Podcasts about health clinical center

Christine Grady is chief of the Department of Bioethics at the National Institutes of Health Clinical Center. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. S. Hendriks and C. Grady. Ethics and Highly Innovative Research on Brain Diseases. N Engl J Med 2024;390:2133-2136.

In today's episode of Nutritious, Arnav interviews Dr. Desai, an endocrinologist with over forty years of experience, to give some insights into chia seeds. Chia seeds have been growing rapidly due to their plethora of health benefits, but in this episode, we'll delve into some other factors like who might be benefiting most and how to incorporate it into our daily routine. He completed his fellowship with the National Institutes of Health Clinical Center in 1990. If you want some more information, check these articles out:WebMD: https://www.webmd.com/diet/health-benefits-chia-seedsHealhline: https://www.healthline.com/nutrition/11-proven-health-benefits-of-chia-seedsHarvard School of Public Health: https://www.hsph.harvard.edu/nutritionsource/food-features/chia-seeds/Food Science & Nutrition Peer-Reviewed Publication: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9834868/Stay tuned for Arnav's Florida Today article! Support the show

Bloodstream infections (BSIs) acquired in the ICU are potentially preventable. Kyle B. Enfield, MD, FSHEA, FCCM, is joined by Sameer S. Kadri-Rodriguez, MD, MS, to discuss the article, Epidemiology of ICU-Onset Bloodstream Infection: Prevalence, Pathogens, and Risk Factors Among 150,948 ICU Patients at 85 U.S. Hospitals, (Gouel-Cheron A, et al. Crit Care Med. 2022;50:1725-1736). Dr. Kadri-Rodriguez is a critical care and infectious diseases physician at the National Institutes of Health Clinical Center in Bethesda, Maryland. This podcast is sponsored by Sound Physicians.

The Novice Roadmap for the Infection Preventionist is an orientation guide and a pathway to earning your CIC. Listen to two of the Roadmap's creators as they discuss the Do's and Don'ts of how to engage with this valuable tool and how to get the most out of your journey through the infection prevention field. Hosted by: Marie Wilson, MS, RN, CIC and Jay Liggins, MS, CIC About our Guests: Lela Luper, BSN, RN, CIC, FAPIC, Infection Preventionist, Chickasaw Nation Department of Health Lela Luper is a certified infection preventionist and fellow of APIC who currently is Manager of Infection Prevention and Control at the Chickasaw Nation Department of Health in Ada, OK. For twenty years, Lela has been an infection preventionist in the rural hospital and ambulatory care setting. Joseph (Joey) M. Scaletta, MPH, BSN, RN, CIC, FAPIC, Infection Control Consultant, NIH Clinical Center Joseph (Joey) M. Scaletta currently works for the U. S. National Institutes of Health Clinical Center as an Infection Control Consultant. He has been certified in infection control since 2007 and has earned the Fellow of APIC designation. The hosts and guests of this 5 Second Rule episode would like to express their indebtedness to the committed group of volunteers and staff who updated and created the interactive web version of the Novice Roadmap for the Infection Preventionist currently located on apic.org. Further Resources: The Novice Roadmap: Developing Infection Preventionists Through an Internship Role [Abstract] Novice Roadmap for the Infection Preventionist 

I've been thinking a lot about fertility in the past few years. Now that I'm pregnant, it's even more on my mind. There was a lot I did in advance to help my body prepare for this experience. Diet is a large part of this. Yet, as my guest explains in this episode, there's a lot more involved than just what you eat.   About Anna Bohnengel, RD After earning her MS in Nutrition Science & Policy at Tufts University, Anna trained in clinical research and medical nutrition therapy at the National Institutes of Health Clinical Center. She kissed the east coast goodbye and moved to Portland, Oregon to accept a position at OHSU to develop and manage wellness programs for researchers, healthcare providers, and educators of the academic medical center. Anna's passion for prenatal health was born with the opportunity to develop a curriculum for the Pregnancy Exercise and Nutrition program.  In 2015 she started her first private practice, helping women to feel their best through good food. Since then, Anna has taken the dive even deeper into women's functional medicine, and what it takes to be a healthy mom growing a healthy family. The preconception period is a uniquely powerful time when women have the most influence over health and wellbeing for generations to come. So, this is where Anna focuses on helping women achieve optimal health now, as a prerequisite to a healthy pregnancy, a manageable postpartum, and having the energy to enjoy motherhood. Anna's life work is teaching women how to nourish themselves to truly feel good - so they can grow the family of their dreams with energy, confidence, and joy.   Getting What Your Body Needs Without Losing Your Head I know a lot of women who consider themselves to be healthy eaters. Yet, they struggle to get pregnant. Anna explains that this is due to several factors. One is that many women simply aren't eating enough. In order to create a whole new person, your body needs to know that it has enough nutrients for the job. However, Anna emphasizes that you shouldn't stress yourself out over being perfect about what and how much you eat. Struggling to get pregnant is stressful. Don't add another stressor by obsessing over getting the perfect diet. Anna describes finding a sweet spot between getting the right nutrients without psyching yourself out.   When to Start Preparing Your Body for Pregnancy There's also a large role that prenatal supplements can play. Anna says that, ideally, women would start preparing for pregnancy a full year in advance. Six months is pretty good too, but it should really be no less than ninety days. It takes your body some time to get your GI health to the place where it can absorb the right nutrients and get your nutrient needs stabilized. A full year gives you enough time to fix any deficiencies long before the egg is forming. It also gives you time to balance macronutrients and evaluate your partner's fertility.  What you shouldn't do is to accept a diagnosis of infertility as final. There is so much you can do to increase your chances and it's never too early to start. What early steps can you take to prepare for pregnancy? Leave a comment on the episode page!   In This Episode How Anna became a nutritionist specializing in fertility [5:00] Steps you can take well in advance to prepare for pregnancy [8:00] Why simply getting enough food is essential to fertility [14:50] Considerations for using supplementation to support fertility [21:00] How early you should be starting a prenatal diet [37:40] Why second pregnancies can be harder to conceive [41:35] First steps to take to improve fertility [44:00]   Quotes “If you can treat your body really well in the pre-conception period, that has multi-generational benefits.” [7:05] “I don't think that nutrition fixes all fertility issues. But the research is very clear that nutrition can have a huge impact.” [15:17] “Just because you're not pregnant one month doesn't mean that you're not ever going to get pregnant in subsequent months. ‘Infertility' makes it sound like it's a life-long diagnosis which it isn't. There's so much you can do to improve fertility.” [43:38]   Review Fed and Fearless on Apple Podcasts! Send a screenshot of your review to hello@lauraschoenfeldrd.com or send me a DM on Instagram and I'll send you my Overcoming Undereating eBook. If you post your favorite episode in your Insta stories and tag me @LauraShoenfeldRD, I'll also send you my 14-Day Calorie Challenge Recipe Guide!   Links Get your FREE Profit Planning Workbook! Find Anna Bohnengel, RD online Follow Anna on Facebook | Instagram | Twitter | YouTube 3-Step Prenatal Checklist Real Food For Pregnancy by Lily Nichols Perfect Health Diet by Paul Jaminet and Shou-Ching Jaminet Smartypants Vitamins Seeking Health Prenatal Vitamin Powder FullWell Prenatal Multivitamin The Fifth Vital Sign by Lisa Hendrickson-Jack The Fertility Diet Leave a review of Fed and Fearless! Sign Up For The Free Training: The 5 Secrets of Fearlessly Healthy Women of Faith Learn more about business coaching with me Got a question you'd love to hear me answer on the show? Leave me a voice message here! Join the Fed and Fearless Society on Facebook Follow me on Facebook | Instagram | Twitter | Pinterest Podcast production & marketing support by the team at Counterweight Creative   Related Episodes Episode 46: All About Fertility Awareness with Lisa Hendrickson-Jack

In this special episode the NYU School of Global Public Health and its Center for Bioethics partnered with The Greenwall Foundation to sponsor the 2021 William C. Stubing Memorial Lecture. We were proud to welcome Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, and Christine Grady, Chief of the Department of Bioethics at the National Institutes of Health Clinical Center, to discuss the public health and ethical challenges of COVID-19. Dr. Sanjay Gupta, CNN's Chief Medical Correspondent, joined us to moderate Dr. Fauci and Dr. Grady's conversation exploring the intersection of bioethics and public health decision-making during the pandemic. We hope you will enjoy this illuminating conversation with three national icons as they reflect on the challenges underscored by the COVID-19 pandemic and what these challenges can teach us about ethically moving forward in public health, medicine, and science. To learn more about the NYU School of Global Public Health, and how our innovative programs are training the next generation of public health leaders, visit http://www.publichealth.nyu.edu

In this episode I'm talking to Kevin C. Klatt, PhD, RD, a registered dietitian and postdoctoral fellow at the Baylor College of Medicine. We discuss nutrition science, research and the dark side of wellness that is oftentimes overlooked. Dr. Klatt explains how those of us without scientific backgrounds can navigate all of the information out there and discern what is legitimate and what is not, and we explore why so many turn to food as a “cause and a cure.” We also discuss the most egregious claims he has seen on the internet; how to become your own researcher; tips for eating to reduce risk of chronic disease; why we tend to make causal links between what we eat and how we feel, and so much more.   Dr. Klatt received his PhD in Molecular Nutrition from Cornell University and completed his dietetic internship at the National Institutes of Health Clinical Center. He is the Inaugural Dennis M. Bier Young Career Editor at the American Journal of Clinical Nutrition and is an active member of the executive committee of the Research Dietetics Practice Group of the Academy of Nutrition and Dietetics.    www.Sakara.com/BLONDEFILES for 20% off your first order. www.Dipseastories.com/BLONDE for your extended 30 day free trial. www.Getcanopy.co with code BLONDE10 at checkout for an additional 10% off your purchase. www.Helloned.com/BLONDE for 15% off your first one-time purchase or 20% off your first subscription plus free shipping.   Produced by Dear Media

Click here to keep up with the latest Goose News: http://wildgoosefestival.org/signup/ "Christ on the Psych Ward" is a story-sharing based on my experiences of mental illness, recovery, and faith. In telling my story, I weave together threads of personal experience, spiritual reflection, and ministry praxis. By ”going first” with my own story of mental illness and mental health, I open up the opportunity for other participants to share their own stories of mental health struggles in their personal lives, family lives, and/or communities of faith. In this episode, we work together to create a shared storytelling space of courage, lament, vulnerability, and hope. David Finnegan-Hosey currently serves as the College Chaplain and Director of Campus Ministries at Barton College in Wilson, NC, having previously worked with campus ministries at Georgetown University, American University and the University of Hawaii. He holds an M.Div from Wesley Theological Seminary and a unit of Clinical Pastoral Education from the National Institutes of Health Clinical Center. He is certified by Mental Health First Aid USA to provide initial help to people experiencing depression, anxiety, psychosis, and substance use disorders. In 2011, David was diagnosed with bipolar disorder after a series of psychiatric hospitalizations. He now speaks and writes about the intersections among mental illness, mental health, and faith. You can read more of his writing on his blog, Foolish Hosey. David lives in Wilson, NC with his wife Leigh and their dog Penny Lane. 

