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2 episodes with Daniel Singer
2 episodes with Daniel Singer
2 episodes with Daniel Singer
Adam Long, Reed Martin, and Austin Tichenor – the cast of the film version of The Complete Works of William Shakespeare (abridged) – reminisce about the 2000 filming of the RSC's signature work, and discuss the extraordinary lengths the production went to ensure they were jet-lagged for the entire process. Revelations include the secret cameo from co-author and RSC founding member Daniel Singer; how different actors must play jokes differently; the Spinal Tap observation that relative size is the difference between funny and scary; how to make friends in British and Irish pubs; and how the RSC vibe might best be described as squabbling siblings bound together in a brotherhood of Shakespeare. (Length 21:33) (PICTURED: Reed Martin, Adam Long, and Austin Tichenor enjoying post-show beverages in Shuttleworth's Pub, Charing Cross Road, 1992. Photo by Kent Tichenor.) The post Filming ‘Complete Works' appeared first on Reduced Shakespeare Company.
Critically acclaimed as one of the finest choruses in the country, MCP is the “voice of the greater Pittsburgh region”. Unlike other professional arts organizations, MCP is comprised of mostly amateur singers with professional-caliber talent, whose day jobs vary from postal clerk to physician to casino card dealer. MCP singers give generously of their talent, passion, and commitment to share the magic of live music with the widest possible audience. Tressa discusses all of this and SO much more - including how MCP is partnering with local nonprofits - in a delightful and insightful chat with MCP's new Music Director, Daniel Singer. Also, our ICYMI good news headline: World First: 13-Year-Old Child Cured of "Incurable" Brain Cancer https://www.themendelssohn.org/ Coming Home | March 9 & 10, 2024 Saturday, March 9, 2024 | 7:00pm | Westminster Presbyterian Church, Upper St. Clair Sunday, March 10, 2024 | 3:00pm | East Liberty Presbyterian Church, East Liberty https://www.auberle.org/ https://cityofasylum.org/ https://www.elcorolatino.com/ https://www.yinzaregood.com/ Instagram: @yinzaregood Facebook: @YinzAreGood Have a story of GENEROSITY or KINDNESS to share with us? Email us at yinzaregood@gmail.com To request a KINDNESS CRATE drop off at your business or school, email us at yinzaregood@gmail.com
Nostradamus Consulting founder Julian Green speaks to Thomas Warner from Proactive London after a 2023 he describes as a "good year" for the business, highlighting a £1mln investment and an expansion of the client base, which includes prestigious names like Thomson Reuters and Intuit QuickBooks. Green also highlights that 2023 was the company's first profitable year, an achievement he attributes to their robust client base and efficient service delivery, which will be further enhanced with the new funding. He goes on to provide some more context, saying that the company's journey began in 2021 with the development of their first product, guided by Professor Andrew Tucker. A significant expansion of their tech team, including the appointment of Daniel Singer, former global head of Kantar Analytics, and data engineer Girish Janin, has bolstered their capabilities. This team is set to refine their data sourcing and curation, ensuring a dynamic and engaging product. Looking ahead to 2024, Green outlines three primary objectives: product improvement, commercialisation, and scaling into new industry verticals such as energy, financial services, EQ healthcare, and online gaming. He says Nostradamus' USP lies in leveraging artificial intelligence and data analytics to provide tangible ESG (Environmental, Social, and Governance) performance metrics, catering to evolving industry needs. Green concludes by identifying their ideal clients as strategy and competitive intelligence professionals, underscoring their ability to deliver superior and faster results through technology and human oversight. #JulianGreen #NostradamusConsulting #TechStartups #InvestmentSuccess #ProfitableBusiness #ClientExpansion #InsuranceIndustry #Fundraising #EISscheme #TechnologyInnovation #AIandDataAnalytics #ESGmetrics #FutureTrends #DataSourcing #Commercialization #IndustryGrowth #StrategyDevelopment #CompetitiveIntelligence #FinancialHealth #BusinessInterview #2023BusinessTrends #TechIndustryInsights #ProactiveInvestors #consulting #invest #investing #investment #investor #stockmarket #stocks #stock #stockmarketnews
