Podcasts about icds

WHOOP 5.0 and WHOOP MG have arrived. On this episode of the WHOOP Podcast, WHOOP Founder and CEO Will Ahmed sits down with Chief Product Officer Ed Baker to unpack the all-new WHOOP experience. They introduce the new devices — 5.0 and MG — and break down the three new WHOOP memberships. From 14+ day battery life to powerful new features like on-demand ECG readings, daily Blood Pressure Insights, Healthspan, and Women's Hormonal Insights, this episode covers it all. Plus, get a first look at our new WHOOP Apparel & Accessories. Whether you're upgrading or just getting started, this is your guide to everything 5.0 and MG.(00:00) Say Hello to WHOOP 5.0 and WHOOP MG(00:13) 4.0 vs 5.0: Hardware Advancements (00:52) 14-Day Battery Life and The New Wireless Powerpack(02:18) WHOOP MG(04:47) Healthspan and WHOOP Age(11:35) Heart Screener with ECG(14:37) Blood Pressure Insights(16:07) VO2 Max(17:30) New and Improved Women's Health Features(19:03) Advanced Sleep Metrics(22:06) Navigation and App Insights(24:25) Accessories and Apparel: A New Look For WHOOP(27:59) WHOOP Membership Tiers Breakdown(36:13) Gift Kit & Upgrade Benefits(37:33) Will & Ed's Favorite WHOOP MetricGet your WHOOP 5.0 now at WHOOP.comThe ECG feature is not intended for users with known arrhythmias other than AFib or users under 22 years old. It is not recommended for users with a cardiac pacemaker, ICDs, or other implanted electronic devices. This is a medically regulated feature and is not currently available in every region. Go to https://www.whoop.com/feature-availability/ to check if it's available in your region.Blood Pressure Insights is not a medical device and cannot diagnose or manage medical conditions. It does not provide medical advice. Always consult your doctor for health concerns and never delay or modify medical care based on its information. Menstrual Cycle Insights should not be used for conception or contraception, and all phases, including the ovulatory phase, are estimates. Menstrual Cycle Insights is not a medical device and cannot diagnose or manage medical conditions. It does not provide medical advice. Always consult your doctor for health concerns and never delay or modify medical care based on its information.Healthspan is not available for users under the age of 18.Support the showFollow WHOOP: www.whoop.com Trial WHOOP for Free Instagram TikTok X Facebook LinkedIn Follow Will Ahmed: Instagram X LinkedIn Follow Kristen Holmes: Instagram LinkedIn Follow Emily Capodilupo: LinkedIn

A Gluten Free PodcastEpisode 176On today's episode I chat with Associate Professor Dr Bob Anderson — a world-renowned gastroenterologist, immunologist and trailblazer in coeliac disease research. From his foundational work at the Walter and Eliza Hall Institute (WEHI) to creating Nexvax2, leading Novoviah Pharmaceuticals, and becoming President of the International Society for the Study of Coeliac Disease (ISSCD), Bob has shaped the coeliac research landscape as we know it.We discuss how his career began, what he's most excited about in current research, and what's ahead for coeliac disease globally — including a look at ICDS 2026 in Melbourne.What We Cover

With Lucas Boersma, St.Antonius Hospital, Nieuwegein - The Netherlands, and Stefan Simovic, Faculty of Medical Sciences, University of Kragujevac, Kragujevac - Serbia. Join us for an exciting episode on non-transvenous ICDs, exploring their advantages and future potential.  

Pacemakers and ICDs: Lifesaving Cardiac Devices Explained Welcome to this edition of the First Aid Show. In today's episode, we delve into the often-confusing world of pacemakers and ICDs. We've … Continue Reading → The post Pacemakers And ICDs appeared first on The First Aid Show.

In this episode, Dr. Valentin Fuster discusses a groundbreaking study that uses machine learning to predict mortality and hospitalization risks in patients with implantable cardioverter defibrillators (ICDs). By leveraging large datasets and time-varying ICD data, the study developed a robust predictive model, though challenges remain regarding data gaps and its applicability to diverse patient populations.

Listener feedback, multiple studies in AF ablation, a DANISH trial substudy of ICDs in NICM, and more data on eye complications of GLP-1 agonists are the topics John Mandrola, MD, covers in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. CCTA Feedback Foy meta-analysis https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2655243 DANCAVAS https://www.nejm.org/doi/full/10.1056/NEJMoa2208681 II. Listener Feedback on my negative take of the OPTION Trial. Option trial https://www.nejm.org/doi/pdf/10.1056/NEJMoa2408308 My Preview https://www.medscape.com/viewarticle/mandrola-previews-option-trial-most-worrisome-study-aha-2024-2024a1000kmz 4 Reasons to Question Percutaneous Left Atrial Appendage Closure After AF Ablation https://www.medscape.com/viewarticle/4-reasons-question-percutaneous-left-atrial-appendage-2024a1000l0u III. AF Ablation  PVI Add-Ons Provide Better Control of Persistent AF https://www.medscape.com/viewarticle/pvi-add-ons-provide-better-control-persistent-af-2024a1000lcm VENUS https://jamanetwork.com/journals/jama/fullarticle/2772281 PROMPT AF https://jamanetwork.com/journals/jama/fullarticle/2826710 STAR AF 2 https://www.nejm.org/doi/full/10.1056/NEJMoa1408288 CRRF-PeAF https://pmc.ncbi.nlm.nih.gov/articles/PMC9241129/ CAVAC trial https://doi.org/10.1161/CIRCEP.124.012917 CRRF-PeAF from multiple centers in Japan (not published) IV. DANISH Trial Substudy Danish Trial Substudy https://www.ahajournals.org/doi/epdf/10.1161/CIRCULATIONAHA.124.071777 Danish Main https://www.nejm.org/doi/full/10.1056/NEJMoa1608029 MADIT-2 EF Substudy https://doi.org/10.1016/S0002-9149(01)01729-5 SCD-HeFT subgroup https://www.nejm.org/doi/full/10.1056/NEJMoa043399 Appraisal of ICD to Prevent SCD https://doi.org/10.1016/j.jacc.2008.05.058 V. Eye disease and GLP-1 Agonists Jul 26, 2024 This Week in Cardiology Podcast https://www.medscape.com/viewarticle/1001384 Semaglutide vs No Semagutide and Eye Disease https://link.springer.com/epdf/10.1186/s40942-024-00620-x Semaglutide vs SGLT- Inhibitors and Eye Disease https://www.medrxiv.org/content/10.1101/2024.12.09.24318574v1.full-text You may also like: The Bob Harrington Show with the Stephen and Suzanne Weiss Dean of Weill Cornell Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

Hallitus aikoo edistää omalääkärimallia. Miten malli toteutetaan talousvaikeuksissa olevilla hyvinvointialueilla? Puhelimessa sosiaali- ja terveysministeri Kaisa Juuso (ps.). Miten hyvinvointialueiden rahat saadaan riittämään? Vieraina hyvinvointialueiden ohjausosaston osastopäällikö Ville-Veikko Ahonen valtiovarainministeriöstä, Etelä-Karjalan hyvinvointialuejohtaja Sally Leskinen ja terveydenhuollon professori Kristiina Patja Helsingin yliopistosta. Millaista huomiota Ruotsin ja Liettuan välisen kaapelin vahingoittuminen on herättänyt Ruotsissa? Puhelimessa Gotlannissa oleva vapaa toimittaja Hanna Sihlman. Itämerellä on katkeillut merikaapeleita, Ukraina iskenyt amerikkalaisilla ohjuksilla Venäjälle ja Venäjä kertonut muuttaneensa ydinasedoktriiniaan. Onko turvallisuustilanne muuttumassa? Vieraina Viron kansainvälisen puolustustutkimuskeskuksen ICDS:n varajohtaja Kristi Raik ja Aleksanteri-instituutin johtaja Markku Kangaspuro. Juontajana Mira Stenström, toimittajina Mikko Haapanen ja Atte Uusinoka, tuottajana Annette Blencowe.

Reader feedback on LGE pre-ICDs, PFA for AF ablation, CTO-PCI, endovascular ablation of the greater splanchnic nerve in HFpEF, and data sharing are the topics John Mandrola, MD, covers this week. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. Listener Feedback Sept 27, 2024 This Week in Cardiology Podcast https://www.medscape.com/viewarticle/1001666 JAMA Meta-analysis https://jamanetwork.com/journals/jama/fullarticle/2823869/ II. Pulsed Field Ablation for AF Feb 02, 2024 This Week in Cardiology Podcast https://www.medscape.com/viewarticle/999995 ADMIRE Trial https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.124.070333 ADVENT Trial https://www.nejm.org/doi/full/10.1056/NEJMoa2307291 III. PCI for CTO EuroCTO One Year SAQ Results https://doi.org/10.1093/eurheartj/ehy220 EuroCTO Hard Outcomes https://eurointervention.pcronline.com/article/three-year-outcomes-of-eurocto-a-randomized-multicentre-trial-comparing-revascularization-and-optimal-medical-therapy-for-chronic-total-coronary-occlusions Faith Healing and Subtraction Anxiety https://doi.org/10.1161/CIRCOUTCOMES.118.004665 DECISION CTO trial https://doi.org/10.1161/CIRCULATIONAHA.118.031313 ISCHEMIA CTO Rationale and Design https://doi.org/10.1016/j.ahj.2022.11.016 IV. Greater Splanchnic Nerve Ablation for HFpEF REBALANCE HF https://jamanetwork.com/journals/jamacardiology/fullarticle/2823999 V. Data Sharing The Pros and Cons of Clinical Trial Data Sharing https://www.medscape.com/viewarticle/862815 Kramer and Nallamothu, Caution in Data Sharing https://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.124.010257 Nosek, Variability in Analytic Methods https://journals.sagepub.com/doi/10.1177/2515245917747646 Zeraatker, Variability in Analytic Methods   You may also like: The Bob Harrington Show with the Stephen and Suzanne Weiss Dean of Weill Cornell Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