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Nicole Stout on the show to discuss cancer rehabilitation and survivorship care.  Dr. Nicole L. Stout is a renowned health care researcher, consultant, educator, and advocate.  She is research assistant professor in the School of Medicine, Department of Hematology/Oncology at West Virginia University Cancer Institute. Dr. Stout is an internationally recognized expert and leader in the field of cancer rehabilitation and survivorship care.   In this episode, we discuss: -Functional morbidity in cancer survivors and the role of rehabilitation -Evidence for rehabilitation and exercise interventions to support individuals with cancer -Physical therapy clinical, research and education needs to develop survivorship care models -Why every clinician should be familiar with survivorship care -And so much more!   Resources: Nicole Stout Twitter Nicole Stout LinkedIn Academy of Oncologic Physical Therapy  2nd International Conference on Physical Therapy in Oncology (ICPTO) American Congress of Rehabilitation Medicine American Cancer Society Nicole Stout Research Gate    Email: nicole.stout@hsc.wvu.edu   For more information on Nicole: Nicole L. Stout DPT, CLT-LANA, FAPTA Dr. Nicole L. Stout is a renowned health care researcher, consultant, educator, and advocate.  She is research assistant professor in the School of Medicine, Department of Hematology/Oncology at West Virginia University Cancer Institute.    Dr. Stout is an internationally recognized expert and leader in the field of cancer rehabilitation and survivorship care. She has given over 300 lectures nationally and internationally, authored and co-authored over 60 peer-review and invited publications, several book chapters, and is the co-author of the book 100 Questions and Answers about Lymphedema. Her research publications have been foundational in developing the Prospective Surveillance Model for cancer rehabilitation.   Dr. Stout is the recipient of numerous research and publication awards. She has received service awards from the National Institutes of Health Clinical Center, the Navy Surgeon General, and the Oncology Section of the American Physical Therapy Association. She is a Fellow of the American Physical Therapy Association and was recently awarded the 2020 John H. P. Maley Lecture for the American Physical Therapy Association.   She holds appointments on the American Congress of Rehabilitation Medicine’s Cancer Rehabilitation Research and Outcomes Taskforce, the WHO Technical Workgroup for the development of Cancer Rehabilitation guidelines, the American College of Sports Medicine President’s Taskforce on Exercise Oncology, and also chairs the Oncology Specialty Council of the American Board of Physical Therapy Specialties. She is a federal appointee and co-chair of the Veterans Administration Musculoskeletal Rehabilitation Research and Development Service Merit Review Board. Dr. Stout is a past member of the American Physical Therapy Association Board of Directors.   Dr. Stout received her Bachelor of Science degree from Slippery Rock University of Pennsylvania in 1994, a Master of Physical Therapy degree from Chatham University in 1998 and a clinical Doctorate in Physical Therapy from Massachusetts General Hospital Institute of Health Professions in 2013. She has a post graduate certificate in Health Policy from the George Washington University School of Public Health.   Read the full transcript below: Karen Litzy:                   00:01                Hey Dr. Nicole Stout, welcome to the podcast. I am so excited to have you on today. So today we're going to be talking about for all the listeners, cancer, survivorship and morbidity burden among growing populations, probably around the world, certainly in the United States. But Nicole, before we even get to all of those sort of big topics, can you define for the listeners what cancer survivorship is? Nicole Stout:                                         Yeah, thanks Karen. That's a great question to start off with. And it's a little bit of a Pandora's box right now. So we've historically defined cancer survivors as anyone from the point of their cancer diagnosis, really through the remaining lifespan that that individual has. So we consider a survivor from point of diagnosis and you know, it's sort of different or it's kind of different than what the word expresses. Nicole Stout:                 01:06                The word survivor, I think in some kind of patient means they're done with treatment, they've survived. And you know, we've seen a bit of pushback in the last few years around people who don't necessarily identify with the word survivor. So if we go back to 2006, there was a very important report that the Institute of medicine released called lost in transition from cancer patient to survivor. And this is where the term came from. Basically that IM report was critical because it said, Hey, medical community, you're doing a great job of treating cancer, that disease, but you're doing a terrible job of helping these people transition back to their life when they're done with treatment. They have a lot of functional morbidities, physical, cognitive, sexual, not managing those things. So this term survivorship was put forward. The idea of managing people to become survivors was put forward. Nicole Stout:                 02:05                And what's been very exciting is to see the evolution of emphasis and focus on better managing the human being that goes through the disease treatment in addition to managing the disease. But we've come so far with treatments and in some regard, some people who have advanced cancers for example, will be on cancer treatments for the rest of their life. And you know, I participate in a lot of social media groups and I hear these people say, I'm not a survivor and I'm never going to be one. Eventually I'm going to die from my cancer. I know that. And it's a matter of time. And so they don't identify with the word survivor or survivorship. So, you know, we're sort of moving away from that a bit and we're talking for now without individuals who are living with and beyond cancer. And I like to use that terminology. Even though survivorship is prevalent in the literature and prevalent in, you know, our conversations and in oncology circles is how we describe it. But I think we're trying to be more sensitive to the much, much broader population of individuals who are going through cancer treatments today. Karen Litzy:                   03:19                Yeah. And I liked that phrase, living with and beyond cancer, it seems a little more inclusive to me. Is that why you prefer that phrase? Nicole Stout:                 03:29                I do. I think that encompasses anyone who ever had a cancer type know who is in treatment, who is a, what we call an ed has completed treatment and has no evidence of disease. And it's also those individuals who may be in palliative care, who are progressing towards end of life, who are still being treated or managed in various ways. So I think it is more encompassing and reflective really of the broad, broad scope of this population. Karen Litzy:                   04:04                Yes. Because I think oftentimes, and myself included, people think you either have cancer or you don't. After you've gone through treatment, you don't have it in you're a survivor. So you forget about that population of people, like you said, who have cancers that they'll be in treatment for the rest of their lives. Nicole Stout:                 04:26                Yeah. And that that is actually a growing population with more sophisticated treatment technologies and changes that we've seen around the immunological therapies, the hormonal therapy treatments. Many of these targeted agents as we've come to so call them. And we are seeing individuals live much, much longer with disease, with stable disease, we're able to stabilize it. And so therefore what they would have died from in six months or a year, they're now surviving. I have years on continued temporization treatments. And so how would we describe those individuals? And yeah, let me make sure that the supportive care needs of those people are met and identified and met. It is a very broad population. So I think sometimes we say survivorship and it is not nearly as homogenous as, you know, that group of you either have cancer or you don't. You've been treated and you're finished. Now some people, for some folks that is the case. But for many, there's this very gray area that is the remainder of them. Karen Litzy:                   05:39                Yeah. And I think saying living with cancer treatment or living through cancer treatment and beyond is just a little more sensitive to the person. Like you said, the person behind the cancer. Because oftentimes when you read articles or even whether it's in a scientific journal or mainstream media and you think about cancer, they are always talking in percentages and numbers but not in the person. And so this kind of brings it down to the personal level. Now you mentioned it a couple of times, as we were talking here about different morbidities related to cancer or cancer treatment. So can you talk a little bit about what people undergoing treatments or maybe have completed their treatments might be experiencing? Nicole Stout:                 06:37                Yeah, that's a huge topic. We could spend hours just talking about that. But first of all, just in general, when we say morbidity, we're talking about the complications and the side effects that impact an individual's ability to function. So we're talking about functional morbidity. And the good news, the good news is this. The good news is we have a growing population of individuals who are living with and far beyond their cancer diagnosis. We talk about the population of cancer survivors growing. And you know, we look back to like the 1970s, all types of cancers. We were looking at about somewhere between a 40 and 50% survival rate to five years. So we have, and today we have dramatically driven that number much, much higher when we look across all cancers. That number today is around 70%. But when you drill into some of the more commonly diagnosed cancers like breast and prostate, those survival numbers to five years or even higher, upwards of 90% plus. Nicole Stout:                 07:47                So the good news is more people are being treated and getting to that side of your Mark of survival with no evidence of disease. And that tells us a story that they're more likely to live the rest of their lifespan, but they are living with significant functional morbidity. And so the side effects of cancer treatments are things that we absolutely anticipate. We know that when people go through different types of chemotherapies or mental therapies, radiation therapy, you named the therapy, they are going to be side effects that negatively impact their function. The issue is how severe is the impact? How disabling does it become and does it persist? So multisystem impacts from these interventions. Chemotherapy is a multi, it's a systemic approach to managing disease burden. And unfortunately chemo is not selective. It doesn't go into your body and say, Hey, here's a cancer cell and there's a cancer cell and it wipes out rapidly dividing cells. Nicole Stout:                 08:54                So is the systemic impact to the body. Your immune system is suppressed, you know, your blood counts drop, you become anemic, you become fatigued. Some chemotherapeutic agents cause cardiac complications and cardiotoxicities some chemotherapeutic agents we know are highly neurotoxic and cause peripheral neuropathies. None of these. And there's a spectrum, right, of the severity of that toxicity that people experience. And so some of those are mild, some of those are more severe. That it is the majority of patients going through treatment will experience at least one or more many experience, more than at least one about 60% experience, at least at one or more functional morbidity. And so when I talk about function, I want to say just sort of as a caveat, I always say I talk about Function with a capital F, meaning that it's not just the physical function. You know, I think in physical therapy we think about movement and mobility and gait and balance and you know, activities. But there's