Daniel shares his amazing story starting from his humble beginnings, to revealing how his love for the beverage industry and relentless determination propelled him to success. Despite his early struggles with dyslexia, he shares how he turns his struggles into his superpower, and builds his company Filthy Foods with drive, integrity, and the strength and love of his family
Daniel Singer (@filthydaniel) is the CEO of Filthy (website, Instagram), a company working to change the way people think about things like cocktail garnishes.Not only did I love this conversation, but Daniel's comments about entrepreneurship requiring a high pain tolerance and his resolve to banish negative thoughts because they are not worth the energy landed heavily on my heart.Mentions: Julia Momosé, Kumiko, Simon Ford, Luxardo cherries, John Lermayer, Joshua Wagner, Colin Asare-Appiah, Amanda Gunderson, olives (are related to fruits like peaches and plums), Dyslexia, LovemarkNot long before our conversation, Filthy released a campaign called “Love is in the Details.” The entire series is worthwhile, but below are several that came up.Thanks for reading to the end! Subscribe to keep up with my work. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit decodingcocktails.substack.com
Join us for a revealing interview with Daniel Singer, founder and CEO of Filthy Food, provider of cocktail garnishes to bars around the world. In this chat, we discuss Filthy Food's inception and how it's revolutionized the category of garnish. Daniel shares his passion for premium ingredients and his mission to make quality garnish accessible to all. ____________________________________ Join us every Monday as acclaimed bartender, Erick Castro, interviews some of the bar industry's top talents from around the world, including bartenders, distillers & authors. If you love cocktails & spirits then this award-winning podcast is just for you. SUPPORT US ON PATREON: Get early access to episodes, exclusive bonus episodes, special content and more: https://www.patreon.com/BartenderAtLarge WATCH OUR VIDEOS ON YOUTUBE: https://www.youtube.com/bartenderatlarge FOLLOW US ON INSTAGRAM: Erick Castro: www.instagram.com/HungryBartender Bartender at Large: www.instagram.com/BartenderAtLarge FOLLOW US ON TWITTER: Erick Castro: www.twitter.com/HungryBartender Bartender at Large: www.twitter.com/BartendAtLarge
Welcome to another episode of The Pink Elephant! Today, I am joined by Daniel Singer, aka Filthy Dan! Dan is the founder and CEO of Filthy Food, a high quality cocktail garnish and mixers company that is served in the best bars, restaurants, and and hotels around the world. Throughout our conversation, Dan shares his story of starting Filthy Foods with his brother Marc, building the business from the trunk of their cars, the vision he had for the company, how it has grown to success, the importance of family and friends supporting you while you chase your dream, the team culture at Filthy, and so much more. Be sure to subscribe so you don't miss out on episodes every Tuesday! Let's Connect! Instagram LinkedIn Ellis Adams Group Website Connect with Daniel Singer Filthy Website LinkedIn
Filthy Foods CEO/Founder Daniel Singer speaks with Fieldcraft Survival Director of Training about the rise of his company that has become the industry standard in beverage garnishes. Singer explains lessons in leadership, business, diversity, and his products. Singer has been a student on Fieldcraft courses and looks forward to future collaboration with the company. Sponsors and Affiliates: Athletic Greens: athleticgreens.com/FIELDCRAFT for FREE One Year Supply of Vitamin D, 5 Travel Packs with first purchase Vertx: Code fieldcraft for 20% off HOIST Hydration: Code fieldcraft10 for 10% off Ketone-IQ: 15% Off with code FIELDCRAFT Ten Thousand: 15% Off with code FIELDCRAFT KC Hilites: Code: fieldcraft for 10% off Anthem Snacks: Code FIELDCRAFT10 for 10% off USCCA Kifaru FOLLOW US: https://fieldcraftsurvival.locals.com/ https://www.youtube.com/channel/UCcj3FycZBXIPNj7QIBKTIDw http://www.instagram.com/fieldcraftsurvival
On Episode 8 of This is Small Business, Andrea talks about the unboxing experience with Daniel Singer, Founder & CEO of Filthy Foods, and design specialist Kaila Piepkow, Creative Director and Owner of Dox Design. They say don't judge a book by its cover… but let's face it, a lot of people do. When it comes to the moment a customer unboxes your product, it matters. But how much? And how do you ensure that your packaging fits your product and suits your customers? Join Andrea as she learns about the ways that you can level up when it comes to the ultimate unboxing experience.See omnystudio.com/listener for privacy information.