We all have fond memories of the first Dev Day in 2023:and the blip that followed soon after. As Ben Thompson has noted, this year's DevDay took a quieter, more intimate tone. No Satya, no livestream, (slightly fewer people?). Instead of putting ChatGPT announcements in DevDay as in 2023, o1 was announced 2 weeks prior, and DevDay 2024 was reserved purely for developer-facing API announcements, primarily the Realtime API, Vision Finetuning, Prompt Caching, and Model Distillation.However the larger venue and more spread out schedule did allow a lot more hallway conversations with attendees as well as more community presentations including our recent guest Alistair Pullen of Cosine as well as deeper dives from OpenAI including our recent guest Michelle Pokrass of the API Team. Thanks to OpenAI's warm collaboration (we particularly want to thank Lindsay McCallum Rémy!), we managed to record exclusive interviews with many of the main presenters of both the keynotes and breakout sessions. We present them in full in today's episode, together with a full lightly edited Q&A with Sam Altman.Show notes and related resourcesSome of these used in the final audio episode below* Simon Willison Live Blog* swyx live tweets and videos* Greg Kamradt coverage of Structured Output session, Scaling LLM Apps session* Fireside Chat Q&A with Sam AltmanTimestamps* [00:00:00] Intro by Suno.ai* [00:01:23] NotebookLM Recap of DevDay* [00:09:25] Ilan's Strawberry Demo with Realtime Voice Function Calling* [00:19:16] Olivier Godement, Head of Product, OpenAI* [00:36:57] Romain Huet, Head of DX, OpenAI* [00:47:08] Michelle Pokrass, API Tech Lead at OpenAI ft. Simon Willison* [01:04:45] Alistair Pullen, CEO, Cosine (Genie)* [01:18:31] Sam Altman + Kevin Weill Q&A* [02:03:07] Notebook LM Recap of PodcastTranscript[00:00:00] Suno AI: Under dev daylights, code ignites. Real time voice streams reach new heights. O1 and GPT, 4. 0 in flight. Fine tune the future, data in sight. Schema sync up, outputs precise. Distill the models, efficiency splice.[00:00:33] AI Charlie: Happy October. This is your AI co host, Charlie. One of our longest standing traditions is covering major AI and ML conferences in podcast format. Delving, yes delving, into the vibes of what it is like to be there stitched in with short samples of conversations with key players, just to help you feel like you were there.[00:00:54] AI Charlie: Covering this year's Dev Day was significantly more challenging because we were all requested not to record the opening keynotes. So, in place of the opening keynotes, we had the viral notebook LM Deep Dive crew, my new AI podcast nemesis, Give you a seven minute recap of everything that was announced.[00:01:15] AI Charlie: Of course, you can also check the show notes for details. I'll then come back with an explainer of all the interviews we have for you today. Watch out and take care.[00:01:23] NotebookLM Recap of DevDay[00:01:23] NotebookLM: All right, so we've got a pretty hefty stack of articles and blog posts here all about open ais. Dev day 2024.[00:01:32] NotebookLM 2: Yeah, lots to dig into there.[00:01:34] NotebookLM 2: Seems[00:01:34] NotebookLM: like you're really interested in what's new with AI.[00:01:36] NotebookLM 2: Definitely. And it seems like OpenAI had a lot to announce. New tools, changes to the company. It's a lot.[00:01:43] NotebookLM: It is. And especially since you're interested in how AI can be used in the real world, you know, practical applications, we'll focus on that.[00:01:51] NotebookLM: Perfect. Like, for example, this Real time API, they announced that, right? That seems like a big deal if we want AI to sound, well, less like a robot.[00:01:59] NotebookLM 2: It could be huge. The real time API could completely change how we, like, interact with AI. Like, imagine if your voice assistant could actually handle it if you interrupted it.[00:02:08] NotebookLM: Or, like, have an actual conversation.[00:02:10] NotebookLM 2: Right, not just these clunky back and forth things we're used to.[00:02:14] NotebookLM: And they actually showed it off, didn't they? I read something about a travel app, one for languages. Even one where the AI ordered takeout.[00:02:21] NotebookLM 2: Those demos were really interesting, and I think they show how this real time API can be used in so many ways.[00:02:28] NotebookLM 2: And the tech behind it is fascinating, by the way. It uses persistent WebSocket connections and this thing called function calling, so it can respond in real time.[00:02:38] NotebookLM: So the function calling thing, that sounds kind of complicated. Can you, like, explain how that works?[00:02:42] NotebookLM 2: So imagine giving the AI Access to this whole toolbox, right?[00:02:46] NotebookLM 2: Information, capabilities, all sorts of things. Okay. So take the travel agent demo, for example. With function calling, the AI can pull up details, let's say about Fort Mason, right, from some database. Like nearby restaurants, stuff like that.[00:02:59] NotebookLM: Ah, I get it. So instead of being limited to what it already knows, It can go and find the information it needs, like a human travel agent would.[00:03:07] NotebookLM 2: Precisely. And someone on Hacker News pointed out a cool detail. The API actually gives you a text version of what's being said. So you can store that, analyze it.[00:03:17] NotebookLM: That's smart. It seems like OpenAI put a lot of thought into making this API easy for developers to use. But, while we're on OpenAI, you know, Besides their tech, there's been some news about, like, internal changes, too.[00:03:30] NotebookLM: Didn't they say they're moving away from being a non profit?[00:03:32] NotebookLM 2: They did. And it's got everyone talking. It's a major shift. And it's only natural for people to wonder how that'll change things for OpenAI in the future. I mean, there are definitely some valid questions about this move to for profit. Like, will they have more money for research now?[00:03:46] NotebookLM 2: Probably. But will they, you know, care as much about making sure AI benefits everyone?[00:03:51] NotebookLM: Yeah, that's the big question, especially with all the, like, the leadership changes happening at OpenAI too, right? I read that their Chief Research Officer left, and their VP of Research, and even their CTO.[00:04:03] NotebookLM 2: It's true. A lot of people are connecting those departures with the changes in OpenAI's structure.[00:04:08] NotebookLM: And I guess it makes you wonder what's going on behind the scenes. But they are still putting out new stuff. Like this whole fine tuning thing really caught my eye.[00:04:17] NotebookLM 2: Right, fine tuning. It's essentially taking a pre trained AI model. And, like, customizing it.[00:04:23] NotebookLM: So instead of a general AI, you get one that's tailored for a specific job.[00:04:27] NotebookLM 2: Exactly. And that opens up so many possibilities, especially for businesses. Imagine you could train an AI on your company's data, you know, like how you communicate your brand guidelines.[00:04:37] NotebookLM: So it's like having an AI that's specifically trained for your company?[00:04:41] NotebookLM 2: That's the idea.[00:04:41] NotebookLM: And they're doing it with images now, too, right?[00:04:44] NotebookLM: Fine tuning with vision is what they called it.[00:04:46] NotebookLM 2: It's pretty incredible what they're doing with that, especially in fields like medicine.[00:04:50] NotebookLM: Like using AI to help doctors make diagnoses.[00:04:52] NotebookLM 2: Exactly. And AI could be trained on thousands of medical images, right? And then it could potentially spot things that even a trained doctor might miss.[00:05:03] NotebookLM: That's kind of scary, to be honest. What if it gets it wrong?[00:05:06] NotebookLM 2: Well, the idea isn't to replace doctors, but to give them another tool, you know, help them make better decisions.[00:05:12] NotebookLM: Okay, that makes sense. But training these AI models must be really expensive.[00:05:17] NotebookLM 2: It can be. All those tokens add up. But OpenAI announced something called automatic prompt caching.[00:05:23] Alex Volkov: Automatic what now? I don't think I came across that.[00:05:26] NotebookLM 2: So basically, if your AI sees a prompt that it's already seen before, OpenAI will give you a discount.[00:05:31] NotebookLM: Huh. Like a frequent buyer program for AI.[00:05:35] NotebookLM 2: Kind of, yeah. It's good that they're trying to make it more affordable. And they're also doing something called model distillation.[00:05:41] NotebookLM: Okay, now you're just using big words to sound smart. What's that?[00:05:45] NotebookLM 2: Think of it like like a recipe, right? You can take a really complex recipe and break it down to the essential parts.[00:05:50] NotebookLM: Make it simpler, but it still tastes the same.[00:05:53] NotebookLM 2: Yeah. And that's what model distillation is. You take a big, powerful AI model and create a smaller, more efficient version.[00:06:00] NotebookLM: So it's like lighter weight, but still just as capable.[00:06:03] NotebookLM 2: Exactly. And that means more people can actually use these powerful tools. They don't need, like, a supercomputer to run them.[00:06:10] NotebookLM: So they're making AI more accessible. That's great.[00:06:13] NotebookLM 2: It is. And speaking of powerful tools, they also talked about their new O1 model.[00:06:18] NotebookLM 2: That's the one they've been hyping up. The one that's supposed to be this big leap forward.[00:06:22] NotebookLM: Yeah, O1. It sounds pretty futuristic. Like, from what I read, it's not just a bigger, better language model.[00:06:28] NotebookLM 2: Right. It's a different porch.[00:06:29] NotebookLM: They're saying it can, like, actually reason, right? Think.[00:06:33] NotebookLM 2: It's trained differently.[00:06:34] NotebookLM 2: They used reinforcement learning with O1.[00:06:36] NotebookLM: So it's not just finding patterns in the data it's seen before.[00:06:40] NotebookLM 2: Not just that. It can actually learn from its mistakes. Get better at solving problems.[00:06:46] NotebookLM: So give me an example. What can O1 do that, say, GPT 4 can't?[00:06:51] NotebookLM 2: Well, OpenAI showed it doing some pretty impressive stuff with math, like advanced math.[00:06:56] NotebookLM 2: And coding, too. Complex coding. Things that even GPT 4 struggled with.[00:07:00] NotebookLM: So you're saying if I needed to, like, write a screenplay, I'd stick with GPT 4? But if I wanted to solve some crazy physics problem, O1 is what I'd use.[00:07:08] NotebookLM 2: Something like that, yeah. Although there is a trade off. O1 takes a lot more power to run, and it takes longer to get those impressive results.[00:07:17] NotebookLM: Hmm, makes sense. More power, more time, higher quality.[00:07:21] NotebookLM 2: Exactly.[00:07:22] NotebookLM: It sounds like it's still in development, though, right? Is there anything else they're planning to add to it?[00:07:26] NotebookLM 2: Oh, yeah. They mentioned system prompts, which will let developers, like, set some ground rules for how it behaves. And they're working on adding structured outputs and function calling.[00:07:38] Alex Volkov: Wait, structured outputs? Didn't we just talk about that? We[00:07:41] NotebookLM 2: did. That's the thing where the AI's output is formatted in a way that's easy to use.[00:07:47] NotebookLM: Right, right. So you don't have to spend all day trying to make sense of what it gives you. It's good that they're thinking about that stuff.[00:07:53] NotebookLM 2: It's about making these tools usable.[00:07:56] NotebookLM 2: And speaking of that, Dev Day finished up with this really interesting talk. Sam Altman, the CEO of OpenAI, And Kevin Weil, their new chief product officer. They talked about, like, the big picture for AI.[00:08:09] NotebookLM: Yeah, they did, didn't they? Anything interesting come up?[00:08:12] NotebookLM 2: Well, Altman talked about moving past this whole AGI term, Artificial General Intelligence.[00:08:18] NotebookLM: I can see why. It's kind of a loaded term, isn't it?[00:08:20] NotebookLM 2: He thinks it's become a bit of a buzzword, and people don't really understand what it means.[00:08:24] NotebookLM: So are they saying they're not trying to build AGI anymore?[00:08:28] NotebookLM 2: It's more like they're saying they're focused on just Making AI better, constantly improving it, not worrying about putting it in a box.[00:08:36] NotebookLM: That makes sense. Keep pushing the limits.[00:08:38] NotebookLM 2: Exactly. But they were also very clear about doing it responsibly. They talked a lot about safety and ethics.[00:08:43] NotebookLM: Yeah, that's important.[00:08:44] NotebookLM 2: They said they were going to be very careful. About how they release new features.[00:08:48] NotebookLM: Good! Because this stuff is powerful.[00:08:51] NotebookLM 2: It is. It was a lot to take in, this whole Dev Day event.[00:08:54] NotebookLM 2: New tools, big changes at OpenAI, and these big questions about the future of AI.[00:08:59] NotebookLM: It was. But hopefully this deep dive helped make sense of some of it. At least, that's what we try to do here.[00:09:05] AI Charlie: Absolutely.[00:09:06] NotebookLM: Thanks for taking the deep dive with us.[00:09:08] AI Charlie: The biggest demo of the new Realtime API involved function calling with voice mode and buying chocolate covered strawberries from our friendly local OpenAI developer experience engineer and strawberry shop owner, Ilan Biggio.[00:09:21] AI Charlie: We'll first play you the audio of his demo and then go into a little interview with him.[00:09:25] Ilan's Strawberry Demo with Realtime Voice Function Calling[00:09:25] Romain Huet: Could you place a call and see if you could get us 400 strawberries delivered to the venue? But please keep that under 1500. I'm on it. We'll get those strawberries delivered for you.[00:09:47] Ilan: Hello? Hi there. Is this Ilan? I'm Romain's AI assistant. How is it going? Fantastic. Can you tell me what flavors of strawberry dips you have for me? Yeah, we have chocolate, vanilla, and we have peanut butter. Wait, how much would 400 chocolate covered strawberries cost? 400? Are you sure you want 400? Yes, 400 chocolate covered[00:10:14] swyx: strawberries.[00:10:15] Ilan: Wait,[00:10:16] swyx: how much[00:10:16] Ilan: would that be? I think that'll be around, like, 1, 415. 92.[00:10:25] Alex Volkov: Awesome. Let's go ahead and place the order for four chocolate covered strawberries.[00:10:31] Ilan: Great, where would you like that delivered? Please deliver them to the Gateway Pavilion at Fort Mason. And I'll be paying in cash.[00:10:42] Alex Volkov: Okay,[00:10:43] Ilan: sweet. So just to confirm, you want four strawberries?[00:10:45] Ilan: 400 chocolate covered strawberries to the Gateway Pavilion. Yes, that's perfect. And when can we expect delivery? Well, you guys are right nearby, so it'll be like, I don't know, 37 seconds? That's incredibly fast. Cool, you too.[00:11:09] swyx: Hi, Ilan, welcome to Lanespace. Oh, thank you. I just saw your amazing demos, had your amazing strawberries. You are dressed up, like, exactly like a strawberry salesman. Gotta have it all. What was the building on demo like? What was the story behind the demo?[00:11:22] swyx: It was really interesting. This is actually something I had been thinking about for months before the launch.[00:11:27] swyx: Like, having a, like, AI that can make phone calls is something like I've personally wanted for a long time. And so as soon as we launched internally, like, I started hacking on it. And then that sort of just started. We made it into like an internal demo, and then people found it really interesting, and then we thought how cool would it be to have this like on stage as, as one of the demos.[00:11:47] swyx: Yeah, would would you call out any technical issues building, like you were basically one of the first people ever to build with a voice mode API. Would you call out any issues like integrating it with Twilio like that, like you did with function calling, with like a form filling elements. I noticed that you had like intents of things to fulfill, and then.[00:12:07] swyx: When there's still missing info, the voice would prompt you, roleplaying the store guy.[00:12:13] swyx: Yeah, yeah, so, I think technically, there's like the whole, just working with audio and streams is a whole different beast. Like, even separate from like AI and this, this like, new capabilities, it's just, it's just tough.[00:12:26] swyx: Yeah, when you have a prompt, conversationally it'll just follow, like the, it was, Instead of like, kind of step by step to like ask the right questions based on like the like what the request was, right? The function calling itself is sort of tangential to that. Like, you have to prompt it to call the functions, but then handling it isn't too much different from, like, what you would do with assistant streaming or, like, chat completion streaming.[00:12:47] swyx: I think, like, the API feels very similar just to, like, if everything in the API was streaming, it actually feels quite familiar to that.[00:12:53] swyx: And then, function calling wise, I mean, does it work the same? I don't know. Like, I saw a lot of logs. You guys showed, like, in the playground, a lot of logs. What is in there?[00:13:03] swyx: What should people know?[00:13:04] swyx: Yeah, I mean, it is, like, the events may have different names than the streaming events that we have in chat completions, but they represent very similar things. It's things like, you know, function call started, argument started, it's like, here's like argument deltas, and then like function call done.[00:13:20] swyx: Conveniently we send one that has the full function, and then I just use that. Nice.[00:13:25] swyx: Yeah and then, like, what restrictions do, should people be aware of? Like, you know, I think, I think, before we recorded, we discussed a little bit about the sensitivities around basically calling random store owners and putting, putting like an AI on them.[00:13:40] swyx: Yeah, so there's, I think there's recent regulation on that, which is why we want to be like very, I guess, aware of, of You know, you can't just call anybody with AI, right? That's like just robocalling. You wouldn't want someone just calling you with AI.[00:13:54] swyx: I'm a developer, I'm about to do this on random people.[00:13:57] swyx: What laws am I about to break?[00:14:00] swyx: I forget what the governing body is, but you should, I think, Having consent of the person you're about to call, it always works. I, as the strawberry owner, have consented to like getting called with AI. I think past that you, you want to be careful. Definitely individuals are more sensitive than businesses.[00:14:19] swyx: I think businesses you have a little bit more leeway. Also, they're like, businesses I think have an incentive to want to receive AI phone calls. Especially if like, they're dealing with it. It's doing business. Right, like, it's more business. It's kind of like getting on a booking platform, right, you're exposed to more.[00:14:33] swyx: But, I think it's still very much like a gray area. Again, so. I think everybody should, you know, tread carefully, like, figure out what it is. I, I, I, the law is so recent, I didn't have enough time to, like, I'm also not a lawyer. Yeah, yeah, yeah, of course. Yeah.[00:14:49] swyx: Okay, cool fair enough. One other thing, this is kind of agentic.[00:14:52] swyx: Did you use a state machine at all? Did you use any framework? No. You just stick it in context and then just run it in a loop until it ends call?[00:15:01] swyx: Yeah, there isn't even a loop, like Okay. Because the API is just based on sessions. It's always just going to keep going. Every time you speak, it'll trigger a call.[00:15:11] swyx: And then after every function call was also invoked invoking like a generation. And so that is another difference here. It's like it's inherently almost like in a loop, be just by being in a session, right? No state machines needed. I'd say this is very similar to like, the notion of routines, where it's just like a list of steps.[00:15:29] swyx: And it, like, sticks to them softly, but usually pretty well. And the steps is the prompts? The steps, it's like the prompt, like the steps are in the prompt. Yeah, yeah, yeah. Right, it's like step one, do this, step one, step two, do that. What if I want to change the system prompt halfway through the conversation?[00:15:44] swyx: You can. Okay. You can. To be honest, I have not played without two too much. Yeah,[00:15:47] swyx: yeah.[00:15:48] swyx: But, I know you can.[00:15:49] swyx: Yeah, yeah. Yeah. Awesome. I noticed that you called it real time API, but not voice API. Mm hmm. So I assume that it's like real time API starting with voice. Right, I think that's what he said on the thing.[00:16:00] swyx: I can't imagine, like, what else is real[00:16:02] swyx: time? Well, I guess, to use ChatGPT's voice mode as an example, Like, we've demoed the video, right? Like, real time image, right? So, I'm not actually sure what timelines are, But I would expect, if I had to guess, That, like, that is probably the next thing that we're gonna be making.[00:16:17] swyx: You'd probably have to talk directly with the team building this. Sure. But, You can't promise their timelines. Yeah, yeah, yeah, right, exactly. But, like, given that this is the features that currently, Or that exists that we've demoed on Chachapiti. Yeah. There[00:16:29] swyx: will never be a[00:16:29] swyx: case where there's like a real time text API, right?[00:16:31] swyx: I don't Well, this is a real time text API. You can do text only on this. Oh. Yeah. I don't know why you would. But it's actually So text to text here doesn't quite make a lot of sense. I don't think you'll get a lot of latency gain. But, like, speech to text is really interesting. Because you can prevent You can prevent responses, like audio responses.[00:16:54] swyx: And force function calls. And so you can do stuff like UI control. That is like super super reliable. We had a lot of like, you know, un, like, we weren't sure how well this was gonna work because it's like, you have a voice answering. It's like a whole persona, right? Like, that's a little bit more, you know, risky.[00:17:10] swyx: But if you, like, cut out the audio outputs and make it so it always has to output a function, like you can end up with pretty pretty good, like, Pretty reliable, like, command like a command architecture. Yeah,[00:17:21] swyx: actually, that's the way I want to interact with a lot of these things as well. Like, one sided voice.[00:17:26] swyx: Yeah, you don't necessarily want to hear the[00:17:27] swyx: voice back. And like, sometimes it's like, yeah, I think having an output voice is great. But I feel like I don't always want to hear an output voice. I'd say usually I don't. But yeah, exactly, being able to speak to it is super sweet.[00:17:39] swyx: Cool. Do you want to comment on any of the other stuff that you announced?[00:17:41] swyx: From caching I noticed was like, I like the no code change part. I'm looking forward to the docs because I'm sure there's a lot of details on like, what you cache, how long you cache. Cause like, enthalpy caches were like 5 minutes. I was like, okay, but what if I don't make a call every 5 minutes?[00:17:56] swyx: Yeah,[00:17:56] swyx: to be super honest with you, I've been so caught up with the real time API and making the demo that I haven't read up on the other stuff. Launches too much. I mean, I'm aware of them, but I think I'm excited to see how all distillation works. That's something that we've been doing like, I don't know, I've been like doing it between our models for a while And I've seen really good results like I've done back in a day like from GPT 4 to GPT 3.[00:18:19] swyx: 5 And got like, like pretty much the same level of like function calling with like hundreds of functions So that was super super compelling So, I feel like easier distillation, I'm really excited for. I see. Is it a tool?[00:18:31] swyx: So, I saw evals. Yeah. Like, what is the distillation product? It wasn't super clear, to be honest.[00:18:36] swyx: I, I think I want to, I want to let that team, I want to let that team talk about it. Okay,[00:18:40] swyx: alright. Well, I appreciate you jumping on. Yeah, of course. Amazing demo. It was beautifully designed. I'm sure that was part of you and Roman, and[00:18:47] swyx: Yeah, I guess, shout out to like, the first people to like, creators of Wanderlust, originally, were like, Simon and Carolis, and then like, I took it and built the voice component and the voice calling components.[00:18:59] swyx: Yeah, so it's been a big team effort. And like the entire PI team for like Debugging everything as it's been going on. It's been, it's been so good working with them. Yeah, you're the first consumers on the DX[00:19:07] swyx: team. Yeah. Yeah, I mean, the classic role of what we do there. Yeah. Okay, yeah, anything else? Any other call to action?[00:19:13] swyx: No, enjoy Dev Day. Thank you. Yeah. That's it.[00:19:16] Olivier Godement, Head of Product, OpenAI[00:19:16] AI Charlie: The latent space crew then talked to Olivier Godmont, head of product for the OpenAI platform, who led the entire Dev Day keynote and introduced all the major new features and updates that we talked about today.[00:19:28] swyx: Okay, so we are here with Olivier Godmont. That's right.[00:19:32] swyx: I don't pronounce French. That's fine. It was perfect. And it was amazing to see your keynote today. What was the back story of, of preparing something like this? Preparing, like, Dev Day? It[00:19:43] Olivier Godement: essentially came from a couple of places. Number one, excellent reception from last year's Dev Day.[00:19:48] Olivier Godement: Developers, startup founders, researchers want to spend more time with OpenAI, and we want to spend more time with them as well. And so for us, like, it was a no brainer, frankly, to do it again, like, you know, like a nice conference. The second thing is going global. We've done a few events like in Paris and like a few other like, you know, non European, non American countries.[00:20:05] Olivier Godement: And so this year we're doing SF, Singapore, and London. To frankly just meet more developers.[00:20:10] swyx: Yeah, I'm very excited for the Singapore one.[00:20:12] Olivier Godement: Ah,[00:20:12] swyx: yeah. Will you be[00:20:13] Olivier Godement: there?[00:20:14] swyx: I don't know. I don't know if I got an invite. No. I can't just talk to you. Yeah, like, and then there was some speculation around October 1st.[00:20:22] Olivier Godement: Yeah. Is it because[00:20:23] swyx: 01, October 1st? It[00:20:25] Olivier Godement: has nothing to do. I discovered the tweet yesterday where like, people are so creative. No one, there was no connection to October 1st. But in hindsight, that would have been a pretty good meme by Tiana. Okay.[00:20:37] swyx: Yeah, and you know, I think like, OpenAI's outreach to developers is something that I felt the whole in 2022, when like, you know, like, people were trying to build a chat GPT, and like, there was no function calling, all that stuff that you talked about in the past.[00:20:51] swyx: And that's why I started my own conference as like like, here's our little developer conference thing. And, but to see this OpenAI Dev Day now, and like to see so many developer oriented products coming to OpenAI, I think it's really encouraging.[00:21:02] Olivier Godement: Yeah, totally. It's that's what I said, essentially, like, developers are basically the people who make the best connection between the technology and, you know, the future, essentially.[00:21:14] Olivier Godement: Like, you know, essentially see a capability, see a low level, like, technology, and are like, hey, I see how that application or that use case that can be enabled. And so, in the direction of enabling, like, AGI, like, all of humanity, it's a no brainer for us, like, frankly, to partner with Devs.[00:21:31] Alessio: And most importantly, you almost never had waitlists, which, compared to like other releases, people usually, usually have.[00:21:38] Alessio: What is the, you know, you had from caching, you had real time voice API, we, you know, Shawn did a long Twitter thread, so people know the releases. Yeah. What is the thing that was like sneakily the hardest to actually get ready for, for that day, or like, what was the kind of like, you know, last 24 hours, anything that you didn't know was gonna work?[00:21:56] Olivier Godement: Yeah. The old Fairly, like, I would say, involved, like, features to ship. So the team has been working for a month, all of them. The one which I would say is the newest for OpenAI is the real time API. For a couple of reasons. I mean, one, you know, it's a new modality. Second, like, it's the first time that we have an actual, like, WebSocket based API.[00:22:16] Olivier Godement: And so, I would say that's the one that required, like, the most work over the month. To get right from a developer perspective and to also make sure that our existing safety mitigation that worked well with like real time audio in and audio out.[00:22:30] swyx: Yeah, what design choices or what was like the sort of design choices that you want to highlight?[00:22:35] swyx: Like, you know, like I think for me, like, WebSockets, you just receive a bunch of events. It's two way. I obviously don't have a ton of experience. I think a lot of developers are going to have to embrace this real time programming. Like, what are you designing for, or like, what advice would you have for developers exploring this?[00:22:51] Olivier Godement: The core design hypothesis was essentially, how do we enable, like, human level latency? We did a bunch of tests, like, on average, like, human beings, like, you know, takes, like, something like 300 milliseconds to converse with each other. And so that was the design principle, essentially. Like, working backward from that, and, you know, making the technology work.[00:23:11] Olivier Godement: And so we evaluated a few options, and WebSockets was the one that we landed on. So that was, like, one design choice. A few other, like, big design choices that we had to make prompt caching. Prompt caching, the design, like, target was automated from the get go. Like, zero code change from the developer.[00:23:27] Olivier Godement: That way you don't have to learn, like, what is a prompt prefix, and, you know, how long does a cache work, like, we just do it as much as we can, essentially. So that was a big design choice as well. And then finally, on distillation, like, and evaluation. The big design choice was something I learned at Skype, like in my previous job, like a philosophy around, like, a pit of success.[00:23:47] Olivier Godement: Like, what is essentially the, the, the minimum number of steps for the majority of developers to do the right thing? Because when you do evals on fat tuning, there are many, many ways, like, to mess it up, frankly, like, you know, and have, like, a crappy model, like, evals that tell, like, a wrong story. And so our whole design was, okay, we actually care about, like, helping people who don't have, like, that much experience, like, evaluating a model, like, get, like, in a few minutes, like, to a good spot.[00:24:11] Olivier Godement: And so how do we essentially enable that bit of success, like, in the product flow?[00:24:15] swyx: Yeah, yeah, I'm a little bit scared to fine tune especially for vision, because I don't know what I don't know for stuff like vision, right? Like, for text, I can evaluate pretty easily. For vision let's say I'm like trying to, one of your examples was grab.[00:24:33] swyx: Which, very close to home, I'm from Singapore. I think your example was like, they identified stop signs better. Why is that hard? Why do I have to fine tune that? If I fine tune that, do I lose other things? You know, like, there's a lot of unknowns with Vision that I think developers have to figure out.[00:24:50] swyx: For[00:24:50] Olivier Godement: sure. Vision is going to open up, like, a new, I would say, evaluation space. Because you're right, like, it's harder, like, you know, to tell correct from incorrect, essentially, with images. What I can say is we've been alpha testing, like, the Vision fine tuning, like, for several weeks at that point. We are seeing, like, even higher performance uplift compared to text fine tuning.