cognitive functioning as well. There's sexual functioning, there's being able to assume your psych. Karen Litzy:                   10:10                Yes. Nicole Stout:                 10:10                Social and psychological functioning and all of that, assuming your roles and your daily life. So we have to think very broadly, but when we talk about the morbidity burden, it's very real associated with cancer treatments in the short term. So while people are going through treatment, we expect to see it. But here's the trick. When treatments are done and withdrawal, people do recover to a very high degree. They regain their strength and mobility. But many of them suffer with persistent morbidity. And that disables many from going back to work or resuming their prior roles. And again, those can be across systems. And they can be encompassing of the physical, the cognitive, et cetera. Karen Litzy:                   10:55                And that gives me a lot to think about as a physical therapist. So if I might be seeing a patient too, let's say they have completed their chemotherapy, radiation, whatever their treatment was a year ago as the physical therapist, it sort of behooves me to ask these questions of them. So even though I may have a patient who's recovering from breast cancer that's coming to see me for knee pain, but these are things that if you are the treating healthcare provider, you have to have in your head and kind of ask these questions of them, of those different systems. Right? Nicole Stout:                 11:41                Absolutely. And that's actually a great and very critical point to make for physical therapists. And you know, even more broadly, occupational therapist, speech and language, all of our rehab cohort, you know, you said one year after treatment that the thing about cancer treatments, and I refer to them as the gift that keeps on giving because even though an individual finishes treatments, the treatments are oftentimes not done with them. Radiation therapy is a great example. We see individuals have side effects of radiation therapy in the acute timeframe, of course that we can see for example with chest wall radiation and breast cancer, we can see changes to the lung tissue, the bone and the cardiac function even years beyond the completion of treatment in five years, 10 years. So it behooves us to think about the history of cancer but not just did it have a history of cancer and concerned about recurrence of disease with what I'm seeing in my assessment. Nicole Stout:                 12:41                That's one little piece of it. But the bigger question is, is the impairment that I'm seeing in this patient in front of me somehow related to their cancer treatments? Quite possibly, I would say yes. And if it is, are there things that I need to know about cancer and its treatments so that I can optimally manage this patient? And I would say yes to that as well. It's funny because in, I've been a PT for over 20 years now. I've worked in cancer for the majority of that time. Almost 19 of those 20 plus years have been exclusively cancer. And I still today have physical therapists say to me, I don't really see cancer patients in my practice. And my response to them is they see you every day. They see you everyday. Someone who has had a history of breast cancer with radiation therapy to the chest wall on the left side 10 years ago. Nicole Stout:                 13:38                And you're seeing them as they are deconditioned, they may have dyspnea, they're now having some cardiac complications that can absolutely be related to radiation cardiotoxicity. You're seeing someone's three years out from prostate cancer treatment who is now having some balance deficits and issues, has had a fall at home for example, do a close assessment of their sensation, because they probably have residual peripheral neuropathy directly related to their neurotoxic chemotherapeutic agents. So we know that many of these side effects persist and can cause what we call these late effects, which are the downstream side effects that patients will experience. And a lot of it is musculoskeletal, neurological as well. You know, there are changes that can happen with regard to sensation, cognition, memory, those types of things also can persist for, can come on more substantially later after the completion of treatment. Nicole Stout:                 14:43                So there are functional needs someone's going through treatment, but those needs may be, they may be less, they actually may be more in some folks as they age. Because by the way, there's that pesky thing called aging. I'm done with cancer treatments five years, 10 years later. But you know, you've also aged whole cluster of what are the co-morbidities that we're facing that this individual is facing. You know, what type of lifestyle behaviors are they choosing. So really looking at that from that very encompassing perspective and in the short and the long term, not negating that history of cancer, even though it was, you know, five or seven years ago. Karen Litzy:                   15:26                Yeah. And you know, you kind of answered the question I was going to ask and that's as a physical therapist, why should we care? Well, I think you answered that one very well, but let's talk about the evidence for rehabilitation. And exercise interventions for these individuals with cancer. What does the evidence tell us? Nicole Stout:                 15:43                Yeah. And so when you asked why should we care, not just to alleviate their morbidity and to give a good quality of life and better function, but there are big, big issues that these folks face that caused downstream medical and healthcare utilization than escalate costs, pain medications, imaging, additional hospitalizations. So we should care from an individual perspective. I want my individual patient to be functioning. We should also care from a system and a societal perspective that we can help to alleviate that burden. So the exercise or the evidence, boy, where do I start? The good news is, as I said, multi-system impact for many of the cancer treatment interventions. And that's everything from surgery through hormonal treatments, including everything in between. But the goodness is there is evidence to demonstrate the benefits of rehabilitation intervention for nearly any patient with any disease type across the continuum of cancer care. Nicole Stout:                 16:50                From the point of diagnosis through end of life, there's evidence to support our interventions. And you know, I always say that about cancer oncologist everywhere. Cancer does not discriminate based on body region. It does not discriminate based on system impact. It doesn't discriminate based on race, based on gender. Everybody is at risk for having a cancer diagnosis. Now you know, there are some nuances there that level of risks. So we have to be thinking about that evidence very broadly. And so if we start at the beginning, at the point of diagnosis, there are some populations for whom a prehabilitation exercise intervention is highly recommended. We have seen over the last decade, the idea and concept of prehab is, you know, many times we make a diagnosis for a patient with cancer and it is not emergent to treat them. Now some types, it is some types of leukemias. Nicole Stout:                 17:49                We immediately begin treatment like the sun doesn't set, we treat them. But for a number of populations, there's testing, there's workups that are done. There's lab work, there's imaging and that can take several weeks. And so in populations like lung and colorectal, we had started to see these prehabilitation exercise programs put into place and there's a nice body of literature that has grown and has strengthened demonstrating the benefit of therapeutic exercise, aerobic conditioning, moderate intensity supervised over the course of about two to three weeks. What it does is it prepares them to enter, whether it's surgery or chemotherapy. First it prepares them to enter. They are cancer care continuum in a much better physical performance status. Really the exciting thing in lung cancer with the pre habilitation exercise that we've seen some evidence, the lung cancer population in general, many of them are not in good physical performance status when they're diagnosed. Nicole Stout:                 18:52                And some of them by virtue of that are not candidates for surgery. They're not candidates for the ideal regimen of chemotherapy because of their performance status. And we're starting to see evidence that that prehabilitation exercise intervention can actually convert someone for being a non surgical candidate to the surgical candidate. And that is, that's where we need to really be looking longer term and saying, does the rehab intervention improve survival in that population? The question is not, you know, something that we haven't answered yet but not far from being plausible. So that's evidence sort of from the point of diagnosis. We also have a large body of evidence around that post usually surgery is the first stop for some, for most folks and that perioperative time period. And it just makes sense. You know, the PT, the rehab consults, for especially our head and neck population, we talk about oropharyngeal, laryngeal parasite as we sort of put those into the head and neck population. Nicole Stout:                 19:56                Immediate referral for speech and language pathology should be done in that patient population. Immediate referral for PT or OT console for upper quadrant for cervical mobility, first those things should be standards that should become standards of care. The evidence is building in that regard. And then as patients move through treatment, the chemotherapy, radiation therapy, sometimes chemo, radiotherapy combined, is sometimes the next stop. And around that time period the exercise literature supports intervention during chemotherapy, the conditioning to help to mitigate fatigue, moderate intensity, low intensity exercise for individuals to alleviate distress, anxiety, depression. So exercise prescription is something that we're really starting to see more focused on. The American college of sports medicine just released new guidelines last week, providing some very specific evidence around exercise prescription. So we're getting to the point where we can actually prescribe exercise for targeted impairments that individuals are experiencing during cancer treatments. Nicole Stout:                 21:17                There's strong evidence around fatigue management exercise.  