brock: The data shows that I will always use the double closure. The only thing I would make an exception for is that sometimes when they get their tubes tied and it will save some time while having a C-section or vaginal delivery. But no, literature says that double closure has lower chances of rupture. Meagan: Would you support someone wanting to VBAC if they had in their op reports a single-layer suture? Dr. Brock: Yes, I would. A higher instance doesn't mean it's going to happen. As all patients, with this one especially, when you have a previous Cesarean section, I don't want you to deliver at home. *Inaudible* Usually, it's not unreasonable to place an epidural catheter in. Not actively, but if something happens, we can just give you some medication so you don't have to put them under general anesthesia. Just to be prepared.Meagan: Right, right. Be prepared. Kara: You prefer that they labor at the hospital and not at home? *Inaudible*Dr. Brock: Yes, yes. Right, because that's a concern we have. The baby will tell us something. I did a VBAC last night and she's not that tall. She's only about 5 feet. This baby seemed huge but it was way out of bounds. The reasons are that the pelvic, mother nature doesn't know about these Cesarean sections. So first-time babies go down low in the pelvis. The cervix is firm and holds the babies in there prematurely but after the first delivery, the cervix can get soft so mother nature keeps an eye until you go into labor otherwise you'll deliver prematurely. But that's when the head is high. The higher the head is, that's going to put pressure on the scar. I feel much more comfortable as the head drops in the pelvis, it's getting below the scar, and the chance, I think, of rupturing drops dramatically when the head drops. But mothers may not drop until they go into labor. Meagan: Right. Talking about preterm, if someone had a preterm Cesarean birth, are they a candidate in your eyes for a vaginal birth after a Cesarean? Dr. Brock: It depends on how premature. Babies vary with premature. We talk about if she didn't go into labor, and they had to have it done. It depends on the thickness of her lower uterine segment. The doctor goes in. He may feel like there's not enough safe room to make a transverse incision so he has to do a low vertical. The low vertical is associated with a lower instance of rupture. Mind you, before we say you have to find your records and find exactly what type of scar on the uterus it is. But now, American College says, “No. If you had a previous Cesarean section, unless you know that it's a low vertical, then you can try for a vaginal.” If it's a high vertical, definitely. Low vertical, it is a little different but we have to wait and see. I'm not against going for a repeat Cesarean section if someone had a 25-week Cesarean section. If the lower uterine segment was not developed, the doctor did it appropriately. There is no harm to the baby coming out low vertically extended up. Meagan: Right. That makes sense. Cara, did you have another question? I know that we were talking about it before. Kara: I was just wondering if I'm preparing for a VBAC, which I am in four months. Is there anything you recommend that patients should do to prepare for a VBAC? That's something I think about all of the time. Is there anything that patients should do to prepare for that? Dr. Brock: There's nothing. There's really nothing that you can do.Kara: No running?Dr. Brock: You don't want to gain too much weight during pregnancy. The more weight you gain, the bigger the baby so that's a major factor. If you start gaining 40, 50, or 60 pounds, then the baby may be bigger and things like that. Most things to prepare are like with any pregnancy. Get yourself into shape before you're pregnant. Get your weight down before you get pregnant. Those are major things that you can do. Once you get pregnant, we tell you not to gain too much weight, but we don't want you to lose weight. Exercise can always be done during pregnancy, but I always prefer getting into shape before you get pregnant. Kara: No one ever tells you that. I swear. Or at least no one's ever told me that. I think that's a good thing to know. Dr. Brock: Yeah, because you're slim. Meagan: Yeah, well just being healthy overall and overall healthy. That's not even just for VBAC. It's just if you're going to have a baby, try overall to be healthy in general every day. Even if you're not having a baby. Good nutrition and all of that. Preeclampsia is something that is sometimes developed. Is that something that someone could TOLAC and have a VBAC with? Dr. Brock: Yes. It really depends but nowadays, with previous history, we give baby Aspirin and try to lower the incidence of recurring. We keep track of the blood pressure throughout the pregnancy. But yes. If I knew the cause of preeclampsia, I'd win the Nobel Prize. It's the mystery of mankind. We know it's associated with first-time mothers, elderly mothers, and twins, but we don't know exactly the cause. All we can do is keep an eye on it and make sure it doesn't occur. Now if it does occur, unfortunately, the delivery for that and the treatment for that is delivery. Meagan: Right. This is a spinoff but HELLP syndrome. If someone develops HELLP syndrome and their platelets are good and everything, are they still candidates for VBAC or is a Cesarean delivery really safer? Kara: Can I ask, what is that? Dr. Brock: First of all, it's a subset of preeclampsia hypertension *inaudible* where the mother can get elevated liver enzymes and low platelets. That is an absolute indication that we have to deliver the baby. Okay? Now, people go ahead and say, “Oh, well you were *inaudible* delivery. We should do a Cesarean section.” I have nothing against doing that but if a patient is, it may take a long process because she's not ready, but I think that she has to be managed in a hospital, her blood pressure is under control, and she has to go for delivery. Now, it may take a day or two and maybe she's not willing to wait that long or her doctor isn't or things like that, but I have no problem as an independent event to have a vaginal delivery if you have HELLP but it's definitely an indication. Meagan: Yeah, isn't that really the only way to help is to get the baby out? Dr. Brock: Correct. The only way to help HELLP syndrome is to get that baby out. Meagan: The only way to help HELLP syndrome is to get that baby out. Yeah. Okay, that is so good to know. It's not as common in our community, but we have definitely seen people ask and then they worry about the platelets and surgery. They never know what's safe or not. Dr. Brock: The other thing is that if the platelets are low or under 100,000 the anesthesiologist is very leery of putting in an epidural. The reason that over a spinal is because platelets are used to clog your veins and if he hits a blood vessel in your spine putting it in, then it can cause damage and cause paralysis so they really don't do spinals. They do general anesthesia, not regional anesthesia if someone has low blood platelets. I had a patient who had very low platelets not from HELLP, *inaudible* and she couldn't get an epidural. We definitely didn't want to do a Cesarean section because she had low platelets so we did it the old-fashioned way. She didn't have an epidural. She had a vaginal delivery and it hurt. Meagan: Yeah, well that's good to know though. That's really good to know. So as someone who's had a vaginal birth after two Cesareans myself and obviously Kara is preparing, we talked a little bit about how to prepare. But is there anything that we need to know? We talked a little bit about the risk earlier but is there anything that we need to know about vaginal birth after two Cesareans that we may not hear about with just VBAC after one?Dr. Brock: I mean, like you said. The risk is higher. The doctor who might be a little nervous or leery obviously, stress shows that doing a Cesarean section may be higher which I understand. If there are concerns, he may cross-match for blood and have it available in case you need that. That's how the doctor is not the issue. Like I said, labor in the hospital and not at home because if something happens, “Oh, I'm five minutes away from the hospital,” but that's not true. You may be five minutes but you're at least 45 minutes before you can get the baby out. You try to hold your breath for 45 minutes, so that's why in the hospital. But like I said, everything is done before you get pregnant. Try to get in the best shape you can and not gain too much weight and make sure the baby isn't huge. If someone had a macrosomic infant and is diabetic, the doctor may take that into consideration. Meagan: Right. We have a lot of people in our community that don't have the support in their area and do find themselves having to travel long distances to their provider that is supportive. I think a big worry is uterine rupture. We talk about uterine rupture and it sounds really scary. We talked about getting to that hospital as soon as you can. But for those who are driving or are further away, are there any signs or symptoms that you would say, “Okay, you need to seriously deviate your plan and go to the nearest hospital at this point?”Dr. Brock: Well, certainly massive bleeding. If you go ahead and have searing pain, that would be from the uterus. There are no absolute signs of anything, but stars up early, that's why you go in early so these things don't happen. Thank god the instance of rupture is very small. In a hospital setting, even with a rupture, there's no guarantee that the baby is going to get in trouble but it's considered a greater risk. If you're not in the hospital, it's a risk to the mother's health and the baby's health. But the instance is small. But common sense is. If you've had four Cesarean sections and now you decide you want a vaginal delivery, you're putting yourself at greater risk. It's not worth the risk. Babies don't do well if mommies aren't around so you want to make sure you're doing fine. Meagan: Make sure everyone's good. Yes. Awesome. Kara, do you have any other questions, especially as a patient? I'm sure you guys have this time in the office to ask as well. Kara: We have an appointment right after this. No, I just feel really grateful to have found Dr. Brock and I really feel that I wish more doctors were as skilled and as knowledgeable as you are. I am really, really impressed with your experience level and your support of mothers trying to do things the way they want and the way were made to do. I'm just very grateful and thank you for being with us today. I know how busy you are with eight deliveries this week. Meagan: Literally, I know. You just had births last night. I'm sure you'll have births today. It's always such an honor to have birth professionals on the podcast because these people who are listening to the podcast really are in a very vulnerable state and want to get all of the information. So it's so fun to have a skilled OBGYN here answering these questions from the community. It really does. It helps people guide and feel better. Honestly, just hearing the support you have, no wonder you're the VBAC king in LA. Dr. Brock: There are a lot of other people who do VBACs. Kara: You're being humble. He's being humble. Meagan: There are. There are a lot of people out there that do VBACs but it does seem to be harder to find people that do VBACs in the manner that you do like, “Let's monitor mother nature, but let's let mother nature do its thing.” It doesn't seem like you have a lot of restrictions. We have a lot of providers out there that do have a lot of restrictions so it's humbling to hear that you're like, “Hey, let's do this. Let's trust the process. I'm going to be here. I'm going to guide you along the way and I'm going to monitor but I want what's best for you and I want to listen to what you want to do and I want to support you.” Thank you so much for being that person for this community. Dr. Brock: Well, the other thing that I was saying is that for someone who is in labor, I do monitor the baby. It's not intermittent monitoring because that's how I keep track of the baby. The other thing I do when I do the tracing is that a good baby can look bad on the tracing, but a bad baby cannot look good. So you have to understand that. If a baby is a healthy baby and has some variation but it comes back and it's back to normal, that's a healthy baby. But even with the worst tracings, statistics say that 50% of the time, the baby gets in trouble. But just a terrible tracing, follow your doctor's advice and do what he says. But still, hopefully, results will come back good. Meagan: Right. Standard practice all over the world really is continuous monitoring with VBAC because we know that fetal heart dropping and distress are one of the main signs that something, some separation may be happening. If you're listening, know that it's pretty standard. That's pretty standard care all over the world. Dr. Brock: It keeps your doctor's *inaudible*. If you're not monitored, we don't know what's going on. Meagan: Right, yes. Okay, well thank you so much for taking the time out of your day and being with us. We really do appreciate it. Dr. Brock: All right, have a good day then. Kara: Thanks, Meagan. Meagan: You too. Bye, you guys. ClosingWould you like to be a guest on the podcast? Tell us about your experience at thevbaclink.com/share. For more information on all things VBAC including online and in-person VBAC classes, The VBAC Link blog, and Meagan's bio, head over to thevbaclink.com. Congratulations on starting your journey of learning and discovery with The VBAC Link.Support this podcast at — https://redcircle.com/the-vbac-link/donationsAdvertising Inquiries: https://redcircle.com/brands

 It's not often that we get to hear about an actual expert spine surgeon giving an account of his own journey back to spine health from both a patient and a surgeon's perspective! This is the remarkable story of one of our own, Dr. Todd Lanman, a spinal neurosurgeon who practices in Beverly Hills, is affiliated with Cedar-Sinai and UCLA medical centers, and who is a member of our prestigious  Medical and Scientific Board. He is also a Spinal Champion. Support the show

Because February is American Heart Health Month, in Episode 3 Alex and Mary discuss the latest research regarding how Covid affects the heart. Listen on our website, www.downthereaware.com/podcast, or wherever you get your podcasts. #Podcast #Spotify #Anchor #research #advocacy #covid #hearthealth #myocarditis #pericarditis #vaccines #bloodvessels #vascularvirus #respiratoryvirus #longcovid #bloodclots #stress #bloodpressure #parosmia #dysgeusia #olfactorynerve Episode Highlights Intro [0:13] Welcome Back! [1:25] February is American Heart Health Month [3:37] Heart issues have increased since 2020 [4:37] Ages 25-44 [4:50] Cedar-Sinai study [6:22] Increase in heart-related deaths across every age group [6:29] Higher viral load exposure [7:13] Immune response in stronger immune systems [7:17] Vaccines [8:50] Virus more dangerous than vaccine [9:14] Weigh the risks [10:00] Myocarditis [11:10] Increase in blood clot formation [13:30] Inflammation in blood vessels [13:45] Increase in stress and blood pressure [13:50] Respiratory virus vs vascular virus[14:05] Oximeter [15:20] Continually changing research [17:00] Long-Covid [17:40] UF Health [18:13] Dysgeusia and Parosmia [19:11] Olfactory nerve[20:45] Shout out to Ann Weismueller! [23:30] Please “Like,” “Subscribe,” and “Follow” DTA [25:27] Thanks for listening! [25:50] Summary Keywords Podcast, Spotify, Anchor, research, advocacy, heart health, myocarditis, pericarditis, vaccines, blood vessels, vascular virus, respiratory virus, long covid, blood clots, stress, blood pressure, parosmia, dysgeusia, olfactory nerve --- Send in a voice message: https://anchor.fm/downthereaware/message

In this episode I welcome on one of my hero's in medicine, Dr. Mark Pimentel. Without hesitation, he changed my career trajectory for the better when I first came across his work in 2007. Since then he has been a mentor, adviser, and educator of me as I have dedicated myself to helping patients dealing with Irritable Bowel syndrome, Small Intestinal Bacterial Overgrowth, and Intestinal Methanogen Overgrowth. We covered so many amazing topics in this episode including: Highlights from the last 5 years of Dr. Pimentel's research His career trajectory from IBS starting as a psychosomatic disorder to know a disorder with a defined pathophysiology The latest 2021-22 research that identified the key microbes involved with hydrogen overgrowth sibo, intestinal methanogen overgrowth, and hydrogen sulfide overgrowth The role of bile acids in Irritable bowel syndrome The role of stomach acid in IBS/SIBO/IMO The role of the migrating motor complex in IBS Post-infectious Irritable bowel syndrome What makes a good GI Doctor the Medically Associated Science and Technology Program (MAST) at Cedar Sinai and more. about Dr. Pimentel: Mark Pimentel, MD, FRCP (Fellows of the Royal College of Physicians – Canada) Mark Pimentel, MD, is a Professor of Medicine at Cedars-Sinai. Dr. Pimentel is also the Executive Director of the Medically Associated Science and Technology (MAST) program at Cedars-Sinai, an enterprise of physicians and researchers dedicated to the study of the gut microbiome in order to develop effective diagnostic tools and therapies to improve patient care. Dr. Pimentel is also a Professor of Medicine at the Geffen School of Medicine, University of California, Los Angeles (UCLA.) As a physician and researcher, Dr. Pimentel has served as a principal investigator or co-investigator for numerous basic science, translational and clinical investigations of irritable bowel syndrome (IBS) and the relationship between gut flora composition and human disease. This research led to the first ever blood tests for IBS, ibs-smart™, the only licensed and patented serologic diagnostic for irritable bowel syndrome. The test measures the levels of two validated IBS biomarkers, anti-CdtB and anti-vinculin. A pioneering expert in IBS, Dr. Pimentel's work has been published in the New England Journal of Medicine, Annals of Internal Medicine, American Journal of Physiology, American Journal of Medicine, American Journal of Gastroenterology and Digestive Diseases and Sciences, among others. Dr. Pimentel has presented at national and international medical conferences and advisory boards. He is a diplomate of the American Board of Internal Medicine (Gastroenterology,) a fellow of the Royal College of Physicians and Surgeons of Canada and a member of the American Gastroenterological Association, the American College of Gastroenterology, and the American Neurogastroenterology and Motility Society. Dr. Pimentel completed 3 years of an undergraduate degree in honors microbiology and biochemistry at the University of Manitoba, Canada. This was followed by his medical degree, and his BSc (Med) from the University of Manitoba Health Sciences Center in Winnipeg, Manitoba, Canada, where he also completed a residency in internal medicine. His medical training includes a fellowship in gastroenterology at the UCLA Affiliated Training Program. papers referenced https://journals.lww.com/ajg/pages/articleviewer.aspx?year=2022&issue=12000&article=00029&type=Fulltext https://pubmed.ncbi.nlm.nih.gov/33534012/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9145321/ #ibs #sibo #imo #irritablebowelsyndrome #dysbiosis

Hello, and welcome to Beauty and the Biz where we talk about the business and marketing side of plastic surgery and www.BlackNoseJob.com with Jason S. Hamilton, MD. I'm your host, Catherine Maley, author of Your Aesthetic Practice – What your patients are saying, as well as consultant to plastic surgeons, to get them more patients and more profits. Now, today's episode is called "www.BlackNoseJob.com — with Jason S. Hamilton, MD." I am a huge fan of specializing. Becoming an expert in something, rather than a generalist in lots of different things, has its advantages…. You have more focus. You get really good at one thing. You stand above the competition. You're able to charge more. Frankly, that's how I grew my own business. I picked a very specific market (cosmetic surgeons) to help grow their practices. I'm pretty sure you wouldn't be following me if I was the self-proclaimed marketing guru to dentists and realtors and lawyers….you get the picture. So, in this week's Beauty and the Biz Podcast, I interviewed someone who took this strategy to heart and really went for it. It's Jason Hamilton, MD, facial plastic surgeon in Beverly Hills. Dr. Hamilton is the director of facial plastic surgery at the Osborne Head and Neck Institute based at Cedar-Sinai Medical Towers. He specializes in primary and revision African American rhinoplasty, while pioneering new methods designed specifically for the black nose. He even owns the URL www.BlackNoseJob.com. We talked about where he got the courage to specialize and what happened when he did (hint: huge drop in business, then came back stronger). Visit Dr Hamilton's Website  

Dr. Mark Pimentel, Cedars-Sinai + Matt Mitcho, Gemelli BiotechWelcome back to one of the first episodes of our new podcast, The Patients Speak. We're combining the business aspects of innovation and the science of innovation with the patient voice and what the opportunities are to incorporate more of the patient experience into our strategies and into our work.Today, we're joined by Dr. Mark Pimentel, executive director of the MAST( Medically Associated Science and Technology) program at Cedar Sinai. And, by Matt Mitcho, CEO of Gemelli Biotech. Dr. Pimentel is also a co-founder and a member of the scientific advisory board at Gemelli.They have been working together since 2018, as founders of Gemelli Biotech, bringing trio-smart, which is a SIBO breath test that identifies gasses that are associated with SIBO, hydrogen methane, and hydrogen sulfide to market. Also, IBS Smart, a blood test that measures two antibodies elevated in people that had a previous event of food poisoning or identifying post-infectious IBS, IBSD specifically.In addition to the clinical, research, and technology assessment, we talked about incorporating the patient voice in seeking proper treatment for IBS patients, which Dr. Pimentel highlights that as a clinician scientist, you are obligated to think around the patient and outside the box.He gives some tips to clinicians:Have the ability to compassionately listen to the patient population and then develop innovative tools that help them get to the resolution more quickly. This aids with patient motivation and resilience With the volumes increasing in treatment clinicians see patterns and upon seeing those patterns, there comes a need to have as many clinical trials as you need to up until the science stacks up, which most times is a long and dedicated processDr. Pimentel gave us tips for tackling systemic challenges like difficulty in getting an appointment with the doctor or not having enough time with the doctor.Have quality time for example an hour for the new patientsEducating their patients empowers them with the information out there and this gives them confidence when they visit the doctor.Matt insists on being patient-centric. In making sure that the culture that is created within the organization focuses on the patient, and getting the patient an answer,In conclusion, we spoke about what's on the horizon that we should be watching out for? In regards to technology and new science.Precision medicine: Having more knowledge about the microbiome in IBS,.They already have one product that looks very promising for the diarrhea side on the basis of exactly what this breath test shows. They plan to spend a lot of resources educating patients and providers to the three gas breath test Exploring telehealth platforms that will give patients that don't have a provider, greater access to tools that they may find benefit from and continuously exploring partnerships for scale.It really comes down to accessing more physicians and making them aware of what they are doing. Alongside making patients aware that they have access to these tools and can go ask their providers about them. And then making sure that they are prepared for the demand on the back end. Having better tools to give folks patients a positive diagnosis, which will allow them to find resolution more quickly. In summary, we narrow it down to the education and empowerment of both patients and clinicians.If you'd like to read more about patient empowerment – along with the 83bar patient recruitment platform – go to www.83bar.comBSB