RIZAL HAMDALLAHOcean Spray Global Chief Innovation Officer Rizal has dedicated his career to creating impact through innovation. As the lead for our Innovation, Research and Development teams, he is charged with developing the next generation of health-focused products for our historic farmer-owned cooperative. “At my core I am a creator, and throughout my career I have been guided to understand and build empathy with consumers. Ultimately, that's how to develop and deliver innovative products that consumers didn't even know they needed," said Rizal. "I am excited to build upon the foundational legacy of Ocean Spray and create the next era of healthy, delicious products for consumers around the world.” Prior to joining Ocean Spray, Rizal was Managing Director at Tyson Foods where he helped the company launch a series of new product categories. He also served at consumer brands such as Unilever, Nestle, Abbott Laboratories and SC Johnson. Additionally, he is the Founder of GetBetty, Inc., a start-up offering on-demand beauty services. In 2019, Rizal was named one of the Boston Business Journal's “40 Under 40” honorees. He is also a US Patent Holder and in 2018 he received the “Most Active Corporation of the Year” Award from Plug and Play, a global innovation platform.Chef Wendy Gauthier About Chef Wendy – Your Chef in TucsonAfter graduating from the Culinary Institute of America, I moved to be a chef in Tucson and worked at Canyon Ranch Health Spa. I then went on to work as a Sous chef at the Flying V at Loews Ventana resort, as I continued to cook, I felt something was missing. I then saw an article about personal cheffing. I thought, “Wow, what a great idea!” Being a personal chef in Tucson would give me a chance to see people's reactions and know that I am really helping someone to have more time with their family, friends or just more free time.Daniel Singer from Filthy Foodshttps://filthyfood.com/Food & Beverage Magazine LIVE! Episode 116James Beard Award Winner Jennifer English and Food & Beverage Magazine Publisher Michael Politz____________________________________________________Food & Beverage Industry brought to life. Live juicy inside scoop from the tastemakers, newsmakers, bread bakers, drink shakers, spoon lickers, clam diggers, farmers, foodies and friends of the Food & Beverage Magazine World! F&B LIVE is a national, industry influencing webcast featuring the leaders in the restaurant, hospitality, branded food and beverage and CPG industries, many of whom are Michael's "friends in the business."Featuring an informal and informative conversation where friends in the business share the latest intel, ideas and best practices for surviving these dynamic challenges we are facing and the future of our brands and businesses.The show is live and broadcast across 5 platforms and features an audience rich with industry influencers. ____________________________________________________*CLICK TO SUBSCRIBE: YouTube: https://www.youtube.com/c/foodbeverag...*Follow Us on Facebook : https://www.facebook.com/FoodAndBever...*Follow Us on INSTAGRAM: https://www.instagram.com/fbmagazine/*Follow Us on TWITTER: https://twitter.com/fb101comwww.fbmagazine.com
This is a re-air of episode 26 with Daniel Singer, which was originally released May 18th, 2018. Daniel Singer, aka Filthy Daniel, is the founder of the cocktail garnish company, Filthy Food. Daniel grew up in England and was an actor with the Royal Shakespeare Company before moving to the States. In 2009, he founded Filthy with his brother Marc, and they set about sourcing the finest olives and cherries to use in their garnishes. Daniel believes that details matter. He is obsessed with providing the best quality ingredients and taking the time to ferment them naturally. Today, Filthy's pickles, cherries, and olives are served in some of the best bars and restaurants in the world, and Daniel is on a mission to make life a little filthier, one cocktail at a time.
Daniel is the Founder & CEO of FILTHY FOOD®. From acting with the Royal Shakespeare Company to being inspired by an idea in 2007. Daniel embarked on a two-year olive pilgrimage, exploring hundreds of varieties of cultivatable olives before creating FILTHY FOOD®, a line of garnishes made specifically for cocktails. Over the last decade Filthy® has become widely recognized as the industry standard used by the best bars, restaurants and hotels in the world. Daniel is an honorary board member of The Duke of Edinburgh's International Award US, a charity that champions young Americans, ages 14-24 and was recently awarded the Key to Miami-Dade County from Mayor Giménez for his contribution to the Miami business community. Daniel currently lives in Miami, FL with his wife Kim and three children. Follow him on Facebook and connect with him on LinkedIn. --- Support this podcast: https://anchor.fm/christie-lawler/support
Snapping photos in the outdoors: is it a distraction or an ultimate form of engagement? We look at the writings of landscape photographer Ansel Adams, cultural philosopher Jean Baudrillard, and interview with amateur photographer Daniel Singer.
I'm very excited about this guest Daniel Singer, we had a great conversation about work, life and personal growth! Listen to this great episode and learn from him! https://www.danielsingervoices.com/ Check out past episodes at: https://www.veronicabarrera.com/podcasts
Bankruptcy and Loss Mitigation with Daniel Singer
Bankruptcy and Loss Mitigation with Daniel Singer
Bankruptcy and Loss Mitigation with Daniel Singer
In this episode of Adapt or Perish, we discuss William Shakespeare’s Romeo and Juliet! For this episode, we watched and discussed: Romeo and Juliet (1936), directed by George Cukor, and starring Leslie Howard and Norma Shearer, with John Barrymore and Basil Rathbone. Watch on iTunes. Romeo and Juliet (1968), directed by Franco Zeffirelli, and starring Leonard Whiting and Olivia Hussey, with Michael York and Robert Stephens. Watch on iTunes and Amazon. BBC Television Shakespeare: Romeo & Juliet (1978), the first episode of BBC Television Shakespeare, which ran from 1978 to 1985, and attempted to film and televise the complete works of Shakespeare. This episode was directed by Alvin Rakoff, and starred Patrick Ryecart and Rebecca Saire, with Alan Rickman and John Gielgud. Romeo + Juliet (1996), directed by Baz Luhrmann, and starring Leonardo DiCaprio and Claire Danes, with John Leguizamo and Pete Postlethwaite. Watch on iTunes and Amazon. Romeo & Juliet (2013), directed by Carlo Carlei, adapted by Julian Fellowes, starring Douglas Booth and Hailee Steinfeld, with Stellan Skarsgård and Paul Giamatti. Watch on iTunes and Amazon. Footnotes: The Complete Works of William Shakespeare (Abridged), written by Adam Long, Daniel Singer, and Jess Winfield. Watch it on Amazon. Seriously, watch it. Reynard the Fox Our episodes on The Princess Bride and Sherlock Holmes ADR or automated dialogue replacement You can follow Adapt or Perish on Twitter, Instagram, and Facebook, and you can find us online at adaptorperishcast.com. If you want to send us a question or comment, you can email us at adaptorperishcast@gmail.com or tweet using #adaptcast.