To moderate and low intensity for fatigue management. There's strong evidence around lymphedema using exercise to help for women who have, especially in the breast cancer population. There's strong evidence also around using weight bearing exercise to mitigate bone density loss that happens with many of the hormonal agents. So I know I'm sort of picking and choosing out of the air here, but in general, what do people experience when they go through cancer treatments? Debilitating fatigue is probably one of the most prevalent impairments across all cancer types. There's also so deconditioning that comes along with that and you know, that's a starting place for exercise interventions and you know, half the battle I feel with the rehabilitation intervention. And I feel like my role sometimes as the PT on the team, half of the battle is engaging the patient repeatedly in a conversation about enabling them because as they go through treatment, they feel terrible. Nicole Stout:                 22:30                You're sick. They're fragile, they're medically complex, right? Their blood counts drop, okay, let's maybe low. So there's risks and you know, it's sort of like the docs will say things like, well, you know, I guess you can exercise but don't overdo it. And that's almost worse than saying don't exercise. And so sometimes it's just, you know, our role in rehab is so critical during that time period of treatment to see them in a repeated fashion. And by that I don't mean, you know, two, two times a week for the duration of their cancer treatment. But you know, maybe it's a monthly basis, maybe it's every other month, maybe it's every three months as they're going through treatment for those check-ins. Re-assessing how their function has changed. Giving them guidance and support and enabling them. Karen Litzy:                   23:23                Yeah. And it reminds me of some of the work that I do with patients who have chronic pain is that it's not like you said, two times a week for six weeks. It's checking in, it's helping to build their self efficacy so that they can do yeah. And they can do more for themselves. Nicole Stout:                 23:47                And within their own bodies and giving them permission to do it. Cause like you just said, well you can work out but not too hard. Well like, yeah, that saying, well that's confusing and sometimes our patients need permission to feel more confident with their bodies. I had a patient say something to me once and I will never forget it and I use it in all of my talks and it's always sort of at the core in my mind. And she said to me, you know, the medical oncologists, they may have saved my life that you gave me my life back and if I'm going to survive cancer, what is it worth if I can't have my life back, at least to some degree to do things that I love to do. That just really hits at the heart of why rehabilitation is so critical for these individuals. Nicole Stout:                 24:39                Because yeah, that treatments that we have now, I mean, we're detecting cancers earlier. The treatments are so much more sophisticated. Many people will go on and live their full lifespan and die from something else and however, it's not good enough anymore for us to say. He said, I have cancer. You should be happy to be alive. You know, even if you're suffering with pain or lymphedema or conflict fatigue or neuropathies and, or cognitive dysfunctions and you're frustrated because you can't think straight and you don't have good short term memory. It's not good enough for us to say you should just live with those things and be happy to be alive. Not when we have the evidence like we do around rehabilitation interventions. And I mean, I could go on about the evidence. We could get into specific impairments, pelvic floor, for example, returning people to continent. Nicole Stout:                 25:32                Again, that's a place where prehab and then following them through the continuum of care. Makes sense. And you know, we in PT and in rehab has to get out of this episodic care mindset when we're working with patients who have cancer. So that's really where we went and we develop the prospective surveillance model. Way back in the early two thousands when I went to work at the Naval hospital in Charleston, Garvey and Cindy falls there, had developed this protocol for a research study and I went in and this prospective surveillance model said, Hey, we know people going through cancer treatment are gonna experience just awful side effects that are going to negatively impact their function. And if we know that ahead of time, why aren't we using rehab prospectively to help to identify the changes, manage them early when they're less intense and can be managed more conservatively. Nicole Stout:                 26:28                So we ran those studies over the course of the next 10 years and published extensively on this concept of prospective surveillance, which is start with rehab at the point of diagnosis, assess function at baseline, know what's normal, follow that patient then at punctuated intervals, throughout treatment, one month after they start treatment, they're going to have had surgery or they're going to have started treatment. They're going to start to decline. See them at that one month period, reassess baseline and identify clinically meaningful change. Everything might look great and then you say, good, I'll see you in three months. And then we follow them on an every three month basis after that for the first year, every six months, then up to two years and you're only out to buy. And what we found was that I do think that we indeed identified impairments early because for most people it's not if they occur, it's when, when is it going to happen? Nicole Stout:                 27:23                So we're able to identify them early. We can treat them much more conservatively when the impairment is less severe rather than waiting for severe, debilitating fatigue or a big fat swollen leg, and trying to fix or rehabilitate, right? We have to be much more proactive and we have the tools to be able to do that. We have the clinical measurement tools, we have the problem solving skills as rehab providers. What we have got to change is our perspective on an episode of care. This really is a more consultative role for rehabilitation and I think that's great. I think it's a great place for us to think about moving to as a profession. Consultation in that, like you said, sometimes you just see the patient, we tweak a little bit on their program and you coached them a little bit and talk about some of the behaviors they want to move towards and talk about. You're going to get there and you enable need and then I'll see you in three months. But sooner if anything goes wrong, you know? Karen Litzy:                   28:21                And now this brings up to me an interesting question for you. So this, you said back in the early two thousands, this work was done on this, prospective surveillance. So now it is 2019 so you know where I'm going with this, right? So, as rehabilitation professionals, where are we? Are we doing this? Has this been put into mainstream practice? And if not, what do we need to do as the rehabilitation professions? Nicole Stout:                 29:00                Yeah. So my heart is really as a researcher and it takes time. It takes time to do good studies. So that protocol kicked off in 2000. We didn't publish really our first remarkable studies until 2008 so it took us that eight years to enroll enough patients, analyze the data, come up with a full data set. You know, we completed our enrollment, we had the full data set. So in 2008 we published the first article from that prospective surveillance trial and then we published many, many more that the first was lymphedema, we published on shoulder morbidity, we published on fatigue and it was sort of this cascade after that, you know, once we had the data collected. So I'll start by saying it takes a long time to do good quality research. So really I sort of start the clock around 2008 and we've all heard the adage it takes 17 years for something to go from, you know, the research being published to actually implementing it in practice. Nicole Stout:                 30:08                So I looked around at my research, okay, I'm out waiting 17 years. How did the escalate the timeline to get this into practice? And, I encourage individuals who do publish, to think about how you advocate for your research. And so where are we right now as a profession? Well for the first few years it was challenging to get people around their head around this concept of prospective surveillance. We had some uptake in some larger cancer centers who said, this makes sense, let's implement and put a physical therapist in the cancer center, which I think is an ideal situation. It's hard to do though because again, in hospital systems we're in our cost centers and you know, the rehabilitation department, you have to have her referral to PT. I mean, we've got to find ways to overcome all of those barriers. Nicole Stout:                 31:03                So, I would say one moment that was a real catapult for us was in 2010, the American cancer society had identified the evidence around prospective surveillance and they said, do you think that this is ready for sort of an expert review panel? And I said, hell yeah. And so I got to work collaboratively with them and some other colleagues in putting together an expert consensus panel on prospective surveillance. We ended up after a two day symposium look, did the research, worked in groups and teams for about another year and publish 16 articles that came out in a supplement to cancer in 2012. And that I feel like was a bit more of a pivotal moment for us. You know, these research studies were great, but to pull all of that together with a group of experts in a consensus forum and say, this is a model that we need to think about for cancer patients because if we start at the beginning, not just with physical function, but if we start at the beginning with things like assessing someone's cognition, assessing their family status, assessing their financial status, assessing their nutrition status, and we follow them prospectively, all of those things are going to take a negative hit at some point during cancer treatments. Nicole Stout:                 32:21                So I think prospective surveillance lends itself to a much larger cancer supportive care model, which is how I have been describing it. And it is my intent to really focus on how we can study that model and look at better avenues for implementation in this new position that I'm in now at West Virginia university. This is my goal, which is amazing. Now how, so, you know, if we look toward the future and hopefully what you will be able to achieve in your colleagues across the medical spectrum, what are there policies that need to change that will impact the future of cancer survivorship or the future of living with cancer and beyond? Yeah, so the good news to that is there are a lot of things we can impact because we've laid this foundation of the evidence. We have laid this foundation of expert consensus and there's been a lot between that 2012 and today, more and more providers in rehabilitation services are becoming aware and engaging in cancer. Nicole Stout:                 33:36                You know, it's not something we prevalently teach in our curriculum in PT school. Think about how you learned about cancer. You learned about cancer in the negative. You learned all of the contraindications to your modalities and exercise and cancer was always one of them, right? You would say in your practical, okay, ultrasound, great, don't do it over the eyes. Don't do it on a pregnant uterus and cancer. So we find it in the negative for so many years. We have generations of therapists out there who love cancer and negative that never learned about the interventions to help to impact improve someone's function going through cancer treatment. So we're seeing that change and it's changing in how do we know it's changing? Individuals are engaging in cancer rehabilitation networks. We're seeing far more publications. We've published on this. A couple of years ago we did a billion metric analysis of the cancer rehabilitation literature and we've seen this tremendous upswing in the evidence base and an increase in volume. Nicole Stout:                 34:39                We're also seeing more therapists move towards specialty practice and evidence of that is what we have seen culminate in the last year with the first ever deployment of the oncology board specialty certification exam. We had 68 people pass the first exam. So we now have a growing conduct contingency and it will continue to go of therapists who are oncologic clinical specialists, which is fantastic. So we are positioning ourselves, we are moving forward. But when you ask where do we go in the future, I really think of three things. Number one is impacting policy, like you said, second is impacting education. And third really is impacting research. And so I think where do we need to move to in the future? We're starting to see the clinical practitioners really grow. We're starting to see residency programs develop. So from that perspective of the clinical focus, there's evidence, there are pathways that's developing. Nicole Stout:                 35:41                We have to start thinking about how do we embed this better into our curriculum. And this was last January in PTJ, the January issue of physical therapy journal. I coauthored a commentary article with Dr Laura Gillcrest, Dr Caringness and Dr Julie silver and Dr Catherine Alfano. We were all putting forward commentary on a recent national Academy of science, engineering and medicine report about longterm survivorship for cancer. And basically that report said rehabilitation should be utilized throughout the continuum of care, cancer care in order to contribute to that