This week, please join Associate Editors Mercedes Carnethon and Karol Watson, as well as Guest Editor Fatima Rodriguez as they present the 2nd annual Disparities Issue. Then join Rishi Wadhera and Ashley Kyalwazi as they discuss their article "Disparities in Cardiovascular Mortality Between Black and White Adults in the United States, 1999 to 2019." Dr. Mercedes Carnethon: Well, good day listeners. I'm Mercedes Carnethon, and I'm joined by my fellow editors, Karol Watson, and Fatima Rodriguez, Associate Editor and Guest Editor for Circulation. And we'd like to welcome you to Circulation on the Run, for our second annual disparities issue. We have a lot of articles to discuss today, many of which we'll summarize, but we encourage you to access the issue and read the articles. First off, Fatima, I believe you have a paper to discuss. Dr. Fatima Rodriguez: Sure thing, Merci. My first paper is a thought provoking article by Nilay Shah, and co-authors from Northwestern University, that examine factors associated with the racial gap in premature cardiovascular disease. Dr. Fatima Rodriguez: This study used data from a well-known cardiac cohort, that aims to identify factors that begin in young adulthood and predict the development of future coronary artery risk. The objective of this study was to examine the relative contributions of clinical versus social factors, in explaining the persistent black/white gap in premature cardiovascular disease. After following around 5,000 black and white study participants for a median of 34 years, black men and women had a higher risk of premature cardiovascular disease. After controlling for multi-level individual and neighborhood level factors measured in young adulthood, the racial differences in premature cardiovascular disease were attenuated. Dr. Fatima Rodriguez: The authors found that the greater contributors to this racial disparity were not only clinical factors, but also neighborhood and socioeconomic factors. The relative explanatory power of each of these factors varied by men and women. This is really noteworthy, since we spent so much of our time in clinical medicine, focusing on identifying and managing traditional risk factors. But in reality, these structural factors and inequities are critically important to address, and contribute to differences in clinical risk factors downstream. Dr. Mercedes Carnethon: Thank you so much, Fatima. That was a really excellent summary. And now, I'm turning to you, Karol. I'd love to hear what you're going to be talking about today. Dr. Karol Watson: I'd like to discuss the paper, Association of Neighborhood Level Material Deprivation with Atrial Fibrillation Care in a Single-Payer Healthcare System Population Based Cohort Study. This is by Dr. Abdel-Qadir and colleagues. Dr. Karol Watson: So in this study, the author sought to determine whether there was an association between neighborhood material deprivation, by that we mean, inability to attain the basic needs of life and clinical outcomes, in individuals with atrial fibrillation. The kicker here is, they did this in an area with universal healthcare. So they wanted to see, if you took away the differences between the ability to see a physician or get your drugs paid for, if you would see any disparities. Dr. Karol Watson: So they performed a population based cohort study, individuals over the age of 66 years of age with atrial fibrillation, in the Canadian province of Ontario. They have universal healthcare there, and full drug coverage for anyone over 65. The primary exposure was neighborhood material deprivation. That's a metric used to estimate the inability to attain basic material needs, like healthy foods, safe housing. Neighborhoods were categorized by quintile, from the least deprived, quintile one, to the most deprived, quintile five. They find that, among about 350,000 individuals with atrial fibrillation, their mean age was 79, and about half of them were women. Those in the most deprived neighborhoods, quintile five, had a higher prevalence of cardiovascular risk factors and non-cardiovascular work comorbidity, relative to those who were in the least deprived areas. Dr. Karol Watson: Even after adjusting for all the confounders, they found that those in the most deprived neighborhoods had higher hazards of death, stroke, heart failure, and bleeding, relative to those in the least deprived neighborhoods. They also found that, despite having universal healthcare and drug coverage, those in the most deprived neighborhoods were less likely to visit a cardiologist, less likely to receive rhythm control intervention, such as ablation, and have worse outcomes. Dr. Karol Watson: And then, the accompanying editorial by Utibe Essien, he reminds us that intervening only on traditional markers of access, like health insurance and drug costs, may not be sufficient to achieve health equity. We have to address all of the structural needs that make people unable to get good help. Further, he points out that, the association between atrial fibrillation and neighborhood deprivation is very likely true with other cardiovascular conditions, as well. Dr. Karol Watson: So, Merci and Fatima, this just reminds us again, that addressing all the social determinants of health are necessary to achieve the best health outcomes. Dr. Mercedes Carnethon: Thanks so much, Karol. I really appreciate that summary of that important piece, focusing on a different domain of disparity. My first paper is an excellent piece, led by one of my favorite other associate editors at Circulation, Dr. Wendy Post, from Johns Hopkins University. And I see a familiar name on here. That's yours, Karol. You two are joined by an all-star list of authors, to describe race and ethnic differences in all-cause in cardiovascular mortality, in the multi-ethnic study of atherosclerosis. Dr. Mercedes Carnethon: MESA is a longitudinal cohort study that launched in 2000, and recruited just over 6,800 adults who identified as black, white, Hispanic, and Chinese. While the study participants were initially free from cardiovascular disease, over an average of 16 years of follow up, 364 participants died from cardiovascular disease. There are a number of novel findings in this paper that led our editor-in-chief to select it as his pick of the issue. Dr. Mercedes Carnethon: The finding that really stands out to me is, how much of an influence the social determinants of health had on black versus white disparities in cardiovascular mortality. In fact, after adjusting for socioeconomic status, the disparities were nearly eliminated. Other critically important findings are that, the oft described Hispanic paradox of lower cardiovascular mortality in Hispanics, as compared with white adults, was demonstrated in this population. And finally, we have longitudinal data on Asians living in the United States. Asian participants in MESA had similar rates of cardiovascular disease mortality as their white counterparts. There's so much to learn in this well designed cohort study, and so many hypotheses about how social determinants and structural racism influence the disparities that we see. Dr. Mercedes Carnethon: So Fatima, I'd like to turn to you next. What else do you have to share? Dr. Fatima Rodriguez: Thank you, Merci. My second paper is a research letter for my home institution of Stanford University, led by my colleague, Dr. Shoa Clarke, discussing how race and ethnicity stratification for polygenic risk course, may mask disparities among Hispanic individuals. Dr. Fatima Rodriguez: This study used data from the Million Veteran Program, to determine how self-identified race and ethnicity impact the performance of polygenic risk scores in predicting coronary artery disease. Dr. Fatima Rodriguez: The investigators found, that the current polygenic risk scores predict coronary artery disease similarly well in Hispanic and non-Hispanic white individuals. However, what I found most interesting, is that there was so much more heterogeneity among Hispanic individuals as measured by K-Means clustering, than among non-Hispanic white individuals. And this study really confirms that there is much more heterogeneity within populations than between populations. And this is particularly true as we think of the extreme diversity of Hispanic populations. Lumping Hispanic populations into one category, may mask important differences in cardiovascular risk prediction outcomes, and even the notions of the Hispanic paradox that you just discussed, Merci. Dr. Mercedes Carnethon: I appreciate you bringing that up again, because there are so many different nuances to the observations that we see in these studies. But I'll keep moving, because we have an embarrassment of riches in this wonderful issue. So Karol I'll turn back to you. Dr. Karol Watson: Thanks, Merci. The next paper I'd like to discuss, is an On My Mind piece by Peter Liu and colleagues, and they entitle it, Achieving Health Equities in the Indigenous Peoples of Canada, Learnings Adaptable for Diverse Populations. Now the author's note that, lessons learned about addressing health disparities from indigenous peoples in Canada, can offer a lot of new lessons for other populations where there are similar disparities. They begin by offering historical perspective, and they say that, most of the health to disparities for the indigenous populations originate from early colonization, in dismantling of the sociocultural economic educational and health foundations, the indigenous communities had historically. Dr. Karol Watson: It's true that, that is true in a number of different countries. This is data from Canada, but we can see similar things in the United States. With the recognition of the historical and ongoing social health inequities, the Canadian government initiated what they call, the Truth and Reconciliation Commission, to recommend a path towards reconciliation, to create best practices for engaging indigenous populations. Dr. Karol Watson: For instance, in Canada, any health research or implementation program, requires the direct engagement of indigenous communities and their elders. They have to try to develop culturally safe environment, including what they say, quote unquote, anti-racism and cultural safety education for all, both indigenous and non-indigenous populations. They want to really respect community values, customs and traditions, including the access to traditional foods, and healing practices, and the support from elders. So they really are making it a very important point, that cultural sensitivity is absolutely critical to engaging these populations. You want to jointly collect data whenever available, to track progress and outcomes. And they offer many examples of successful programs developed using these principles, such as the Diabetes and My Nation program, in British Columbia, or the mobile diabetic telehealth clinic. Dr. Karol Watson: They offer discussion of future initiatives as well, that can help other communities in Canada. Such as, there's an initiative addressing hypertension in the Chinese population in Canada. Dr. Karol Watson: So this thoughtful paper, really looks at disparities in unique populations in Canada. More importantly, it offers potential roadmaps for other populations, solutions to address longstanding legacies of racism and colonialism. Dr. Mercedes Carnethon: Thank you so much, Karol, for that description from our neighbors from the north. Dr. Mercedes Carnethon: My second paper is really relevant during this hot month of July, in much of the United States and the upper hemisphere. And that's because Sameed Khatana and colleagues from the University of Pennsylvania, discuss how extreme heat is associated with higher cardiovascular mortality. For those of us who welcome the heat of summer and the opportunity to get out from behind our desks and exposed to some vitamin D, Khatana and colleagues reviewed county level daily data on temperature, and linked those data with mortality rates. Dr. Mercedes Carnethon: But before I summarize the findings, I invite you to California based cardiologists to join me in Chicago, where extreme heat is really only a problem for about 30 days a year. The authors found that between 2008 and 2017, when the heat index was above 90 degrees Fahrenheit, or 32.2 degrees Celsius, there was a significantly higher monthly cardiovascular mortality rate. In total, extreme heat was associated with nearly 6,000 additional deaths from cardiovascular disease. And sadly, black adults, older adults, and men, bore the greatest burden of mortality rates from extreme heat. So, we can all take lessons from that. Dr. Mercedes Carnethon: But turning to you now, Fatima. Dr. Fatima Rodriguez: Thanks so much, Merci. I'm from Florida, so I can definitely relate to the issues of extreme heat, but I'm very happy for the perfect year round weather here in Northern California. Dr. Fatima Rodriguez: My third paper is led by Dr. Zubair (and Chikwe) and colleagues from Cedar Sinai, and it describes changes in outcomes by race, in children listed for heart transplantation in the United States. I won't give all the details, but this research letter really nicely summarizes how the 2016 Pediatric Heart Allocation Policy revisions may have inadvertently widened health disparities between white and non-white children. This article touches on the difference between equality and equity, even in the most well-intentioned national policies. And I invite our listeners to read the full details in this special Circulation edition. Dr. Mercedes Carnethon: Thanks Fatima. Karol. Dr. Karol Watson: The next paper I'd like to discuss, is a community based cluster randomized pilot trial, of a cardiovascular mobile health intervention, preliminary findings of the FAITH! Trial, from LaPrincess Brewer and colleagues from the Mayo Clinic. Dr. Karol Watson: So it's well known that African Americans have suboptimal cardiovascular health metrics, such as less regular physical activity, suboptimal blood pressure levels, suboptimal diets. So the authors of this study hypothesize, that developing a mobile health intervention, in partnership with trusted institutions, such as, African American churches, might be an effective means to promote cardiovascular health in African American patients. So using a community based participatory research approach, they develop the FAITH! trial. FAITH stands for Fostering African American Improvement in Total Cardiovascular Health. The manuscript in this issue reports, feasibility and preliminary efficacy findings from this refined community informed mobile health intervention, using the FAITH! App, developed by the investigators. Dr. Karol Watson: They performed a cluster randomized control trial. Participants from 16 different churches in the Rochester, Minnesota and Minneapolis St. Paul, Minnesota areas. The clusters were randomized to receive the FAITH! App, that was the intervention group, or were assigned to a delayed intervention program. The 10 week intervention feature culturally relative and sensitive information modules, focused on American Heart Association's Life's Simple 7. Primary outcomes were changes in the mean Life Simple 7 score, from baseline to six months post intervention. They enrolled 85 participants, mean age was 52, and about 71% were female. Dr. Karol Watson: At baseline, the mean Life Simple 7 score was 6.8, and 44% of the individuals were characterized as being in poor cardiovascular health. The mean Life Simple 7 score of the intervention group, after the end of the intervention, increased by 1.9 points. In the control comparator group, it only increased by 0.7 point. Highly statistically significant, with P value of less than 0.0001 at six months. Dr. Karol Watson: Now this FAITH! Trial demonstrated preliminary findings, that suggest that a culturally sensitive and mobile health lifestyle intervention could be efficacious, promoting ideal cardiovascular health among African Americans. I think what's so important about this is that, they partnered with a very trusted group, the churches, and getting buy-in to a community that has had many reasons not to trust in the past, I think is critically important. Dr. Mercedes Carnethon: Well, thank you so much, Karol. My third paper is an original research investigation by Anoop Shah and colleagues from the University of Edinburgh, arguing that socioeconomic deprivation is an unrecognized risk factor for cardiovascular disease. Dr. Mercedes Carnethon: In their study, the authors evaluated how risk scores, with and without indicators of socioeconomic deprivation, performed in a population study in Scotland, the Generation Scotland: the Scottish Family Health Study, of over 15,000 adults. Again, I won't give away all the details, so that I keep our listeners excited to read the article, but all risk scores aren't created equally. And the observed versus expected number of events varied, based on whether the risk score included socioeconomic indicators or not. Further, the performance of the risk scores varied, based on the degree of deprivation that participants were currently experiencing. It's a thought provoking piece, that may challenge us to reconsider how we identify risks for cardiovascular disease in the population. Dr. Mercedes Carnethon: And I'm turning to you now, Fatima. Dr. Fatima Rodriguez: Sure thing, Merci. My last paper is led by Dr. Anna Krawisz, and is looking at how differences in comorbidities explain racial disparities in peripheral vascular interventions. This study used Medicare fee for service data from 2016 to 2018, to examine risks of death and major amputation, one year following peripheral endovascular intervention. They found that, black Medicare beneficiaries had higher population level need for peripheral endovascular interventions, and that black race was associated with adverse events following these interventions. However, after adjusting for the higher prevalence of comorbidity, such as diabetes, hypertension, and chronic kidney disease in black populations, this observation was eliminated. Again, like a common theme in many of the articles we've discussed today, this is to suggest, that moving upstream to reduce risk factors is really critical to eliminate disparities in cardiovascular disease outcomes. And this includes the understudy disease of peripheral arterial disease. Black adults were also less likely to be treated with guideline directed medical therapies in this study. Dr. Mercedes Carnethon: Well, thank you so much, Karol and Fatima, for your wonderful summaries of all of the excellent pieces in this issue. Dr. Karol Watson: And I'd like to thank all of the fantastic investigators who submitted their really fantastic work, so that we could produce this issue. And really, keep them coming. We thank you for this. Dr. Mercedes Carnethon: Well, thank you. So now we'll transition to our feature discussion with Drs. Wadhera and Kyalwazi, from Beth Israel Deaconess Medical Center, and the Harvard Medical School. Dr. Mercedes Carnethon: Welcome to this episode of Circulation on the Run podcast. I'm really pleased to host this feature discussion. My name is Mercedes Carnethon, from the Northwestern University Feinberg School of Medicine. And I'm pleased to have with us today, Drs. Ashley Kyalwazi and Rishi Wadhera from Beth Israel Deaconess, and the Harvard Medical School. And they shared with us a really important piece of work for our disparities issue, that is describing disparities in cardiovascular mortality, between black and white adults in the United States from 1999 to 2019. First of all, I really want to thank you both for submitting your important work to circulation. Dr. Rishi Wadhera: Thanks so much Mercedes, and thanks for the opportunity to submit and revise our manuscript. Ms. Ashley Kyalwazi: Thanks so much for having us. Dr. Mercedes Carnethon: Wonderful. I'd like to start out with you Rishi. Tell our listeners about the objectives of your study, and what your motivation was for carrying out this work. Dr. Rishi Wadhera: Well, I think it's been well established that, black adults are disproportionately impacted by cardiovascular disease, and experience worse cardiovascular outcomes, due to systemic inequities and structural racism. And so, the goal of our study was really, to perform a comprehensive national evaluation of how age adjusted cardiovascular mortality rates have changed for black adults, compared with white adults, over the past two decades in the United States, with a focus on some key subgroups, like younger adults and women. Dr. Rishi Wadhera: In addition, because we know that the neighborhood community or environment in which you live in the US, has an immense influence on cardiovascular health, we also examine changes in cardiovascular mortality for black and white adults by geographic region, rurality, and neighborhood racial segregation. And our primary objective was really, to understand whether disparities in cardiovascular outcomes between black and white adults improved, worsened, or didn't change, from 1999 to 2019. Dr. Rishi Wadhera: And there are some reasons to think we might have made progress in narrowing the mortality gap between these groups over this time period. There have been substantial improvements in preventative care and treatments for cardiovascular disease over the past two decades. And the expansion of insurance coverage under the Affordable Care Act, led to increases in access to care, cardiovascular risk factor screening and treatment, particularly, for black adults. At the same time, we know that, black adults were disproportionately affected by the economic recession of 2008, and experienced worsening poverty, job loss, and wealth loss, all of which are inextricably tied to cardiovascular health, and more broadly, health. And so that was our interest in really exploring how disparities in cardiovascular mortality have changed amongst black and white adults between 1999 and 2019. Dr. Mercedes Carnethon: Thank you so much for that summary. It's really nice to have these sort of pieces that really outline for us a lot of data, and across a number of different domains. Because it allows us really, a chance to think about those data, and how we can use those data in order to help improve health. Dr. Mercedes Carnethon: So tell me a little bit, Ashley, about what your study found. Ms. Ashley Kyalwazi: Absolutely. Yeah. So in the United States, overall, we found that age adjusted cardiovascular mortality rates declined for both populations, so both black and white adults, by around 40% from 1999 to 2019. So encouraging declines across the country. We found that these patterns were similar for both women and men, when we stratified by gender, over the 20 year period. While mortality rates declined in all regions, we still did find disparities when we stratified by age. So between the younger and older black women, versus younger and older black men, we found that, younger black men and black women were dying at higher rates, and were at increased risk of death from cardiovascular mortality, compared to younger white women and men, respectively. But we also found that black women and men living in rural areas consistently experienced highest mortality rates. And then finally, black adults living in higher areas of residential racial segregation, and compared to those living in low to moderate areas of residential racial segregation had higher mortality rates, as well. Dr. Mercedes Carnethon: Wow, this is a lot. And it's really describing a lot of disparities across multiple domains that we can easily measure. Which aspects of these results in your work did you find the most surprising, Ashley? Ms. Ashley Kyalwazi: Yeah, I was intrigued, I think overall, by just the gaps. I was very encouraged by, I think, the declines over time. On an absolute scale, the country has made a lot of progress, in terms of reducing cardiovascular mortality rates for both groups. But still, by the end of the study period, there were notable gaps between black adults and white adults. Particularly, between black, younger women and white, younger women, we see that by the end of the study period, black, younger women still remain over two times the risk of death from cardiovascular disease than younger white women. Which I think, leaves something to be desired from a public health and health policy standpoint, with regards to how we're going to kind of decrease these disparities. Dr. Mercedes Carnethon: I wanted to follow up on that point. Why do you think you see such disparities between black and white younger women? I love the opportunity of the podcast to allow authors a chance to speculate, beyond what they would do in the paper. Ms. Ashley Kyalwazi: Absolutely. I think that, there are a lot of great efforts on a national scale right now, to kind of address the disparities between black and white women. The Association of Black Cardiologists, for example, had a whole paper out about ways to really target and provide preventative measures for black women. So for example, working with communities, where there's a high proportion of black women, to figure out what community based research looks like. Engaging with churches, different types of methods, to really understand the barriers that black women face towards obtaining preventative care. Ms. Ashley Kyalwazi: I think the disparities that we are seeing, could potentially parallel well known and documented disparities in maternal health outcomes. So I think, from a perspective of preventative care, really thinking about, what are the barriers to healthy cardiovascular profiles for black women pre and postnatally, to ensure that their cardiovascular health is an actionable before and after the pregnancy? Ms. Ashley Kyalwazi: And then I think, broadly, the challenges that black women face, mirror the challenges of black adults, plus the additions of like social stressors, things that we looked at in this study neighborhood residential racial segregation, access to healthcare, and all of those things kind of contribute to the profile that black women face, in terms of being often, the heads of their households as well, and carrying on a lot of different societal challenges. Dr. Mercedes Carnethon: Thank you so much for that. I really appreciate that. Dr. Mercedes Carnethon: As I read the paper, one of the findings that I found the most surprising, and it was challenging for me to understand, is that while the absolute difference in rates was declining, or getting smaller over time, between black and white men and women, the rate ratios remained elevated across the course of time. I think, these concepts can be a little challenging to understand, not just to me, but to others as well. That when one measure of effect is showing progress, but another is still reporting a disparity. Dr. Mercedes Carnethon: Rishi, could you explain for our listeners, how we can see progress on one metric, but still find a mortality rate ratio that's 1.3 times higher in black, as compared with white men, for example? Dr. Rishi Wadhera: Thanks for that really important question, Mercedes. Just to summarize, we presented two outcomes that compared cardiovascular deaths among black and white adults in our paper, absolute rate differences, and then separately, rate ratios. And I think, both measures provide important complementary insights. I think that, understanding the absolute rate difference in cardiovascular deaths is critically important from a public health perspective, because it characterizes excess deaths experienced by black adults, compared with white adults. The fact that the absolute rate difference in cardiovascular death has narrowed over the past two decades between these groups is positive news. In contrast, the rate ratio provides us with important insights on the relative difference, or disparity or gap, between black and white adults. Dr. Rishi Wadhera: So again, both are important, both provide sort of synergistic and complimentary insights. And just to sort of cement that, as an example, you were talking to Ashley earlier, about some of the patterns we noticed amongst younger black women and white women. The absolute rate difference in cardiovascular deaths between younger black women, compared to younger white women, decrease from 91 per 100,000 in 1999, to about 56 per 100,000 in 2019. And that's good progress. However, our rate ratio analysis indicated that, still in 2019, young black women were 2.3 times more likely to die of cardiovascular causes than young white women. Highlighting that, we still have a lot of work to do, to address disparities between these groups. Some of which, Ashley already talked about. Dr. Mercedes Carnethon: Thank you so much for that excellent explanation. I know it's certainly, I find it alarming to hear, but then I remember I'm actually not young anymore. So maybe this doesn't apply to me quite as much. But no, I appreciate the explanation. Dr. Mercedes Carnethon: So your report was really unique, in that you studied these disparities, as we discussed, across a number of domains, age, geography, even racial residential segregation. Whereas, the pronounced disparities have been reported in a few of the other domains that you studied. I'm really interested in hearing more about racial residential segregation. I think, a lot of people don't fully understand what the concept is, and the ways in which racial residential segregation may contribute to higher rates of cardiovascular death among blacks. Dr. Mercedes Carnethon: Ashley, would you mind explaining to us first, what racial residential segregation is? And then really, how it would contribute to higher rates of cardiovascular death? Ms. Ashley Kyalwazi: Yeah, absolutely. So in its simplest terms, racial residential segregation is just the physical separation of two or more groups by race and/or ethnicity into different neighborhoods. What gets tricky is, like the long history within the United States of how we got to this point, where you see numerous degrees of segregation across the country. Residential racial segregation in the United States dates back to policies pre World War II, that resulted in kind of discriminatory banking practices and policies. For example, reverse red lining and gentrification, much of which the extent still exists today. And that's what we see kind of, I think, in our results when we looked at high versus low to moderate areas of residential racial segregation, and how those kind of track onto the trends that we see in cardiovascular mortality over time. Ms. Ashley Kyalwazi: The residential racial segregation impacts almost every aspect of life. You can imagine where you live, we know definitely impact, for example, your zip code can impact health outcomes. We've seen individual's cardiovascular health kind of trend with something as simple as your zip code. Where you live really does impact your, for example, access to affordable housing, health insurance, where your primary care physician is, whether or not you even have one. What that trip looks like to see your primary care physician, is it hours on end, and unrealistic to get to, or is it just around the corner? Ms. Ashley Kyalwazi: Educational opportunities, which leads to income, which we know is linked to cardiovascular disease employment in all of these aspects. Even access to green space. In some metropolitan areas that are more segregated, we see that, black adults, for example, have less access to green space, and numerous studies have shown that, that does impact overall health, but then also, from a cardiovascular disease perspective as well. So I think that, given that we know that lack of access to all of these key determinants can adversely affect cardiovascular mortality, and just general cardiovascular health, I think is very interesting that we found that, there was this link between high residential racial segregation and cardiovascular mortality. That we definitely can look into more, and understand kind of in more detail, that the mechanisms at play and ways to intervene. Dr. Rishi Wadhera: And just to layer onto and reinforce Ashley's really excellent answer to that question. We know that black adults are more likely to live in disadvantaged neighborhoods, because of the intentionally racist policies that were put in place many decades ago, that Ashley described so well. And black communities and segregated communities, as Ashley mentioned, are less likely to have access to primary care, high quality hospital care, and green spaces, but also, pharmacies and healthy foods. And we also know, there's a lot of empirical work that's shown that black communities, disproportionately experience psychosocial stressors, trauma. Dr. Rishi Wadhera: Also, these communities are disproportionately exposed to climate change, such as extreme heat. There was a recent paper that extreme heat has been linked to increases in cardiovascular mortality, and disproportionately affects black communities. These communities are also disproportionately exposed to pollution. All of these things we know are linked to cardiovascular health, and represent the effects of again, intentionally racist policies that were put into place many decades ago, the effects of which still persists today. Which will require equally intentional policies that aim to dismantle these longstanding effects, if we hope to make progress in advancing health equity, and specifically, cardiovascular health equity. Dr. Mercedes Carnethon: I appreciate the facility with which the two of you address the multiple complex contributors to cardiovascular health. It's even more impressive coming from two clinicians. So I really appreciate you taking the time to explain this. And this is where I really like the opportunity to open up and say, what more do you want your clinical peers to know about? For example, how does this affect the day to day encounters that you have in clinic with black patients, and other patients who've been traditionally underrepresented? How do you hope your clinical peers will use this information to promote cardiovascular health equity? And I'll open it up to either of you to respond. Ms. Ashley Kyalwazi: Yeah, I can get on that one. I think that, the disparities that our paper highlights, really requires a multisystem level approach to tackling, from public health to public policy. But I think at a provider level, to your question, Mercedes, physicians must be able to, I think at first, read the data and understand that these disparities exist. Ms. Ashley Kyalwazi: If there's no insight with regards to the risk profiles, that simply black women and black men have, because of systemic racism, because of these inequities, then I think, we're already kind of steps behind where we need to be. So recognizing disparities in cardiovascular disease burden for black men and women, prioritizing education on cardiovascular risk. A lot of the conditions are preventable with appropriate access to care and education around these topics. And so, providing education about the signs and symptoms of heart disease and treatment options for black men and women. Recognizing the history of medical mistreatment for black adults in this country. And really, tailoring the approach towards the individual who comes into the office, who might have very valid reasons for hesitating to take a medication, or a lot of questions that need time and consideration. Ms. Ashley Kyalwazi: At a research level, I think, more data and resources should be spent on studying risk prevention and treatment for cardiovascular disease in black adults, and really, developing more community based models, that really get at the specific interventions that work within black communities, that are culturally specific, that are targeted and relevant, for the populations that we're talking about. Ms. Ashley Kyalwazi: I think finally, and I'll let Rishi chime in, I think, this is shockingly low level of racial and ethnic representation in the field of cardiology as a whole. And we know that, diversity in healthcare can improve health outcomes. So from a cardiology perspective, I think, training the next generation of black young men and women to take up their seats at the table, and really advocate for some of these issues, alongside individuals who are already doing great work, would be essential towards reducing disparities that we see. And so all of the above, I think, I would encourage for my colleagues. Dr. Mercedes Carnethon: Thank you so much. Rishi, any final thoughts? Dr. Rishi Wadhera: No, I'll just add onto Ashley's again, really outstanding response that, this is a tension we face when we see patients in cardiology clinic all the time. I think, awareness about disparities, and the multiple factors that contribute to disparities in cardiovascular health, particularly, as it relates to race and ethnicity, are increasingly being recognized as they should be. Dr. Rishi Wadhera: And one of the challenges, how much can clinicians do within the bounds of hospital walls? We can make sure that we get patients the treatments they need. We can make sure we screen patients appropriately. But we know, as we've discussed, that so many factors beyond hospital walls, like widening income inequality, that's disproportionately affected black adults, and has been worsening over the last several decades. Widening educational inequality, that again, disproportionately affects black adults, and has been worsening over decades, also affect how. So I think, thinking about how clinicians, researchers, and policy makers, can work together to address some of these challenges, issues, and broader social determinants of health, that also exist outside our clinical practice, or hospital walls, will be really, really important, if we are serious about advancing health equity in this country. Dr. Rishi Wadhera: I don't think, we can operate in silos anymore. In the clinical world, in the research world, in the policy making world, we need more researchers and clinicians to have a seat at the table when it comes to policy making, individuals who understand how all of these complex factors are inextricably tied to one another, so that we can seek and implement solutions that advance cardiovascular health. Dr. Mercedes Carnethon: Thank you so much. The insights that we've gotten, from not only your written work, but even more importantly, this opportunity to speak with you today, and share with our readership, have just been invaluable. And I really appreciate the amount of time that you spent, in preparing the manuscript, and really contextualizing the findings with us today, as well as in writing. So thank you so much for contributing this really important work to our annual disparities issue. Dr. Rishi Wadhera: Thank you so much, Mercedes. We really appreciate all the time you and the Circulation team took to make the manuscript stronger. Ms. Ashley Kyalwazi: Thank you so much for having us. It was truly an honor to have this conversation and to submit our work. Dr. Mercedes Carnethon: Well, thank you. Dr. Mercedes Carnethon: That wraps up our feature discussion for this episode of Circulation on the Run podcast. I'm Mercedes Carnethon, from Northwestern University, Associate Editor and guest editor of the disparities issues. So thank you so much. 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 hajournals.org.