The post E835: Panda.af founder Daniel Singer created a voice-controlled camera that brings to life the movie in your head, takes on Snapchat & Facebook, shares the secrets of Gen Z & being a serial entrepreneur at 18 appeared first on This Week In Startups.
The post E835: Panda.af founder Daniel Singer created a voice-controlled camera that brings to life the movie in your head, takes on Snapchat & Facebook, shares the secrets of Gen Z & being a serial entrepreneur at 18 appeared first on This Week In Startups.
Daniel Singer is the founder and CEO of Filthy Foods. Daniel opens up on all things “filthy” and his mission to build the best premium drink garnish brand in the world. He’s a husband, father, former Royal Shakespeare Company actor, and quintessential “Midlife Male” pushing the boundaries of balance, spirit and entrepreneurship. He’s also one of the best humans I know.
Scott interviews Daniel Singer and Joel Markovitz with special servicing company, the Law Offices of Daniel Singer. Love the show? Subscribe, rate, review, and share!Here's How »Join the Note Closers Show community today:WeCloseNotes.comThe Note Closers Show FacebookThe Note Closers Show TwitterScott Carson LinkedInThe Note Closers Show YouTubeThe Note Closers Show VimeoThe Note Closers Show InstagramWe Close Notes Pinterest
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. Dr. Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. In today's episode, we are discussing very important new data regarding stroke risk stratification in patients with atrial fibrillation. First though, let me give you the highlights of this week's journal. The first paper provides mechanistic evidence that endothelial-derived microparticles may play a key role in the development of endothelial dysfunction following acute coronary syndrome. In this paper from first author, Dr. Abbas, co-corresponding authors, Dr. Toti and Morel from the University of Strasbourg in France, authors expose core sign coronary artery endothelial cells to microparticles shed from senescent cells, or circulating microparticles from patients with acute coronary syndrome. They showed that exposure to these microparticles induced increase senescence-associated beta-galactosidase activity, oxidative stress, and early phosphorylation of MAP kinases and AKT, and upregulation of p53, p21 and p16. Depletion of endothelial-derived microparticles from acute coronary syndrome patients reduced the induction of senescence. On the other hand, pro-senescent microparticles promoted endothelial cell thrombogenicity. These microparticles exhibited angiotensin-converting enzyme activity and upregulated AT1 receptors and ACE in endothelial cells. Losartan and AT1 receptor antagonist and inhibitors of either MAT kinases or PI3-kinase prevented the microparticle-induced endothelial senescence. In summary, these findings indicate that endothelial-derived microparticles from acute coronary syndrome patients induce premature endothelial senescence and thrombogenicity suggesting that targeting endothil-derived microparticles and their bioactivity may be a promising therapeutic strategy to limit the development of endothelial dysfunction post-acute coronary syndrome. The next study is the first large and prospective study showing that NT-proBNP is associated with cardiovascular events in patients with adult congenital heart disease independent of multiple clinical and echocardiographic variables. This is a study from first author, Dr. Bekan; and corresponding author, Dr. Roos-Hesselink and colleagues from the Erasmus University Medical Center in Rotterdam, the Netherlands. The author studied 595 clinically stable patients with adult congenital heart disease who attended the outpatient clinic between 2011 and 2013. All patients underwent clinical assessment, electrocardiography, echocardiography and biomarker measurement, including NT-proBNP, high-sensitivity troponin T and growth differentiation factor 15. Patients were prospectively followed over a median of 42 months for the occurrence of cardiovascular events including death, heart failure, hospitalization, arrhythmia, thromboembolic events and reintervention. They found that of the three evaluated biomarkers, NT-proBNP was most strongly associated with cardiovascular events. Importantly, patients with a low-risk of death and heart failure could be accurately identified with a high negative predictive value. In patients with elevated NT-proBNP, elevations of high sensitivity troponin T and growth differentiation factor 15 identified those patients at highest risk of cardiovascular events. In summary, these biomarkers may play an important role in the monitoring and management of patients with adult congenital heart disease. The next study describes heart failure stages among older adults in the community. Dr. Shah and colleagues from the Brigham and Women's Hospital in Boston Massachusets classified more than 6,000 participants in the atherosclerosis risk and community study into heart failure stages. These were stage A; asymptomatic individuals with heart failure risk factors, but no cardiac structural or functional abnormalities. Stage B; asymptomatic individuals with structural abnormalities such as left ventricle hypertrophy, dilation, dysfunction, or valve disease. Stage C1; clinical heart failure without prior hospitalization. Stage C2; clinical heart failure with prior hospitalization. They found that only 5% of examined participants were free of heart failure risk factors or structural heart disease. 