are longterm outcomes. And if that not doing so, not including rehabilitation during cancer treatment is almost negligence based on the breadth and depth of the literature that we have. So that was a pretty strong statement in that workshop document. So those are the types of things. Recommendations from the national academies will help us change policies. Nicole Stout:                 36:48                And by policies, I mean, you know, it's not just how do we get paid for what we do, but also policies around, standards, policies that our accreditation bodies use to designate cancer centers. In fact we are seeing, I think they were just released today, the commission on cancer, which accredits probably 95%, I think it is, of cancer centers around the country. So they're a big gorilla, their standards for an accredited comprehensive cancer center and include a standard for rehabilitation care services. It used to just be a criteria that you had to have a referral source to rehabilitation. But in 2020, the new standards that will come out from the commission on cancer actually has a rehabilitation care service standard. So it's been elevated. That's going to be critical for us because it will require your cancer committee in your hospital to identify policies and procedures for rehabilitation practices in oncology. Nicole Stout:                 37:56                So, you know, this is a place where we've got to start to see uptake in from our rehabilitation directors or administrators in large healthcare systems. The PTA, you know, we were really gonna need to see them start to put forward recommendations. How do we do this to practice? What is the best practice? What are some tools and tool kits that we can rule out. So those things, those policy changes are drivers for us. The education piece, I've spoken to a bit, I think embedding more education into curriculum for the entry level PT. And I think it's critical. You know, we get so bogged down in, well, you know, the capte requirements are, but they are in our curriculum's already too tight and it's a bit of a red herring argument because I see places around the country who have champions for oncology rehab who has put it into the curriculum. Nicole Stout:                 38:51                It just takes someone to understand what is the best practice look like for an educational model and how do we implement it. So places like Oakland university in Michigan, Emory in Atlanta is working right now on elective modules. So there are some real novel ways that these are being incorporated into PT curriculum. And the third area that I think of for the future is research. And you know, as I said, wow, we've seen an explosion in research in the last decade. It's phenomenal. A greater volume. A lot of that has focused on intervention. It's been within some very specific populations like breast and prostate. There is a lot of breast and prostate, understandably. But we need to look at going beyond. We really should be thinking about how do we look at populations with regard to our rehab interventions of cohort studies, large population studies, and we've got to start thinking a little bit beyond end points. Nicole Stout:                 39:54                Like function, function is important, don't get me wrong, it's the core of what we do. But if we improve function through rehab intervention, does it change the downstream utilization of healthcare services? Does it mitigate costs? Do we see them spend less time in the hospital? Did they have less than, do they adhere to their chemotherapy better? Do they have less severe toxicities? Do they have better overall survival? So they've got to think about some different end points and take a bit of a health services research approach. I think in oncology rehabilitation going forward. That's what I would love to see as the future and really at the core, the change in clinical practice so that we are a proactive consultative risk stratifying, triaging, screening, and proactively assessing profession when it comes to dealing with oncology. Karen Litzy:                   40:52                Yeah. And, and you really teed it up for me to ask you this last question here. My question is what advice would you give to your everyday clinician working, whether that be an inpatient or outpatient to allow them to begin to think differently about cancer? Nicole Stout:                 41:19                And that's critical because the fact of the matter is we look at places like Johns Hopkins and university of Penn and MD Anderson and those are like the preeminent cancer centers in the country. The truth of the matter is the majority of people get treated for cancer and community hospitals right down the street from where you live and in outpatient, freestanding oncology clinics. So the likelihood that you're going to see them is very high. So it is important for, as I said, the general therapist. It's also important for specialty practice therapists to improve their knowledge base in cancer. So how do you do that? There are some great resources. I'm always going to point to the APTA oncologic Academy for physical therapy. We're now an Academy. We used to be the section, I still call it the section. Nicole Stout:                 42:13                But we have an Academy for oncologic physical therapy and there are phenomenal resources there. They do continuing education programs. They provide fact sheets. They often have great evidence base that you can access to understand what are the measurement tools they should be using, what are the questions I should be asking someone. I feel there are also some, you know, continuing education courses focused specifically on the general therapist and I teach one of them. So there's my bias opinion and my disclosure there with great seminars, but I tell people that in the beginning of the course, one of the first things I say is my goal is not to spend two days with you to get you to become an expert in cancer rehab. My goal is to change the way you think about every single patient that you see regardless of the diagnosis, regardless of the setting that you are in. Nicole Stout:                 43:05                If they had a history of cancer, what questions do you need to ask? What might you be seeing in your intake that is indicative of side effects of disease treatment, late effects or even metastatic process. The other flip side of that that we haven't talked about and certainly helped me to delve into is that as primary providers, as frontline providers as we are in rehab, right? The direct access. Now, how many of us ask, about screening, cancer screening? How many of us ask questions? How many of us even know what the screening guidelines are for cervical cancer, for breast cancer, for prostate cancer, new screening guidelines for lung cancer. Again, I think that's a great way for physical therapy professionals to brush up in their knowledge base and to start to have these conversations. I'm not going to be the one to order a low dose CT scan for my patient who's at risk for lung cancer, but I might be the person to plant the seed with them and to incite a behavior change if no one else on their medical team has talked to them about it or if they're hesitant about it. Nicole Stout:                 44:12                Colorectal cancer screening as well. So all of those, we should take responsibility to have those conversations. And that is 100% of the patients that we see to ask those questions. So I think we need to sort of self-assess and say, how can I do this? Knowing that we had, we have 17 million individuals in the United States right now that we call cancer survivors. We are expecting that number to double, double by 20, 40 just because of the growing population, first of all. And because of the escalating rates of survivors, because we're treating the disease so much better. So there are going to be far more of them with the aging population and far more needs for us to meet. So yeah, therapists should be asking themselves, what are the resources out there? There are a lot of places now hospitals, health systems do cancer rehabilitation programs. Nicole Stout:                 45:10                They're doing continuing education courses and they're doing conferences as well. So take a look at some of the, I know Mary free bed, rehabilitation center up in Michigan, Brooks rehabilitation hospital down in Jacksonville, Florida, Marion joy, Northwestern. Many of these rehab hospitals are looking at doing one day, two day symposium open, you know, for folks to attend. So many hospitals as well are doing these cancer rehabilitation one day symposium and NYU is doing one next year, university of Miami. There's also an on pitch this because it's fantastic. And the ICPTO, which is the international conference in oncology, physical therapy, physical therapy oncology. I see PTO, it will be in Copenhagen in may of 2020. That's not a terrible place to go. This is the second that we, the second conference that we've done, the first conference we had over 280 participants from over 25 different countries around, well just physical therapists just in oncology. Nicole Stout:                 46:17                It was just amazing. It gave me tingles to be in that room. And so we're hoping to have an even bigger groups. So those are just, you know, again, sort of a snippet of some resources that I can provide. But looking at each of those, I think you can delve deeper into the resources that they have and have them have available within the APTA within the Academy and within some of those other ACRM is another one. The American Congress for rehab medicine has a cancer networking group and that's a beautiful place to go because it is interdisciplinary PT, OT, speech. You have behavioral psychologists, you have interventionalists, you have lifestyle medicine, desire, interest. It's really great. And they have continuous track of cancer rehabilitation content at their conferences. Unfortunately their conferences in early November. So it's coming up quickly, but every year it's in the fall. Next year it will be in Atlanta. So you know, another great place to look for. How do I start to build my knowledge base in this area? Karen Litzy:                   47:30                Yeah, this is great. Thank you so much for all of those resources and we will put as many of those up in the show notes at podcast.healthywealthysmart.com. Quick question on some of those resources. When you were talking about the different screening tools, can you find those screening tools under the APTA's oncologic PT? Nicole Stout:                 47:50                So if you're talking about the Academy for oncologic physical therapy, the hotly debated title. Yes, there are. So screening tools for identifying functional morbidity. Yes. So the course that was the evidence database to guide effectiveness, the edge test scores for oncology has published over 25 systematic reviews and have looked at measurement tools with by disease type within different measurement domains. So for example, you can find how do I measure functional mobility in colorectal cancer? How do I measure best measure lymph edema in head, neck cancer? So it's broken down by disease type and then domain of measurement. So that's there. It's an annotated bibliography on their website. So they give you a nice little simple compendium. But for the larger screening population screening guidelines, many of those are American cancer society and the us health prevention preventive task force. Those are, you know, large scale guidelines that are developed and put forward for screening for disease. Karen Litzy:                   49:02                Yeah, perfect. Perfect. Well that's great. That is a lot of resources for people. So hopefully any rehab professional listening can, if you have no familiarity with any of this information, would you say where's the first place they should go? Nicole Stout:                 49:21                Well, the first place, that's a great question. And I can help you put some seminal articles up there too. I think there are one and the open access articles. Julie silver wrote a fantastic article in 2013, about impairment driven as a rehabilitation. I feel like it's foundational. It's a great starting place for someone to get their head around all of the stuff