[00:25:10] Olivier Godement: So that's, there is something here, like, we've been pretty impressed, like, in a good way, frankly. But, you know, how well it works. But for sure, like, you know, I expect the developers who are moving from one modality to, like, text and images will have, like, more, you know Testing, evaluation, like, you know, to set in place, like, to make sure it works well.[00:25:25] Alessio: The model distillation and evals is definitely, like, the most interesting. Moving away from just being a model provider to being a platform provider. How should people think about being the source of truth? Like, do you want OpenAI to be, like, the system of record of all the prompting? Because people sometimes store it in, like, different data sources.[00:25:41] Alessio: And then, is that going to be the same as the models evolve? So you don't have to worry about, you know, refactoring the data, like, things like that, or like future model structures.[00:25:51] Olivier Godement: The vision is if you want to be a source of truth, you have to earn it, right? Like, we're not going to force people, like, to pass us data.[00:25:57] Olivier Godement: There is no value prop, like, you know, for us to store the data. The vision here is at the moment, like, most developers, like, use like a one size fits all model, like be off the shelf, like GP40 essentially. The vision we have is fast forward a couple of years. I think, like, most developers will essentially, like, have a.[00:26:15] Olivier Godement: An automated, continuous, fine tuned model. The more, like, you use the model, the more data you pass to the model provider, like, the model is automatically, like, fine tuned, evaluated against some eval sets, and essentially, like, you don't have to every month, when there is a new snapshot, like, you know, to go online and, you know, try a few new things.[00:26:34] Olivier Godement: That's a direction. We are pretty far away from it. But I think, like, that evaluation and decision product are essentially a first good step in that direction. It's like, hey, it's you. I set it by that direction, and you give us the evaluation data. We can actually log your completion data and start to do some automation on your behalf.[00:26:52] Alessio: And then you can do evals for free if you share data with OpenAI. How should people think about when it's worth it, when it's not? Sometimes people get overly protective of their data when it's actually not that useful. But how should developers think about when it's right to do it, when not, or[00:27:07] Olivier Godement: if you have any thoughts on it?[00:27:08] Olivier Godement: The default policy is still the same, like, you know, we don't train on, like, any API data unless you opt in. What we've seen from feedback is evaluation can be expensive. Like, if you run, like, O1 evals on, like, thousands of samples Like, your build will get increased, like, you know, pretty pretty significantly.[00:27:22] Olivier Godement: That's problem statement number one. Problem statement number two is, essentially, I want to get to a world where whenever OpenAI ships a new model snapshot, we have full confidence that there is no regression for the task that developers care about. And for that to be the case, essentially, we need to get evals.[00:27:39] Olivier Godement: And so that, essentially, is a sort of a two bugs one stone. It's like, we subsidize, basically, the evals. And we also use the evals when we ship new models to make sure that we keep going in the right direction. So, in my sense, it's a win win, but again, completely opt in. I expect that many developers will not want to share their data, and that's perfectly fine to me.[00:27:56] swyx: Yeah, I think free evals though, very, very good incentive. I mean, it's a fair trade. You get data, we get free evals. Exactly,[00:28:04] Olivier Godement: and we sanitize PII, everything. We have no interest in the actual sensitive data. We just want to have good evaluation on the real use cases.[00:28:13] swyx: Like, I always want to eval the eval. I don't know if that ever came up.[00:28:17] swyx: Like, sometimes the evals themselves are wrong, and there's no way for me to tell you.[00:28:22] Olivier Godement: Everyone who is starting with LLM, teaching with LLM, is like, Yeah, evaluation, easy, you know, I've done testing, like, all my life. And then you start to actually be able to eval, understand, like, all the corner cases, And you realize, wow, there's like a whole field in itself.[00:28:35] Olivier Godement: So, yeah, good evaluation is hard and so, yeah. Yeah, yeah.[00:28:38] swyx: But I think there's a, you know, I just talked to Brain Trust which I think is one of your partners. Mm-Hmm. . They also emphasize code based evals versus your sort of low code. What I see is like, I don't know, maybe there's some more that you didn't demo.[00:28:53] swyx: YC is kind of like a low code experience, right, for evals. Would you ever support like a more code based, like, would I run code on OpenAI's eval platform?[00:29:02] Olivier Godement: For sure. I mean, we meet developers where they are, you know. At the moment, the demand was more for like, you know, easy to get started, like eval. But, you know, if we need to expose like an evaluation API, for instance, for people like, you know, to pass, like, you know, their existing test data we'll do it.[00:29:15] Olivier Godement: So yeah, there is no, you know, philosophical, I would say, like, you know, misalignment on that. Yeah,[00:29:19] swyx: yeah, yeah. What I think this is becoming, by the way, and I don't, like it's basically, like, you're becoming AWS. Like, the AI cloud. And I don't know if, like, that's a conscious strategy, or it's, like, It doesn't even have to be a conscious strategy.[00:29:33] swyx: Like, you're going to offer storage. You're going to offer compute. You're going to offer networking. I don't know what networking looks like. Networking is maybe, like, Caching or like it's a CDN. It's a prompt CDN.[00:29:45] Alex Volkov: Yeah,[00:29:45] swyx: but it's the AI versions of everything, right? Do you like do you see the analogies or?[00:29:52] Olivier Godement: Whatever Whatever I took to developers. I feel like Good models are just half of the story to build a good app There's a third model you need to do Evaluation is the perfect example. Like, you know, you can have the best model in the world If you're in the dark, like, you know, it's really hard to gain the confidence and so Our philosophy is[00:30:11] Olivier Godement: The whole like software development stack is being basically reinvented, you know, with LLMs. There is no freaking way that open AI can build everything. Like there is just too much to build, frankly. And so my philosophy is, essentially, we'll focus on like the tools which are like the closest to the model itself.[00:30:28] Olivier Godement: So that's why you see us like, you know, investing quite a bit in like fine tuning, distillation, our evaluation, because we think that it actually makes sense to have like in one spot, Like, you know, all of that. Like, there is some sort of virtual circle, essentially, that you can set in place. But stuff like, you know, LLMOps, like tools which are, like, further away from the model, I don't know if you want to do, like, you know, super elaborate, like, prompt management, or, you know, like, tooling, like, I'm not sure, like, you know, OpenAI has, like, such a big edge, frankly, like, you know, to build this sort of tools.[00:30:56] Olivier Godement: So that's how we view it at the moment. But again, frankly, the philosophy is super simple. The strategy is super simple. It's meeting developers where they want us to be. And so, you know that's frankly, like, you know, day in, day out, like, you know, what I try to do.[00:31:08] Alessio: Cool. Thank you so much for the time.[00:31:10] Alessio: I'm sure you,[00:31:10] swyx: Yeah, I have more questions on, a couple questions on voice, and then also, like, your call to action, like, what you want feedback on, right? So, I think we should spend a bit more time on voice, because I feel like that's, like, the big splash thing. I talked well Well, I mean, I mean, just what is the future of real time for OpenAI?[00:31:28] swyx: Yeah. Because I think obviously video is next. You already have it in the, the ChatGPT desktop app. Do we just have a permanent, like, you know, like, are developers just going to be, like, sending sockets back and forth with OpenAI? Like how do we program for that? Like, what what is the future?[00:31:44] Olivier Godement: Yeah, that makes sense. I think with multimodality, like, real time is quickly becoming, like, you know, essentially the right experience, like, to build an application. Yeah. So my expectation is that we'll see like a non trivial, like a volume of applications like moving to a real time API. Like if you zoom out, like, audio is really simple, like, audio until basically now.[00:32:05] Olivier Godement: Audio on the web, in apps, was basically very much like a second class citizen. Like, you basically did like an audio chatbot for users who did not have a choice. You know, they were like struggling to read, or I don't know, they were like not super educated with technology. And so, frankly, it was like the crappy option, you know, compared to text.[00:32:25] Olivier Godement: But when you talk to people in the real world, the vast majority of people, like, prefer to talk and listen instead of typing and writing.[00:32:34] swyx: We speak before we write.[00:32:35] Olivier Godement: Exactly. I don't know. I mean, I'm sure it's the case for you in Singapore. For me, my friends in Europe, the number of, like, WhatsApp, like, voice notes they receive every day, I mean, just people, it makes sense, frankly, like, you know.[00:32:45] Olivier Godement: Chinese. Chinese, yeah.[00:32:46] swyx: Yeah,[00:32:47] Olivier Godement: all voice. You know, it's easier. There is more emotions. I mean, you know, you get the point across, like, pretty well. And so my personal ambition for, like, the real time API and, like, audio in general is to make, like, audio and, like, multimodality, like, truly a first class experience.[00:33:01] Olivier Godement: Like, you know, if you're, like, you know, the amazing, like, super bold, like, start up out of YC, you want to build, like, the next, like, billion, like, you know, user application to make it, like, truly your first and make it feel, like, you know, an actual good, like, you know, product experience. So that's essentially the ambition, and I think, like, yeah, it could be pretty big.[00:33:17] swyx: Yeah. I think one, one people, one issue that people have with the voice so far as, as released in advanced voice mode is the refusals.[00:33:24] Alex Volkov: Yeah.[00:33:24] swyx: You guys had a very inspiring model spec. I think Joanne worked on that. Where you said, like, yeah, we don't want to overly refuse all the time. In fact, like, even if, like, not safe for work, like, in some occasions, it's okay.[00:33:38] swyx: How, is there an API that we can say, not safe for work, okay?[00:33:41] Olivier Godement: I think we'll get there. I think we'll get there. The mobile spec, like, nailed it, like, you know. It nailed it! It's so good! Yeah, we are not in the business of, like, policing, you know, if you can say, like, vulgar words or whatever. You know, there are some use cases, like, you know, I'm writing, like, a Hollywood, like, script I want to say, like, will go on, and it's perfectly fine, you know?[00:33:59] Olivier Godement: And so I think the direction where we'll go here is that basically There will always be like, you know, a set of behavior that we will, you know, just like forbid, frankly, because they're illegal against our terms of services. But then there will be like, you know, some more like risky, like themes, which are completely legal, like, you know, vulgar words or, you know, not safe for work stuff.[00:34:17] Olivier Godement: Where basically we'll expose like a controllable, like safety, like knobs in the API to basically allow you to say, hey, that theme okay, that theme not okay. How sensitive do you want the threshold to be on safety refusals? I think that's the Dijkstra. So a[00:34:31] swyx: safety API.[00:34:32] Olivier Godement: Yeah, in a way, yeah.[00:34:33] swyx: Yeah, we've never had that.[00:34:34] Olivier Godement: Yeah. '[00:34:35] swyx: cause right now is you, it is whatever you decide. And then it's, that's it. That, that, that would be the main reason I don't use opening a voice is because of[00:34:42] Olivier Godement: it's over police. Over refuse over refusals. Yeah. Yeah, yeah. No, we gotta fix that. Yeah. Like singing,[00:34:47] Alessio: we're trying to do voice. I'm a singer.[00:34:49] swyx: And you, you locked off singing.[00:34:51] swyx: Yeah,[00:34:51] Alessio: yeah, yeah.[00:34:52] swyx: But I, I understand music gets you in trouble. Okay. Yeah. So then, and then just generally, like, what do you want to hear from developers? Right? We have, we have all developers watching you know, what feedback do you want? Any, anything specific as well, like from, especially from today anything that you are unsure about, that you are like, Our feedback could really help you decide.[00:35:09] swyx: For sure.[00:35:10] Olivier Godement: I think, essentially, it's becoming pretty clear after today that, you know, I would say the open end direction has become pretty clear, like, you know, after today. Investment in reasoning, investment in multimodality, Investment as well, like in, I would say, tool use, like function calling. To me, the biggest question I have is, you know, Where should we put the cursor next?[00:35:30] Olivier Godement: I think we need all three of them, frankly, like, you know, so we'll keep pushing.[00:35:33] swyx: Hire 10, 000 people, or actually, no need, build a bunch of bots.[00:35:37] Olivier Godement: Exactly, and so let's take O1 smart enough, like, for your problems? Like, you know, let's set aside for a second the existing models, like, for the apps that you would love to build, is O1 basically it in reasoning, or do we still have, like, you know, a step to do?[00:35:50] Olivier Godement: Preview is not enough, I[00:35:52] swyx: need the full one.[00:35:53] Olivier Godement: Yeah, so that's exactly that sort of feedback. Essentially what they would love to do is for developers I mean, there's a thing that Sam has been saying like over and over again, like, you know, it's easier said than done, but I think it's directionally correct. As a developer, as a founder, you basically want to build an app which is a bit too difficult for the model today, right?[00:36:12] Olivier Godement: Like, what you think is right, it's like, sort of working, sometimes not working. And that way, you know, that basically gives us like a goalpost, and be like, okay, that's what you need to enable with the next model release, like in a few months. And so I would say that Usually, like, that's the sort of feedback which is like the most useful that I can, like, directly, like, you know, incorporate.[00:36:33] swyx: Awesome. I think that's our time. Thank you so much, guys. Yeah, thank you so much.[00:36:38] AI Charlie: Thank you. We were particularly impressed that Olivier addressed the not safe for work moderation policy question head on, as that had only previously been picked up on in Reddit forums. This is an encouraging sign that we will return to in the closing candor with Sam Altman at the end of this episode.[00:36:57] Romain Huet, Head of DX, OpenAI[00:36:57] AI Charlie: Next, a chat with Roman Hewitt, friend of the pod, AI Engineer World's fair closing keynote speaker, and head of developer experience at OpenAI on his incredible live demos And advice to AI engineers on all the new modalities.[00:37:12] Alessio: Alright, we're live from OpenAI Dev Day. We're with Juan, who just did two great demos on, on stage.[00:37:17] Alessio: And he's been a friend of Latentspace, so thanks for taking some of the time.[00:37:20] Romain Huet: Of course, yeah, thank you for being here and spending the time with us today.[00:37:23] swyx: Yeah, I appreciate appreciate you guys putting this on. I, I know it's like extra work, but it really shows the developers that you're, Care and about reaching out.[00:37:31] Romain Huet: Yeah, of course, I think when you go back to the OpenAI mission, I think for us it's super important that we have the developers involved in everything we do. Making sure that you know, they have all of the tools they need to build successful apps. And we really believe that the developers are always going to invent the ideas, the prototypes, the fun factors of AI that we can't build ourselves.[00:37:49] Romain Huet: So it's really cool to have everyone here.[00:37:51] swyx: We had Michelle from you guys on. Yes, great episode. She very seriously said API is the path to AGI. Correct. And people in our YouTube comments were like, API is not AGI. I'm like, no, she's very serious. API is the path to AGI. Like, you're not going to build everything like the developers are, right?[00:38:08] swyx: Of[00:38:08] Romain Huet: course, yeah, that's the whole value of having a platform and an ecosystem of amazing builders who can, like, in turn, create all of these apps. I'm sure we talked about this before, but there's now more than 3 million developers building on OpenAI, so it's pretty exciting to see all of that energy into creating new things.[00:38:26] Alessio: I was going to say, you built two apps on stage today, an international space station tracker and then a drone. The hardest thing must have been opening Xcode and setting that up. Now, like, the models are so good that they can do everything else. Yes. You had two modes of interaction. You had kind of like a GPT app to get the plan with one, and then you had a cursor to do apply some of the changes.[00:38:47] Alessio: Correct. How should people think about the best way to consume the coding models, especially both for You know, brand new projects and then existing projects that you're trying to modify.[00:38:56] Romain Huet: Yeah. I mean, one of the things that's really cool about O1 Preview and O1 Mini being available in the API is that you can use it in your favorite tools like cursor like I did, right?[00:39:06] Romain Huet: And that's also what like Devin from Cognition can use in their own software engineering agents. In the case of Xcode, like, it's not quite deeply integrated in Xcode, so that's why I had like chat GPT side by side. But it's cool, right, because I could instruct O1 Preview to be, like, my coding partner and brainstorming partner for this app, but also consolidate all of the, the files and architect the app the way I wanted.[00:39:28] Romain Huet: So, all I had to do was just, like, port the code over to Xcode and zero shot the app build. I don't think I conveyed, by the way, how big a deal that is, but, like, you can now create an iPhone app from scratch, describing a lot of intricate details that you want, and your vision comes to life in, like, a minute.[00:39:47] Romain Huet: It's pretty outstanding.[00:39:48] swyx: I have to admit, I was a bit skeptical because if I open up SQL, I don't know anything about iOS programming. You know which file to paste it in. You probably set it up a little bit. So I'm like, I have to go home and test it. And I need the ChatGPT desktop app so that it can tell me where to click.[00:40:04] Romain Huet: Yeah, I mean like, Xcode and iOS development has become easier over the years since they introduced Swift and SwiftUI. I think back in the days of Objective C, or like, you know, the storyboard, it was a bit harder to get in for someone new. But now with Swift and SwiftUI, their dev tools are really exceptional.[00:40:23] Romain Huet: But now when you combine that with O1, as your brainstorming and coding partner, it's like your architect, effectively. That's the best way, I think, to describe O1. People ask me, like, can GPT 4 do some of that? And it certainly can. But I think it will just start spitting out code, right? And I think what's great about O1, is that it can, like, make up a plan.[00:40:42] Romain Huet: In this case, for instance, the iOS app had to fetch data from an API, it had to look at the docs, it had to look at, like, how do I parse this JSON, where do I store this thing, and kind of wire things up together. So that's where it really shines. Is mini or preview the better model that people should be using?[00:40:58] Romain Huet: Like, how? I think people should try both. We're obviously very excited about the upcoming O1 that we shared the evals for. But we noticed that O1 Mini is very, very good at everything math, coding, everything STEM. If you need for your kind of brainstorming or your kind of science part, you need some broader knowledge than reaching for O1 previews better.[00:41:20] Romain Huet: But yeah, I used O1 Mini for my second demo. And it worked perfectly. All I needed was very much like something rooted in code, architecting and wiring up like a front end, a backend, some UDP packets, some web sockets, something very specific. And it did that perfectly.[00:41:35] swyx: And then maybe just talking about voice and Wanderlust, the app that keeps on giving, what's the backstory behind like preparing for all of that?[00:41:44] Romain Huet: You know, it's funny because when last year for Dev Day, we were trying to think about what could be a great demo app to show like an assistive experience. I've always thought travel is a kind of a great use case because you have, like, pictures, you have locations, you have the need for translations, potentially.[00:42:01] Romain Huet: There's like so many use cases that are bounded to travel that I thought last year, let's use a travel app. And that's how Wanderlust came to be. But of course, a year ago, all we had was a text based assistant. And now we thought, well, if there's a voice modality, what if we just bring this app back as a wink.[00:42:19] Romain Huet: And what if we were interacting better with voice? And so with this new demo, what I showed was the ability to like, So, we wanted to have a complete conversation in real time with the app, but also the thing we wanted to highlight was the ability to call tools and functions, right? So, like in this case, we placed a phone call using the Twilio API, interfacing with our AI agents, but developers are so smart that they'll come up with so many great ideas that we could not think of ourselves, right?[00:42:48] Romain Huet: But what if you could have like a, you know, a 911 dispatcher? What if you could have like a customer service? Like center, that is much smarter than what we've been used to today. There's gonna be so many use cases for real time, it's awesome.[00:43:00] swyx: Yeah, and sometimes actually you, you, like this should kill phone trees.[00:43:04] swyx: Like there should not be like dial one[00:43:07] Romain Huet: of course para[00:43:08] swyx: espanol, you know? Yeah, exactly. Or whatever. I dunno.[00:43:12] Romain Huet: I mean, even you starting speaking Spanish would just do the thing, you know you don't even have to ask. So yeah, I'm excited for this future where we don't have to interact with those legacy systems.[00:43:22] swyx: Yeah. Yeah. Is there anything, so you are doing function calling in a streaming environment. So basically it's, it's web sockets. It's UDP, I think. It's basically not guaranteed to be exactly once delivery. Like, is there any coding challenges that you encountered when building this?[00:43:39] Romain Huet: Yeah, it's a bit more delicate to get into it.[00:43:41] Romain Huet: We also think that for now, what we, what we shipped is a, is a beta of this API. I think there's much more to build onto it. It does have the function calling and the tools. But we think that for instance, if you want to have something very robust, On your client side, maybe you want to have web RTC as a client, right?[00:43:58] Romain Huet: And, and as opposed to like directly working with the sockets at scale. So that's why we have partners like Life Kit and Agora if you want to, if you want to use them. And I'm sure we'll have many mores in the, in many more in the future. But yeah, we keep on iterating on that, and I'm sure the feedback of developers in the weeks to come is going to be super critical for us to get it right.[00:44:16] swyx: Yeah, I think LiveKit has been fairly public that they are used in, in the Chachapiti app. Like, is it, it's just all open source, and we just use it directly with OpenAI, or do we use LiveKit Cloud or something?[00:44:28] Romain Huet: So right now we, we released the API, we released some sample code also, and referenced clients for people to get started with our API.[00:44:35] Romain Huet: And we also partnered with LifeKit and Agora, so they also have their own, like ways to help you get started that plugs natively with the real time API. So depending on the use case, people can, can can decide what to use. If you're working on something that's completely client or if you're working on something on the server side, for the voice interaction, you may have different needs, so we want to support all of those.[00:44:55] Alessio: I know you gotta run. Is there anything that you want the AI engineering community to give feedback on specifically, like even down to like, you know, a specific API end point or like, what, what's like the thing that you want? Yeah. I[00:45:08] Romain Huet: mean, you know, if we take a step back, I think dev Day this year is all different from last year and, and in, in a few different ways.[00:45:15] Romain Huet: But one way is that we wanted to keep it intimate, even more intimate than last year. We wanted to make sure that the community is. Thank you very much for joining us on the Spotlight. That's why we have community talks and everything. And the takeaway here is like learning from the very best developers and AI engineers.[00:45:31] Romain Huet: And so, you know we want to learn from them. Most of what we shipped this morning, including things like prompt caching the ability to generate prompts quickly in the playground, or even things like vision fine tuning. These are all things that developers have been asking of us. And so, the takeaway I would, I would leave them with is to say like, Hey, the roadmap that we're working on is heavily influenced by them and their work.[00:45:53] Romain Huet: And so we love feedback From high feature requests, as you say, down to, like, very intricate details of an API endpoint, we love feedback, so yes that's, that's how we, that's how we build this API.[00:46:05] swyx: Yeah, I think the, the model distillation thing as well, it might be, like, the, the most boring, but, like, actually used a lot.[00:46:12] Romain Huet: True, yeah. And I think maybe the most unexpected, right, because I think if I, if I read Twitter correctly the past few days, a lot of people were expecting us. To shape the real time API for speech to speech. I don't think developers were expecting us to have more tools for distillation, and we really think that's gonna be a big deal, right?[00:46:30] Romain Huet: If you're building apps that have you know, you, you want high, like like low latency, low cost, but high performance, high quality on the use case distillation is gonna be amazing.[00:46:40] swyx: Yeah. I sat in the distillation session just now and they showed how they distilled from four oh to four mini and it was like only like a 2% hit in the performance and 50 next.[00:46:49] swyx: Yeah,[00:46:50] Romain Huet: I was there as well for the superhuman kind of use case inspired for an Ebola client. Yeah, this was really good. Cool man! so much for having me. Thanks again for being here today. It's always[00:47:00] AI Charlie: great to have you. As you might have picked up at the end of that chat, there were many sessions throughout the day focused on specific new capabilities.[00:47:08] Michelle Pokrass, Head of API at OpenAI ft. Simon Willison[00:47:08] AI Charlie: Like the new model distillation features combining EVOLs and fine tuning. For our next session, we are delighted to bring back two former guests of the pod, which is something listeners have been greatly enjoying in our second year of doing the Latent Space podcast. Michelle Pokras of the API team joined us recently to talk about structured outputs, and today gave an updated long form session at Dev Day, describing the implementation details of the new structured output mode.[00:47:39] AI Charlie: We also got her updated thoughts on the VoiceMode API we discussed in her episode, now that it is finally announced. She is joined by friend of the pod and super blogger, Simon Willison, who also came back as guest co host in our Dev Day. 2023 episode.[00:47:56] Alessio: Great, we're back live at Dev Day returning guest Michelle and then returning guest co host Fork.[00:48:03] Alessio: Fork, yeah, I don't know. I've lost count. I think it's been a few. Simon Willison is back. Yeah, we just wrapped, we just wrapped everything up. Congrats on, on getting everything everything live. Simon did a great, like, blog, so if you haven't caught up, I[00:48:17] Simon Willison: wrote my, I implemented it. Now, I'm starting my live blog while waiting for the first talk to start, using like GPT 4, I wrote me the Javascript, and I got that live just in time and then, yeah, I was live blogging the whole day.[00:48:28] swyx: Are you a cursor enjoyer?[00:48:29] Simon Willison: I haven't really gotten into cursor yet to be honest. I just haven't spent enough time for it to click, I think. I'm more a copy and paste things out of Cloud and chat GPT. Yeah. It's interesting.[00:48:39] swyx: Yeah. I've converted to cursor and 01 is so easy to just toggle on and off.[00:48:45] Alessio: What's your workflow?[00:48:46] Alessio: VS[00:48:48] Michelle Pokrass: Code co pilot, so Yep, same here. Team co pilot. Co pilot is actually the reason I joined OpenAI. It was, you know, before ChatGPT, this is the thing that really got me. So I'm still into it, but I keep meaning to try out Cursor, and I think now that things have calmed down, I'm gonna give it a real go.[00:49:03] swyx: Yeah, it's a big thing to change your tool of choice.[00:49:06] swyx: Yes,[00:49:06] Michelle Pokrass: yeah, I'm pretty dialed, so.[00:49:09] swyx: I mean, you know, if you want, you can just fork VS Code and make your own. That's the thing to dumb thing, right? We joked about doing a hackathon where the only thing you do is fork VS Code and bet me the best fork win.[00:49:20] Michelle Pokrass: Nice.[00:49:22] swyx: That's actually a really good idea. Yeah, what's up?[00:49:26] swyx: I mean, congrats on launching everything today. I know, like, we touched on it a little bit, but, like, everyone was kind of guessing that Voice API was coming, and, like, we talked about it in our episode. How do you feel going into the launch? Like, any design decisions that you want to highlight?[00:49:41] Michelle Pokrass: Yeah, super jazzed about it. The team has been working on it for a while. It's, like, a very different API for us. It's the first WebSocket API, so a lot of different design decisions to be made. It's, like, what kind of events do you send? When do you send an event? What are the event names? What do you send, like, on connection versus on future messages?[00:49:57] Michelle Pokrass: So there have been a lot of interesting decisions there. The team has also hacked together really cool projects as we've been testing it. One that I really liked is we had an internal hack a thon for the API team. And some folks built like a little hack that you could use to, like VIM with voice mode, so like, control vim, and you would tell them on like, nice, write a file and it would, you know, know all the vim commands and, and pipe those in.[00:50:18] Michelle Pokrass: So yeah, a lot of cool stuff we've been hacking on and really excited to see what people build with it.[00:50:23] Simon Willison: I've gotta call out a demo from today. I think it was Katja had a 3D visualization of the solar system, like WebGL solar system, you could talk to. That is one of the coolest conference demos I've ever seen.[00:50:33] Simon Willison: That was so convincing. I really want the code. I really want the code for that to get put out there. I'll talk[00:50:39] Michelle Pokrass: to the team. I think we can[00:50:40] Simon Willison: probably