52% were categorized as stage A, 30% stage B, 7% stage C1, and 6% stage C2. Worst heart failure stage was associated with a greater risk of incident heart failure hospitalization or death at a median follow up of 608 days. Left ventricular ejection fraction was preserved in 77% of stage C1 and 65% of stage C2 respectively. In corporation of longitudinal strain measurements and diastolic dysfunction into the stage B definition, reclassified 14% of the sample from stage A to B. Abnormal LV structure, systolic function, whether based on ejection fraction of longitudinal strain, and diastolic dysfunction, were each independently and additively associated with the risk of incident heart failure hospitalization or death in stage A and B participants. The authors concluded that the majority of older adults in the community are at risk of heart failure, appreciably more compared to previous reports in younger community-based samples. The study also highlighted the burden of heart failure with preserved ejection fraction in the elderly and provided evidence that left ventricular diastolic function and longitudinal strain provide incremental prognostic value beyond conventional measures of LV structure and ejection fraction in identifying patient at risk of heart failure hospitalization or death. The next study sheds light on the association of the LPA gene, ethnicity and cardiovascular events. First author, Dr. Lee; corresponding author Dr. Tsimikas and colleagues from University of California San Diego studied 1,792 black, 1,030 white, and 597 Hispanic subjects all enrolled in the Dallas Heart Study. They measured LPA snips, apolipoprotein A isoforms, LP(a) and oxidized phospholipids on apolipoprotein B100. These individuals were also followed for a median of 9.5 years for major adverse cardiovascular events. The authors found that the prevalence of LPA snips and apolipoprotein A isoforms were very different across ethnic groups. LPA snips that were associated with elevated LP(a) in whites were associated with low LP(a) in Hispanics mainly due to differences in apoliproprotein A isoforms size. After multi-variable adjustment, LP(a) and oxidized phospholipids on apolipoprotein B were both predictors of major adverse cardiovascular events. Conversely, LPA snips and apolipoprotein A isoforms did not add predictive value to models and did not show clinical utility in this study. These data suggests that much of LP(s) mediated major adverse coronary events is driven by oxidized phospholipids. Importantly, elevated LP(a) and oxidized phospholipids on apolipoprotein B must be recognized as important predictors of major adverse cardiovascular events across racial groups. The final study addresses the question of the optimal antithrombotic regimen for longterm management of patients with symptomatic peripheral artery disease, or PAD, with a history of limb revascularization. To answer this question, Dr. Jones and colleagues from Duke Clinical Research Institute looked at the EUCLID trial, or examining use of ticagrelor in PAD trial, which randomized patients with PAD to treatment with ticagrelor 90 milligrams twice daily, or clopidogrel 75 milligrams daily. As a reminder, patients in EUCLID were enrolled based on a normal ankle-brachial index of less .8, or a prior lower extremity revascularization. The current paper really focus on the subset of 7,875 patients who were enrolled based on a prior lower extremity revascularization criterion. The authors found that after adjustment for baseline characteristics, patients enrolled based on prior revascularization for PAD had higher higher rates of myocardial infarction and acute limb ischemia with similar composite rates of cardiovascular death, myocardial infarction and stroke when compared with patients enrolled based on the ankle brachial index criterion. Overall, there were no significant differences between ticagrelor and clopidogrel for the reduction of cardiovascular or acute limb events. Those were your highlights. Now, for our featured discussion. On today's podcast, we are discussing the very, very important issue of stroke risk in patients with atrial fibrillation. Most of us use the international guidelines for anticoagulation in atrial fibrillation that mostly suggest that we use the CHADS VASc scoring system to determine the stroke risk in a particular patient and then determine whether or not this patient meets the threshold for anticoagulation. This assumes that the CHADS VASc score corresponds to a fixed stroke rate. Today, in our journal, we have very, very interesting results from a paper with corresponding author, Dr. Daniel Singer who really suggest that we may need to rethink that. Dr. Daniel Singer joins us today from Massachusets General Hospital. Welcome Daniel. Dr. Daniel Singer: Thank you for having me. Dr. Carolyn Lam: Great. Today, we also have Dr. Sana Al-Khatib who's the associate editor from Duke University who managed this paper. Welcome Sana. Dr. Sana Al-Khatib : Thank you Dr. Carolyn, I'm happy to be here. Dr. Carolyn Lam: Daniel, could we start by you letting us know what you sought to do in your study and what you found? Dr. Daniel Singer: We all know that anticoagulants are extraordinarily effective at preventing stroke in patients with atrial fibrillation, but they also raise the risk of bleeding, and sometimes that bleeding could be quite serious and even fatal. As a result, for that past 10, 15 years, we have used a risk-based approach to the decision about whether to start a patient on anticoagulation, and that risk is the stroke risk that a patient faces if they weren't taking anticoagulants. Then we figured that anticoagulants will reduce it by about two-thirds. There are formal decision analysis and then a more informal sense that a patient has to face an anticoagulated risk of stroke of about 2%, some people might say 1% to 2% before anticoagulation results in an expected net clinical benefit that the effect in reducing ischemic