involved with cancer treatment and the functional morbidity. And then I think the PTs for PTC oncology Academy is a great place. But also if you're an OT or speechie, you can join the Academy of oncology, PT, you can be an affiliate member, you can get access to our journal and our resources. Karen Litzy:                   50:06                Oh, that's cool. Good to know. That's very good to know. And you know, I think as from what I've got out of this conversation, because I am not embedded in with the oncological Academy but what I am have come to realize through this conversation is that regardless of your setting, you may in your career encounter a patient that has had cancer or is going through cancer treatment and regardless of whether you're in sports, PT, orthopedics, neurological pediatrics, odds are you're going to treat someone at some point with a cancer diagnosis present or past. And to understand the basics of how that might affect overall systems is incredibly important regardless of whether you work at Sloan Kettering full time within specifically cancer population or you are the physical therapist for the New York Knicks, you know, you may encounter this population. Nicole Stout:                 51:32                Yeah, that's really a beautiful summary. Karen, I appreciate the way you articulated that because I like to say oncology is everywhere and that's exactly it. It doesn't matter the setting you're in, it doesn't matter what specialty you practice. It doesn't matter geographically where you live. It does not matter, you know, age, gender, et cetera is, it's there, it is everywhere. Multi-system impact across body systems. So I think that's it. And across the lifespan. So I think it's beautifully summed up with that. You just said that, that's how we think about it. Oncologists everywhere. So every patient that you see there is either the risk of them having a cancer diagnosis in the future. So are you talking about the screening guidelines for the chances they'd had a diagnosis in the past and then asking yourself, is that impacting what I'm seeing here in front of me? There's so much we can spend an hour talking about pediatric oncology right now we're talking about red flags, you know, but look around many of the continuing education consortia around the country, med bridge. You know, many of those have a variety of content or are in process of building content for continuing education always look at the references. CSN is a great place to go to get a ton of oncology resources. Karen Litzy:                   53:00                Got it. And that is coming up in February over Valentine's day weekend in Denver, Colorado. So if you're a physical therapist or not, maybe you just want to go and hang out with 13,000 other PTs. You can go to Denver and you look at the oncology track for CSM. Nicole Stout:                 53:20                Definitely bring your sweetheart, make a ski weekend, I guess with the ecology content. Yep, definitely. Karen Litzy:                   53:32                Excellent. All right, so before we wrap it up, I asked the same question to everyone and that's knowing where you are now in your career, in your life. What advice would you give yourself as a new grad out of PT school? So this is the advice you would give to you. Nicole Stout:                 53:48                The advice I would give to me, it's funny. People would say, if you look back, what would you change? And I always say not a damn thing. I guess my advice to myself is what I hold close to my heart and what I convey to others is go for it. Don't be hesitant to take on something new or different because the new and different is what is going to expose you to a pathway you never would have imagined. I never would have imagined coming out of school that I would be doing oncology work. I was worried about in PT school. I didn't know that this career pathway could exist. I didn't know a clinical research pathway was something that I could even pursue. And as the opportunity came up, if I would've been hesitant, if I wouldn't have been interested in taking the risks, so go for it. Don't be afraid to take a risk. And sometimes that means moving to a different city, that might mean taking a pay cut. You know, a lot of times if we chase the things we love, we're not necessarily chasing the money along with it. I think if we chase a big paying salary, sometimes miss things above, so go for it and be open to try and taking those different pathways. Karen Litzy:                   55:02                Yeah, great advice. And now where can people find you if they have questions or they want to talk about oncology physical therapy? Nicole Stout:                 55:12                Oh, you can find me on Twitter, on social media outlet. I really used to try to engage professionally. So it's @NicoleStoutPT. And you know, you can certainly find me there. My Facebook accounts were private. That's where like family and friends stuff. But definitely access and hit me up on Twitter or LinkedIn yet. Another great place. I post a lot of our research articles there. I'm on LinkedIn, so you can certainly connect with me there. Or just email me and always see how many times you can just cold call or cold email. It's some of the most engaging conversations I'll get on the phone with anyone. I will fly anywhere to talk about kids or rehabilitation and you know, some of the best conversations that started with, Hey, I don't want to bother you, but you have some time to talk and I'm happy, you know, to start a conversation via email. So more than happy to engage. Karen Litzy:                   56:09                Perfect. And Nicole, thank you so much for a really great talk and I think that you have given the listeners a lot to think about and also a lot to look up into research and hopefully spark someone out there to, this might be the path I would like to take. So thank you so much. Nicole Stout:                 56:24                Well, I thank you for the opportunity. I'm just grateful for everything that you've done to put PT on such a stage and I'm really excited to have been a part of that, so thank you. Karen Litzy:                                           Thank you so much. And everyone out there listening, thanks for listening. Have a great couple of days and stay healthy, wealthy, and smart.     Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on iTunes!

This episode is a live recording from our live interview with Dr. Le Lu, Executive Director of PAII Bethesda Research Lab and former NIH staff scientist, at the CVPR 2019 conference. He discussed the progress of applying deep learning in medical research and the challenges the industry is facing. View the full interview transcripts and more inspiring talks at Robin.ly: http://bit.ly/2XyTUs9 Bethesda Research Lab. PAII Inc. is a tech-driven company focusing on smart city technologies, intelligent education programs and advanced technical solution on healthcare imaging and clinical informatics. Prior to PAII, Dr. Lu worked with the National Institute of Health Clinical Center. His research focuses on improving the modern medical image understanding and semantic parsing to fit into revolutionary clinical workflow practices.

This podcast interview features integrative health expert Russell Jaffe, MD, PhD, CCN, who shares his philosophy about addressing men's health issues in clinical practice. Jaffe discusses hormonal balance, prostate health, gastrointestinal health, cardiovascular health, and inflammation. About the Expert Russell M. Jaffe, MD, PhD, is CEO and Chairman of PERQUE Integrative Health (PIH). He is considered one of the pioneers of integrative and regenerative medicine. Since inventing the world’s first single step amplified (ELISA) procedure in 1984, a process for measuring and monitoring all delayed allergies, Jaffe has continually sought new ways to help speed the transition from our current healthcare system’s symptom reactive model to a more functionally integrated, effective, and compassionate system. PIH is the outcome of years of Dr Jaffe’s scientific research. It brings to market 3 decades of rethinking safer, more effective, novel, and proprietary dietary supplements, supplement delivery systems, diagnostic testing, and validation studies. About the Sponsor PERQUE Integrative Health (PIH) is dedicated to speeding the transition from sickness care to healthful caring. Delivering novel, personalized health solutions, PIH gives physicians and their patients the tools needed to achieve sustained optimal wellness. Combining the best in functional, evidence-based testing with premium professional supplements and healthful lifestyle guides, PIH solutions deliver successful outcomes in even the toughest cases. If you are interested in delving more deeply into this and other integrative health topics, we invite you to join the PIH Academy. Transcript Karolyn Gazella: Hello, I'm Karolyn Gazella, the publisher of the Natural Medicine Journal. Thank you for joining me today. Our topic is men's health, and my guest is integrative health expert, Dr Russell Jaffe. Before we begin, I'd like to thank the sponsor of this topic, who is Perque Integrative Health. Dr Jaffe, thank you so much for joining me. Russell Jaffe, MD, PhD, CCN: Thanks for the invitation. Gazella: Well, before we dig into the specific health issues that men face, you believe in a philosophy first approach. I'm sorry, physiology first approach. What do you mean by- Jaffe: The philosophy is physiology. Gazella: Exactly. Jaffe: So, that was appropriate. Yeah- Gazella: So, what do you mean by that? Jaffe: Right. It's a high level, brief, 2 words, physiology first. What we mean is, physiology before pharmacology. We mean physiology first because it seeks an upstream assessment of the causes of risk or symptoms, in contrast to most conventional care today, even holistic or not, that remains rooted in downstream symptom management. Physiology first uses global evidence to reduce risks and prevent people from falling into the river of disease. Physiology first uses nature's nutrients in supplements, with enhanced uptake and chaperone delivery, for safer, more effective, essential replenishments, items we must take in since our body doesn't make them. Physiology first urges organic or biodynamic or locally grown sources of nutrient-dense whole foods, as minimally contaminated as possible. Physiology first focuses on underlying causes. For example, too little of essential needs being met, which are eating, drinking, thinking, doing—those are the 4 headline categories—rather than working back from symptom-reactive case management. And finally, physiology first uses predictive biomarkers interpreted to their best outcome goal values. Now, this is a paradigm shift for many colleagues but we now can impersonalize predicted, proactive, primary prevention practices, save individuals probably a million a year just by applying physiology first. Gazella: Yeah. Well, that's exciting so I'm glad that we went over that. Now in general, what should be on the radar of clinicians when it comes to addressing the special health needs of their male patients? Jaffe: Yes, and here again, now that we've kind of gotten the hundred thousand–foot level, we start and recommend colleagues start with self assessment. This includes transit time, urine pH after rest, hydration, and a sea-cleans as overall global self assessments, very inexpensive. The individual does much of it themselves, brings it to the expert who interprets it so that we get a snapshot of the metabolic or metabolon/microbiome, the digestion and metabolism. You interpret that to best outcome goal values. You use that to inform and inspire and motivate people to put it in effort for the 6 to 7 weeks that it takes to change a habit of daily living and you can add years to life, years of quality life and life to years. In people with chronic symptoms, well. Take a careful family history although family history is highly relevant if you have the same behavior and environmental factors. If you change your behavior, your habits, your environment, then your family history to a very large extent disappears into the midst of history. If there have been prior treatments and treatment failures, it's important to assess that. We use the predictive biomarkers to help people celebrate when they are at