We Support The Troops, But Not Chris Pratt: Travis Barker Hospitalized, Pratt the Brat & Relationships This week Travis Barker was at Cedar Sinai with pancreatitis while his daughter was on tiktok (weird). We then move on to Chris Pratt's redemption tour for a show we don't care about! Lastly we wrap up with a few celebrities couples you either love or had no idea we're even together after announcing they've split. As always stick around for our crushed and sour grapes along with our weekly recommendation! All this and more over Nina Dobrev & Julianne Hough's Fresh Vine Chardonnay! Hosts: Courtney & Erryonna Producer: Ethan D Follow us on Instagram @thruthegrapevinepod & on Twitter @ThruTheVinePod.

Sen. Bill Cassidy of LA, who is also an MD specializing in GI or liver disease, had an interview with POLITICO for the Harvard Chan School of Public Health series Public Health on the Brink on May 19. He has claimed to be unapologetically “prolife”, but said in this interview when asked what needs to be done about LAs high maternal mortality rate, “About a third of our population is African American; African Americans have a higher incidence of maternal mortality. So, if you correct our population for race, we're not as much of an outlier as it'd otherwise appear. Now, I say that not to minimize the issue but to focus the issue as to where it would be. For whatever reason, people of color have a higher incidence of maternal mortality.” I discuss these statements with Charles Johnson who founded of 4Kira4moms on 2017 after losing his wife Kira Dixon Johnson during a routine cesarean at Cedar Sinai hospital in Los Angeles. He is a voice for families facing unnecessary maternal loss and ending the maternal mortality crisis in this country. Recently, he worked with congress to pass the preventing maternal death act which is the first ever to combat the maternal mortality crisis in the US. The bill was signed into law on 12/21/2018 and dedicated to the memory of Kira Dixon Johnson. --- Support this podcast: https://anchor.fm/adoctordeliverspodcast/support

Nicole Mitchell serves as Cedar-Sinai's inaugural Chief Diversity & Inclusion Officer where she is responsible for providing strategic leadership, developing and driving the implementation of programs and initiatives that promote a culture of diversity, inclusion, and belonging. For over ten years Ms. Mitchell has been creating and driving culture change in both the for-profit and not-for-profit sectors. She has developed multifaceted strategies for diversity and inclusion encompassing human resources, employee engagement, philanthropy, communications, and supplier diversity and has led executive-level diversity and inclusion committee activities.   In this episode, Deanna and Nicole discuss the importance of creating spaces where rest is prioritized, particularly after events that take place in our society -- and not only creating space for others but prioritizing rest for ourselves as well. Nicole shares how the team at Cedars-Sinai was impacted by the pandemic and social unrest as a result of the murder of George Floyd, and how they have pivoted since 2020. She details how they have moved forward to begin addressing important issues, and how that has resulted in a three-year strategy for DEI. To connect with Nicole, you can find her on LinkedIn at: https://www.linkedin.com/in/nicolembellmitchell  Topics In This Episode  Starting from a place of listening instead of action   Creating psychological safety  Moving from listening to action, and where to begin  Unconscious bias and its role in health equity gaps   Work-life sway and how it differentiates from work-life balance.   Connect  LinkedIn: https://www.linkedin.com/in/nicolembellmitchell   Other Conversations We've Enjoyed Health Equity and Why It Matters Marketing that Fosters Diversity and Inclusion Learn more about your ad choices. Visit megaphone.fm/adchoices

In his words: I feel dirty. I'm sweating bullets. It's already been a fourteen-hour day on set in the blazing Los Angeles sun and all I want to do is the shower. That is NOT going to happen. My day was far from over. Every other Thursday that summer of 2004, I would finish shooting Jerry Bruckheimer's acclaimed TV series Skin and then tack on a four-hour nightcap at Cedars-Sinai Medical Center. As tough as my days were, I knew they'd get a lot worse if I skipped my date with four bags of poison at the all-night chemo ward. I would pass the hours of those late-night infusions watching classic 50s reruns, thinking about work, and thinking about life. Where I had been, where I was going, what I'd leave behind. That's where the seeds of this book were planted: in the desolate basement of Cedar-Sinai, while I waited for my fortnightly poison cocktail to empty into my arm and get to work. Not Just Sunglasses and Autographs follows me from bar bouncing in Boston to working on award-winning television and movies as I made my way up the entertainment industry ladder. It is an endearing story of overcoming the odds through dark humor, tenacity, authenticity, and a smile. I had originally envisioned this as the memoir of a man who'd beaten Hodgkin's Lymphoma and lived to tell the tale, but that was before I was pitched a curveball called Parkinson's Disease. Equal parts pep-talk and gut-punch, this unvarnished and vulnerable memoir-meets-handbook shares lessons I've learned in life and work and encourages readers to keep moving forward, embrace resilience, step out of their comfort zones, and take life head-on. Not Just Sunglasses and Autographs is 70,000 words and stands alone, but I also have stories in mind for a follow-up book. I look forward to hitting the road and supporting this book as I have brought hope and inspiration speaking about the film industry for the last twenty years.   I've been in the industry for nearly forty years. Nicknamed “the Irish Bull” by my west coast colleagues, I earned my reputation and secured Assistant Director credits on productions including the film Close to Home, Skin, CSI Miami, the pilot for Desperate Housewives, and many others. I spent the last five years of my film career on location in Chicago, working as First Assistant Director on Chicago PD from 2014-2019. After my Parkinson's diagnosis in 2019, I hung up my AD walkie and returned to the west coast to enlist all of my drive, determination, spirit, stubbornness, and good humor in the second battle of my life.

A conversation about Peter's life. Peter grew up in Cardiff, Wales. He studied medicine first at Oxford University and then St Barts in London before leaving med school just weeks before graduation to pursue his long held passion - acting. After training at Guildhall drama school, he had a successful career, doing lots of television work in particular both in the UK and, after his big break in the tv show Highlander, in the US. He worked on numerous famous shows including 24 and CSI: Miami. In 2011 Peter returned to medical school in Vermont - having to do the whole course again despite having only missed the last few weeks in St Barts - and now he is Peter Wingfield, MD and Anesthesiologist in Cedar Sinai hospital in Los Angeles. He lives up in the hills near the Hollywood sign. I'm sure you'll agree Peter has had a fascinating journey in his life and I really enjoyed hearing all about it. Episode guide: 0.00 Intro 2.58 Childhood in Cardiff 6.38 Studying medicine in Oxford and St Barts 13.22 Decision to leave Med School weeks before graduation to become an actor, then starting at Guildhall 25.05 First acting job out of Guildhall. Starts working regularly in British TV. The employment insecurity all actors face 33.35 Big break. Methos in Highlander 44.18 Hollywood film sets. Behaviour of high status actors etc. Working on 24. Kiefer Sutherland going off at an actor for not bringing character to set. Peter's own behaviour being possibly a bit "Hollywood" 59.25 Transition out of acting and return to medicine 1.14.15 Going to Med School in Vermont. Why anesthesiology? Most memorable and profound moments since practising 1.32.34 Does he miss acting? 1.37.43 Post-script on the mysterious nature of anesthesiology and consciousness 1.42.26 Outro Guest: Peter Wingfield Host and producer: Donal Gallery  Artwork by Anna Obert https://www.instagram.com/annaobertillustration/  Music by Donal Gallery  Twitter: https://twitter.com/PathsPodcast  Patreon: https://www.patreon.com/PathsPodcast  Get in touch with stories of people who've lived unusual lives at pathspodcastpeople@gmail.com  Thanks for listening Support this podcast

Part 3 of 3 Are we really hungry for food... or seeking meaning, identity & creativity, in midlife? Join me, Dr. Sarah Milken, in an honest conversation about Satisfying Our Hungers for Food, Meaning & Purpose in Midlife. Dr. Adrienne Youdim lets us in on why we might always be feeling hungry. She gives us details and tools on how to evaluate if we are really hungry for food, or if we are searching for more meaning, belonging, purpose and creativity, in midlife. Adrienne's specialized treatments have helped so many people overcome their weight issues by looking inward and digging deep into the various types of internal hunger. We are going to dig deep into the details of Adrienne's journey, in her “midlife remix”, in her second half of life. Get up close and personal!  Some highlights:  Being a resident at Cedar Sinai / developed her own program and was named co-director of the Center for Weight Loss Different types of diets: Keto, Paleo… (pros and cons) Anxiety comes from the gut / telling you to eat Fasting Psychology of food How to “make it matter”, with our food choices Difference between reading labels and ingredients lists Zero carbs doesn't mean zero Feeding our internal hunger for creativity, belonging, and meaning The book Hungry for More: Stories and Science to Inspire Weight Loss From the Inside Out Looking forward to connecting with you! Here are some ways to connect with me! THE FLEXIBLE NEUROTIC SHOW NOTES: https://www.theflexibleneurotic.com/episodes/23 THE FLEXIBLE NEUROTIC INSTAGRAM: https://www.instagram.com/theflexibleneurotic/ THE FLEXIBLE NEUROTIC WEBSITE: https://www.theflexibleneurotic.com/ THE FLEXIBLE NEUROTIC EMAIL: sarah@theflexibleneurotic.com This podcast, along with associated websites and social media materials, are not intended to be a substitute for professional medical advice, diagnosis, or treatment. The views expressed are that of Dr. Sarah Milken, and that of her guests, respectively. It is for informational purposes only. Please consult your healthcare professional for any further medical or psychological questions.

Part 2 of 3 Are we really hungry for food... or seeking meaning, identity & creativity, in midlife? Join me, Dr. Sarah Milken, in an honest conversation about Satisfying Our Hungers for Food, Meaning & Purpose in Midlife. Dr. Adrienne Youdim lets us in on why we might always be feeling hungry. She gives us details and tools on how to evaluate if we are really hungry for food, or if we are searching for more meaning, belonging, purpose and creativity, in midlife. Adrienne's specialized treatments have helped so many people overcome their weight issues by looking inward and digging deep into the various types of internal hunger. We are going to dig deep into the details of Adrienne's journey, in her “midlife remix”, in her second half of life. Get up close and personal!  Some highlights:  - Being a resident at Cedar Sinai / developed her own program and was named co-director of the Center for Weight Loss - Different types of diets: Keto, Paleo… (pros and cons) - Anxiety comes from the gut / telling you to eat - Fasting - Psychology of food - How to “make it matter”, with our food choices - Difference between reading labels and ingredients lists - Zero carbs doesn't mean zero - Feeding our internal hunger for creativity, belonging, and meaning - The book Hungry for More: Stories and Science to Inspire Weight Loss From the Inside Out Looking forward to connecting with you! Here are some ways to connect with me! THE FLEXIBLE NEUROTIC SHOW NOTES: https://www.theflexibleneurotic.com/episodes/23 THE FLEXIBLE NEUROTIC INSTAGRAM: https://www.instagram.com/theflexibleneurotic/ THE FLEXIBLE NEUROTIC WEBSITE: https://www.theflexibleneurotic.com/ THE FLEXIBLE NEUROTIC EMAIL: sarah@theflexibleneurotic.com This podcast, along with associated websites and social media materials, are not intended to be a substitute for professional medical advice, diagnosis, or treatment. The views expressed are that of Dr. Sarah Milken, and that of her guests, respectively. It is for informational purposes only. Please consult your healthcare professional for any further medical or psychological questions.

Part 1 of 3 Are we really hungry for food... or seeking meaning, identity & creativity, in midlife? Join me, Dr. Sarah Milken, in an honest conversation about Satisfying Our Hungers for Food, Meaning & Purpose in Midlife. Dr. Adrienne Youdim lets us in on why we might always be feeling hungry. She gives us details and tools on how to evaluate if we are really hungry for food, or if we are searching for more meaning, belonging, purpose and creativity, in midlife. Adrienne's specialized treatments have helped so many people overcome their weight issues by looking inward and digging deep into the various types of internal hunger. We are going to dig deep into the details of Adrienne's journey, in her “midlife remix”, in her second half of life. Get up close and personal!  Some highlights:  - Being a resident at Cedar Sinai / developed her own program and was named co-director of the Center for Weight Loss - Different types of diets: Keto, Paleo… (pros and cons) - Anxiety comes from the gut / telling you to eat - Fasting - Psychology of food - How to “make it matter”, with our food choices - Difference between reading labels and ingredients lists - Zero carbs doesn't mean zero - Feeding our internal hunger for creativity, belonging, and meaning - The book Hungry for More: Stories and Science to Inspire Weight Loss From the Inside Out Looking forward to connecting with you! Here are some ways to connect with me! THE FLEXIBLE NEUROTIC SHOW NOTES: https://www.theflexibleneurotic.com/episodes/23 THE FLEXIBLE NEUROTIC INSTAGRAM: https://www.instagram.com/theflexibleneurotic/ THE FLEXIBLE NEUROTIC WEBSITE: https://www.theflexibleneurotic.com/ THE FLEXIBLE NEUROTIC EMAIL: sarah@theflexibleneurotic.com This podcast, along with associated websites and social media materials, are not intended to be a substitute for professional medical advice, diagnosis, or treatment. The views expressed are that of Dr. Sarah Milken, and that of her guests, respectively. It is for informational purposes only. Please consult your healthcare professional for any further medical or psychological questions.

In today's episode, we talk with Cliff Atkinson and Shon Davis from the New Flight Awards, which aims to help students in south-central Los Angeles join the worlds of advertising in film and create a portfolio that will help them get started and pursue careers in those fields. They will also receive a grant to further their education. Learn more at https://www.newflight.us. Cliff Atkinson is an innovative Digital Marketing Executive with 20+ years experience developing and implementing digital strategies for some of the largest brands in the world. Cliff began his career at Grey NY and has progressed through the dynamic world of digital with key posts at Deutsch NY and LA, Saatchi&Saatchi LA and RPA. His account experience includes Toyota, Honda, Procter & Gamble, Coors Light, Cedar Sinai, Sony Consumer Electronics, and Starwood Hotels to name a few. He's currently the Co-founder at Mesh Communities developing solutions designed to support content creators, communities and brands. Shon Davis is an innovative Account Executive refusing to watch the industry be renovated from the sidelines. As Co-Founder of the New Flight Awards, Shon has transformed investments from ThinkLA's MAT Program and ADCOLOR's Futures into a platform that will inspire today's youth to reshape the fields of Advertising + Entertainment.

Our #FreeBritney episode! Initial thoughts on Framing Britney.Dana's theories on what is really going on behind the scenes with Britney. What did Dana do with Woody Harrelson? A timeline of the night of Britney's 2008 visit to Cedar Sinai.Who was at Britney's house the night of the ill fated incident?Breakdown of the conservatorship documentation. What are her specific constraints?Who else did Sam Lutfi represent and why is he such a weirdo?A timelines of the legal events that follow in 2008.Britney's secret messages through social media... Conspiracy theories or reality?What is the importance of celebrity insurance?Dana talks about a potential benefit of a conservatorship. What is Dana's biggest problem with Jamie Spears being in charge of Britney?What is Dana's advice to Britney Spears?Sam Asghari is super hot...and Jamie Spears is a dick... but Dana reveals a rumor about him.A recent update with Jamie Spears's court appearance!Support the show (https://www.patreon.com/user?u=47889672)

Dr. Dre was released from Cedar Sinai hospital after spending a couple weeks recovering form an aneurysm. We wish Dre a speedy rehab and hope to see him back in the studio.