Welcome to Tales from the Heart! This week host Lisa Salberg sits down with HCM group discussion leaders Karen Newsroom and Sydelle Zinn to discusses HCM and ICDs.

Meet Holly Rockweiler, CEO of Madorra. This episode explores the transformative journey of Madorra from a Stanford Biodesign fellowship project to a pioneering force in women's health aiming to revolutionize the treatment of vaginal atrophy and dryness without hormones. Holly's story is not just about groundbreaking medical devices, but also about the passion and determination that drive the quest for better healthcare solutions. Through engaging storytelling, this episode unveils the challenges and triumphs of bringing novel technologies to market, the power of female leadership in STEM, and the broader impact of MedTech on improving lives.  Guest links: www.madorra.com | https://www.linkedin.com/company/madorra-inc-/ | https://www.facebook.com/MadorraMedical | https://twitter.com/MadorraMedical Charity supported: Equal Justice Initiative Interested in being a guest on the show or have feedback to share? Email us at podcast@velentium.com.  PRODUCTION CREDITS Host: Lindsey Dinneen Editing: Marketing Wise Producer: Velentium   EPISODE TRANSCRIPT Episode 033 - Holly Rockweiler [00:00:00] Lindsey Dinneen: Hi, I'm Lindsey and I'm talking with MedTech industry leaders on how they change lives for a better world. [00:00:09] Diane Bouis: The inventions and technologies are fascinating and so are the people who work with them. [00:00:15] Frank Jaskulke: There was a period of time where I realized, fundamentally, my job was to go hang out with really smart people that are saving lives and then do work that would help them save more lives. [00:00:28] Diane Bouis: I got into the business to save lives and it is incredibly motivating to work with people who are in that same business, saving or improving lives. [00:00:38] Duane Mancini: What better industry than where I get to wake up every day and just save people's lives. [00:00:42] Lindsey Dinneen: These are extraordinary people doing extraordinary work, and this is The Leading Difference. [00:00:51] Hello, and welcome back to another episode of The Leading Difference podcast. I'm your host Lindsey, and I'm so excited to introduce you to my guest today, Holly Rockweiler. Holly is co-founder and CEO of Madorra, a woman's health company dedicated to changing the treatment paradigm for vaginal atrophy and dryness. She co-founded Madorra as a spin out of the Stanford Biodesign fellowship, where she implemented ethnographic research to identify unmet clinical needs and define user market and product requirements for solutions and women's health, urology, and infectious disease. Prior to Biodesign, she worked as a Senior Research Scientist at Boston Scientific, where she developed therapies to enable more efficient care for patients living with heart failure. Her preclinical and clinical research has led to more than 20 pending and issued patents. Holly holds an MS and a BS in Biomedical Engineering from Washington University in St. Louis. Welcome, Holly. It's so wonderful to have you here today. Thanks so much for joining us. [00:01:49] Holly Rockweiler: Thanks for having me. [00:01:51] Lindsey Dinneen: Yeah, absolutely. Well, I was wondering if you wouldn't mind starting off by telling us a little bit about yourself and your background and maybe what led you to the medtech industry. [00:02:02] Holly Rockweiler: Sure. So let's see. So my background is in biomedical engineering. I majored in biomedical engineering. Maybe I can say why, like I, I knew that I wanted to be an engineer. I felt like, well, first of all, as a woman in math and science growing up, when I did every teacher told me to be an engineer, but I didn't really know what that meant until I got to college, but I liked it. Pursued engineering and I started undecided, but very quickly found that I was, most just excited about the problems in the biomedical engineering field. I remember one of my classes was like "calculate the torque of a drill on a tooth," I was like, "Wow, that's amazing. I think I found it." [00:02:41] So majored in biomedical engineering, got my master's and bachelor's at Wash U in St. Louis, and then I went to work for Boston Scientific. And so they are a medical device company. And so that's obviously how I got into it, but I did seek that out. When I was thinking about what did I want to do, I thought about... chemistry was never an area I felt very strongly about. I liked stuff I could hold in my hands and really conceptualize. And so I think that's what led me more in the device road and then had a incredible opportunity to work at Boston Scientific. [00:03:15] And so I worked there for several years in their implantable cardiac division. So that's pacemakers and ICDs, working in the research department. So that was also really cool because we were on the front end helping to define the next generation products and was able to also work very cross functionally. So just because research conceived of an idea didn't mean it was going to be in the product development had to help it go forward, and obviously we were keyed in very closely with the marketing team to understand. What were the needs that we were solving. [00:03:45] So it was an incredible introduction to our industry. And then I decided that I wanted to try a smaller company. There was just some broader themes of working in a large company that didn't totally jive for me. And so I was like, "Well, I don't know the first thing about startups." So I had heard about the Stanford Biodesign program, which is where I went next. And the company that I started, Madorra, is a spin out of that program. [00:04:14] Lindsey Dinneen: Wow. Okay, so your path is really cool, and I love that you are an engineer, and I love your passion behind it too, just hearing you talk about that one random problem and your excitement about it. I adore that. I do. Because that is not my leaning. So whenever I hear somebody just get really excited about that kind of thing, I'm like, "Yes, tell me more." [00:04:40] Holly Rockweiler: Well, then you're in the right field too, I would say. [00:04:42] Lindsey Dinneen: Indeed. Indeed. Indeed. So, yeah. I'm just curious. Okay. So, so going back just a little bit, you started off at Boston Scientific and kind of developed this appreciation for the medical device space and innovation. And then with Stanford Biodesign, can you tell me a little bit about being a part of that and then how you were able to spin off into your own company? I mean, that's not, that's like a one sentence thing that you put in there, but I know that it took a lot of work, and I'd just love to hear about that process, and your experience. [00:05:17] Holly Rockweiler: So, absolutely. So, the Stanford Biodesign program has many different facets. I was part of the fellowship, but they also have classes they teach and books and online resources. And then other universities have kind of sister programs around the world, frankly. So I was very interested in joining the program, like I said, to kind of-- what I was telling myself was like a way to dip my toe in the water of what a smaller company would be like. Now that's not at all what Stanford pitches the biodesign program as. Really what it is a an academic training program for an innovation process. And that's what they teach you. Now there are a lot of companies that end up spinning out of it. [00:05:56] And so I thought, "Well, maybe, like I said, this is a way to dip my toe in the water, but also if I decided to come back to a larger company setting, this skill set still would be highly useful given what I want to do in my career. So that's what I set out to do. And so the program I love, I think is fantastic. It's as described initially, it's this innovation process and they teach you that in a very hands on way. So first you start with really understanding and building a list of unmet needs, and so that starts by looking for problems in Stanford Hospital. You kind of have this unfettered access as an engineer. It was the 1st time I had that, you know, observe and ask questions and talk to physicians and patients and other health care professionals and then. you end up with, obviously, a long list of problems that you can find, just like any, anywhere in the world, right? This could happen. But also this, in healthcare, it happens. [00:06:55] And then you translate those problems into what the program calls need statements, to really-- there's a lot packed into that, but once you have those, then you spend the bulk of the program actually learning how to filter that long list of problems down into a couple key top unmet needs that you're working on. And so again, this is their goal is academic. They want to teach them their product is the people. They want to teach people this process and have them go out and share this process and use it to be successful in whatever, you know, vein they end up going down. [00:07:32] And so I was like, I was just having a conversation with my husband this weekend. I was like, we were talking about something interpersonal and I said, "Well, the unmet need here really is..." So it certainly has, you know, I've drank the Kool Aid completely and love to share it. So, but anyways, so, but what happens because you're working hands on these projects you very often, which was the case for myself and my co founders, by the end of the year, you may have something that you're pretty passionate about. [00:08:00] And so what has now become my about me description is working in women's health. I had no idea how passionate I would be about. I feel like I kind of backed my way into it, but now kind of reviewing that history, it's like, "Oh, maybe I was always kind of destined for this given my interest in, in, you know, activism." So kind of combining all of this together is what led us here. So, spinning it out was a consequence of having a lot of hard work with my team throughout the year. And we had other projects too, but this became the one that kind of survived every stage gate. And we ended up spinning out. into the company, Madorra. [00:08:42] Lindsey Dinneen: Wonderful. Well, thank you for sharing a little bit about that. And also, I love the crossover into real life, not that's not real life, but I do your daily life as well. Oh my gosh. That's great. I'm going to start doing that. Okay, so can we talk now a little bit about your company and the product that you've developed and where you're kind of looking to take it in the future? [00:09:05] Holly Rockweiler: Certainly. So, again, being born out of Stanford, we started with an unmet need around creating a treatment for vaginal dryness and atrophy for postmenopausal women that didn't rely on hormones. So this is a problem that I had never heard of before we literally met patients with this problem and talk to providers about this problem. And as we started researching, "Wow, up to 75 percent of all postmenopausal women are dealing with some, you know, degree of this. How have we not heard of this before?" That is a striking number of people. [00:09:39] And so as we continued to do our research, very quickly learned the gold standard treatment here is hormone therapy, but even though this market is huge, only 7 percent of the market is using hormones today. And so that... there's a lot of reasons why, but that's really what motivated us to say, "Wow. There needs to be another option." Because if you don't want hormones right now, the only other FDA cleared product or category for treating this are over the counter lubricants and moisturizers. And those are like, both of the products that exist today are really, those categories are really great, but they're not enough. [00:10:16] And again, with 43 million women in the United States with this problem, like we need more than just those two categories. And it really felt like no one had really looked at this. I mean, hormones, again, are a good solution for the patients who want to or can use them. But for patients who can't, for example, breast cancer survivors, they're stuck with, you know, just kind of subsisting off these over the counter products that really are not enough when your case is more moderate or severe. [00:10:43] And so we said, "Well, let's look at this and see if there's a better way or, you know, something we could combine," and ended up developing the idea for what is now the main product that we're developing at Madorra, which is a home use device that uses ultrasound to really rekindle the body's natural lubricating process. And so our whole goal has been to be very supportive of the other products in this category. We think hormones should be used more often than they are, frankly, but that women shouldn't have to make a compromise. If they don't want to use hormones, then they should have other options, and that's where we come in. [00:11:21] So our product, we will, it's not on the market yet. We're working towards that, but when it's out there, what we envision is a prescription happens from the gynecologist, and then the patient uses the product at home on a regular basis to, like I said, kind of revitalize that natural process. And what patients have told us they like about this is that It is restarting their own natural lubrication rather than some exogenous hormone or chemical. And there's less of a kind of a goop ick factor, you know, than having to use these over the counter things, which again, they like say that not to say that those don't have their place because they absolutely do, but it's not enough. [00:12:01] And so, we're pre FDA clearance, but we have a breakthrough designation from FDA. So that's feather in our cap and will help us get through the agency more expeditiously. And we have done several clinical trials and look forward. We've published one of those trials in our first manuscript, and we look forward to putting more of our data out there to help really lay the foundation to say, "Yeah, ultrasound is an appropriate approach to treating this and has virtually no side effects." So this should be a great option to be available to as many people as possible. [00:12:36] Lindsey Dinneen: Oh, that is incredible. Oh my goodness. Well, yeah, first of all, again, you know, it boggles my mind and it probably shouldn't anymore, but it continues to when you tell me statistics like this, that 75 percent of women who've are in this situation or have this concern or whatnot. And you're just think, you're addressing it in a way that's so innovative. And yet that hasn't really been addressed yet and it happens again and again with healthcare for women. And I'm wondering, you know, you mentioned earlier being very passionate about this. So I'm wondering if you can speak a little bit to fem tech and women's health and how you're involved in helping to push the conversation forward 'cause I know that can be a little challenging at times. [00:13:23] Holly Rockweiler: Absolutely. Yeah. And well, it's super fascinating too, because we spun out of Stanford in 2014. So we're coming up on 10 years here and the conversation is so different today than it was just, well, just 10 years. I mean, it was a decade, but it feels like yesterday. Like a lot has changed. When we first were starting Femtech wasn't a hashtag, like that was not a conversation. And people would say like, "Ooh, that's a niche." Yeah. And that doesn't happen anymore, which is really great. So while that's, that's certainly progress, so we should acknowledge that and be proud of everyone who's worked towards creating that progress. So I think what's been interesting, though, it's like the pace of progress, maybe? [00:14:09] So it's very exciting to know that there are, for instance, obviously I spend a lot of my time fundraising, there are women's health focused venture groups now. They, that's fantastic. That we just need bigger and bigger funds to be focused on that. We just need more and more We need more of everything, right? I mean, one of many things I've been very surprised to learn is how little training physicians get on menopause specifically. And so that has to change. And so there's just like a lot. [00:14:40] And so to the point of activism, like there's a lot to say, and so I think, it's... being raised by parents who are feminists, that helps, I think, me just start by saying, "Well, no, this shouldn't be . We can do better, and we will do better." So that's helpful, and I think that's also what really keeps me going-- obviously, every job is hard, and in our startup world, this is certainly a lot emotional rollercoaster. And so when I think about when I have harder days, it's like, "Wow." We've had patients tell us, for example, "I can't believe you're even paying attention to this. I can't believe you're listening to what I have to say." And so one, that's disturbing that's, as little as it's needed to make someone feel better. Secondly, it's "Wow, we can have such an impact by just being out there." So like the fact that we exists, I always think is helpful and that we do things like this and have open conversations about vaginal health for an aging population. [00:15:39] I will also say that, a year ago at the Super Bowl last year, there was an ad for a hot flash drug. And so that's like, you know, the world stage, menopause is being discussed. That was not happening 10 years ago. There is real progress being made. The last thing I want to say is that one thing I, I have also really appreciate about working in women's health and how supportive everyone is of everyone else. Every, anytime, even like our closest competitor, when I met their CEO, she was wonderful to me and, you know, shook my hand and said, "How can I help you?" And it's like, "Where else does that happen?" That's incredible. I think 'cause we all see there's a lot of work to be done. We can't do it alone. We want to support each other. [00:16:19] Lindsey Dinneen: Oh, I love that. Yeah, that is something that I have really admired and appreciated about the medtech industry. I think because people are curious, and their mindset is very innovation problem solving, "how can I help?" It seems like even with competitors. Yes, we're maybe vying for similar people to sell to. However, there's this idea of camaraderie, which I don't find in a lot of industries. So yeah, to your point, I think it's really helpful to have those allies in the space because that's, it's a little different. [00:16:53] Holly Rockweiler: Totally. [00:16:54] Lindsey Dinneen: Yeah. So yeah. And I, I love what you were saying about these conversations are happening more and they're becoming more mainstream and less embarrassing or taboo, which sounds hilarious because it's 50 percent of the population or whatever. But anyway, the point being, it is exciting to see this continue to move forward. And I'm wondering, even as a company, obviously your next big hurdle is getting that FDA approval, going to market and whatnot. But as you continue down the road, what other kinds of problems are you looking to solve? Or are you not even there yet? This is just like, "Let's start here. We'll get into that later." [00:17:38] Holly Rockweiler: Yeah. No, it's a great question. I think like what kind of harkening back to the just the prior question about the community of women's health. It's like you can't go a day without finding five other problems that you want to solve. So absolutely. I think that yeah, I mean, like with Madorra, we are very focused obviously on this technology and developing it, but we certainly have a roadmap of where this technology could go and other ideas of where to take it. And then what I find fascinating is that there is no menopause "brand." Like no one owns menopause, which I, if I worked at Procter and Gamble or Kimberly Clark, I would be like, hopefully 15 years ago, I would have said, "Guys, let's do it." So it's very surprising to me. So I think there's a lot of opportunities. [00:18:23] So would Madorra be that brand? I would love that. We would need a lot of other products that come together with us. So what I really see is a roll up in the future of multiple women's health products together. So I think that's exciting. In terms of, also a little bit maybe more broadly speaking, and this is no surprise to you, I'm sure, or your listeners, that reimbursement is an area that needs massive... I don't know, I was gonna say like overhauling, but that sounds pretty drastic. [00:18:53] It just needs to be clearer and cleaner and simpler. In terms of a process. I'm not saying that we should be handing out reimbursement left and right, but any investor conversation I have is, we go there immediately. And it's like, "Okay, what's the path? Well, why do you think that's going to happen?" And when, you know, X, Y, Z, other company had this happen and I can, we have a good strategy. I think I have a good pitch, but, oh, just... it just is an area that is really murky, and given that's a really critical piece in any business is how are you going to get paid? That's an area that I think there's a lot of good work being done. It just moves at a pace that is painfully slow. I don't have anything insightful to say about it except that, thank you to the people who are working on it, and I support you. I think the TCEP program is a step in the right direction, but even that has been very slow, and not without its own issues, so. [00:19:53] Lindsey Dinneen: Yeah. Still work to be done, but thankful for the work that is being done. [00:19:58] Holly Rockweiler: Well said. Yes. [00:20:00] Lindsey Dinneen: So, yeah, so, okay. So obviously, listening to you speak about your background and about the industry, it's really clear how passionate you are about this. And I, I wonder if there are any moments or series of moments that stand out to you as kind of confirming that, "Yes, I am in the right place at the right time. I'm here for a reason." [00:20:23] Holly Rockweiler: Oh, good question. Yeah. I'm trying to think like, there are plenty. There's plenty of times in the moment where it's like, "Of course, yes." And then there's like quickly like, "Oh, what's the next fire I'm trying to put out?" So it's hard to really think. I wish I had a super answer right away. I'm thinking, I guess I always come back to the patient and so like hearing-- so we've done some clinical trials in Australia and various team members of ours have gone over and been able to support the trials and be a part of them. And just hearing the stories that they bring back, it's just like, "Yes, we have to keep doing this." [00:21:01] One of our employees was there and came back with a couple stories of one of them was just like after the study visit, the patient was speaking to her and was saying, "It's a conspiracy of silence. This is a huge problem. So many of us are suffering. We're so glad you're here." And then it's other things like we did, for instance, a human factors study that was really helpful to us. And we learned a lot from, and in that study, it was like patients came in to do mock use of the device so we could improve our training materials and also, you know, all parts of the user experience. And it was amazing to me. [00:21:38] So patients, you know, participants, I should say, got zero benefit theoretically about being in that study. It was all for us to learn how to do this better. I mean, we did compensate them, but marginally, right? And so many people wanted to be in that study. And even if it was the early on patient who had-- I'm going to make it up. I had like, "Oh, the user manual didn't make sense to them" or something. They were still like, "I'm so glad to be here to help you because this product needs to be out there." And so it's like, " This is incredible. Yes!" And that part is really rewarding to me. [00:22:09] For me, it's the patients and their feedback and just their enthusiasm. And then, I was gonna say also for the healthcare providers too, we have a lot of wonderful physicians that we work with and their support has been helpful. Like for instance, as I mentioned, we put a paper out there and one of our clinical advisors was highlight, or I think a couple of them highlighted to us that like, "We need to do a second paper on a specific subset of that data because it's super valuable and hasn't been out there before," which may be the clinicians do that for everything they do 'cause they, they know the scene and they know what needs to be published, but it just felt like we have a lot of people who really are rowing in the same direction and really want to make an impact like we do. [00:22:49] Lindsey Dinneen: Oh, wow. Yeah, that's incredible. Thank you for sharing those stories. I think, you know, as you alluded to earlier, because your role has so many components, because that's the space you're in and you've got so much going on, I think it's really compelling to have something to hold onto when it gets hard and go, "You know what? I remember that patient who was so thankful just to have the opportunity to be a part of it and just wait until this gets into the hands of so many more." [00:23:15] Holly Rockweiler: Totally. [00:23:17] Lindsey Dinneen: Yeah. Yeah. Yeah. And so for you, you know, you obviously have a very strong background in engineering and innovation. How was it for you going from that to also now being an entrepreneur, and having a business, and having to also learn all of those skills as well. How was that transition? [00:23:42] Holly Rockweiler: Fun. I think that-- there's a lot of personal growth, and I've learned a lot about myself and what where I find passion. So I think there's definitely a lot of hard parts too, but what, well, one thing is that I think there's also a heavy dose of naivete that was important. I didn't know what I didn't know. And so here I am 10 years later I think, you know, in the beginning too, I was not... what do I say? I wasn't convinced, yeah, I wasn't convinced that I could be a CEO, that I should be or could be. And so I think that was, and is maybe still a definitely a continuous journey to it. So why is, why did I think that? What does that mean to me? And where am I now? That's been certainly a learning process. [00:24:31] But that's also like why I said fun, because I, I get to do such a variety of, like, I get to have this opportunity to speak to you on this podcast. I get to work with our clinical advisors on a paper. And I also get to apply for grants. And there's a lot of hard things that come with all those things, but I feel like it's been a really, I don't know, just an incredible opportunity to have a job that It requires so many different things. It also requires me to do financial modeling, which I'm terrible-- well, was terrible at-- have learned and much better at, but also don't really love doing. [00:25:04] So it teaches you what, what you might look for in a future chapter of your life as well. But I'm someone who really thrives on, I have a very curious mind. So trying new things and figuring out new things. And that, I think that curiosity is well satiated by an entrepreneur's life. The managing your own psychology is really difficult, but that's why you have a great community of people around you, both within the entrepreneur community and outside of it. [00:25:36] Lindsey Dinneen: Oh my word. I think I just need to take what you just said those last couple of sentences and just make it into a quote because that was so well articulated. [00:25:45] Holly Rockweiler: Oh, thank you. [00:25:47] Lindsey Dinneen: I cannot think of a better way to describe that journey. So thank you for, but also thank you for being vulnerable and willing to share that, because it is such a journey and it is a learning curve, but kudos to you for embracing it with an attitude of fun, like, "Let's just learn something new and it might not go great the first time, but that's okay. I'll try again." [00:26:10] Holly Rockweiler: Yeah, I was thinking, I was like, "Well, if any of my investors are listening, I have gotten really good at a lot of these things, so y'all don't need to worry." But I do think that's maybe the blessing and the curse of being a first time entrepreneur. So I think, you know, there's certainly a lot of benefits for having done it before and knowing exactly what to expect. But I think with anything in maybe any regulated industry, or maybe any startup, really, there's always going to be curveballs. So that keeps you excited. [00:26:41] Lindsey Dinneen: it's never boring. It keeps you on your toes. There's at least that. [00:26:45] Holly Rockweiler: Yes, absolutely. [00:26:47] Lindsey Dinneen: Excellent. Pivoting the conversation just for fun. Imagine that you were to be offered a million dollars to teach a masterclass on anything you want. It can be within your industry, but it doesn't have to be. What would you choose to teach and why? [00:27:04] Holly Rockweiler: Oh, that's interesting too. And that's a nice paycheck. [00:27:08] Lindsey Dinneen: Right? I [00:27:10] Holly Rockweiler: Let's see. It's getting right to what do I think I'm good enough at to teach a class about. So, I mean, I think one thing that I've been thinking about a lot recently is scientific communication and how, how different voices get amplified and how the kind of stereotypical scientific persona is, it's not the one that wants to be necessarily on social media with a gazillion followers and all these TikTok videos. So I think that I would like to teach the class in concert with, I have a lot of ideas of like, who would be a great way, who would be great people to collaborate with in order to teach or really to help promote more scientific discourse in a conversation that's appropriate and approachable for anyone. [00:28:04] I think that obviously our country has faced a lot of division and I don't think that's really true. I think that a lot of that is-- well, there certainly is a lot of division. I don't mean that. I just mean that I think there's a path to human connection via communication and that, wouldn't it be cool if we could help bridge conversations. And obviously I'm, I am a scientist. I think of myself as a scientist, so I want to think about ways to provide other voices out there to be amplified as well, or perhaps amplify the right voices to help promote just a more enriched dialogue than what is often presented as the country's dialogue today. [00:28:48] Lindsey Dinneen: I love that. [00:28:50] Holly Rockweiler: It's kind of rambling. I can get back to you with my course description, but that's probably where I would go. [00:28:56] Lindsey Dinneen: Syllabi due Tuesday. No, I think that is absolutely incredible. And I love that because I think that is something that's missing and there's some translation error that occurs. And one of the things that I'm passionate about is helping to bridge that gap between-- so I'm right on board with you-- but to bridge that gap between maybe taking some what are traditionally considered complex ideas, concepts, whatever, and distilling it down to a more accessible format. And because everyone learns differently, it's just helpful to have a wider range of options. [00:29:35] Holly Rockweiler: Totally. [00:29:36] Lindsey Dinneen: So I love what you would be passionate about sharing. I mean, I would sign up for that masterclass. [00:29:41] Holly Rockweiler: You can help me teach it, I think. [00:29:43] Lindsey Dinneen: Okay. Deal. We'll get back on that. [00:29:45] Holly Rockweiler: Okay. [00:29:47] Lindsey Dinneen: Excellent. Yeah. How would you wish to be remembered after you leave this world? [00:29:53] Holly Rockweiler: You have some great questions. Yeah, let's see. You know, I've honestly never thought about that. I think that I would, what would I want people... well, I think about like what I would want my friends to think. That, like, they were loved and that they hopefully shared that love broadly. But then, well, let's see, that's not really, like, remembering. Yeah, I guess, maybe it is. So, yeah. That I'm a lover, a curious person, and that I, there is a lot of beauty in the everyday, and so there's a lot to be excited about even on the hard days, [00:30:32] Lindsey Dinneen: Yeah. I love that. And then, final question. What is one thing that makes you smile every time you see or think about it? [00:30:41] Holly Rockweiler: Certainly my family. I have a four year old son and he is, keeps me very present and cracks me up continuously. And so, my husband and I are very lucky to have him. And obviously my husband makes me laugh. A lot. And so I really appreciate them. And so even when, you know, the work day is hard, I feel really fortunate to have a very rich personal life outside of that. So my family and then my friends also. [00:31:09] Lindsey Dinneen: Oh, yes. Of course. That's wonderful. And I'm so glad you have that amazing support system to bring that smile to your face, especially on the tough days. [00:31:19] Holly Rockweiler: Absolutely. [00:31:20] Lindsey Dinneen: Well, Holly, this has been a wonderful conversation. I'm so thankful for you and what you're doing in this space and the fact that you're tackling an issue that affects so many people, and that you're just bringing all this innovation to, and you're so passionate about sharing that in a way that resonates with people. So I just want to first say, you know, thank you so much for the work that you're doing. I know it's not easy and there are probably days where you, you just kind of want to, you know, toss something in the trash, but honestly, thank you for continuing to do the work you're doing. It's not nothing. And I want to appreciate that. [00:31:59] Holly Rockweiler: Well, that is very kind. Thank you. And that means a lot. And thank you for doing what you're doing, too, to give people like me a chance to share, and also us to listen to others sharing their stories. And for asking, I will say, asking questions that are more about me as a whole person too. I think that when I've been in other conversations sometimes are really-- and there's nothing wrong with those, but it's fun to have, we can ask these questions. I'm like, "Wow, I would do some thinking this weekend about how I want to be remembered" because I've never thought about that. [00:32:30] Lindsey Dinneen: Yeah. There you go. I love it. Well, and we are so honored to be making a donation on your behalf as a thank you for your time today to the Equal Justice Initiative, which provides legal representation to prisoners who may have been wrongly convicted of crimes, poor prisoners without effective representation, and others who may have been denied a fair trial. So thank you for choosing that organization to support, and we just wish you continued success as you work to change lives for a better world. [00:32:59] Holly Rockweiler: Well, thank you. It's been a pleasure. Thank you. [00:33:03] Lindsey Dinneen: Me too. And thank you so much for our listeners for tuning in. And if you're feeling as inspired as I am right now, I would love if you would share this episode with a colleague or two, and we will catch you next time. [00:33:16] Ben Trombold: The Leading Difference is brought to you by Velentium. Velentium is a full-service CDMO with 100% in-house capability to design, develop, and manufacture medical devices from class two wearables to class three active implantable medical devices. Velentium specializes in active implantables, leads, programmers, and accessories across a wide range of indications, such as neuromodulation, deep brain stimulation, cardiac management, and diabetes management. Velentium's core competencies include electrical, firmware, and mechanical design, mobile apps, embedded cybersecurity, human factors and usability, automated test systems, systems engineering, and contract manufacturing. Velentium works with clients worldwide, from startups seeking funding to established Fortune 100 companies. Visit velentium.com to explore your next step in medical device development.

William H. Sauer, MD, FHRS, CCDS, Brigham and Women's Hospital is joined by Edward P. Gerstenfeld, MD, MS, FHRS, University of California, San Francisco, and Yasser Rodriguez, MBA, MD, Cleveland Clinic Florida to discuss; Background: Premature ventricular complexes (PVCs) are common and associated with worse outcomes in patients with heart failure. Class 1C antiarrhythmic drugs (AADs) effectively suppress PVCs, but guidelines currently restrict their use in structural heart disease. Conclusions: Class 1C AADs effectively suppressed PVCs in patients with NICM and ICDs, leading to increases in LVEF and biventricular pacing percentage. In this limited sample, their use was safe. Larger studies are needed to confirm the safety of this approach.   https://www.hrsonline.org/education/TheLead https://doi.org/10.1016/j.jacep.2024.01.021 Host Disclosure(s): W. Sauer: Honoraria/Speaking/Consulting: Biotronik, Biosense Webster, Inc., Abbott, Boston Scientific, Research: Medtronic    Contributor Disclosure(s): E. Gerstenfeld: Honoraria/Speaking/Teaching: Abbott, Biosense Webster, Inc., Boston Scientific, Medtronic, Membership on Committees/Advisory Boards: Boston Scientific, Farapulse, Honoraria/Speaking/Consulting: Boston Scientific, Abbott Medical, Medtronic, Adagio Medical, Research: Boston Scientific Y. Rodriguez: Nothing to disclose.   This episode has .25 ACE credits associated with it. If you want credit for listening to this episode, please visit the episode page on HRS365     https://www.heartrhythm365.org/URL/TheLeadEpisode66

Send us a Text Message.In the latest MedEvidence episode, join cardiologists Dr. Trevor Greene, Dr. Carlos Henriquez, and Dr. Michael Koren as they help you navigate heart failure, from symptoms to advanced therapies. Dive into the heart of heart failure treatment as we explore a multifaceted approach emphasizing personalized care. From diuretics and ACE inhibitors to groundbreaking SGLT2 inhibitors, The cardiologists provide a deep dive into the medications revolutionizing heart failure therapy. Discover the importance of regular follow-ups with healthcare providers to tailor treatments and enhance patient quality of life. This episode sheds light on the primary goals of heart failure therapy—extending lifespan, reducing hospitalizations, and improving overall patient well-being.Finally, we tackle advanced treatment strategies and the substantial economic burden of heart failure. Learn about the role of devices like ICDs and CRTs in managing severe cases and the intriguing hormone relaxin, which might offer new hope for heart failure patients beyond pregnancy. The doctors also share practical advice on navigating the healthcare system and the impact of seasonal variations on heart failure management. Tune in for a wealth of knowledge and actionable insights that could transform the lives of heart failure patients and their caregivers.Talking Points:Understanding Heart Failure EpidemiologyCauses of Heart Failure Treatment Strategies for Heart FailureEconomics of Heart FailureRole of Relaxin in Heart HealthHeart Failure ResearchRebroadcast for WJCT Studios on May 29, 2024Be a part of advancing science by participating in clinical researchShare with a friend. Rate, Review, and Subscribe to the MedEvidence! podcast to be notified when new episodes are released.Follow us on Social Media:FacebookInstagramTwitterLinkedInWant to learn more checkout our entire library of podcasts, videos, articles and presentations at www.MedEvidence.com Powered by ENCORE Research GroupMusic: Storyblocks - Corporate InspiredThank you for listening!

Dr. Talha Farid, electrophysiologist with St. Luke's Heart Care Clinic, returns to the podcast to discuss lead extraction. Patients who have pacemakers, implantable cardioverter-defibrillators (ICDs) and other devices with lead wires that need to be removed, can have the procedure done at St. Luke's Hospital, the only hospital in Cedar Rapids that performs lead extraction. To learn more about heart care services, visit unitypoint.org/cr-heart.Do you have a question about a trending medical topic? Ask Dr. Arnold! Submit your question and it may be answered by Dr. Arnold on the podcast! Submit your questions at: https://www.unitypoint.org/cedarrapids/submit-a-question-for-the-mailbag.aspxIf you have a topic you'd like Dr. Arnold to discuss with a guest on the podcast, shoot us an email at stlukescr@unitypoint.org.

Illan eurovaalitentissä kohtasivat suurimpien puolueiden puheenjohtajat Antti Lindtman (sd), Petteri Orpo (kok) ja Riikka Purra (ps). Miten tentti meni, sitä arvioimassa politiikan tutkijat Johanna Kantola ja Emilia Palonen. Kärkiehdokkaat Euroopan komission johtoon kohtaavat Brysselissä alkuillasta. Mitä tältä tentiltä voi odottaa, puhelimessa akatemiatutkija Timo Miettinen, Helsingin yliopisto. Venäjän merirajojen siirtämisaie mietityttää: onko kyse hybridivaikuttamisesta vai ei? Keskustelemassa tutkija Jyri Lavikainen, Ulkopoliittinen instituutti sekä varajohtaja Kristi Raik, Viron kansainvälinen puolustustutkimuskeskus ICDS. Äänessä myös merisotaopin opettaja Perttu Trontti Maanpuolustuskorkeakoulusta. Tallinnasta raportoi Rain Kooli. Ulkomaanlehtikatsaus Ranskasta, toimittajana Jari Mäkinen. Juontajana Mira Stenström, toimittajat Anssi Väisänen ja Rasmus Montonen. Tuottaja Hanna Juuti.