their best outcome goal value and take action when their risks increase. Now, men and women at all ages need activity, at least 45 minutes a day of walking or equivalent. Sitting is the new smoking. Weight-bearing exercise or cardio exercise 2 or 3 days a week and knowing about it or preaching about it is one thing. It's when you actually do it. I'm glad to tell you that I had just enough glimpse of the consequences of not doing that I do what I'm recommending. Now we want to teach men to prepare for sleep, achieve restorative sleep, using physiology before pharmacology, using salt and soda baths, Epsom salts and baking soda, plus or minus aroma oil, essential oil. The baking soda alkalinizes and relaxes muscles in the pores of the skin, and the Epsom salts, which is magnesium sulfate, allows the magnesium to come in and that's often very helpful. We recommend that teaching people, particularly men who have sleep issues, about abdominal breathing and active meditation and green dichromatic light, along with nature's sources of serotonin and melatonin, which is tryptophan. We ask about changes in urine stream flow and quality after urination. Is there any dribbling? How many times do they get up at night to urinate? And we make lifestyle suggestions tailored to the individual at their phase of life. We want to be proactive with prostate support nutrients, such as micellized soft gel that contains all of active saw palmetto, [inaudible 00:06:03], lycopene. Free lycopene, not just some ketchup. Hygeium, with 14 or 15% beta sitosterols. Urtica dioica, also known as stinging nettles. Zinc, in the picolinate form. And selenomethionine, selenium in the selenomethionine, healthier, safer form. And all of this micellized in pure pumpkin seed oil to enhance uptake in retention, to improve function. And we think people can be pleasantly surprised at how effective and synergistic the above prostate health support is, available in a single, easy-to-swallow soft gel. Ask about adult beverages. If they consume more than 5 a week, provide comprehensive liver support and recommend a glass of water above the four quarts or four liters a day that humans need to avoid marginal dehydration—1 or 2 or 3 percent dehydrated is a big stress on every organ in your body. So this is, again, at a headline level, how our comprehensive approach actually works. Gazella: Perfect. Now I'd like to kind of narrow our conversation and I want to stay on the prostate because you mentioned the prostate. So, what are the roles that testosterone plays when it comes to prostate health and men's health in general? Jaffe: Right. Both men and women need testosterone. They need a balance of free and bound testosterone. They need good and not bad testosterone. Now, what does that mean? Well, you can measure in saliva or in plasma. The free and the bound, free and total testosterone. You can measure the dihydrotestosterone. You don't want much of that, maybe zero. You can measure oxidized testosterone. You want zero of that. And you want to enhance the good T, the good testosterone and reduce the bad T based on testing results because testosterone is needed for brain and muscle and organ and joint and bowel renewal and many other functions beyond just being a male hormone. You want to enhance healthy testosterone production through healthy microbiome and metabolon functions, especially the family of the central antioxidants. Vitamins, minerals, and cofactors that along with good hydration optimize your healthy testosterone, which is one of the vitality factors in the body and minimize the bad testosterone that causes everything from hair loss to loss of erections. Gazella: Okay, perfect. So before we leave the prostate, remind us what the significance is of the PSA test. Jaffe: That's a very important question and I think we're finally, after half a century in laboratory medicine and I've been following the issue all of that time. The PSA test is a measure of prostate repair. So, the PSA goes up if you have prostatitis. For example, if you just sit in your car too long and hold your urine in too long. And the PSA goes up in some but not all prostate cancers, and you can fractionate the PSA, free and bound, and that usually but not always helps distinguish the prostatitis from the cancer risk. If you had concern about the prostate and about PSA levels and have a biopsy, after a single biopsy—often there are multiple biopsies—the future PSA has no interpretable value that I know of except for population, but we're talking about 1 man at a time. And so many review articles that I have seen in the last few years say do other tests of prostate health and don't even do the PSA because if you don't need the test, you wouldn't do the test. If it's a question, it's a gray zone, that's exactly what the test is not very sensitive or specific. Gazella: What about enlarged prostate? Jaffe: The first thing I would do and have recommended for many years for enlarged prostate is to take that combination of prostate vitality factors and we have had men whose prostate was double or triple than usual size come back to that of a 40-year-old by following for about 6 months a program that includes the supplements that I recommended just a few minutes ago, along with eating foods that the man can digest, assimilate, and eliminate without immune burden, and that means the lymphocyte response assay test that measures T and B cell function and that then says eat this and don't eat that, take the supplement and don't take that, follow this mental and physical plan because in the 80,000 cases that we put in our database, we've evolved a very personalized approach to, say, prostate size. Gazella: Okay, perfect. So, let's move on. What does it mean when a man wakes up with an erection or doesn't have an erection? Is that significant? Jaffe: Oh, absolutely. The headline is that every healthy man should wake up in the morning with an erection. In essence, it's the quality control check of the distinctive male. Too often and very commonly, when a man does not wake up with an erection, that's a sign that they have pregnenolone steal, that they have high stress cortisol levels and low DHEA, which is the antistress hormone, usually with low free healthy testosterone, often with a sluggish thyroid and an exhausted adrenal gland, due to lack of adequate intake of the essential antioxidants, minerals, cofactors that are necessary. In addition to prostate health nutrients, I would recommend checking the thyroid, TSH, 3T3, 3T4. That can be done on a blood spot or in many different ways. But you must, by my recommendation, get the 3T3, 3T4, TSH all at the same time, and the healthy range for TSH is .5 to 2.5, not above. The usual range has too many unwell people. (Usual lab range.) You want to check adrenal stress hormones, cortisol and DHEA at four times during one day. And at the same time, in the same saliva or plasma specimen, you can measure male and female hormones and their sources, their precursors to see if the body has learned a distress response that steals the healthy progesterone and pregnenolone and produces too much distress hormone cortisol and too little healthy male and female hormones. They come from the same source. You want to get both and in balance. Now in regard to male sexual performance, there are natural solutions to erectile dysfunction. The following vitamins, minerals, and amino acids work as a team to improve the quality and duration of erections B complex. One phrase is 'B complex is for boners'. Keep the urine sunshine yellow and feel the difference comprehensive B complex means. C, it is ascorbate vitamin C, always fully buffered, fully reduced and we recommend based on the C cleanse, taking that amount is associated with healthier and the more robust erections. Vitamin D is really a neuro hormone and it does a lot of things, including improving cell function and providing cell energy to sustain the generally sixfold increase in blood retention during an erection. Then magnesium choline citrate. Magnesium is essential for a lot of different things, including a healthy sexual function, and choline citrate at the same time, say 220 mg of magnesium solves and a teaspoon of choline citrate. That enhances the uptake dramatically. It enhances the retention because it is an alkalinizing, rather than an acidifying source. Most magnesium solves and magnesium products have very low bioavailability and are in the acid form, which makes the magnesium run out almost as soon as it comes in. And then last is L-citrulline and L-arginine, and these are 2 amino acids. They both enhance nitric oxide production inside cells, and when you take about a gram of L-citrulline and 500 mg of L-arginine 30 minutes before adult activities, most men notice the difference, especially men over 40. Foods that are rich in these amino acids include nuts, seeds, chickpeas, and other legumes, also known as garbanzos, and meats. Making an avocado and chickpea hummus with some mustard seeds or black and white sesame seeds added plus or minus some toasted pine nuts with fresh ground black peppers and your favored high-quality salt, that can blend into a nutritious, delicious, amorous and traditional food. Gazella: That's great and it sounds yummy as well. Jaffe: It is. It should be nutritious and delicious. Gazella: Exactly, exactly. Well, let's now move onto the gastrointestinal tract. What should practitioners focus here when it comes to their male patients? Jaffe: Well, in the 21st century it is a pretty fair assumption that the person sitting across a professional has mild digestion dysbiosis, some degree of atrophy known as enteropathy, a long transit time. Transit time should be 12 to 18 hours. We recommend doing that with charcoal. We have an online instruction if folks are interested because you want to assess what's called the microbiome, which is the digestive tract in its fullness, or the GNS, known as the gut nervous system, which is in constant conversation and communion with the reigning central nervous system. And so we recommend focusing on a full complement of personalized native antioxidant, minerals, and cofactors in their safer higher uptake forms based on the assessments and the predictive biomarker tests that we recommend. We want to pay attention to hydration because even a little bit 1, 2, 3% dehydrated puts a stress on every part of the body. We want to have prebiotics. That is unprocessed fiber from diet or supplements, 40 to 100 grams a day. That's what Dennis Burkitt taught me and the most knowledgeable nutritionists that I know recommend that much fiber a day. Probiotics, 40 to 100 billion healthy by a mixed bacteria, bugs. Then synbiotics, which is really recycled glutamine to energize and repair the lining of the digestive tract. Then you want to eat what you can digest, assimilate, and eliminate without immune burden. So, you've done some functional immunology testing like LRA, lymphocyte response assay. Take in no empty calories. You are sweet enough as you are. If you feed parasites and pathogens, fungi and yeast, they will grow. Improve the digestion, the microbiome and metabolon, the innate biological detoxification competencies and enhance your digestion by eating what you can digest, assimilate, and eliminate without activating your immune responses. We teach people to stop feeding the pathogens and they disappear as digestion improves, repairs improve, resilience is restored, and habits of daily living are improved. Then you want to look at the secretory IgA if you're concerned about the interface between digestion and the body. It's called SIgA, secretory IgA. You can measure that in saliva. There should be protected mucins so that if partially digestive materials get near the wall of the body, they don't become foreign invaders if you have healthy mucins and healthy secretory IgA. And there are other elected protected digestive functions that healthy people have that are lost when people lack the essential nutrients or the essential minerals when their cellular metabolism becomes acidic, when their body is reaching out, calling out, actually crying out for repair enhancement essentials, things you have to take in that you can't make in the body. So, we wanna taper or possibly discontinue medications that impair digestion. We want to use prebiotics, probiotics, and synbiotics, especially in people who have had antibiotics