stroke will exceed the risk of increasing bleeding. While the CHADs VASc score has been widely accepted as the basis for estimating that risk, it became apparent to us as we looked across the studies that were underlying that assumption, that the risk that were associated with various CHADs VASc scores were extremely variable. Many of these risks actually were less than that 1% or 2% threshold for anticoagulation. What I mean is that the stroke risk associated with CHADs VASc score of one, or two, which is the basis for the guideline threshold for anticoagulation actually corresponded to risk less than 1% in many of these very large studies. We have conducted a systematic review just to be sure that we were capturing the overall evidence base for this, and that's what we report in our paper. Dr. Carolyn Lam: Perhaps you could start by letting us know exactly how far off are we in our stroke risk estimation. Dr. Daniel Singer: We looked at 34 studies that were quite large and then we zeroed in on the largest one. If you looked at the rate for stroke overall, they varied enormously in terms of the overall stroke rate. Then when we focused down on CHADs VASc score of 1, or 2, we found that the majority of these studies, actually, for CHADs VASc 1, was less than 1% per year. For CHADs VASc 2 score was in the majority these studies less than 2% per year. Both of those stroke risks have raised us the question where are these patients could gain in that clinical benefit from being anti-coagulated, because those stroke risk, if they were reduced by two-thirds, would really be a very small reduction in risk and yet they'd still face the bleeding risk. Among the most interesting findings actually is that we found that a Swedish national database and the large Danish national database came up with threefold difference in their estimate of stroke rates. The Swedish database produced lower risk, and the Danish database produced substantially higher risk. If you think about it, there are probably no two countries in the world that are more similar in terms of gene, social environmental, medical care systems, and that raises the specific question of, "Is it underlying rates that vary across different cohorts and different geographies, or is it a different in methodology?" We think a lot of the differences are due to methodologic difference, and that we need to standardize these differences together, better handle on what the real stroke rate is among patients with these low CHADs VASc scores. Dr. Carolyn Lam: The variability that you pointed on your paper is really striking, but another possibility, do you think, is that maybe stroke risk isn't static. Dr. Daniel Singer: Yeah. If that's the case, we face a great difficulty in developing predictions rules of what the stroke risk could be. I think most people feel it's the function of their age, and whether they've had a prior stroke, and whether they have the comorbidity, hypertension, and diabetes, and so on, that are incorporated into the various stroke risk scores, in particular, CHADs VASc. We tend to think that that's pretty fixed until you get older or until you accumulated another comorbidity. I think the striking difference is that, one, that we actually anticipated in the beginning, was that the stroke rates in people with atrial fibrillation were also coming down. The stroke rates in general have been dramatically decreasing for decades now. One issue is whether that applies as well to atrial fibrillation associated stroke. There is a suggestion of that, but the variability across the cohorts is so great that you can't pick up a strong signal in terms of calendar time. Although I suspect that there is a strong calendar effect. Exactly why that is, we could speculate. I suspect a lot of it is control of blood pressure, but that's speculation. Dr. Carolyn Lam: Daniel, congratulations again for that fascinating and really very sobering findings. Sana, you managed this paper. It's very important paper. In fact, important enough that you invited an editorial. Could you please share some of your thoughts? Dr. Sana Al-Khatib : Oh, yeah. Absolutely. First, I'd like to start by congratulating Daniel and his team on conducting this really important study. I enjoyed reading it and managing it. Definitely, congratulations. A couple of thoughts that I have. I completely agree with this really important finding, that there is a lot of variability in the rates of stroke that come from different patient populations and databases. As you pointed out Daniel, I think this is indeed largely due to differences in methodology in terms of how the information was selected, how certain things were defined. I agree with you there. You called for standardization of this, and I wonder if you have any thoughts about how we can go about doing that. I also want to bring up some of the newer studies now that are showing some significance in terms of biomarkers. Is that really adding significantly to the predictive ability of risk prediction models? I wanted to get your thoughts on that as well. Dr. Daniel Singer: Let me address your last question, which is simply you state that the CHADs VASc score, the CHAD score and so on, are based on very simple clinical features, and it would be unusual for them to be highly predictive. In fact, they're only mediocrely predictive, and the addition of biomarkers high-sensitivity troponin proBNP, now, people have suggested the imaging biomarkers like magnetic resonance to asses fibrosis in the left atrium. These are all very, very promising in terms of getting better models. The problem is to do that on a very scale such that we can get precise and well-calibrated predictions. We've found when we're analyzing to pair risk scores, we