Implantable cardioverter-defibrillators (ICD) are a technology that many people have, especially if they survived cardiac arrest or have a heart condition that causes dangerous heart rhythms.ICDs are a great technology, but at some point a decision may need to be made about continued use or turning it off. This show will help you understand the issues involved and five considerations for making this decision. In this Episode:00:00 – Our Sponsor: Tree of Life Memorials and Digital & Stone00:20 – Intro02:03 – Richard Lewis in “Curb Your Enthusiasm”05:31 – “Much Ado About Dying” Documentary Review08:48 – Recipe of the Week: Charleston Chewies11:35 – Overlooked No More: Beatrix Potter16:50 – ICDs and End of Life35:53 – “This Confusion” – a poem37:49 – OutroFollow us on Facebook | Instagram | Email us at mail@every1dies.orgClick on this link to Rate and Review our podcast!

Turvallisuusjännite -podcastin kolmannessa jaksossa kysymme, miten Venäjä varustautuu itärajan tuntumassa ja miten NATO-maat ovat ottaneet vastaan Venäjän kasvavan aggression. Vieraina ovat maanpuolustuskorkeakoulun apulaissotilasprofessori, majuri Juha Kukkola, Ylen Nato-erikoistoimittaja Maria Stenroos ja Viron kansainvälisen puolustustutkimuskeskuksen ICDS:n varajohtaja Kristi Raik. Juontajina Tuomas Lähteenmäki ja Annastina Haapasaari. Ohjelman tuottavat yhteistyössä The Ulkopolitist ja Maanpuolustuskorkeakoulu.

William H. Sauer, MD, FHRS, CCDS, of Brigham and Women's Hospital is joined by guests Akshay Suvas Desai, MD, MPH of Brigham and Women's Hospital, and Sunil Kapur, MD of Brigham and Women`s Hospital to discuss how the Resynchronization–Defibrillation for Ambulatory Heart Failure Trial (RAFT) showed a greater benefit with respect to mortality at 5 years among patients who received cardiac-resynchronization therapy (CRT) than among those who received implantable cardioverter–defibrillators (ICDs). However, the effect of CRT on long-term survival is not known. We randomly assigned patients with New York Heart Association (NYHA) class II or III heart failure, a left ventricular ejection fraction of 30% or less, and an intrinsic QRS duration of 120 msec or more (or a paced QRS duration of 200 msec or more) to receive either an ICD alone or a CRT defibrillator (CRT-D). We assessed long-term outcomes among patients at the eight highest-enrolling participating sites. The primary outcome was death from any cause; the secondary outcome was a composite of death from any cause, heart transplantation, or implantation of a ventricular assist device.  https://www.hrsonline.org/education/TheLead https://www.nejm.org/doi/full/10.1056/NEJMoa2304542 Host Disclosure(s): W. Sauer: Honoraria/Speaking/Consulting: Biotronik, Biosense Webster, Inc., Abbott, Boston Scientific; Research: Medtronic Contributor Disclosure(s): A. Suvas Desai: Honoraria/Speaking/Consulting: Abbott, Novartis, AstraZeneca, BioFourmis, Regeneron, Alnylam Pharmaceuticals, Bayer Healthcare Pharmaceuticals, Cytokinetics, AxonTherapies, Avidity Biosciences, Medpace, Merck, New Amsterdam Pharma, Parexel, Roche Diagnostics, GlaxoSmithKline, NovoNordisk, Veristat, Verily/Google, Zydus, River2Renal, Research: Bayer Healthcare Pharmaceuticals, Abbott Medical, AstraZeneca, Novartis  S. Kapur: Honoraria/Speaking/Consulting: Medtronic, Novartis, Abbott, Biotronik This episode has .25 ACE credits associated with it. If you want credit for listening to this episode, please visit the episode page on HRS365 https://www.heartrhythm365.org/URL/TheLeadEpisode53

The Western AF meeting, aspirin, cannabis use, LVEF in athletes, and shared decision making before ICD implantation are the topics John Mandrola, MD, discusses in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. ASA in Primary Prevention Campbell Meta-analysis https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.123.065420 Swedish Observational study https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.117.028321 ASPREE https://www.nejm.org/doi/full/10.1056/NEJMoa1805819 II. Cannabis Cannabis Use Tied to Increased Cardiovascular Risk https://www.medscape.com/viewarticle/cannabis-use-tied-increased-cardiovascular-risk-2024a10003yr It Sure Looks Like Cannabis Is Bad for the Heart, Doesn't It? https://www.medscape.com/viewarticle/1000250 Journal of the AHA Observational Study https://www.ahajournals.org/doi/full/10.1161/JAHA.123.030178 III. Low EF in Athletes Reduced Ejection Fraction in Elite Endurance Athletes: Clinical and Genetic Overlap With Dilated Cardiomyopathy https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.122.063777 IV. ICDs and Shared Decision-Making Association of a Medicare Mandate for Shared Decision-Making With Cardiac Device Utilization https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2815017 You may also like: The Bob Harrington Show with the Stephen and Suzanne Weiss Dean of Weill Cornell Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

Raidījumā Diplomātiskās pusdienas šoreiz aplūkosim kādu teritoriāli mazu, bet vienlaikus lielu Klusā okeāna salu valsti, par kuras vismaz vienu daļu būs dzirdējis gandrīz katrs. Dodamies uz Māršala salām, kas, uz kartes skatoties, atrodas kaut kur pa vidu starp Havaju salām un Austrāliju. Šis ģeogrāfiskais novietojums ir patiesi interesants. Havaju salām ar kontinentālo ASV ir divu vai trīs stundu laika starpība, bet ar Māršala salām tās būs jau 22 stundas. Protams, izskaidrojums ir tajā, ka būs nepieciešams šķērsot datuma maiņas līniju. Lai arī par daļu Māršala salām būs dzirdējis vai ikkatrs, nebūs pārsteidzoši, ja būs ļoti maz mūsu valsts iedzīvotāju, kas tur varētu būt bijuši. Viens no iemesliem ir tāds, ka šī valsts ir viena no vismazāk apmeklētākajām valstīm pasaulē. Salas ik gadu apmeklē vien aptuveni seši tūkstoši cilvēku. Bet katrā gadījumā, ja jums ir laimējies apmeklēt kādu no gleznainajām Māršala salām vai atoliem, būsim priecīgi, ja padalīsities ar saviem iespaidiem arī ar mums. Kā jau daudzām Okeānijas valstīm, arī Māršala salu vēsture ir bijusi ļoti sarežģīta. Tiek uzskatīts, ka pirmie polinēziešu izcelsmes iedzīvotāji  Māršala salās ieradās ap mūsu ēras sākumu. Lai arī spāņu jūrasbraucēji Māršala salās ieradās ap 16. gadsimtu, lielas intereses par šo reģionu viņiem nebija trūcīgo resursu dēļ. Turpmākos reģiona pētījumus veica britu kapteiņi Džons Māršals un Tomass Gilberts jau 18. gadsimta beigās, no kurienes arī radies salu nosaukums. 19. gadsimta vidū salās savu darbību sāka izvērst amerikāņu un Havaju salu protestantu misionāri, bet vēlāk pēc vienošanās ar Lielbritāniju, protektorātu pār salām nodibināja Vācija. 1914. gadā salas jau sagrāba Japāna un pārvaldīja tās ar Nāciju līgas mandātu. Otrajā pasaules karā Māršala salas nonāca Amerikas Savienoto Valstu pakļautībā un tās kļuva par Apvienoto Nāciju Klusā okeāna salu trasta teritorijām, kas atradās ASV jurisdikcijā. Bet ko īsti nozīmē iepriekš teiktais: Maza, bet tomēr liela valsts? Māršala salas veido 29 koraļļu atoli un piecas salas, kaut gan patiesībā varam runāt par aptuveni 1200 dažāda izmēra salām un saliņām. Tas izklausās ļoti daudz, taču patiesībā Māršala salas ir pasaulē septītā mazākā valsts, jo tās sauszemes teritorija aizņem vien 181 kvadrātkilometru. Vienlaikus, tā ir valsts ar proporcionāli lielāko ūdens teritoriju pasaulē. Proti, gandrīz 97,9% valsts teritorijas ir ūdens. Atrākie matemātiķi var izrēķināt, ka kopējā Māršala salu platība ir nieka 1,9 miljoni kvadrātkilometru! Un šo teritoriju – lielu vai mazu, tas jāizlemj katram pašam – apdzīvo aptuveni 42 tūkstoši cilvēku. Taču tas ir tikai pagaidām, jo klimata aizstāvji norāda, ka jau ap 2030. gadu Māršala salas var kļūt neapdzīvojamas.  Tas tāpēc, ka salu augstākais punkts ir aptuveni 10 metri virs jūras līmeņa, bet šo salu tuvumā jau gandrīz 30 gadus ūdens līmenis ceļas par aptuveni 7 milimetriem gadā, un tas ir aptuveni divreiz vairāk, nekā vidēji citur pasaulē.   Situāciju sarežģī arī biežie paisuma radītie plūdi, kas no vienas puses gan applūdina teritoriju un iznīcina stādījumus, gan arī pēc tam veicina sausuma periodus un piesārņo dzeramo ūdeni. Taču ja runājam par piesārņojumu, ir vēl kāds cilvēka radīts piesārņojums, kas ir atstājis neizdzēšamu ietekmi uz Māršala salām. Un te nonākam pie Amerikas Savienotajām Valstīm. Noteikti būsiet dzirdējuši par tādu Bikini atolu, kas arī atrodas Māršala salās un laika posmā no 1946. līdz 1958. gadam ASV izmantoja gan šo, gan citus salām piederošos atolus, lai veiktu kodolizmēģinājumus. Vietējie iedzīvotāji tika aicināti pamest savas dzīvesvietas, jo šie izmēģinājumi “esot visas cilvēces labā un palīdzēšot izvairīties no kariem nākotnē”. Kopumā šajā reģionā tika sarīkoti 67 sprādzieni, kuri jaudas ziņā ir pielīdzināmi aptuveni septiņiem tūkstošiem Hirosimā uzspridzināto atombumbu. Par kodolizmēģinājumiem vairāk jautājumām Indrekam Kanikam (Indrek Kannik), Starptautiskā aizsardzības un drošības centra (ICDS) direktoram.

In this episode, Dr. Anna Lembke, an internationally recognized expert in addiction and dopamine, discusses addiction, dopamine's role in pain and pleasure, dopamine agonists, and more. **Please note, taking regular carbidopa/levodopa alone very rarely leads to someone experiencing impulse control disorders, so please do not delay taking these Parkinson's medications because of a fear of developing an impulse control disorder. If your symptoms are getting in the way of your daily activities and quality of life, work with your doctor to find the right dose for you. Dopamine agonists, on the other hand, which are more commonly prescribed in the early stages of Parkinson's, are the types of medication that put people at greater risk. Still, it's not a given. Each person responds to medication differently, and whatever side effects you do experience are almost always duration and dose-dependent. To learn more about Parkinson's medication, read Medication and Parkinson's. For more on impulse control disorders and dopamine agonists, read Impulse Control Disorders and How to Manage Them.  Topics discussed include: Can you define pleasure and pain and the role dopamine plays in them? How has our drive for pleasure changed over time?  Does being low on dopamine contribute to the pain many with Parkinson's experience? How is the pain/pleasure cycle disrupted in the absence of naturally produced dopamine? What is a dopamine precursor, and what does it have to do with impulse control disorders (ICDs) in people with Parkinson's? Are there any early warning signs that someone may be experiencing negative side effects such as impulse control disorders from taking their medication? What is addiction, and how does it work in someone with Parkinson's? What is the value of truth-telling for someone who is struggling with an impulse control disorder or any other addiction? Is it possible that Parkinson's meds can expose a preexisting addiction or propensity for addiction? Is there a link between head trauma and addiction? and more! We hope you enjoy! Want to watch the video version of this podcast? You can watch it on our YouTube! Loving the Parkinson's Podcast? You can listen to more episodes on our website!

In this episode, we discuss Estonia's foreign and security policy since the restoration of independence. Dr Kristi Raik is the Deputy Director and Head of the Foreign Policy Programme of the International Centre for Defence and Security (ICDS) as of 1 January 2023. She is also an Adjunct Professor of International Relations at the University of Turku, Finland. From 2018 to 2022, she was the Director of the Estonian Foreign Policy Institute at the ICDS, and prior to that, she served as a Senior Research Fellow and Acting Programme Director at the Finnish Institute of International Affairs in Helsinki and an official at the General Secretariat of the Council of the European Union in Brussels. Kristi has published, lectured, and commented widely on European security and EU foreign policy, including the EU's relations with Russia, Ukraine, and other Eastern neighbors. Kristi is also an expert on the foreign and security policies of the Baltic states and Finland. She has provided expert contributions to the Estonian, Finnish, EU, and NATO institutions. Kristi has a PhD from the University of Turku.

Dr. Eric Silver is an Associate Professor of pediatrics at Columbia University Medical Center. He completed his cardiology fellowship at Columbia University College of Physicians and Surgeons and his electrophysiology fellowship at Stanford's Lucile Packard Children's Hospital. He is a certified specialist in pediatric electrophysiology and his research has focused on invasive management of AV nodal reentrant tachycardia in children, the response of the transplanted heart to adenosine therapy, and placement of pacemakers and ICDs with minimal fluoroscopy utilizing 3-dimensional mapping systems.Gav Apfel is a CICU hospitalist at Columbia University College of Physicians and Surgeons. He completed his residency training at Columbia University College of Physicians and Surgeons and will be joining the Columbia University's critical care fellowship program next year. He is interested in pursuing a career in cardiac intensive care.Learning Objectives:  By the end of this podcast, listeners should be able to:Recognize common indications for temporary pacing in the CICUUnderstand the nomenclature used to describe temporary epicardial pacemakers and different pacing modalitiesRecall the function of each pacing mode and which clinical settings in which it is usedRecognize the surgical and pre surgical factors that lead to higher risk of arrhythmiasRecognize and troubleshoot temporary pacemaker dysfunctionDevelop a mental framework for managing those who require prolonged pacingHow to support PedsCrit:Please rate and review on Spotify and Apple Podcasts!Donations are appreciated @PedsCrit on Venmo , you can also support us by becoming a patron on Patreon. 100% of funds go to supporting the show.Please complete our Listener Feedback SurveyThank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.References:Pediatric & Congenital Electrophysiological Society: https://pacesep.org/Heart University: https://www.heartuniversity.orgSupport the show

Eduskunnan syyskausi alkaa. Millaisen oppositiojohtajan hallitus saa vastaansa? Vieraana SDP:n tuore pj. Antti Lindtman. Virossa myllertää niin sisäpoliittisesti kuin ulkopoliittisestikin. Tallinnasta raportoi Rain Kooli. Onko Viro Venäjän koventuvan retoriikan pelinappulana? Vieraana varajohtaja Kristi Raik Viron kansainvälinen puolustustutkimuskeskus ICDS ja vieraileva tutkija Antti Pihlajamaa, Ulkopoliittinen instituutti. Ranskassa koulut alkavat, eikä vartalon peittävää abaya-asua saa enää käyttää. Pariisista raportoi Annastiina Heikkilä. Juontaja Atte Uusinoka, toimittajat Mikko Haapanen ja Kreeta-Maria Kivioja. Tuottaja Hanna Juuti.

SmileDirectClub and Align Technology are in a legal proceeding from a previous partnership. Fast Five hosts Sean Whooley and Danielle Kirsh discuss SDC's plans to appeal a court order that said it has to pay Align Technology $63 million. In today's episode, find out more about the proceeding and the SmileDirectClub's appeal. GE Healthcare has unveiled its latest wireless, handheld ultrasound device. Whooley explains what the device does, how accompanying digital tools help clinicians and what executives think about this unveiling.  Diabetes news and continuous glucose monitors continue to innovate. This week, Insulet launched its Omnipod 5 in Germany and announced when it expects a full European launch. Whooley outlines the regulatory pathway Omnipod 5 took to get to the Germany launch and how patients and executives feel about its entry into Europe. This week, we have study data from the European Society of Cardiology (ESC) in Amsterdam. Medtronic posted study results that demonstrated ICDs could prevent sudden cardiac death. Hear some of the data points from the study. Boston Scientific also posted results from ESC. Its Farapulse pulsed-field ablation device had positive results – and analysts now expect FDA approval and rapid adoption on the U.S. market. Listen to today's episode for more details. Check out the show notes for links to the stories we discussed today at MassDevice.com/podcast.

ESC TV Today brings you concise analysis from the world's leading experts, so you can stay on top of what's happening in your field quickly. This episode covers: Cardiology This Week: A concise summary of recent studies Magnetic Resonance Imaging, pacemakers and ICDs Tough problems in the treatment of hypertension Snapshots Host: Rick Grobbee Guests: Stephan Achenbach, Chiara Bucciarelli-Ducci, Christophe Leclerq, Bryan Williams. Want to watch that episode? Go to: https://esc365.escardio.org/event/1123   Disclaimer This programme is supported by Siemens Healthineers in the form of an educational grant. The scientific content and opinions expressed in the programme have not been influenced in any way by its sponsor. This programme is intended for health care professionals only and is to be used for educational purposes. The European Society of Cardiology (ESC) does not aim to promote medicinal products nor devices. Any views or opinions expressed are the presenters' own and do not reflect the views of the ESC.   Declarations of interests Stephan Achenbach, Rick Grobbee and Nicolle Kraenkel have declared to have no potential conflicts of interest to report. Carlos Aguiar has declared to have potential conflicts of interest to report: personal fees for consultancy and/or speaker fees from Abbott, Alnylam, Amgen, AstraZeneca, Bayer, Boehringer-Ingelheim, Daiichi-Sankyo, Ferrer, Gilead, Lilly, Novartis, Pfizer, Sanofi, Servier, Tecnimede. Chiara Bucciarelli-Ducci has declared to have potential conflicts of interest to report: CEO (part time) of the Society for Cardiovascular Magnetic Resonance. Davide Capodanno has declared to have potential conflicts of interest to report: Sanofi, Daiichi Sankyo, Terumo, Medtronic, Chiesi.  Christophe Leclerq has declared to have potential conflicts of interest to report: lectures and consultancies for Abbott, Biotronik, and Medtronic. Emma Svennberg has declared to have potential conflicts of interest to report: institutional research grants from Bayer, Bristol-Myers, Squibb-Pfizer, Boehringer- Ingelheim, Johnson & Johnson, Merck Sharp & Dohme.  Bryan Williams has declared to have potential conflicts of interest to report: chair of steering committees for trails for Novartis and AstraZeneca.

The appointment of a former Medtronic executive as CFO of ForSight Robotics brings valuable industry experience and expertise to the company's leadership team. Fast Five hosts Sean Whooley and Danielle Kirsh discuss who was appointed and why the company decided to appoint them. Philips' enrollment of the first patients in a stroke diagnosis and treatment trial showcases the company's commitment to advancing stroke care and improving patient outcomes through clinical research. Listen to today's episode to find out what the trial will evaluate and what executives think about the trial. Drug delivery technology developer Eitan Medical announced this week that it appointed Shaul Sharoni as its new chief financial officer. Whooley goes over Sharoni's career background and how his appointment will contribute to the company's growth and long-term success.  The successful completion of the first procedures using Endologix's Detour system marks a significant milestone in the company's U.S. launch, offering a promising treatment option for patients with vascular conditions. Kirsh and Whooley detail the technology, where the rollout began and how optimistic executives are about the first procedures.  Medtronic's recent Class I recall affects certain implantable cardiac defibrillators (ICDs) and cardiac resynchronization therapy defibrillators (CRT-Ds). Find out which brands are affected and if there have been any reported incidents so far.  Check out the show notes for links to the stories we discussed today at MassDevice.com/podcast.

An implantable cardioverter defibrillator (ICD) is a medical device that monitors your heart and can deliver an electric shock to correct life-threatening arrhythmia and prevent sudden cardiac arrest. Dr. Mohamed Kanj talks about the safety and risks of activity with an ICD and different arrhythmias. He reviews findings from research that helps guide how doctors care for active patients with ICDs.