Update: Dr Dre reports he is doing great as he recovers after suffering a Brain aneurysm on Monday --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/herwordshertruth/support

This episode of PROSTATE PROS reviews and summarizes the year’s advancements in prostate cancer as well as looks forward to future updates. Beyond prostate cancer, the episode examines how COVID-19 has impacted the healthcare landscape and discusses news of the vaccine. Catch up on the latest and stay tuned for an exciting announcement. Liz:  [00:00] We have an exciting prostate cancer update.  Since recording this episode, the FDA recently approved the PSMA PET scan.  Keep that in mind when listening to the episode.  If you’d like further information, visit fda.gov. Dr. Scholz: [00:18] We’re guiding you to treatment success and avoiding prostate cancer pitfalls. I’m your host, Dr. Mark Scholz. Liz: [00:24] And I’m your cohost, Liz Graves. Dr. Scholz: [00:28] Welcome to the PROSTATE PROS podcast. Liz: [00:31] A lot has happened this year and we’ve covered many topics on the podcast. This episode we wanted to highlight a couple of exciting advancements and talk about some updates. Dr. Scholz: [00:44] The elephant in the living room of course, is the COVID situation. That’s impacted the way we do business. It’s impacted our patients. It’s impacted all of you dramatically. I thought I’d give a little update on what’s happened in our over 2000 clients. As you know, we serve a population of men between fifty and ninety plus our oldest patient just turned one hundred. This is a high risk group. Men are at higher risk for COVID complications and as we get older, particularly over 80, the complication rate goes up and the mortality rate goes up. We’ve actually lost one patient to COVID in our whole practice in 2020. It was an unfortunate individual that was traveling in Egypt in the January, February timeframe and when he came back to the United States he was ill. This was before people were really clear of what was going on, went to the hospital with pneumonia, and unfortunately passed away. We’ve had other patients, perhaps a dozen or so that have caught the COVID. They’re sort of evenly divided between men who really report that it wasn’t much of anything at all and others, the other half, they got pretty darn sick, a really bad flu. None of them fortunately had to go to the hospital. They all recovered. This is rather remarkable considering our vulnerable demographic. It shows that if people are careful and they isolate, they wash their hands, keep their hands off their face, most people aren’t going to catch this. Of course, when I talk to patients, I’m impressed by how much isolation is going on out there, how much care they are taking. Many men have come to the office and said that I am the first out of the house experience that they’ve had in 2020. So people are being very careful and clearly being careful does work. Liz: [02:49] Yeah. I remember early on in the pandemic, our office had way less traffic and was almost empty. Now it seems like things are picking back up and people are checking back in on their health. Dr. Scholz: [03:01] We’ve had a bunch of people come to the office who maybe had some cold symptoms, everyone’s on edge, and we’ve tested them for the COVID antibody to see if they did indeed have previous exposure. These tests are almost always coming back negative. We’re told by the scientists that these tests are probably 80% to 90% accurate. They’re not 100% accurate when you do the antibody test. That’s the test to determine if you’ve had previous exposure to COVID. We believe, and some people disagree, that if you’ve had previous exposure and your antibody test is positive, that it’s as if you’ve had a vaccination and you can’t catch COVID and you can’t transmit it. That of course would be good news. We’ve tested several hundred people now and almost all of them are negative. The ones that are positive are the ones that told us previously that they knew they had COVID. These antibody tests confirm it. This is a different test than the nasal swab, where doctors are trying to determine if you actively have the COVID virus. Those tests are more accurate, perhaps approaching 99% accurate. Patients who think that they have symptoms need to find a place to get tested, to rule in or rule out whether they are infectious. After they’ve been sick, they want to be tested again, to make sure that the infection risk has gone away. Liz: [4:38] We’ve had inquiries about where to get tested. We usually just send whoever across the street to Cedar Sinai, and they’ll do it there. The turnaround on these test is quick enough that people can just wait for their results and they should know within an hour. All right, Dr. Scholz, I think the biggest information about COVID right now is news of a vaccine. I think one thing a lot of people are concerned about is how quickly this has developed vaccines usually take years, if not a decade to get developed. This has happened within a year, which is pretty incredible. Do you think it will be safe? Dr. Scholz: [05:15] So there’s been debates, everyone’s heard them, that will the vaccine work, will it have durability? At this point, the preliminary science suggests that it will work and it will have durability. There’s three different companies that are putting forth a new product. The hope is that by the end of the year we will be having people getting vaccinated. Of course, there’ll be selective preference for the elderly people in healthcare. How this is all going to roll out is a big question. But it seems at this point, there’s no doubt that by early 2021 a vaccine is to be available and it will be effective. Liz: [06:00] It is changing really quickly. I know we were just talking about this last week and when I went back to review, I almost had to research it all again. So it’s important to stay up to date on this. Dr. Scholz: [06:14] Yeah everything that we do in the oncology realm and in this realm as well is predicated on what we call a risk-benefit ratio. We give dangerous medicine sometimes in oncology, but we are treating life-threatening cancers and sometimes rolling the dice and taking a chance with a treatment makes a lot of sense if the disease is much worse and very dangerous. So it’s going to be different for different people, for myself as a physician, meeting people all day long and basically in a high-risk situation, it seems to me that I’ll be lining up early for the vaccination. For those of you out there that are comfortable in your isolated state and are willing to sustain that, 2020 showed us that people can remain pretty safe if they’re very careful, but the social isolation is taking a big cost in our patients’ mentalities, their lifestyles, their social lives. It’s been painful and difficult when people have to make a personal choice as to whether the relatively small risk of getting a vaccine is too great to consider as opposed to continuing in their existing lifestyle. We’ll have more information every month as this vaccine rolls out as to how dangerous or how many risks there’ll be associated with it. That is unknown at this point. But as a lot of people are going to be getting this vaccine, we should have very good information within a few months. I think one last thing to emphasize is that we’ve learned that the COVID virus complication rate goes up astronomically in men over 80. Men over 80 and the elderly are at the very highest risk and mortality rates start to become very significant in this group. It would seem to me that these elderly men are going to want to try and get a vaccine, even if there are some risks associated with the vaccine, because the virus for them is very dangerous. Liz: [08:22] So another paradigm shift that occurred this year was the shift towards telehealth. It seems like about half of our visits now are being conducted over the phone or via FaceTime or Skype. Dr. Scholz: [08:36] This has been a really big change. In trying to understand it and wrap my brain around it, it seems that it’s a radical shift in accessibility. In the past, phone visits were discouraged because the impetus was to get people into the office and be able to bill for your services. Now, both private and Medicare insurance has essentially mandated insurance coverage for telehealth. This has rapidly been accepted by patients due to the accessibility, the ease of communication. It’s even been nice to be able to take off my face mask and see the body language of my patients and communicate non-verbally with Skype and FaceTime. In the office employees, patients alike are all wearing masks and we’re making eyes at each other, using our voices and trying to overcome the muffled communication that has become routine now in our lives. Liz: [09:44] I think something else that the telehealth has brought is connection. Right now people are feeling kind of anxious and separated. If they are skipping doctor’s appointments to avoid waiting rooms and being close to other people, it’s such a great way to catch up on the latest in prostate cancer and catch up with you. Your face appears in their living rooms and it’s like they’re right in your office. Dr. Scholz: [10:10] Yeah it is very personal. It’s as you all have experienced now, your face fills the screen and it’s not as disconnected as people might think. The risk to patients with telehealth is obviously reduced. But one component of the way we do medicine, of course, is blood tests, injections, and treatments, and certain in office visits are still unavoidable. If patients go to a remote facility for blood testing, they’re still going to have some contact. But so far as has been demonstrated, the COVID infection rate for our patients has been very low, whatever precautions people are taking seem to be working quite well. One thing about telehealth is it appears to be here to stay. I’ve talked to high-level insurance people about the future of telehealth asking, will it go away once the COVID risk disappears? The general consensus is that there’s no going back. This increased accessibility seems to be the future of medicine. Liz: [11:19] So even big topics that are maybe a little more involved or confusing are easily addressed over Skype or FaceTime or a phone appointment. Let’s start talking about a couple of those that are new developments for 2020. Dr. Scholz: [11:34] We already covered PARP inhibitors but they, being brand new treatments for advanced prostate cancer, merit a quick review. PARP is an enzyme that helps repair DNA. About 10% to 15% of men with advanced prostate cancer have a mutation that causes their DNA repaired to work less efficiently. One application of this mutation, which is called BRCA, is that there’s a little higher risk of getting prostate cancer. The men who get prostate cancer that have BRCA tend to have a more aggressive form. The PARP inhibitors exploit this mutation and men that have this mutation respond much, much better to PARP inhibitors. PARP inhibitors are pills that make it even more difficult to replicate or duplicate DNA. These already impaired cancer cells then die more easily and more quickly than your normal cells of your body. We’re always looking for a differential effect with cancer treatments, a treatment that focuses more on the cancer, then your cells killing cancer without causing a lot of side effects. So the medicines we’re talking about are Olaparib and Rucaparib two new pills that help men with BRCA mutated cancer and are now FDA approved. Liz: [13:01] These two approvals really highlight how important using genetic testing is. This will help men with prostate cancer find treatments that may have only been FDA approved for another cancer. Doing genetic testing is very easy. It can be accomplished with a mouth swab or a blood test, and it’s almost always covered by insurance. So we briefly covered some updates and genetic testing. Let’s review the PSMA PET scan really quick. Dr. Scholz: [13:32] We did a whole podcast on this because it’s a big breakthrough. Most of you have heard of it by now, but for the first time we can accurately locate the prostate cancer wherever it is in the body and the prostate and the lymph nodes in the bones with one single scan. This scan may be five times more accurate, ten times more accurate than any previous scan that was available. What a wonderful addition to our diagnostic armamentarium. This is going to have an impact for people with early stage disease, late stage disease. Unfortunately, the FDA has not yet approved it, but we’re anticipating approval within the next six months or so. In that situation, it will be covered by insurance and it will be very popular. Liz: [14:18] Some companies are investigating using PSMA as a therapeutic target rather than just a diagnostic target. Dr. Scholz: [14:28] Exactly. So the diagnostic scanning is incredibly useful reconnaissance for figuring out where the cancer is and helping design a treatment protocol. But if we’re able to accurately locate the cancer with these scans, wouldn’t it be possible to use this same target, to make therapies stick to the surface of the cancer cells? There are two very exciting types of treatment. One we’ve talked about before uses an antibody to stick to PSMA and draw a high energy radioactive molecule right next to the cancer cell and kill the cancer cell. This is called Lutetium- 177. The phase three trials in prostate cancer have been completed. We’ve had patients on trial or outside the country, get this treatment with very nice responses. We’re talking about a treatment for men that have already had chemotherapy, become hormone resistant to Zytiga and Xtandi, and who perhaps have limited treatment options getting nice PSA declines with relatively little, if any, toxicity. There is a PSMA antibody on the salivary glands, so some people get a little bit of a dry mouth. Some people with radiation, it can cause some lowering of blood counts, but for the most part, there’s practically no side effects with dramatic responses to Lutetium-177. The phase three trials are completed and they’re waiting for them to mature to validate that there is a survival advantage. Once that happens and the study results are released, the FDA has six months to approve or disapprove the treatment for broad spectrum dispersal amongst the population for therapy and insurance coverage. Liz: [16:14] So it seems like there’s a lot to look forward to with PSMA being used as a diagnostic test as well as its role in therapeutics, especially for men with advanced prostate cancer. There are a couple immunotherapies that are exciting on the horizon. Can we talk a little bit about those? Dr. Scholz: [16:36] Amgen has developed a connector molecule that instead of linking a radioactive moiety to the antibody that clips to PSMA, it’s sort of like a pheromone tag that draws in your T-cells. I don’t know how many of you are familiar with how the immune system works, but the soldier cells of the immune system are called the T-cells and the T-cells are the component of your immune system to go in and attack the cancer cells and kill them directly. Theoretically, if you can get the T-cells in close approximation with the cancer cells, they will attack and kill them. There is new technology from Amgen, a very large pharmaceutical company, that has developed this and is doing phase two testing in men with advanced prostate cancer and responses are indeed occurring. So the patients are injected with a substance that clips onto PSMA i.e. the surface of the cancer cells and draws the patient’s immune system close to the cancer cells so that it will attack it. Liz: [17:49] As you can see, there’s so much information about prostate cancer this year alone, we’ve covered focal therapy, brachytherapy, radiation, immunotherapy, chemotherapy; the list goes on and on. So looking forward, it’s important to always stay in touch and stay up to date and keep sharing and keep listening. You might find it useful to go back and review old episodes of PROSTATE PROS. You can find us on your favorite player. So Dr. Scholz, another exciting thing 2020 was the 10th anniversary of your first book Invasion of the Prostate Snatchers. Something you may not know is that this year, Dr. Scholz and I have been working hard to update his first book Invasion of the Prostate Snatchers. So about 10 years ago, when the first edition was published, it was really the first introduction to active surveillance. I think Dr. Scholz received a little flak from that, and now it’s more widely accepted, but with that, there’s still a lot of the industry that patients need to be careful of. That includes over-treatment. That includes dangers of surgery and random biopsies. So we’re really looking to restart the conversation, and get patients to be their own advocates. Dr. Scholz: [19:16] There’s a theme in the prostate cancer world that you have to educate yourself. I hope that both of my books encourage people to do their own research, to take responsibility for their health and to double check the information, rather than just accepting the first pitch you hear from a doctor. Prostate cancer is big business. It’s a multi-billion dollar world, and people are trying to make a profit. Ethically, no doubt, there’s so many gray areas in the prostate cancer world. You need to double-check and you need to find the original, basic information that leads you to the truth. Liz:  [19:59] So this new completely rewritten second edition of Invasion of the Prostate Snatchers will be out in 2021.  We’re really excited to share it with you.  Telehealth has really connected us this year, and we’re looking forward to staying connected in 2021.  Remember to tune into the podcast and share with your friends.  If you have any topics you want us to cover in the upcoming year, you can email us at podcast@prostateoncology.com.

Your earbuds will film their own hot wet video when Director Patrick Hoelck and Rachel "Kitty" Sterling tag team Big Luck's, 'Ol Blue Eyes and Chumahan in the Chateau Du Virus, hear about Rachel's all out brawl with her butt hurt sound engineer, how she wants COVID to shut up already, hear How Patrick flew into the Arabian Nights to walk Sterling down the aisle in one of numerous and short-lived weddings, hear how Patrick shot Sterling when she was naked and younger, hear what Cedar Sinai doctors said about Patrick's member after a full testicular ultrasound, BONUS TRACK: find out if 'Ol Blue Eyes would wear Ms. Sterling's undergarments on his face.Support this podcast at — https://redcircle.com/the-hard-luck-show/donationsAdvertising Inquiries: https://redcircle.com/brandsPrivacy & Opt-Out: https://redcircle.com/privacy

In this episode of the '97 Demo Podcast, we discuss the latest news and what artsists have done during the COVID pandemic to stay relevant and still enegage with their fan bases. Headlines on Tap: - Billboard Music Award nominees - Meg Thee Stallion is dope - Cedar-SInai reports confirms Meg the Stallion's story - Kanye giving GOOD music artist their masters - Rolling Stone ranks top 500 albums of all time 0:05:25 - Chart Rundown 0:15:00 - New Releases 0:23:57 - Headlines 0:45:00 - Demo Discussion 1:02:45 - Project of the Week/Outro Be sure to catch all of the latest episodes of the '97 Demo. Follow us on Twitter! '97 Demo: @the97demo Nnamdi: @NnamEgwuon Noah: @noahamcgee_ Avery: @AveryDalal

If you're a hospital that uses AIDOC's software, less people will die. That's the impact that medical-grade AI imaging software can have when built by the likes of Elad and his co-founders, Michael and Guy.About AIDOC: AI software that helps radiologists prioritise sick patients by flagging acute injuries. Scanned over 3.5m images in the world's best hospitals such as Cedar Sinai in LA. Square Peg led their US $26m Series B in 2019.On today's episode, you'll here: About Talpiot. The best founder training program you've never heard of; What it was like to be the Head of AI + Algorithms for the Israeli Airforce; How a big misunderstanding helped sell them sell into hospitals; About product-market-regulation fit.Learn more about AIDOC: https://www.aidoc.com/