found that the most important issue is the underlying risk, so that, yes, you can get a great model, but if you have high variability in the underlying rate, you can have a problem specifying an individual with a stroke risk. We have to standardize and improve the quality of bringing people into these cohorts, and of interrogating the cohorts and databases and making sure that we have the same approach to assessing outcomes. This could probably be best done in very big scientific prospective registry studies, but it's tough to get all that information. There are some registry studies now ongoing, the ORBIT registries, the GARFIELD registries that may help us a lot with specifying stroke risk, but they don't have the biomarkers embedded in them. I'm hopeful that with better message, and large studies, and incorporating biomarkers, that we'll really get down to very accurate and generalizable stroke risk. I think the CHADs VASc and similar simple stroke risk scores will be in the rear-view mirror. Dr. Sana Al-Khatib : That's great. Can I ask one other question, because I completely agree with you looking at your numbers and the data that you presented, is that when you look, especially at the CHADs VASc score 1 patient, the risk seems to be pretty low. As you very well know, the guideline documents don't really ... At least, for the American AHA/ACC guideline document, they don't really verbalize very definitively the need to anticoagulate patients with a CHADs VASc score of 1. If you look at the numbers related to a CHADs VASc score of 2, I'm not sure that I completely agree that the risk is very low. Certainly, there was 33% of the studies reported stroke rates of greater than 2% per year. I think maybe different people have different thresholds. While I completely agree with you on the CHADs VASc score of 1 patients, I find that the findings on patients with a CHADs VASc score of 2 a bit more concerning. In fact, if anything, I would want based even on your data, not on the guidelines to offer anticoagulation to patients with CHADs VASc score of 2. What would you say to that? Dr. Daniel Singer: I'm looking at our table that has this, and a lot of the CHADs VASc 2 scores are under 2%, but they're in mid 1%. In the North American cohorts in particular, the rates tend to be lower. That said, I think the heart of the problem here is that we have focused on the threshold for anticoagulation. I think there's an argument to be made that you lay out the risks and benefits to the patients and engage them in a decision, particularly with regards to these lower CHADs VASc scores. At least you make a lot of, perhaps, even more emphasis on being sure that the higher CHADs VASc scores, that anticoagulation is the net benefits of anticoagulation are made very clear to the patient, and that we don't have large fractions of patients who can take anticoagulants not taking them. We know from the pinnacle registry and other registries, that even at high CHADs VASc scores, we have 40% plus of atrial fibrillation patients who are not getting anticoagulants. I think that's where we have a lot more assurance that the net benefit is positive and that we can make a different both in terms of a patient in front of us, and in terms of the overall public health aspects of atrial fibrillation and stroke. Dr. Sana Al-Khatib : I do believe that this is really important, but it is also important to keep in mind that with the novel novel oral anticoagulants, I think the whole landscape has changed. Not only do patients have different options to consider, but certainly, the risk of bleeding, which is the other part of this equation, has gone down significantly with the novel agents. I think as we engage in shared decision making with patients, I think it is really important to highlight these really very remarkable features about the agents that have really changed the care of patients with atrial fibrillation. One thing to add to this whole topic is, really, all the new advances that we're seeing in this field that has been really life-changing for us and for our patients. Dr. Carolyn Lam: Indeed Sana. I was about to bring up the bleeding risk part, the flip side of the coin as well. Also, the point that most of my patients with atrial fibrillation, they really strongly value the avoidance of stroke even more than avoidance of bleeding. Someone, that needs to be taken into consideration as well. Daniel, I'd love to give you the last words. You mentioned that you like to highlight, maybe, some more of the implications of your findings. Dr. Daniel Singer: I guess I would say there's a scientific implication, which is what we've ben discussing, which is the importance of trying to get these rates down correctly and accurately, and maybe we have to get people together to say how they're doing these studies. The second is, for the individual patient, that we should engage them in this discussion. Maybe patients who are perfectly willing to a novel anticoagulant and CHADs VASc score of zero. That would come out of a discussion with the patient. That our emphasis at this point since we're a little unsure about the threshold level, our emphasis both at the individual patient level, and then from the public heath perspective should be on the higher CHADs VASc scores where we know that we can expect a net clinical benefit from the vast majority of patients with AF. I agree with Dr. Al-Khatib, that the novel anticoagulants post an important advantage in the sense not so much in their overall bleeding, but particularly in terms of their intercranial bleeding, which is the lethal bleeding we most want to avoid. Dr. Carolyn Lam: Thank you both for joining us. Thank you listeners for joining us. Don't forget to tune in next week.