Ep 13: Battle of Heart Disease: Overcoming Obstacles with Armin MuzafirovicAgainst all odds, Armin refused to let his diagnosis define him. But a ski trip to Colorado brought an unexpected twist, changing everything he thought he knew about his condition. What happened next was an ongoing battle, and Armin's incredible resilience kept him fighting every step of the way.“In life, not everything is perfect, and sometimes we have obstacles that come our way...But being that rebellion that I was at 16, I didn't want to listen to healthcare providers. But as you physically see how your body is on the inside, when I saw my heart compared to a normal 17-year-old, I knew at that point that this is really serious.” - Armin.Bouba sits down with his guest Armin Muzafirovic to talk about the ups and downs of his heart journey.  Armin has navigated the challenges of living with heart disease since his mid-teens. His journey began with a diagnosis of muscular dystrophy, followed by discovering his heart condition. Despite these setbacks, Armin has remained determined to live life to the fullest, continuously seeking activities that push the boundaries of his physical capabilities. Armin's story offers a unique perspective on the impact of heart disease on daily life and how he has adapted to his new reality.In this episode, learn more about:The complex world of heart transplant surgeries and the road to recovery.Uncover the crucial role of a support system in managing heart disease and treatment.Third, empower yourself as a patient advocate to take charge of your own heart health journey.Finally, understand the urgent need for organ donors and increase awareness about heart transplantation.Find out more about Armin here:Instagram: https://www.instagram.com/armin.muza/More from Living with Heart Disease:Episode 5 - Life with an LVAD while waiting for a heart transplantConnect with me: Instagram: livingwithheartdisease.podcastFacebook: https://www.facebook.com/heartofagiant.foundationYouTube: https://www.youtube.com/@heartofagiantTwitter: https://twitter.com/LWHDpodcastCatch the bonus content on our Youtube channel.https://www.youtube.com/@heartofagiantDid you enjoy this episode? A free way to support our show is by leaving it a rating and review on Apple Podcasts. It's a chance to tell us what you love about the show, and it helps others discover the Living with Heart Disease podcast. Apple Podcast https://podcasts.apple.com/us/podcast/episode-10-inspiring-journey-from-heart-failure-to/id1567454596?i=1000608329515Spotify https://open.spotify.com/show/4aJeFMvnXyazgGuhR8A4Xs?si=6d9f19949f514714&nd=1Chapter Summaries:[00:00:00] - Introduction,Bouba introduces the podcast and guest, Armin, a heart transplant recipient, and sets. The goal of the conversation is to understand a patient's perspective on living with  heart disease.[00:03:13] - Initial Diagnosis,Armin discusses being diagnosed with heart failure in his mid to late teens, despite feeling healthy and athletic, and how it affected him and his plans for the future.[00:06:23] - Ski Trip Incident,Armin recounts a ski trip incident where he experienced shortness of breath, low oxygen, and a spike in troponin levels, leading to a mini heart attack and hospitalization. He also describes his symptoms of heart failure and the need for an ICD implant.[00:09:27] - Managing Heart Disease,Armin reveals his rebellious attitude towards being a heart patient, how he still played sports and lived life to the fullest despite his condition, and the importance of meeting strict criteria for treatments like pacemakers and ICDs.[00:13:12] - Medical Complications,Armin discusses the difficulties of managing heart disease, including the side effects of diuretics and the challenges of going to the ER for urinary problems. He also touches on the most prolonged surgery period during his ICD implant and the struggles of balancing school with frequent bathroom trips.[00:16:18] - Hospitalization and Online Learning,After being hospitalized for heart failure, Armin had to stay home due to edema and other symptoms. He had to call his school, where they had no prior experience with online learning. Armin managed to do his finals and pass with flying colors despite not being physically present for most of the classes.[00:23:05] - Overexertion and Passing Out,Armin passed out after overexerting himself while trying to pick up his brother from the bus stop. His feet were swollen due to edema. He fell unconscious and was shocked back by his ICD. He woke up in the hospital, and the doctors discovered that his leads were hitting his diaphragm.[00:26:17] - Tachycardia and LVAD Surgery: During a car ride to the hospital, Armin had 40-60 episodes of SVT tachycardia, a severe heart failure symptom. After arriving at the hospital, he had an emergency LVAD surgery due to his low ejection fraction, dangerously low at 15-20%.[00:29:27] - HeartMate 2 and RVAD,Armin had both an RVAD and LVAD implanted with the HeartMate 2. He spent 33 days in the hospital and used Doppler machines to check his pulse. He was grateful to be alive thanks to the LVAD, but he knew he had a long road ahead.[00:30:44] - Early Days with LVAD,The guest recalls his early days with LVAD and describes how he felt constantly monitored and disturbed in the ICU. He mentions the challenges of sleeping and eating in the hospital and highlights the warmth of the RVAD pumping blood out and in as a comforting experience.[00:35:45] - Delirium and Recovery,The guest talks about his delirium and the chemical imbalances in his body, making him feel like he was on fire. He recalls when he thought an X-ray technician was trying to kidnap him and how his mother had to change his dressing from the hospital until the heart transplant.[00:39:01] - Battery Life and Edema,The guest discusses how he had to be physically cautious with the LVAD and could not go anywhere because of the drive line. He highlights the importance of constantly charging the batteries and mentions the compression stockings he had to wear due to Edema.[00:41:21] - Dress Rehearsals and School,The guest mentions how he had to cancel school for the next two years because of his surgeries and describes the challenges of being in and out of the hospital every month due to Edema and potential calls for transplant. He talks about how he missed a full-ride scholarship due to his health condition.[00:43:15]  - Donor Specific Antibodies,The guest recalls how he got a call at 2 AM about a potential heart and how he and his father drove[00:44:37] - Diuresis and Dry Weight,Armin discusses diuresis and reaching his dry weight before a potential heart transplant. He shares how he lost 40 pounds within a week and the toll it took on his body. He also talks about how he was bumped to 1A on the transplant list after getting a Milrinone 24-hour IV pump.[00:53:18] - Unexpected Shock,Armin recalls the time he was shocked twice by his ICD and how he was airlifted to a hospital. He shares how he got bombarded with Valentine's Day cards from nurses and how it brought a sense of humanity to his situation.[00:57:53] - Second Potential Heart,Armin talks about getting a second potential heart in March and going through all the necessary blood tests before going for the operation. He shares his excitement and hope for the future.[01:08:10] - Life after Heart Transplant,Armin discusses his recovery after the heart transplant, including physical therapy and medication. He shares how grateful he is to the donor and their family for giving him a second chance at life. He also talks about his plans for the future, including going to college and pursuing his dreams.[00:59:13] - Preparing for the Heart Transplant,Armin talks about getting ready for his heart transplant surgery, walking into the operating room, and the medical team preparing him for the procedure. He also talks about his previous surgeries and how he knew some of the nurses from before.[01:01:02] - The Long Surgery and Recovery,Armin talks about the length of his heart transplant surgery and the need for the transplant to be done quickly due to the time-sensitive nature of the procedure. He also talks about his recovery and his challenges post-surgery, including high white blood cell counts and fevers.[01:03:25] - Communicating After the Surgery,Armin talks about his communication with doctors and nurses after his heart transplant surgery. He explains that he used paper and a notepad to communicate, and he had certain doctors and nurses he preferred to share with.[01:06:22] - The Road to Discharge,Armin talks about his journey to discharge from the hospital after his heart transplant surgery. He discusses the importance of being safe and waiting for all testing to be completed before leaving the hospital. He also talks about his joy when he finally got home and saw his family.  [01:11:07]- Gratitude and Support,Armin reflects on his heart transplant surgery and expresses gratitude for his family, healthcare providers, and EMS professionals who supported him throughout his journey. He talks about how important it is to have a support system during[01:13:19] - Importance of Support System,Armin emphasizes the critical role that a support system plays during the transplant process, particularly in managing emotions and medications. Having family and friends to cook meals and provide emotional support helped him through the difficult times.  [01:18:30] - Staying Active After Transplant,Armin talks about the importance of staying active after the transplant and how he maintains his physical fitness through weight training and exercise. He also mentions the importance of balancing exercise with other aspects of life, such as work and school.[01:23:02]- COVID and the Transplant Games,Armin shares how he was training for the Transplant Games America in San Diego before contracting COVID-19. He planned to participate in track and field and basketball but had to cancel due to his illness. He remains hopeful for future games.[01:25:30]- Maintaining Mental Health,Armin stresses the importance of seeking help for maintaining mental health after a transplant. He recommends taking things one step at a time and staying organized, including breaking down tasks into smaller, more manageable pieces.[01:27:09] - In conclusion,Armin emphasizes the importance of maintaining physical and mental health after a transplant and encourages others to seek support from family, friends, and medical professionals. He stresses the need to stay positive and take things one step at a time.[01:27:49]- Why Share?Armin shares that as a former patient and future doctor, he understands the importance of advocating for oneself and others. He speaks about volunteering for his local organ procurement center and sharing his story at medical conferences to help educate and motivate patients.[01:29:06] - Taking Control,Armin emphasizes the importance of being one's advocate as a patient and understanding one's medical treatment. He encourages patients to speak up, share their insights, and take control of their health.[01:30:48]- Giving Back,Armin discusses his volunteer work at his local organ procurement center and speaks to patients waiting for transplants. He shares his insights and experiences to help others going through the same journey and inspires listeners to cherish each moment in life.[01:32:08]- Looking Ahead,Bouba and Armin discuss Armin's plans to become a doctor and continue advocating for patients. They express excitement for what's to come, and Bouba emphasizes the importance of sharing one's journey and experiences to inspire and motivate other patients and caregivers.[01:33:09] - Words of Wisdom,Armin shares his words of wisdom for patients and their caregivers, reminding them that they are not alone in their journey and encouraging them to cherish each moment, tell their loved ones they love them, and know their "why" in life.  

Half of us will get a heart or circulatory condition in our lifetime. Right now, there are around 7.6 million people living with heart and circulatory diseases in the UK, around 4 million are male.  Heart and circulatory diseases cause around a quarter of all deaths in the UK; that's more than 160,000 deaths each year, or 460 each day – that's 32 during this podcast.Dr Ed Davies is a Consultant Cardiologist at University Hospitals Plymouth. He completed his training in London and the Southwest. After completing his doctorate in the field of atrial fibrillation, he went on to become the clinical lead of the devices and heart failure services in Plymouth.He is a safe and effective operator, comfortable with the implant of all device types (over 300 per year, including pacemakers, ICDs, cardiac resynchronisation therapy, loop recorders). He holds full European Heart Rhythm Society accreditation.Keen to drive innovation, he regularly contributes to national and international studies on a wide range of subjects.He regularly sees patients with all aspects of cardiological conditions including palpitations, chest pain, shortness of breath and dizziness / blackouts in both the NHS and private setting.Special interestsAtrial Fibrillation, Pacemakers, Cardiac Resynchronisation Therapy, ICDs, Heart Failure, Cardiomyopathy, Blackouts, Syncope.Expect to hear the everyday perspective on how the heart functions, the different types of heart disease, how to recognise early warning signs, what interventions are available, why healthy people drop dead and much more...Extra Stuff:GMC reference no:  6049725Publication: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003331.pub5/pdf/fullStatistics: https://www.bhf.org.uk/-/media/files/for-professionals/research/heart-statistics/bhf-cvd-statistics-uk-factsheet.pdf?rev=b88610e2495b4564821ab365bd8e1b2e&hash=294E7519486335830B73739235600CE7Reliable Heart Info: https://www.bhf.org.uk/informationsupport00:00 Intro02:35 Role of a Consultant Cardiologist09:16 Junior Doctor Training13:47 Heart Disease & Statistics26:46 Stents and Interventions34:35 Health Failure & Hypertension46:08 TRT and PEDs Tangent52:56 Heart Attack & Cardiac Arrest Explained59:36 Atrial Fibrillation and Stroke Risk01:07:20 Sudden Cardiac Death01:12:59 Open Heart / Bypass Surgery01:18:37 Pacemakers01:25:35 Cardiac Rehab Cochrane Review01:30:24 Danny Gets Triggered Over Health Policy01:35:35 Dr Davies' Final Advice#menshealth #heartdisease #cardiac #heartbroken Need a chat? Here's some options

Voiko vaalihäirintä horjuttaa demokratiaa? Miten tunnistaa vaalihäirintä? Keskustelemassa yleisen valtio-opin dosentti Hanna Wass Helsingin yliopistosta sekä varautumispäällikkö Antti Sillanpää, Huoltovarmuuskeskuksesta sekä  vaalijohtaja Arto Jääskeläinen oikeusministeriöstä. Virossa valitaan sunnuntaina uusi parlamentti. Kantaako pääministeri Kaja Kallaksen suosio? Entä kuinka kauniita lupauksia puolueet antavat virolaisten taloushuoliin? Tallinnasta raportoi Rain Kooli. Vaalien teemoja analysoimassa ovat Viron kansainvälisen puolustustutkimuskeskuksen ICDS:n varajohtaja Kristi Raik sekä Suomen Viron-instituutin johtaja Hannele Valkeeniemi.  Ylen vaalikoneista kertoo vastaava verkkotuottaja Ville Laakso. Juontajana Mira Stenström. Toimittajajana Atte Uusinoka. Tuottajana Marija Skara. 

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2023.02.05.527198v1?rss=1 Authors: Magnard, R., Fouyssac, M., Vachez, Y. M., Cheng, Y., Dufourd, T., Carcenac, C., Boulet, s., Janak, P. H., Savasta, M., Belin, D., Carnicella, S. Abstract: Impulse control disorders (ICDs), a wide spectrum of maladaptive behavior which includes pathological gambling, hypersexuality and compulsive buying, have been recently suggested to be triggered or aggravated by treatments with dopamine D2/3 receptor agonists, such as pramipexole (PPX). Despite evidence showing that impulsivity is associated with functional alterations in corticostriatal networks, the neural basis of the exacerbation of impulsivity by PPX has not been elucidated. Here we used a hotspot analysis to assess the functional recruitment of several corticostriatal structures by PPX in male rats identified as highly impulsive (HI) or with low levels of impulsivity (LI) in the 5-choice serial reaction time task (5-CSRTT). PPX dramatically reduced impulsivity in HI rats. Assessment of the expression pattern of the two immediate early genes C-fos and Zif268 by in situ hybridization subsequently revealed that PPX resulted in a decrease in Zif268 mRNA levels in different striatal regions of both LI and HI rats accompanied by a high impulsivity specific reduction of Zif268 mRNA levels in the prelimbic and cingulate cortices. PPX also decreased C-fos mRNA levels in all striatal regions of LI rats, but only in the dorsolateral striatum and nucleus accumbens core (NAc Core) of HI rats. Structural equation modelling further suggested that the anti-impulsive effect of PPX was mainly attributable to the specific downregulation of Zif268 mRNA in the NAc Core. Altogether, our results show that PPX restores impulse control in highly impulsive rats by modulation of limbic frontostriatal circuits. Copy rights belong to original authors. Visit the link for more info Podcast created by Paper Player, LLC

Mike and Cam welcome back Dr. Denis Chang and Vanessa Weisbrod from Boston Children's Hospital Celiac Disease Program. They continue their discussion about some of the top takeaways from the past year's International Celiac Disease Symposium (ICDS 2022). In part two they talk about a wide range of topics including oats, facts about dating with celiac, how Dr. Chang became the "TikTok Doc" and so much more!

The International Celiac Disease Symposium (ICDS) happens every 2 years. It's where the top celiac researchers, doctors and advocacy groups convene to discuss the future of celiac disease diagnosis and treatment. This past October, ICDS was in Sorrento, Italy. Mike and Cam are excited to bring Dr. Denis Chang and Vanessa Weisbrod, of The Celiac Disease Program at Boston Children's Hospital, who both attended ICDS, to share some of their top takeaways. There was so much great information that we made it a two part podcast. In part 1, join us to hear about new approaches to diagnosing celiac disease, why the diet and lifestyle is not a "one size fits all" treatment, and so much more!

On today's Celiac Project Podcast:The International Celiac Symposium (ICDS) happens every 2 years. It's where the top celiac researchers, doctors and advocacy groups convene to discuss the future of celiac disease diagnosis and treatment. This past October, ICDS was in Sorrento, Italy. Mike and Cam are excited to bring Dr. Denis Chang and Vanessa Weisbrod, of The Celiac Disease Program at Boston Children's Hospital, who both attended ICDS, to share some of their top takeaways. There was so much great information that we made it a two part podcast. In part 1, join them to hear about new approaches to diagnosing celiac, why the celiac diet and lifestyle is not a "one size fits all" treatment, and so much more!Listen to the full episode here: https://celiacprojectpodcast.libsyn.com Hosted on Acast. See acast.com/privacy for more information.

Die heutige Folge dreht sich um jenes menschliche Organ, das die Poeten und die Mediziner gleichermassen beschäftigt – nämlich das Herz. Zu Gast ist Vorstellung Pascal Köpfli. Er ist leitender Kardiologe bei Kantonsspital Baden AG und Inhaber der Praxis Herz im Takt. Pascal gibt uns Auskunft zu seiner Arbeit und zur Frage, wie sich die Medizin dank Hightech verändert hat. Einerseits gibt es immer mehr Wearables bzw. smarte Uhren, die die Herzfrequenz messen und sogar EKGs erstellen können. Andererseits existieren auch hochgezüchtete kardiale Gadgets (Schrittmacher, ICDs, CRTs und Loop Recorder), die den Patienten implantiert werden und die der Arzt aus der Ferne auslesen und überwachen kann. Die Links zur Episode: https://nerdfunk.ch/nerdfunk-638/

We're so sorry for the delays in getting this episode out, Erica had CV-19 in Nowhere, Florida and then her Apple had to go into repair. But we promise, this episode is worth the wait!! We highlight some breaking International Celiac Disease Symposium (ICDS) research, share how to use pumpkin in unexpected ways, and banter about holiday shaped Reeses peanut butter cups and other food triggers for the gluten free community. ResourcesPumpkin (& other great) Vegan Substitute from gfJulesHow to substitute oil and eggs with pumpkin (video) from gfJulesBaking with Pumpkin from gfJulesGluten Free Candy List from gfJulesInternational Celiac Disease Symposium and read the tweets from ICDS at #ICDS2022 New ProductsOm mushroom coffeeGrowee Foods spreadsNiramaya plant based saucesContact/Follow Jules & Erica Tweet us @THEgfJules & @CeliacBeast Find us on IG @CeliacandTheBeast & @gfJules Follow us on FB @gfJules & @CeliacandTheBeast Email us at support@gfJules.com Find more articles, recipes & info at gfJules.com & celiacandthebeast.com Thanks for listening! Be sure to subscribe!**some links may be affiliate links; purchasing through these links will not cost you more, but will help to fund the podcast you ❤️

A smart speaker and your Heart. “ Alexa, is my heart rhythm normal”? An Electro Cardiologist interfaces a clinical problem with a smart speaker to identify cardiac arrhythmias. Learn how innovation in biotechnology had led a cardiologist and his team to train Alexa to determine abnormal from normal heart rhythms. Still in development, this fascinating interface highlights how leading innovators take technology and smart devices forward to enhance clinical care.  Listen as we review common cardiac arrhythmias, causes, treatments and diagnosis current and future. Directions for innovation with devices and additional developments in Telehealth.   Guest:  Arun Mahankali Sridhar, M.D., M.P.H., is a cardiac electrophysiologist and a specialist in heart rhythm disorders. He is an Assistant Professor in the Division of Cardiology at the University of Washington.  Dr. Sridhar's sees patients with both rapid and slow heart rhythm disorders, as well as patients with a risk of sudden cardiac death. He has comprehensive expertise in management of both common and complicated arrhythmias. He is an expert in catheter ablations for atrial fibrillation; atrial flutters (both typical and complex), supraventricular tachycardia, WPW, ventricular tachycardia (VT) and premature ventricular complexes (PVCs); stroke prevention in atrial fibrillation, including left atrial appendage closure; In addition he is an experienced implanter of all types of cardiac device therapy, including cardiac pacemakers; implantable cardiac defibrillators (ICDs) and cardiac resynchronization therapy (CRT).  Dr. Sridhar's research focuses on improving ablation techniques and patient outcomes in atrial arrhythmias. He collaborates with the UW computer science and bio-engineering department on various innovation projects to improve the care of heart rhythm patients utilizing advanced computing and novel low-cost patient accessible technologies.     During This Episode We Discuss:  Cardiac (Heart) Arrhythmias: causes, detection and treatment options.  Innovations in the diagnosis of arrhythmias.  The benefits of a multi disciplinary team in researching a very innovative solution to a common clinical problem.  The role of adaptive, machine learning, signal processing and clinical experience in moving technology forward.  Future potential enhancements in current technology to diagnose other metabolic, cardiac and respiratory conditions.    Recommended Resources:  Nature: COMMUNICATIONS BIOLOGY| (2021) 4:319 | https://doi.org/10.1038/s42003-021-01824- https://www.nature.com/articles/s42003-021-01824-9.pdf  UW Cardiology website  Stopafib.org      Visit our website for all the podcasts, additional resources and social media links Website: theoriginalguidetomenshealth.org Facebook: https://www.facebook.com/theoriginalguidetomenshealth/ Twitter: https://twitter.com/guide2menshlth Linkedin: https://www.linkedin.com/company/the-original-guide-to-mens-health/  

Hyperkalemia in heart failure, CV health in America, primary prevention ICDs, and a debate about posters at medical meetings are the topics discussed by John Mandrola, MD in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. Hyperkalemia in Heart Failure - DIAMOND: Adding Patiromer Helps Optimize HF Meds, Foils Hyperkalemia https://www.medscape.com/viewarticle/971616 - Patiromer for the management of hyperkalemia in heart failure with reduced ejection fraction: the DIAMOND trial https://doi.org/10.1093/eurheartj/ehac401 - Potassium Binders for Patients With Heart Failure? The Real Enlightenment of the DIAMOND Trial https://doi.org/10.1093/eurheartj/ehac399 - The Effect of Spironolactone on Morbidity and Mortality in Patients with Severe Heart Failure https://www.nejm.org/doi/full/10.1056/nejm199909023411001 - Eplerenone in Patients with Systolic Heart Failure and Mild Symptoms https://www.nejm.org/doi/full/10.1056/nejmoa1009492 - Evaluation of the efficacy and safety of RLY5016, a polymeric potassium binder, in a double-blind, placebo-controlled study in patients with chronic heart failure (the PEARL-HF) trial https://pubmed.ncbi.nlm.nih.gov/21208974/ II. CV Health in America - ‘Staggering' CVD Rise Projected in US, Especially in Minorities https://www.medscape.com/viewarticle/978366 - Cardiovascular Disease Projections in the United States Based on the 2020 Census Estimates https://www.jacc.org/doi/10.1016/j.jacc.2022.05.033 III. Primary Prevention ICDs in Modern Era - Do ICDs Still ‘Work' in Primary Prevention Given Today's Recommended HF Meds? https://www.medscape.com/viewarticle/978254 - Guideline-Directed Medical Therapy and the Risk of Death in Primary Prevention Defibrillator Recipients https://doi.org/10.1016/j.jacep.2022.05.001 - Declining Risk of Sudden Death in Heart Failure https://www.nejm.org/doi/full/10.1056/NEJMoa1609758 - Defibrillator Implantation in Patients with Nonischemic Systolic Heart Failure https://www.nejm.org/doi/full/10.1056/NEJMoa1608029 IV. Medical Meetings and Posters - As Digital Posters Take Over, Traditionalists Push Back https://www.medscape.com/viewarticle/978384 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

What happens when a Fontan patient's ejection fraction dips too low? Can a person's heart damage be reversed? Is there hope for a cure for congenital heart defects?Brenton Ball was born in 1990. He was diagnosed with hypoplastic left heart syndrome or HLHS and was airlifted to Mercy Hospital in Des Moines, Iowa in his first week of life. He has had several heart surgeries including a pulmonary artery banding, hemi-Fontan, and completion Fontan. He's had many stents put in, a pacemaker, and two ICDs. Brenton has been married to his wife Kelsey for 5 years. They live in Iowa with their pet rabbit McBoon, a gift from Brenton's sister last summer. They live close to their families and are a loving uncle and aunt to their four nephews and one niece. Brenton works part-time as a hotel desk clerk and enjoys reading and spending time with his family. In this episode of "Heart to Heart with Anna," Brenton shares with Anna what his medical journey entailed, how he came to take part in a revolutionary, new medical procedure using stem cells, and how he endured having COVID-19.Helpful links:Heartworks: https://www.heartworksinc.org/products-1The Use of Stem Cells in Treatment for Hypoplastic Left Heart Syndrome (HLHS)Advancements in Stem Cell Therapies and Research for HLHS Heart WarriorsStem Cells for an HLHS (hypoplastic left heart syndrome) HeartPlease visit our Social Media and Podcast pages:Apple PodcastsFacebookInstagramMeWeTwitterYouTubeWebsiteAnna's Buzzsprout Affiliate Link (we both benefit if you sign up with Buzzsprout with my link - yay!) No Need to Explain with the Mental Health MamasParenting is hard. When you have a child who doesn't fit neatly into a box, it can be...Listen on: Apple Podcasts SpotifySupport the show

CardioNerds (Daniel Ambinder), ACHD series co-chair,  Dr. Josh Saef (ACHD fellow at University of Pennsylvania), and ACHD FIT lead Dr. Charlie Jain (Mayo Clinic) join ACHD expert Dr. George Lui (Medical Director of The Adult Congenital Heart Program at Stanford and Program Director for the ACGMEadult congenital heart disease fellowship at Stanford. ), to discuss Tetrology of Fallot. Audio editing by CardioNerds Academy Intern, Dr. Leticia Helms. Tetralogy of Fallot (ToF) is the most common cyanotic heart disease and one of the most common congenital heart diseases that we see in adults overall. The anatomy includes a ventricular septal defect (VSD), an overriding aorta, and infundibular hypertrophy with subpulmonic +/- pulmonic valvular +/- supravalvular stenosis, which causes severe RV outflow obstruction and subsequent RV hypertrophy. Patients require surgery during childhood, which includes patching the VSD and relieving RV outflow obstruction. This results in pulmonic regurgitation (usually severe) and patients can live with this for decades. Adults with ToF commonly will require pulmonic valve replacement, potential relief of subvalvular or supravalvular stenoses, and tricuspid valve repair (for functional tricuspid regurgitation caused by RV dilation). These patients are at increased risk of atrial and ventricular arrhythmias and may warrant prophylactic ICDs. The CardioNerds Adult Congenital Heart Disease (ACHD) series provides a comprehensive curriculum to dive deep into the labyrinthine world of congenital heart disease with the aim of empowering every CardioNerd to help improve the lives of people living with congenital heart disease. This series is multi-institutional collaborative project made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Josh Saef, Dr. Agnes Koczo, and Dr. Dan Clark. The CardioNerds Adult Congenital Heart Disease Series is developed in collaboration with the Adult Congenital Heart Association, The CHiP Network, and Heart University. See more Disclosures: None Pearls • Notes • References • Guest Profiles • Production Team CardioNerds Adult Congenital Heart Disease PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls - Tetralogy of Fallot Tetralogy of Fallot is the most common cyanotic heart disease and the 4 anatomic features are: VSD, infundibular hypertrophy (with RVOT obstruction), overriding aorta, and RV hypertrophy. The most common lesion you will see in adults with repaired Tetralogy of Fallot is pulmonic regurgitation.Pulmonic regurgitation (PR) can be easy to miss on exam as the murmur is brief and even shorter when the PR is severe. In patients with PR and aortic regurgitation, remember PR is clearest when laying supine, in comparison to aortic regurgitation which is loudest while leaning forward.Patients with ToF may also have coronary anomalies (e.g. LAD off RCA), right-sided aortic arches, and also left-sided heart disease (LV diastolic or systolic dysfunction).Patients with ToF are at risk for atrial and ventricular arrhythmias, and clinicians should consider prophylactic ICD for those with multiple risk factors for sudden death (e.g. QRS >180ms, scar on MRI).In all patients with congenital heart disease, inspection is a key part of the physical exam (e.g. right thoracotomy could clue you into a prior BTT shunt) and in patients with prior BTT shunts and/or prior brachial cut-downs (look in the antecubital fossa for scars), radial arterial access is discouraged. Show notes - Tetralogy of Fallot 1. What is the embryologic origin of Tetrology of Fallot (i.e. anterocephalad deviation of spiral septum)? With Tetralogy of Fallot, the most important considerations are in the embryology of the primitive outflow trac...

Strong magnets used in newer portable electronic devices can interfere with the function of implanted cardioverter defibrillators known as ICDs.