Transcription:David S. Chernow 0:03 We made a decision to take on all COVID patients immediately. And we worked with our partners and dedicated units and one of our four key results, my five plus six equals for is bad math. Our four key results are to keep our patients and each other safe, to create an exceptional patient experience, to create an exceptional employee experience, and then and only then to meet our annual business plan.Gary Bisbee 0:30 That was David Chernow, President and CEO, Select Medical, discussing how Select's decision to accept all COVID patients was pre-determined by their corporate strategy. I'm Gary Bisbee, and this is Fireside Chat. As David described Select Medical, he provided an excellent outline of the post-acute care business, as well as the rationale for expanding into homecare, Select medical operates nationally, and David provides color on growing a large and diverse business. He spoke about where scale matters in the post-acute care business, what are the keys to successful partnerships and where solid operations make a difference. Let's listen to David respond to a question about characteristics of a leader during a crisis.David S. Chernow 1:13 Everybody's relying on you. They're looking to see how you respond and how you respond will help others respond accordingly. I'm a big believer in servant leadership. I believe that making other people successful, having them be successful will drive the success of your organization.Gary Bisbee 1:30 David has a fascinating personal background. Spoiler alert, he was a ball boy at UCLA and one of the great John Wooden's basketball teams. Don't miss David sharing his favorite John Wooden story. delighted to welcome David Chernow to the microphone. Well, good morning, David. And welcome.David S. Chernow 1:51 Thank you, Gary. And I'm very pleased to be here and I appreciate the time.Gary Bisbee 1:55 We're pleased to have you at the microphone for sure. Let's kick right off here. Some of us are more familiar with Select Medical than others? Could you please describe Select Medical for us, David?David S. Chernow 2:05 Sure. Select medical is a post-acute care provider to companies. Now it's grown quite a bit over the last 10 years in particular, although we're 22 years since our founding by Bob and Rocky Ortenzio. When I say post-acute, we provide four levels of services in the post-acute arena. One, we're a provider of what we call critical illness recovery hospitals or long term. Most people know them as long term acute care hospitals. We actually have 101 of those hospitals around the country in 28 states. We're also a large provider, I think we're the second largest provider of inpatient rehab hospitals, where currently we have 29 of those specialty hospitals operating in 12 states and we have 17 partnerships, which I think we'll talk about later on in our podcast here. We're also a provider of outpatient services, physical therapy, occupational therapy and speech, and we have 1750 locations around the United States in 37 states in the District of Columbia. And then we're also providers of occupational medicine, with Concentra and more recently, the acquisition of US Health Works. We have approximately 525 centers in 41 states so that rounds out sort of our post-acute services I will say also, some people ask us if we're in the skilled nursing facility business, we are not, but we are in just venturing into the home health business in a partnership with a entity called A.S.H.N. which is alternate solution Health Network, a terrific provider of home health, who shares our mission, vision and values.Gary Bisbee 4:02 So quite an extensive operation. Why did Select Medical choose to focus on post-acute care, David?David S. Chernow 4:09 It's interesting, Rocky or Rocco Ortenzio, who's really one of the great pioneers of inpatient rehab has had four companies over the span of close to 50 years and his son, Bob, or Ortenzio, who's been in the business close to 40 years with him. They were really rehab guys. Started out in the rehab business and through merger, consolidation and the like, over 20 years ago, decided to start Select Medical, that's really their background, but the quiet corner of healthcare was nobody really knew about long term acute care, although it was similar, not exactly the same as inpatient rehab, and ironically, I think there was probably a non-compete way back when and they ended up going into long term acute care, but their real background/passion was inpatient rehab. So I think once the non-compete went away, they started getting into the other areas of post-acute including inpatient rehab and outpatient. Ironically, Rocco is a PT by background. So it's really his first love, and we started venturing into the - not only LTAC, but inpatient rehab, but getting into outpatient and I believe it was in 2003. We got into the outpatient business with the acquisition of Nova Care, which you may know about in the Philadelphia market and then really have expanded the services there. So post-acute has always been our laser like focus. And as you know, Gary, it hasn't been the focus until more recently, of a lot of health systemsGary Bisbee 5:49 For sure. Actually, quick story on Rocky, when I was at Kidder, Peabody investment banker at Kidder. Rocky came in and we were talking about possibly doing a deal with what I think was probably his first company at that point. And we covered the post-acute business on the research side and Rocky spoke at several of our meetings, so small world. But back to your point about post-acute care. What's your thought about that? It has never been the darling of healthcare. In fact, you could argue that it really has been under resourced. What do you think about that? And why is that? And how's that changing, David?David S. Chernow 6:29 Yeah, it's a great question. And I would tell you, I've been here 10 years now, and things have changed over the last 10 years, even though the company's 22 years old. I think, with the evolution of healthcare, where, as you know, a lot of the health systems are trying to get away from hospitalization, which is the highest cost service in the healthcare continuum, of course, post-acute getting patients out of the hospital sooner. Hopefully getting them home and healthy, but having specialized services has really become the priority. And so most health systems who are trying to deliver high quality cost effective care, there really hasn't been that focus once they get discharged, how do we treat those patients in a cost effective and a high quality way? So I think now, with the whole look towards value based purchasing, and the like, the opportunity to really explore how we can provide all those services. You know, I'm an old healthcare guy, where it always used to be the focus was oncology, orthopedics and cardiology in the service world. Now, as you know, what's happened is, I think post-acute has become a very high priority for most of the systems, especially as they're trying to figure out how to manage the patient population in our population health strategies that most health systems have today.Gary Bisbee 7:59 I'll be interested to follow your home healthcare initiative because it strikes me that it's a terrific addition just when you think about the continuum of care.David S. Chernow 8:09 While we're on the topic, let me just share with you you know, since I've been here, and I've learned a lot since I've been here, I was a board member for seven years prior to joining in leadership back in 2010. But ever since I came here, I know Bob and Rocky, were always talking about our goal would be to get people home and healthy. And it was a missing piece, and of course like every health system, there's always the challenge of how do you develop that service line. We stick to our knitting, we know what we're good at, and we know what we're not necessarily good at, and we've been laser like focused with long term acute care critical illness that we call inpatient, rehab and outpatient, but all of our partners have been asking us: "if you're a post-acute preferred partner, why aren't you in home health?". And so for several years we've been looking at: Okay, do you build it? Do you buy it? Or do you partner? And we made a strategic decision with the input of many people who, you know, on our board, they gave us the advice and counsel that we need to figure out a way to get in that business. And so we literally went down the road of evaluating, do we build it? No, really hard to develop. Do we buy it? As you know, there's a lot of good players out there, but it's difficult to buy in the prices that were out there, it was potentially risky to purchase. And then we decided, let's find somebody who has the same culture, the same values and the same business model. And that's what we did. And so we were fortunate enough to partner with A.S.H.N., Alternate Solution Health Network out of Dayton. And literally, they have the same operating, centralized operating model, high quality provider, already existing partnerships. And so we're trying to leverage that relationship and bring that to the benefit of our partners in local markets.Gary Bisbee 10:05 That sounds terrific. Another question, David. So how to Select medical work with physicians?David S. Chernow 10:11 So unlike other organizations, we do employ in some markets, but it's a small amount. But what we do do is we have about 130 specialty hospitals. 130 of them. In each one of those hospitals. We have medical directorships. We have affiliations with directors of quality, directors of wound care. We have medical directors, typically in pulmonary critical care, a lot of specialties PM&R physicians - physical medicine and rehabilitation. So we have relationships where we engage the physician community to provide high level services, and we work very collaboratively with them and develop standards of care and make sure that we're operating at the highest quality. So, physicians are critical to our delivery of our services in the post-acute. It's just that it's more of a, if you will, arm's length and it's not an employed, perfectly employed model like some healthcare systems.Gary Bisbee 11:15 You made reference to Select Medical growing through the years, particularly the last 10 years. Where does scale matter in the post-acute business, David?David S. Chernow 11:24 I would tell you, just to give you sort of a sense of things when I came aboard, we were about at 20,000 employees, and about $2 billion dollars in revenue. Currently, today we're over 55,000 employees, and approximately five to five and a half billion of revenue. I will tell you and it sort of goes maybe to some future questions that you may have. Bob and Rocky have developed over the years a great centralized business model that allows us to scale, quickly. And as you know, one's ability to scale, a business is based on leadership, and having a strong bench and having a really great strong mission and vision and values and a great culture. And so, scale does matter to us because our ability to leverage our infrastructure, from an IT perspective, from a billing and collecting perspective, from a procurement perspective, all the things that drive efficiency and healthcare, we've been able, fortunately to do a really good job. We are operators by heart. That's really who we are. And I remember early in my career, Pricewaterhouse was always doing things on how you integrate in scale. There was “Five Frogs on a Log”. I don't know if you remember the book, but execution is the key to success in business, in general and in healthcare, in particular. And I think we've been honestly pretty darn good. Even when I was a board member, they were always doing great jobs of integrating new businesses, new services, and new partnerships. And so, scale does matter. Not that bigger is better. But I'm proud to say that we've delivered a high quality service line in all of our four business lines or service lines. And we've been able to do it efficiently because of our centralized business model.Gary Bisbee 13:27 The scale question might lead us into the next section, which would be the COVID crisis. And of course, that's hit all providers. What did the COVID crisis present for Select Medical either in terms of challenges or opportunities, David?David S. Chernow 13:41 With COVID, I will tell you, I joke about this, Gary, and it's not really proper math, and some people say it's probably stupid math, but I talked about how five plus six equals four. And people will say, what does that mean? And I said, Well, I know it's not very good math, but what it does mean is that our five core values, plus our six cultural behaviors equal our four key results and why I bring that up in COVID is our five core values are delivering superior quality and all that we do, treating others as they would want to be treated, and being results oriented and being team players, but most importantly, especially in this environment of the pandemic COVID-19 is we're resourceful in overcoming obstacles. And we've been challenged like we've never been challenged in the history of the company. And it has provided us with not only enormous challenges, but enormous opportunities. The major challenge for Select was, how do we take on that patient population, the COVID-19 patients and every health system had a decision to make, do we take them on? Where do we put them? How do we tackle the problem? We have a terrific chief medical officer and chief quality officer Dr. Hammerman, who happens to be a critical care and pulmonologist who helped us define the standards by which - obviously following CDC and other things, but we made a decision to take on all COVID patients immediately. And we worked with our partners and dedicated units. And one of our four key results, my five plus six equals four is bad math. Our four key results are to keep our patients in each other safe, to create an exceptional patient experience, to create an exceptional employee experience, and then and only then to meet our annual business plan. Well, that first key result, which is to keep our patients and each other safe, has been the complete focus of our company for the last four months during COVID. And I'm happy to say that with that challenge was an enormous opportunity. I think I mentioned we're in 28 states with our critical illness recovery hospitals. We've been asked by partners and non-partners to stand up units in local markets to be able to address the problem. I interviewed Bob Ortenzio on our own podcast, our executive chairman, and he reiterated which I will reiterate to you. We've never been more proud as a company in our ability to treat patients and deliver on our mission and our vision relating to this COVID pandemic. So it's been a great challenge, but I will tell you, some of the other things that have happened in major cities in this country, not only have health systems come to us, but state health departments have come to us and said, “Can you help us?”, because I think I mentioned this to you before, we're one of the largest providers of ventilator care in this country. And so while people didn't really understand what ventilators meant, or what intubation meant, I think everybody now understands what that means. And so we've been very fortunate to be able to step up, and be a solution provider to be a problem solver in many of the markets around this country, providing the level of care that gets us up each and every day and makes us excited to be part of the solution in this country of providing good care to the patients who need us the most.Gary Bisbee 17:17 David, how did the PPE supply chain hold up?David S. Chernow 17:20 Again, we were pretty fortunate. I mentioned to you our business model of centralized procurement, because we have over 100 long term acute care or critical illness recovery hospitals. We had a pretty strong supply of ventilators in the normal course of our business. And when we started hearing about some of the things going on, we were relatively proactive in making sure that we had not only surgical gowns and masks, but maintained our high level of ventilators. So we've never been, if you will, caught with a delay, and of course, keeping our patients and each other safe is critical. So Having the PPE was critical to our success of being able to not only address the issue and to treat the COVID positive patients, but also to keep our employees happy or safe in this environment.Gary Bisbee 18:15 What was the policy for relatives and visitors?David S. Chernow 18:18 It's a great question, Gary. We had a no visitation policy. We followed CDC guidelines, we were pretty conservative on our approach. I will tell you we also, just like any good partner, in any good partnership, we're also in a lot of host hospitals. Of those hundred and one hospitals, over 80% of those hospitals are “HIHs” or hospitals within a hospital. And we got partners in many of our hospitals who we were following their guidelines, which may have been a little inconsistent with our standard policy. So if you can imagine if a post hospital has no visitation or has visitation and we have no visitation, there'd be a bit of a conflict. So we just worked through in every one of our relationships. We took a policy of no visitation and where there was, quote, unquote, a difference of approach. We work with our host hospital or our partners and make sure that we are consistent with what was going on in the local market. By and large, though, there was mostly no visitation initially.Gary Bisbee 19:26 Well, that's a good lead into partnerships, which are hard work in the best of circumstances and Select medical has been quite successful at them, what are the key principles that make a partnership work for both sides, David?David S. Chernow 19:41 I don't mean to make light of this, and Gary, I think you know this. I've been blessed and personally, I've been very fortunate that Bob and Rocky are vice chairman and executive chairman and co-founders and have allowed me the opportunity to be front and center of most of these partnerships in the negotiation. And I've been able to work with my contemporaries, fellow CEOs and health systems to help drive the post-acute strategies of these partnerships. And what I would tell you is I tell every one of them that the best advice I ever got was from my mother-in-law, who before I got married, she said, the key to a great marriage is three C's. And I said, What are you talking about? And this is before we got married, she said, Well, if you practice the three C's, you will have a great marriage. And I sort of look at marriage like partnerships, by the way the three C's are, and we've extended it to the four C's, but the three C's were compassion, communication, and compromise. And we added a fourth which was collaboration, but I will tell you in each and every one of our partnerships, there's trust, there's confidence and there's the four C's. There's A great deal of communication. There's a great deal of compassion and understanding of what the needs are of our partner. There's an enormous amount of compromise in my definition. I don't know about yours, Gary, my definition of compromises that nobody's happy. But the truth of the matter is with those four C's, and of course, there's collaboration, you're never going to face a problem you can’t handle. And I will tell you that some people have asked the question, have you ever walked away from a partnership? We do believe in the sanctity of partnerships. And I will tell you that it has to have a basic fundamental concept to make the partnership work, and that is that we have common values and a common culture. And by the way, this is not a criticism in any stretch of the imagination, but we as an organization, really look at that first and foremost and say: Do they believe in the things we believe in. I told you about the five plus six equals four - are their values - do they believe in delivering superior quality in everything they do? Do they want to treat others as others would like to be treated? Are they results oriented? Do they believe in results? Do they believe in team play? Do they want to overcome obstacles? And the answer, invariably, with all these great institutions, most of them, are is they're exactly like us. And I think that's what's made us successful. We've never had a problem. We always can work through the issues. And I will tell you that the reason the partnerships work is I think we're solving a problem or have laser-like focus in a particular area that our partner maybe did not. And that's what makes for really good partnerships is that we're able to have shared culture and values and we're able to deliver a service that maybe is not their priority, but now is.Gary Bisbee 22:56 So I was going to ask what are the reasons a large health system pursues a partnership and you pretty much answered that. Let me ask a different way, which is how do you connect with these large systems? Do they reach out to you? Or do you reach out to them?David S. Chernow 23:09 I will tell you that, like everything in life, it's just relationships and people we know. But I will say that more recently, with the change in sort of strategy and population health, value based purchasing, getting people out of hospitals, I think the changing healthcare environment has really pushed many health system leaders to look at post-acute in a different way. And I think most of them have had the challenge of saying, I want to get people home and healthy, and I can't send them home. And I'm not delivering and not focused on these post-acute services. How do I get into that? How do I deliver that service which is so well needed in my community? And they either have to make the decision or I'll build it on my own. Maybe I'll buy it in service. And ironically, Gary, most of our partnerships are with not-for-profits. So a lot of them may need capital. A lot of partners come to us and they say, I currently have a small unit or rehab unit or an LTAC unit. But I need my beds for inpatient medical surgical, can you help me deliver that service outside my hospital, so I can free up those beds. And by the way, I need capital. And I need a real high quality provider to provide the service and do it in a way that we're accustomed with high quality and cost effective care. So they're looking for someone who shares the mission, vision and values but can also provide that level of service with a laser-like focus that they'll be proud of, and that's sort of what we've been fortunate to do. I will say that I'm pretty involved like you in VHA and we're with Cleveland Clinic and UCLA and Cedars, and I think sometimes word of mouth helps, right if we've done a good job with Emory. And they'll say, they've delivered the service and they've done what they said they're going to do. So that always helps. But we also identify which markets may have a need for post-acute services that's underserved. And we may go out and approach a health system that says they're not delivering the service that needs to be done in that market, and we'd love to figure out a way to partner. We're not a greenfield go in, establish a foothold and do something independent. We do love partnering. It's really who we are.Gary Bisbee 25:38 Let's turn to your personal background, which is quite interesting. And it's always fun to learn about a CEOs background. You graduated from UCLA, graduate degree from Pepperdine. Did you grow up in California?David S. Chernow 25:50 I joke about it. My father went to UCLA. I'm a twin. So my twin brother and I both attended UCLA. Little known fact about me: I did grow up in California, I've always been a UCLA Bruin supporter. My only claim to fame, Gary, is that I'm actually looking at the picture. I was a ball boy, John Wooden. You're talking about leadership, so he inspired me when I was 13-years-old — There's a famous picture. I joke with everybody. It's a famous picture of Bill Walton, who's above the square fly swatting a ball out to his point guard, to lead a fast break, and everybody looks at the picture and says, oh, wow, that's great. Who's that? Says Bill Walton. I tell them they're not looking at the right person, because underneath his foot is a kid who's ready to dry up the sweat off the floor. I grew up there. I went to law school. My dad was a lawyer, worker's comp lawyer, my twin brother's a lawyer, but he sort of followed the family footsteps and not to get too personal but at a very young age right after graduate law school, I ended up getting cancer. And that's what actually pushed me into the healthcare world and I got treated, ironically, as I told the CEOs of both UCLA and Cedar Sinai. I've been in all their hospitals and been treated. And it was destiny that we were going to do something together. But thankfully, I had great care. And it got me into the oncology world where I started my career in helping put together what later became US Oncology, but I loved UCLA. I grew up in California and my own health issues when I was 23. And going through some struggles, is what prompted me to get into healthcare.Gary Bisbee 27:41 Well, I've got to ask this story, David. So what's your favorite John Wooden story?David S. Chernow 27:46 My favorite John Wooden story is - and by the way, I think I have every one of his books and I believe in his pyramid of success and leadership. Interestingly enough Bill Walton, many of your listeners may know who was a pretty Radical young man - superior athlete. One day he went up to John Wooden. And he said, sir, I believe in freedom of speech, I believe in freedom of expression. I know you have a policy of no facial hair, and I believe that I should have the ability to express myself and be able to grow a beard and do what I need to do. And John Wooden looked at him and he said, I agree with you, you should have the right to express yourself and you should have the right to look the way you want to look. And Bill it was a pleasure having you on our team. Obviously he shaved his beard and was national Player of the Year but Wooden is an idol of mine and a mentor. I have two great mentors. Rocky Ortenzio is a great mentor of mine and John Wooden is more of a leadership mentor to me.Gary Bisbee 28:50 That's an absolutely terrific story and both those gentlemen are top notch for sure. Looking at your professional background, you could be viewed as an entrepreneur. Or an operator? How do you view yourself David?David S. Chernow 29:03 Interestingly enough, Gary, in my background - I always thought - I was a tennis player. By the way, when I went to UCLA, I played tennis there for my first year, and then had Tommy John surgery ironically. So my career ended quickly. And I always thought I'd want to be a sports agent. I grew up, dreaming of that. And ironically, I ended up being in the healthcare world, professional services working with physicians through most of my career. And so I found it to be an interesting similarity of representing and working with highly professional, highly talented individuals, which sort of marked my career but I've been fortunate that I've had some entrepreneurial ventures and ironically I talked to you about Rocky and Bob Ortenzio. They actually gave me my first start, I came up with an idea way back when in the late 80s that I thought we could develop a physician practice model in oncology and build cancer centers. And they gave me the original money with Russ Carson to start what later became US Oncology. Honestly, this isn't false modesty, I didn't really know what I was doing. But sort of learned along the way, but had great mentors and people like Ross Carson, and Rocco, and Bob, who believed enough in me to do something. So I would have to say I'm a bit entrepreneurial. Although I've learned to become an operator, I'm more of a development entrepreneurial type of guy. I will tell you that all kidding aside, you know, the joke is that David can't keep a job because he's had about four different careers. But this may get into our leadership discussion, but I had one of the great jobs ever in the world, if you will, when I was recruited to run Junior Achievement in the United States as the CEO and then I became the head of JA worldwide, but I did that for about six years, which was to educate and inspire young people to be successful in life through free enterprise education, involving entrepreneurship, financial literacy and workforce readiness. So I've seen the great side of people, and had one of the great jobs in America and worldwide, which was educating and inspiring young people around our great democratic and American free enterprise system.Gary Bisbee 31:26 You've had an interesting background. This has been a terrific interview, let's move to leadership to wrap up. What do you think the characteristics of a leader during a major crisis are?David S. Chernow 31:36 I think the ability to maintain a coolness calmness, a rational approach to things to not get too high, not get too low is critical, I have to say is I had this fantastic father, who was just a brilliant guy and just seemed to have that calmness that steadiness that is required in adverse situations. One of our core values is being resourceful and overcoming obstacles. And I will say two more personalize this. When you've had some really difficult things happen in your life, and one of mine was losing my father at a young age and also having cancer at a young age. I think you build up this sort of strength and this resolve to be able to deal with problems and adversity. And so I know that Bob Ortenzio and Rocco have these great qualities and I try to be the same, which is, keep a level head, be calm, and make sure that you're addressing the problem. You're not getting too worked up over things because everybody's relying on you. They're looking to see how you respond and how you respond will help others respond accordingly. I'm a big believer in servant leadership. I believe that making other people successful, having them be successful will drive the success of your organization. While I have a great title and a great responsibility. It's really not about me. And one of the great things I love about Select and most of our partners know this, is that there's a humility and humbleness that emanates from Rocky and Bob and throughout the organization. And I'm proud to be part of that in part of a humble servant type organization that our whole goal is to make others successful.Gary Bisbee 33:26 Great point of view, and you do it very nicely. I'd like to wrap up with a final question if I could. You made the point that you've learned to be an operator, what lessons did you learn that make you a good operator, David?David S. Chernow 33:41 It's interesting for me, because I'm more of a development, maybe try and be strategic, try and be a bigger thinker. On the one hand, on the other hand, Select has always been an operating company who's delivered results. And the thing that I've learned is that not one week, not one month, not one quarter necessarily dictates how good an operation can be, you got to have the long term view. And the key to being good operators is to treat people well. And to make sure that you educate, inspire and motivate your workforce to deliver the four key results, which again, are keeping our patients and each other safe, delivering exceptional patient experience, delivering employee experience, because if you don't have happy employees, you're never going to deliver a great patient experience. And then and only then, and remember, there's four key results, but then and only then can you deliver on your business plan. And I will tell you that delivering on the business plan, you have to have those other three elements - those other three key action items, and what we've learned being operators is that we have to be sensitive to other people and every market is different, and you can't just make a blanket statement as to why things are happening. You have to really dig deep into the reasons why things aren't happening and be willing to make corrections and be a good listener to your employees. That's what I learned is being an operator.Gary Bisbee 35:19 David, thank you so much for the time today. Just a terrific interview and continued success at Select Medical.David S. Chernow 35:28 Thank you, Gary. It's a pleasure and stay safe and stay healthy.Gary Bisbee 35:32 This episode of Fireside Chat is produced by Strafire. Please subscribe to fireside chat on Apple podcasts or wherever you're listening right now. Be sure to rate and review fireside chat so we can continue to explore key issues with innovative and dynamic healthcare leaders. In addition to subscribing and rating we have found that podcasts are known through word of mouth. We appreciate you spreading the word to friends or those who might be interested in. Fireside Chat is brought to you from our nation's capital in Washington DC, where we explore the intersection of healthcare politics, financing and delivery. For additional perspectives on health policy and leadership, read my weekly blog Bisby's Brief. For questions and suggestions about Fireside Chat. Contact me through our website, Firesidechatpodcast.com or Gary@hmacademy.com. Thanks for listening. 

Narración del extraño suceso acontecido en el hospital de Cedar Sinai en el que apareció una mujer de apariencia grotesca bañada en sangre. El caso sigue sin tener explicación a día de hoy, pero a la mujer se la bautizó como "la inexpresiva".

Narración del extraño suceso acontecido en el hospital de Cedar Sinai en el que apareció una mujer de apariencia grotesca bañada en sangre. El caso sigue sin tener explicación a día de hoy, pero a la mujer se la bautizó como "la inexpresiva".