and other digestive-interfering medicines. We want to check transit time, should be 12 to 18 hours. When I have roast beets as a main part of my dinner, I expect to see red in the commode in the morning. But I can tell you after all these years when I see that red, my first thought is never, "Oh, I had beets last night" so that's why we use charcoal. Now, avoid fat-binding medications and supplements that reduce essential fat-soluble vitamin uptake. That's vitamins A, D, E and K. And you need bile from the liver to do that and for that you need phosphatidylcholine-rich foods and/or supplements, and we happen to micellize all of our soft gels with this PC, with this—not politically correct—phosphatidylcholine. Now, many men have atrophy of their intestinal lining because of stress and toxin exposure and it's the 21st century, and maybe less than perfect eating, breathing, and drinking. So, getting the essential needed nutrients restored may mean intensive supplementation for a few months, followed by maintenance supplementation for a long, healthy life, and I personally plan to be dancing at 120 and I would like you to join me. Gazella: That sounds perfect. So, you mentioned tests to assess the microbiome and you also mentioned secretory IgA. Are there other tests that you recommend in terms of assessing the microbiome? Jaffe: Right. So, the transit time we talked about, it's one of the self-assessments, 1 of the 4. Then this SIgA, the secretory IgA, in saliva or serum, with the comprehensive lymphocyte response assay, if there's any indication that the person has shifted from elected protected mode into survival mode, which means all the protective and repair functions are down regulated, that's called chronic illness to happen, or hormone tests that include cortisol and DHEA at 4 different time points, male and female hormones can be measured in their precursors on the same saliva specimen. You can use plasma if you wish. Adrenal and thyroid adaptogenic supplementation is recommended either based on clinical history or these test results. By all means include some way of determining how much ascorbate that person needs because ascorbate is the maternal antioxidant that sacrifices yourself that all others may be presode. And then the magnesium with enhanced uptake choline citrate. The choline helps build acetylcholine, an important neurotransmitter and neurochemical. It also helps build the choline-rich biosalts that are more soluble and help get the thicker bile out of the gallbladder and into the digestive tract, where that helps emulsify fat to be taken up into the body. And then based on the urine pH, we would adjust how many doses of the magnesium choline citrate you take. Do a regular hydration assessment and when in doubt, what I recommend is that you have a carafe of water in front of you and a glass. If the glass is full you drink it and if it's empty you fill it, and you just keep doing that. And personally my goal is to go to the bathroom at least every couple of hours and then I cut down the amount of liquid I take in after 7 or 8 PM so then I'm not overhydrated when I go to bed. But underhydration is a much more common and unappreciated problem. Monitor the breadth of our little chemicals, and this can give very interesting insights that are both diagnosis-specific of mild digestion dysbiosis enteropathies and so forth. But in addition that information often makes it very clear to the individual that this is true for them and not in general. And the last is a zinc taste test. Developed by Harry Henken, you drop a zinc solution on the tongue. The people who need zinc can't taste it. The people who say the zinc tastes strong have enough. And it's a pretty good one-dollar type assessment of a critical mineral and specifically for men, men need lots of minerals but especially zinc. You lose about 25 mg per every ejaculation. Gazella: Yeah, that's good. That makes a lot of sense. So, now it's time to discuss inflammation. Is inflammation really repair deficit and how does that change clinical practice? Remind us why that's such a big deal. Jaffe: Right. Well, we started with the physiology-first concept. Now I'm a doubly board-certified pathologist. I know the 5 aspects of inflammation. I know it's taught as a fire to be fought, something that has to be suppressed with anti-inflammatories. And now I pause and say: Anything that starts with 'anti' is using pharmacology before physiology. Inflammation is repair deficit. What my pathology colleagues see as inflammation is the cumulative lack of repair when your immune defense and repair system is doing too much defensive work because of foreign invaders from the breath or the skin or the gut, and if you enhance the innate immune system's ability to repair, your infrastructure is reborn, your bones get rebuilt, your joints are renewed, your mood is better. Your ability to get restorative sleep and meaningful relationships all are improved when you recognize that repair deficit is an opportunity. You use the hsCRP test as a predictive and validated biomarker. It's also an all-cause mortality, morbidity marker. The healthy goal value—and this is, again, where we have the reframing. I don't even look at the lab range because that includes too many unwell people. You know the goal value for this test, hsCRP, and it's less than 0.5. Ignore statistical lab ranges unless you're treating statistics, and knowing the best outcome goal value we add ascorbate based on the [inaudible 26:350, magnesium choline citrate based on the urine pH, and other similar kinds of monitoring so that the person gets more safely the forms that are more effective because of their enhanced uptake and retention and therefore the deficits get corrected more quickly. I mentioned hydration. I keep mentioning it only because every part of your body is healthier and more resilient and more able to repair when you take in healthy water, 4 liters a day or more of either mineral-rich, I happen to have well water but some mineral-rich water that's not contaminated and/or sparkling water. I happen to like Pellegrino but there's also Gerolsteiner and Apollinaris and actually every culture has a mineral-rich water known as a therapeutic or beneficial or health-promoting mineral water. So, you want to drink hard water, so water softeners are not recommended, at least not total home water softeners. If you want to soften the water in the pipes, I don't care, but your blood vessels are not pipes and now I care about the quality of the water that you take in. Gazella: Perfect. So, I love your perspective about looking at repair deficit as an opportunity. Are there other ways to kind of take advantage of that opportunity to reduce oxidative stress and reign in inflammation? Jaffe: Yes. And again, in a physiology-first point-of-view in regard to, say, blood fats. Cholesterol and triglycerides and blood fats and [inaudible 00:28:14]. If you keep the oxidation of those fats, if you keep oxidized cholesterol to zero, if you keep oxidized LDL to zero, because you're taking enough antioxidants and especially ascorbate. Now, the fat-related cardiovascular risks just went away. What remains is understanding your hemoglobin A1C, your hsCRP, your homocysteine, your LRA (lymphocyte response assay immune responses), your vitamin D, your first morning urine pH, your omega-3 index, and [inaudible 00:28:51]. Those are the eight predictive biomarker tests and we have online for folks to peruse and/or download or watch on YouTube discussions of why these eight predictive biomarkers cover all of that genetics, which is 92% of your lifetime quality of life and health. And yes, you can blame mom and dad for the other 8%, and yes transgenerational influences on RNA are a big scientific field but not yet ready to measure clinically. Live in the moment, do one thing at a time, practice gratitude and random acts of kindness, breathe abdominally for at least 5 minutes a day, and make enhance repair your practice and banish inflammation. Gazella: That's perfect. It's a very integrative approach that includes lifestyle as well. I'd like to end with heart disease because heart disease remains the leading cause of death for men in the United States. So, what do you recommend when it comes to protecting heart health for male patients? Jaffe: Yes, and as I think you know part of my primary research when I was in government service at the National Institutes of Health Clinical Center was collaborating with the Heart Institute on animal models of heart disease. Now, Paul Dudley White in the 1930s was a famous cardiologist. He helped invent the electrocardiogram. He taught when I was a young student that in the 1930s at Mass General Hospital in Boston, Massachusetts if they had 1 heart attack a year, they published the case. And yet 40 years after that, cardiovascular disease was the major killer of Western civilization. That's not a genetic change. It's too quick for genetics. A lot has to do with smoking and sitting, sedentary lifestyle, processing of foods, and all that goes with that. Jaffe: So, cardiovascular disease. If your heart attacks you, if you have a clog in a blood vessel, an artery, if you have a stroke, you didn't pay attention to the upstream warnings that you would know about if you did the self-assessment, if you did the predictive biomarker tests because these change. Your risk goes up dramatically decades before catastrophe. And if you change your consumption and attitude, if you change the environmental toxin exposures and by the way 80% of the toxins that people have in their body are of recent exposure, and you can dramatically reduce that by certain simple lifestyle changes. Include 1 to 300 mg a day of micellized CoQ10 in 100% rice-brand oil, and no glycose. No antifreeze in your CoQ10. Keep the 8 predictive biomarkers at their best outcome goal value and when they are, when those 8 tests are at their best outcome goal value, you have a 99% chance of living 10+ years, even if you're 100 at that point, and my main teacher Buntey was 110 when he passed and as I mentioned before I plan to be dancing at 120 by following this lifestyle, and I urge anyone who is willing and interested to join me. Gazella: That's perfect. Well, Dr Jaffe, we covered a lot today. Before I let you go, I'm just wondering if there's any final thoughts or anything else that you'd like to share with our listeners today. Jaffe: Yes. In essence, the physiology-first, the epigenetics is 92% of your life quality has to do with consumption, which you eat and drink and how you think and what you do. Now whatever season of your life is as a man, that may be different. When you're young and immortal, that's one thing. As soon as you're beyond young and immortal, be prudent. Cardiovascular disease starts in teenage years. Cancer risks goes up dramatically when your innate anti-cancer mechanism is turned down because you're eating foods that are causing too much defense burden in your immune defense and repair system. So, just follow through on this physiology-first approach looking at your individual needs for personalized health promotion and put pay to chronic ill health. Gazella: Perfect. Well, once again I'd like to thank today's sponsor, Perque Integrative Health, and Dr Jaffe I'd like to thank you for taking the time and sharing so much information with us today. Jaffe: Well, thanks for inviting me and for making it such an enjoyable time. I hope the listeners will take away much that will be of value, and it's my pleasure. Gazella: Well, thank you and I hope you have a great day. Jaffe: You the same, Karolyn. Always a pleasure. Gazella: Yes, it is. Bye-bye.

Summary of the April 15, 2014 issue, including articles on U.S. trends in prevalence and control of diabetes, quantifying delirium severity, virtual autopsy versus traditional medical autopsy, high-energy extracorporeal shock-wave therapy for shoulder tendinitis, and point-of-care tests for detecting albuminuria, as well as the USPSTF recommendation statement on vitamin supplementation to prevent cardiovascular disease and cancer and commentaries on the Physician Value-Based Payment Modifier program, the National Institutes of Health Clinical Center's experience with a carbapenem-resistant Enterobacteriaceae outbreak, and the American Board of Obstetrics and Gynecology's recent decision to reverse its stance on gynecologists treating men.