Continuing the series on health and wellness, today's focus will be a Mind-Body approach called The Alexander Technique. Mitchell's guest is senior teacher Daniel Singer. Daniel Singer is a certified senior educator of Alexander Teachers and is on the staff of the American Center for the Alexander Technique Teacher Certification Program. Graduating from the State University of New York at Buffalo. he himself later trained at the American Center for the Alexander Technique and was certified to teach the Alexander Technique in 1981 by AmSAT (American Society for the Alexander Technique) He also pursued post-graduate Alexander studies in London. He helped found the national professional organization AmSAT, the main certifying agency for Alexander Teachers in the USA. Additionally, Daniel serves on the faculties of Circle-in-the-Square Professional Theater School, the Michael Howard Acting Studio and the American Musical and Dramatic Academy. He maintains a private practice for all people from all walks of life. Daniel is lead author of the book The Sacred Portable Now (Prima Publishing, 1996) and co-produced a CD “The Back Alive Advantage” based on principles of Alexander Technique self-lesson work. Additionally, Mr. Singer is trained and certified in the therapeutic uses of imagination by the American Institute for Mental Imagery. In addition to teaching Alexander Technique and working with Imagery to help people. Daniel is an electro-magnetic healer, a gift he was apparently born with, which he uses to assist people toward wellness. He is also an artist whose mediums were glassblowing as well as paint, is a poet and currently has a passion for dancing Argentine Tango. --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/abwmitchellrabin/support
Hilary Putnam (1926-2016)is considered to be one of the most influential minds of the 20th Century – making significant contributions to the fields of philosophy, mathematics, and computer science, among others. Putnam received his undergraduate degree from Penn in 1948 and received an honorary Doctor of Humane Letters from the University in 1985. Putnam was the Cogan University Professor Emeritus at Harvard University. He served as faculty in the Department of Philosophy starting in 1965. In this special OMNIA podcast, we speak with professors Gary Hatfield, Scott Weinstein, and Daniel Singer of Philosophy about Putnam's legacy in their field and his unique connection with Penn as scholar and alumnus. Produced by the School of Arts & Sciences, University of Pennsylvania Recorded, edited, and narrated by Alex Schein Music by Blue Dot Sessions Visit OMNIA online at: http://omnia.sas.upenn.edu
Hilary Putnam (1926-2016)is considered to be one of the most influential minds of the 20th Century – making significant contributions to the fields of philosophy, mathematics, and computer science, among others. Putnam received his undergraduate degree from Penn in 1948 and received an honorary Doctor of Humane Letters from the University in 1985. Putnam was the Cogan University Professor Emeritus at Harvard University. He served as faculty in the Department of Philosophy starting in 1965. In this special OMNIA podcast, we speak with professors Gary Hatfield, Scott Weinstein, and Daniel Singer of Philosophy about Putnam’s legacy in their field and his unique connection with Penn as scholar and alumnus. Produced by the School of Arts & Sciences, University of Pennsylvania Recorded, edited, and narrated by Alex Schein Music by Blue Dot Sessions Visit OMNIA online at: http://omnia.sas.upenn.edu
Hilary Putnam (1926-2016)is considered to be one of the most influential minds of the 20th Century – making significant contributions to the fields of philosophy, mathematics, and computer science, among others. Putnam received his undergraduate degree from Penn in 1948 and received an honorary Doctor of Humane Letters from the University in 1985. Putnam was the Cogan University Professor Emeritus at Harvard University. He served as faculty in the Department of Philosophy starting in 1965. In this special OMNIA podcast, we speak with professors Gary Hatfield, Scott Weinstein, and Daniel Singer of Philosophy about Putnam’s legacy in their field and his unique connection with Penn as scholar and alumnus. Produced by the School of Arts & Sciences, University of Pennsylvania Recorded, edited, and narrated by Alex Schein Music by Blue Dot Sessions Visit OMNIA online at: http://omnia.sas.upenn.edu
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