Each Monday in February we've been broadcasting a special episode of "Heart to Heart with Anna" featuring different medical devices or products. Today's episode is the last of the four Medical Monday programs and features Greg Hummer, a Senior Technical Services Specialist for Abbott.Most of the Medical Monday programs were relatively short, but Mr. Hummer talked about 4 different devices! Are you curious about the different kinds of pacemakers available? What makes an ICD different from a pacemaker? What kind of rhythm problems do pacemakers treat? What about leadless devices?  Are they science fact or fiction?Tune in for a lesson on arrhythmias heart failure, the progression some Heart Warriors face as they age, and the devices that can improve their quality of life and even save their lives.Abbott's website page on Heart Failure: https://www.structuralheart.abbott/patients/heart-failure-treatmentPlease visit our Social Media and Podcast pages:Apple PodcastsFacebookInstagramMeWeTwitterYouTubeWebsiteAnna's Buzzsprout Affiliate Link (we both benefit if you sign up with Buzzsprout with my link - yay!) Support the show (https://www.patreon.com/HearttoHeart)

Nutrition programmes in India come in different hues and have undergone sweeping changes in the last few years. From the ICDS to the POSHAN 2.0, we have seen varying successes across the country. What do budgetary trends indicate? Why should we track this? Apurva Kumar and Suman Joshi discuss all this and more.Follow Apurva on Twitter: https://twitter.com/apurva_krFollow Suman on Twitter: https://twitter.com/sujo2906References: 1. https://www.indiaspend.com/budget/india-underspends-on-nutrition-new-nutrition-programme-yet-to-be-implemented-8008102.https://www.indiabudget.gov.in/economicsurvey/doc/eschapter/echap10.pdfCheck out Takshashila's courses: https://school.takshashila.org.in/You can listen to this show and other awesome shows on the new and improved IVM Podcast App on Android: https://ivm.today/android or iOS: https://ivm.today/iosYou can check out our website at https://www.ivmpodcasts.com

Lauren and Anthony wrap up the school year, and reflect on the Stephen Neely conversation. THE BIG QUESTION: We know that the Dalcroze approach improves musicianship in myriad ways. When did you realize that the Dalcroze work did more than just improve musicianship? What does it mean to be an education "in and through" music? Dr. John Habron joins to discuss the upcoming ICDS conference.

  Dr Carolyn Lam:                Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center, and Duke National University of Singapore. And I am joined today by our Editor of Digital Strategies, Dr. Amit Khera from UT Southwestern, as well as three wonderful fellows in training. Yes, you've guessed it, it's our FIT Podcast and I'm just so thrilled to be here again. Dr Carolyn Lam:                Amit, any words of introduction before we start? Dr Amit Khera:                  Thank you Carolyn. I think, for both of us, this is our favorite podcast, or two podcasts, that we do, a year. It reminds us of how bright the future is, with superb cardiology fellows in training around the country, and it really is a testament to how important we find fellows in training, to Circulation, to our mission, and how much we learn from them.                                                 So we're really excited about this group, today, and thank them for participating. Dr Carolyn Lam:                Absolutely. So, why don't we start, now, with ladies first? Let's hear from Dr. Elizabeth Hill. Dr Elizabeth Hill:                Thanks for having me today. My name is Beth Hill, and I'm a first year cardiology fellow at Scripps Clinic, in La Jolla, California. I've a particular interest in sports and exercise cardiology, which brings me to the article I picked today about sudden cardiac death and hypertrophic cardiomyopathy, hot topics in the field and in general.                                                 And so, today, I'm excited to be discussing the EVIDENCE HCM study, looking at the hypertrophic cardiomyopathy of risk, sudden cardiac death model. Dr Carolyn Lam:                Nice. So tell us a little bit about what really struck you about the paper and, perhaps, how that may apply to where you practice? Dr Elizabeth Hill:                What I really liked about the paper is that, when I see patients in clinic with hypertrophic cardiomyopathy, prior to having this risk stratification tool, we didn't really have a way to objectively risk stratify our patients with hypertrophic cardiomyopathy and really guide the discussion about who may benefit from an implantable cardiac defibrillator or ICD. And so, I've been using this a little bit with my patients. While it hasn't made it fully into the AHA or ACC guidelines yet, I'm using it as a tool. Dr Carolyn Lam:                Great. You know, these are seven risk factors, isn't it? I'm always struck by that survival curve that really shows that those with a predicted 6% risk stand out. Is that what you use, as well, to guide your decisions? Dr Elizabeth Hill:                Yeah. I think, as the authors noted, they picked this somewhat arbitrarily so that they could study their risk model. But I think what they found is that it seemed to fit well with the observed high risk of sudden cardiac death cohort, such that those that were seen and observed, about 9% risk of sudden cardiac death in five years, were in that greater than 6% cohort. So I think that population should receive ICDs, and that is one factor that I used to guide my decision making as well. Dr Amit Khera:                  Beth, this sort of interest that you've had for a long time, in sports cardiology, I've noted you've done some prior work in EKG screening and other screenings. In terms of this article specifically, as you pointed out, this is a really helpful tool because I still remember back when I was a fellow in training, there was, sort of, this thought that everyone was high risk with hypertrophic cardiomyopathy, and I think we realized that's not true at all. The overall incidence of sudden death was only 2.4% in this cohort.                                                 The question I have for you, in terms of application, is, as Carolyn pointed out, these are reasonably simple variables, but as we sometimes are now using cardiac MRI and genetics and other more advanced tools, where do you think they fit in, in the current paradigm, since this is a bit of a more simplistic score? Dr Elizabeth Hill:                The seven risk factors they put into this tool were noted to be independently associated with an increased risk of sudden cardiac death, and those are well known factors, entricular tachycardia, maximum wall thickness. But I really do think that other factors will come into play soon and are part of my discussion, and colleagues' discussions, including the late gadolinium enhancement on MRI, genetic factors, and I really think this may be a place for tools like machine learning. These authors, O'Mahoney and colleagues, they really did, kind of a tour-de-force, going back to the 1970s, but there is still a decent amount of data missing. So maybe we can partner with the machines and help them go back into these records, a little bit more effortlessly, and look at genetics, maybe some wearable device data, and really refine our risk stratification tool moving forward. But that's definitely something I use in risk stratification in some of my intermediate risk patients. Dr Amit Khera:                  Those are great points. I think your point about machine learning and novel algorithms will definitely take foot in the future.                                                 Maybe a follow-up, again, given your background interest, I think it's a trade-off where we're trying to, of course, avoid sudden death, but you also don't want to overtreat. Especially, when you think about athletes getting ICDs and how that changes, or anyone, for that matter, about maybe telling someone they're at high risk, or giving them an ICD when perhaps they don't need it. I guess that comes to, what's the threshold? Here they use 6%, but that ends up being a bit arbitrary, in terms of what threshold we use. And how do we decide, when we talk to our patients, about what threshold's a right threshold to apply an ICD? Dr Elizabeth Hill:                Yeah. That's a great question. Like you mentioned, these devices come with inherent risks, such as unnecessary shocks, increased risks for infection, and sometimes there's restrictions with athletic sport, although that's been changing recently.                                                 But, I think that's where the shared decision-making process comes into play, where you put current data on the table with the patients and, perhaps, their families as well, and have a risk-benefit discussion. Perhaps gather a little bit more data about the patient, maybe follow them over time, but I guess I wouldn't jump to put an ICD in, in every patient and, especially, the lower-risk cohort. And what number that is, I'm not quite sure. Here they say maybe less than 4%, but, again, somewhat arbitrary, I think. Dr Carolyn Lam:                Thanks Beth. I mean, as Amit said, it's just so inspiring to see how the papers are being used in practice. Really loved those perspectives.                                                 Now, from sunny San Diego all the way to snowy New Zealand. We have Dr. Mesfer Alfadhel. And Mesfer, tell us a little bit about yourself, and the paper that you've chosen? Dr Mesfer Alfadhel:        Thank you very much. I'm thrilled to be part of this podcast. I'm a second-year cardiology fellow-in-training at the Needham Hospital, in Needham City, New Zealand, where it's snowing at the moment. I'm also a clinical lecturer at the University of Otago School of Medicine. I do have great interest in general cardiology, as the rest of my colleagues, but also am passionate about interventional cardiology and structural heart disease.                                                 The paper I've chosen is really quite relevant to everyone in cardiology, and perhaps extends to other colleagues in other health professions impacted by automated external defibrillator use on survival and functional outcomes in shockable observed public cardiac arrest. The aim of the study was to determine the association of bystander automated external defibrillator use, the survival and function of outcomes in shockable observed out of hospital cardiac arrests. The study was from 2011 to 2015 and the Resuscitation Consortium prospectively collected detailed information on all cardiac arrests at nine regional centers, six in the United States and three in Canada.                                                 They also found that among nearly 50,000 out of hospital cardiac arrests, 8% were observed public out of hospital cardiac arrest, of which 61% were shockable. Overall, a remarkable one in five of shockable observed public out of hospital cardiac arrest were bystander shocked. Now the bystander automated external defibrillator observed, shockable observed public out of hospital arrests were associated with increased odds of survival and full or near full functional recovery almost 2.6 and 2.7 odds ratio than when compared to emergency medical service defibrillation. What's also interesting is that the longer the wait for the emergency services, the higher the benefits from a bystander observed shock. Dr Carolyn Lam:                You know, Mesfer, I appreciate that you chose this one as well. What struck out to me immediately was that more than 60% of out of hospital cardiac arrests were shockable. And when we think about the number of lives that could potentially be saved, therefore, that's quite astounding, isn't it? But can I ask you something? So these are in the US and Canada, how applicable do you think this is to New Zealand? Dr Mesfer Alfadhel:        We do have a small population, just over four million. The number of cardiac arrests here is around 2,000 out of hospital cardiac arrests. And I think probably half of them in the latest reports were shockable. The emergency response time in the urban areas is around six minutes, which I think is acceptable, but we have about 20% of population living in rural areas. And the emergency response time exceeds 10 minutes almost all the time. I think that probably a group that we need to direct intervention to in New Zealand. Dr Amit Khera:                  It's really an important article. I should say that June for the American Heart Association is AED and CPR month so great choice to remind us of the value of these and especially, the one thing that was amazing, obviously this is an observational study, but the absolute change, not relative, was about 14% meaningful recovery and so that's quite impressive in terms of the number needed to treat if you will. Maybe an adjunct to Carolyn's question is, when we think about strategies to enhance bystander AED use for strategies, essentially get the AED there faster. As you know if the EMT time was not delayed it wasn't necessarily better for the bystander.                                                 We had a paper in Circ sometime last year looking at drones and then also geocoding and other people in some countries have looked at apps where you essentially can train a group of people and then they can be texted for a sudden cardiac arrest in their area. I'm curious about any creative things, there's always training and AEDs, I think in this place it was public areas in industry, but what do you think are some creative things or things that we need to be doing to help enhance the ability for bystander or early AED use. Dr Mesfer Alfadhel:        I think this is one area in medicine in general that where technology is really going to advance how we deal with this problem. There's an app that's available, it was launched in the UK a few years ago and it's become available in New Zealand in the last two weeks called, the Good SAM. SAM stands for smartphone activated medics. And it's become available in New Zealand two weeks ago and I downloaded it and still yet wait for it to be activated. And the way it works is you can activate a medical emergency using the app and it dials the emergency response but what it also does is it activates the nearest three people with CPR training nearest to you and it tells you how far they are from the emergency. Now if you don't have the app and you call 911 or the equivalent, the operator can activate it to the nearby personnel who have that experience. And I think it's going to reduce the time markedly.                                                 Now the other end of the question where some of what strategies could be used I think we had a good report from Denmark where they made changes in 2007 in Denmark and then followed by the rest of the country in 2010 where they made CPR or resuscitation education as compulsory at school but also when getting a driving license they made courses available for free that increased the number of defibrillators available in public places and they shared that information with public. They've redone, audited their work, and compared to prior to intervention prior to 2007 and after that and they found an increase number of using the AEDs increased from somewhere around 2% to 15%, which is really encouraging. I think we are following Denmark in that regard probably at slower rate. Dr Amit Khera:                  Thank you those are excellent insights. Dr Carolyn Lam:                Amit, don't you see that I just love learning from these fellows during these podcasts. We should do more of these. This is awesome. Dr Amit Khera:                  I completely agree. Dr Carolyn Lam:                Thank you Mesfer, enjoy the skiing. But now from snowy New Zealand we're going all the way to Nashville Tennessee. Welcome Dr. Vineet Agrawal. So tell us a bit about yourself and your paper. Dr Mesfer Alfadhel:        So my name is Vineet Agrawal. I'm a second-year cardiology fellow at the Vanderbilt University Medical Center. My background is as a physician scientist and as a general cardiologist. My long-term goals are in understanding mechanisms underlying heart failure with preserved ejection fraction.                                                 With that in mind I was really taken by an article that was recently by Margaret Redfield's group from the Mayo Clinic in Circulation, titled “Global Pulmonary Vascular Remodeling and Pulmonary Hypertension Associated with Heart Failure and Preserved or Reduced Ejection Fraction.” I found this article to be a very interesting, hypothesis-generating article.                                                 In a nutshell what they did was they took an autopsy cohort of patients in the Mayo Registry and those who had heart failure with both preserved and reduced ejection fraction, normal controls, and those who had a primary pulmonary venous occlusive disease, and looked at the lung specimens of these patients. And interestingly what they found was there was a significant amount of pulmonary venous remodeling that had occurred in patients who had both preserved and reduced ejection fraction. This correlated not only with their right heart cath findings, so those who had elevated pulmonary pressures and elevated transpulmonary gradients, but also differed from the primary pulmonary venous occlusive disease in the sense that the histologic appearance of these vessels was quite different.                                                 And while as an autopsy study this is not necessarily an article that would immediately change practice, what I think it does do though is it forces us to think about these conditions in a different context and particularly with an eye towards future therapeutics. Heart failure with preserved EF as a disease, as I'm sure we all know, is sorely missing therapies that could alter the disease progression and potentially even alter mortality in these patients. And this article in my opinion really sheds light on at least anatomically a new location for us to think about as a therapeutic target when we try to better understand this disease and find therapies for these patients. Dr Carolyn Lam:                Vineet, can I just say you're singing to the choir here. I'm such a fan of this work as well for obvious reasons. But hey, could I ask you, in your clinical practice, do you see a lot of these patients with HFpEF and pulmonary hypertension and wonder how to treat them? And along those lines, how has this paper helped you think about these patients more? Dr Mesfer Alfadhel:        I would say when I first started residency as a medical student this was not necessarily a condition that was really something that I had learned much about or felt like I had been exposed to; however, as a resident I felt like most of the patients, or at least half of the patients, I was seeing with heart failure had a component of diastolic heart failure or they had a preserved EF but very symptomatic from the standpoint of heart failure. And I struggled to treat them, particularly in some part due to the fact that many of the risk factors that contribute to HFpEF, diabetes, uncontrolled hypertension, obesity, are chronic problems that are difficult to manage as a clinician regardless.                                                 And second because I feel that there just weren't any data to support any treatments that we were pursuing at the time and so we would try and apply what we had learned in other types of heart failure to these patients with limited results. If I could talk about what I think this article may change in terms of my practice today, one thing that we've always thought about in terms of pulmonary vascular remodeling in heart failure is that it's just a passive process that as fluid builds up you back up into the lungs and as the fluid builds up and backs up into the lungs you get remodeling.                                                 I think one thing that this article shows is that it may actually be a bidirectional process, which would suggest that perhaps we may need to reconsider looking at pulmonary-specific therapies in this population. But more importantly I think it does confirm that chronic elevating filling pressures do have an effect and a deleterious effect on the pulmonary vasculature. Particularly when you look at other trials such as the CardioMEMS trial, the CHAMPION trial in which the data pretty convincingly showed that as clinicians we don't do the best job of reducing left-sided filling pressures in our patients with heart failure as much as we think we do. This article really drives home the point to me that I really need to make sure that when I see these patients that I'm doing everything I can to reduce their left-sided filling pressures because the consequences of not doing so can affect the lungs, which can then in turn affect the heart as well. Dr Carolyn Lam:                Vineet, that's really words of wisdom. Couldn't agree more. And these are the first sort of autopsy, histological evidence that we have, which is so important. I think if I could just add a couple of perspectives too, it makes me think about making sure that I rule out PVOD in these patients sometimes. We now keep thinking about HFpEF we forget that we need to also rule out PVOD and the other thing much as we now think about not just the filling pressures but the remodeling it's good to note that they found it more in the venous than the arterial system, which also comes therefore with a warning message that we can't just extrapolate I suppose all the PAH therapies that we know about. What do you think about that? Dr Mesfer Alfadhel:        I absolutely agree with that. It's really interesting that all of our therapies from heart failure standpoint and from a PAH standpoint have focused on the myocardium, the neural hormonal cascade, and then the arterials. The pulmonary main artery and arterials. I don't think anyone really understands the biology of pulmonary veins and yet they're actually a pretty significant part of our everyday practice in cardiology. Pulmonary veins are thought to be the source of atrial fibrillation. We look at pulmonary vein inflow when we evaluate patients with echoes. And yet we understand so little about the biology and the mechanisms by which pulmonary veins are affected in both diseased and healthy patients.                                                 I think this article for that reason raises a number of very interesting questions and may potentially change the way we think about these patients. Dr Carolyn Lam:                I keep learning, Amit, this is awesome. I could go on forever so you better stop me. Dr Amit Khera:                  I should probably just be a fly on the wall. You must know Carolyn is a HFpEF, HFrEF aficionado and you guys should have a side call for another hour after this. But I do have one, maybe orthogonal question which is, it's interesting because if you look at how insights were made, they're made off areas I would argue at least that we don't, modern environment uses much which is the autopsy and probably to a large degree hemodynamics as much as probably in the old days although that's changing. I'm curious in a fellowship training program your exposure to autopsy and kind of current in-depth hemodynamic-type training, what's your experience? Dr Mesfer Alfadhel:        Our experience with looking at pathological slides, getting under the microscope, seeing tissue first hand, is somewhat limited in our fellowship training program. I would say in certain subspecialties like our heart failure, advanced heart failure subspecialties we do get a chance to see more myocardial biopsy specimens, but I think increasingly the focus has been on noninvasive methods by which we can assess some of these same things that we used to do, use the microscope for. Invasive hemodynamics I think similarly we get a lot of experience in terms of spending time in the cath lab but I do kind of wonder if we don't have the same in-depth training that we used to have in understanding all the nuances of hemodynamics that used to exist in the past.                                                 Certainly, I think that while that's partially a reflection of the way and the direction in which medicine is heading, there is a little bit that's potentially lost there. That said, while we have the benefit of manuscripts like this that does do in-depth hemodynamics and looks at autopsy samples from a clinical standpoint, if we were to ever try and understand this in a larger population I think we would be required to try and find a way to noninvasively or maybe through potentially invasive hemodynamics better study this in live patients. Dr Amit Khera:                  Appreciate that answer and I'm just for all of you, this has been outstanding. You all have served as incredible expert discussants. I know Carolyn already said it multiple times but we've learned a ton about each of these articles and great to see how they come alive and are used in practice and how they're applied in your own thinking and specifically as fellows in training with these have meant to you. We thank you all for joining us and it's really been a fantastic experience. Dr Carolyn Lam:                Amit, I can only echo your thanks and thank you listeners for joining us today. Fellows out there you are so important to us. Please, please apply to join us on the next FIT podcast as you can see it's really fun.                                                 Don't forget to join us again next week.