A word to healthcare workers, when Jewish patients ask for last rights or confession, this is our version for them to be able to say when they are gravely ill or know that they are at the end of life. This DOES NOT mean that they have given up hope. It is a means to ask for forgiveness and be able to clearly see and acknowledge G-ds role in their lives. The following version/order was recommended by Rabbi Jason Weiner, chaplain at Cedar Sinai medical center in California from the Jewish deathandmourning.org pamphlet. (Also includes psalms 91 yashev bseter, 121 esah enei, and 130 mimaamakim)                                                            

All right everybody It is now time for the gut check project. Let's talk about some of our sponsors for today's show, Episode Number 31. Of course, we're going to start it off with Atrantil you can get your own Atrantil at lovemytummy.com/KBMD chock full of nature's best defense against IBS and bloating polyphenols. Dr. Brown, what do you want to add to that? One of the things is that we know that the future of protecting our microbiome and if you listen to this podcast, you will realize that we're it's all about health span. It's all about protecting your health. And the microbiome is the most important thing that you can actually augment Atrantil augments the microbiome. If you happen to be somebody that has IBS and bloating well we fix that also. So in other words, if you have issues take Atrantil. If you want to protect your health span take Atrantil.So Atrantil, not only for your gut health protect your lifespan lovemytummy.com/KBMD, lovemytummy.com/KBMD. Don't get it from, Amazon. Get it directly from the Atrantil manufacturers themselves. You know what, because you need to just get on with this, I'm going to correct you on this. You said lifespan, I said healthspan. Two different things. I want you to be healthy. That's the bottom line. Doesn't matter how long we live. If you end up with Dementia, Alzheimer's Parkinson's, and things like that healthspan, my brother.That's why we get Dr. Brown on the show and not just me. So lovemytummy.com/KBMD. Now talking about KBMD, we also have another sponsorship, KBMD CBD. KBMD CBD is all organic CO2 extracted and has been used clinically where we gotten results correct?Correct Absolutely. So one of the things is everybodyis talking about CBD, CBD these days, but getting the proper CBD is the key here. If you cannot get direct access to a Certificate of Analysis, you're starting off on the wrong foot. All KBMD CBD lot number to lot number. Every single run, has an associated Certificate of Analysis so that you know that inside that bottle is exactly what appears on the label. And everything that we've ever or the Dr. Brown has ever found as a benefit from CBD has been tested in his own GI clinic and not just with himself with many of his own colleagues. So KBMD CBD, you can get your own at KBMDhealth.com. And you can also find the Dr. Brown signature protection package, which includes CBD and Atrantil. Now why would someone want to do that?That is great question Eric. And the reason why is because when we've been talking to scientists, we realize that when you take Atrantil with CBD, it actually augments your own endocannabinoid production. Meaning, you explain that please.Well, if you enhance your own endocannabinoid production, what you're going to do is give your body all of the elements that it needs to balance your immune system along with your nervous system. And by having that type of balance, you begin to decrease the, the negative effects of over inflammation. Or you could find out that you could sleep a little bit better that you just don't say have the same aches and pains. Essentially, there's a great reason that we're discovering that CBD is essential as a micro-nutrient that we could consume every single day. I'm so proud of you. Thank you. You've learned so much. I've learned so much.Go to KBMDhealth.com, use code GCP save 20% on anything that you wish to purchase.So ultimately, what happens is that the polyphenols Atrantil actually decrease the enzyme that breaks down your own endocannabinoids and that's how come I started getting into the science of this and I realized that every time everybody takes the KBMD CBD with Atrantil they do better. It augments, it meaning, they work together. 20%? That's on top of the discounts that already come in the...Sounds like i'm going to lose money on that. What's important, is that everybody can rest assured you will not have money as a barrier to entry for your health.You know, that's exactly it. I don't even care about that. So we're gonna lose a little money on this, but you guys get healthy. I'm on it, my kids are on it, my staff is on it, you're on it, your kids are on it, everybody's on it. Everytime you get in front of somebody. Our job with the gut check project is to promote health.100% And this is one way to do it. Speaking of promoting health, we have our first external sponsor that we'd like to go ahead and talk about that is going to be somebody who made it a an appearance on episode number 30. The Unrefined Bakery so unrefinedbakery.com, unrefinedbakery.com. You can use, code gutcheck to save 20% off your very first purchase. And it doesn't matter where you live, even though they are based in the DFW Texas Metroplex, anywhere you live, they can ship to you. Gluten-free, paleo, keto compliant, whatever you're after in your special diet. That's what they specialize in. Low sugar, breads, cupcakes, mix. It's incredible food, that just happens to be gluten free. What do you think of the of the foods that Unrefined Bakery made this week?Absolutely amazing. They were absolutely delicious. But, here's something else I want to say. I had a patient that just came to me, and they went to the Mayo Clinic they were Cleveland Clinic. They were like desperate, right? And they were told by their gastroenterologist that gluten sensitivity is not a thing. Weird. Guess what? Gluten sensitivity is a huge thing to me. Because every time I eat it, I'm pretty much stuck in the bathroom. So Unrefined Bakery. I love the fact that we brought them on. We had Taylor and Ann. And they, they crushed it. They're super smart.Definitely. They're dedicated to their customers without question. Dude, they have the same passion that we do, which is ultimately just promoting health, that's it.Absolutely. So I know, I had to laugh. This patient came to me and he goes, Yeah, my doctor told me that gluten sensitivity was not a thing. Like it, really is because I live it.Yeah, absolutely. Unrefined Bakery, unrefinedbakery.com, use code, gutcheck, save 20% off your first order. Make it a big order. So save 20% off a bunch of stuffed. 20%? They're losing money also.Absolutely. If you walked away thinking you can't have bread anymore, start here. They sell bread, they sell bread dough, they sell cupcakes, they sell cookies they sell like I said.Can you get on the rest of the show, because I'm gonna drive there. Right now. And go get some cupcakes.Unrefined Bakery. You're doing too good of a job of selling this, holy cow.We may not have a show, this may be it. This may be Episode 31 right here. So unrefinedbakery.com. Be sure and check them out. Use code gut check. And now we're onto the show. You're gonna love Episode 31. Dr. Brown is going to dive pretty deep and we'll get started here in 3,2,1. Alright everybody is now time for the gut check project. It's Episode 31, we got a special topic here today that Dr. Brown is going to cover. Has anybody ever thought about fecal microbial transplants almost screwed up the way I said it, just then.No, no, no, you can't screw up poop.You can't screw up poop. You can't screw up poop.No, so I didn't. It's like. It's like everything's fine.Yeah, I want to try something completely different here. So what, what happened and the reason why I'm to do this show, you and I is that I were surprisingly getting some reach. I got reached by somebody, instant messaged me from Sweden.Someone from Sweden, Sweden.Because they actually had GI issues developed bacterial overgrowth, SIBO. And then, in her desperation, she did a fecal transplant. In other words, she took somebody else's poop and put it in her body. So if this sounds weird, it's not that weird. It's something that's like gaining a ton of traction. And then she reached out to me because she ended up feeling way worse and developed several autoimmune issues. And that's what I want to get into the fact that FMT, Fecal Microbial Transplant is not a totally benign thing. And if, Are you open to maybe having me interview her?I think it'd be fantastic if you interviewed her. There's nothing like real world conversation with people who have real world elements with real world answers.That's so awesome. Because one little thing that I want to discuss is a recent article was sent to me in the Journal of Psychology Okay? Where openness to experience is linked to several things. So I would like everybody listening. The gut check project is about checking your ego at the door and being open to different things. So one of the things that I'm really proud of is that every time we do this show, people reach out to us we get a lot of email, we get a lot of people talking to us, and then I have to address it. Well, this particular show where I interview Helly, I want to make sure that if you have IBS, if you have SIBO, bacterial overgrowth, if you suffer from anything. Watch this because what I'm going to do is put a face to the disease. And she was so kind to reach out to me and say, film me, and I want everyone else in the world to know. So the Swedish person, who was very open about everything. She has exactly what I do in clinic, every single day. So what you're going to watch is what I do with her. It was a two hour interview. I cut it down to 15 minutes Right? So if you know anybody, please refer them. If you actually wants to sit there a little little bit more, we have our friend, Shivan Sarna.Shivan Sarna, with SIBO SOS Summit. SIBO SOS Summit, yeah, absolutely.SIBO SOS Summit. She's interviewed all the experts. I actually directed Helly over there, but more importantly, be open. So if you're like, if you're about ready to go ah, no, I'm not into it. What I'm going to tell you is, a recent study came out in Psychology Today, that talks about openness. All right. And the fact that you said open, makes me super excited.I hope I'm as excited when this is all over.I love how we show up. I hold papers and you're like, where are you going with this?Sometimes you give me papers I don't even know they're there. Alright, put simply.Okay.Openness is the drive to explore novel aspects of human experience. Okay? Now, here's what's fascinating. This article did this whole interview where they looked, and 95% of Americans feel that they are more open to new experiences than other Americans. Well, Wow, that's amazing.There's only that 5% that everyone's competing with.I know. So it's funny, because as we sit there and look at this, we realize that 95% of these Americans responded that they're more open than everybody else. But, as it turns out, when they actually went through the rest of the questionnaires, they're not. Okay. As we age, we become very entrenched in our own habits.Familiarity, I'm sure is probably already 100%. It's gotta be.I love the fact that I threw a curveball at you here on the show. And I'm like, you look I'm gonna we're gonna do a zoom with a person in Sweden. So that's pretty much our gas this time.Sweet. So, anybody who is open to experiences, they have shown that the people that are more open to new experiences tend to be financially better, tend to have better relationships, and they tend to be happier. Okay. So as much as you sit there and say, oh, well, I have my routines, being open and jumping off bridges and that, I don't mean that literally. Sure, sure. Yeah, yeah. The figurative. Figuratively because you and I jump off a lot of bridges, figuratively. But doing that more, actually results in a more prosperous life.Doesn't that make sense though, because whenever something's new, it expands your mind. You have a new experience, and doing the same thing over and over again. Look what happens with people who have quote unquote, "stale relationships." They say we did the same thing. And if that happens, then you people always use the term spice things up. Where does spice come from? Spice comes from, from change, right? So embrace the change and take, take what's coming at you.Embrace the change. So what we're going to talk about today is a couple simple techniques. So this study, and then we're going to get into the interview. Okay? And then I'm going to, I mean, I wish I had some way to geek out like some signs. It's like, Okay, I'm going to geek out now because the article I'm going to get into..Yeah, geek out, like now we're gonna geek out. So I mean, I find myself I had a patient in that was a PhD, and I was sitting there, tell her about some stuff, and we started talking and next thing I know, it's like 30 minutes and we're way beyond the actual issues that she came in to see but I'm like, I'm like eating her brain about what she knows and, and she's like, Oh my gosh, hey, if you do this, and this and this and this and this. Like the inner connection of what we can do when we start pulling our mind power together, is really amazing. Yes, it's kind of what this is about. This is being open to new and novel things..Maybe Paul can put a little sciences geek out.Alright So I'm going to tell you how to be open. Okay So rather than argue whether it's good or bad.. so the number one nudge the edge of your comfort zone, ..Okay So it has been shown in human studies that the more that you push things, as we grow older, we tend to confine ourselves more and more and more and more. YeahAs kids, they will push themselves. And you know, they'll just try anything. There's no established boundary. There's no established boundary. As adults, we tend to say this is my boundary, so I should not do that. I am not going to dance, because that's not who I am. I am not going to be silly. I that's I guess that's why I love comedians. They just get up there and just throw down.Sure yeah, I love my grandpa or my granddad, used to have funny little sayings. And one of the things he always said is "you otta throw it against the wall, see if it sticks." I love it.You know, you turn, turn the key and see if it starts anything like that you he's basically just using metaphors for trying things out.We have one shot at life and we tend to limit ourselves because of the fear of the unknown.I would agree with that.Quit doing that. Nudge your boundary, push your confidence to levels. And guess what? It's okay to fail.It is okay to fail.That's the thing. Number two, the number two way to actually become more accepting in that to openness is prototype over perfection.Prototype over perfection. Kind of interpretation of that would be it doesn't have to be perfect to be used. Doesn't have to be perfect to be tested. Right?That's funny how you interpreted it that way. Because the way that I read it was Eric Rhaegar. And Ken Brown, we are prototypes over perfection.Quick, get some microphones and a camera. And let's see what happens.Now, so Thomas Edison made 1000 unsuccessful attempts at making a light bulb. Yeah. And he actually was asked, how did it feel to fail 1000 times. Edison's response was, I didn't fail 1000 times the light bulb was an invention with 1000 steps. Absolutely.So whatever it is that you're doing, whatever it is that you're trying to do, you're not failing. No. It just becomes a step in the process. Be open to more things. Hundred percent.Yeah, I couldn't agree with that more.And when you realize that people like Edison failed 1000 times. Step up. Yeah, no more excuses. And then this is my favorite, right? The number three way to be more open. Follow your curiosities, not your passions. So you have two boys Gage and Mac.Correct? And you know we always sit there and tell people follow your passion, follow your passion. But the reality is, a passion is a very weird and personal thing. Yeah. And curiosities. Are, can be stimulated in many different ways.. I agree with that. Curiosities can be built from different angles. They can be built from experiences they can be built from whatever follow the curiosity the curiosity will lead to a passion. I'm gonna brag on my oldest here right quick, because he does play competitive basketball and they both do Gage and Mac both play competitive basketball and Mac hasn't had this opportunity. So this story is really just about Gage but he has or had some opportunities after he graduates high school this year to go and possibly explore playing basketball in a smaller school setting, etc. But as much as he enjoys playing basketball, he, he doesn't think that's what he wants to define him. He wants to keep his passion as his hobby, and be inspired by being a traditional college student being able to discover because he's afraid that for him, not for everyone, but being a collegiate athlete would basically wall him off from his ability for exploration. I mean, that's almost verbatim how he described it. He wants to be able to be a young man to still explore beyond the boundaries of a basketball and I think that's completely awesome would have been a lot cheaper, on everybody play basketball but that's that's not we all live once and that's not what was going to make him happy.Is that fascinating? Because I know that I mean, we've talked a lot about Gage, Gage explores his curiosity..Sure.He plays music he artist does artists, he does video editing, he does different things. My kids do the same thing where I just didn't cure. I want to encourage the whole curiosity aspect of it. And I didn't even realize that that is what makes you open. Sure. When you're curious, you're open when you're open, you accept other ideas. When you accept other ideas, you accept other people, you can see that there's a whole path here. You eventually by being open, you have empathy. Oh yeah. You end up saying, I get where you're coming from. I could see what this is. You don't wall yourself off.Yeah, absolutely. Now I'll brag on my younger one Mac Mac is often times with his large massive collection of friends, which spans about eight years in each direction. He, he often times refers to them from their station in life if they've had like a struggle or big win I've heard him say, they must be feeling this because this looks like that this would have felt good or bad and then kind of gives their you know, their environment perspective. So yes, I agree with that that the curiosity would would breed empathy like that. That's really cool. So this particular doctor when they wrote this article, they said while passion is fickle, and high voltage curiosity, on the other hand is deep and abiding. When you approach something with a curious mindset, you're seeking growth and newness, for the sake of novelty. So stay curious, my friends.Yeah. And it sounds like somebody else who said that. Yeah. Somebody else I'm sure we can reference it becauseNot supposed to.So I just, I think it's interesting that and in this particular show, we're going to do something unique or we're going to put in a video of me interviewing a patient, but being open to new ideas being curious.Sure. That is the kind of stuff,so as a physician, when I'm curious, I went down some rabbit holes on this particular topic event. I bet.And I loved it. I love it. I'm a I'm a better doctor. This shows makes me a better doctor, this show is going on Shivan's webcast makes me a better doctor, I have to prepare for it. I have to do different things. I mean, we all have to sit there and realize, okay, I am going to be curious about this topic. I'm going to learn it, I'm going to do it. And then all of a sudden it opens up a new door and you're like, we haven't thought about that. No.That's what this shows about. So if you ever heard about Fecal Microbial Transplant, meaning poop transplant, that's what this is about, and there's a lot of hype around it. If you haven't heard it. I listened to multiple podcasts on this. Dave Asprey had an expert on I mean, like all people that I like to listen to.Sure Ben Greenfield.Ben Greenfield did this. Everybody did this? I'm going to sort of rock the whole ship here. Okay, today, I know. Let's be open everything. Let's be open. The fact that if you're open, you're going to be open to ideas. You're going to be open to different perspectives. But the reality is it's gut check project, check your ego at the door. What we're going to talk about is SIBO bacterial overgrowth, IBS, and if you want to watch somebody spilled their guts and really be genuine and be open. I have an interview here that we're going to play in the next few minutes. With Helly from Sweden, nice and she was open and cool. And you're not alone. If you have any digestive issues, you're not alone, and that's the bottom line. So she the story is this. She got sick then she was not right. Then in her desperation, meaning like she had the typical SIBO stuff. She got a fecal microbial transplant, she went to a doctor, he did a colonoscopy and placed poop from another person into her. And then she got sicker. Oh, that wasn't what they were after. That's not what they were after, right? And then she went back to the doctor. He's like, well, let's try again. And let's try again, and then she contacted me because she developed a multitude of autoimmune issues. Interesting. And she is essentially, she feels like she's dying. Hmm. So I would not normally respond to a message but she said, Hey, I need your help. I'm like, Look, here's what we're going to do. I don't know if I can help you. But if you're willing to share your story, we'll play it and we'll learn together. So what I want is everyone, every doctor, every patient to listen to this and say we're going to find something new to fix people. That's what that's what this is about. So let's go ahead and turn it over. This is my interview with Helly from Sweden, who reached out about having complications from a poop transplant, Fecal Microbial Transplant.All right, tune in.So tell me a bit about yourself.Okay, I'm 36 um, I've always been healthy until 2015. But after Flagyl everything my health went downhill. I started it gave me horrible panic attacks, I started getting depressed in movement. This is this sounds strange, but I could actually feel it in my stomach. It was like a nervous kind of feeling. You know, when you have butterflies in your stomach, but it wasn't like a good feeling. You're like you don't have an appetite. It was just like that. Yes, brain fog and the worst thing I had ever felt in my life was something called the realization. You know, when I had nausea all the time all the time. For two years I had not imagined you have a stomach flu that goes on every single day, every waking hour for two days, for two years, that's what I had. And I lost my new job that I had gotten a week before I got Flagyl so I couldn't stay so I it for three years this brain fog and, and my my, because my also my bowel movements. I mean, I had never always gone to the bathroom every day. I got maybe once every two days or something. But after Flagyl my my stool wasn't the same horrible horrible fatigue. I the brain fog I couldn't focus I couldn't I was always panic this this panic was the worst. I wouldn't I mean, if you have panic attacks.So essentially 2015 you get the antibiotics. You start with this down this path you are you eat specially carby foods, you get very bloated. And then you ended up having quite a few beginning with neurologic issues where you had the brain fog, panic attacks and depression some sleep disturbance out of frustration. You had, insomnia, you you went to several different doctors One of them was an advocate for FMT, known as Fecal Microbial Transplantation. And you got ultimately over over a course three different fecal transplants. First one being with a colonoscopy. Second one being with an enema and then an enema again. Okay, so both, and after each one, you had a reaction to it where you had what you felt like the flu and you had lymph nodes that got big. And then since then, you've had very significant skin and scalp issues with Alopecia meaning your hair's falling out. You've had biopsies which are permanent. And now the really unusual one is the hypermobility and the feeling like your joints are getting slightly bigger. And, that is something that seems to be progressing with you right now. Is that correct?Yes. Okay. Yeah, it's in jaws, back. It just pops and pops everywhere. Okay.That is quite the history there Helly. And I'm very sorry, you're going through all of that. Let's try and make a little bit of sense. I don't know if I can help you. But I do at least want to try and explain a few things just so that you're, you're very intelligent. A ton of reading, I'm going to share my screen real quick. So one thing that we do realize when we talk about, this is a moving target as you can see, and so you have a history which is very consistent for somebody to develop bacterial overgrowth. We know that SIBO can happen if you go through a stressful event. If you take care antibiotics are having an infection. And you kind of had all three happen at a similar time. We know that that can affect the motility and all comes down to motility. So you've already learned the basics of bacterial overgrowth, a SIBO and you understand that it's a can be population of bacteria growing where it shouldn't. So when you eat the bacteria break it down. These are just some recent studies that we've been looking at that kind of show how these different gases can affect things. So this is the effects and mention of how methane affects ileo-motor function. And if you listen to Dr. Pimentel talk, what he discovered in his lab, is that what the methane does, it doesn't just shut it down. It actually makes your intestines do an uncoordinated contraction. So it's like it just sort of spasms. And when it does that it doesn't move anything, thus allowing bacteria to continue to grow. Now we know that you drew out both hydrogen and methane. And we do know that when you have hydrogen, if it can actually bind and produce hydrogen....But more hydrogen. Yes.More hydrogen. So what what I see in my practice is that it is the multi biome. It's how these different organisms interact with each other, including fungal organisms producing possibly CO2 or the or the methane back background. Now hydrogen sulfide is a big deal, because what we do know is it's it can actually, the cysteine residue that normally reproduce on our diet gets absorbed and gets converted, but when you have bacterial overgrowth, it produces hydrogen sulfide, which leads to inflammation. Ultimately, inflammation is the root cause of all of this. And so what I think we're seeing in you, yes, that you have root causes the inflammatory process. You're exactly right, that when you had your your Genova stool test, that when you had the fat in there, you are mal-absorbing fat now are you mal-absorbing fat due to bacterial overgrowth, it could also be pancreas and we do see this overlap with that. But it is completely linked all these different things that a lot of times other doctors say well, you just have chronic pain, Fibromyalgia fatigue, migraines, but your initial presentation was all about the brain. The thing that I think you'll find it interesting is that once we know that we set this inflammatory cascade off, I want to show you this arrow right here. Yes, new data has shown that when a mass cell gets stimulated, it'll release histamine and serotonin proteases. But the histamine itself will actually stimulate the enteric nervous system, which will go straight to the CNS. So when you mentioned earlier, I do know that there is a gut brain connection vaguely? Well, it's mediated through the entire nervous system and it is very, very, very sensitive. So have intestinal inflammation, there is your gut brain connection. So if you look at this, the new evidence is now showing that this gut brain connection is in all different kinds of Dementia, Autism, Anxiety, ADHD, you know, the newest term it's really fascinating is leaky brain, because what they've done is that they've actually shown that you can soak colonic tissue in inflammatory mediators. And then they soaked blood, the blood brain barrier, and they show that both of them become permeable. So know that there is no doubt about it. It's not in your head, that whole depersonalization, that anxiety that depression can all be related to leaky brain. I do I am getting into quite a bit of research and cannabidiol or CBD. And there is there are some in vitro studies where they actually looked at how they can improve the blood brain barrier, which ultimately helps with all that so my fear is that these kind of things will continue. Like like you're already worried, continue to progress to lead to more autoimmune issues to lead to more things like that. So the whole FMT thing is really fascinating to me, because we got very excited about it. And then the FDA came in, and then and then they basically pulled the plug. And then we said, no, it's very effective in clostridium difficle infections. Yes, I know that. Yeah. And so that's what it's really only allowed for here, though, the whole concept of just saying we'll just take somebody's super donor a poop. Getting back to the how we prepare it, you may have a super donor right here, meaning you have a diverse microbiome. But once we process it, you may decrease the viability of that even if you do DNA analysis, you don't know if that bacteria is viable. So what I'm getting at is I think it would be very interesting to, in somebody like you, let's say that we advanced the science of this we can go oh okay, Helly, I think that unfortunately, we this particular donor did not have enough of butyrate producers bacteria. How do we get more of that in that? I am a big fan of spore based biotics. megaspore biotic.Megaspore?Yeah, so if you want..That's a probiotic, how can I take that?So I want you to go to our show, I actually we actually interviewed their their CEO, PhD, ..., and beautiful how he explains the science of probiotics. And it's incredible how he explains how the spore based biotics send signaling to other bacteria. So one of the things that they can do and the reason why we're teaming up is because we realized that the polyphenols and Atrantil can actually help feed the spore base bacteria. And what it does is it goes through and doesn't become out of its spore phase until it gets to the illeum at which point signaling goes it goes, Oh, we're gonna end up in the colon. Then it gets to the colon wakes up and starts tapping other bacteria and goes hey guys, we need to diversify a little bit. And they've actually shown that they can deliver vaccines this way and stuff. So the whole concept of spore based biotics is, is really fascinating and new barnwood spore based but so..But can I just ask you Atrantil I have there sir, I know that three ingredients. One is from peppermint, which is fine. I just don't know all that much from about this bark tree thingy.. is it?Well, you know that all really good questions all extremely complex. So, the bark you're talking about is Quebracho, Quebracho Colorado. That's the thing that makes us so unique is because we actually are the only product that has this. Quebracho Colorado is a proanthocyanidin or a tannin. So it's the tannins are proanthocyanidins combined into a large molecule. So the thing that we needed to help with SIBO is that we needed Atrantil to be a poorly absorbed molecule. So when we were talking about scientists, then we looked at all the animal data that had been done. And so what we do know is that in animal models, sheep and cattle that are fed this tend to have a much healthier microbiome, they tend to produce better milk, they tend to have increased weight gain and things like that. So from an animal perspective, we've been feeding cattle for a long time. from a human perspective, you're getting it in a lot of different sources that you didn't really realize, for instance, wine. Things like that, you're getting a lot of this. polyphenols, yeah, but polyphenols is a huge umbrella. Before every time somebody does some research on it, it appears that they are beneficial in ways that can that can become very complex. So this is that whole post biotic conversation that when you take a polythenol and or an undigested polysaccharide that gets to the colon, bacteria can break them down into different things. There are different molecules so that bacteria can break something