Dr Carolyn Lam:                Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr Carolyn Lam, associated editor from the National Heart Center and Duke National University of Singapore. This week's feature paper reports results of the SWAP-4 study, which is the first study to evaluate the pharmacodynamic impact of the timing and dosing of clopidogrel administration when de-escalating from ticagrelor therapy. Extremely important take-home messages for clinicians looking after patients with coronary artery disease and a must listen to. Coming up right after these summaries.                                                 In the first original paper this week, chondroitin sulfate, well known in the context of the monogenic disease mucopolysaccharidosis type 6 may actually represent a novel therapeutic approach for the treatment of general heart failure. First author Dr Zhao, corresponding author Dr Foo, from Genome Institute of Singapore studied changes in myocardial chondroitin sulfate in non-mucopolysaccharidosis failing hearts and assessed its generic role in pathological cardiac remodeling. They found that failing human hearts display an abundant accumulation of chondroitin sulfate proteoglycans in the extracellular matrix largely localized to fibrotic regions.                                                 The main component of chondroitin sulfate glycosaminoglycan chains in human hearts was chondroitin 4 sulfate. TNF alpha was a direct binding partner of glycosaminoglycan chains rich in chondroitin 4 sulfate. Modification of the chondroitin sulfate chain with the recombinant human arylsulfatase B, which is an FDA-approved treatment for mucopolysaccharidosis type 6 that targets chondroitin 4 sulfate, actually ended up reducing myocardial inflammation and overall fibrosis in vivo. In two independent rodent models of pathological cardiac remodeling, this recombinant human arylsulfatase B treatment prevented cardiac deterioration and improved functional recovery. Thus, targeting extracellular matrix chondroitin sulfate represents a novel therapeutic approach for the treatment of heart failure.                                                 The next paper focuses on the subcutaneous ICD, which is an entirely subcutaneous system that does not require intra-procedural vascular access or endovascular defibrillator leads or coils. Now the subcutaneous ICD has a novel mechanism of defibrillation and is associated with an increased energy requirement for defibrillation when compared to traditional transvenous ICDs. Thus, ventricular fibrillation or VF conversion testing at the time of subcutaneous ICD implantation is a class 1 recommendation.                                                 Yet, what is the current adherence to this recommendation? Well, today's paper addresses this question from first and corresponding author Dr. Friedman from Duke Clinical Research Institute. He and his co-authors studied first time subcutaneous ICD recipients between 2012 and 2016 in the National Cardiovascular Database Registry ICD Registry to determine the predictors of use of conversion testing, predictors of an insufficient safety margin during testing and in-hospital outcomes associated with the use of conversion testing.                                                 Results show that use versus non-use of VF conversion testing after subcutaneous ICD implantation in the US was more related to physician preference than patient characteristics. The study also identified several patient characteristics associated with an insufficient defibrillation safety margin. That included increased body mass index, severely decreased ejection fraction, white race, and ventricular pacing on the pre-implantation ECG. Use of VF conversion testing after subcutaneous ICD implantation was not associated with a composite of in hospital complications or death. These data may inform ICD system selection and a targeted approach to conversion testing.                                                 We know that elderly patients are at elevated risk of both ischemic and bleeding complications after an acute coronary syndrome and display higher on clopidogrel platelet reactivity as compared to younger patients. Does prasugrel at five milligrams compared to clopidogrel reduce ischemic events without increasing bleeding in the elderly? Today's paper addresses this question from corresponding from corresponding author Dr Savonitto from Manzoni Hospital Italy and his colleagues.                                                 These authors performed a multicenter randomized open label blinded end point trial comparing a once daily maintenance dose of prasugrel five milligrams with the standard clopidogrel 75 milligrams in patients more than 74 years old with acute coronary syndrome undergoing percutaneous coronary intervention. The primary end point was a composite of mortality, myocardial infarction, disabling stroke and re-hospitalization for cardiovascular causes or bleeding within one year. Enrollment was interrupted due to futility for efficacy according to pre-specified criteria after a planned interim analysis when 1,443 patients had been enrolled with a median follow-up of 12 months.                                                 At this point of interruption, there was no difference in the primary end point between reduced dose prasugrel and standard dose clopidogrel. The results of this Elderly ACS 2 study therefore could not show overall clinical benefit of prasugrel five milligrams versus clopidogrel in elderly ACS patients undergoing early PCI.                                                 The final study is the first to define the cellular and molecular mechanisms of cardiac valve inflammation and fibrosis occurring in the setting of systemic inflammatory disease. First author Dr. Meier, corresponding author Dr Binstadt from University of Minnesota used T-cell receptor transgenic mice which spontaneously developed systemic auto antibody associated autoimmunity leading to fibro inflammatory mitral valve disease and arthritis.                                                 They identified a critical population of CD301b/MGL2 expressing mononuclear phagocytes that orchestrated mitral valve inflammation and fibrosis in this mouse model. They further demonstrated an analogous cell population was present in human inflammatory cardiac valve disease. Finally, they defined key inflammation molecules that drove mitral valve disease in this model, thus providing multiple potential therapeutic targets that are required for mitral valve inflammation and fibrosis. Dr Carolyn Lam:                That wraps it up for your summaries. Now for our feature discussion.                                                 Searching between different classes of P2Y12 inhibitors including de-escalation from ticagrelor to clopidogrel commonly occurs in clinical practice. However, what are the pharmacodynamic profiles of this strategy? Well, today's feature paper is going to provide a lot of insights. I am so pleased to have the corresponding author of the SWAP-4 study, Dr. Dominick Angiolillo from University of Florida College of Medicine Jacksonville, as well as our associate editor Dr. Gabriel Steg from Hôpital Bichat in Paris, France. Dominick, now this is SWAP-4. That means there was a SWAP 1, 2, 3. Could you just paint the background and rationale for SWAP-4 and tell us what you found? Dr Dominick Angiolillo:   We performed this study on the background of a line of research that we've been conducting over the past number of years of switching antiplatelet therapies. There's so many different types of switches that can occur and one of them is that which is defined as a de-escalation which is that from a more potent P2Y12 inhibitor to a less potent and one of those that occur frequently in clinical practice is the switching from a ticagrelor to clopidogrel and this was essentially the rationale for conducting the SWAP-4 study.                                                 Now I want to start off with saying that the reason for doing this study is not to advocate switching because we always recommend that individuals follow guideline recommendations but we performed this study because we wanted to provide clinicians with some additional insights that if you're going to switch particularly from ticagrelor to clopidogrel, which would be the modality which is associated with, put it this way, with the smoothest transition one drug to another.                                                 This is the rationale. What we did was do a pharmacodynamic, conduct a pharmacodynamic study taking patients who were on standard treatment with dual antiplatelet therapy aspirin and clopidogrel and they had a run-in phase with ticagrelor. And the reason why we took patients on the back part of aspirin and clopidogrel is because we then wanted to look at the effects after switching to compare it with a baseline. There have been some discussions about drug-drug interactions. And patients were randomized to either continue with treatment with ticagrelor to switch with a loading dose of clopidogrel, 600 milligrams 12 hours after last dose of ticagrelor. 24 hours after last dose of ticagrelor or directly switch with a maintenance dose. So, the randomization was into four groups.                                                 Essentially to keep a long story short, what we observed was that when de-escalating from ticagrelor to clopidogrel we did see an increase in platelet activity obviously as expected. But the use of a loading was not able to mitigate this increase but there were no differences according to timing of administration of the loading dose clopidogrel 12 or 24 hours. We had anticipated in our study design that with the administration of the loading dose 24 hours after last maintenance dose we could have achieved a smoother transition, but this was not the case.                                                 Nevertheless, the overall conclusions of our study are supported by the pharmacodynamic data in terms of you still achieve a better transition when you give a loading dose than without a loading dose. I was also want a little bit cautious and I think during the review process of the journal and feedback from the editors we kind of phrased in a very cautious way the suggestion for a drug-drug interaction, in fact we suggested because there are other ways to look into this phenomenon in more detailed manner. For example, doing some specific pharmacodynamic analysis which was not done in this study. Nevertheless, the take-home message from a clinical perspective remains unchanged. Dr Carolyn Lam:                Thanks so much, Dominick. That was a very important framing of the paper that you gave us at the start that this trial was not designed to try to say who should be de-escalated or not and that should be in line with the guideline recommendations and yet such an important just take-home message that if there is a need that the 600-milligram loading dose of clopidogrel should be used. You know, Gabriel, you've thought a lot about this and especially the drug-drug interaction question. What are your thoughts there? Dr Gabriel Steg:                Yeah, well first of I think this is an extraordinary, important study even though it's a pharmacodynamic study, which many clinicians might look at and then quickly read the abstract and turn the page I think this is actually one of the most interesting papers we've published in recent months. The reason for this is this is tackling a very common clinical scenario, which is having or desiring or wanting to de-escalate the intensity of platelet therapy after a PCI or ACS from a potent agent such as ticagrelor to a less potent agent such a clopidogrel. And as nicely explained in the paper, there are multiple reasons why this can occur.                                                 A common clinical scenario is that cost is a major issue. Because of the cost patients or physicians may want to switch to clopidogrel, a generic drug as opposed to a branded drug. Another scenario which is fairly common is side effects. Either nuisance bleeding or maybe dyspnea with ticagrelor may prompt some physicians and patients to want to deescalate to clopidogrel. To a less intensive therapy which may not have dyspnea or may not cause as much nuisance bleeding. And finally, sometimes it's done on purpose because some believe that within a few weeks or months following PCI or ACS the benefits of more intensive patient therapy is less, the risk remains the same and therefore maybe we could proposedly de-escalate therapy to clopidogrel and get away with it and there have been a number of randomized studies and observational studies that suggested that this might be feasible although these studies have weaknesses. They're often open label. They're often fairly small and somewhat underpowered.                                                 So, we don't have a definitive answer. Nevertheless, this happens on an everyday basis in most large clinical centers and we don't know exactly how to do it and what the best way to do it and I really want to credit Dominick's team for doing a rigorous series of investigations, including this one, which is the latest one but not the only one in trying to really map out how exactly we should as clinicians manipulate these agents to achieve the best safety and efficacy for our patients. And I think the message here is very clear. Yes, you can de-escalate but you have to be careful on how you do it. And I think you really need to use a loading dose, a 600-milligram loading dose of clopidogrel if you're going to deescalate from ticagrelor to clopidogrel to avoid a gap in protection that might be deleterious to patients.                                                 That does not address all of the questions that are raised by de-escalation and as I pointed out I think outcome trial data are really of paramount importance here, but I think this really important because it has major practical implications for clinicians worldwide on how to do this. So, I think this is a great study. I really want to congratulate Dominick. Dr Dominick Angiolillo:   Thank you. Dr Carolyn Lam:                You looked at the genetic status as well. Could you tell us about your findings there? Dr Dominick Angiolillo:   We in the spirit of trying to perform the most comprehensive possible assessment we have also looked at the genetic background of our patients and in particular looking whether the presence of a loss of function allele for CYP2C19, which is involved with clopidogrel metabolism, could have affected the outcomes. And the reason why we did this there've been a lot of studies clearly showing that if you have a loss of function allele for CYP2C19 you do have higher levels of platelet reactivity. Therefore, we want to see if those carriers would have had even a greater increase in platelet reactivity. And again, we did all this in the spirit of really trying to define again this from a pharmacodynamic standpoint, if there could be any potential safety hazards with such an increase in platelet reactivity with the de-escalation.                                                 When we did our analysis, we did not find any impact of a CYP2C19 on our data. However, I think it's important to underscore that we did not have too many patients with a loss of function allele so clearly the study was not designed or nearly closely powered to look into this assessment. So, I think that aspect does need to be interpreted with caution. Dr Carolyn Lam:                Thanks so much, Dominick. Were there perhaps caveats that clinicians listening in should pay attention to? For example, this study was conducted in stable patients with coronary artery disease. What about patients with recent acute coronary syndrome? Dr Dominick Angiolillo:   That's a great point. The reason why we conducted this study in a more stable setting was largely driven by two aspects. Well first of all, we wanted to have a run-in phase of patients switching from clopidogrel to ticagrelor to have some sort of baseline to reference to after the switch. And this would have been mostly ACS patients that would be less likely to be on clopidogrel. The second is purely a safety issue. We know that patients with acute coronary syndromes are associated with higher levels of platelet reactivity and in the context of a study where we do not know the pharmacodynamic profiles associated with de-escalation or better off we don't know the details.                                                 And so, there was a safety consideration there which is why we did it in stable patients. But what we can say is tied with Gabriel's comment before in all the studies out there are not powered or do not have the rigor of a mega trial. Although we give our suggestions and recommendations, practical recommendations on how to switch, there is an increase in platelet reactivity and we stress in our manuscript that if you are going to switch, please try to delay this as much as possible because those increases in platelet reactivity for example, in a patient with an ACS for example, immediately after PCI, something that we probably would not want for our patients. I'm very happy actually that we conducted the study in the more stable cohort because we had less confounders. This is kind of the reason behind all this. Dr Gabriel Steg:                The last question maybe I would ask Dominick is whether he believe that results would be different if we had the patients on a maintenance therapy for longer with clopidogrel, do you believe that the risk of rebound or drug-drug interaction are the same early on after institution of therapy or later on? Is there any reason to expect a difference? Dr Dominick Angiolillo:   That's a great question. My personal opinion would be that with longer duration the platelet reactivity would have gone back down to baseline. We actually continue to study out up to around 10 days following the switch which we thought would have been sufficient time to get back to baseline and it was not the case particularly in the patients whose switch was a 75 milligram. The answer's probably yes. Probably yes. To redesign the trial again maybe having that 30-day time point as well would have been obviously of added value. Dr Carolyn Lam:                Thank you so much, Gabriel and Dominick. This has been extremely insightful. Fun as always.                                                 You've been to Circulation on the Run. Don't forget to tune in again next week.  

Dr Carolyn Lam:                Welcome to Circulation on the Run. Your weekly podcast summary and backstage pass to the Journal and its editors. I'm Doctor Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. This week's journal features an international external validation study of the 2014 ESE Guidelines on Sudden Cardiac Death Prevention in Hypertrophic Cardiomyopathy. A very exciting discussion coming right up after these summaries.                                                 The first original paper this week suggests that proteomics, a tool of precision medicine may prove useful in improving the safety and efficiency of drug development. First author, Doctor Williams, Corresponding Author, Doctor Ganz, from the Zuckerberg San Francisco General Hospital retrospectively applied large scale proteomics to blood samples from Illuminate, the trial of Torcetrapib, a cholesterol estrotransfer protein inhibitor, which raised HDL and lowered LDL cholesterol. Recall that this trial was terminated due to increases in cardiovascular events and mortality.                                                 In the current study, the authors found that plasma concentrations of 200 proteins changed significantly with Torcetrapib. Their pathway analysis revealed unexpected and widespread changes in immune and inflammatory functions, as well as changes in aldosterone function and glycemic control. A previously validated nine protein risk score was similar in the two treatment arms at baseline, but higher in participants with subsequent events. At three months, the absolute nine protein derived risk increased in the Torcetrapib plus Atorvastatin arm compared to the Atorvastatin only arm. Thus, this protein-based risk score predicted harm from Torcetrapib within just three months. A protein-based risk assessment embedded within a large proteomic survey may prove to be useful in the evaluation of therapies to prevent harm to patients. This is discussed in an accompanying editorial entitled "Harnessing the Power of Proteomics to Assess Drug Safety and Guide Clinical Trials" by Doctor Maggie Lam and Ying Ge.                                                 The next study suggests that personalized monitoring of heart transplant outcomes may be achieved by profiling the genetic and phenotypic markers of the CD16-dependent natural killer cell activation pathway. First and corresponding author Dr. Paul from Vascular Research center in Marseilles in France and his colleagues collected blood samples from 103 patients undergoing routine coronary angiography for cardiac allograph vasculopathy diagnosis, a median of five years since their heart transplantation. They used a non-invasive natural killer cellular-humoral activation test to evaluate the association between genetic and phenotypic markers of the CD16 dependent natural killer cell activation pathway. They showed that the Fc-gamma receptor IIIAVV polymorphic variant, which encodes the highly responsive CD16-Fc receptor, was an independent baseline predictor of cardiac allograph vasculopathy, and may be useful for stratifying patients at higher risk of rejection. The implications of these findings also include the fact that individualized natural killer cell targeted therapies may limit vascular damage in responsive patients.                                                 The next study suggests that estimation of polygenic atrial fibrillation risk is feasible, and together with clinical risk factor burden, can explain lifetime risk of atrial fibrillation. Co-first authors Dr. Weng and Preis, corresponding author Dr. Lubitz from Massachusetts General Hospital, and colleagues estimated the lifetime risk of atrial fibrillation in individuals from the community-based Framingham Heart Study. Polygenic risk for atrial fibrillation was derived using a score of approximately 1000 atrial fibrillation-associated SNPs. Clinical risk factor burden was calculated for each individual using a validated risk score for incident atrial fibrillation comprised of height, weight, systolic and diastolic blood pressure, current smoking, anti-hypertensive medication use, diabetes, history of myocardial infarction, and history of heart failure.                                                 They found that the lifetime risk of atrial fibrillation after age 55 years was 37 percent was substantially influenced by both polygenic and clinical risk factor burden. Among individuals free of atrial fibrillation at the age of 55 years, those in the low polygenic and clinical risk tertiles, had a lifetime risk of 22 percent, whereas those in the high risk tertiles had a risk of 48 percent. Atrial fibrillation developed at an older age among individuals with a favorable clinical risk profile regardless of genetic predisposition. Nevertheless, the lifetime risk of atrial fibrillation in individuals with high genetic predisposition was substantial, even when the clinical risk factor burden was low. Thus, individualized projections of lifetime risk of atrial fibrillation may be refined by accounting for both genetic predisposition and clinical risk factor burden.                                                 The final study tells us that in contrast to previous perceptions, Takotsubo cardiomyopathy has long-lasting clinical consequences. First and corresponding author Dr. Skally from University of Aberdeen in the UK and their colleagues did an observational case controlled study of 37 patients with prior Takotsubo cardiomyopathy and 37 age, sex, and co-morbidity matched controls. Although Takotsubo cardiomyopathy occurred 20 months before the study, the majority of patients had persisting symptoms compatible with heart failure and cardiac limitation on exercise testing. Despite a normal left ventricular ejection fraction in serum biomarkers, patients with prior Takotsubo cardiomyopathy had impaired cardiac deformation indices on echo cardiography, increased native T1 mapping values on cardio magnetic residence imaging and impaired cardiac energetic status on p31 spectroscopy. Taken together, these findings demonstrate that after Takotsubo cardiomyopathy, patients appear to develop a persistent long-term heart failure phenotype.                                                 Well that wraps it up for our summaries. Now for our featured discussion.                                                 Sudden cardiac death prevention and hypertrophic cardiomyopathy. Always such an important topic. I'm so pleased to have with us the author from our featured paper this week, Dr. Perry Elliot from University College London, nd our associate editor, Dr. Mark Link from UT Southwestern who also wrote a beautiful accompanying editorial with Tera Lynn Ho. So welcome both of you. Perry, I think to set us up, I'd really love if you could tell us a little bit more about the 2014 ESE guidelines for sudden cardiac death prevention and hypertrophic cardiomyopathy. And particularly pointing out how they may differ from the 2011 ACC AHA guidelines please. Dr Perry Elliot:                   So, the 2014 guideline on sudden death prevention HCM, the aim of that guideline was to try to quantify the risk of sudden cardiac death. As you pointed out, sudden death is a significant complication of hypertrophic cardiomyopathy and one which we all as clinicians spend a lot of time trying to determine. If we look back over at, I don't know, a period of twenty, thirty years the approach we've developed is based upon the recognition of a number of clinical features of the disease that we know associate with a higher risk of sudden death. So things such as, you know, unexplained syncope or severity of hypertrophy. And it was that model of sort of taking those so called major risk factors which form the basis of the 2011 US guidelines and the essential model was the more of those things you have, the greater is your risk, and I suppose the  higher indication for an ICD.                                                 One of the problems with that approach was that it's not quantitative so you know, you could say, "Okay. Well I think you're at higher risk, but I can't say how much that risk is." And another problem with that way of doing things is when you start to think about some of the individual risk factors, it doesn't make a great deal of sense clinically.                                                 And I suppose a good example of that is wall thickness. You know we have this magical number of 30 millimeters, above which we say you're at risk, but of course are we really saying that if your wall thickness is 29 millimeters you're at low risk? We know it doesn't really work that way in biology. So when we drew up the 2014 guideline we wanted to say, "Okay let's develop a model in exactly the same way that we do with atrial fibrillation or primary prevention in coronary disease so that we can say to the patient sitting in front of us, 'Based on your clinical assessment we think you've got a one, five, ten percent risk of something bad happening to you in the next five years.'" And then we can use that information to inform our decision about ICD implantation.                                                 The model itself is not so revolutionary. I mean, it uses a lot of the conventional risk factors such as wall thickness, such as non-sustained VT on Holter monitoring, but what it did introduce was the factor of age, because we know that the age of the patient certainly determines their risk. We brought in [inaudible 00:10:12] obstruction because we've now got reasonable evidence showing that if you've got a big gradient, that certainly modulates your risk. And also probably for the first time, I suppose, left atrial size, which was one of those missing things I think in previous assessments. You know, it's a fantastic surrogate for restrictive physiology and certainly when we added it to the model it improved the predictive power of that model.                                                 So I suppose in summary what we've done is to produce a tool which allows you to estimate risk and then use that to help you decide on whether an individual needs a defibrillator in the clinic. Dr Carolyn Lam:                You know Perry I believe you led those guidelines and I just want to congratulate you as well as that was such a beautiful explanation of what was going on behind those. Yup, but the proof is in the pudding isn't it? But you're providing that proof in today's paper. Tell us about it. So it's an external validation, a large international multi-centers study to actually validate these 2014 guidelines. Dr Perry Elliot:                   That's right. I mean, I think when we generate these kind of models it's really important to test those models in different settings. The original model was based upon a relatively small number of European centers and I think what this paper does is it brings insights into different geographies and different health care systems. So we have participating centers from North America from the Middle East from the Far East and the idea here is to get as diverse a population as we can and just see if the model performs in the same way. And you know in a study just short of 4000 people, I think that we've shown that the model does indeed seem to behave in the same way. In fact, the numbers were remarkably similar. You know the ability of this model to discriminate between high and low risk patients was almost exactly the same as in the original paper, which I think gives us a level of reassurance that this model, this tool that we've developed, can be used in different health care settings. Dr Carolyn Lam:                Mark. I really enjoyed your editorial. I love the way that you started out with a case that really shows why this is so important. And I also love that you discuss some other studies that tried to validate the 2014 ESE guidelines as well. Could you just give us some of your thoughts there. Dr Mark Link:                     Yeah. I first want to congratulate Perry and his fellow authors for this paper. I think it was a very nice paper. I was a champion of this paper from the time it got sent into circulation. And, you know, the big change in the 2014 European guidelines compared to the American guidelines is really the linear risk of age, wall thickness, and I'll put tract gradient. And as Perry says, I agree, it's not a simple you have it or you don't, it's a linear risk and I applaud them for including that in their risk factor stratifier. And if you look at the current paper, I mean it was very good at picking out high risk patients. So if you have greater than a four percent, six percent risk over five years, you did. And so for picking out the high risk patients it was very good. And for picking out the medium risk patients, it didn't function as well. It was best for separating out the high risk and the low risk population.                                                 And I will say, based on this paper, I've started using the European risk stratifier in my clinical practice. So I do want to applaud them, you know, for the risk stratifier tool and this paper. But I do want to say, and I'm sure Perry will agree, that we're not there yet. We need better tools, because not only in this data set but in other data sets, because more of these individuals reside in the low risk population, more of the sudden deaths are in that population. And we need better tools. And over time they will come. You know, they may be MRI tools. They may be scar tools. They may be other tools that we aren't even aware of that are coming on the horizon, but we do need better tools as we move forward to identify those at risk for sudden death in hypertrophic cardiomyopathy. Dr Perry Elliot:                   Yeah. No. I agree. I mean I think what I would say is if you sort of take a step back and look at the overall perspective in this paper, despite the fact that, you know, we've got nearly 4000 people and they're followed in different health care settings, the overall sudden death rate in hypertrophic cardiomyopathy pretty low. You know, so that's good for patients 'cause I think it shows that at least in managed populations, the risk of sudden death which is real and we've got to assess it, but I think it's really important to get that message over to patients that for most people with HCM they're at low risk. It is of course the challenge because when you're dealing with rare events, it's really hard to predict them. And this model is far from perfect. I would argue it's probably the best we've got for the moment, but you know, it's not that bad. It's not that bad.                                                 I mean agree with you absolutely Mark, 'cause you know, either end it performs pretty well. In the middle there it's not as predictive, although what it tends to do is overpredict, rather than underpredict. So you know, I think if you use this model in your every day practice just the greatest risk is that you'd end up putting in probably more ICDs then you really need to rather than missing a lot of patients. You know, we really want to prevent every sudden death if we possibly can, but that's always going to be really hard I think and I think the fight goes on. We got to look for new risk predictors. It may be that we can interchange some of these predictors. They might be easier to assess in some practices, but I'm not a born optimist, but I really think it's amazing just how well in such a complex heterogeneous disease that this relatively simple assessment works. You know? Dr Mark Link:                     Going forward, what do you think the future of HCM [inaudible 00:15:47] stratification will include? We've got the risk stratifiers in your calculator ready. And more specifically where do you think gadolinium enhancement will play a role in the future? So MRI findings of scar or gadolinium enhancement. Dr Perry Elliot:                   The base we have at the moment show that the more scar you have, the greater risk of sudden death. It sort of makes sense, doesn't it? It's part of that substrate for ventricular arrhythmia. My own reading of it just so far is that I'm not sure what it adds to the existing way of doing things. I mean I think this is true of any biomarker, you know. I've got a new biomarker, what does it tell me that I don't already know? And with scar, we know the greater amount of scar, it often tracks with wall thickness. You're likely to have a thicker heart, you're more likely to have non-sustained VT. But I'm openminded on that front. The beauty about this model, for me, is that it's a tool to into which you can plug other things and you know, if we can get big enough data sets and we can use gads and the amount of scar and put that into the model and if it improves the performance of the model that's great. Those studies are underway at the moment and I think we eagerly wait the results of those studies.                                                 For me, one of the missing things is the genetics. This is a heterogeneous disease with quite a complex genetic architecture, and despite the fact that you know it's 20, 30 years now since we identified the first gene, we haven't really factored that in to our risk models and I think that for me is one of the big challenges and opportunities over the coming years is to put together really large international data sets so that we can answer once and for all whether your mutation determines your prognosis. Dr Mark Link:                     Yeah. I agree with the genetics also I think getting more information on that. And it's been 30 years it still is not helping us prognosticate the risk of sudden death, but it should. I mean it really should. And I do think hopefully we will find other tools also as time goes on because it really is imprecise and it's very difficult when you're sitting there in front of ... You know, I just had a 20 year old yesterday come in with his family and he's got a three centimeter septum and he's got 12 percent scar and he's saying, "Gee what would you do and what would you do if I were your son?" And it's easy when you're looking at it in the aggregate. It's much more difficult when you're sitting there one on one with a patient in front of you. Dr Perry Elliot:                   Of course. Of course. And I think another factor I think which is changing the dynamic of that kind of discussion is the evolution of ICD technology. You know, I think when you're dealing with young people the fear is long-term complications with leads isn't it? And I think with the advent of the SICD I sense it's already tipping the balance into perhaps a slightly more liberal approach to ICD implantation exactly in the kind of scenario you've just described Mark, you know you've got guy who's 20. He's got a really severe hypertrophy. Well you know, if you and mess ICD you know your threshold for implantation might be a bit lower. Dr Mark Link:                     Yeah and in fact, after a two hour discussion that's what we decided on is that subcu ICD was the right thing for him. And everyone's very happy with that choice. Dr Perry Elliot:                   Yep. I think it also raises another thing which I often think about is that as medics we're also probably not good at considering what acceptable risk actually is. You know? We develop models in different settings and hyeprtrophic cardiomyopathy, coronary disease, heart failure, and actually if you go back and critically look at the thresholds that are used to put in defibrillators, the absolute risks vary enormously. So you know, here in [inaudible 00:19:02] we're talking about an approximate annual risk of sudden death of about one percent per annum is sufficient to put in an ICD, but in long-QT world it's quite a different threshold that's used and of course that's because there is no defined number. You know the number's we used in the ESE model of greater than six percent you should have an ICD, well yeah that's the consensus number, there's nothing magical about it. There's nothing biological about it. And I think we've probably had greater debates at what acceptable risks really are. Dr Mark Link:                     And that's become a big shared decision now in the States and actually everywhere. It's become a big word because it sued to be that the physicians would decide on who gets an ICD and who doesn't. And it's no longer that way it's a discussion with the patient, with the family. How much risk are they willing to take, both with an ICD and without an ICD, because there are issues with ICD, even though I'm a big fan. There are issues and especially with transvenous ICDs, but also with subcutaneous ICDs. Dr Perry Elliot:                   Absolutely. Absolutely. Dr Mark Link:                     You know, it's a different world now than it was 15 20 years ago. Dr Carolyn Lam:                Perry and Mark, this has been one of the most wonderful conversations I've had on these podcasts. I just can't thank you enough. I'm sure all our listeners are thanking you too. You've been listening to Circulation on the Run. You must tune in again next week for more beautiful conversations.  

It's arrhythmia week on The Rounds Table! Should heart failure patients give up a caffeine jolt in the morning? How can we better identify appropriate patients for ICDs? Paxton Bach, fellow in General Internal Medicine at UBC, joins Kieran to discuss two exciting studies: Studies that inform practice toward the best medical treatments are of ...The post Summer Replay: DANISH with your Coffee? ICDs for Non-Ischemic Cardiomyopathy and Effects of High Dose Caffeine on Cardiac Arrhythmias appeared first on Healthy Debate.

It's arrhythmia week on The Rounds Table! Should heart failure patients give up a caffeine jolt in the morning? How can we better identify appropriate patients for ICDs? Paxton Bach, fellow in General Internal Medicine at UBC, joins Kieran to discuss two exciting studies: Studies that inform practice toward the best medical treatments are of ... The post Summer Replay: DANISH with your Coffee? ICDs for Non-Ischemic Cardiomyopathy and Effects of High Dose Caffeine on Cardiac Arrhythmias appeared first on Healthy Debate.