down, and then produce a molecule called eurolithin. Eurolithin signals old and sick mitochondria to die. So that is my topic. So this is this is the kind of complex signaling that's going on.So when they die, those new mitochondria that does the body produce more or?..Yes, so it's like autophagy. Autophagy...YesIt's mytophagy. It's just the signaling to say, hey, you're an old and functioning powerhouse. And we need a new one over here. So okay, so then the big argument if you talk to in vitro scientists or bench researchers that look what they know is that these polyphenols like reservatrol, like berberine, like, all these molecules are similar like quercetin like tumeric all these. They'll say, Oh, well, one of the problems that Is that it actually creates a little bit of stress on cells. And so that's that antioxidant thing that you're talking about, which is too many antioxidants, then we don't know what it does. in vivo, I think what's happening is is that that is a version of hormesis. Actually, I think there's a term for it. It's called xeno- hormesis, meaning you're outside of hormesis is the adaption to a stress. So the reason why you work out and the reason why exercise is functional is because that's, that's a hormetic response. The reason why Oh, you're in Sweden, you guys are loving saunas, right? You guys are a big sauna society?It's more Finland. But yea.I'm a huge sauna fan, because that's a great example of turning on,  heat shock proteins. And so what that does is you stress your body a little bit to make it adapt more. So you get this bigger, this bigger response. I think that the whole emerging role in the US were we're really limited by the research that we do is usually funded by pharmaceutical companies. Yes. Here that's what that's really what I'm trying to do is try and bridge this gap and say, okay, how do we look at some of this consistent research that's been done in the lab done in animals, some small studies in humans and say, can we translate this to benefit somebody like you? So I want I what I will tell you all I will do is I'll try and dive more into the FMT thing ask around if they've had some different challenges like this. And in the meantime, I hope that this helps you discuss a little bit more with your doctor and.. I will.. You know Helly, I think we should probably wrap this up. But..Yes. So what's the next step? You will you will get in touch with me when you've found someone and then we can set up a meeting for, for them for the new thing for the new recording. The show or what..Yea, we need to heal you and bring you back on so that we can heal? .. Next step is for you to tell everybody to watch the gut check project so that maybe one FMT expert will see it and go, okay, I'm willing to talk and then we can pick their brain. Okay.Perfect. Thank you so much. So. So..Hang in there. I hope that this..I will. I hope the zoom at least helps you to relax a little bit. And we know that people are still trying. There's a lot of scientists out there working on a lot of these things. The joint thing, I'm a complete loss. I've always thought of the EDS as a genetic thing. But then again, we have this whole epi genetic field where yes, you carry a gene, and then something happens that turns it on that's another process. So.Yeah, yeah. So it will be interesting to see if I have that gene. I'm going to ask for investigation in that too, because if I don't have it, then it really really is proof that it it's something with SIBO or from the gut. Yeah, and I would know.Yeah.Fascinating. Yeah.. Yeah. Okay. Dr. Brown, thank you so much for your time. And..Helly thank you so much for allowing us to share this with our audience. A lot of people realize that you put a face to a problem. A lot of people feel alone when they're doing..Yeah, yeah. Yeah they do. Hopefully we can figure this out? Yeah. Okay. Dr. Brown, thank you so much I don't want to take much more of your time now. Thank you. You too.Keep in touch okay? I will. Thank you. Bye.Alright, so we're back after the video. Hey, I get to see you at the procedure setting whenever we do the colonoscopies. Is it like that every day in the clinic side because we don't have those kind of interactions with the patients whenever we have them come through so I mean we just heard about the Hashimoto Ehlers-Danlos and screwed up how to say.Ehlers-Danlos.Thank you, but so we hear that that's what she said. Alopecia. Losing hair. Yeah. I mean, this is a beautiful woman who's this has disrupted her life. That's why I wanted it, you know, and thank you to Helly for letting us do. Thank you Helly very much.Yeah, you're right, Pedram. Yes, it actually adds a face to the disease. This is what I do every day people come in and they're desperate. And I want to talk about something unique that nobody's putting this thing together. Let's do it. And hopefully, people like Shivan Sarna can spread the message about what I think I uncovered. When I was preparing for this, with with Helly and listening to her like, Oh my gosh, wait a minute, I think I know what's going on. Because the key to Helly is so it was a two hour interview and I cut it down to 15 minutes. So there's a lot that's left out. Okay. Much like Shojai Pedram, what's his name? Yeah. When when he interviewed me for his Netflix movie, and we did Like 30 minutes of filming, and I got like 30 seconds of airtime.Well, the goal is not through everything. Not all golden hills.Pedram Shojai. Yeah. Pedram Shojai. Yeah. So he's got he does this docu series.You said right the first time he did it with a with a last name comma first name. Oh. So yeah, that was a you end up on the editing floor and I remember like to love it said why don't you just be more interesting and you'll make it into the actual film..Love it holding back.Alright, so anyway, so it was a two hour interview that we that I clipped down so that the thing that people want to hear and if you're that person, and if you have SIBO or IBS or autoimmune issues, there's a high likelihood that some of what she talked about is relevant to you.Correct. Which the thing that kept resonating to me is the anxiety. So she can deal with most of it, but the anxiety and the depression and the panic, never had in her entire life and just something happened. So that's what I want to get into post fecal microbial transplant. She ended up having all these issues.Yeah and your right, having anxiety basically takes away the ability for the coping mechanism to deal with the other present problems. And it's just a it's compounding the issue.Yeah, it's like insult to injury. Yeah, yeah. So you can have gut issues, but now you're having brain issues.And I can't even reason through it without feeling kind of terrible. Well, I want to explain all that. And I started looking into this. And then I started doing some Google searches, on FMT, which is fecal microbial transplant. Sure. And one of my partners that I was gonna interview Dr. Ackerman, who's actually done a bunch of this. We started talking about the consequences of this, and hey, we don't really understand exactly what's going on. So if you Google it, it looks Looks like it's the panacea. People are offering this for autism, Parkinson's or Alzheimer's. They're saying I have the cure to this. But I'll let you know right now that the FDA is regulating this because there's been recently two deaths on fecal microbial transplant. And so the FDA is getting involved. So a lot of these different clinics and stuff are doing in outside of the US.Yeah, Mexico, Mexico, and Central America, Bahamas. Exactly.So patients always ask me about this. And if I had a way to say I'm about ready to geek out, I'm gonna geek out. So I want to go into a deeper discussion into the science and talk about improving the risk and improve the beneficial effects of fecal microbial transplant. I remember I've had so many friends call me up and they're like, hey, my mom has Dementia. Do you think a microbial transplant ? If you've never thought about it, it seems weird. But once you're desperate, it seems like the easiest thing that you can do. Sure. I'm gonna take my poop from this good, healthy person, but in somebody else, and people are discussing how it affects all these other diseases. This is an example of how somebody did it. And it unlocked diseases in her..Interesting..The epigenetic phenomena. epigenetics means that you have genes in you. And then when you have an environmental shift, you end up unlocking these genes and they become relevant. It's super complex. So in my own practice, I've actually had twins that had all sort of one had ulcerative colitis, and they gave a fecal microbial transplant from the healthy twin to the the one that had ulcerative colitis, and they did it multiple times. And so the colitis better.Good. Interesting.She also took on the traits of the twin. She ended up having acne, she ended up putting on some weight, she ended up doing some different things. Fascinating. Yeah, think about that. I can sit there and put this. So then I started looking into it. And then there's mouse studies where they have looked, and they have shown that if you take a mouse that has Parkinson's, and they can genetically modify mice to have that, and then you give a non-Parkinson's mouse or a non Parkinson's mouse and you transplant, they end up developing Parkinson's. And that happened with blood pressure, diabetes, stroke, obesity. traits get transferred in the bacteria, it's nuts. So we sit there and go, Oh my gosh, that's like a big deal. So The original studies that have actually been done have looked and humans have shown this, where when they do a microbial transplant, nobody's writing about this. Everybody's saying it's a fantastic thing. Sure. There's this biome.org thing where they're collecting poop and they're given to people. What I want to get into is why I'm not saying it's good or bad. What I'm what I want to discuss is the science of how bad things can happen...which is very unpopular. Like, everybody wants it to work. Everybody wants it. So do we.. we'd be awesome. But..So like in Helly's case, she developed, I really think that she developed Ehlers- Danlos syndrome from it. It's nuts.Yeah, that is nuts. And just just as a caveat, this is not to undermine the research the application of FMT whatsoever. It's just basically just what gut check projects for let's discuss everything that's applicable here.So in a recent review, so FMT, I'm just gonna refer to as FMT, fecal microbial transplant has emerged as it legitimate treatment for the FDA recognizes it for C. diff infection, Clostridium difficile infection, which.. which is real bad. What happens is if you take antibiotics, you can actually wipe out all your other bacteria in one lives, and then they just sort of colonize and create habit. So we do know that it works very well for that. But in a recent review, 2 to 6% of people that have actually done FMT had very serious adverse events. Infection was noted in 2.5%. One of the problems is that the current screening process is very similar to blood. So if I'm going to take your poop put it in me, I'm just going to say do you have had a, b, c, AIDS.. you're good? Because we're treating it like blood, but it's not blood. It's not blood. We don't know enough about it. Yeah, so the current process is that this is what we're actually doing. And then I started looking online, and I found out that there's all these DIY, I do it yourself. Hmm. websites that tell you how to do it. So they're not even screaming for that. They're just saying fine. Now that I do not know, there's DIY websites for how to do an FMT on your own.Dude, I got so deep into the weeds in this thing, the fecal microbial transplant thing everybody wants to say it'll fix I mean, it'll fix everything you name a disease, somebody saying that it fixes it. This is what I want to talk about right here. This is why we do this show. The problem is that right now, a super donor, which is what Helly had. So her doctor gave her a super donor, which is a somebody that has no infection that they could find, okay, and they had a broad microbial species is more important than anything else.. What we don't really take into account is how does that super donors bacteria that that person developed their entire life. And they interact in an epigenotic way, meaning that they actually interact with your body. Why would that be the same as you? I don't know. Because, you know, it being a.. because it essentially a micro environment that's inside, what if you don't live in the same region of the world that I do? What if you don't participate in the same activities that I do?If you don't eat the same foods that I eat? It's there's a lot left open to interpretation and understanding, it seems to me.Totally. And then as it turns out, one thing that we're not even discussing is the byproducts of bacteria.. So when I say byproducts, I don't mean that as waste. What I mean is that the bacteria, the bacteria that we have in our bodies, that our micro biome produces certain beneficial thing..Urolithin and all kinds of cool stuff like that..Post biotics.Post biotics. Well, I I love it because when I gave the lecture at natural grocers, I was talking about post biotics and one of the dietician said, Well, what about short chain fatty acids? And I thought on a local level butyrate, which helps colonocytes? And I said, Well, I, I don't consider that a post biotic. She's like, I think you should reconsider, because the reality is that those short chain and then guess what she was 100%. Right. She was spot on. Spot on. Yeah. So props to natural grocers to hiring super smart people and teaching me and as it turns out, the short chain fatty acids probably pay a huge role in this whole process. Sure. It's a byproduct of bacteria. And what happens is when you eat vegetables, or complex polysaccharides, or prebiotics, or polyphenols, they all kind of do the same thing. They basically go to the colon where your bacteria then break them down.. and they produce certain short chain fatty acids, these short chain fatty acids interact to the body in different ways. So it sounds really chemistry, but it's one is called butyrate, which as it turns out is fantastic for your body sure what it's called acetate. Oh, acetate, is that the thing that develops when you workout really hard and deplete your ATP? Yes, same thing. So, as it turns out, that crosses the blood brain barrier.... And creates inflammatory process... So these short chain fatty acids, what I'm getting at is I'm going to take somebody else's poop, put it in you, and we're hoping that it all works out. This particular article looked really deep into the different short chain fatty acids that are actually produced.. And in Helly's case, even though she got her transplant from a super donor. I think that one of her issues is that her body's own micro biome may have interacted and she produced more lactate producing bacteria interesting, which crossed into her brain which caused her panic attacks.So lactate of course, is something that we measure on somebody who has over activity if somebody has a rhabdomyolysis, and then there's all kinds of implications of too much lactate, and of course, that's related to lactic acid. You get that whenever you're fatigued, so she has bacteria, you can only imagine if they're over producing that, that that would, of course make her fatigued and more inflammed, right?Absolutely. Satish Rao, who's a gastroenterologist all over gusta George's, the SIBO expert. I think Shivan interviewed him actually Satish. Yeah, yeah. He published a study which showed that if you take a lactate producing bacteria, that those people that take a probiotic with SIBO, they end up with more anxiety and more depression. And it all fits.Interesting. So Helly if you if you want to Interview Heloise like the thing that bothered me the most was my anxiety and my panic. She even talked about a deep personalization experience, where every time she she's like, I don't get it. I've never been like that. I'm telling you that the bacteria produced lactate that cross the blood brain barrier that resulted in brain inflammation that resulted in your anxiety.The behavioral change.A behavioral change. Yeah, just from bacteria. That's, I mean, it's, it's wild, but it's, it's probably true. I mean, micro biome has evolved in the gut together, and it's very complex. They signal if you watch our show with Kieran, he talks about how the bacteria talk to each other. Definitely. So when we sit there and say, oh, we're going to wipe this one out, or I'm going to give more of this one that may adversely affect the chain downstream.Well, it's probably all the more reason why a DIY FMT is a is a poor idea. Your there's some much more research needs to be done.You know, the whole FMT thing is, is scary because well, it's just because we just don't know what to do know. We don't know enough yet. We don't know enough. Yeah, Peter Aditya said it past where he was like he goes, we have the ability to test tool. We don't know what to do with it. Yeah, he did. He's the first person just blunted it down.But he said it several times. And I agree with him. Yeah.So the one thing we know is that we do need a high diversity. Correct? So the more diverse your microbiome is, the better. So now here's sort of the cool part. In a healthy individual, the colon is predominantly, gonna get geeky, ready?Ready. The colon is predominantly dominated by obligate anaerobes. Obligate anaerobes, okay. Do you know what that is? Lack of oxygen. Lack of oxygen.Yeah. They need to exist in order to proliferate with a lack of oxygen. Correct? Correct. Okay.So they need to, they will proliferate in an article oxygen free environment.. names like bacteroides infirmities and these different phylum that we talked about. This allows for a higher production of butyrate, the short chain fatty acid.Which is beneficial to colonocytes.Which is beneficial to colonocytes. And as it turns out, it's beneficial to all intestinal tract stuff. Colonocytes just is a fancy way of saying colon cells. So just so you know.You're so nerdy. Yes, you're right. A lot of sites are colon cells. Alright, so our friend Dr. Pimentel, he's actually described how when he's been treating people with SIBO, bacterial overgrowth, small intestinal bacterial overgrowth that he has shown that there are blooms..Oh okay.Of facultative anaerobes and he uses the terms blooms.Facultative anaerobe. What he means is somehow the SIBO people end up with more facultative anaerobes in the colon. So, SIBO is small intestinal bacterial overgrowth, bacteria growing where it shouldn't. And then when we try and look at them, he's got the technology at Cedar Sinai, just show that they're colonic bacteria. They have an overabundance of facultative anaerobes. Meaning.. what? What does that mean?I don't know. Because when you use obligate anaerobes, it's almost like an interchangeable before I didn't really I'm not really used to the adverb, oblogate and facultative so kind of explore that. This is new to me.Yeah, it's awesome. So basically, it's a badass bacteria that can swing both ways. Oh, if you give it oxygen, it will.Different result?It will say I can deal with oxygen. I prefer anaerobe. Wow. So if you take the oxygen out, I will do better but in Oxygen environment, I'm going to proliferate more, but meaning you have this balloon. So Pimentel describes it as a bloom, meaning we're producing too many facultative anaerobe..Interesting Oh it's super wild.So just as an analogy, what we're saying here is there are some freshwater fish and there are saltwater fish, but you also have those fish that can basically change the way that they handle their respiration and their, their salt water content. And they can exist in both brackish they can exist in brackish water and go back and forth between fresh and salt. So this is kind of like what a facultative..You know what, thank you for making that analogy, because I wasn't thinking like that at all. But yeah, you're exactly right. The transitional bacteria. Yeah, it's a transitional bacteria that will adapt to the environment.Interesting.This is really interesting. So what he has said is that when you have these blooms of facultative anaerobes these bacteria will prefer an anaerobic environment, but they will switch to oxygen and grow quickly. This may be the root cause of dysbiosis. So this could be the reason why I see the SIBO people. Yeah. And they're bloating, it's better but they're still constipated, they're still..So the problem is just adapting.So what was it turns out is and we're going to get into it a little bit. We may be promoting the facultative anaerobes. Okay.And this is why it's a chronic condition. So if you're somebody that is suffering with SIBO I think that maybe your diet choices could be singularly selecting a facultative anaerobe, which does not produce butyrate.So when you're doing current, we need to take things that encourage butyrate production that we're getting to?That's exactly what I'm doing to. So I'm circling around everything where I'm like, we are not producing enough butyrate or body.So knowing and I don't want to jump ahead, but just to bring the audience along, knowing kind of that we want that and that that is typically a byproduct of the bacteria that we already have. I would assume the most natural way for us to execute this is to give those bacteria the tools to make butyrate correct? Is that where we're going? You're spot on. You're a smart Dude, you don't know about that?But I think that I want my, my colon bacteria to produce butyrate.So this is all a lead up to this one particular article, this to my knowledge. This is the first article to address how the actual process of FMT may affect what we're doing to people.... And when I think back to Helly, I'm like, I think this happened to you. Yeah. So currently, if you take someone's poop. What they do is for a fecal microbial transplant, you take someone's poop, you screen it for the typical pathogens. So you're going to look for AIDS, Hep C, whatever, the same stuff we always do for, for blood and they're gonna say, look, it's it's not there. And then they will label them as a super donor if they have a huge diversity.. so now your proof is actually worth something if you actually want to, I know that you donate a lot of plasma and sperm and everything else that you do to raise money. It's, it's all I could do to get here today. Yeah, I know, it's for gas money. But now, if you actually have, if you're a super poop donor, you can you can label that one on there. It just sounds like another 30 minutes of my day.So a super donor, somebody that has actually a broad diversity of, of bacteria. And so in Helly's case, what she did is that she received a colonoscopy when they were they did there and then she did two enemas afterwards. Okay, so they did a slurry. So I started getting into it. And I started looking at this. And this particular article made total sense to me. I'm like, why would Helly have such horrible issues when they've used this stool? So this particular Institute in Sweden uses this super donor all the time, they found what they thought was a super donor. These guys showed the problem is, is that the process is to take someone's poop. And you mix it with sterile water.. and then you blend it.Okay?You blend it...Meaning that the blending process draws oxygen into the compound. So now you're facilitating not the action that you wanted. And there's going to be oxygen dissolved in water. It's the first time ever that somebody has thought about this where they said by the blending process by the actual process of what we're doing for the fecal microbial transplant, we're automatically promoting facultative anaerobes, not obligate anaerobes. Wow, interesting. And it's in I would imagine by proxy, now you're decreasing the byutrate production of these exact..100%. Okay. And that's exactly what we don't want, right?Yeah. So they actually propose that if you're going to do this, so these, by having the facultative anaerobes means that we're going to have less butyrate. And we're going to have more of the lactate. .. the proprynate and these different short chain fatty acids, which by the way, they have shown that they took mice and as I mentioned earlier, where they when they transplanted, but one of the really cool things is that they show that the level of lactate not only affected the brain, but it affected insulin resistance and blood pressure.Has to if you think about the way the body responds to high exercise and fatigue, yeah, because that's what we do.So we're sitting here giving drugs to people were like, wait a minute... is the real way to health to feed the microbiome so that it produces more butyrate? So what they did is they took a mouse model, they went Holy cow, is there a way to produce more butyrate producing bacteria. So they did a fecal microbial transplant test where they did anaerobic slurries. OkayI don't know how they do that. But they basically kept oxygen out of the blender somehow.Okay. And then they stored it with prebiotics.Interesting, oh, and allowed them to.. And allowed the bacteria..To build some butyrate.To build some butyrate. Nice And then they transplanted the butyrate concentration in the mice that they did that with went through the roof. That's, that's what we want. That's exactly what we want. So then they looked at that and went, well, what What actually produces the most butyrate and I looked at prebiotics. Prebiotic is and an undigested fiber. And then I started looking at different studies. And as it turns out, people have done this research already..Polyphenols man.Polyphenols, so as it turns out, polyphenols, same ones, and Atrantil actually get the bacteria to produce more butyrate.Shout out to Joe, Joe Botel out in Exeter University in the UK who was doing the research on athletes and talking about butyrate just the same. That's that's exactly why she said that anthocyanidin polythenols were so, so powerful and helping athletes. So anyway, just to piggyback on that..Our little superweapon just sent me an article this morning that show that proanthocyanidins are extremely protective against Alzheimer's disease through the mitigation of rat reactive oxygen species. But I would counter that and say I I think this is all a big venn diagram. I think it's butyrate ROS or RNS, which is reactive nitrogen species and everything.That's so funny because that's what Joe was talking about was the ROS. side. And now we got your example with Helly, where we're trying to reduce lactate all the while producing butyrate. Correct? Correct. So you're exactly you're right. It's a Venn diagram on why the correct prebiotics to allow the right microbiome to break them down into the beneficial products that your body needs is important. And that's why having enough polyphenols would be essential.All right. So let's tie this back in what's the point of reading all these articles if you can't sit there and apply it? So one of the things I said at the early the first part of the show is that I love doing this because it forces me to be open.. I just told you why being open is important, right? It forces you to be open to accept new ideas and new Now let's apply this particular article that talked about FMT and how blending it creates oxygen, which leads to the wrong type of bacteria growing Correct. We do this in our SIBO people, we tell them to eat low fodmap. We tell them to do SCD we tell them to elemental. So we're trying to protect our small bowel. So we should increase fodmap. Well, in the reality, we're starving, the obligate anaerobes that wants to produce butyrate.Yeah, we're changing their environment.. We're changing their environment!They're response is to not make buytrate.This is the aha moment that I had. I went, Oh my gosh, I'm sitting here looking at this we bridged the gap. That's our job is to bridge the gap. Now I've got you know, the low fodmap diet. Yes, it'll make you feel better. But guess what, maybe that's why Pimentel goes now we have blooms. This is tying it all together. This is why now it's a chronic issue. So I'm sitting with my patients going Know what? So when we had Doug Wallen on the show, yeah, Episode 29. him and I talked afterwards and he said when he first started doing a plant based diet to get super bloated, when he powered through it, he's never felt better. I believe we're doing something wrong by telling people to restrict their diet. I think we should muscle through it. I think that we should tolerate the bloating. I think that we should take Atrantils, ifaxim, and neomycin whatever you're going to do carry out that exact thing in the small bowel. But you have to feed your bacteria so that you have the proper bacteria to produce butyrate and decrease the inflammatory response.That is really interesting. You know, I like analogies. So if you had if you had a dog in the backyard, okay. This is how just kind of picture.I know you love analogies, but sometimes your analogies I'm just like, what?Yeah, you got a dog in the backyard right? And you're supposed to be feeding him. I'm looking at you right now. I kind of feel like Rick and Morty.Yeah, as long as your Morty. Here we go hop on the spaceship. Let's go. Yeah. So, but I just think of it like a dog that's in the backyard and you're feeding it and you're feeding it and feeding and suddenly one day you don't feed it anymore and you have this nice wooden fence all the way around. That dog doesn't want to die. That dog is going to chew a hole in that fence and destroy your nice little fence and it's going to go and find food somewhere else now that that holes the breach that hole is the illness that hole is the overproduction of lactate that's kind of the..You're exactly right. It's it the dog is the bacteria wants to eat..It's going to survive, one way or the other.It's going to make its adjustment because it doesn't want to die. And so feeding it the correct meals. The prebiotics is probably a much better avenue than just avoiding everything that it was after.So expanding on your analogy, the way that I would view it is a little bit like this that you have I'm horrible analogies, I would say. Okay, so you have the same fence. You have the same yard.Yeah, you're really original.And you have two seals. And one dog. Okay. No water. Yeah. So there's so there's,  there's a pool. So that PETA doesn't come. So there's pools so the seals are hanging out, and every day you out there, and you throw fish at the seals and the dog, and the dog doesn't like fish.Right? So the dog will chew its way out. Correct. The seals are like, Let's have a party, they get on their cell phones and they call more seals.. And then you end up in a backyard full of seals. And now you have to keep feeding fish. So the analogy is similar, but basically you're, you're pre selecting. YeahBy doing low fodmap all these other things. You're not you're not having a diverse microbiome, the ideal backyard would be a harmonious zoo. Right? I'm in a menagerie. Yeah.Much like your own backyard. That's right. So many animals. Would you please explain what a menagerie is? And why..You could go back to some other episodes and like going back that far, like menagerie is a word for a collection of a bunch of different animals. That's all you need to know.Yes. So it's, it just got me thinking, I'm like, I'm gonna change how I do. I'm gonna change how I treat SIBO, what we need to do is we need to get rid of the bacteria. And then we need to feed the bacteria. How can we do that? Oh, Mind blown. That's why I think Atrantil has worked over time. So as it turns out, I found a bunch of articles, mouse articles, human articles, movies, other things where I would have people that would come to me and be like, you know, I've taken it for like three months and now I'm better I believe that we fixed SIBO and then we fed the bacteria every single day.That's I mean, in all honesty, pulling the curtain back, that's not the way that we've been studying the polyphenol effect from the beginning. This is very eye opening, it actually is still, I mean, I can still see how FMT is could probably still be incredibly beneficial, but it has to be delivered and prepared the right way.Oh, these authors went into a whole different deal where they were trying to figure out how can we improve FMT? And they thought about, like, putting it with antibiotics to decrease certain bacteria, and then what they realized is, you can't play God..That's a mess. That's a hot mess. That's like chemical warfare. An that's how come they said, why don't we just throw a bunch of prebiotics in there and see what happens.Let me ask you, so what

Josh Lobel is an extraordinary human being and one of the smartest guys I've ever met.  He co-founded and for over a decade was the Co-Managing Partner of Archer Capital, which focused on investing in companies undergoing some form of operational or strategic transition.   Subsequent to this discussion, Josh founded Centerline Capital Management in partnership with Platinum Equity to focus on operational change thesis minority investments in public equities.  But his impressive bio doesn't do him justice. Josh is a veracious reader, an avid pilot, and a dedicated husband and father of five including, 2 sets of twins. Josh is a champion For the men and women who have served in our military and intelligence agencies who lack the services and support that they desperately need when they return to life as civilians. He is on the Board of Directors of Cedar Sinai and involved with many other important non-profit organizations.  Ladies and gentleman, school is in session   You can find the Podcast's Instagram @thedealpod https://www.instagram.com/thedealpod/?hl=en   Youtube Link to This Episode   Check Out Josh

In this episode, we are joined by Jacob Comeaux, a first-year student in the Master of Science in Human Genetics and Genetic Counseling program. A graduate of UC Santa Cruz, Jacob enters KGI with a wide range of experience, including internships at Amgen and a shadowing experience with Cedar Sinai.

On this week’s episode of Conversations with Maria Menounos: The Podcast Edition, learn how to move beyond fear and doubt in order to unlock your full potential, how to worry usefully and get to the source of what’s holding you back in life and so much more from Amber Rae, author of ‘Choose Wonder Over Worry.’ Plus Dr. Jeremy Rudnick, director of the Brain Tumor Program at Cedar Sinai explains the warning signs and symptoms of brain tumors, treatment options such as surgery, chemotherapy, radiation & Optune and alternative therapies such as a Ketogenic diet. --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app

Single payer health care and war on California, Keith goes to Cedar Sinai, money owed in arrears, Bicycle Thief in Europe, Thelonious Monster plays a Helena Montana rodeo and Wisconsin, political vibe in California, props for Gary Tovar for helping T Monster, 

(New intro) It's my birthday week so we're revisiting our Eliza's birth! In this episode originally airing 7/17, we share the highlights of our second daughter’s totally outrageous birth, including audio from the day. Special thanks to our birthing dream team: our mama bear doula Carmen, OBGYN Dr. Susan Morrison, and all the fabulous nurses at Cedar Sinai hospital. To all you Atomic Mamas, thank you all for keeping us company on this 40 week pregnancy journey.Subscribe on iTunes.com/AtomicMomsFind us on social media: Instagram: @atomicmoms, Twitter: @atomicmoms, and Facebook: “atomic moms podcast”

Uncle Harry and Bert host the Podtalk Season 1 Finale from a hospital room at Cedar Sinai where David lays in a coma. Werner Herzog brings a camera crew to document the moment. Michael Caine, Jason Statham, Jim Parsons, Billy Bob Thornton, Alan Alda, Albert Brooks, Daniel Radcliffe and more stop by to pay their respects to David.   Cast: Jason Kaye as Harry Lipschitz, Michael Caine, Jason Statham, Jim Parsons, Billy Bob Thornton, Alan Alda, Albert Brooks, Daniel Radcliffe, Quentin Tarantino, Sean Connery, Werner Herzog, Jeremy Irons, Melquides and Gary. Matthew Sweeny as Bert. 

Meet the brand new love of our lives: Eliza Sztykiel (8 lbs, 8 oz, 21 inches long)! In this 'mom'umental episode, Ellie Knaus (hi!) and Adam Sztykiel share the highlights of our second daughter’s beautiful, hilarious, and wild unmedicated hospital birth, including audio footage Adam secretly and lovingly taped (best push present for a podcasting mom ever!) Special thanks to our birthing dream team: our mama bear doula Carmen, sunny OBGYN Dr. Susan Morrison, and all the fabulous nurses at Cedar Sinai hospital. To all you Atomic Mamas, thank you all for keeping us company on this 40 week pregnancy journey.Subscribe on iTunes.com/AtomicMomsFind us on social media: Instagram: @atomicmoms, Twitter: @atomicmoms, and Facebook: “atomic moms podcast”Please share the podcast with mom friends!

Dr. Carolyn Lam:               Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center, and Duke National University of Singapore.                                                 In our feature discussion today, we will be talking about insights from the PROMISE Trial regarding the prognostic value of non-invasive cardiovascular testing in patients with stable chest pain. First, here's your summary of this week's journal.                                                 The first paper reports novel findings on gene smoking interactions in coronary heart disease. Co-corresponding authors Dr. Salahin from the University of Pennsylvania and Dr. Riley from Columbia University and colleagues used data on almost 61,000 coronary heart disease cases and more than 80,000 controls to investigate effect modification by smoking behavior at established coronary heart disease and smoking-related genetic loci.                                                 They found that the cardio-protective effects associated with allelic variation at the A-D-A-M-T-S seven, or ADAMTS7 locus, were attenuated by 60% in patients who smoked tobacco, compared to those who did not smoke. Allelic variation in ADAMTS7 associated with reduced coronary heart disease risk, was associated with reduced ADAMTS7 expression in human aortic endothelial cells and lymphoblastoid cell lines.                                                 Furthermore, exposure of human coronary artery smooth muscle cells to cigarette smoke extract led to induction of ADAMTS7. These human genomic data therefore provide new insights into potential mechanisms of coronary heart disease in cigarette smokers and suggests that inhibition of ADAMTS7 may be a novel potential therapeutic strategy for coronary heart disease that may have particular benefits in individuals who smoke cigarettes. This is discussed in an editorial entitled Holy Smokes, an Interaction, by Dr. Braxton Mitchell.                                                 The next paper provides first evidence that genetic over-expression of CD39 may offer ischemic cerebral protection. CD39 is an ectoenzyme with a PYRase activity, which cleaves ATP and ADP. CD39 is expressed on the surface of myeloid and vascular endothelial cells where it dissipates the high local concentrations of ATP and ADP, which would otherwise serve as potent pro-inflammatory and pro-thrombotic signals.                                                 In the current study from first author Dr. Bick, corresponding author Dr. Pinsky from University of Michigan Medical Center and colleagues, authors used a model of permanent middle cerebral artery occlusion to show that CD39 expression reduced edema, infarct volume, and inflammation with corresponding improvements in neurological outcomes, compared to control mice. Over-expression of CD39 in only the myeloid cells also reduced cerebral infarct volume. Thus, amplification of endogenous CD39 expression, or even administration of exogenous circulating CD39, may be of future interest as a therapeutic target to minimize ischemic injury caused by cerebral ischemia.                                                 The next paper provides pre-clinical data to show that MicroRNA93 may have a therapeutic role in peripheral artery disease. First author Dr. Ganta, corresponding author Dr. Annicks and colleagues from University of Virginia, used MicroRNA-106b-93-25 cluster knockout mice and showed that MicroRNA93 over-expression alone was sufficient to enhance angiogenesis, arteriogenesis, and perfusion in ischemic muscle via increased M2-like macrophages.                                                 MicroRNA93 targeted interferon regulatory factor 9 to inhibit immune response gene 1, and itaconic acid generation in macrophages to induce M2-like macrophage polarization. Furthermore, MicroRNA93 over-expression produced a paracrine effect on macrophages that induced angiogenesis and skeletal muscle recovery under hypoxic conditions in vitro.                                                 Thus, these data demonstrate that MicroRNA93 induces beneficial effects in multiple cells that can enhance perfusion in ischemic limb and thus identifies MicroRNA93 as a putative therapeutic target in clinical peripheral artery disease.                                                 The next study is a large scale genetic analysis that represents the most comprehensive causal assessment of adiposity with cardiometabolic diseases to date. Co-corresponding authors Dr. Cassis and Dale from University College London used 97 snips for BMI, and 49 snips for waist-hip ratio adjusted for BMI, to conduct mendelian randomization analysis in 14 prospective studies supplemented with coronary heart disease data from CADRIoGRAM+C4D, stroke data from METASTROKE, Type II Diabetes data from DIAGRAM and lipids data from GLGC Consortium.                                                 They found that both waist-hip ratio adjusted for BMI, and BMI had causal effects on coronary heart disease and Type II Diabetes, and were associated with higher left ventricular hypertrophy, glycemic traits, interleukin 6 and circulating lipids. However, only waist-hip ratio adjusted for BMI increased the risk of ischemic stroke. Thus, both the amount of adiposity and its distribution play important roles in influencing multiple cardiometabolic traits and the development of cardiometabolic disease.                                                 Furthermore, the findings indicate that body fat distribution has multiple roles in disease that are independent of general adiposity. This suggests that physicians should pay attention to measures of adiposity beyond BMI.                                                 The next study addresses the conundrum that clinical trials show benefit of lowering systolic blood pressure in people aged 80 years and above, but yet, non-randomized epidemiologic studies suggest lower systolic blood pressure is associated with higher mortality. In the current study by Dr. Ravindrarajah and colleagues of King's College London, a population based cohort study was conducted using electronic health records of 144,403 participants aged 80 years and older, registered with family practices in the United Kingdom, and followed for five years.                                                 Mortality rates increased with frailty level, and were highest at a systolic blood pressure of less than 110 millimeters mercury. Furthermore, systolic blood pressure trajectories showed an accelerated decline in the last two years of life, without evidence of intensification of anti-hypertensive therapy.                                                 Thus, a terminal decline of systolic blood pressure in the final two years of life suggests that non-randomized epidemiological associations of systolic blood pressure with higher mortality may be accounted for by reverse causation. That is, participants with lower blood pressure values were closer on average to the end of life. This is discussed in an accompanying editorial by Dr. Naveed Sattar.                                                 Well, that wraps it up for our summaries. Now for our feature discussion.                                                 The evaluation of stable patients presenting with suspected coronary artery disease is by far one of the most common diagnostic evaluation strategies that we need to undertake in cardiovascular medicine. There's a whole host of evidence supporting prognostication based on various non-invasive tests, such as anatomic imaging with coronary computed tomography angiography, but also with stress testing, or functional testing, such as stress nuclear or echocardiography, or exercise electrocardiography.                                                 However, our paper today really sheds light on the comparison of these two strategies. And I'm just delighted to have starts with me. First, the primary author of the paper, from the PROMISE Trial, Dr. Udo Hoffmann, from Massachusetts General Hospital, Harvard Medical School, and the editorialist of a beautiful accompanying editorial, Dr. Leslee Shaw from Emory University School of Medicine, Atlanta, Georgia.                                                 Welcome both. Dr.  Udo Hoffmann:        Hi, Carolyn. Hi, Leslee. Dr. Leslee Shaw:               Hi, Udo, how are you? Dr. Carolyn Lam:               So, Udo, could you start by just sharing what you did in this PROMISE Trial? Dr. Udo Hoffmann:          The Promise Trial is a large comparative effectiveness trial that was done between 2009 and 2012, with follow-up ending 2013, at [inaudible 00:10:13] sites across the U.S. and Canada. And what it did was compare two strategies for testing patients with suspicion of coronary disease, symptomatic patients. These patients were randomized to either receive a functional test first, or an atomic test first, and the idea was to see whether providing the functional information or the anatomic information leads to differences in outcomes of these patients.                                                 As you know, the primary paper showed that the health outcomes of these two strategies were similar and not different. Now in this paper here, we took the slightly different approach and we really wanted to see how the results of the tests as they were seen by the [inside 00:11:02] so it was all based on the sight interpretations of these tests. How the results of these tests actually were associated, or were associated with the health outcomes. And so we directly compared categories of CT results, and categories of functional testing results, and how they are related to outcomes. The good news I think is that sight interpretations in real life do actually have prognostic value for both the anatomic or the CT, and also the functional testing, and so findings as significant disease [inaudible 00:11:36] ischemia have in fact similar prognostic value. And we also saw that on the lower end of the findings, so mildly abnormal findings for example, that the ability to see nonobstructive CAD, perhaps if you're a difference maker and identify from additional patients or group of patients that is at risk for [inaudible 00:12:01]. Dr. Leslee Shaw:               I think that often times we struggle with negative trial results, if I can put PROMISE in that negative trial results. And here we have a paper that I think really applies clinically. I think it's going to have far-reaching clinical implications. I think if you look at the CTA findings, this is a real world practice. I think there's a simplicity to CTA interpretations that really is amplified in the nice ability to risk stratify. Whereas the functional interpretation, as you both know, is complex. It integrates a lot of factors, wall motion, perfusion imaging, ST segment changes, exertional symptoms, all of that, and I think we see a lot of sight variability in that image interpretation on the ischemia-side of the functional testing arm.                                                 But there's and important finding from this paper, which I think we have seen in bits and pieces prior to this report, and that is that on the CTA side, you had about a third of the patients having pure normal coronaries. So you see that very low risk in that population. But what you see on the functional testing arm is that the event rate in patients with normal studies and in patients with a mildly abnormal study, the event rates were identical, which is fascinating.                                                 And importantly, two thirds of the population on the functional testing arm were in those normal and mildly abnormal subgroups, something like that. And that has important implications for what is in that one third on a CTA side with normal findings versus three quarters? Well I think from this randomized trial, I think we can infer that you're going to have some non-obstructive disease in that population, but you're also going to have non-ischemic obstructive disease.                                                 We know from FFR and all of the angiographic literature that not every obstructive lesion is ischemic. And so on the stress testing side, we have a lot of obstructive disease that potentially is missed. And I think this study really clearly illustrates that limitation of stress testing and it reflects sight variability in imaging and the interpretation. It reflects the patient populations and the struggles with doing stress testing, but also just flat out reflects the ischemic cascade, and what we can expect from an obstructive lesion, or a non-obstructive lesion, that may not elicit ischemia.                                                 So to that extent, I think Udo's paper is just, just far-reaching and really clearly one of the most advanced papers that we have seen in such a long time. From really providing an important message for those imagers and for folks doing stress testing in this country. Dr. Carolyn Lam:               should we then always do anatomic testing first before selective stress testing? Dr. Udo Hoffmann:          The choice of testing is very much I think tied to the population of the patient you're talking about. I think when you follow the literature, 30 years ago when all the classic studies out of [experienced centers 00:18:53] such as Cedar Sinai, were published, the ischemia burden was much higher in the tested population. Back then you had probably a third or 40% of patients who in fact had some abnormality or ischemia on stress testing. One of the findings here in this study, and that is true for both tests, is that the prevalence of severe findings, severe abnormalities, whether ischemia or obstructive disease, is what I found testing is pretty similar, so it's both around 12%, but it is relatively infrequent. And I think that has changed.                                                 And you cannot expect, as Leslee pointed out nicely, it is not expected from a stress test to detect non-obstructive disease that has prognostic value, but doesn't necessarily explain these symptoms that the patient is presenting. So we should not forget that these patients do not come for primarily for prognostic assessment, they come because they're symptomatic. And the primary question is do we find an equivalent that could explain the symptoms of the patient? And only once we are convinced that there's no such equivalent that would for example lead us to further assess the patient for potential reverse [inaudible 00:20:19] therapy, then the second question that can be answered is for the prognostic implication of the test. And I think in this relatively low risk population, this prognostic aspect gains more importance irrelative to the diagnostic aspect. Dr. Carolyn Lam:               I think Leslee made it very clear in her editorial as well, not to forget in essence at the extremes of disease, that both tests, both strategies conveyed similar prognostic information, and it was more for the fine grain teasing apart that perhaps we need to consider very, very carefully what your paper is saying. But at the end of the day, it's about treating the patients for their cardiovascular risk management, isn't it? Recognizing that even if you don't have ischemia, if you've got the risk factors, like you nicely showed, that we should be treating them for the risk factors.                                                 Leslee, want to share some of your thoughts there? You covered that so nicely in your editorial. Dr. Leslee Shaw:               Well I think that's one thing we've seen from PROMISE, SCOT-HEART, and many, many other recent trials as of late, over the last three or four years, is that the stress test is an opportunity not only to assess ischemic burden, or that CTA's not only a test to assess the extent and severity of coronary disease as well as plaque, but it's an opportunity to identify clear, preventive strategies for the patients.                                                 And this is really something that I don't think at least historically within the stress testing community, that we have taken upon ourselves in order to say, "Okay, here we have a symptomatic patient. We not only are going to assess ischemia, but we're going to look at what else they need to do in order for us to guide prevention." I think this is a clear reminder that this is a great opportunity for us to have a bit of a paradigm shift on the diagnostic testing, to take that whole picture if you will of the patient, and really to focus in on prevention because that is a great opportunity, as Udo talked about just a few minutes ago, it's a great opportunity for us to set the patient on the correct course.                                                 The guidelines, as both of you know, focus in on having that diagnostic evaluation and to implement guideline directed medical therapy as a front line examination. This is a great opportunity for us to just use that diagnostic evaluation ad the initiation of appropriate care for the patient, and then to look at symptom burden, recurrent symptoms, the need for additional interventions. But that first step is guideline directed medical therapy for the patient. Dr. Udo Hoffmann:          Continuing on Leslee's excellent point, I think the paper I think is hopefully a starting point to think about randomized trial, because we assume some maybe come to the conclusion, okay, if you have non-obstructive disease, you should be treated with [inaudible 00:23:13] and aspirin. But we don't know that. I think this is really a call for randomized trial. PROMISE was the one, and it was a good trial. It looked at the association of strategy with an outcome. I think one trial that is needed is to look what specific therapeutic decisions based on imaging or based on test diagnostic test findings, would be justified and would potentially lead to improved outcomes. And that is true for both the stress testing and the CT side. So I think this paper shows the opportunities, but I don't think we have the randomized data to exactly define what are the management options for each of these details of the information that these test results deliver us. Dr. Carolyn Lam: