Podcasts about ikr

On today's MJ Morning Show: Diddy trial set to begin Target may be getting rid of self-checkout Morons in the news Purple warning Fester got free food for a year This is the worst way to start an e-mail at work MJ's flights Cardinal Pizzaballa MJ IG at TPA... IKR? Kentucky Derby Ferry collision McDonald's Sprite hack First garage door opener winner Arizona bar has bad promotional response to underage drinking busts MJ vacation plans for summer Nike pre-scuffed sneakers? The Sun says there's a cheaper supermarket than Publix opening locations Air traffic controller stays not to fly to THIS airport A pilot's wife says not to to wear this on a flight Lady Gaga concert bomb plot foiled Hi Speed chase on Gandy Blvd. NYU dorm story Woman in Polk County throws can of soda into a car at a gas station, hits baby

Krieket: Die witbal-afrigter van die Proteas, Rob Walter, is oortuig die groep wat hy vir aanstaande maand se IKR Kampioenetrofee aangewys het, besit die potensiaal om die titel te wen. Die groep van 15 lede sluit die snelboulers, Anrich Nortjé en Lungi Ngidi in, wat die hele internasionale seisoen tuis weens beserings misgeloop het. Kolwers Tony de Zorzi, Ryan Rickelton en Tristan Stubbs, asook die veelsydige Wiaan Mulder, speel die eerste keer in ʼn senior IKR-toernooi oor 50 boulbeurte. Volgens Walter het die groep baie ervaring.

Radiosportens intervjuer, reportage och sporttips för barn och unga. Lyssna på alla avsnitt i Sveriges Radio Play. I Kråkebergets skog utanför Skövde fostras framtidens enduroförare som lär sig grunderna i den krävande sporten som går ut på att köra motorcykel i terrängen.Längs med långa leriga stigar och knixiga sandspår så flyter en lång rad av unga enduroförare fram och mitt ibland dem finns en SM-guld medaljör som tog sina första gastag på just Kråkeberget.

This weeks roses involves a secret kid? IKR....Tune in to find out how! Website

KTheChosen is your Friendly Neighbourhood Rapper who creates music that is both entertaining and enlightening. K is a Zimbabwean-raised and Calgary-based artist who believes in the power of storytelling to share the experiences of those around him. His 2021 album, +Vice (pronounced "add vice") covered topics such as grief, feminism, and mental well-being. This community-focused album resulted in K being included in The Calgary Herald's Top 20 Compelling Calgarians list and a nomination for Rap Recording of the Year at the 2022 YYC Music Awards. He has recently introduced a new persona known as “Heartbreak K” through his last two EPs, titled IKR and IRL.Join us on this episode as K shares his immigration story, some culture shocks and being an artist in Canada. He shares about how he got into the music industry and his experience with tokenism especially during Black History Month. Listen, learn and be inspired. Don't forget to laugh!Follow KtheChosen on Instagram at @kthechosen | His website is kthechosen.com-----------If you are a Black African or Caribbean immigrant and would like to be a featured guest on Afros in the Diaspora Podcast, please fill out this GUEST FORMIf you need advice or you have a confession, fill in this ANONYMOUS ADVICE FORMIf you need financial advice as an immigrant, fill in this ANONYMOUS FINANCIAL ADVICE FORMJOIN THE COMMUNITY ---Facebook | Instagram | TikTok | Threads - @afrosinthediasporaX - @aitd_podcastFor Email Inquiries - hi@afrosinthediaspora.com

We are back and moving forward into 2024! Tune in to some insights, revelations, and encouragement that was birthed out of a very awkward situation...IKR?! But it's a true story! Put on your headphones to find out this week's Confession & Lesson! Scripture Ref: Ephesians 4:32, Colossians 3:12-13, Matthew 18:15 --- Support this podcast: https://podcasters.spotify.com/pod/show/samantha-helene/support

I Król. 19,8-16 (8) Eliasz wstał, posilił się plackiem, napił się wody i tak posilony szedł przez czterdzieści dni i czterdzieści nocy, aż dotarł do Góry Bożej, do Horebu. (9) Tam wszedł do jaskini, aby przenocować. Wtedy jednak doszło go Słowo PANA: Co tu robisz, Eliaszu? (10) Żarliwie obstawałem przy PANU, Bogu Zastępów — odpowiedział — dlatego, że Izraelici porzucili przymierze z Tobą. Poburzyli Twoje ołtarze, wybili mieczem Twoich proroków i zostałem ja sam, ale mnie także chcą pozbawić życia. (11) Wówczas Eliasz usłyszał: Wyjdź i stań na górze przed PANEM. A oto przechodził PAN! Przed PANEM dął wiatr, silny, porywisty, poruszał góry, odrywał kawałki skał — lecz nie w tym wietrze był PAN. Po wietrze zatrzęsła się ziemia — lecz nie w tym trzęsieniu był PAN. (12) Następnie wystrzelił ogień — lecz nie w tym ogniu był PAN. Po ogniu zaległa cisza, zaszemrał cichy szept. (13) Gdy Eliasz to usłyszał, otulił płaszczem twarz, wyszedł i stanął u wejścia do jaskini. Wtedy doszedł go głos: Co tu robisz, Eliaszu? (14) Żarliwie obstawałem przy PANU, Bogu Zastępów — odpowiedział — dlatego, że Izraelici porzucili przymierze z Tobą. Poburzyli Twoje ołtarze, wybili mieczem Twoich proroków i zostałem ja sam, ale mnie także chcą pozbawić życia. (15) Wtedy PAN polecił: Idź, ruszaj w swoją drogę. Udaj się na pustynię przy Damaszku. Kiedy tam dotrzesz, namaścisz Chazaela na króla Aramu. (16) Jehu, syna Nimsziego, namaścisz na króla Izraela, a Elizeusza, syna Szafata, z Abel-Mechola, namaścisz na proroka, który zajmie miejsce po tobie. Nauczanie z dnia 19 listopada 2023

Spotted in the Podcast studio this week: Hebba Youssef and Rodney Evans chatting about the role of gossip in the workplace and how sometimes, it can actually be a good thing (IKR?).  Brave New Work podcast host and Partner at The Ready, Rodney Evans was heard talking up a storm about the unseen emotional labor of HR professionals in the workplace and breaking free from the codependent caretaker role they often take on.  I also heard a juicy rumor that HR might go the way of the dinosaurs. Out with a bang, amiright? My sources heard Rodney say, “It's an evolve-or-die situation for HR. If HR doesn't take the evolution game seriously, it's just going to become a non-function. It will ultimately be disbanded if it doesn't change into the thing that HR people know it should be.” Later, Rodney and Hebba were overheard discussing the pitfalls of performance management, the power of influencing and politicking, and the importance of having a clear vision and obtaining the necessary permissions to drive change.  But don't take it from me. Tune in to hear all the hot tea they spilled in the podcast for yourselves. Trust me, it's a game-changer.   XOXO -Gossip Girl   00:00:09 - The Cycle of Rescuing and Regret 00:01:12 - Exploring Workplace Cultures with Rodney Evans 00:01:46 - The Evolution of HR: Adapt or Perish 00:03:54 - The Unseen Emotional Labor of HR 00:07:43 - Breaking Free from Codependent HR Behavior 00:12:27 - The Role of Gossip in Establishing Rules 00:20:39 - The Impact of Influencing in the Workplace 00:28:17 - Transforming HR: Permission, Not Perfection 00:32:10 - Navigating the Challenges of HR Initiatives 00:39:32 - Creating Psychological Safety in Meetings 00:44:09 - The Evolution and Challenges of HR 00:45:59 - Connect with Rodney for HR Insights   And if you love HR Therapy, sign up to I Hate it Here, the newsletter for jaded, overworked, and emotionally burnt-out HR/People Operations professionals needing a little inspiration. https://workweek.com/discover-newsletters/i-hate-it-here-newsletter/   For even more exclusive insider content, don't forget to check out my YouTube page.    Follow Rodney:  LinkedIn: https://www.linkedin.com/in/rodneyeevans/ Website: https://www.theready.com      Follow Hebba:  YouTube: https://www.youtube.com/@ihateit-here/videos LinkedIn: https://linkedin.com/in/hebba-youssef Twitter: https://twitter.com/hebbamyoussef   15Five is the performance management platform that drives business results and gives HR teams a complete solution to deliver high employee performance, engagement, and retention while improving manager effectiveness.    Find out more about 15Five here.  

Денис Мосин. 36 лет. Родился в городе Бишкек. Высшее образование отсутствует. В 2007 году переехал в Москву. Работал в студиях Nimbler, Aero, агентстве Red Keds, руководил студией Nile, после этого 10 лет был сооснователем и дизайн-директором агентства Sensitive Brands. В 2019 закрыл агентство и вышел в Яндекс. На данный момент отвечает за промышленный дизайн умных устройств компании Яндекс. Лауреат премий Red Apple, Белый квадрат, ADCR, ADCE, EFFIE, Red Dot. 10 лет преподавал в школе ИКРа и занимался корпоративным консалтингом. Denis Mosin. 36 years. Born in the city of Bishkek. There is no higher education. In 2007 he moved to Moscow. He worked in the Nimbler and Aero studios, the Red Keds agency, and headed the Nile studio, after which he was a co-founder and design director of the Sensitive Brands agency for 10 years. In 2019, he closed the agency and entered Yandex. Currently, he is responsible for the industrial design of smart devices at Yandex. Winner of the Red Apple, White Square, ADCR, ADCE, EFFIE, and Red Dot awards. He taught at the IKR school for 10 years and was engaged in corporate consulting. FIND DENIS ON SOCIAL MEDIA Facebook | Instagram ================================SUPPORT & CONNECT:Support on Patreon: ⁠https://www.patreon.com/denofrich⁠Twitter: ⁠https://twitter.com/denofrich⁠Facebook: ⁠https://www.facebook.com/mark.develman/⁠YouTube: ⁠https://www.youtube.com/denofrich⁠Instagram: ⁠https://www.instagram.com/den_of_rich/⁠Hashtag: #denofrich© Copyright 2023 Den of Rich. All rights reserved.

It's Friday, Friday, see Rebecca Black on a Friday. Honest. You can. IKR?

Krieket: Die Walvis Bay Salt Eagles het Kenia met sewe paaltjies gewen. Kenia het eerste gekolf en 64 lopies met die verlies van 10 paaltjies na 30 boulbeurte aangeteken. Die Eagles kon maklik 67 lopies in 16 boulbeurte behaal. Eagle Junior Kariata is as die speler van die wedstryd aangewys. Die Eagles spook sake uit in die IKR se onder-19 Mans Wêreldbeker Afrika kwalifiserende reeks in Tanzanië teen die gasheerland, asook Nigerië, Sierra Leone en Uganda vir ‘n plek in die toernooi in Sri Lanka. Die afrigter Oscar Nauhaus gee sy mening oor die wedstryd...

Bakit

Pete McCabe, author of Scripting Magic 1&2 sits down to discuss, amongst other things, scripting magic! IKR! He also tackles head on people's biggest misconception about scripts in magic that will change the way you think about scripting forever.

In this episode, Nick and Matt discuss what content marketing is. Should churches even be using marketing? Why is content marketing so effective? And what are some examples of blogs, pillar pages, white paper, ebooks and podcasts to help your church reach Gen Z and Millennials in a Digital and Hybrid form of ministry? Follow us on Twitter - http://www.twitter.com/hybridministry Or check us out online - http://www.hybridministry.xyz LINKS EBOOK EXAMPLE https://21023629.fs1.hubspotusercontent-na1.net/hubfs/21023629/101%20Things%20to%20do%20this%20Summer.pdf?utmmedium=email&hsmi=220409116&hsenc=p2ANqtz--GvYYsBn799IT7tZQ07OLdeLeNshWl6rRnS5f0wNelRUcxnmSP6GBZ4rNYmusr63ghavYI8SAUk3drn2tD3kuUF929s7xlw622qVQVuVCXDVsrlvE&utmcontent=220409116&utmsource=hsautomation WHITE PAPER https://www.dare2share.org/gospel-advancing/value1-prayer MICHAEL HYATT'S BLOG https://fullfocus.co/blog/ CROSSROADS PODCAST NETWORK https://www.crossroads.net/media/podcasts/ PILLAR PAGE EXAMPLE https://www.typeform.com/blog/guides/brand-awareness/ TIMECODES 00:00-02:42 Intro and Beard Discussion 02:42-05:33 Should churches do marketing? 05:33-11:02 Why Content Marketing is so effective 11:02-16:53 How do develop a church ebook 16:53-23:49 How to use White Paper for churches 23:49-27:45 Blogging for churches 27:45-33:29 Podcasting for churches 33:29-34:24 Pillar Pages for Churches 34:24-37:00 How to convince your boss 37:00-38:37 How to get started on each item 38:37-40:48 Which one do I start with? 40:48-44:36 What are the best services to use to capture this stuff? 44:36-45:38 Outro TRANSCRIPT Nick Clason (00:01): Well, hello, everybody. Welcome back to another episode of the hybrid ministry podcast. In today's episode, we are going to be talking about marketing in the church. And what exactly is content marketing? I'm your host, Nick Clason sitting in alongside my amazing friend. The bearded wonder himself, Matt Johnson, how you doing this morning? And how's your beard. Matt Johnson (00:27): Beard is good. Trimmed up, you know, a little bit cleaner, you know, we're, we're in summertime. So, you know, I like to keep a little shorter and, Nick Clason (00:34): Uh, is that like shots fired at me? Is that shots fired at my no, Matt Johnson (00:37): No shots fired at you it off. Cause when the winter comes around, I stopped trim it. So Nick Clason (00:45): Yeah. It's nice. Well, I mean, I just announced everybody that I'm gonna be moving to Texas, so I don't even know if I'm gonna see winter anymore. Matt Johnson (00:54): Probably not. No. I think, uh, your winters are in the past now, so which is really good for you. Nick Clason (01:00): Yeah. And my wife told me my Beard's looking kind of boxy, so I'm not sure what to do with that. I feel like that's code code for trim it. Matt Johnson (01:08): code for shape it a little bit. Nick Clason (01:11): Yeah. Come on, get rid of the box there. So yeah. Anyway, I interrupted you. You said you're doing good. Matt Johnson (01:17): Yeah, I'm doing good. How are you doing Nick Clason (01:19): Great, man. Great. I'm a little sleepy cuz you know it's it's Thursday. We had church last night. So of course I was out late, but oh as well. Um, some do idiot decided to plan an event with silly string. And then I watched as the facilities team looked glaringly and begrudgingly on at the mess that was being made on the patio. And I thought to myself, dang it. Now I probably should clean this up. So that took a minute Matt Johnson (01:51): Oh, let me get a little silly string, Nick Clason (01:54): Um, silly string and then Matt Johnson (01:55): We're very messy Nick Clason (01:57): And then we're getting ready to do a, a, a baptism out on the patio. So there's a big tub out there. And of course all the kids are like getting water from it and throwing it on each other. So whoever thought let's get this set up on a Wednesday before the event, they, they obviously forgot that we were gonna be out there. So Matt Johnson (02:15): Yeah, like let's get ahead of it. Be prepared. Oh actually we made a bigger mess and we had to refill it up. Nick Clason (02:22): Exactly. And they're initially stringing it now. So Matt Johnson (02:25): well, people are getting baptized Sunday. You know, you might find some silly string. Nick Clason (02:31): You might come out with some, uh, lines of pink on you. It's okay. Don't worry. It's not no need that's it's just silly string. Matt Johnson (02:38): No need to concern yourself. Nick Clason (02:40): So, uh, Matt, one of the things I think is an interesting conversation and I'd like to talk about it first here is like, is marketing a thing that churches should even be focused on? Cause a lot of what we're talking about, uh, in, in all these episodes is marketing is kind, kind of like brand recognition, getting yourself out there and different tips and strategies for that. And so I think there may just be a natural aversion to the word marketing, cuz it sounds very secular. It sounds very like businessy. Um, so what, what would be your response to someone who is like marketing in the church? Like, you know, you should be flipping tables for that. Matt Johnson (03:19): absolutely. No, I, I used to be under that ideas. Like why would you ever market Jesus? Like that's not something that needs to be marketed mm-hmm and I think something that you should think about when we think about marketing is not your traditional sense of marketing, of like, Hey, there's a billboard for us. We have commercials. We have radio ads or even like Facebook or TikTok ads. Um, that's not what I'm talking. That's not the primary focus of market anymore. Primary focus marketing is, uh, really just awareness and something. I always go, Seth, always you're marketing, trying to change world with your marketing, you're failing as a marketer. Um, so when you put that in a context, your marketing mind should shift cuz I mean we're working in the church and you should be trying to change the world. So this is definitely something that we should be, you know, evangelizing essentially. Matt Johnson (04:11): And it's I'm so what, how a good way to put this in your mind is like, Hey, how do we do a, you know, have an evangelistic mindset for our church in the modern era. And uh, I always just think back to, you know, the pastorals they've marketed Christianity in a totally different way. So it's always been quote marketed, but you just gotta think that brand awareness, bringing awareness to what you're trying to do and how you're trying to help the community and that stuff not, Hey, come by Jesus. Cause if, and if that's what you're at, like you're totally missing the entire point of everything we've talked about. Nick Clason (04:46): Yeah. I think about Paul says, uh, I become all things to all people and I think that he would use the digital means that are available to him today, you know, to, to help get the message of Jesus spread. You know, I think one of the, I dunno, probably issues or maybe concerns would just be that there seems to be an oversaturation maybe of messaging out there. And so how can, uh, how can the church stand apart? Like what sets them, you know, in obviously we're, we're coming from a different position, but how do we do it? Well, because if we, I feel like if we don't do it well, we're just gonna get lost in a sea of kinda white noise that's out there. Matt Johnson (05:31): Yep, exactly. Nick Clason (05:33): So, uh, one of the, one of the things you told me the other day was, uh, this idea about content marketing. So first of all, mm-hmm what is content marketing? Matt Johnson (05:45): Yeah. So content marketing is this idea that you're using content that you're creating to market. So it's like, again, we're not talking about, you know, TikTok ads, Facebook ads, Instagram ads, we're not talking about, um, popup ads or uh, um, ads before a YouTube video. We're actually talking about giving people in our churches and that we want to come to our church content, that markets who we are. Um, so we'll get into all the nitty gritty details of what that looks like in a little bit, but uh, it's just providing a value, um, more than just a Hey here's who we are. Nick Clason (06:25): Yeah. Or here's service times, right? Or here's, here's our address. You should come to our service. Like it's, it's providing, I like that we're providing value, you know, giving them something that they can, that that's useful to them valuable to them. And Matt, do you think, um, before we get to nitty gritty, do you think that this type of thing, if you're gonna try and provide quote unquote value, can it be done on multiple levels? Can you provide value, um, and information content to people that are already disciples inside your church and people not inside your church? Or do you feel like you need to choose one or the other? Like what would you say to that? Matt Johnson (07:07): No, I would say it could be both very easily. Um, as you start, you know, deciding what the content you wanna do and what the purpose of your content is, you can really start to figure out what that value is. You add, um, content marketing can virtual your people that already disciples, and then it can also bring in you new people can be an evangelism tool at Casa breed, new discipleship tool. You have so many avenues that can go with content marketing, um, and all that stuff that we had talked about, like services and, uh, we, this, Nick Clason (07:54): No, I was say, yeah, if you add value, then there's gonna be a more natural trust that's built and then an easier step into coming to service or coming to that event because you've already, you've already built a bridge and a relationship to those people. Matt Johnson (08:10): Exactly. Yep. Nick Clason (08:12): So I think, you know, so then if it can be done for both, then this doesn't feel like such a, such a foreign idea to the job description of most local church pastors. I think what it does maybe feel like though is, uh, like a lot of extra work, um, at least, you know, for me, you know, not cuz I'm not really sure what we're talking about with the, when it pertains to content marketing. So let's dive into that, but first tell, tell everyone the stat you told me the other day about why content marketing is so effective. Matt Johnson (08:47): Yeah. Content marketing is the most effective form of marketing that, you know, us marketing experts have identified right now. And I can see this, this personally and all the stuff that we've been testing through my career, but, uh, it's 64% more effective than traditional marketing. It's three times cheaper. So when you hear that, you go, okay, I'm gonna get better results and spend way less money, which is always news, good news to the years of anybody that's got a strict budget. So yeah. Uh, if you can really start implementing some of this, uh, content marketing strategy, uh, you're gonna start seeing results and you're gonna be able to grow your torch or church organically. So mm-hmm Nick Clason (09:29): Yeah. And so like, alright, so then let's take all that. So we're not marketing Jesus. We're just creating awareness around our church, which our church is truly speaking. The best message that there is in the entire world, the literal good news that you can have death, or you can have life because your sin has caused you death. And so we want to share that message with people and we want to, uh, go to the ends of the earth. And so we're going to use the digital means that are given to us. We've become all things to all people to get this message out there. And in light of all that it is the most effective form of marketing secular or not. And it is also the cheapest or maybe it's not the cheapest, but it's three times more cheap you said than, than some of the other ones. Nick Clason (10:12): So in light of all that, it bodes really well because all, all it really requires of us. The cost, it really requires of us is just some, some like additional work or some, you know, this sounds so old, but some elbow grease, I don't know if that's a thing people say anymore, but just get down, get down. Yeah. I don't know, whatever. Get in there, make some stuff happen. Um, create some things. And so I think like the way I think about it is there's really like two prongs to it. There's the content and then there's the distribution of it. Right. So let's talk through just some of the actual content first. Um, and then when we get done with that, let's just chat through like different ways that churches can begin to create a distribution model for it, whether that's through setting up ads or websites or whatever the case may be. Sound good. Matt Johnson (11:00): Mm yep. Sounds great. Nick Clason (11:02): All right. So, uh, what the first one I have in mind is an ebook. Can you, I mean, most people know an ebook is, but can you give a few ideas or a few examples of what an ebook might look like for a church or how they could use an ebook as a form of content marketing? Matt Johnson (11:18): Absolutely. So I'll give some like real practical examples too, that, uh, I've personally helped create or that we've used. So, uh, one of our most recent one was the summer ebook, which I believe we probably talked about in a performer. Uh, and we're about to launch our fall ebook and, uh, what these eBooks are designed to is for our next gen ministry at, uh, our current church. And that is really to help, you know, promote everything you can do with your kids, um, in the summer or the fall at the end of the ebook we're promoting event. So for the summer one, it was to really promote, uh, summer jam, which is our version of vacation Bible school. And then now for the follow you book, we're gonna be promoting trunk or treat, which, you know, we all know what trunk or treat is. And it's just a good way to like, Hey, we have this resource for you. Matt Johnson (12:03): That's not all about who we are, but this resource can also bring you to us. Um, another good example is like, uh, you, Nick who's, you know, a youth leader, you could create an ebook for your summer camp. Um, like, uh, mm-hmm, , here's, uh, the summer camp checklist for every student, for every parent. Like you can create an ebook about that stuff. Or, um, for small groups you can create ebook about like, Hey, here's everything you need to know about joining a small group or, um, you know, so on and so on and so on. So they're just sit down and think of like, okay, what could I actually fill, you know, like 10 pages of, with some fun stuff and it doesn't have to be like, copy extensive. It can honestly just be a lot of images checklist, but you have a ton of opportunity there. And it's a way to get people to actually give you their email and their phone number mm-hmm and then we can reach out to them. And it's also a good way to promote, Hey, this is what we have going on. Nick Clason (13:00): Yeah. So like, so on a workflow side, the ebook, we curated ideas for families. So all we did was we just sent out emails and texts to people who have young kids and say, what are things you know about? And then we just threw it all together in a big Google doc, and then we organized it. And so like a couple of fun things that we did within that was we did like a park list. So broken down by city or community, we just gave them names of good parks. Another thing we did was we created an ice cream trail, uh, so that families could have a, like a, a goal to try and hit every ice cream shop or whatever over the course of the summer. Um, and that, wasn't a thing that was created. Like we just gathered different ice cream places. And then we created, uh, this quote unquote trail, you know, like, like when I lived in Cincinnati a couple years ago, there was a, an official like donut trail. Nick Clason (13:58): And that, you know, that was a thing that was like actually known and marketed, but like this ice cream trail thing, like we just came up with this. Um, and then other thing we did was we made like a, we made like a scavenger hunt, um, in, in there about like different parks and stuff. So if you figure out like a local park or preserve or whatever, like try and find a caterpillar or try and find a leaf or whatever. And so theoretically you could print that out if you're like a family and you could take that to the preserve with you or to the park, and then you could do your little scavenger hunt thing. And so I think, like to Matt's point, what you're saying is you're like, this is the thing that provides value and it isn't even a promotion of an event or a promotion of our church. Nick Clason (14:37): It's really just a way for us as a, as an organization to help support, um, families, you know, in, in this time to give 'em something to do over the summer. Cause everyone's looking for different things to do, you know, over the summer. And so, so you can do that. Yeah. That's what we did, but you can do that all kinds of different things. So I'm gonna throw the link in there to, uh, our ebook into the show notes in case you wanna check it out. Um, but, and you might get subscribed to our email list as a result of that, but Hey, that'd be cool too. Um, anything else on eBooks, Matt? Matt Johnson (15:11): Um, no, I think that's about all I have on eBooks, honestly. Uh, yeah. Nick Clason (15:17): How Matt Johnson (15:17): Long they use 'em they're really easy to make. Nick Clason (15:20): Let me ask you this. So we, we crafted, we came up with all the content, right? Like here's the list of things and then we organized it and then we handed it to you and you actually, you know, usually you outsource this, but this time you just created it, how long did that take you to create it? And where did you create it? Matt Johnson (15:38): Uh, I created it in Canva cuz I just, uh, wanted to, you know, see what, what we could do with Canva. I'm not, I usually use Adobe and stuff for that kind of, uh, project. Um, honestly probably took about two to three hours to do the whole thing, um, of actual work it's, I mean it took, you know, more time cause there was a lot back and forth and approval processes and all that kinda stuff, but uh, yeah. And then when can have cheap, you can do it for like 12 bucks a month and for the pro version of it and really create something nice, but you can use free version to make a pretty ebook. And if you really wanna get like creative, you do Photoshop and illustrator and um, put all in design. So, Nick Clason (16:17): And last, last I checked, I think Canada has a nonprofit license for churches. So you can look into, into that and reach out about that. And so that's a really great free resource. So, you know, theoretically from cover to cover, you did that in two to three hours. So anyone with even a little bit of design ability should be able to throw that together. Not, not too, it's not too much work once you kind of get everything built together. So, um, Matt Johnson (16:43): Yeah, you can work off a template. Nick Clason (16:45): Yeah, yeah, exactly. That's one of the advantages of Canva. It comes with those things prebuilt in there. So mm-hmm all right. Uh, white pages, um, what, what are those and why are they useful? Matt Johnson (16:58): uh, white pages are honestly one of my favorite things to do in marketing, uh, and a white page is usually just an informational document that, um, can highlight features of like the church, your product, like whatever that looks like to whatever you're trying to market, um, could be your services, uh, and what you can do with like white papers, which we, uh, I did when I was working at dare to share was, uh, we did a white paper for all the gospel advancing values, all a sudden values. So each value had a white paper for it and it was a, you know, a highlighted solution of like what those values looked like. And those were one of our greatest lead generators to get leaders, to become gospel advancing leaders. So, um, find that thing that you were like, okay, we could actually write an informational document about this. Matt Johnson (17:50): So, uh, could that be, maybe you provide daycare at your church, like you're, you should probably do a white paper about why your is a great solution for in the community, just to some there, um, maybe your church, uh, it takes a, you know, um, baby dedication very seriously. So why not do a baby dedication white paper to talk about like the biblical reasons behind that and what the difference between baby dedication and baby baptism is. And, um, especially in our culture, which is, you know, primary Catholic, that's probably something that we should do so people can understand, like we're not, we don't really baptize babies, but we would love to dedicate your baby. And here's the reasons why and stuff like that. So, um, you can really define those solutions. You could honestly do a white paper for all the ministries that you have going on. So we could do a student, uh, white paper. That's all about like what students offers and uh, why, you know, students is a great opportunity. Um, and these can be long documents or they could be, you know, kind an infograph, uh, and I've seen both work really well. And the idea of the white paper is just to have another way to people download and get some more information from you. Nick Clason (19:01): Hmm. So it, it sounds like this is like, like a PDF or something like that, that people can download. And then it, it is that what's the reason why that is a good, uh, searchable or lead generator for people. What makes the fact that it's a PDF? What makes it, um, what makes it so good for marketing, I guess on the back end? Like what makes Google find it? Or, you know, whatever. Matt Johnson (19:31): Yeah. So you're, there's a couple things. So the big thing that's gonna differ white paper from like the ebook or, um, even some of this other stuff we're gonna talk about is a white paper is a lot of information usually, and people are looking for that for like, you know, uh, literally searching for that information they wanted. They're trying to build trust within. You're gonna build a lot of trust if people download your white paper, mm-hmm so the back end of Google, it's gonna wanna like, so that conversion rate's gonna be really high for the people that are searching for that, which Google is gonna like. Um, so it's gonna be a little more, you know, specific to, um, what you're creating the white paper for, but if people are searching for that, they're gonna Mo you know, there's probably like a 60% chance they're actually gonna download it, which is way better than, you know, an ebook you're probably looking at, you know, an 11% chance to download it if you're, you know, on a good day. So, Nick Clason (20:27): So this is something that's like a, a PDF document that you create your positional paper or stance or whatever, maybe with infographics and stuff like that on baby dedication. Why is it good to have all of that information in a downloadable, uh, nice looking PDF style thing, as opposed to all that, like all those keywords and words and verbiage sitting on a website. Matt Johnson (20:52): Great question. So the big reason in my mind is cuz it's a marketing lead for me. It's a lead generator for me, so I can get people to download it. Um, and they're gonna give their info and we know, uh, that because people are gonna wanna download it. If they're searching for it, you're more likely like that conversion rate is gonna be higher on it for those white papers. Uh, you're also, um, we'll get into content cluster and we don't want, you know, uh, or pillar page. Uh, those are gonna be a little bit longer. Honestly, a white paper is usually about 2,500 words and I've seen pillar pages that are 30,000 words. So, you know, OK. It's, uh, it could be very, it's a little bit more digestible, but it's a little bit bigger than the ebook. It's more info. Um, it's just kind of a next step for people. So if you are somebody that loves to write, um, you know, you're a pastor that loves writing their sermons a lot, uh, and you are like, Hey, I've always wanted to write a little book or whatever the eBooks, a great Legion, but I wanna write like in depth about, um, something that's going, some solution that we have at our church for, you know, maybe it's for alcoholism or something. And you guys have great solution for that. You have ed, you might write a big thing about that and get that known. Nick Clason (22:07): Well, I'm even just thinking about, like, we have a, we have like a, um, in person wall, you know, in our building. And one of the things we have a little pamphlet there and it's just called like the guide to student ministry at our church. And I was like that right there with, I feel like the right like amount of like search terms and, and keywords and stuff like that. That would, that would be a great example of what we're talking about here. Mm-hmm again, right? Like when we created it, we were only thinking about in person experiences. So only people that are gonna be in our lobby looking for it in our lobby, as opposed to also creating it and finding a place for it to live and exist on our website so that people can also find it there. It's just it's that switch. Right? It's that flip of a switch of thinking like you, you, more than likely already have something like this because you've created a brochure or pamphlet or something like that. Mm-hmm so then turn that same piece of content into something that can go, um, on a website, like, like you're talking about. Matt Johnson (23:06): Yeah. And, uh, you we've started, I mean, you've probably seen this Nick when we were like staying at church on Sunday, but I don't see a lot of people go to our physical walls without, you know, direction to so, uh, it's not a good awareness piece, you know, I've had plenty of people come on, go what's the student ministry about, I'm like, oh my goodness, we have failed, you know, give them more content to, you know, be able to figure out, you know, and identify these solutions for them. Nick Clason (23:35): Does, does that, uh, dare to share, like, do those websites, do they still exist? Like could we link to them? Matt Johnson (23:41): Uh, they should. Yeah, I can. I'll uh, I'll dig 'em up. We just, we revamped the whole website since we did those. So I'll just have to find where we re put those, so. Nick Clason (23:50): Okay. Yeah. So I'll give you a link to that. Give you a link to what the summer ebook looked like. Uh, the next thing is, um, blogs. Let's talk about blogs. Blogs seem like, um, old news they've been around forever. So are they still useful piece of content marketing? Are they still worth our time? What, what would you say to that? Matt Johnson (24:08): Uh, I'd say blogs are probably the lowest hanging fruit that anyone listens in this podcast could start, you know, um, doing right now. Um, and the reason I say that is cuz they don't need to be long. Uh, if you get a consistent rhythm of blog writing, you're gonna have consistent search. Uh, your SEO's gonna continue to be updated. And also you're gonna have, uh, consistent reason for people to continue to come back to you, which that's the key of a lot we've talked about. We want people to just come back to us and we don't want it to only be on Sunday mornings at church. We want to come on a Wednesday at work when they're on their lunch break and go, Hey, I wanna check out what my church has going on with it. So, um, blogs are honestly one of the easiest things to start implementing right now and the traffic and the potential of a blog is still massive. Matt Johnson (24:58): So a great example of this is Michael Hyatt, um, who, uh, if you guys don't know who Michael I Hyatt is, you know, they grow up full. He, uh, he's a designer, full focus planner. He was an SEO or a CEO at a book publishing company. Uh, he's a hugely influential person in the marketing world and he started his entire company based off of blog writing, um, by giving like daily tips, um, like, uh, how to balance your day, uh, how to be a good boss, how to be a leader. Um, and he was doing that while I was a CEO. And then, uh, he turned that into an entirely functional company right now and full focus. So, uh, that is a great example of like what a blog can do for you. Uh, and blogs are just, uh, something that everyone can write, honestly, like it's your voice, it's your personality, that's your opinion on it. So, um, and they don't have to be long. Like you can write a, you know, 300, 500 word blog and that's all you need. Nick Clason (25:56): Yeah. Great. So here, like, and Matt correct me if I'm wrong, but I feel like most like template website builders are sort of built on like a blog style, uh, idea, like it's built with the idea of like posts. So it's pretty easy for most church websites to create some sort of blog type thing where you just throw quick hitters of like your thoughts. Matt Johnson (26:19): Exactly. And you, there's probably not a lot. You need to change. You just gotta look at some formatting stuff. Uh, like I said, it's gonna be a huge win for you. If you can actually start getting your blog going and be consistent, that's the one thing you will say, don't start a blog if you're not gonna be consistent and you're not gonna write it. So if you're gonna commit to a blog, say I'm gonna have a blog up every day. Like every Tuesday at 10:00 AM, make sure it's up every Tuesday at 10:00 AM, cuz that's gonna help also, uh, unlike the algorithm side of things. So Nick Clason (26:50): What's a good, what would be a good recommended rhythm? Would you say for someone who's gonna blog? How often, how frequent all that stuff? How long? Matt Johnson (26:58): Yeah, so I would start once a week, you know, get your, your toes wet, your fingers warmed up as you're typing for. Um, uh, and I would pick a day that you might see that might be the best day for traffic, for you at your, uh, at your church. So like for us, we have found Thursdays at, you know, 9:00 AM to be the best time to post anything. So, uh, that's when we would post, uh, you know, a new blog or whatever. Um, and then, uh, as you like start building your blog up or if you're like, Hey, this is something that I could definitely add more to start doing two a week or three a week. Um, you know, Michael Hyatt was doing one every day, which that's pretty, that's pretty intense. So I mean, if you have the time to do that and you wanna do that and you have the drive to do that, go for it, but I would just start with one at day right now and then build on there. Nick Clason (27:46): All right. Great. So let's talk a little bit then Matt, about podcasts. Um, are, I feel like podcasts similar to blogs have been around forever? Are they still like a useful marketing tool? Matt Johnson (27:59): Oh, absolutely. Yeah. If people are, wanna find a topic, um, they're gonna, um, traditionally look for podcasts now, especially the younger demographic. Nick Clason (28:09): Yeah. What was like, what was the, what was the stat hubs stat came? Hub spot came out with a couple of weeks ago or months ago about, uh, the average, average American or average person listening to podcasts. Matt Johnson (28:22): Yeah. So podcast listeners. So those are people that send a podcast, 84% of them listen to eight hours or more podcast a week. You have 78% of Americans are aware of podcasts and almost 60% of people in America listen to podcasts. So, um, a lot of people are, I mean, podcasts are continually to grow. Um, I mean younger people, it's definitely something that they do to pass the time now, especially on commutes and walking and, um, runs and working out and all that kinda stuff. And then, uh, you, you know, older people, old, older generations are starting to, you know, jump on the podcast bandwagon. So Nick Clason (29:01): Yeah. So do you think that it's just recording your sermon, throwing it in on a podcast? Is that what you're recommending here? Matt Johnson (29:09): Uh, I mean that, that's where you can start, honestly. I mean, that's not gonna give you, you know, the traditional traction of a podcast, uh, just because, you know, you're only gonna get people that wanna listen to your sermon at that point. They're not gonna necessarily be searching for like that topic for help. So, so like creating a parenting podcast or like an interview type podcast where people are like, Hey, I'm kinda looking for this kinda thing, but it is a good place to start and you already have the content. Nick Clason (29:37): Yeah. Yeah. Um, crossroads in Cincinnati, uh, they have a like almost entire podcast network. Um, and I was I'll link to it in the show notes, but I was scrolling through it the other day. And so like, their pastor's name is Brian to, so they have a podcast called the aggressive life with Brian to then they have one called freed up it's about money. Then they have one called you can do this and it's a parenting podcast. And then they have one called, um, IKR question mark. It says real conversations with real women. One called I love Cincinnati, one called too long. Didn't read. And that's like a cliff notes version of like the Bible one called man skills, one called spirit stories. Um, so yeah, like they have what, whatever that is like seven, eight, something like that podcast summer, obviously. Right. I love Cincinnati. Nick Clason (30:32): That's very like regional to them. And so it's just a podcast about yeah. Cincinnati and showcasing the best things about there. And, um, he, he does interviews with interesting people from Cincinnati and then they got one on like just the Bible, like, Hey, maybe the Bible, isn't something that's a regular rhythm or discipline to your life, but here's a quick hitter of, of different books, different chapters, you know, stuff like that. Um, so I, I I'll link to that in the show notes, but I love their approach to that. Cuz I think like you said, a lot of people are just starting with just the sermon. Um, and obviously crossroads is a big church, so they have a lot of resources to make some of these things happen, but you can begin to start thinking and looking and seeing ways that you can create other topics or other podcasts that might be interesting. And it's honestly, man, yeah. This is like episode what, seven or eight for us like this isn't been that hard. Like it's actually really fun. no. And Matt Johnson (31:27): So fun. It's easy and it's yeah. Nick Clason (31:30): Yeah. You're just having a conversa conversation. We're just recording a conversation, you know, between you and me. And so if you can get two people that don't sound awkward on a microphone, like which is in a church is probably pretty easy because you get people that stand up talking to microphones all the time. So that that's not that that, you know, far off of a skillset of what they probably already have within their repertoire to do exactly. So. Yeah. Yep. Um, and then out of that, uh, one of the things that, uh, I think I've heard you recommend is transcripting those so that you can get all the words onto a website Matt Johnson (32:09): Mm-hmm yep, absolutely. Uh, highly recommend doing transcripts, uh, cause everything we've talked about over the last half hour or so is all, you know, searchable terms. So, and you can do, there's plenty of transcripting services out there that are fairly, very cheap to, you know, that you could just upload your MP3 two and they'll transcribe it for you. Nick Clason (32:31): Yeah. I mean basically every time we do this, it's anywhere from 30 to 40 minutes and a AI subscription service through rev.com, um, will basically give me this transcript for anywhere from eight to $10. And so that's not super expensive. You, you put that along with the link to the podcast, whether you're using a hosting service or you're hosting it directly on your own website, um, and boom, there you go. You got all the words from it and you know, sometimes they messed stuff up. Like they spell my last name wrong every time. Yeah. But that's the catch go change it. Solos deal. Well, no, they put a Y in it when I say Clason it's there's no, Y a Y so Matt Johnson (33:13): Whatever to call you, it says calling Nate Clauson. Nick Clason (33:17): Cause you know how everyone says the word Jason and Mason, right? Like that's, that's how you're supposed to say those words too, obviously. Sorry. Matt Johnson (33:26): Nick Clason (33:28): All right. Uh, pillar pages. What are those? We talked about those a little bit last time. So if you, if you didn't listen to the last episode, go back and listen. We went pretty, pretty nerdy and pretty in depth on those. But for those that weren't here, give a quick, give a quick hitter of what those are and the purpose of them, Matt Johnson (33:45): Uh, pillar page is a page specifically designed to help with SEO. Um, so search engine optimizations, and it's a large page also known as a content cluster of lots and lots of copy and information about something that's searchable. So good example of this is that we, uh, we're working on a pillar page right now at our church called, uh, the everything you need to know about Christian Small groups. And we identified those search terms. And now we're gonna just write a bunch of content all about that. So, um, and that's gonna be, you know, a pillar page to help drive traffic to our find your people stuff. Nick Clason (34:24): So let's pretend that you are marketing genius. You are sitting here or you're at least marketing interested. You're hearing this. You're like, yes, yes, yes, yes, yes. But you are like multiple steps away from decision making. You are not the senior leader in your church and you go to your senior pastor and you experience some form of opposition. How would you Matt advise that person to enter into said conversation about one of these things? Matt Johnson (34:58): Just any of them? Nick Clason (35:00): Well, yeah, let let's hit Matt Johnson (35:02): Pillar Nick Clason (35:03): Pages. Let's hit it from a no from, from all of 'em. All of 'em. Yeah. Let's hit it from a high level. So you're, you're not the, you're not the decision maker, but you want to, how do you go about convincing your senior leadership that content marketing is worth doing? Matt Johnson (35:19): Yeah. Uh, I would go to your senior leadership with just a lot of this information we talked about. So, you know, a big way I started pitching a lot of the stuff, you know, at a current church is a lot of the stats that, you know, we're seeing, um, in the marketing world. So, uh, we know how effective content marketing is and how it can actually, you know, nurture our, uh, congregation. I, um, for your church, it could be the blog. It could be the podcast. Um, really depends. So, uh, I would go in with that in mind, go in, um, with change management in mind. So just, you know, go in and, uh, talk about, uh, what you're seeing, what the goals are and why you can do it and how you're gonna be able to do it, uh, is my best advice for all that it is gonna, can be kinda challenging, especially if you have, uh, older church and older, uh, executives on your team to kinda pitch some of this stuff. Matt Johnson (36:25): Um, um, especially some of the stuff that, you know, they might not see instant gratification from. So like a podcast you're not gonna see instant numbers from, it's something that you put time, money and effort into. That's gonna take, you know, um, a while to actually build your community up. But once it's built, it's usually pretty solid. And people typically once they're, you know, in the world of a podcast or whatever they can, uh, um, they stick around. So that's just the kinda stuff that you need to come in, ready to answer. So pick something that, you know, you can succeed at that, uh, can give you some fairly quick wins. Um, and then, uh, just be able to talk about that with that change management in mind. Nick Clason (37:00): So let's, let's, uh, keep, let's do this super quick, but let's pretend that you, uh, got approval to do one of these things. And in one month, what would be a win? I wanna just go through each of these. I want you to just lay out what you think a win might look like. So what would be a win if in one month you launched an ebook, what is a, a measurable win, something that you can point to your, your boss about like, Hey, look at this, this is what we saw. This was a win because blank happened. Matt Johnson (37:31): How many new people downloaded your ebook Nick Clason (37:34): And Matt Johnson (37:34): Depending on the size of your church, that number is gonna vary. Nick Clason (37:37): Sure, sure. Sure. What about white page? Same thing. Matt Johnson (37:41): Uh, white page. Yeah. White papers, probably pages. I would say the same thing is, uh, probably how many new people actually downloaded it. Nick Clason (37:49): Okay. How about a blog, Matt Johnson (37:52): A blog? I would just say how many, uh, people have read your blogs so you can actually get those stats, you know, you don't want people skimming it, um, not, or just bouncing away from it. So like actually having that bounce rate low and that read rate high on it. Nick Clason (38:06): OK. Podcast, Matt Johnson (38:09): Uh, podcast, it shows, uh, how many people are listening to it and these don't need to be new people. Like I said, a podcast is really gonna start with your and then grow Nick Clason (38:18): And then pillar page, Matt Johnson (38:21): Uh, pillar page is going just be how many people clicked on the page that's SEO related. So the bounce rate could be really high, but if you get someone stuck on for also biggest of that in mind. Nick Clason (38:35): Yeah. Okay, great. Um, alright. So you're a small church. You don't have anything of any one of these things and we just hired you to be our marketing consultant. What would be your number one project that you'd say, Hey, do this to get started, Matt Johnson (38:53): Look at this, the stats and who your congregation is and who your target is. But, um, most 90% of the time, I would say blog or podcast, just because it doesn't take a lot of extra effort on your end, um, podcast. You're gonna have to do a little bit editing, of course. Um, and the blog, you know, you're gonna have to set that up and, but the time commitment's a little bit less than some of these other things. And ebook is a quick way to get, you know, huge, uh, like to not get huge numbers, but to start seeing some of the new numbers come in a white paper, you'll have better, stronger leads. And then, uh, you know, a pillar page is a massive project. I wanna reiterate that there're a lot of work, so, um, but they won't give you the most traffic to your website. Nick Clason (39:33): Well, and I think like, if you, if we're thinking about this from like an in person ministry strategy, like everything you do for in person requires a lot of work. Like I'll just say, as a youth pastor, I have to build an entire schedule for an entire semester. I have to recruit in, uh, secure several different like locations, host homes, small group leaders, get them screened, um, create like a theme for every week and teaching and content and all these different things. Like there's a lot of work to be done. And so mm-hmm, um, like just because what we're talking about here in, in like digital form is a lot of work. It doesn't mean it's, it's not worth it, or you should only take the easy way out. It just means that you also have to set up all the infrastructure and framework to make it work too. And once you do, mm-hmm, , it's gonna be worth your while, but you have to have someone who cares about it and keep it going. Just like you have someone who cares about your student ministry, just like you have someone who cares about your women's ministry, keeping those things up and running and keeping them organized and brought together and the framework built and all the same types of things that we're talking about here. Like, it is a lot of work, but it's also worth it. Matt Johnson (40:47): Mm-hmm exactly. Yep. Nick Clason (40:49): So, so last thing, Matt speaking around this idea of organization, like all these things are a great idea, but how like, like, especially like eBooks white pages, like you're trying to capture emails. And so what is the best way to get your, get the word out there with these things? Um, is there like, cuz you, you know, you wanna do some sort of like email marketing type of thing and your church may have that may not mm-hmm but so you're gonna want to grab people's names, grab people's emails. Um, you're gonna need websites. Like what is the best distribution method? Is it advertising E like talk through it, just like that entire process from, um, getting it out there on Google, getting it, getting it out there on Facebook for ads, getting people to click on your thing, getting people to put their name in, um, where's all that stuff go, how's it how's doing. How do you keep it, keep all these things, uh, all these parts of the machine moving and working together. What's the best way to do that. Matt Johnson (41:50): Yeah. We could do a whole episode about advertising, probably a couple episodes, honestly, cause it's such a beast. Um, and distribution in general, but I would say like to get you started, I'm just gonna give you a soft answer since we've already given you so much info in this one is social media. So just do what organically on social, figure out what your delivery method is. So if you wanna, you know, do MailChimp, I don't know what your church has in place right now. So if it's a that you have, or, um, maybe you're doing a hub or you have rock RMS, whatever that you're capturing people already. So you have some way that you're capturing emails already. There's probably a form option that connects to that, that you can deliver PDFs for. Um, I would say probably nine times outta 10. That's probably true. So, um, Nick Clason (42:42): Well in most of those, most of those, whether, yeah, most of those, whether you pay for them or not, um, you know, cuz there might be churches here that don't, that don't have those things built yet, you know? So you gotta, you gotta land something as a distribution. So figure that out. There are some free ones, but it they're all gonna be limited until you start paying for 'em. And so if you're not already paying for one, you can go find a free one, but it, it may take some time to find one that works for free because certain features like automatic, like opt-ins with automatic email triggers, like that often costs a little bit of money, you know? So you just have to be yeah. Kinda aware going into that. Matt Johnson (43:23): Yep. Oh absolutely. And, and that's, and then just post that on social to start out and get people to share that organically. Um, especially if you, like, I don't have any money for advertising. Don't worry about advertising right now. So start with some organic, um, ways to do that and build up your social presence, which will help you when you get to the advertising stage and you might have budget. Nick Clason (43:47): Hmm. Yeah. And you can, I mean, think about it. You you're in an organization, no matter like, even if you're under a hundred people like that, you have uh, 50, 75, whatever raving fans about you. So ask for their help to get the word out because how many times Matt do you and I like make a decision based off of a word of mouth recommendation, more than Yelp mm-hmm more than the stars on Google. Like if you tell me about a good restaurant, like I'm gonna trust you way more than a restaurant with 505 star reviews. Like I just am. Yep. Cause it that's just, that's just how our brains work for one reason or another. Like we don't all the other people that we don't know don't matter as much to us. Um, but, but you tell me about a good restaurant. I'm like, yeah, I'll try it, you know? Matt Johnson (44:34): Yep, exactly. Yeah. So keep that in mind. Nick Clason (44:37): Yep. For sure. All right. Any listen, tons of stuff here. Um, we'll try to link all the different examples that we put in there, uh, in the show notes so that you can see, cuz I don't know about you, but I'm visual. So we're talking about eBooks. I wanna show you an example. We're talking about white pages. I wanna show you an example. Um, but any, any other like last parting thoughts around this stuff, Matt, that you have before we, before we sign off? Matt Johnson (45:02): Um, no. I mean pick one of these and go, try to, you know, start brainstorming some ideas to get it done. So Nick Clason (45:10): Love it. All right guys. Good luck. Let us know how it's going. We'd love to hear from you@hybridministryontwitterhybridministry.xyz is the website and uh, we'd love for you to subscribe to this podcast. Give it a rating, give it a review. And if you found this helpful man, please share it with a friend. Uh, same thing we just said, let people know you found this helpful. So until next time we'll talk to you later. Bye guys.

Hi football lovers ,Im glad to inform you that season 2 of your favorite football podcast will be coming out in few weeks !!! Yahhh !!!… Are you happy ? , yes! Ikr

As we enter the fifteenth year of this podcast (IKR!), here is an hour long mix of fifteen uplifting sing along top 40 & vocal house remixes from Beyonce & Freemasons, Bananarama, Tove Lo, Swedish House Mafia & The Weeknd, Alesso & Zara Larsson and more!More of Joelby and this podcast: https://linktr.ee/djjoelby .Donate: PAYPAL: https://www.paypal.me/joelbylucas .Please support by rating and commenting on Apple Podcasts, Podomatic, your podcast provider, or just sharing to your Facebook or Instagram which helps more people enjoy the tunes!Featuring:1 - Tove Lo - No One Dies From Love (220 Kid Remix) .2 - Shab - Criss Cross (Moto Blanco Club Mix) .3 - James Hurr, Xoro, & Adam Griffith feat. Shayan - Toxic Game (The Way We Are)(Extended Mix) .4 - Mentis - This Aint Real (Extended Mix) .5 - That Kind - Love On Me (Extended Mix) .6 - Firebeatz - Don't Stop Moving (Extended Club Mix) .7 - Alex Gaudino x Tobtok x Jayover - Talk Talk (Extended Mix) . 8 - Ashley Paul - Feel Your Fire (Until Dawn Club Mix) .9 - GhostMasters - Down (Extended Mix) .10 - Rich Hennesey - Keep Your Love (Until Dawn Club Mix) .11 - Bananarama - Favourite (Shanghai Surprize Mix) .12 - John Gibbons x Lyra - Edge of Seventeen (Extended Mix) .13 - Beyonce vs Freemasons - Break My Soul vs Dirty Organ (ENN Mashup) .14 - Alesso & Zara Larsson - Words (Extended Mix) .15 - Swedish House Mafia feat. The Weeknd - Moth to a Flame (Extended Mix) .Until next time...!

Really, this episode should be titled "Allergies are the woooooorst" (sung in the style of Jean Ralphio from Parks & Rec) But really, allergies can suck it. And that goes for all types of allergies. With it being springtime here in Michigan, we thought it would be a fun topic to talk about (IKR allergies, fun???) Listen to us ramble on about all things allergies and how we cope with them.

This episode, we are giving you the latest DLP news and then treating you to a VERY detailed breakdown of what we saw, ate and did during our recent three day park trip. Every aspect of the 30th Celebration gets discussed and completely over-thought. (Plus, you'll get to know Cooper, the large, quadrilateral mascot of Campanile hotels-  IKR???) Be sure to keep listening until the very end, as this month we have an added bonus feature: a 20 minute live recording from Disneyland Paris that lets you feel like you are right there in the hub, experiencing the fab new "Dream and Shine Brighter" show. As always, don't forget to follow D2DLP on Instagram, Facebook and Twitter. Our website is dedicatedtodlp.com and there you will find news, polls and practical guides to planning your next Disneyland Paris trip! Thank you for listening.

Vi har samlet det bedste fra uge 11 på KRÆS. En ungdomsbog om puttemiddage og grænseoverskridende seksuel adfærd fik i mandags kulturministeriets forfatter- og illustratorpris. I Kræs talte vi med forfatteren bag bogen Tina Sakura om, hvorfor det er vigtigt at belyse emnet nuanceret i netop en bog til de unge selv. Bibliotekerne rundt om i landet står klar til at tage imod de ukrainske flygtninge, det meddeler Danmarks biblioteksforening. Det har bibliotekerne god erfaring med fra tidligere flygtningestrømme - to tidligere flygtninge skal du møde senere her i klip fra ugen. De fortæller, hvordan bibliotekerne var en vigtig del af deres integration. Musikeren Uffe Lorentzen ramte det dybeste mørke under corona-nedlukningen, da alle hans koncerter var aflyst. Det har fået ham til at lægge sit rock n roll-liv om. I en alder af 50 er han stoppet med at ryge og drikke. See omnystudio.com/listener for privacy information.

Play with passion!! My guest is high school friend Keith Rodriguez. We didn't know each other really in HS but what we did know about each other back in the day was our impeccible musical taste. It was fun to reconnect with Keith and get to know him. Classical guitarist Keith Rodriguez received his Bachelor's degree in Music from UCSD and his MBA in guitar performance from San Diego State University, both under the instruction of Celín Romero.  During this time, he had the privilege of receiving several lessons from the Romero quartet´s founder, Celedonio Romero.  He continued to perfect his craft by doing post-graduate studies at the Conservatorio Superior Real de Madrid under the instruction of José Luis Rodrigo.  In 1996, he was awarded a scholarship to attend the renowned masterclasses “Música en Compostela”, focusing on Spanish guitar music and technique.  He has attended masterclasses under the instruction of Pepe Romero, David Russel, Piero Bonaguri and Gabriel Estarellas amongst others.  He has performed as soloist with recitals in México, USA, Spain and Portugal.  The Spanish periodical El Mundo has said after one of his performances “perfect intonation, impeccable interpretation and a diverse program were a delight for all those who attended a glimpse of what was sure to be a brilliant career”.  He has performed extensively both as a soloist as well as forming part of various chamber music ensembles, combining guitar  with cello, violin, and voice, etc.   Beginning in 2009, he discovered a passion for choir conducting through the J.H. Newman Colegio Internacional, where he has been teaching music history, choir and guitar since 2005. This choir has been awarded numerous first prizes in the Comunidad de Madrid school choir competitions, as well as receiving a silver medal at the 2018 Spanish national youth choir competition.    In addition to performing classical music, he has performed jazz with the Keith Andrews Quartet, as well as blues with his previous group The Blue Roosters. He has also composed music for diverse theater performances and is active as both a performer and music educator.   Originally from San Diego, he moved to Madrid in 1995 to pursue his musical studies, where he has been living since with his wife and four children.   Keith has truly blessed us with lots to listen to. Here's the full performance of the song I played a brief part of during the interview: https://www.youtube.com/watch?v=-8hLHVrBIiIHere's the Under Pressure performance by him and his students: https://s3.us-west-2.amazonaws.com/life.revelrevel/public/Under%20Pressure%20jhnewman%20video%20final_2.mp4Here's his newest video: https://youtu.be/-8hLHVrBIiI I had never heard of Celin Romero--here's his info too: https://en.wikipedia.org/wiki/Celin_Romero   Other topics covered:No books to mention-SHOCK AND AWE! IKR? but these other items might interest you. The Netflix show I mentioned with Pope Francis is called Stories of a Generation https://www.netflix.com/title/81306329(And don't forget: my bookshop.org list of recommended books is always available. If you want a personally curated list of banned books too, please let me know.) The creator of this School of Community: https://en.wikipedia.org/wiki/Luigi_Giussani NOTE on Spotify: On the ep I talk about the Spotify situation. Here I'd like to address that if things haven't changed by my next episode, I'll be pulling my podcast off of the platform. As you can see from my stats below, this is purely a principle stance as my numbers on spotify don't hurt them at all. I apologize to these listeners though. Please use your voice to be heard that you won't stand for misinformation (and Rogan is still on all the other podcast apps, so, please support your musicians! My Spotify Stats: All time starts 160 streams 99 listeners 52  

Barn under tolv år kommer inte få vaccin mot covid-19. I Unga personer är mer positiva till livet än tidigare. I Kråkor kan lära sig att slänga cigarettfimpar. Reporter: Odessa Fardipour och Ingrid Forsberg

In case you didn't know, Palm Oil is in nearly everything – everything from pizza, doughnuts, and chocolate, to deodorant, shampoo, toothpaste, lipstick, and many more. IKR?? How the heck did that happen? In this episode, we talk about Palm Oil, its products, its effects on our environment, and what we can do to support its sustainable production and use. You'll be surprised how something so simple is actually in almost all products we use in our everyday lives. Full episode is now available on Youtube, Spotify, Apple Podcasts, and more! Link in bio! ----- Youtube episode: https://youtu.be/aVKPlkQaOnw Instagram/Twitter: @MakePeasNotBeef Website: https://www.makepeasnotbeef.com Be sure to follow me on social media and give me a shout! Questions and comments are welcome!

Please join authors Christopher Granger and Anthony Carnicelli, as well as Associate Editor & Editorialist Shinya Goto as they discuss the article "Direct Oral Anticoagulants Versus Warfarin in Patients With Atrial Fibrillation: Patient-Level Network Meta-Analyses of Randomized Clinical Trials With Interaction Testing by Age and Sex" and accompanying Editorial "Patient Level Meta-Analysis: End of the Era for DOAC Developmental Trial in AF Patients?" Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts. I'm Dr. Carolyn Nam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, Associate Editor, Director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr. Carolyn Lam: Greg, I'm so excited about our feature discussion today. It is about DOACs versus warfarin in patients with atrial fibrillation, a really important patient-level network meta-analysis of randomized control trials with interaction testing by agent six. So you can already tell something very, very clinically relevant and important discussed by not only the authors, but our dear associate editor and editorialist. Dr. Carolyn Lam: Okay. You just got to tune in, but first I'm going to start us off with some coffee, as well as a description of this first paper in today's issue. The 2018 AHA ACC multi-society cholesterol guidelines states that statin therapy may be withheld or delayed among intermediate risk individuals in the absence of coronary artery calcium. Dr. Carolyn Lam: However, two traditional cardiovascular risk factors associate with incident atherosclerotic cardiovascular disease events among individuals with zero coronary artery calcium over the long term? Well, this is the question that investigators decided to answer in today's paper and they're led by Dr. Virani from Baylor College of Medicine in Houston, Texas. Dr. Carolyn Lam: They studied 3,416 individuals with coronary artery calcium score of zero at baseline from the MESA study, which is a prospective cohort study of individuals free of clinical atherosclerotic cardiovascular disease at baseline. Among these individuals with zero coronary artery calcium, cigarette smoking, diabetes and hypertension were found to be independently associated with incident atherosclerotic cardiovascular disease events over long-term follow up. Dr. Greg Hundley: Ah, very interesting. Another piece of information relating to how we might use coronary artery calcium scores in, it sounds like, a high-risk patient population. So, Carolyn, what's the take-home message here? Dr. Carolyn Lam: Well, even if individuals have a coronary artery calcium of zero, if they are current smokers, if they have diabetes melitis or hypertension, initiation and long-term use of statin therapy, along with a heart healthy lifestyle and risk factor modification may still be warranted as part of the patient/clinician risk discussion. Dr. Greg Hundley: Very interesting Carolyn. Well, I've got a clinical study to tell you about. And, Carolyn, as you know, obesity and diabetes are associated with a higher risk of heart failure and the inner relationships between different measures of adiposity, including overall obesity, central obesity, fat mass, and diabetes status for heart failure risk, are not well established. Dr. Greg Hundley: And so this investigative group, led by Dr. Ambarish Pandey, from UT Southwestern Medical Center, looked at the ARIC, the visit five in ARIC and CHS, the visit one, and cohorts together, and they were obtained from the NHLBI BioLINCC. They were harmonized and pooled for the present analysis, excluding individuals with prevalent heart failure. Dr. Greg Hundley: So using multi-variable adjusted fine-grade model models were created to evaluate the associations of body mass index, waist circumference, and fat mass with risk of heart failure in the overall cohort, as well as among those with, versus without, diabetes at baseline. Dr. Greg Hundley: And the population attributable risk of overall obesity with BMI greater than 30 kilograms per meter squared, abdominal obesity with waist circumference greater than 88 and 102 centimeters in women and men, respectively, and high fat mass above the sex-specific median for incident heart failure, was evaluated among participants with and without diabetes. Dr. Carolyn Lam: Ooh, I'm so in interested in this topic. So what did they find, Greg? Dr. Greg Hundley: Right, Carolyn. So a large study, it included 10,387 participants, about 53% from ARIC, 25% had diabetes, and the median age was 74 years. And higher levels of each adiposity measure were significantly associated with higher heart failure risk. The population-attributable risk percentage of overall obesity, abdominal obesity, and high fat mass for incident heart failure was higher among participants with diabetes versus those without diabetes. Dr. Greg Hundley: And so, Carolyn, we can conclude from this research that higher BMI, higher waist circumference and higher fat mass, are strongly associated with greater risk of heart failure among older adults, particularly among those with prevalent diabetes. Dr. Carolyn Lam: So, so nicely done. Thank you, Greg. Well, the next paper talks about common ancestry-specific ion channel variants and how they predispose to drug-induced arrhythmias. Now, we know that multiple reports associate the cardiac sodium channel gene Scn5a variants, and these are the specific variants, S1103Y and R1193Q, with Type 3 congenital long QT syndrome and drug-induced long QT syndrome. Dr. Carolyn Lam: These variants are, however, two common in ancestral populations to be highly arrhythmogenic at baseline. The S1103Y allele frequency, for example, is 8.1% in Africans and the R1193Q is 6.1% prevalent in East Asians. So the investigators, led by Dr. Roden from Vanderbilt University Medical Center in Nashville, Tennessee, and colleagues, determined the effect of the S1103Y variant on QT intervals among 1,479 Africans from a large electronic health record with no confounding medications or diagnosis of heart disease. Dr. Carolyn Lam: Now, while both the specific variants generated increased late sodium current, baseline action potential durations in cardiomyocytes from induced pluripotent stem cells carrying these variants were unexpectedly normal. The re-polarizing potassium current, IKR, was markedly increased in these induced pluripotent stem cells with the variants, accounting for normal baseline action potential duration but, with exposure to an IKR blocker, they displayed exaggerated action potential duration prolongation and after depolarizations. Dr. Greg Hundley: Wow, Carolyn, interesting. So tell us, what are the clinical implications of this really exciting research? Dr. Carolyn Lam: Yeah. So here's the take-home message. These common ancestry-specific variants do not affect baseline re-polarization, despite generating an increased late sodium current. So the authors propose that increased re-polarizing potassium current, IKR, serves to maintain normal re-polarization, but increases the risk of manifest QT prolongation with IKR blocking in these variant carriers. So we need to be aware of that and, further, these findings highlight the need to include ancestral diversity in genomic and pharmacogenomic studies. Dr. Greg Hundley: Oh, wow. Beautifully described, Carolyn. I really appreciate that. Just excellent discussion. Well, Carolyn, my next paper comes to us in an investigation regarding doxorubicin or anthracycline-associated induced cardiotoxicity. So, Carolyn, multiple pharmacogenetic studies have identified the synonymous genomic variant rs7853758 and the intronic variant rs885004 and SLC28A3 as statistically associated with a lower incidence of anthracycline-induced cardiotoxicity. Dr. Greg Hundley: However, the true causal variant, or variance, of this cardioprotective mechanism at this locus, the role of SLC28A3 and other solute carrier transporters in anthracycline-induced cardiotoxicity and the suitability of solute carrier transporters as targets for cardioprotective drugs has not been investigated. Dr. Carolyn Lam: Wow. Got it. So what did these investigators do and find, Greg? Dr. Greg Hundley: Right. So Paul Burridge and his colleagues at Northwestern University found that the patient-specific cardiomyocytes recapitulate the cardioprotective effect of the cGAS-identified SLC28A3 locus, and the authors functionally confirmed for the first time, the role of SLC28A3 in doxorubicin-induced cardiotoxicity. Dr. Greg Hundley: And a novel genetic variant, the rs11140490, is the potential causal variant in the SLC28A3 cardioprotective locus. And finally, Carolyn, the solute carrier transporter inhibitor desipramine protects against doxorubicin-induced cardio toxicity through decreasing the intracellular uptake of doxorubicin into the heart. Dr. Carolyn Lam: Wow. That is a lot of data. Could you summarize it for us, Greg? Dr. Greg Hundley: Right, Carolyn. So these investigators provide two potential therapeutic options to attenuate doxorubicin-induced cardiomyopathy, either repurposing FDA-approved desipramine, or therapy with long non-coding RNA SLC28A3-AS1. Also, Carolyn, they propose that a simple clinical test to detect the presence of rs11140490 can be used to predict that a patient will be less likely to experience doxorubicin-induced cardiomyopathy, and that, perhaps with future clinical trials, it may be possible for these patients to be treated with a longer duration, that is a higher accumulative dose of doxorubicin, to enhance the efficacy of their chemotherapy. Dr. Carolyn Lam: I love the way you took that home for us. Thank you, Greg. Well, also in today's issue is a Research Letter by Dr. Chen on multifaceted spacial and functional zonation of cardiac cells in an adult human heart. Dr. Greg Hundley: Right, Carolyn. And Professor Constantine has a Letter to the Editor entitled Pravastatin Versus Placebo in Pregnancies at High Risk of Term Preeclampsia. Well, Carolyn, how about we get onto that feature article and learn about DOACs versus warfarin in this very large network meta-analysis? Dr. Carolyn Lam: Yes, yes, yes. Let's go, Greg. Thanks. Dr. Greg Hundley: Welcome, listeners, to our feature discussion today. And we're very fortunate. We're going to review the utility of DOACs in patients with atrial fibrillation. And we have with us two of the authors of this original research, Dr. Anthony Carnicelli from Duke University, and Dr. Chris Granger from Duke University. Dr. Greg Hundley: Additionally, we have with us our associate editor, Dr. Shinya Goto, from Japan. Welcome, gentlemen. Anthony, we'll start with you. Describe for us a little of the background information pertaining to your study and what was the hypothesis that you wanted to address? Dr. Anthony Carnicelli: Yeah, thanks so much, Greg, for having us here to discuss this. I started working in the DOAC space when I was a resident at Brigham and Women's Hospital with mentorship from Dr. Bob Guigliano there, and was really fortunate to connect with Dr. Granger when I came to Duke for a fellowship, and we had this unique opportunity to take data out of the four largest trials of anticoagulants in the atrial fibrillation, and take individual patient data from these international centers and combine them to form the combined AF database from which we did this analysis. Dr. Anthony Carnicelli: So a very unique opportunity here to have individual patient-level data from over 70,000 patients, and perform this analysis. And, really, what we aimed to do was to do the kind of highest quality meta-analysis using network meta-analysis methods to investigate the relative safety and efficacy of DOACs versus warfarin and a broad and diverse, but randomized, population of patients with atrial fibrillation. Dr. Greg Hundley: Very good. So you started to describe for us your study population and your study aligns. So tell us a little bit more, who were these patients, and then maybe specifically give us a little bit of the outline of your meta-analysis. Dr. Anthony Carnicelli: Yeah, so these were, again, a very broad patient group, but from kind of 10,000 feet, this was a population of patients with atrial fibrillation who were at risk of stroke, from CHADS score perspective. So there are some nuances from each of the included studies, of course, regarding the individual risk of stroke from one study to the next. But largely, as I mentioned, in patients with non-valvular atrial fibrillation randomized to either DOAC or warfarin. Dr. Anthony Carnicelli: And, from a method standpoint, we are fortunate at Duke and at DCRI, to have an expert in the network, meta-analysis methodology, whom we've worked with, Dr. Bonnie Huang, who helped to put together the analysis here and to proceed with this kind of network methodology. Dr. Anthony Carnicelli: And so, again, our goal was to evaluate the overall safety and efficacy of DOACs versus warfarin, but then also to dive into some specific subgroups, both from a categorical covariant perspective, and then also to evaluate some continuous covariants, specifically age, and to assess gender across the entire spectrum of continuous age in our population, which, of course is a unique opportunity in the individual patient-level data. Dr. Greg Hundley: And, Anthony, you had, gosh, it looks like over 70,000 patients in this particular analysis. Tell us a little bit about the results. Dr. Anthony Carnicelli: Yeah, so interesting, actually, and I agree that the biggest strength of our meta-analysis is the individual patient-level data and also the profound number of randomized patients included. So I think, from a high level, the most important results to highlight are the fact that there is a 19% relative risk reduction in stroke or systemic embolism among patients who are randomized to DOACs compared to warfarin, with an 8% reduction in all-cause death and a 55% reduction in intracranial hemorrhage. Dr. Anthony Carnicelli: So a massive reduction in the most feared complications of both atrial fibrillation and then also those associated with systemic oral anticoagulation. We also found a trend towards less bleeding in patients randomized to the standard-dose DOAC group, as well. Dr. Greg Hundley: Very good. Well, Chris, we're going to turn to you. What an exciting discovery here, and beautiful methodology. I wonder, in addition to what Anthony has shared with us, were there particular outcomes that were pertinent to men versus women or perhaps related to age? Dr. Christopher Granger: Yeah, Greg. So, again, we're proud of this as being really the state-of-the-art ability to evaluate safety and efficacy in this incredibly important population of patients with Afib and at risk for stroke, and to be able to dive into the subgroups and to the individual outcomes, even the less common outcomes. And one of the most striking things, and this really reinforces prior data, but with the greatest confidence of any study ever done, there was this 55% at reduction in intracranial hemorrhage and 19% reduction in total stroke and systemic embolism, really highlighting that these drugs are clearly better than warfarin, from reinforcing the guidelines. Dr. Christopher Granger: And the message with the subgroups is there was really a remarkable amount of consistency. And specifically in the older population where people are really concerned about anticoagulation, there was a clear and consistent major advantage of DOACs over warfarin. Men versus women, clear, clear, compelling benefit of DOACs over warfarin across each of these outcomes, including mortality, by the way, 8%. But highly statistically significant reduction in total mortality. Dr. Christopher Granger: A couple of the interesting ones, there was some effect modification. In other words, some evidence of an even greater benefit in patients who were not previously on a vitamin K antagonist or who had lower creatinine clearance, really important group, right? The renal impairment group. Dr. Christopher Granger: And then there was a greater benefit of lower risk of bleeding for patients with low body weight. And, in fact, the younger population, if anything, had a greater benefit with respect to less bleeding. And the bleeding is so important, Greg and Shinya, right? Because that's the major reason that people are not using anticoagulation, warfarin or DOACs, for this large population of patients who are untreated. And I hope this meta-analysis will be viewed as evidence that have really safe and effective treatments that are underused for this population that we're concerned about bleeding. Dr. Greg Hundley: Excellent. Thanks so much, Chris. Well, Shinya, you see a lot of papers come across your desk. What attracted you to this particular paper? And then can you help us put these results in the context with others that have evaluated the utility of DOACs in patients with atrial fibrillation? Dr. Shinya Goto: Thank you, Greg. Let me congratulate for Anthony and Chris and also group for conducting this great work. I mean, combine AF with amazing success for sharing the clinical trial database. So that all the four with a DOAC available is approved by each country based upon individual trial. Individual trial itself, large enough, right? Include more than 10,000 patient, but this time the [OSA 00:19:49] accumulated all four DOAC trial database together so that it is easy to say clinical trial data sharing provided robust evidence. Dr. Shinya Goto: But it is difficult, actually, to conduct it. I really commended OSA to conduct this success. So the data is predicted, I would say. Individual clinical trial itself shows lower risk of bleeding in DOAC as compared to warfarin. But this paper really provides the first time standard dose of DOAC reduce the risk of stroke and systemic embolism and death as compared to warfarin. Dr. Shinya Goto: So I really commented OSA. So this paper have a strong impact on the medical care. DOAC rapidly change the standard of care already. But superior efficacy was shown only in a few dose of DOAC, like 150 milligram BID of dabigatran, 60 milligram QD edoxaban, and five milligram apixaban. But this combined AF provides a stronger and a trustable robust evidence DOAC is better than warfarin. Dr. Greg Hundley: Very nice. Well, gentlemen, I want to turn back to you. I'll start with Anthony and then Chris, and then Shinya. Anthony, what do you think is the next study to be performed, really, in this space? Dr. Anthony Carnicelli: Well, it may be a bit of a pitch, but I mean, we have many opportunities in the combined AF data set to perform additional analyses, but I think that one of the most important next steps in this space that I'm most excited about is with respect to the newer oral anticoagulants that are coming down the pike. Dr. Anthony Carnicelli: For example, the Factor 11 inhibitor space. I mean, I think that there is another opportunity in the near future to potentially revolutionize the systemic anticoagulation space. And I think that data from combined AF could potentially be used to help continue moving the ball forward, again in the development of newer agents. So I think that's probably the thing that I'm most excited about in this space. Dr. Greg Hundley: Very good. And, Chris? Dr. Christopher Granger: Greg, I think there's so many unanswered questions and I think, as Tony points out, this highlights the fact that we know a lot, but there's a lot of unanswered questions. And those, some of the ones that I'm most interested in are low burden AFib, this AFib that we're detecting now with smart watches and devices, and what we do with that. And patients with renal impairment, including all the way down to renal failure, where those are relatively underrepresented, including in the combined AF data set. Dr. Greg Hundley: Very good. And, Shinya? Dr. Shinya Goto: Yeah. Yeah, Anthony and Chris talked about a little bit the plans to space, but I insist there is a lot of space that also could do with the combined AF database. We can expect a lot of sub-analysis, like you conducted as a continuous variable in this paper, but you can do that with eGFR as continuous variable, PMI as continuous variable. So we can expect a lot of sub-analysis. Probably, this is the end of publication from the individual DOAC development trial. You change the game with the combined AF data set. Dr. Greg Hundley: Very good. Well, listeners, we want to thank Dr. Anthony Carnicelli, Dr. Christopher Granger and our own associate editor, Dr. Shinya Goto, for bringing us this very interesting result from the meta-analysis that, compared to warfarin, DOACs have a more favorable efficacy and safety profile among patients with atrial fibrillation. Well, on behalf of Carolyn and myself, we want to wish you a great week and we will catch you next week on the run. Dr. Greg Hundley: This program is copyright of the American Heart Association, 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

In this episode of Online Dating In 2022. What You Should and Should Not Expect, we discuss First Dates. You have seen all your efforts on the Dating Sites (Match, Zoosk, Plenty of Fish,...etc) pay off. There is genuine interest and you are ready to meet someone for the first time. There are Tips and Pointers for having an awesome first date. Topics of conversation, appropriate attire, safety precautions and measures, and escape plans, (IKR) are just some of the things we discuss while helping you navigate these mean Online Dating streets! Please join the movement and support the podcast by subscribing and referring all your single friends. Let's make 2022 a great year by finding your significant other and a new best friend. Have an awesome rest of your holiday season and may God Bless! Thanks! #FirstDates #FindingLoveandRomance #OnlineDatingIn2022 --- Support this podcast: https://anchor.fm/andrew-knight4/support

Investment expert Mark Copsey believes that the bank is the worst place that you could be keeping your money.  In this episode of Full Blown Adult, he explains how, through smart investing, you can expect to double your money in ten years.  And with his not-yet-teenage kids already having a better investment portfolio than Veronica he just might be onto something!  Learn what it costs, how to do it, and If NFT's and ETF's have ever made you say WTF, (IKR), then this is the episode for you.   Host Veronica Milsom, Guest: Allworths Wealth Management's Mark Copsey See omnystudio.com/listener for privacy information.

Did you know active listening starts with relationship and genuine curiosity? Educator, creative, and half-marathoner Rahbin Shyne teaches the top 3 practices to improve listening and how to keep your listening skills sharp.  When she's not teaching, Rahbin is the host "365 Brothers Podcast" where she interviews diverse African American men by asking each of them the same 11 questions during an intimate convo. IKR? What a lovely idea! Learn more and contact Rahbin Shyne at 365brothers.com

Anna Juul er hovedforfatter bag komedieserien Fantomforhold, der kommer på Xee. Den handler om en terapigruppe for folk med kærestesorg. I Kræs' portrætserie Stjæl som en kunstner fortæller Anna om den kreative udvikling af programmet, og at hun har stjålet fra et særlig intenst forhold i hitserien Lost til sin egen serie. Men først kan du i dagens udsendelse møde professor i Nordisk Dan Ringgaard, der netop er valgt ind i Det Danske Akademi. Ind til for nylig har medlemmerne i Det Danske Akademi langt hen ad vejen passet sig selv på Karen Blixens kunstnerhjem Rungstedlund, men bølgerne er gået helt anderledes højt i den stolte litterære institution, siden lektor i nordisk litteratur og medlem af akademiet Marianne Stidsen gik i clinch med #metoo-bølgen ved bl.a. at kalde bevægelsen for en "vanvittig massepsykose". Det skræmmer dog ikke det nye medlem. Sidst i programmet skal det handle om cancel culture i forbindelse med balladen om Thisted Bryghus og deres øl med Pernille Vermunds ansigt på mærkatet. Selvom cancel culture er et negativt ladet ord, er der faktisk gode ting ved principperne bag - så længe det ikke skal handle om forbud, lyder det fra professor på Institut for Kommunikation, Vincent Hendricks. Vært: Maja Hald. Tilrettelæggere: Tjelle Vejrup, Isa Samuelsen og Mathias Wissing. See omnystudio.com/listener for privacy information.

Anna Juul er hovedforfatter bag komedieserien Fantomforhold, der kommer på Xee. Den handler om en terapigruppe for folk med kærestesorg. I Kræs' portrætserie Stjæl som en kunstner fortæller Anna om den kreative udvikling af programmet, og at hun har stjålet fra et særlig intenst forhold i hitserien Lost til sin egen serie. Men først kan du i dagens udsendelse møde professor i Nordisk Dan Ringgaard, der netop er valgt ind i Det Danske Akademi. Ind til for nylig har medlemmerne i Det Danske Akademi langt hen ad vejen passet sig selv på Karen Blixens kunstnerhjem Rungstedlund, men bølgerne er gået helt anderledes højt i den stolte litterære institution, siden lektor i nordisk litteratur og medlem af akademiet Marianne Stidsen gik i clinch med #metoo-bølgen ved bl.a. at kalde bevægelsen for en "vanvittig massepsykose". Det skræmmer dog ikke det nye medlem. Sidst i programmet skal det handle om cancel culture i forbindelse med balladen om Thisted Bryghus og deres øl med Pernille Vermunds ansigt på mærkatet. Selvom cancel culture er et negativt ladet ord, er der faktisk gode ting ved principperne bag - så længe det ikke skal handle om forbud, lyder det fra professor på Institut for Kommunikation, Vincent Hendricks. Vært: Maja Hald. Tilrettelæggere: Tjelle Vejrup, Isa Samuelsen og Mathias Wissing.

Fourteen year old Tim and Tove' started dating in the fall of 2007, and it was rocky from the start. Tove' is controlling and tries to isolate him from his friends, although he was also a jealous partner. They were both unfaithful to each other during their two years together. Tim with several girls, and Tove' with her ex-bf Gordon...After Gordon and Tove' broke up in 2007, he began seeing....guess who; Therese Rojo...oh and then Therese and Tim made out! IKR! Scandalous! But as you know, them crazy ass teenagers took it too far.   simplisafe.com/creeper   EVERYTHING TRUE CRIME GUYS:   https://linktr.ee/Truecrimeguysproductions   Patreon.com/truecrimeguys Merch: truecrimeguys.threadless.com   OhMyGaia.com Facebook Twitter/Instagram: @TrueCrimeGuys @AndImMichael @sandupodcast STICKERS CREEPER MERCH     Sources: https://www.youtube.com/watch?v=klYXKlfusCo   https://www.simplylearningtuition.co.uk/advice-for-parents/everything-you-need-to-know-about-the-swedish-education-system/   https://web.archive.org/web/20100118231119/http://www.dn.se/sthlm/mordet-pa-therese-johansson-rojo-1.933376

Now a days we have the fullness of the Gospel restored, we do have access to something or actually someone better than nanotech and His name is Jesus Christ, we don't have to have clunky heavy suits that weigh us down and are super inconvenient to even walk around in. We can build custom suits with Christ, like Tony Stark's newest Iron Man suit, with the tools God has made available to us in these latter days. Speaking of armor, another suit I really love is the King T'challa's Black Panther suit made of Vibranium Micro Weave Mesh which hides in his super cool necklace and is also deployed in an instant. Did you know the last suit Tony Stark made was called the Mark 85 Ironman Armor? IKR! I want to see those movies too! Tony Stark's Iron Man Suit Evolution Video Armor of God Scriptures: Ephesians 6 ; D&C 27: 15-18

The whole gang is back *yes everyone IKR!!!* and we catch up on the topics we missed during our brief hiatus. We cover the MIL deluxe, CLB, Donda, and more. --- Support this podcast: https://anchor.fm/from-lagos-with-love/support

Shelly Avery is a member of Microsoft's Healthcare Solution Acceleration Team, helping Healthcare customers digitally transform their businesses.  As you listen to this conversation you'll realize, as we did, that Shelly knows the tech AND the human side of the tech very well! References in this episode: FHIR Tom Scott - There is No Algorithm for Truth   Episode Timeline: 4:30 - The high value of customization and integrations in BI in the current era of Middleware, Microsoft Teams and how good it is at connecting humans, The speed of Innovation at MS (some of which is directly customer influenced) 32:10 -  Microsoft's FHIR (Fast Healthcare Interoperability) is revolutionizing the rather large problem of interoperability in the Healthcare space 49:30 - Microsoft Viva is born from My Analytics, Rob gets into Headspace, using data for nefarious purposes Episode Transcript: Rob Collie (00:00:00): Hello friends. Today's guest is Shelly Avery. We've had a lot of Microsoft employees on the show and Shelley continues that tradition. The reason we have that tradition is because there are so many interesting things going on at Microsoft these days. And Shelley brought some super fascinating topics and perspectives to our conversation. For instance, she has a deep background and history with the Teams product for Microsoft. And so we got into the question of what is it that makes Teams so special? I really, really, really appreciated and enjoyed her answer. Rob Collie (00:00:31): And given her current focus on the healthcare industry and on health solutions, we talked a lot about how Microsoft's business applications and Power Platform strategy is actually a perfect fit for what's going on in healthcare today. We did touch on some familiar themes there, such as the new era of middleware, how a 99% solution to a problem is often a 0% solution to a problem. How even 100% of a solution itself is a moving target. And my only slightly partisan opinion that may be Microsoft's competitors in all of these spaces should just save themselves the trouble and tap out now. We talk about the virtual teams that exist on the Teams team at Microsoft. Sorry, I just had to work that into the intro. Rob Collie (00:01:17): I learned a new acronym, FHIR, which is the new upcoming regulatory and technological standard for data interoperability in the healthcare space. We talk a little bit about Veeva. Have you heard of Veeva? I hadn't. It's one of those technologies with a tremendous amount of potential to be used in a positive way and maybe a little bit of potential to be misused if we're not careful. And that conversation was also the excuse for our first ever sound effects here on the Raw Data Podcast. We spared no expense. An iPhone was held very close to a microphone. All in all, just a delightful conversation. I smiled the whole time. We also had the ever upbeat and awesome Krissy in the co-pilot's chair for the duration of this conversation. And with that completely unintentional rhyme out of the way, let's get into it. Announcer (00:02:04): Ladies and gentlemen, may I have your attention please? Rob Collie (00:02:11): This is the Raw Data by P3 Adaptive Podcast, with your host, Rob Collie. Find out what the experts at P3 Adaptive can do for your business. Just go to p3adaptive.com. Raw Data by P3 Adaptive is data with the human element. Welcome to the show. Shelly Avery, how are you doing this morning? Shelly Avery (00:02:35): Hey guys, doing good today. Rob Collie (00:02:37): Well, thanks so much for being here. Another brave soul, first time meeting us. You're willing to have it recorded. That's into the breach. I like it. Shelly Avery (00:02:45): It's good to meet you guys. I'm happy to talk to you today. Rob Collie (00:02:48): We brought Krissy today. Krissy Dyess (00:02:49): How's everybody doing? Rob Collie (00:02:51): How are you Krissy? I mean, it's earlier your time. Krissy Dyess (00:02:53): It is early. Yeah. So normally we do these in the afternoon, but it's early. I'm enjoying the sunrise this morning. Rob Collie (00:03:00): Oh, fantastic. Krissy Dyess (00:03:00): Doing good. Rob Collie (00:03:01): Yeah. A cup of joe, maybe. Krissy Dyess (00:03:03): I don't drink coffee. Shelly Avery (00:03:04): I've had two today. Rob Collie (00:03:05): Shelly, I actually already noticed that. I had noticed before we started recording that the color of your coffee cup changed. That, yeah, she just hot swaps the coffee. Shelly Avery (00:03:16): Travel mug to drop off the kids this morning and then real mug once I got back to the home office. Rob Collie (00:03:22): So Shelly, why don't you tell us what you're doing these days. Give us your CV. Shelly Avery (00:03:25): I am at Microsoft now. I am in a new role that Microsoft has created. I am on a team that is called the Healthcare Solution Acceleration team. And our job is to really help our healthcare customers digitally transform their businesses, hopefully using Microsoft technology. But I've been here five years. I started as a technical specialist, helping customers migrate from on-premise server base infrastructure to Office 365, Exchange and SharePoint in OneDrive. And then Microsoft Teams came around because it wasn't around. It didn't exist when I started, and I became a Microsoft Teams technical specialist. I thoroughly enjoyed it. I loved it. Shelly Avery (00:04:12): Teams has really empowered the world to figure out how to do work different. It created lots of opportunities for people to create new ways of solving their business problems. And it was a lot of fun to be able to partner with our customers and really help them understand how technology can be an advocate for them and just help them do things faster and more efficiently and on their own terms. And so that was super fun, especially working with healthcare. I learned through that about some other features that Microsoft had, not that I didn't know, they didn't exist, but Power Platform, Power BI, Power Automate, Power Apps, and then later Power Virtual Agents. Shelly Avery (00:05:00): And using those inside of the UI of Microsoft Teams to even further enhance what Teams does, which is communication and collaboration, but then putting apps, low-code, no-code apps, and BI and data at the fingertips of these individuals to really, really step up their game and how they're solving their business problems. It's just been super fun and I thoroughly enjoy it. And so taking all of that into my new role, specifically working with healthcare and trying to help them accelerate solutions in their organization to solve their business problems. I thoroughly enjoy what I do every day. Rob Collie (00:05:41): Do you think that your recent background in Teams was a selection criteria for going into health? It would really seem to me like that strong basis in Teams is really quite an asset for you in the healthcare specific role. Shelly Avery (00:05:55): Well, I of course would love to say yes. And I think it is for me, that's how I learned. It's a background that I feel like I'm an asset to my customers, but my new team is comprised of people from all different backgrounds. And so what our new team hopes to be is people who are deep in various different technology areas so that we can lean on each other's expertise when a solution isn't bound by Microsoft Teams. So maybe we need to create a bot in Azure and build it off of a SQL database and put it in Teams. And so we're crossing the entire Microsoft stack. And so, yes, I'm deep in Office 365 and Teams and getting much better into the Power Platform, but as soon as I need to build a bot in Azure, I'm like, "What, how do I do that?" Shelly Avery (00:06:59): So I need that other person on my team who is deep in that area. We're here with you guys. I know y'all are deep in Power BI. We have data scientists on our team and experts in Power BI, which I am not that, but I leverage them because when I talk to my customers, they want to create dashboards and reports that they can have actionable insights on. And so I understand the use case or the problem they're trying to solve. And then I work with my data scientists on the team to help. We come together and bring our skills together to help the customer. So it's just a super fun team. We all geek out in our own area. Rob Collie (00:07:38): Yeah. I mean, it is really a perfect little microcosm of what Microsoft is trying to do with the Power Platform in general. Isn't it? Years ago when they renamed, they Microsoft renamed the Data Insights Summit to be the Business Applications Summit, it wasn't really clear what was going on. There just seemed like one of those funky Microsoft renames. You know how Microsoft changes the acronyms for all you folks in the field, every 18 months, just for yucks. It seemed like one of those, but no, that wasn't it at all, right? There actually was a really long-term grand plan that was already clear behind the scenes there, that just wasn't really clear on the outside. Rob Collie (00:08:18): And all of these technologies coming together, the low-code, no-code or rapid development, whatever you want to call it, right? All of these tools, they enable something to come to life that every single environment, every single customer is different and their needs are different. Their fundamental technological systems that they use, all their mind of business applications, all of those are different and unique. They're unique mix. Plus then you add in the unique challenges that are going on in their particular environment. Rob Collie (00:08:45): You want something off the shelf, but at the same time, if it's not incredibly flexible, if it's not incredibly customizable, it's never ever, ever going to meet the needs of that reality. And I think Microsoft has one of the strongest long-term bets I've ever seen Microsoft make. And it's been really interesting to see it come into focus over the years. Shelly Avery (00:09:06): I'm glad you see that and a lot of people do, but we have a lot of customers. I keep saying health because that's who I work with, that there are health care pointed solutions that are out there that have a single purpose and they are off the shelf. And they do usually do a great job at what they do, but they only do one thing. And we find that almost every application or SaaS that they subscribe to or purchase, has to be connected to data or systems or things like that. And then they have 50 different apps all connected to 50 different things, and it becomes complex. And you have service contracts and everything has to be managed. And so we are pushing that we have a turnkey solution. Shelly Avery (00:09:54): We're actually saying the opposite. We have a solution that gets you 80, 85% of the way there, but then that last bit is fully customizable to make it exactly like you want. And so sometimes that's hard to tell a customer that, "Hey, you're going to pay for something and then you have to build it," or, "You have to pay someone else to help you build it." And they have to be able to see the benefit of that to keep costs down and reduce complexity and app sprawl is something that we see a lot. And so being able to streamline that is something that we definitely try to do and help our customers understand the benefit of. Rob Collie (00:10:33): Sometimes 99% rounds to zero. You have a 99% solution to something, but you simply cannot do the last 1%. And a lot of cases, that's just a failure. I think a lot of off the shelf software, even if it got to 99% of what you need, which is a phenomenal number, it's still not doing it. Plus we also got to remember that the 100% target is also not static. Things change. Even if you're 100% today, your needs tomorrow are going to be different. The ability to customize, the ability to create new integrations and new applications, even if they're lightweight within your environment, is an ongoing must. Rob Collie (00:11:16): I think approaching this as a platform while at the same time making that platform very humane, it doesn't require me to sit down and write C-Sharp every single time I need something new, that's just amazing. I think if you zoom back on all of this, it's almost obvious once you know what to look for. All of the individual systems that we buy, and this is even true of our business here at P3. We're, "Best of breed," in terms of all the line of business software that we've adopted. Best of breed, AKA, whatever we stumbled into at that particular point in time. All those little silos, those line of business silos are very competent. Maybe not excellent all the time, but they're very competent at what that silo is supposed to do. Rob Collie (00:11:59): But an overall business environment, an overall team environment doesn't stop at those silos. It's like the whole thing. It's the whole picture. It's the whole organic total across all of those silos. That's where you live. You don't live in one of them. And so integration across them of various flavors. I think we're in this new second or third era of middleware right now. And Microsoft is just so, so, so well positioned in this game. I didn't see this coming. I just woke up one day and went, "Oh, oh my gosh. Look at what my old buddies are up to." Checkmate. It's been really cool to watch. Shelly Avery (00:12:40): Yeah. It's been really awesome to be here and live it. Sometimes when you're in it, you don't see it happening. And then you look back and you say, "Wow, we've come a long way in the last three years or five years." Rob Collie (00:12:52): Yeah. Let's talk about Teams a little bit more before we switch back into health. Shelly Avery (00:12:57): Yeah, sure. Rob Collie (00:12:57): I find the Teams phenomenon to be just fascinating, which is another way of saying that I missed it a little way, right? Back when I worked on the Excel team, every few years whenever office would finish a release, there'd be like this open season of recruiting. People could move around within office, like a passport free zone. You could just go wherever you wanted. I always struggled to get people who had never worked on Excel to come work on Excel. It was scary. Rob Collie (00:13:24): They've been working on things like Outlook or Word or something like that. It's easy to be, "An expert user of Outlook." It's easy to be an expert user of Word. In other words, the difference between the 80th percentile user of those apps and the 99th percentile user of those apps, it's hard to even distinguish. You can't even really tell the difference between them and practical usage. That's not true for Excel though, right? Shelly Avery (00:13:44): Right. Rob Collie (00:13:45): An Excel expert is like a magician compared to an amateur. And so that was really intimidating, I think. That was the fundamental reason why people struggled to take the leap to come to the Excel team. They felt more comfortable where they were, but a pitch I always gave, which were about a 20% success rate, was data fits through a computer really well. A CPU can improve data. It's built for that. Whereas Outlook and Word, even PowerPoint, I've revised my opinion on all of these since then, but this is me in my early 30s. Going, all those other things, those are about ideas, and communication, and collaboration. Rob Collie (00:14:25): And that's all human stuff. And human stuff doesn't really fit through a CPU all that well. It doesn't come out the other side, enriched in the same way that data does it. Hubris in hindsight, right? I said, "There's never an end to how the improvement that can happen in Excel." Whereas something like Outlook or Word, might be essentially nearing its end state. Then comes Teams, right? Teams is the kryptonite to that whole pitch. I hear myself back in the early 2000s, Teams is all about human interaction. I guess that's what it does. Rob Collie (00:15:02): I guess, to me, it's this alien form, Teams has just exploded. People love it. It's everywhere. I mean, this is an impossible question to answer, but I'm going to ask it anyway, because it's fun to do. What is it? Why are people so excited about Teams? For a while there, it's like SharePoint held a fraction of this excitement. It's in a similar spot, the hub for collaboration in the Microsoft ecosystem. It feels like Teams has said, "Here, let me show you what that really looks like." Shelly Avery (00:15:36): Yeah. I'll do my best to try, but this is my opinion. I don't know what anybody else thinks, but I think it takes the best of the consumer world and the best of the enterprise or commercial world and puts it together all in one app. It has things that when you chat with somebody, it's like you're using a text message. So it's no different than, if you're an Apple user, you open your phone and you go to the green text message app or you go to the Teams app and it looks exactly the same. It has gifts and it has reactions, and you can put stickers and memes in there. And so it's super fun. Shelly Avery (00:16:19): But then you take that enterprise and you can also share a OneDrive link or create a meeting or send someone an Outlook invite or whatever. So it takes that enterprise and mushes it with consumerism. And so it's like taking Facebook and LinkedIn and Office and SharePoint and smashing it all into one app. And so you can have fun with it. You can build relationships with your colleagues or even people external to your organization, but then you can also build presentations and dashboards and create, and even use the Power Platform from a low-code dev perspective, right inside of Teams. Shelly Avery (00:17:02): It spans the spectrum of fun to developing brand new stuff. And so everybody can get something out of it and they can use it the way they want to use it for the purpose that they need to work on, whatever they're doing for the day. And so it can be great for various different people in various different ways. Rob Collie (00:17:28): I love that answer. Krissy Dyess (00:17:29): I have a different perspective. I came from a background of data and technical and all of that type of thing, but this Teams, really with everything transitioning to remote in a hurry over the last year, I feel like it really helps with a level of organization and communication and assets that you talked about, Shelly, to centralize all that because in a difference of data coming at you from many places, now we have communications, now we have remote teams. Krissy Dyess (00:18:05): And I love, like you said, it is fun, it's interactive. Here's where I'm struggling a little bit with Teams. I love it, but what is proper Teams etiquette in terms of like meetings and conversations? For example, I'm having a meeting and I don't want to interrupt somebody, so I'm going to put it in the chat. But then sometimes people feel like, well, the chat is still a form of interruption. I see it as a form of participation. And so I think people are still learning how to embrace these tools. Shelly Avery (00:18:38): Yeah. Well, I think that it also comes to culture. Krissy Dyess (00:18:41): Sure. Shelly Avery (00:18:41): And Microsoft has an amazing culture. We have been on a journey through Satya, our CEO, on really changing the culture of inclusivity and a growth mindset. And it's interesting when we interact with customers who don't have a very friendly and open culture. But I think you use it the way it works for you and for the people that you're working with and your culture. So if you're in a small team setting and it's friendly people, you should feel comfortable to use it the way that it makes you feel comfortable. Shelly Avery (00:19:23): But if you're in a quarterly business review with executives, I mean, think about it. If you're going to lunch with your buddies, you're going to act different than if you're going to a formal dinner with executives, right? And so you use the technology in a way that you would use real life. And so if I'm going to lunch with my buddies, I'm going to be cutting up and giving them funny gifts and patting them on the back. And if I'm in a business meeting with executives, I'm going to have my best dress on and my polite manners. So I'm going to act that way in a meeting too. Krissy Dyess (00:19:51): I totally agree with you. I've had the opportunity recently to work with the Microsoft team and I agree there's a completely different culture than what we see, even from my background, even from our culture, I mean, we're all friendly and stuff. Every organization does have their own culture and exactly what you pointed out, even within that organization, there are different levels and cadences. Shelly Avery (00:20:13): Yeah, it's crazy. So I spent the last three years helping IT organizations deploy Microsoft Teams. And I did that in the midst of COVID, in healthcare. So when you say remote work overnight, literally help telecare organizations enable 35,000 individuals for Teams over a weekend. To the question about culture, it was very difficult for some of the IT organizations to say, "Well, what should we allow our users to do?" There's sensitivity that you can set on gifts in a team. You can say, do we want them to be explicit or PG-13 or PG or G? Shelly Avery (00:20:58): And I had one organization that if there was anything to do with a gift that had to do with politics, that was seen offensive, because what if I sent you a Trump gift and you were a Biden person. I mean, how dare you do that? And so that company was very, very sensitive and they would only allow gifts at a G rating. And a G rating were like cartoons and stickers, where other organizations are like, whatever. If you don't like it, don't use it. Shelly Avery (00:21:29): So there's definitely different cultures and different organizations across the country. And so luckily, there are the controls in the back end and the administrative section on those kinds of things. And then for data too, do you want data to be shared externally or do you want people to be able to chat externally or not? And who do they want to be able to chat with? So there's lots of governance and data protection controls in the background. Krissy Dyess (00:21:58): And being a data person, what is really cool about Teams and all these things that you just described is on the backend, all of that stuff is just data. That's why you can control. That's why you can help your organization with these. And I think that's really cool. I am super excited about Teams. I was excited about Power Pivot in Excel, and I was excited with Power BI Desktop, and what you explained too, how it starts to integrate the Power Apps, the bots, all of that into this changing ecosystem of how we work, the ability to bring that from the top level all the way down to the frontline workers, to impact and drive actions, I am super excited about Teams. I can't wait to see how organizations learn more, how that they can adopt these tools, because I think there's so much that people just don't know because it is so new and it's a different way, just like Power BI was. Shelly Avery (00:22:57): I'll give you an example about that. We have this one group inside of Microsoft, it's called the [SLATE 00:23:04] team. And you know how Microsoft is with making acronyms. I have no idea what SLATE actually stands for, but what they do is they work with customers who have a unique idea and they help them build low-code or apps inside a Teams. And they built this one app called the Company Communicator. Basically what it is, is it's like a mass texting app, where I can create a little message and push it out via chat or via a Team to everyone in the organization or to a subset of people. Shelly Avery (00:23:39): And it created a cute little adaptive card where you could put a headline and a picture, and then a little message. After that got so popular, Microsoft built it into the product, right? It started from a customer, it went through a program. It was customer purpose built. Then it got so much organic growth through all of our customers loving this idea of pushing notifications. So we turned it into code and now it's in the product. I think that, that is so cool, how Teams is democratizing the ability for customers to influence product and future releases that now everybody in the world gets to take advantage of. Shelly Avery (00:24:28): So that's another thing that I just, I love about it as a product, but also we call it the Teams team at Microsoft, is they're innovating so fast and I'm just a few months out of that role and I already feel behind. I just saw a blog with what's new in Teams in August. And I'm like, I need to go and read this to make sure I know everything that's new because they just come out with so much new stuff every month. And it closes the gap, Rob, you mentioned earlier, when a product's only 99%, it's really zero. Shelly Avery (00:25:03): I think the bet on Microsoft is, it might be 99% today, but it's probably going to be 100% in a couple of months because we're innovating so fast. And your 99% today, isn't going to be your 99% in six months. And so it's a moving target, not only for the customer, but for Microsoft too. And so we want to catch up with features that are on the backlog, but the backlog just keeps growing and growing. And so the faster we can innovate and build these into the product, we will. Rob Collie (00:25:33): I just feel like if you're watching a really high stakes chess match, which I never do, but imagine that you did, to the untrained eye, this is an even game. And all of a sudden, one of the chess masters just resigned, just tips the king over and says, "Yeah, I've lost." I just feel like as a software industry, we should just take a moment and say, "Hey, Salesforce, all your other, your SAP, do y'all just want to call it, you want to just tip your Kings over, save us all a lot of trouble." I don't even work for Microsoft and I'm looking at this going, "Oh, boy." Remember, I'm not paid to say this. I really think Microsoft has really, really, really dialed it in. Rob Collie (00:26:16): I'd like to also go back to your answer about why Teams is so special. I think it was a perfect answer. Rewind 10 years, 11 years, I'm struggling to explain to people why this whole DAX and tabular data modeling thing that was only present at that time, only in the Excel environment, and only as an add in, it was, in some ways the most primitive exposure possible of this new technology. I was trying to explain to people why this was so special. And it was particularly difficult to explain it to people who had intimately known it's [4Runner 00:26:49], which was the analysis services multi-dimensional. Rob Collie (00:26:52): And really, technologically speaking, there wasn't too much about this new thing that was superior. If you looked that gift horse in the mouth and examined its lines and everything, you'd be like, there's really not much different here or it's clearly better. Now it had one thing that was clearly better, which was the in-memory column oriented compression. And that was pretty sci-fi. That was pretty cool, but it wasn't the tech. It wasn't like one of these was able to make the CPU scream at 500% capacity or something like that. It wasn't that at all. It was that this new tech fit the way humans work so perfectly. It met the humans where they were, whereas the previous one forced the human world to bend to its will. The humans had to come to it and meet it where it was. And this is a very subtle and nuanced point. Rob Collie (00:27:49): But in practice, it is everything. In practice, it means that a company like ours, that operates completely differently than the data consulting firms and BI professional services firms of the past, and really honestly, today, I think most firms are still operating that old way. We're a completely different species of a company. And we exist because these tools work a different way for the humans. And over and over and over again, this is why the ROI from Power BI is so insane when you use it the right way, when you really lean into it strikes. Your explanation about Teams, it echoed that for me. It's professional tool that fits the humans really well. Rob Collie (00:28:36): And you don't typically talk about stuff like that. If you're a technology professional, those kinds of answers, you're always looking for some sort of more hardcore answer. It's capabilities. Look at the check boxes it's got on the box, right? This other description of it fits the humans really well, it's not a good sales pitch, but in reality, it's everything. It's a difficult thing to do, right? Rob Collie (00:28:59): One of its chief strengths is also just, doesn't make a good sound bite or like, oh, okay. So now you have to wait and see it for yourself. You have to experience it. And I think that's what we've seen. Is that the people who've really leaned into Teams, they all have this surprised reaction, or they say, six to 12 months after really getting into it, as they describe how much they like it, there's this undertone of, "Yeah, it's really turned out to be amazing." You can tell that they didn't quite expect it. And now they're a convert. Shelly Avery (00:29:31): Well, I think a lot of IT organizations, they push applications out and Teams to the masses is, oh, it's just another application that IT is forcing us to use. And they're resistant to change because the last app IT pushed out wasn't great. And then they finally get in there and they do what you and I are talking about. They chat in it, they text in it, they meet in it, they have fun in it. And then six months later, they're like, "How did I do my job without this?" They enjoy it. It's easy to use, it's very accommodating and friendly to different personalities and different work types. And it's so unique in the way that you and I and Krissy can all use it all day long, every day, and we use it completely differently, and yet we all have the same opinion of it, is it works great for me. Rob Collie (00:30:30): That's the whole mark of a successful product. And one that spreads itself, right? It develops impassioned evangelists. Again, just like everyone else, I would not have seen that coming. Shelly Avery (00:30:41): You were at Microsoft from an Excel Power Pivot perspective and you now are not, and have started your own business and they're successful in that. I know people that worked at Microsoft and literally quit Microsoft just to be a YouTube star on how awesome Teams is and all the cool stuff you can do with it, and they've made a living out of it because it's a product that does so much and it's never ending in the way that it can be used and how unique it is. It blows me away when I actually saw a gentleman who was at Microsoft as a product manager and I followed him on YouTube, and then one day he said, his YouTube post was, "I am retiring from Microsoft." And he was younger than I am. I'm like, "How are you mean you're retiring?" Krissy Dyess (00:31:32): I followed the same story that you did, Shelly. I know exactly who you're talking about. What I really love, what the appeal of it to me is, is it's always these little things that people don't know that make the biggest impact. And when you're in an environment where you're not exposed to people doing those neat tips and tricks, having the ability of finding somebody out onto YouTube sharing that, and then you can bring it into your organization and start to spread it, it's really impactful because a lot of times people think, "Oh, it needs to be this complicated technical solution." And honestly, it's always the little things that people are like, "Wow, I didn't know I could do that." Shelly Avery (00:32:12): Agreed. Rob Collie (00:32:13): So let's turn the corner. Let's talk about health, Shelly. Where should we start? Shelly Avery (00:32:16): Well, when you were talking earlier about how Microsoft Teams is this new thing, I think people had an aha moment and I think there is an aha moment that is about to come in health. And I'd love to talk about that for a minute. I think it plays into your audience well because it's about data. Rob Collie (00:32:41): Very important question. Are there people involved? Shelly Avery (00:32:43): There are people involved. Rob Collie (00:32:45): Oh, okay then. We're good. We're good. Shelly Avery (00:32:46): Yeah, yeah. Rob Collie (00:32:47): Okay. All right. Shelly Avery (00:32:48): Yeah. There is interoperability of data in health. So think about, from a human perspective, heaven forbid you get in a car accident and you go to an ER and they have to bandage you up. That ER is owned by some health organization and they now have data on you, but it's not the same health organization where you go to see your primary care physician. And so how does your primary care physician know about your ER visit and how do they know what medicines that you were given and whether those had adverse reactions to you or not? Shelly Avery (00:33:22): Well, without interoperability of data, that just doesn't happen. And there is an old version of healthcare interoperability called HL7. Again, another acronym, but the new interoperability standard is called FHIR, Fast Healthcare Interoperability. The idea of FHIR is supposed to be universal so that that ER can digitally transfer that information to your PCP, your primary care physician. And so your medical record and your information can stay up-to-date with all the people that are medically treating you or for even you, like if you move to another city and you want to say, "Hey, I need all my information. I'm going to take it to my new doctor." Shelly Avery (00:34:10): And so this idea of interoperability, it's not a Microsoft thing. It's a healthcare standard that is happening in the industry. But what Microsoft has done is we have gone full steam ahead on this FHIR interoperability and built a stack of technology solutions based on ingesting data through FHIR. And we have a bunch of healthcare APIs, FHIR API being one of them, to now take all those low-code, Power Platform, Microsoft Teams, bots, and hydrate those apps with all of this data from healthcare to now be able to really unleash this data. Shelly Avery (00:35:02): So you need an app to have a rounding solution bedside in a hospital. You now have the ability to suck that data in from Rob, that he's been to the ER and his primary care physician, and now you're in for knee surgery. And so I have all that information that's aggregated from all over, and now it's in this cute little rounding app that we built off of Power Platform, or same thing with Power BI, or a chat bot in Teams. We can chat this health data and say, "Hey, is Rob's labs ready yet?" And the chat bot goes and sucks that data in and says, "Yes, here's Rob's labs. Here's the link to it." Shelly Avery (00:35:44): And so just being able to unleash that and build these apps or bots or experiences for the human to be able to interact with that data is really what we are trying to do. And so I'm super excited about it. This is a new team that I'm on and this is really what we're trying to drive. So I think it's going to be game changer for the industry. Rob Collie (00:36:09): So this is my first time hearing of this new interoperability standard. First of all, FHIR, it sounds cool. I like it. It definitely sounds like it's useful for sharing healthcare and patient information across organizations. Do you also see it as something that's going to be useful even within an organization, like between the silos, between these different systems within a single entity? Shelly Avery (00:36:32): Yes. And it will do that first before it goes across organizations. And- Rob Collie (00:36:37): Okay. Shelly Avery (00:36:38): This is a challenge internally too, because there's software technology that these electronic medical records, that your medical record, my medical records sit in at each of these organizations. And most large healthcare providers have multiple instances of these electronic medical records. Sometimes they have multiple different types through mergers and acquisitions and growth over time, or this department got an upgrade, but the other department didn't. And even amongst themselves, they can't share information with each other. And so if a call center services 10,000 patients, but they have four different electronic medical records, when Rob calls into that call center, how the heck do I know which one you're in and who you are and all that? Shelly Avery (00:37:30): So if we can use this FHIR interoperability to aggregate all of that and have it in a single place, now we've built this great call center app that knows that Rob is calling in and who you are. And I immediately have your information. I could say, "Oh, Rob, are you calling about the meds that you got from your ER visit last week?" It's very personalized. So let's personalize care. Let's have better patient engagement. Let's round with our patients and have the right information where we need it, regardless of where the original data sits. Rob Collie (00:38:01): So it's a new standard, FHIR, right? Shelly Avery (00:38:04): Yes. Rob Collie (00:38:04): And so let's pretend I'm a healthcare organization and I have, again, these, "I've got a best of breed set up." I've got a jillion different siloed line of business systems. Some of them are new, some of them are not. These older systems that I have, they're not going to be playing nice with this new FHIR standard. They haven't even heard of it, that software. So- Shelly Avery (00:38:24): That's correct. Rob Collie (00:38:25): How do I, as an organization, connect those wires when some of my more long-ended two systems aren't going to be supporting the standard natively? Shelly Avery (00:38:36): And that's part of our challenge right now. A lot of the customers that we're talking to, they see the future, they like the vision that Microsoft is painting. They want these human interactions like we're discussing, but they'll say to us, "We aren't ready for FHIR," or, "We haven't made that transition yet." Our comment back to them is we can help you get there. And it is a requirement that they get there by a certain date in the future. So why not have a company like Microsoft help them? Shelly Avery (00:39:11): Now, it's not necessarily an easy task. There are data mappings that have to happen. And a lot of these electronic medical systems are in the old standard, which we can map from the old standard to the new standard. It takes a little bit of manual work, but you only have to do it once, because once you do it once, it's in the standard and now you've unleashed that data. There's also custom fields though. Some developers- Rob Collie (00:39:38): Of course. Shelly Avery (00:39:38): Have gone into these electronic medical records and they built some custom field that doesn't map to FHIR. So then you got to have somebody who knows that. And so there is hard work to do it in the beginning. I'm not trying to say that there isn't, but we do have healthcare interoperability partners, and system integrators, and Microsoft to help these organizations get into that standard. And the new marketed term for all of this is the Microsoft Cloud for Healthcare. Shelly Avery (00:40:10): And so it's all about ingesting that data and then unleashing that data to create these great, either apps or applets, or bots, or scenarios that empower the people who either work at these systems or even for patients to be able to interact with and have better experiences for themselves. And so, you only have to do the hard work once and then it's in there. And so you're right. It isn't a turnkey, there is work that has to be done, but they're going to have to do it eventually. So we'd love to be able to partner with them and help them get to meet those regulatory compliances that are coming in the near future. Rob Collie (00:40:52): Yeah. Another example of where it's good to have a platform, right? Shelly Avery (00:40:55): Right. Rob Collie (00:40:56): If that missing 1% is interoperability, that's a big 1% that a platform like Microsoft is very, very, very prepared to help you connect those dots. It also, it's really helpful that these older systems that we're talking about, if they already had to, as you pointed out, if they already had to play ball with an older interoperability format, that's end sharp contrast to your average line of business software that has no interest in interoperability at all. T Rob Collie (00:41:26): he average line of business system is like, no, no, no, no, no. We are a silo and we like being a silo. And why would we ... Mm-mm (negative), no. We are here to hoard the valuable data that is collected in here. Mm-mm (negative), no. Even though it sounds rightfully like labor intensive, one time investment, compared to the average interoperability game that happens across the world, across all industries, it sounds like there's already a really, really, really strong starting point. That's a big, big, big point in your favor. Plus if it's going to be a regulatory standard in the future, that is unheard either. Shelly Avery (00:42:00): Right. Krissy Dyess (00:42:01): I'm curious though, as to what changed, because honestly, it is one of the reasons why I'm appointment averse, is because every time you go into a different doctor and it's really common for people to move nowadays. And you're like, oh, I got to fill out all the same forms, over and over again. In my mind, I always thought it's somewhere. Why can't it be everywhere? I guess I thought maybe there was some privacy reason that was the blocker. Has something changed there? Shelly Avery (00:42:28): You're absolutely right. And no, there is still what's called the HIPAA regulations. And so the entire Microsoft Cloud for Healthcare is HIPAA compliant. It does meet all of the requirements for that. And so the FHIR standard, FHIR mandate is under that HIPAA compliance. And so that's a U.S. regulation. It's not in the EU or others. They have their alternative to HIPAA around keeping healthcare information protected. And it's important to be able to do that. And so the old HL7 standard of interoperability was highly customizable and the new FHIR standard is less customizable, and that is how it is able to have more liquid interoperability. Shelly Avery (00:43:27): I'll give you an example. Sex and gender are two completely different things. And we know that in this day and age, but in the FHIR standard, there is a born sex and it is one or another, and you can't really change it. But in the HL7, you could add seven or eight or nine or 10 different categories for that. So when you have the FHIR standards met, born sex is a one or a zero, basically. Right now they have the other category of gender that there's a bunch of options there. And then they even have another category. And so it's creating the standard that everyone in healthcare has to meet as opposed to going in and making it where I can make 37 customizations because in my hospital, I allow them to have 37 choices. Shelly Avery (00:44:28): Religion is another one. Religion is huge. I mean, there's endless amounts of religions. In the FHIR standard, there's a set amount and then in other. And so you have to fall into either the set amount or other, and that allows for that more liquid interoperability, or that is the goal. That's the goal of FHIR. Now, I'm getting a little deeper into more of the regulatory compliance and how the standards work. There's tons more deep technical experts on healthcare compliance than I am. I'm more of a technologist than a healthcare compliance expert, but knowing how it works a little bit helps you understand why the technology is empowering or we hope in the future has the potential to empower the industry to be able to do more with this data. Rob Collie (00:45:18): Even that little deep dive there, I mean, that really, for me and for the listeners, you really just certified your bonafides there. If anyone was wondering how deep you were into this stuff. You always got to be careful. You're not the expert on that. There are people who know it much better than you. The fact that you know that much while also being on top about all those other stuff, you're in the right role. Like Holy cow. Shelly Avery (00:45:41): For my role, they did require healthcare expertise. And we have another team that partners with us that actually are folks from the industry. So we have MDs, PhDs, ex-CIOs and nurses with their RNs, from industry that work at Microsoft as the healthcare industry team, that partner with us around more of these deep healthcare needs. And when we're talking to chief medical officers or chief nursing officers, who doesn't like their title to be matched. Shelly Avery (00:46:18): So when we have a chief medical officer like Dr. Rhew at Microsoft, or a chief nursing officer, or ex-CIOs of healthcare organizations to come in and talk to current CIOs, they feel like we're talking to them from their shoes. And so my team partners with that industry team. Not that they aren't technical and don't understand how the technology works, but we are supposed to understand healthcare enough and how the technology fits for those healthcare scenarios and use cases that they need help with. Rob Collie (00:46:52): To use a metaphor, if you're going to build re race cars, it helps to hire some people who drive race cars. Shelly Avery (00:47:00): Exactly. Rob Collie (00:47:00): Right. I've seen this evolution on the Excel team over the years too. There's more and more people on the Excel team who came up not originally as software engineers, but as people in finance and things like that. Whereas I was a computer science major that had to learn Excel in order to work on the Excel team. And so it was, if you populate a team with nothing but me, back then anyway, you end up with a team of mechanics who has no idea what it's like to go into turn three cars ride. I'm using a racing metaphor. I don't even watch racing. I find it incredibly dull, but I love a good metaphor though. Shelly Avery (00:47:40): Sure. Absolutely. I think Microsoft has done that and is continuing to expand that industry team, even our president of health and life sciences comes from the industry. A lot of our leaders from even a marketing perspective or from a product development perspective, they're starting to hire from the industry. Rob Collie (00:48:03): That's wisdom. That's humility. I think 20 years ago, we would've probably seen Microsoft put some up and coming computer science guard in that role. And you still need those people for sure. Someone who grew writing C++ isn't going to know everything that they need to know. It's again, there's this whole notion of collaboration. The thing we keep coming back to. It takes a lifetime to amass the expertise to be truly good at something. Rob Collie (00:48:29): And so, guess what, you're never going to find everything that you need in one person. You're going to need people with different histories in order to be successful. And so it's simple. And yet I don't take it for granted, when I see teams being assembled this way, I've learned to respect it, that it is a necessary and good thing. It's always worth praising even if it seems like it's table stakes. A lot of people don't view it as table stakes. Still, they've got some things to learn. Krissy Dyess (00:48:55): So Teams is empowering, it's a central hub, it's a window into all these other applications, the Power BI that brings the insights, the bots, the Power Apps, the drives actions. Tell me a little bit about the Veeva. I hear about Veeva, that whole human side. Tell me how you're seeing Veeva start to make its way to help balance, I think. Rob Collie (00:49:21): And what is Veeva? Krissy Dyess (00:49:21): Yes. Veeva. Shelly Avery (00:49:23): Yeah, sure. Microsoft Veeva is what we have marketed the name of our employee experience platform. If you're a Microsoft E, you've probably seen in the past years something in Outlook called MyAnalytics. MyAnalytics was the very early stages of what is now Microsoft Veeva. MyAnalytics was a analytics engine that had some AI in it that would give you insights about your day, or your week, or your month. It would tell you, "Hey, Shelly, you were meeting with Krissy like every week for a few weeks and you haven't talked to her in a while. Do you think it's about time to reach out?" And then it will even give you a button that says, chat with Krissy now, or schedule a meeting with Krissy now. Krissy Dyess (00:50:18): And I love that. Shelly Avery (00:50:19): Yeah. It would pop open your calendar- Krissy Dyess (00:50:21): Because I would forget. You have all your lists and you have all your things. And honestly, when those things would come across, I was like, "Oh, yeah, you're right." And I was like, wait a minute. The technology is getting on top of all this stuff that I can't keep track of. It's amazing. Shelly Avery (00:50:34): Yeah. That was the beginning of it. Microsoft also came out with another tool called Workplace Analytics, which was the next step of MyAnalytics, where it would anonymize the data and send it to your manager or to your direct report and it would go up the chain all the way. So if my manager had 10 people on it, he would get a daily or weekly report that said, "Hey, your 10 people, this is what they're doing. They're multitasking in their meetings or they're working after hours. Hey, maybe you should encourage them to close the lid of their laptop at night. Let them have better work-life balance." It provides the manager with insights. Right? Krissy Dyess (00:51:17): That's right. Because these are important. This is important to your overall health of your business, your company, your culture. Shelly Avery (00:51:24): Exactly. So Microsoft Veeva took MyAnalytics and turned it into what is now called Veeva Insights. And then there is Manager Insights and Workplace Insights. And so insights is really just a rebranding and a movement from MyAnalytics in Outlook. And it's now insight of Microsoft Teams. Because Teams has that developer side of it, there's so much more that you can do with that information in Teams than it is within Outlook. And so it gives you nudges also to set focus time on your calendar or set learning time on your calendar, and it updates your status, your green, yellow, red, to focusing or away or things like that. And so it uses AI to help you know maybe when you're overworking or who you might need to collaborate with. Recently, Microsoft made a investment with a meditation company, Headspace. Krissy Dyess (00:52:30): Yes. Yes. See, this speaks to me. I love it. Shelly Avery (00:52:33): Yeah. It's built into Microsoft Veeva. What I use it for is there's a feature called your Virtual Commute. We all used to drive in and drive out of the office and you had, and I forgot about it, but you had that me time in the car. We could listen to a podcast or veg out on the radio or something, but it was some me time while you were in the car, going home from work. And we lost that when we all went remote. It's like I literally shut my computer and then I walk in the kitchen and start cooking dinner. It's like, where is that me time? And so I use the Virtual Commute and I don't use it every day. It's about a five to seven minute decompression. It says, are you ready to wrap up your day? Krissy Dyess (00:53:17): I need this. Shelly Avery (00:53:17): Do you have any last minute emails you need to send? Do you need to create any to-dos? And it integrates with Microsoft to-dos, so you can click on things and say, add to my to-do. And then it walks you through a little meditation. Yeah, Rob's got it on right now. Krissy Dyess (00:53:38): This feels amazing. You just took this conversation to a new place and adding in the music. I'm feeling it. This is just taking work to a new level. Rob Collie (00:53:50): Imagine a world of Raw Data. Data with the human element. Krissy Dyess (00:53:58): No, no. Make it come back. Shelly Avery (00:54:00): Yeah. Krissy Dyess (00:54:00): Oh, no. Can we get that? Rob Collie (00:54:06): I couldn't help it. Krissy Dyess (00:54:08): No. This is what people need. Honestly, when I heard about this, and I'm surprised when I say Veeva, people are like, "What's Veeva?" And I loved your explanation because it gave so much more detail and history, people need this. Think about like, it gives tap it into how long you've been sitting and giving you that balance. This is amazing. Wow. I'm even more excited about this. Shelly Avery (00:54:31): Well, and I think- Krissy Dyess (00:54:33): I think I can make it another 50 years in the work environment now, like [inaudible 00:54:37]. Rob Collie (00:54:37): I said, that was the plutonium battery that you needed. Shelly Avery (00:54:41): Well, and it's so cool because just like there's a Teams team, there's a Veeva team and they are just getting started. They're integrating LinkedIn learning into Veeva learning and all these other learning platforms. So you can learn right in the UI of Teams and you don't have to single sign on and then MFA and forget your password to log into all these other learning tools. And it allows you to share it right inside of Team, say, "Hey, team, I just did this great learning. I think it'd be great for you." Shelly Avery (00:55:11): And customers can upload their own learning modules to it. There's Veeva topics, which is this Wikipedia where it's self-curated information. And what is great, like we've talked about acronyms at Microsoft, every acronym has a topic page now at Microsoft. So anytime you type an acronym, it hyperlinks it. So I'm chatting you in Teams and I say FHIR. And it's like, what the heck is FHIR? You hyperlink it and it gives you an explanation of what FHIR is. Krissy Dyess (00:55:43): That's game changer in itself. Rob Collie (00:55:46): So, does it also pick up pop culture, like if I type IKR, I know, right? And someone else doesn't know what that means. Usually I'm on the receiving end of this. Someone used an acronym yesterday in a chat with me that I'm sitting there going like, "Oh, what new hipsters saying is this?" And it turned out, no, no, no, no, no. That's the customer, Rob. Krissy Dyess (00:56:08): Here's something really weird too. I love this Veeva thing. I love Teams and all this productivity and pulling all the pieces together. Gosh, back in the day, when I moved from back east to Phoenix out west and I started working at the company I was with, they actually had a meditation person that would come in every so often and they would have us stand up and do exercises. And then even to just like little chair massages and it all- Rob Collie (00:56:41): Please continue. Krissy Dyess (00:56:42): Right. Oh, this is just as amazing. I don't even know what track you got, what meditation track, but I just need this in my day. And so many other people do. Rob Collie (00:56:55): Do you see that? I feel compelled to not even hold the phone steady. I have to move it in a circle, a very gentle circle as I play it into the microphone. I didn't even know I was doing that. Shelly Avery (00:57:06): It makes you want to sway. Rob Collie (00:57:11): Yeah. In the middle of the meditation music, you heard my reminder for my next meeting go off. Oh, it really spoiled the mood. Krissy Dyess (00:57:21): And you haven't reviewed that 50 page slide deck. And then- Rob Collie (00:57:25): That's right. Krissy Dyess (00:57:26): Here it goes. Reality comes right back in. You're like, "Oh, okay. Veeva, Veeva, help me." Shelly Avery (00:57:32): I Mean, not to pitch, I'm not selling Veeva anymore. I'm a user of it, but those are also things it does. It gives you alert in the beginning of the day that says, "Hey, Shelly, here's what your day looks like. You got these six meetings. Here's a PowerPoint that you were working on, that might go with this meeting. Do you need to review it?" The Outlook team has also built in, I don't know if you guys have seen this. In Outlook now, you can create 25 minute meetings, 45 minute meetings or 55 minute meetings that either start five minutes late or in five minutes early to give that bio break meeting buffer between meetings. Krissy Dyess (00:58:14): That's right. Shelly Avery (00:58:14): Because when you're fully remote, all I do is sit around and I click the join button all day. I need to go refresh my drink, I need to stand up, I need to stretch. And so, again, we talked about culture at Microsoft earlier, and Satya has been on multiple news outlets talking about how we were the customer zero for Veeva and for this workplace balance. And it's so incredibly crazy to me how much people care about people. It's what we need to do as a human race. We just need to care about people more and allowing technology to play a part in that. It's so cool that we have that. Hopefully organizations take advantage of it for their employees. So more people can have ... It's just the little things- Krissy Dyess (00:59:06): It is the little things. Shelly Avery (00:59:06): You mentioned, Krissy, earlier, it's the little things, like five minute less meetings. It's a sign of respect. Let me use the restroom. Don't be mad at me if I'm not on at the top of the hour. I need two minutes to jump from my last meeting to switch my train of thought to get into the next one. And I think that it's super cool that I get to be a part of a company that's offering that to others. And I hope the rest of the world sees it and gets to take advantage of it. Krissy Dyess (00:59:35): This week, just recently, because I am seeing the five minute grace period, the meetings start five after, but I just, this week, because now people are starting to creep in at 10 after. So it's like everybody expects that five minute because exactly like you said, you're on back-to-back meetings, you don't get a break, but now that five minutes, now it's okay if you're 10 minutes after. Then it's going to be 15. Right? Rob Collie (00:59:59): Yeah. It's like back when I used to teach classes, I would tell people we're going to take a five minute break and we'll resume in 10. Right? Shelly Avery (01:00:08): Yeah. Krissy Dyess (01:00:09): That's right. Rob Collie (01:00:10): But if I tell you it's a 10 minute break, it becomes a 15 minute break. You can't have that. So just say, "Five minute break, but I'll see you in 10 minutes." Krissy Dyess (01:00:17): When I was training, there was no break. So all my students out there- Rob Collie (01:00:20): You just powered through? Krissy Dyess (01:00:22): Because there was so much cool things that I ... I was like, "No breaks. Let's keep going." And they're looking at me. Rob Collie (01:00:28): In the morning, everybody please come in, sit down at a seat that has a book in front of it. And in the bag next to it, is your astronaut diapers for the day. Krissy Dyess (01:00:38): Don't drink water or you might have to go. Rob Collie (01:00:41): Yeah, yeah. We have capitas. Krissy Dyess (01:00:43): I was a different person back then. Now I'm embracing the Veeva and the breaks. I feel sorry for all my students, but that's what I did, because there was so much cool stuff. No breaks. Rob Collie (01:00:52): While we're on this topic, just briefly, this Veeva thing, it seems like one of those technologies that it's not the only thing like it, for sure. But it can be used for good, but it could also be used in a very dark way, if we're not careful. When we were talking to Jen [Stirrup 01:01:08] on a recent podcast, even dashboards reports and things can be used as a form of workplace surveillance. I do see all of the glass half full potential here. Are there any concerns about customers saying, "Yeah, yeah, yeah, we'll use this for the positive, the meditation and the humane," but then they just turn around and roll it out as like the Amazon horror stories of the driver's not allowed to take bathroom breaks. And this is a means of enforcing that. Shelly Avery (01:01:36): Yeah. I think there is fear of that. I mean, I know a ton of people they put duct tape over their cameras and they don't want windows hello because they think the world's spying on them. There are just people that have that fear. Rob Collie (01:01:49): I don't know any of those. Shelly Avery (01:01:51): Yeah. But I think Microsoft is trying to protect customers a little bit in this area, that you are the only one that can see your data. Everything else is anonymous. Now, if you're a team of one and you report to your manager, obviously the manager is going to know it's you or a team of two, there are those things. But as you go up from a manager one to an M two, to a director, to a VP, and then all the way up to HR, unless you're a very, very small company, the data is segregated into demographics, and geographies, and departments, and roles, and skills, and tenure. And they slice and dice that data to learn insights as to how one population is performing or working over another population. Shelly Avery (01:02:42): I think it was one engineering group at Microsoft that was really, really being overworked. Not that they weren't all being overworked. I'm sure everybody is overworked in every position at every company everywhere. But there was this one in particular organization at Microsoft, I think they were putting in like 18 hour days. It was ridiculous. And the feedback they got from these individuals was, "We have to work after hours because we are in meetings all day." And they were individual contributor. They were coders. They needed that three to four hours to get that line of code written or tested or whatever. Shelly Avery (01:03:17): They made a meeting free Wednesdays. They literally wouldn't allow people to have meetings. Now you could collaborate with people and set your own, but no internal or manager type meetings those days. And the productivity of that group after three or four months, just completely changed. And so using the data, that's what the data is meant to be there for. Now, there are people in the world that are just going to make Ponzi schemes. They're just evil people. Data can be used, I'm sure in malicious ways. I think Microsoft is trying their best to make it so they can't be super micromanagement at least down to the individual level. Rob Collie (01:04:02): It's a certainly a very, very challenging frontier for a technology company, right? We're going there as an industry. It's inevitable. It's happening. There's no point in trying to say, "Oh, no, let's put up the firewall here." We're seeing this thing. This goes back to my original, something I said a long time ago in this discussion about how certain things don't go through a computer very well. I think this is one of those examples. We're seeing it with Facebook and YouTube. Technology companies, they're in the position now, these companies, of being the arbiters of truth and there's no algorithm. Rob Collie (01:04:36): There's actually a really great YouTube video, or this one guy in the UK talks about, there is no algorithm for truth, but we've created these platforms that are the primary disseminators of information in the world and they're completely and forever ill equipped to be arbiter of truth. Wow, look at the world that we're in. So, I don't think this particular topic is on that scale. It doesn't have that same reach. I don't think as the other things, but I think it's a cousin of those problems in some ways. It's a more solvable problem, I think, than the Facebook and YouTube problem that we're seeing. But this is where the real stuff is. Is like, how do we deploy these things in a way that is a net benefit to humanity? And not just as a net benefit to shareholders. Shelly Avery (01:05:27): Exactly. Rob Collie (01:05:28): That's attention, especially I think in the United States. It's a very different dynamic like in Europe, for instance. I can imagine the adoption profile of something like Veeva in Europe will be very different than in the USA. Shelly Avery (01:05:40): Well, it will have to meet European standards. European has GDPR around privacy laws. And so there might be different settings or features that can or can't be enabled in a product like Veeva in UK or in Europe to comply with those. Rob Collie (01:05:58): A lot of consumer products in the United States, they have to meet California standards. Shelly Avery (01:06:03): Exactly. Rob Collie (01:06:04): And then because of that, the whole country is California in terms of its standards, because you're manufacturing product. Software's a little different, it can be tuned differently in different places. Shelly, I have really enjoyed this conversation and thank you so much for making the time. You also get a gif of yourself. Why don't have to be mentioned that. Krissy Dyess (01:06:19): A G-I-F not G-I-F-T. Gif. Rob Collie (01:06:22): Right. Not a gift, but it is a gift- Krissy Dyess (01:06:24): It's a gift or a gif. Rob Collie (01:06:29): Or a gif. Yeah. Shelly Avery (01:06:29): Yay. Fun. Rob Collie (01:06:29): Yeah. Krissy Dyess (01:06:29): And you could frame it. Rob Collie (01:06:29): It needs to be a movable frame. We could sell it as a

(8-26-21) Penrod had a crazy dream and Paul was in it. He actually woke up and narrated into his phone what happened in it. Maybe he shouldn't eat ice cream before bed. Did you know Samsung can brick your tv! We play band or not a band. Test yourself to see how well you do. Do you track your children on their phones? Do they track you? We have another edition of Penrod's Book Club and the Taliban wants to help fight climate change. IKR!

Et fotografi af Lone Hørslevs oldemor som ulykkelig brud, fik forfatteren til at dykke ned i familiens historie. Og dét er blevet til en levende og vellykket bog, der hedder Halvt i himlen, som netop er udkommet. Flere forfattere har skrevet bøger med afsæt i egen familie. Og der er blandt danskerne en stigende interesse for at få skrevet sin slægtshistorie, fortæller Forlaget Fortæl. I Kræs får du også dagens vigtigste kulturnyheder: Bob Dylan er blevet sagsøgt for seksuelt misbrug af en mindreårig pige. YouTube vil forbyde terror Taliban-kanaler. Heteroseksuelle og hvide er blevet nægtet adgang til stor Pride-fest. Og så får du et par litterære bud på bøger, du kan læse for at forstå den nuværende situation i Afghanistan. See omnystudio.com/listener for privacy information.

Et fotografi af Lone Hørslevs oldemor som ulykkelig brud, fik forfatteren til at dykke ned i familiens historie. Og dét er blevet til en levende og vellykket bog, der hedder Halvt i himlen, som netop er udkommet. Flere forfattere har skrevet bøger med afsæt i egen familie. Og der er blandt danskerne en stigende interesse for at få skrevet sin slægtshistorie, fortæller Forlaget Fortæl. I Kræs får du også dagens vigtigste kulturnyheder: Bob Dylan er blevet sagsøgt for seksuelt misbrug af en mindreårig pige. YouTube vil forbyde terror Taliban-kanaler. Heteroseksuelle og hvide er blevet nægtet adgang til stor Pride-fest. Og så får du et par litterære bud på bøger, du kan læse for at forstå den nuværende situation i Afghanistan.

I Kræs jagter vi nemlig for tiden de næste store stjerner i kulturen, og i dag møder du Asger Nordtorp Petersen. Bedre kendt som Guldimund skriver han poetiske og hudløst ærlige sange fra parforholdets mørkeste kroge og er blevet kaldt et eksempel på ”den nye følsomme mand”! Senere i programmet snakker vi om Ny Carlsbergfondets største udsmykningsprojekt gennem sine snart 120 år lange historie. Vi hører også om frustrerede festivaler, et nyt, dansk kæmpetalent, der skaber overskrifter i Tour de France og nyt fra den spektakulære retssag om popikonet Britney Spears kamp for at få fjernet sin far som værge. Vært: Astrid Date

I Kræs jagter vi nemlig for tiden de næste store stjerner i kulturen. I dag møder du Sofie Jo Kaufmanas, skuespiller og komiker, der mener, at vi alle sammen burde grine meget mere af os selv. Hun er bl.a. aktuel i DR2's satireshow "Hvorfor snakker vi ikke om mig?", og kan også ses i TV2's underholdningsshow Stormester til efteråret. Senere i programmet bliver vi klogere på statuer: Hvad betyder statuer for byrummet, og hvordan de sætter gang i masser af debat. Vi skal også høre om et videospil til millioner af kroner, en ny diversitetspolitik i musikbranchen og en tegneseriekanin, der til manges fortrydelse er blevet gjort mindre sexet. Vært: Astrid Date

I dag møder du Anna Juul, der nok er bedre kendt som den fiktive karakter Veronika Katinka. En karakter som opstod i Den Korte Radioavis på Radio24/7 – og som hun både har udgivet en bog på vegne af og lave tv-serien "Min Kamp" på DR3 om en kvinde med skizofreni, som hun også selv lider af. Vi ser på hvad der har formet dem som kunstnere – og på hvordan de kommer til at forme os som samfund. I Kræs jagter vi nemlig for tiden de næste store stjerne i kulturen for at få en forsmag på, hvem den næste Thomas Helmig eller Mads Mikkelsen er. Derfor kan du i vores sommerserie om unge talenter møde 10 lovende kunstnere, som vi kan komme til at se - og høre - meget mere til i fremtiden. Vært: Astrid Date

I Kræs jagter vi for tiden de næste store stjerne i kulturen. Derfor møder du i vores sommerserie om unge talenter 10 lovende kunstnere, som vi kan komme til at se og høre meget mere til i fremtiden. I dag er det med 33-årige Niels Erling, der er sceneinstruktør, forfatter og modtager af teaterprisen Reumert Talentpris. Og så skal Danmark møde England i semifinalen ved EM i aften, og vi snakker med en ekspert om den særlige nationalfølelse, som det vækker i os.

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IKR? I think we have all said this at one time or another. Get the Caffeinated humor books! The books that made the podcast! Time for Coffee! Coffee.org has all of your caffeinated needs!Buzzsprout - Let's get your podcast launched! Start for FREEDisclaimer: This post contains affiliate links. If you make a purchase, I may receive a commission at no extra cost to you.Support the show (https://www.buymeacoffee.com/venozofe)

Skuespiller Nicholas Cage har lavet en dokumentar om bandeordenes historie ”History of Swear Words”. I Kræs viser forfatter og sognepræst, hvad vi sprogligt kan lære af at kende ordenes betydning – og han understreger, hvorfor konfirmander skal lære at bande. Historien gentager sig – vi har altid festet på trods, fortæller forsker og historiker, når vi sætter corona-fester i et kulturhistorisk perspektiv. Du får også Ugen På Vers og kan høre hvem musiker Caroline Henderson har samlet for at hylde den sorte, kvindelige musikhistorie.

This week's episode features author Peter Schwartz and Associate Editor Sami Viskin as they discuss the article "Exercise Training-Induced Repolarization Abnormalities Masquerading as Congenital Long QT Syndrome." TRANSCRIPT BELOW: Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and it's editors. We're your co-hosts, I'm Dr Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, associate editor, director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Well, Carolyn, this week's feature, we're going to learn a little bit more about long QT syndrome and whether or not those that are athletes should continue exercise training. Maybe some can and before, we thought that they couldn't. But before we get to that, how about we take a look at some of the other papers in this issue. Dr. Carolyn Lam: Wow, that was a good hook, Greg. But yes, I want to tell you about this first paper, which is all about weight loss and changes in body composition. So, we know that intentional weight loss is associated with a lower risk of heart failure and atherosclerotic cardiovascular disease, especially among patients with type 2 diabetes. However, what is the contribution of baseline measures and longitudinal changes in fat mass versus lean mass and waist circumference to that risk of heart failure and myocardial infarction in patients with diabetes? Dr. Carolyn Lam: Well, investigators led by Dr. Pandey from UT Southwestern and colleagues evaluated more than 5,000 adults from the Look AHEAD Trial without prevalent heart failure. Fat mass and lean mass were predicted using validated equations and compared with DEXA measurements in a subgroup. Adjusted Cox models were then used to evaluate associations of baseline and longitudinal changes in fat mass, lean mass, and waist conference over one and four years follow up with the risk of overall heart failure, HFpEF, and HFrEF and myocardial infarction. Dr. Greg Hundley: Interesting, Carolyn. So, what did they find? Dr. Carolyn Lam: So, among patients with type 2 diabetes and who were overweight or obese, fat mass and lean mass could be estimated using anthropometric equations with good overall agreement compared with DEXA, so that's the first finding. Next, a decline in fat mass and waist conference, but not lean mass, were each significantly associated with a lower risk of heart failure, but not myocardial infarction. Dr. Carolyn Lam: Furthermore, a decline in waist circumference was significantly associated with a lower risk of HFpEF, but not HFrEF. Fatness and waist circumference may represent key modifiable targets for lifestyle interventions to reduce the risk of heart failure with preserved ejection fraction in type 2 diabetes. Cool, huh? Dr. Greg Hundley: Yeah. Very nice, Carolyn. Well, my first paper comes from Professor Davide Capodanno, and it's examining self-expanding bioprostheses for TAVR. So, Carolyn, there are few randomized trials comparing these bioprostheses for transcatheter aortic valve replacement or TAVR, and no trials have compared TAVR bioprostheses with the supra-annular design. So, this SCOPE 2 trial was designed to compare the clinical outcomes of the ACCURATE neo and the CoreValve Evolut valves. Dr. Greg Hundley: Now, it's a randomized trial performed at 23 centers in six countries between April 2017 and April 2019. And patients greater than 75 years with an indication for transfemoral TAVR as agreed by the heart team were randomly assigned to receive treatment with either the ACCURATE neo, so there are 398 of those patients, or the CoreValve Evolut bioprostheses, also 398 patients. The primary endpoint powered for non-inferiority of the ACCURATE neo valve was all-cause death or stroke at one year. The key secondary endpoint powered for superiority of the ACCURATE neo valve was new permanent pacemaker implantation at 30 days. Dr. Carolyn Lam: Okay. So, what were their results? Dr. Greg Hundley: Well, Carolyn, the transfemoral TAVR with the self-expanding ACCURATE neo did not meet non-inferiority compared to the self-expanding CoreValve Evolut in terms of all-cause death or stroke at one year. And was associated with a lower incidence of new permanent pacemaker implantation. In secondary analyses, the ACCURATE neo was associated with more moderate or severe aortic regurgitation at 30 days and cardiac death at 30 days and one year. Cardiac death at 30 days was 2.8% versus only 0.8% with the CoreValve Evolut. And moderate or severe aortic regurgitation at 30 days was 10% versus only 3% and they were significantly increased again in that ACCURATE neo group. Dr. Carolyn Lam: Wow. Okay. Thanks for that, Greg. Well, my next paper is from the basic science world. Dr. Colucci from Boston University Medical Center and colleagues tested the hypothesis that sarco/endoplasmic reticulum, calcium ATPase or SERCA, which is a major regulator of calcium homeostasis in the heart, whether or not it plays a critical role in mediating mitochondrial calcium and mitochondria-dependent apoptosis in response to reactive oxygen species. Dr. Carolyn Lam: So, in adult rat ventricular myocytes expressing an oxidation-resistant mutant of SERCA in which the cysteine-674 was replaced by serine. Mitochondrial calcium and the rise in mitochondrial calcium to exposure to an oxidant were decreased as was apoptotic myocyte death by mitochondrial pathways. Mice with the same SERCA mutation were protected from adverse cardiac remodeling, apoptosis, and progression to heart failure following chronic aortic constriction. Dr. Greg Hundley: Mm-hmm (affirmative) Carolyn, so this is another one where I get to ask you, what were the take home messages and what were the clinical implications? Dr. Carolyn Lam: I thought you'd ask that, Greg. So, these findings indicate that by contributing to sarcoplasmic reticulum calcium load, the chronic oxidative activation of SERCA may play a critical role in promoting the adverse effects of hemodynamic overload leading to pathologic remodeling. These findings illustrate the importance of post-translational modifications of SERCA and raise the possibility that the expression of a redox-insensitive form of SERCA may be of value in the treatment of heart failure. Dr. Greg Hundley: Very nice, Carolyn. Well, my next paper also comes from the world of basic science and looks into the mediators of atrial fibrillation. So, as some background, Carolyn, ibrutinib is a Bruton's tyrosine kinase inhibitor with remarkable efficacy against B-cell cancers. But it also increases the risk of atrial fibrillation, which remains poorly understood. Dr. Greg Hundley: So, the investigators performed electrophysiologic studies on mice treated with ibrutinib to assess the inducibility of atrial fibrillation. In human subjects, again, one of the strengths of some of these basic science papers in Circulation, the pharmacovigilance database or VigiBase, was queried to determine whether drug inhibition of an identified candidate kinase was associated with increased reporting of atrial fibrillation. Dr. Carolyn Lam: Oh, that's really interesting, Greg. So, it seems like these authors were working toward understanding the mechanism of atrial fibrillation in those receiving ibrutinib. So, what did they find? Dr. Greg Hundley: Right, Carolyn. So, the authors found that using chemoproteomic profiling they were able to identify a short list of candidate kinases that was narrowed by additional experimentation, leaving C-terminal Src kinase or CSK, as the strongest candidate for ibrutinib-induced atrial fibrillation. Cardiac-specific CSK knockouts in mice led to increased AFib, left atrial enlargement, fibrosis, and inflammation, phenocopying ibrutinib treatment. Disproportionality analyses in VigiBase confirmed increased reporting of AFib associated with kinase inhibitors blocking CSK versus non-CSK inhibitors with reporting odds ratio of eight. So, Carolyn, perhaps CSK inhibition is the mechanism by which ibrutinib leads to atrial fibrillation. Dr. Carolyn Lam: Wow. That is convincing. Well, there are other really nice papers in today's issue. First, there's a research letter by Dr. Iglesias on the effects of fentanyl versus morphine on ticagrelor-induced platelet inhibition in patients with STEMI, the PERSEUS randomized trial. There's also a research letter by Dr. Young entitled the characteristics and outcome of COAPT eligible patients in the MITRA-FR trial. Another research letter by Dr. Zhang on specific modified mRNA translation system. Dr. Greg Hundley: Very nice, Carolyn. Well, I've got an exchange of letters by Dr. Spal, Whitlock, and Kebabs regarding the article, Impact of Left Atrial Appendage Exclusion on Short-Term Outcomes in Isolated Coronary Artery Bypass Graft Surgery. And then our own Mark Link discusses changes for practicing physicians regarding the new AFib guidelines. Dr. Greg Hundley: And finally, Dr. Vera Bittner has a perspective piece on the new 2019 ACC/AHA Guidelines on the primary prevention of cardiovascular disease. So, this new primary prevention guideline two fills a critical gap by pulling together and updating, as appropriate, guidance on nine topic areas of risk assessment, diet, exercise and physical activity, obesity, type 2 diabetes mellitus, blood cholesterol, hypertension, smoking cessation, and aspirin use. Dr. Carolyn Lam: Nice. Well, Greg, guess what? That brings us to the last issue in 2020. Can you believe it, Greg? It's been just so great working with you. It's been such a privilege working with Circulation. And, drum roll, new for 2021, Circulation on the Run is returning with a new format. Watch out for it. Let me give you a hint, it's going to come with a double feature per issue. Isn't that great, Greg? Dr. Greg Hundley: Absolutely. Some of the things that you hear folks really enjoy those opportunities we have with authors to review their papers. Well now, with many of the issues next year, we'll have two feature discussions. Dr. Carolyn Lam: Exactly. So, you've been listening to Circulation on the Run, but we've been listening to you, too. So, join us again in 2021 for our new features and new format. Thanks. Dr. Greg Hundley: And yes, Carolyn, but first, we've got to go and listen to this issue's feature discussion and talk about that long QT syndrome, exercise training-induced repolarization abnormalities. They can masquerade, perhaps, as long QT syndrome. Dr. Carolyn Lam: Cool. Dr. Greg Hundley: Welcome, listeners, to our feature discussion today. And we're very fortunate, we have Prof. Peter Schwartz from Istituto Auxologico Italiano in Milan and our own associate editor, Dr. Sami Viskin from Tel Aviv Medical Center. And we're going to be reviewing exercise training induced repolarization abnormalities, masquerading as congenital long QT syndrome. Well, first Peter, we'd like to start with you. And could you tell us, or provide us with some of the background information of why you wanted to perform this study and what hypothesis did you want to address? Prof. Peter Schwartz: The background is a very simple and I've been involved in the long QT syndrome since exactly 50 years. And as a partial result of that, I developed the idea that usually I... despite my making many errors in many areas, usually I don't miss the diagnosis of long QT syndrome. As a matter of fact, the study that you're publishing now is the result of a complete serendipity. It was not planned. We had to no hypothesis. It simply started because at one point I entered the impression that we might've made a diagnostic error and this bothered me very much. Prof. Peter Schwartz: It all started about eight, 10 years ago. When in some cases of our patients in whom we had made a clear diagnosis of long QT syndrome. At their yearly controls, we found that the LQT had been completely normalized. So I was pretty upset about it because I couldn't understand it. And my first reaction a natural reaction was to blame my associates, "We have made a mistake. You've did an error. There was an error in measurement." But as a matter of fact, there were no errors. Prof. Peter Schwartz: So I start thinking, "What the hell is going on here?" Now we are in a fortunate position because due to my long standing activity in the long QT syndrome, we are a referral center for all cases or most cases in Italy where people are suspected have the long QT syndrome. In Italy by law, anyone who wants to practice any type of sport at an amateur level or pro-competitive level, needs to have an eligibility certificate. So they have to go to sport doctors and it eases when the problems arise because not infrequently these doctors with somewhat limited experience in diagnosing prolongation and abnormalities in the QT intervals, are worried to make a mistake because a mistake can be a fatal one if the subject allow them to practice pause or die suddenly on to field. So they tend to refer them to us. Prof. Peter Schwartz: And so the advantage in my position was that we had a large number of these kids or young people coming to us. When I started to realize that it was not one accident, but another accident, another situation where these young people who clearly had to stop training in an intensive way, because they will no longer allowed by the sport doctors to practice sport. And the normalization of the T-wave abnormalities of the QT interval. I said, "Well, I mean, there must be something here." Prof. Peter Schwartz: So we start collecting the data, increasing the numbers, and I think it should be evident there was no design. I mean, it was a clinical observation that was evolving with time, but with adequate numbers. And then of course at one point we start following it more carefully, everything. And these led to the actual numbers that, in my opinion, were sufficiently strong to junior agents in need to publish it and to give a message because essentially this situation in one in which is very possible that even good and experienced doctors make a mistake. And the mistake could be a very bad thing, because if you miss the long QT syndrome and there is, of course, the patient is at risk of dying. But if you leave it, someone is affected and he is not affected, you are affecting his or her quality of life because they cannot practice sport, you generate anxiety. So a proper diagnosis is important. This was the basis of our study. Dr. Greg Hundley: Very good. So, it sounds like you're going to be performing a cohort study. Can you describe for us a little more specifically, how many subjects did you include? And who did you include in this cohort? And what measurements did you address? Prof. Peter Schwartz: So essentially we looked at the consecutive cases, sent to us by sport doctors with a suspicion of long QT syndrome. They were, if I remember, correctly 310 such individuals about 100 were found not to have the long QT syndrome. And these doctors were concerned they made the wrong measurement and measurement error. All the things that happened that are very well-known. About the remaining 200 in, I think about 120, we had a genetic confirmation of the long QT syndrome. We found disease causing mutation. So, that was pretty clear. Prof. Peter Schwartz: Then we had a group of individuals who are genotype-negative. We know very well. I mean, I proposed this thing in 1979, 1980, confirmed it in 1999, that there are some individuals affected by the long QT syndrome. But whoever I did a normal QT interval and that's a possibility, who are genotype-negative. Prof. Peter Schwartz: So, it's not surprising that in some cases we have genotype-negative individuals, but with a pattern so clear in terms of long QT syndrome that will make it to diagnosis. Within this group of genotype negative, there was another, let's call it a subgroup. I think it was about 15, 18% of the entire group who were genotype-negative, no family, sorry, neither had an event, a typical, absolutely typical electrocardiographic pattern with a fairly long QT interval QTc in the range of 490. So clearly prolonged significant repolarization abnormalities. Prof. Peter Schwartz: But when they were stopped in terms of exercise within three, four or five months, their pattern normalized completely, the QTc went back to normal, repolarization abnormalities disappeared. So this is the group on which we did focus and focusing for the next studies. And in some of them, when we told them, "You don't have the long QT syndrome, is a reaction that we interpret is due to the mechanical stretch of your heart because of very intense exercise training." Prof. Peter Schwartz: Some of them did return to practice sport in a very intensive way and all these patterns reappeared again, proving, I think this was the most important point. I mean, shows that you can go back and forth if you stretch the heart in this way, the abnormalities reappear. Prof. Peter Schwartz: So this is the essence of the study that carries in my opinion, a number of practical implications, because I think that now, when we are dealing with these youngsters, where we would be making a complete diagnosis. In some cases, I actually started even beta blockers, which is... I mean, afterwards it turns out to be an error and it bothers me, because I don't like to make an error with these patients. But they were so clear. I mean, I could have bet anything that they are affected by the long QT syndrome. But within four or five, six months, they were completely back to normal. Prof. Peter Schwartz: So the essence of the studies that we think the youngsters who practice intensely sport, some of them react to these physiological similar situation in an abnormal way. In analogies like with the food allergy. I mean, if you take something that bothers you and the point is, then you just avoid it. With exercise, of course is more difficult for other reasons, but probably it's the quantity of exercise. Prof. Peter Schwartz: Now, one change I've observed in recent years is that for youngsters practicing sports, a lot of things have changed. I've done a lot in sports myself soccer, tennis before moving toward golf. But in our days we were just playing, yes, we were playing a lot. But what has changed now is that all these kids have a trainer. They are sent for regular exercise two hours a day, five days a week. And that is probably too much for some of them. Prof. Peter Schwartz: So we need to recognize that there are certain individuals who, for whatever reason, I suppose that there is a genetic predisposition tend to react to these excessive amount of exercise training with abnormalities in their electrocardiogram. And for them, probably the logical thing is to reduce the amount of exercise. I would not stop it completely, they should reduce the dose and then have probably a normal life. Prof. Peter Schwartz: This is also raises the analogy with drug-induced long QT syndrome. When you have a parent in normal individuals who take any drug that contains an IKr blocker and they could develop to a certain point and the long QT syndrome. Now the situation with exercise is probably not so severe. I don't think the risk is so high, but clearly it is people have a tendency to react to  possibly a variety of stimuli with QT prolongation. so they should be more careful about it. Dr. Greg Hundley: You know, I'll tell you, I think the world thanks you for your just observational skills and working through that whole situation that you observed in a very precise, organized fashion to bring us this interesting result. Well, Sami, can you help... Obviously this caught your eye as an associate editor at Circulation. What else attracted you to this study? And how would you like to comment on what Dr. Schwartz has just provided to us? Dr. Sami Viskin: Well, in Circulation, we were immediately attracted to this study, especially coming from Peter. Peter has been a pioneer in the entire area for long QT for many, many years. We call him Mr. QT because of his contributions to the field. So we're immediately interested in the paper, which is fascinating. It came a few months after we had reviewed a different paper that deals with patients who have the positive-phenotype, for long QT syndrome and have negative-genotype. Dr. Sami Viskin: That was a paper published in the July issue of Circulation with senior author Connie Bezzina. They performed a genome-wide association study to 1,800 patients with long QT, and they compared them with 10,000 healthy individuals. And what they found in these patients who represented 11% of the entire long QT syndrome population was that even though they do not have mutations, they tend to have several genetic variance together. None of them is severe enough to cause the disease but present by itself when they were in their group together in a single individual, then they create the phenotype of long QT syndrome, which is as severe as the phenotype of those who have bona fide mutations.   Dr. Sami Viskin: So, that article was like the background for this one. And in fact, one of the arguments one could do is that the athlete's described by Peter could just have phenotype-positive, genotype-negative long QT, but what Peter would make sure to stress is that they do have electrocardiogram, but not only they do not have symptoms, they have a low pre-test probability of having the disease because they were discovered by screening and also they have a negative family history. So it's a different group of individuals what Peter is describing here. And time will tell. I mean, I'm sure we will be seeing more publications on this, and I will tell you, it's probably that we just looking at a new form of acquired long QT syndrome. Time will tell. Dr. Greg Hundley: Very nice. Just briefly, both gentlemen, maybe in 20 seconds or so, what do you think is the next study that needs to be performed in this new group that's been discovered? Prof. Peter Schwartz: Greg, we have already started the next study. We are going to compare 700 relatively younger athletes who have intensive exercise and who have a completely normal QTc and completely normal T wave to all our subjects that have defined these phases in our study that performing a similar level of exercise show these changes. And then we are collecting their DNA, and we're going to have an whole exome study for the possibility of identifying some genetic markets that might predispose to something like this. Prof. Peter Schwartz: One possibility that I'm interested in is the possibility that the underlying mechanism, maybe something related to the so-called sex activated trainers, which might lead to an increase in intracellular calcium and produces alterations. There are other possibilities, but this is one. And in doing this study, we are also going to begin to look at echocardiography and imaging to see if there are different patterns in terms of mechanics that might contribute to explain. Prof. Peter Schwartz: So the point is that on the one hand we wanted and we did confirm the clinical data. So, we know that we are dealing with a factor and we think that's a fact as practical implications for management. Now, the next questions, which I wish to attack as well is why is it, what is the underlying mechanisms? Dr. Greg Hundley: Very good, Sami. Dr. Sami Viskin: That exactly the direction we were expecting to see if they have a similar polygenic risk score factor as in the study by Bezzina. Dr. Greg Hundley: Very nice, well listeners, this has been a wonderful discussion. And we also want to thank Dr. Peter Schwartz for all of his efforts for many years in this area of long QT syndrome and bringing this new finding to light that there is now an observation that not necessarily are all long QTs. Number one of the 300 subjects, 100 actually didn't have it. And then there are some that are phenotype-positive, but not genotype-positive. And we have more to learn about the variance that swings with the presence of the long QT after strenuous exercise. Well, on behalf of Carolyn and myself, we want to thank Peter, thank Sami Viskin and wish all of you a great week. And we will catch you next week on the Run.   This program is copyright the American Heart Association, 2020.  

The masculinity has been brought to the interview! That's really it. @mannon_taylor comes to the show live and discusses his experiences in the transgender community, and how we both new each other in high school. IKR!!! --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app Support this podcast: https://anchor.fm/vincent-natasha-gay/support

Este programa é um encontro entre convidados e os criadores deste podcast, onde são discutidos temas diversos dentro da área da  Ciência da Informação e todas as suas disciplinas.  Um bate papo provocativo, cheio de reflexões e questionamentos que vai te acompanhar muito além do play.  Alexandra Feitosa Graduada em Biblioteconomia (UFPE);Mestranda no Programa de Pós Graduação em Ciência da Informação (UFPE);Membro do ecossistema de Startups do Porto Digital. Elton Nascimento Graduando em Biblioteconomia (UFPE);Membro do ecossistema de Startups do Porto Digital. » Episódio 24: Novas Perspectivas na Ciência da Informação PARTICIPARAM DESTA EDIÇÃO:  Armando Manuel Barreiros Malheiro da SilvaAlexandra FeitosaElton Nascimento ========  FALE CONOSCO Acesse: www.cimplifica.comE-mail: contato@cimplifica.comFacebook: www.facebook.com/CImplificaTwitter: www.twitter.com/CImplificaInstagram: www.instagram.com/cimplifica/========  CONTRIBUA COM O CIMPLIFICA Quem apoia o CImplifica ajuda a manter o podcast no ar e ainda recebe toda semana um apanhado das notícias mais quentes do jeito que só o CImplifica sabe fazer. Corre lá, quem assina está recomendando para todo mundo e ainda concorre a prêmios.  Acesse através do PicPay ou Catarse========  EQUIPE CImplifica Diretoria – Alexandra Feitosa | Elton NascimentoEquipe Técnica – Equipe CImplifica========  ARTES E DESIGN GRÁFICO Amanda Virginia Torres ========  PLATAFORMAS DE STREAMING iTunes, Spotify, Blubrry, Stitcher, TuneIn, SoundCloud, Google e Deezer. ========  INDICAÇÕES DESTA EDIÇÃO  Para ler: Ikrítika: Estudos Críticos Em Informação e Ciência da Informação Estudos de Epistemologia e Ética ========  Link para o post: https://cimplifica.com/episodio-24 #InformationScience #SegundaGuerra #TecnologiaInformática #BigData #Cibertecário #EloyRodrigues #InformationScienceSchools #MétodoQuadripolar #CITCEM #Literacia #LiteraciaInformacional #MotoresDeBusca #FakeNews #TICs #LiteraciaInfocomunicacional #CapacidadeCríticaDaInformação #CiênciaDeDados #DadosVsInformação #FranciscoPaletta #TOI #CongressoInternacionalEmTecnologiaEOrganizaçãoDaInformação #Transdisciplinaridade #Interdisciplinaridade

AfriForum in Suid-Afrika het die hoop uitgespreek dat die Internasionale Krieketraad sanksies sal toepas teen Krieket Suid-Afrika weens vermeende politieke inmenging. Die organisasie het ‘n verslag aan die IKR voorgelê waarin hulle sê daar was reeds sedert 1998 politieke inmenging deur KSA. Die liggaam is deur omstredenheid geteister wat daartoe gelei het dat ‘n hele nuwe tussentydse raad aangestel is. Ronald Peters van AfriForum sê hulle het prestasieverskille tussen rasse uitgewys, maar ook die gedwonge rassekwotas en die uitwerking van hierdie beleid:

Kræs-vært Rikke Collin elsker et godt gys. I Kræs efterårsspecial dykker hun i tre programmer sammen med et hårrejsende gyserpanel, ned i det, der skræmmer livet af os. Dagens program handler om det filmiske gys. Hvorfor har mennesker lyst til at udsætte sig selv for rædselsvækkende billeder, der kan være er med til at ødelægge vores nattesøvn? Og hvilke gyserfilm skræmmer livet af dagens panel?

Kræs-vært Rikke Collin elsker et godt gys. I Kræs efterårsspecial dykker hun i tre programmer sammen med et hårrejsende gyserpanel, ned i det, der skræmmer livet af os. Dagens program handler om gys i spil . Er det mere eller mindre skræmmende at opleve en historie, man selv er en aktiv del af, end når man læser den eller ser den i en film? Og hvilke spil kan få det til at løbe kold ned ad ryggen på dagens panel?

No, not the show. Let's take a look at Ecclesiastes 4. And yes, the Bible even talks about having friends. Shocking? Ikr. --- Send in a voice message: https://anchor.fm/hearmenow/message

Hey guys, it's Ken! I am so excited to be starting season 2 of the podcast. We were MIA for a while because we had to regroup and re-strategize but we're back and we're better! In this episode, we talk about dealing with comparisons. IKR, the internet makes it seems like everyone is having a good time and getting rich which makes you begin to question your own existence. So I'm here to remind you that your path, your pace and your problems are so different from the next man so please do not get caught in the webs of comparison. Love you and can't wait to go on this journey with you. --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app --- Send in a voice message: https://anchor.fm/vivify365/message

Piosenki religijne | Hymn Królestwa (I) Królestwo zstępuje na ziemięIАа… Аа… Аа… Аа…Królestwo Boże zstąpiło na ziemię(zstąpiło na ziemię)w osobie Boga, w bogactwie i pełni.Jak można tym nie cieszyć się(nie cieszyć się)?Jak więc można stać,jak można nie zatańczyć?Podnieś więc Syjonie sztandarzwycięstwa i uczcij Boga.Zwycięstwa zaśpiewaj pieśń,Jego święte imię głoś na świecie!Ludzie chwalą Go z radością,wywyższają Boże imię wciąż.Oczy ich zwrócone są na Jego dzieła.Królestwo Boże na ziemię zstąpiło już.IIWszelkie stworzenia na ziemi,obmyjcie się, ofiarę Bogu złóżcie.Gwiazdy wróćcie do domów swych na niebie.Na nieboskłonie ukażcie wielkość Boga.Głosy z ziemi podnoszą się,by śpiewać Mu dziś z miłością.Bezgranicznie oddają cześć.Bóg pochyla się i słucha ich!Ludzie chwalą Go z radością,wywyższają Boże imię wciąż.Oczy ich zwrócone są na Jego dzieła.Królestwo Boże na ziemię zstąpiło już.IIIGdy wszystko zostaje ożywione,Bóg w osobie swej zstępuje na ziemię.Kwiaty z radością kwitną, ptaki śpiewają!Wszystko już wokoło cieszy się!Na dźwięk królestwa Bożego,imperium szatana upada,zdeptane, już nie podniesie się,zniszczone wobec hymnu pochwalnego.Ludzie chwalą Go z radością,wywyższają Boże imię wciąż.Oczy ich zwrócone są na Jego dzieła.Królestwo Boże na ziemię zstąpiło już.IVKtóż ośmieli się sprzeciwić i powstać?Gdy Bóg przybywa, wśród ludzi się pojawia,przynosi ruinę i gniew i klęski wszystkie.Teraz świat stał się Jego królestwem.Obłoki się kłębią, falują po niebie,rzeki, jeziora śpiewają Mu.Zwierzęta się budzą i wychodzą z nor.Każdego człowieka budzi Bóg ze snu.Wyczekiwany nadszedł dzień.Wszyscy oddają Bogu cześć,śpiewając Jemu najpiękniejszą pieśń!Ludzie chwalą Go z radością,wywyższają Boże imię wciąż.Oczy ich zwrócone są na Jego dzieła.Królestwo Boże na ziemię.Królestwo Boże na ziemię zstąpiło już.z księgi „Słowo ukazuje się w ciele”Ewangelia o zstąpieniu królestwa: https://pl.kingdomsalvation.orgKościół Boga Wszechmogącego: https://pl.godfootsteps.org Błyskawica ze Wschodu: https://pl.easternlightning.org/Zachęcamy do pobrania aplikacji Kościoła Boga Wszechmogącego.Google Play: https://play.google.com/store/apps/details?id=org.godfootsteps.thechurchofalmightygod&hl=pl App Store: https://apps.apple.com/us/app/the-church-of-almighty-god/id1166298433 CAG Hymns - Nowe pieśni Królestwa App:Google Play: http://bit.ly/31AlJ6vApp Store: https://apple.co/2ITpeMUE-mail: contact.pl@kingdomsalvation.org Infolinie dobrej nowiny: +48-514-118-291

Selvom fødsler er en fuldstændig normal ting i livet - hvornår har du så sidst set en? I Kræs ser jeg nærmere på Dea Trier Mørchs billede af fødslen. En udstilling af hende er netop flyttet ind på Kunstmuseum Brandts i Odense. Du kan også høre fra de gamle hiphoppere Jonny Hefty og Jøden, der er på 20 års jubilæums tourné og Det Kongelige Teaters kreative Corona-beredskab. Medvirkende: Kasper Holten, teaterchef ved Det Kongelige Teater, Louise Cathrine Nørmark, mor til to piger på 16 og 13 år og en dreng på 2 år og stifter af Foreningen Bedre Barsel, Jonny Hefty og Jøden, Rasmus Lang Hedegaard, stifter af Fars Klub, Marie Laurberg, kurator og museumsinspektør på Louisiana Museum of Modern Art og forfatter til bogen "Dea Trier Mørch.

Wissen Sie, was der Kontenrahmen in der #Buchhaltung eines #Unternehmens ist bzw. umfasst? Welchen der zahlreichen Kontenrahmen man verwendet? IKR, #SKR03 oder gar SKR04? Was steht in diesem Kontenrahmen? Je nachdem welchen Kontenrahmen Sie wählen, fällt es Ihnen je nach Unternehmen leichter oder schwerer mit ihm zu buchen.

Ikr?

Please welcome our guests this week, Alli and Latasha of IKR! IKR is a podcast for women by women and is associated with Crossroads Church in Cincinnati. We're so excited to have them with us!

  Moxey and Mei talk about vibrating rods. Oh! Also oranges, eggs, and apples. IKR?   Talk to us! @euphoralytic @meiwonderful @moxeymunchies

Hey Basique Fam, we are still loving weddings, IKR. So we brought on some wedding photographers to help us plan and execute the best photos for that special day. Pompy Portraits is a force d'être in Duval and an very exclusive photography team, who opens up about their processes and the thoughts and ideas you should have for your wedding. Trista from @YourBeautyPro comes on and adds some great planning ideas like a cherry on top. Featured Guest: Pompy Portraits www.PompyPortraits.com @pompyportraitsphotography Music: Torrean Miles @Omega5dawg Beauty: Trista @YourBeautyPro

Hop in as we pop the top off and get scangie with this Katt Shea directed film, that is surprisingly based on a true ordeal (IKR!), with costumes by Ellen Gross.  This is the quintessential DREWCEMBER film.

In this episode of RatC, we will talk more about a little of everything. This time with a real living guest. (IKR, how weird)

Dr Paul Wang:   Welcome to the monthly podcast, On The Beat for Circulation: Arrhythmia and Electrophysiology. I'm Dr Paul Wang, editor-in-chief, with some of the key highlights from this month's issue.                                 In our first paper, Ruairidh Martin and associates used ultra-high-density mapping to access the ventricular tachycardia circuit dependent upon re-entry, with scar regions in 36 tachycardias in 31 patients. The author has found that 11 of the ventricular tachycardia circuits and isthmuses were single-loop, and 25 were double-loop. Three had two entrances, five had two exits, and fifteen had dead-end activation. Isthmuses were defined by barriers which included anatomical obstacles, lines of block, and slow conduction in 27 out of 36 isthmuses. The barrier to conduction in isthmus appeared to be partially functional in 75% of circuits. Isthmus voltage is often higher in ventricular tachycardia than in sinus or paced rhythms. The authors found that conduction velocity in the VT isthmus slowed at the isthmus entrances and exits when compared with mid-isthmus. The mean conduction velocity was 0.08 meters per second in entrance zones, 0.29 meters per second in isthmus regions, p < 0.0001, and 0.11 meters per second in exit regions. P = 0.002.                                 In our next paper Daniel Duprez and associates found that plasma collagen biomarkers, particularly at elevated levels, were associated with excess risk of atrial fibrillation. In a stratified sample of the Multi-Ethnic Study of Atherosclerosis (MESA), initially age 45 to 84 years, the authors examined in 3,071 participants plasma Procollagen Type III N-Terminal Propeptide, also known as P3NP, which reflects collagen synthesis in degradation in Collagen Type I Carboxy-Terminal Telopeptide, also known as ICTP, which reflects collagen degradation at baseline. The authors aimed to determine if the levels of these biomarkers were associated with incident atrial fibrillation in participants initially free of overt cardiovascular disease. Incident atrial fibrillation in ten-year follow-up was based on a hospital ICD code for atrial fibrillation or atrial flutter, in or outpatient Medicare claims, or ECG ten years after baseline. The authors found that baseline levels of these markers were positively related, both p < 0.0001 to incident atrial fibrillation in a model adjusting for age, race, ethnicity, and sex. These findings were attenuated but remain statistically significant after further adjustment for systolic blood pressure, height, body mass index, smoking, and renal function.                                 In our next paper, Ahmet Adiyaman and associates conducted a randomized controlled trial comparing the safety and efficacy of minimally invasive thoracoscopic pulmonary vein isolation with left atrial appendage ligation versus percutaneous catheter ablation pulmonary vein isolation. In 52 patients with symptomatic paroxysmal or early persistent atrial fibrillation, paroxysmal atrial fibrillation was present in 74% of patients. The authors found that percutaneous pulmonary vein isolation with a 56% single procedure arrhythmia-free survival at two years was not inferior to minimally invasive thoracoscopic pulmonary vein isolation with left atrial appendage ligation, which had a 29% arrhythmia freedom, p = 0.059. Procedure-related major adverse events occurred in 21% of patients undergoing minimally invasive thoracoscopic pulmonary vein isolation, compared to none undergoing percutaneous catheter ablation with p = 0.029.                                 In the next paper, Richard Ang and associates examined whether the glucagon-like peptide-1 receptor agonist exendin 4 has an effect on ventricular action potential duration in susceptibility to ventricular arrhythmia in the rat heart in vivo and ex vivo. Ventricular monophasic action potentials recorded in anesthetized rats in vivo in isolated profused rat hearts in sinus rhythm and/or ventricular pacing. In vivo systemic administration of exendin 4 increased heart rate and this effect was abolished by beta adrenoceptor blockade. Despite causing sympathetic activation, exendin 4 increased axon potential duration at 90% repolarization, APD90, during ventricular pacing by 7% and reversed the effect of beta adrenoceptor agonist Dobutamine on APD90. In isolated profused hearts, 3 nanomolar exendin 4 increased APD90 by 14% with no effect on heart rate. Exendin 4 also reduced ventricular arrhythmia inducibility in conditions of beta adrenoceptor stimulation with Isoproterenol. Exendin 4 effects on action potential duration in ventricular arrhythmia susceptibility were prevented in conditions of muscarinic receptor blockade or inhibition of nitric oxide synthase. The authors concluded that glucagon-like peptide-1 receptor activation effectively reverses the effects of beta adrenoceptor stimulation on cardiac ventricular excitability and reduces ventricular arrhythmic potential. The effect of glucagon-like peptide-1 receptor activation on the ventricular myocardium is indirect, mediated by acetylcholine and nitric oxide, and, therefore, might be explained by stimulation of cardiac parasympathetic neurons.                                 In our next paper, Michael Barkagan and associates examined the role of modulating baseline impedance on ablation lesion dimension. Radiofrequency ablation was performed using an irrigated catheter at a fixed power setting of 30 watts 20 seconds and a multi-step impedance load from 100 to 210Ω ex vivo in 20 swine hearts and in vivo in the right atrium and in thigh preparations. Ablation was performed using similar power settings at three baseline impedances: low, 90 to 130Ω; intermediate, 131 to 180Ω; and high, 181 to 224Ω. The relationship between baseline impedance, current, and lesion dimensions were examined. Baseline impedance had a strong negative correlation with current squared for all of these experimental models with R either -0.93 or -0.94. Lesion dimensions at similar power setting were directly related to current squared with R = 0.853 for width and R = 0.814 for depth. In thigh muscle lesion depth was greatest at low impedance, 8.2 millimeters, compared to 6.5 millimeters and intermediate impedance and 4.2 millimeters at high impedance, p < 0.0001. In right atrial lines, low baseline impedance resulted in wider lines, 7.2 millimeters, relative to intermediate 5.8 millimeters and high impedance, 4.7 millimeters, p < 0.0001.                                 In the next study, Virginie Dubes and David Benoist and associates examined the origin of ventricular arrhythmias in animal model of repair of tetralogy of Fallot. They studied six piglets undergoing tetralogy of Fallot repair-like surgery compared to five sham-operated piglets. Twenty-three weeks post-surgery, the authors found that right ventricular dysfunction was present, while left ventricular function was preserved in tetralogy of Fallot pigs. Optical mapping showed longer action potential duration on the tetralogy of Fallot left ventricular epicardial and endocardium. Epicardial conduction velocity was significantly reduced in the longitudinal direction but not the transverse direction in tetralogy of Fallot ventricles compared to sham. Elevated collagen content was found in left ventricular basal and apical sections from the tetralogy of Fallot pigs. The tetralogy of Fallot left ventricles had a lower threshold for arrhythmia induction using incremental pacing protocols.                                 In our next study, Meera Varshneya and associates sought to understand the individual roles of slow and rapid delayed rectifier potassium currents, IKS and IKR, and quantify how effectively each stabilize the actions potential, protecting cells against arrhythmias across multiple species. The authors compared ten mathematical models describing ventricular myocytes from human, rabbit, canine, and guinea pig. They examined variability within heterogeneous cell population, tested the susceptibility of cells to a pro-rhythmic behavior, and studied how IKS and IKR responded to changes in the action potential. They found, one, models of higher baseline IKS exhibited less cell-to-cell variability in action potential duration; two, models with higher baseline IKS were less susceptible to early afterdepolarizations induced by depolarizing perturbations; three, as action potential durations lengthened, IKS increases more profoundly than IKR, thereby providing negative feedback that resists excessive action potential duration prolongation; and four, the increase in IKS that occurs during β-Adrenergic stimulation is critical for protecting cardiac myocytes from early afterdepolarizations under these conditions. The authors concluded that slow, delayed rectifier current is uniformly protected across a variety of cell types, suggesting that IKS enhancement could be potentially anti-arrhythmic.                                 In our final paper, Piotr Podziemski and Stef Zeemering and associates performed a direct one-to-one comparison between phase and activation time mapping in high-density epicardial direct contact mapping files of human atrial fibrillation. The authors examined 38 unipolar electrum files of ten seconds duration recorded in 20 patients with atrial fibrillation using a 16 x 16 electrode array placed on the epicardial surface of the left atrial posterior wall or right atrial free wall. Using sinusoidal recomposition and Hilbert Transform, 138 phase singularities were detected, with 104 out of 138 phase singularities detected within on electro distance, 1.5 millimeters, from a line of conduction block between non-rotating wave fronts determined by activation mapping. Only 18 rotating wave fronts were detected out of 8,219 detected waves based on wave mapping. Fourteen out of these 18 cases were detected as phase singularities in phase mapping. Phase analysis of filter electrograms produced by simulated wave fronts separated by conduction block also identified phase singularities on the line of conduction block. The authors found that phase singularities identified by phase analysis of filter epicardial electrograms colocalized with conduction block lines identified by activation mapping. The authors concluded that detection of phase singularity using phase analysis has a low specificity for identifying rotating wave fronts using activation mapping of human atrial fibrillation.                 That's it for this month. We hope that you'll find the journal to be the go-to place for everyone interested in the field. See you next time.

EP147- Industry News, Amazon, Apple, Recode, Shop.org, and holiday forecasts  It's a news-a-palooza this week including including Amazon, Apple, Recode, Shop.org, and holiday forecasts and more.  Scot and I get together in person in Chicago to discuss all the news an implications. Amazon News Amazon Go opens in Chicago and Jason has a trip report Bloomberg reports Amazon may have plans to open 3000 Amazon-Go stores Amazon Storefronts is a new feature for small businesses to curate collections Amazon has launched a new AI based visual discovery tool, Amazon Scout SnapChat and Amazon have partnered on a new social shopping experience, using visual search Amazon launched 14 new Echo devices Amazon and Good Housekeeping partner on Mall of America Pop-Up Apple News Iphones ship with new commerce features Background NFC Scanning Native QR Scanning Augmented Reality in web-browser via ARKit 2.0 Other News Holiday forecasts are beginning to come in Deloitte: 17-22% ($128b-$134b) (19.5% midpoint) Internet Retailer 15.5% ($120b) Forrester (preliminary) forecast 14-16% Adobe acquires Marketo Farfetch (luxury e-commerce marketplace) has successful IPO Event Recaps Code Commerce in New York.  All the interviews are available on YouTube (thanks to @DelRey) Shop.org in Las Vegas. Interesting new vendors: Seek - Augmented Reality in Mobile Browser hosted solution for retailers/brands. Hero - Connecting online shoppers live with associates in the physical store. Upcoming: Groceryshop October 28-31, Las Vegas Don't forget to like our facebook page, and if you enjoyed this episode please write us a review on itunes. Episode 147 of the Jason & Scot show was recorded on Monday, September 24th, 2018. http://jasonandscot.com Join your hosts Jason "retailgeek" Goldberg, SVP Commerce & Content at SapientRazorfish, and Scot Wingo, Founder and Executive Chairman of Channel Advisor as they discuss the latest news and trends in the world of e-commerce and digital shopper marketing. Transcript Jason: [0:25] Welcome to the Jason and Scott show this is episode 147 being recorded on Monday September 24th 2018 I'm your host Jason retailgeek Goldberg and as usual I'm here with your co-host Scot Wingo. Scot: [0:41] Hey Jason welcome back Jason Scott show listeners for long-time blisters you may detect something different in the audio today. Jason and I are actually physically in the same room together this only happens about, maybe one in 10 episodes maybe one in 20 but I am in Chicago for the B2B show called B2B next that started this evening and then is ramping up tomorrow and I'm giving a talk about, winning the away game for B2B companies and Jason lives in Chicago even though he rarely is here so it was fortunate we were in the same city at the same time. Jason: [1:15] It's super fortunate I'm just finding out now that you didn't exclusively come to Chicago to see me so I'm a little hurt but I am thrilled for your company and companionship none the less. Scot: [1:27] Yeah I can Chicago to see you... And do a quick cake. Jason: [1:31] Yeah I mean I feel like if I knew Scott wing it was coming to Chicago I would throw a trade show just to get you to do it. Scot: [1:37] That's thank you I appreciate it we should do a Jason Scottrade shift I'll be our next one of our 2020 goals. Jason: [1:45] Yeah if you're any of our friends in the trade show industry don't worry Scott's just joking. Scot: [1:49] Will have peanut butter and jelly sandwiches it'll be within the range of 6 Starbucks. Jason: [1:58] I like that last part a lot. Scot: [2:00] Call somebody excited to be here because there's an Amazon go store and I am going to stop by tomorrow morning if it's not raining but I heard you have already been. Jason: [2:10] I have indeed I've been super excited to touch you because I feel like this, week is just busting with exciting e-commerce news that Amazon go store actually opened last week, and I was out of town so some of that Amazon go stores are in locations that are open 7 days a week this particular one, is in a busy downtown area during the week that's kind of dead on the weekend so the store wasn't open over the weekend so today was my first chance. To go shopping and compare and contrast it to the Seattle locations. Scot: [2:47] Brickell what were the the pros the cons the differences the similarities. Jason: [2:52] So I have a feeling most Shoppers would feel that they were very similar to the Seattle one is a reminder just walked out technology you have to use an app. Scot: [3:04] JJ Watt hashtag JJ Watt. Jason: [3:05] #Jay Watts you have to use an app to get in the store you cameras watch you throughout the store you grab all your purchases at this convenience store format, and then you just walk out and Amazon automatically charges your account for your purchase at so that's the original promised the first store in Seattle had a very visible, kitchen until like the majority of items they sold we're actually not National brand food products they were. [3:34] Sandwiches and in meal kits that were made on site on the premise. And they also in that original store later got a liquor license and started selling alcohol, they open the second location in Seattle that did not have a kitchen and I and many others assume they use the one kitchen as sort of a hub-and-spoke and deliver food to, go shuttle locations from that kitchen so I was really curious to see what they do in Chicago when they open their first store and once again there is not a public kitchen so either they have. A private kitchen somewhere else in Chicago and they're delivering the meals in or, and I did seem slightly farfetch but they're delivering the meals from out of town, and restocking on the I was kind of curious if they had the date that they were made on the sandwiches and they they have the date their best consumed by. Which most of the sandwiches that were available when I was in the store where best consumed today so. Scot: [4:36] You could fly them in on that Fleet of Amazon Prime planes. Jason: [4:40] It's always remotely possible and since the store just hoping you can imagine there's a kitchen coming somewhere else that isn't live yet or maybe it already is why there's no there's no I could have been his one way or another store has more. Gondolas in the original store so there's more aisles in the store which since they're watching you with a bunch of cameras in the roof I imagine the aisles are a little harder to do because they potentially block lines of sight. It has two entrances. [5:12] So that adds a little bit of complication you walk through kind of a Subway style turnstile and scan a QR code on your Amazon Go app, to get into the store in the very first or when you were running the app and you grabbed purchases you could kind of see on the app I running, shopping cart you could see what Amazon thought you had it when you put something back you could see it disappear in real time from your cart. In this store and I did two shopping trips you don't get any real time does ability to what you're taking you walk out of the store and frankly the second you walk out it's not clear. If you been charged at all and then a minute later this receipt pops up that says pending and then about 3 or 4 minutes later, you get an itemized receipt that shows you what you charged and I don't know why the difference but I bet the. The scenario here seems a little problematic you could potentially being a cab on your way away from the store and find out you were. You are Miss charge for something. Scot: [6:14] Sounds like human intervention in there this is one reason I can think of you to have a pause like that you know of some kind of Mechanical Turk like check that's going on somewhere. Jason: [6:24] Potentially it the original store, they actually have Windows and you can see a video observation area where a bunch of guys in red shirts are watching video and this was like, even when I was an employee only mode none of that is visible in the store now that doesn't mean it's not there it just means they they didn't choose to build a. A window in that first or is in an Amazon owned building so you imagine, it's cheaper and easier for them to do exterior things where they're just a tenant in a in an office building. In the Chicago store so unclear they have an army of people watching I did two purchases and both were accurate, I bought a web we just walk out technology technology coffee mug for my wife some Amazon go. Scot: [7:15] You're hopeless. Jason: [7:16] I am I am Amazon go chocolate for for Stephen and I got the beam on a sandwich because, we heard that's the number one skew and I thought this would be a super exciting gourmet sandwich and Jeff if you're listening the sandwich wasn't that good I was so disappointed. Scot: [7:34] Too much Mayo not enough a Sprouts what what was off. Jason: [7:37] The bread to be my ratio I thought was way off it was way too much bread for two little feeling. Scot: [7:44] It's interesting that there's been a fair amount of traffic on Twitter around people that have gone to the store and initial reaction is oh I'm not worried about grocery stores I'm worried about 7-Eleven. At is a kind of what you think through this. Jason: [8:00] So I think there's two categories that are potentially at risk one is 7-Eleven or just hit more generically non gasoline convenience store so it turns out, that 80% of convenience stores sell gas and that's a special reason to go there that the Amazon go doesn't have so it is a competitor for those doors, but. Those those kind of sore tennis sell a bunch of prepackaged food in National Brands and there's a little bit of that in this store so there's National brand drinks and there's a few different varieties of chips but the assortment. Bike is probably like more Amazon made stuff it probably feels slightly fresher and more healthy than. Scot: [8:45] It sounds like an old Bon Pain or those are called or a Marks & Spencer in the UK where they're saying yeah kind of. Jason: [8:50] So I was actually going to say like a pretty amazed you or maybe sort of grab-and-go pre-made sandwiches like. Scot: [9:00] Where I'm from we call it pret a Manger you get the fancy French talk. Jason: [9:04] I work for a French company so I've learned like for French words and you just heard 3. The other ones not suitable for our general audience podcast in some ways. It feels like the primary use case for this store is, office workers grabbing lunch and not being gone from their desk that long and so you can imagine that that was the original problem that Jeff was trying to stuff for was getting Amazon employees back to work quicker, and yes I could be the Subway sandwich that this is more a threat to. Scot: [9:39] Yeah one of the writers so internet retailer is here in the city and one of the writers was saying in Chicago it is a huge problem to go out for lunch and his it's a four minute longer walk to the Amazon go store but it took him 2 minutes to get in and out and all the other places he walked by we're at the 30 minute wait so it is you know we've had arguments with some folks on Twitter that talk about, it's not really convenience and then one of the things I think long-term they're going for is there going to be less labor a better one that goes to one says it's got like three times the labor of any other store they've ever been in. How to get Amazon's just Staffing that early days to get people, trained and download the app to help kind of jump start it but I think long-term I think the labor will be very low on these. Jason: [10:27] Yeah I think you're right like the you are out customers are definitely outnumbered by Amazon employees at the moment. That's because there's some new things that customers are having to be taught and so you know we we were talking earlier it's it's someone analogous to an ATM machines first launched and Banks would staff a human to stand next to the ATM and teach you why in the short run that that didn't make sense why why. Put a person next to the machine trying to replace a person but once I want to learn how to use ATM machines they were able to get rid of those trainers in the airline's did something very similar with, electronic boarding passes where they had a lot of help initially so at the moment. They remove the friction of standing in line to pay but they had this new friction of having to download an app before you can even get in the darn store so that a lot of people standing outside the store in the rain, helping you install your your app now luckily Amazon's from Seattle so that people are familiar with standing in the rain, presumably they imagine a future when everyone already have the app install the and or it'll become more familiar and so they won't they won't need all that labor to explain everything to everybody. Scot: [11:42] Brickell and then last week you were at shop.org which unfortunate had to miss due to some hurricane issues but give us a little trip report from shop.org what was interesting there it was in Las Vegas this year your favorite City. Jason: [11:56] Sorry one other thing I forgot to mention on the Amazon go they just want to ride their super quick they did add alcohol to the Seattle store and there's been a lot of talk that's another, friction point because now you have to have another human you know you're supposed to just be able to walk out when you're done but now you have to have a human when you're walking out they can check your ID, and Zoe you know we talked about the pros and cons of that this store does not have alcohol so that that may have been some decision or maybe that it takes longer to get a liquor license. Scot: [12:28] This may seem unrelated but in my city of Raleigh we were a Goldilocks City for a lot of different things because we have just like a million million at people Ivory digital City and all that good stuff we have all of the different kind of Transportation model so we have all the lime bikes the birds and all that stuff I've tried all of them and what's interesting is they all have, if you're over 18 to use this and I'll have a driver license scanning mode where else can the front, Idaho Ciara and they scan the back and they're saving that data as you saying I am over this age I don't think that works for alcohol but, I kind of think there could be some way to do that and you have to work with the local alcohol real people but you know, Amazon really good at kind of saying alright let's take a room of people and put them somewhere in a back alley in Seattle not in front retail space and just like you know we fly all these drones out of remote locations why not have a lot of the stuff pushed to a cheaper location somewhere like maybe the people in the Amazon store they're standing around maybe they're standing somewhere in Seattle for the Chicago store if there's no reason to have to physically be there. Jason: [13:35] Telepresence for doing a d Checkers and in fact you can imagine that use that same teleprinter sentence for delivering alcohol at some point and I D Jackson. All kinds of boys like that I have zero doubt that Amazon can solve the technical problem of doing, inaccurate age verification at your point it will probably take slightly longer and be slightly harder to get the, the Bureau of Alcohol to agree that that's a suitable approach. So you would ask me about shop.org we had surgery on last week and we did talk a little bit about some of the content with sucharita so she gave, a presentation about marketplaces that was super interesting I know that's a topic that you sometimes have a personal interest in. I did some stuff on on the areas where artificial intelligence is actually getting Traction in retail in Commerce and got some decent feedback, but one of the things that jump. Org has added in the last couple years is an innovation section so this is a, less expensive portion of the trade show floor that's cheaper to exhibit that's enticing, newer younger emerging companies and so it's one of my favorite parts of the shofar to walk because I'm generally familiar with most of the, vendors that have been exhibiting shop.org for many years but it's fun to see some new you know sometimes crazy stuff. [15:04] Answer this year two companies kind of jumped out at me there's a company called Shiro. Which is really focusing on the problem of digital. Digital Shoppers getting the equivalent, personal experience of an in-store Shopper and so along the lines of the ID check you just talked about these guys are essentially, creating a telepresence solution so that store staff when they're not helping an employee customer in the store, can I have live chats and create video content for customers that are shopping the website. I'm so it's sort of a way to have a more human interaction with web Choppers that's whatever Jean the in-store labor force and that's, part of the genre of omni-channel that I think is really smart and interesting so I like that. Approach and then there was a company called seek and and I suspect we can talk a little bit more about this in general terms later but, Sikhism, augmented reality company for mobile phones we've talked a lot about how augmented reality is probably much more important than, virtual reality for Commerce in the short run and what seek is really focused on is. [16:28] Apple in OS 12 just launched some new features that now that you do good augmented reality in the web browser no app required and so seek is. One of the first companies with a tool set that retailers can, license on the cloud to have good a our experiences in a mobile web browser without having to get an app downloaded and I think that's really smart and obviously there. Timing their company launched with the the release of this new product last week. Scot: [17:02] Brickell and then last but not least I think you were going to New York to go to recode did you were you able to make it to that to see mr. Del Rey. Jason: [17:10] So sadly so I have a ticket I had a client call me in another Direction at the last minute but I did get an opportunity to watch, a lot of Jason's interviews on YouTube and they're they're uploading all the all the speakers to YouTube so if you're interested you are, they're all available in a couple that stood out to me the founder of Shopify who seems like. He's sort of up to his his public visibility in the last few months that you used to be kind of a rekluse that didn't, do a lot of public presentations he had a good conversation with Jason Delray I had sent Jason all kinds of specific questions I wanted to ask about shopify's size and Market penetration which I notice. Jason didn't get a chance to ask but he did talk a little bit about who's probably the Marquee you know Enterprise customer using Shopify which is Kylie Jenner, interview back into some of his answers you don't think he he was saying that over the last 2 years, Kylie Jenner sold 900 million dollars worth of product on the, maybe two and a half years sold 900 million dollars on Shopify which is in a pretty good scale we normally think of Shopify as a long tail solution for very small Merchants but that's a pretty good size. Scot: [18:39] Yeah I think what makes it work is I think it's not a huge number of skews right I think there's like, two nail polishes and tendus too. So I think she just has like in a quantity of Brazilian of 50 skews which doesn't put a cart through too many of its Paces Paces you don't need a fancy content management system you just need scalability in robustness on the check outside. Jason: [19:00] Yeah I know I totally agree there are some boxes that that checks that shows that they have good elastic availability for these peak days but you're right like there's a lot of things that you would exercise in the catalog with a million skews in it that. [19:14] That particular site isn't isn't demonstrating scale on it at all, I had asked Jason if you could ask who some of the big catalog we can go there but it was interesting cuz he what he talked a lot about hey we started trying to solve for the small business customer, and a lot of companies as they grow try to move up market and he he's claiming the day over we don't want to do that they don't want to abandon. Their core market so they want this new product Shopify plus which is intended to be more upmarket but they explicitly, launch that with a new team and a new office in a new city and sort of partitioned it. From the original offering so it really Leverage is the quote the court code base and add some new capabilities and services but his promise for. [20:10] How he was going to expand their Market rather than a band in the the low end of the market to move up was, The Silo this the Shopify + offering and he talked a lot about how in his mind, front and commerce experiences are actually pretty easy and he's a coder you mentioned a lot of the original Cody Road, is still in the platform and hasn't needed to change for the front end but they're like 90% of the ongoing development effort they're doing are all the post order code in. Complex water management and integration to to Legacy Erp systems and one of the big features they just launched for Shopify plus is the ability to manage multiple Warehouse locations for exam. Scot: [20:57] There was you I saw some people kind of kind of gasp on Twitter because I don't think that those numbers were public that Kylie had that he revealed I mean she had talked about in 2017 we talked about this on episode 145, what was out there that they were dude they did 300 million in 2017 so it means they probably did for 5500 maybe even 620 18th so you know I don't think a lot of people would have guessed, what was that big so kind of added her Revenue I don't know if she was aware of that or happy or sad or she's probably more on Instagram than following what's going on too. Jason: [21:33] Exactly where she I think she left Twitter so so he was safe I don't know yeah but that was the first time I heard some confirmation from a third-party Source oh. That was interesting another talk with Jen Rubio and Jen was actually at shop.org but then she she was also interviewed by Del Rey she's one of the two co-founders of a way which is, terrific example of a digital native vertical brand in the luggage space. Scot: [22:01] Yeah and I have my birthday present was away luggage to this is my first trip using it and I have to say I'm very pleased right now. Jason: [22:06] Nice so I feel like it gets really high marks we may need a product review from you the one thing I'm always curious about is I think a lot of the way luggage has the option for a smart battery built into the luggage, and there's a lot of controversy now about the airlines not letting you certainly not letting you check that but in some cases, making you take the battery out to even carry it on which frankly doesn't make sense to me. Scot: [22:32] Yep so it's checking it you can't check it with the lithium in there and they now pops out so I think they're V1 was fixed and now it meaning it could not. Jason: [22:40] The ball so it's easy to pop out and put in your lap. Scot: [22:41] Injectable that makes a lot easier to charge to like lifting your suitcase up onto the. Jason: [22:48] Well I look forward to buying something electricity from you at Future shows that we travel together. Scot: [22:52] Absolutely just at yeah I've got a milliamp hours of plenty. Jason: [22:57] So we've heard a little bit about a way one of her investors what was on Earth from Comcast best Adventures was on her show earlier, this year but one of the interesting comments that she made the Jason that I thought was really clever so they have a few stores at the moment one in SoHo in New York, in one of the kpi that they have for the store is. How many times people upload Instagram pictures from the store. In a way that sounds cheesy and sort of superficial but as we're in this world where, sort of Assortment and low friction shopping is moving out of brick and mortar and onto the you know these big online marketplaces one of the main roles for brick-and-mortar is around experiential environments, and one of the ways you know you've accomplished a exponential environment is when people shopping in the store, want to memorialize their trip to the store so I actually thought that was a kind of clever and smart metric to be looking at, maybe we'll do a deeper dive in some other show but there's this big trend of these instagrammable spaces the for example the Ice Cream Factory in San Francisco there's a couple temporary ones you just opened here. Scot: [24:19] Yeah I have a I have two teenage kids and every time we go on a trip we have to include their the things they want to do or these instagrammable places that they've seen on Instagram so. What time it was this bubbly ice cream thing and then it was raw cookie dough then it was let's see it's rolling ice cream is big now. Jason: [24:40] No answer I mean on the way. Scot: [24:42] The food is very instabul in which is a huge part of the experience. Jason: [24:46] And that sounds somewhat silly on one hand but it it makes a lot of sense and you know it someone reminded me in the old days like to differentiate yourself you just had to be unique amongst your 200 code students, in your high school class or ever did your high school class was, but these days you have to be unique amongst your ten thousand friends on Instagram and so you know it is harder to differentiate yourself and so these these opportunities for, more digitally native Shoppers to have a differentiated experience and share it you know makes a lot of sense so that's a smart thing for for retail designers to be thinking about. Scot: [25:25] Packaging for a way was really interesting that comes in a cardboard box what you expect, but then the bag is in a really nice kind of a cloth bag and then when you open it there's a whole experience around there's a little booklet there global travel pack that comes with it, and then they train you on how to use it and then there's a little book about, it is very much pitch is a Lifestyle brand of you know the things you can do with your way and then they promote hashtags that you should, do while you're going and you know it's almost kind of like the beginning of an adventure around travel and and going to see things so it's pretty well done your versus you're just like you know. Popping open a Samsonite or something and you know it'll be just fall out in this kind of experience. Jason: [26:10] The premise of her shop.org talk was. They build the brand less about talking about the features and benefits of luggage and trying to sell luggage and then said they are, they start from the perspective of selling travel experiences so the store, is less about here's how to demonstrate all the things in the luggage you can of course do that but the luggage is in vignettes of aspirational trips to Bora Bora in Amsterdam, and it's it's really about reading to me in for you having this fabulous vacation and oh by the way, you need this luggage to get there as more so than it is features and benefits of the Prada. Scot: [26:51] Absolutely cool thanks for the trip reports I think that was some good stuff like I got trips happening and it wouldn't be a Jason Scott show without. [27:16] So a lot to cover in Amazon news we talked to Jason give us his live report from the Chicago Amazon go store and then a friend of the show we going to get him on here Spencer soap. Yeah he he broke a story where there have been internal talks and I'll Circle back on this about. Amazon potentially opening 3000 Amazon go stores by 2023. Jason: [27:46] I think I might have been like 20/21 I thought it was a relatively short. Scot: [27:51] This is funny because we've been talking on Twitter about you. Just feels like. There are they are opening stores at a pretty good pace and it feels kind of prime now when they they decided with prime now it's go time and then suddenly there was 40 to 60, Prime storage pronounce doors to 3000 is a stretch just kind of getting that real estate I've heard a lot of skeptic say it's impossible while they do that and it figured out how the end of the alcohol sign 3000 Lisa's that fast so I think it will be. I think what could be happening here is your encourage the Amazon meetings to do a lot of brainstorming to write press releases from a future State and I think maybe there's some of that that kind of came up so I'm not sure. Yeah it feels like damn it nailed the format yet I think they're probably won't get a couple more figure it out but you know, when they do on a scale these getting to 3000 I don't think that's impossible. Jason: [28:48] Yeah I'm sort of in the same boat I'm up to mine so for sure. Part of the Amazon methodology when they first pitch new idea they write the six-page memo. Attached to that memo is they write an aspirational press release that they want to be able to issue when the things been successful so for sure there is a press release for Amazon go stores that talks about a mask deployment so. Scot: [29:12] We just open the 3000 store. Jason: [29:15] So that would that would be the exact Spencer one possibility is someone just saw that press release and misunderstood its purpose. The the other side of my brain says Amazon actually is pretty good at keeping secrets and they don't tend to have a lot of unintentional weeks so the fact that this was weed. Partly I believe that probably wasn't completely unauthorized and so, is that because they really are preparing for scale and if so you know I was surprised cuz I wouldn't have thought they nailed the format. [29:53] But you know or is it potentially I had fake I don't know but what I will tell you is, it's absolutely possible possible to open that many stores and Retail in that time. And retailers have done it, in the nineties I work for Blockbuster entertainment we opened a store every 12 hours for my entire 10 year so once you get to a certain scale, like these things are really Temple dies then the the advanced teams are you know just 6 weeks out in front cutting deals on leases and everything Cascades from that and so it. Absolutely possible if they decided to just penciled out and that they needed a big footprint of stores they could run 3000 stores by 2021 now. 3000 stores if this is really can me competing with a convenience store 3000 stores actually probably isn't enough to have a real meaningful business and now that Amazon's a trillion-dollar company. [30:52] You know if there's a million-dollar p&l for each of these 3000 stores like. Arguably isn't a big enough business to get in to be really material to Amazon so we'll have to see. Scot: [31:04] Do you think he'd stores doing a million dollars but what is convenient store to get to take gas out. Jason: [31:09] Yeah I'm trying to and I don't have specific knowledge that this is an estimate based on other types of small format stores, and I would imagine that in the those convenience stores there's a huge standard deviation cuz there's going to be some fast Runners that are easily 10 million dollar stores. If you have 3000 there's there's going to be some snow our stores in there too so to me, you know a million to a couple million per year for many kinds of restaurants would be very good. Scot: [31:41] So million at 3000 is 3 billion so each million is 3 billion so if they did five that be 15 but that's a needle mover for them to hunt. Jason: [31:53] You never like to talk about Revenue you always like to go with the big number. Scot: [31:56] Well then there's a multiple there that yeah so yeah so that that's. Jason: [32:06] That's going to be interesting to watch that would be to meet someone fascinating if that's the brick-and-mortar format that gets. Scale the fastest versus the books or the or you know some information of the grocery pick-up for some of the other things they've done. And a new store format won't will probably talk about in a minute but another piece of online news that we saw from Amazon this. Weaker last week was this new Amazon small business store fronts, and so I thought you might have a POV on that but the gist of it is it's a way for small business that's a 3-piece seller on Amazon to offer a curated collection, of products and have their own sort of landing page and in some ways you'd be where some of our listeners might not, Amazon used to have a Amazon webstore which was essentially. Competed with Yahoo web store and let us small business run their own website on their own URL that's not what this is. Scot: [33:13] Yes in a lot of people depressed confusing these things. That's the problem one of the main problems with Amazon webstore was it had the initials a w s s cousin to the cloud computing AWS, PSO2 Amazon used to have a thing where they would go out and run a store for people it was the downgraded kind of technology that. Your Target and all those guys ran this to me is just really giving a little bit of content to the store owners desk and be types so they can tell them or their story, and they're highlighting some of them and, part of the press release was really starting to thump their chest and say over 50% of the items or the units sold on Amazon or from third parties and there's an integrated TV commercial as well I haven't seen it running. So it feels like a didn't get like a huge I haven't seen on NFL games are in that kind of stuff which of the big spots I'm so don't know where they're running it but I did see the online version so but it is you if your 3-piece seller it is pretty cool to have an Amazon you know out there used to be kind of this dirty secret that some of the stuff you bought from Amazon list of these third parties now Amazon's kind of put you more front center so it felt like a big. If something is change they're pretty dramatically and how they're thinking. Jason: [34:32] And so I I think you sort of app we described it but I have heard people, sort of think of it as a Etsy competitor which is not really right Amazon does sort of have another offering that's more competitive with that seat and then the Jason Delray did Ash Shopify, if they considered it competitive and he had the the sort of typical competitor answer it feels like a little bit of a trap to me. Scot: [34:59] It's a trap. Jason: [35:02] Pictures of Admiral Ackbar. Scot: [35:05] Black bar on it yeah yeah I don't know if it's true or not I mean it is very hard for. Jason: [35:13] Going on Amazon I would use it likely wouldn't make that my only destination on the web like me Amazon has one channel for most people shouldn't be there exclusive Channel. Scot: [35:24] When your Kylie Jenner you can have your own store and not worry about Amazon and you know also comes to you and I'm sure she had a lot of power in their relationship. Promosi small business out there and you start on Amazon and then you're lucky if you get anyone to your website so so yeah yeah I think it makes a lot of sense for four people to embrace it and and, rapper on it a lot of people that's because some of the ones that are highlighting do you have more of car that Homespun handmade kind of provide to him like there's this handmade Candle company that was both on the front page of the store fronts and on the TV commercial I hope those people have a lot of inventory because it felt like they're going to sell out of those handmade candles pretty darn fast. Jason: [36:04] Yeah I was always a problem when you highlight the small businesses right. Scot: [36:08] Couple of quick things Amazon has been obsessed with visual shopping and they've done several kind of things around that so, the the first one is they've had they had something called visual shopping where you can kind of like pick some colors and stuff then they deprecated that, then they have active on the homepage if you look at the top bar I'm always logged in this Prime and I think this is available and non-prime to it'll say new and interesting finds and that's kind of like a Pinterest so you could put together a little you know of Jason's Board of interesting finds of cool gadgets I'm so Scott a Pinterest board, feel to it that I've always thought of new and interesting is kind like their Pinterest competitor have a new one called Scout if you go to amazon.com Scout and it's more of a Instagram meets machine morning to see thumbs up thumb down some stuff and then it's supposedly going to learn about what you like and don't like and and. Pretty quickly after 5 to 10 ups and downs you'll get to some interesting new products that that it learns that you may want so then so that kind of feels like Pinterest Army sorry Instagram so they've got. [37:15] Pinterest and Instagram covered the other big visual thing out there is Snapchat and actually just today announced integration with SNAP, where are you can go and take a snap of the picture and then Snapple use I assume they're using the machine learning a library that Amazon has for Parker Mission so you see a cool celebrity you see Kylie on your way home tonight you take a picture of her sneakers and it will identify them and then show them to you over on Amazon which feels kind of like an affiliate type model so I'm sure there's a rough share there but it is pretty interesting that snap is the front end of an Amazon kind of the backend which is Young so now they have an integration on the snap sides the good kind of, the three visual shopping Technologies covered in a way to different business models which is pretty pretty. Jason: [38:02] No I I would agree the Scout thing was kind of interesting to me I've heard some people describe it as Tinder for shopping. Scot: [38:10] Apple swipe right. Jason: [38:11] Yeah you go get products and go hot or not and they're broken at in the category so you know you you decide you're looking for, home furnishings and then you can say lighting and you get 5 chandeliers and you say like don't like don't like in as you're doing that, the assortments getting curated to visually 2/5 chandeliers that match your taste in so it's it's pretty fun and fast and immediate and they're promising, more categories to come it's slightly reminded me of you go old school on Amazon when they used to mainly sell this, stack of books and video. [38:52] The recommendation logarithm was based on what you bought but of course you could buy a book arm or watch a video that you didn't like and so they act they used to have an interface where you could look at all the stuff you bought and go back and say you liked it or didn't like it, and sort of refine your own recommendations and so if you want to invest some time you can improve it in my mind this felt like, how much more evolved visual version of that so that it's interesting to invent new ways to shop and, Amazon's always been great for the spearfishing but like you know browsing and Discovery has been the Gap so it's it's interesting to see them try new things and it seemed interesting the snap one to me. [39:36] Is a very interesting because a lot of social networks have tried to integrate Commerce and they generally try to do it in a bran friendly way, and like it's not particular brand friendly to say and we're going to sell everything on. Amazon right like when when you want that feature so this is like the Pinterest wins feature which is a visual search capability but then connecting all of those visual searches to Amazon, no other retailers ever going to buy an ad on your platform and so part of me wonders if snap was only able to do this because they sort of are in the Challenger position, Instagram feels like it's getting more of the momentum and so this was, a a big move snap could make but potentially the risk of alienating a lot of other advertiser's. Scot: [40:27] Yes snaps been under pressure and there. Their head of Partnerships left recently and he is a big yeah she was an internet analyst I've known for a while and, I imagine they may have been building some stuff out they realize how hard the backend is and they kind of got the front end working and they just decided to marry them together instead of having to go to all that. One thing that occurred to me as you're talking about they are stuff earlier is Amazon does have an AR functionality and it used to be buried in that so you'd have to go kind of down the sub menu at the hamburger menu down three levels in the camera app now and then update, you have, you have your normal scan barcodes but now you can search with photos is is kind of promoted to a very high level up inside the camera and then also you can do smile codes and then last but not least you could do if you had room so it's right in the camera now so they've they've upgraded the AR View and in the Amazon that up into the camera, which is pretty nursing another part of this visual search is Dave and Kurt are going to take out your Amazon app hit the camera button there's a lot of cool new stuff inside of there to play with now. Jason: [41:32] Yeah I know it's very cool, another big an Amazon announcement as if they didn't have enough is they had a president last week and they launched I want to say 14 new products with Echo embedded in them. Scot: [41:47] Yeah and I was really excited for you cuz I know you are really big on the Amazon button e things and they had an amazonbasics microwave and it has a button on there where you can order more popcorn. And I just envisioned you and having that installed by now have you bought and installed one of them. Jason: [42:05] So the challenges I have a 3 year old son that's where and how to talk to all the Echoes and. Would constantly be running the microwave if it was too in closer to the ground so I feel like it's probably a bad combination of might like Echo cook popcorn with nothing in the microwave will be happening a lot in my house. Scot: [42:26] I saw a lot of people scoff at this but you know the the microwave is a challenging thing so every every microwave you come across is different, and yeah sure if you're going to do a minute heat up or something it's not a big deal but for my microwave whenever I want to defrost something or whatever I have to take out the little guy and there's this complex you know, non-intuitive side of things you have to do where is it be really cool to say you know Alexa you know heat up this pizza and it just kind of knows that okay you need the heat at 50% and so it's I think there's actually something there that that actually is a time-saver to be able to say that for the microwave and have it kind of decode oh you know I need to go 50% power so the cheese doesn't get all rubbery or whatever it is that did microwaves do, so I don't think a lot of people realize that that it's doing that behind the scenes there's there's a fair amount of complexity as I read more about it, in there about what it's going to do with the voice that. I think it's pretty interesting. Jason: [43:21] No I I think there is some very real world use cases a lot of the space saver microwaves don't have a numeric keypad anymore and so you know now you have this. Awkward, dial that you know is sort of variable speed that you have to use to set microwave for 3 and 1/2 minutes and so like voice is the perfect way to have a minimal space footprint but still have no easy low-friction access to, you know all of those features that often don't get used in the microwave because they're too hard to find. Scot: [43:53] When when I was excited about is in my car I can I can put an echo dot in there and. It takes a little works at to connect it to the Bluetooth every time is it's not like Auto connected to the Bluetooth, but it's a really cool Auto interface but you know I don't think my OEM is ever going to have Alexa and the dash certainly they'll be some people that do that some people are brought into the Apple ecosystem some people are building their own so one of the projects I was excited about was called Echo Auto so it's kind of like an echo. But I think the Bluetooth going to be more persistent and smart and connect better but also has it kind of lays flat and I think you can velcro it to your dash and it also has eight little microphones on top so you know they're saying that it'll be able to hear inside of a car better, sex can be a pretty interesting auto experience that's why the one I was most excited about, but sadly I know you can't pre-order it unless you have an invitation so all the Amazon people listening I know I would love an invitation I don't know about Jason, Jason Jason would probably love an invitation to. Jason: [44:56] For sure without doubting you for your fancy Fleet of automobiles I'm just going to say that your OEM probably wouldn't add an Alexa interface unless and until Jeff Bezos divested blue origin. Scot: [45:10] Yes. Jason: [45:11] But there were a bunch of other products they improve the core products so they did another iteration of like the view in the. The View has a is a smaller footprint, overall but a bigger screen so I have a couple of the 7-inch devices and use them in my house and so now the, 10 feels more appealing they have a clock which it's an analog clock and I. I don't have a place to put this but I really want this, so it is a traditional analog clock that looks like a standard kind of office wall clock, when you set timers which is one of the things I'm most frequently do with the echoes in my house they have sort of stealthy LEDs around the rim of the clock, that show you the progress of the timer so you can see him visually how much, time you have left in a timer but the feature that I think is most cool which is super lame is when daylight savings happen, the hands on the analog clock actually moved to automatically change your analog clock for daylight savings. Scot: [46:17] You give me staying up you're going to get this or you have to stay up till 3 a.m. my time does it still 3 a.m. in Chicago or is it to him. Jason: [46:23] I couldn't tell you because I have no analog clocks and all the digital lens automatically adjust. Scot: [46:27] You can stay up all night watching and waiting to see what it does like this it just doesn't stand still for an hour and our plastic depends on if we're going forward or backward this is this is we're going to do a live report. The world's best book still nothing happening. Jason: [46:45] Rest of it we have some grass growing. My big thing I felt was interesting about all these releases is you know we talked about it CES this year that Alexa was embedded in like five thousand devices are 4,000 devices into, there was a school thought that they made these initial products to see the market and they're happy to sell these core products but that, they were you know trying to be very appealing to oems to get embedded in a lot of other products and so it's somewhat surprising to see them. Expanding the line of first-party products that they in bed in themselves and arguably. That could make it less appealing for other microwave ovens to license the tech or. They could make that the must have desirable feature that then entices other opm's to take the future. Scot: [47:37] Yeah I got a fire watching the video that they were. There's been a couple microwaves actually integrated with with Alexa and I get the feeling they're underwhelmed and I think they wanted to say here's where the bar needs to be you no have it, be able to talk about different recipes and talk about you know defrost my vegetables and have it understand that stuff. I think they're frustrated that allow that Williams to do that kind of thing. No some of the commands for like Alexa run the oven at 50% power which is I think they were trying to make more of an intuitively than than though instead. Jason: [48:10] No I think I think you could have hit the nail on the head with that I did feel to mention one other interesting product they have them or audiophile. Alexa now so you can I get an Alexa with a. Remote subwoofer which more directly causes us to compete with like the Sonos is of the world. Scot: [48:31] Recode pregnancy. Jason: [48:33] I teased earlier in our Amazon segment that we were going to talk about another new retail format from Amazon and that format is a pop-up shop that Amazon and Good Housekeeping, just opened at Mall of America. So this a curated assortment of products from Good Housekeeping and they all have smile codes which you mention which is Amazon's proprietary 3D barcode and you scan any of those smile codes, to be able to order those products from Amazon. Scot: [49:08] Cold sores a kind of touch and feel and then you can't really buy from there you have to buy them online. Jason: [49:12] Yeah my sense I have not visited yet Mall of America for a long time with the largest mall in the US it's so realize that status but it's this huge huge destination Mall in Minneapolis. Scot: [49:25] I've been there Camp Snoopy as big giant thing in the middle. Jason: [49:28] Yeah that's an amusement park in the middle of the mall I I've spent weeks Sweeping in that mall we don't we don't need to rehash those. Scot: [49:35] So we'll save that for another podcast. Jason: [49:36] Those stories but so an interesting new new partnership as Amazon you know partners with more these curators create you know novel newcomers experiences. Scot: [49:50] Okay that was Amazon news and looking at 9 Amazon news I like to keep track of everyone's holiday forecast cuz we're sitting here knocking on the door of October and so we Deloitte was out our good friend Casey and they are at 17 to 22% incest pretty robust with a 19 and a half midpoint internet retailer came out this week at 15 and a half and then sucharita was on and she talked about how they haven't formalize our forecast but she was thinking kind of 14 to 16% and she kind of highlighted that the the Grinch this year could be these tariffs and there is, creasing noise even since we had to treat on like literally 3 or 4 days ago you know Walmart is really kind of banging the drama and there's a lot of people out there saying, hey this this could be a pretty big head when coming in the holiday so we'll have to see how that plays out. Jason: [50:42] There's a part of this could be a scare tactic but they're saying in some categories that does terrorist could drive 10 to 25% pricing keep creases in some category. Scot: [50:52] And it's all the dollar store but what are they going to do. Jason: [50:56] Yeah that would that would obviously. Scot: [50:56] Scot a dollar 15 store doesn't have the same ringtone. Jason: [51:00] It doesn't but if you shop at our store you'll find a lot of not. I don't already sorry spoiler work yeah. There was another big acquisition in my world, on Friday I want to say and that was that a Dobby has been very active lately and Acquisitions we talked about their acquisition of Magento the e-commerce platform on Friday they acquired martello. Which is a big marketing automation platform that particularly excels in the B2B space. Scot: [51:38] That was a was a big deal in it how do you think that's going to is that kind of tying into Magento one report I saw so now that adobe owns Magento there's a lot more Wall Street people talking about it, I'm in every report I read is not very favorable towards Magento and it talks about them as a share loser to Shopify Bigcommerce, now a lot of that's anecdotal so do these Channel checks and there is kind of hearing you know if they'll be at these still be at the shop. To hear Rumblings Aid you agree with the B is this some kind of a very trying to stitch together a cloud in an interesting way because sales horses gut you know Cloud for everything they've got you Noah house Cloud car Cloud marketing Cloud sales Cloud 9 Stein cloud. Is Adobe playing catch up what's going on. Jason: [52:27] Infernus to Adobe I'm not even sure I would say they're playing catch-up they me depending on how you look at it, Head Start of lead sales for Salesforce from day one was Cloud oriented with a single product right so they they, yeah unquestionably dominated the cloud CRM model in eventually put a world of hurt on the, the traditional on-prem CRM folks and they've expanded to have what they now call is a marketing Cloud right so their marketing cloud, then they added exacttarget which was their sort of direct marketing thing and they since added a bunch of pieces to the the Salesforce marketing cloud. So they printed to me and where that actually is at sorry to be complicated a second Cloud for sales. Scot: [53:18] Is Commerce club. Jason: [53:19] It's a Commerce cloud and said they've Salesforce about to Commerce put Solutions, demandware and Cloud trays which is more B2B so that's in the Commerce Cloud Suites you got a bunch of these marketing activation tools in the the marketing cloud, Adobe has probably had a marketing Cloud longer than Salesforce and also through acquisition they acquired a bunch of, they would put their analytics Solutions in their CMS solution their campaign management solution and they have a bunch of customer data product, so I would actually argue adobe's had a more comprehensive. Suite of capabilities and what they call the marketing Cloud then Salesforce. [54:09] One of the tools in that sweet is called campaign manager and that probably is not the absolute strongest product in the sweet and it's primarily focused on b2c, outbound Communications and so Marketo bolsters that capability and sort of experience and in the B2B. I would agree that that in general Magento is a share loser to some of the cloud-based Solutions most notably Shopify but I would say, an area of strength for Magento has probably been on the B side of Commerce in so you could look at that from Adobe and say, hey the marketing cloud has been pretty successful and well penetrated in the The Big Brand b2c space. Between Marketo and Magento. Probably bolsters their treads in the B2B space and you know potentially on the longer tail a little bit more. Scot: [55:07] That was way deeper than I was. Jason: [55:09] Yeah I'll see a lot of my Adobe friends in my travels this week so that I'm sure they're going to tell me if I got that wrong. Scot: [55:15] Quotes of this was also a big week because we're both Apple Fanboys and lot of new stuff out there's new watches and phones and you had a fun Journey on your phone's I'm sure listeners would love to hear about. I had one where I I did the whole get up at 3 and was disappointed cuz launch day was the 21st and then I got to like 28th October 5th ship date, but being good under-promise over-deliver I got my Apple my new phone today. Came in 5 days earlier which was exciting and I was frantically installing and upgrading and so I got the x-maxx and I'm really happy with it it's got a longer battery doesn't feel ginormous I feel like I'm back to that plus format. I also have a. Pixel 2 and it feels like it's almost the exact same format as up until 2 so it's been good and then I also got the new generation 4 watch sadly it does not have the ECG yet it's coming soon, but the thing they did those genius there is they got rid of the bubbles and it just feels like the data display is, in a 50% larger so there's a lot more information on the watch which is which is kind of neat and it seems like the battery life there is dramatically improved tell us about your your phone experience. Jason: [56:31] Well first let me just paint a word picture for our listeners during this entire podcast on our face-to-face and Scott has mainly been playing with the Amazon VR feature on his giant Max phone and flashing his humongous Apple watching me. So I have some serious Apple Envy as we sit here I'm sad to say I had to replace my Apple watch 3 months ago so I did not pull the trigger on a Gen 4, I knew after I. Scot: [57:00] Is your screen cracked. Jason: [57:01] No not yet but it may be by the time I get home tonight. Scot: [57:05] Girl accident. Jason: [57:07] After I saw it I was going to have some screen envy and I I certainly just watching you and having some screen Envy, luckily there's a 24-hour Flagship Apple Store about 300 yards from where we're sitting right now so I can fix it on the way home and I don't think they're in a constrained Supply situation I think you can walk in and buy a watch. Scot: [57:28] Sounds like a fun trip that we can report on next week. Jason: [57:31] So I got up in the middle of the night in the middle of shop.org to place my. IPhone upgrade order at the earliest possible moment and I also pay a little bit of extra money in this Amazon upgrade program because you generally have. Preference for the new stuff. Scot: [57:50] The Apple subscription program. Jason: [57:52] Apple subscription program includes AppleCare so if you're going to buy AppleCare anyway it actually and you were for sure going to replace your phone every year, it actually does a pencil out to be a decent economic deal but the main reason I do what I don't want to get anyone is because, I want to make sure I get that new phone day one because frankly all my clients on day two are going to be disappointed if I show up without the new Apple product. Scot: [58:20] You have a secret it says retailgeek right on your laptop you have to I mean you at the bar very high. Jason: [58:25] Yeah so I got up early, finish my pre order was promised a launch-day phone I was traveling on launch day I sent that and it signature required so, I sent a signature required form to be put out in my house while I was gone somewhere justix went awry on that and the the phone didn't get there so I came home Friday night to a sorry we missed you. Scot: [58:52] Sad. Jason: [58:53] The saddest worst customer experience although it's my fault it still is the most disappointing customer experience you can possibly have your want your phone was here but now it's not. Scot: [59:05] Wow wow wow. Jason: [59:07] So jump on the UPS website change the delivery address to some UPS lockers very close to my house, and get it rescheduled for Saturday delivery so now I don't need a signature or sometime Saturday UPS is going to drop this at a walker that's half a mile from my house so I'll get it into the day Saturday still in time for my trip this week. Saturday 6 I get the exciting note that is in the locker walk over to the locker the locker opens and is empty. Want Walmart so that was very disconcerting turns out the driver made a mistake. They delivered it to the locker wait tonight and so I I did in fact like my phone, moments before we started this podcast but unlike you did not have time to activate it yet so I also got a big capacity Max and then and I'm excited for that as well. Scot: [1:00:08] So you know we ordered about the same time and you pay all that extra for the subscription I got my phone earlier. Jason: [1:00:13] Yes I mean the main takeaway from this whole story is Scott is better than Jay. Scot: [1:00:17] It just luck of the draw. Jason: [1:00:21] But I will say there were a couple things they were either surprises in this more the OS X launch and the hardware or that I just don't have missed during announcements but there's two kind of, relevant features to Commerce, so we did mention when the OS 12 operating system was iOS 12 was launched that there's a new improved AR library in it called AR Kit 2.0 what I missed, is AR Kit 2.0 that you do AR in the web browser no app required and so I'm that's the capability that are friends at Sea car using, to watch that so in general I don't recommend retailer spend a bunch of money on an app, because there's a lot of friction to getting users to download the app I do IKR experiences for a lot of in-store retailers and so now I get the best of both worlds my retail clients can implement, the in-store AR shopping features without requiring an app so that that's actually very exciting, and then the Easter egg in the hardware is the phones that you're holding the access model so that excess in the excess Max which is not how Apple want you to say it by the way they want you to say 10s. Yes in 10s maxed and coming soon 10 r. [1:01:46] All have an improved NFC chip over the previous generation, and what's exciting about this new NFC chip is a, it has a passive reader in it so the original phones with NFC chips they can really only be used for Apple pay and you couldn't use them for other experiences, now we have a complete implementation of NFC, and one of the things that means is for example a store could put an NFC tag in every fact tag in the store, and if you just wave your phone you don't have to launch an app or do anything you just have to have the phone unlocked if you just wave your phone over that tag. You will go to a web page that can have supplemental product information for all those pages so now we can have NFC tags that we put in our house to like, trigger scenes for virtue we can use them for shopping all sorts of capabilities in the NFC stack that we didn't used to have now with this new hardware we did so I actually bought. In NFC writer in a bunch of tags to start playing with us and they came even though I didn't get the phone so. Scot: [1:03:00] What are the most fun apps and if you look on Twitter iOS 12 I think comes with measure so you can go measure all kinds of random stuff there's always funny people pictures of people measuring like their cat's tail and all kinds of interesting thing so it's a it's a cool way to experience they are. Have a lot of fun measuring stuff. Jason: [1:03:19] I will say this some of the third-party measuring apps that use it still better than measure but it's fun to have a native Native program. Scot: [1:03:27] Call any other fan boy stuff. Jason: [1:03:31] Nope nope that was it again I think there's going to be another announcement with some iPads and then there's probably at least one model of iPad on my list for that so I'm. Scot: [1:03:43] One thing that we watch Pretty closely is the stock market to see what's going on in IPOs and there was an e-commerce IPO this week There's a European luxury Marketplace called farfetch and they went public on the New York Stock Exchange and this one was interesting date they price a little bit below the range but they end up raising 875 million which is not too shabby and the stock, October 50% on on diepio day does farfetch Marketplace lol you probably haven't heard of evaluation of 6.2 billion, be billion there revenues are about 400 million a year which we know that's a very good multi, but they're growing north of 50% year-over-year so that's why they are commanding a really good multiple there so it should be interesting to see what they do with those phones or largely European I'm in focused on luxury you can imagine more International expansion and maybe even a push into the US that's what I would do where I European luxury Marketplace. Jason: [1:04:43] The Ed suddenly found a lot of excess capital. Scot: [1:04:47] And did not this time I thought it was interesting we've talked a lot about a rvr on the show we did a deep dive you and I are kind of hobbyist on this and what did we miss in VR at least is that killer app, so I'm a big Elon Musk fan and he announced kind of surprisingly a SpaceX, project funded by a Japanese billionaire where they are going to go on a moon travel servngo launch from Earth on the bfr the big Dokken rocket and they're going to take that puppy and circle the moon and then come back and he announced on Twitter I use a mouse with air quotes because. Alive not a hundred percent sure he's serious about this but he generally is like you know what he says he's going to solve things that are not flamethrowers but they really are they did that, the boring companies real most the stuff that you think is a joke end up being real he did say they're going to live stream in 4k you were going to have series of cameras mounted on the spaceship and they're going to Live cast of er to imagine of your experience where you. [1:05:57] Be on the spaceship and looking around as it goes around the Moon bee that could be the killer app and I'm I'm curious to see what headsets he's going to work with and know you'll on, probably would decide the ones out there aren't up to spec so maybe they'll have to be a boring headset or a SpaceX headset or something that comes along with it so they'll be fun to watch and kind of out there, pretty super geeky. Jason: [1:06:21] You and I could be at the geekiest launch party ever for that product as weak sit in a dark room with her. Scot: [1:06:27] If you see the only sold two of them and it's the same guys that bought the Fire Phone. Jason: [1:06:35] Exactly there is a retail tie in there that the Japanese billionaire you know I think he sold like, 8 seats for this first flight in the Japanese billionaire bought all 8 he's a retail billionaire and he runs a

What if the secret to living an adventurous, meaningful, satisfying life wasn't in thinking of life as a puzzle to be solved, but as a work of art to be created. Alli and Latasha kick off season two of IKR? looking for the good life at an art museum, over a bottle of wine, and with a local visual artist.

IKR? is back for a second season, beginning August 22nd. This time around, hosts Alli and Latasha are on the lookout for the good life - one of beauty, joy, creativity, and fun. And we think it might have something to do with thinking about life less as a puzzle to be solved and more like a work of art. Subscribe, share with a friend, and enjoy this extended look at episode 1.

Who wouldn't want just a quick bonus episode where Lori and Amy talk about being moms, about how Amy wrote her book (Chin Up) on motherhood because it felt like a lopsided dress on her when it looked so beautiful on everyone else, and on some bonus encouragement for the weekend? No one, that's who.But most of all, can we talk about how amazing the line-up is for the next several episodes? Yes, let's! Courtney Defeo (author, podcaster of "Leading Girls") Ashlee Gadd (podcast: Coffee and Crumbs and author of The Magic of Motherhood) Alli Patterson (podcast: IKR? and pastor at Crossroads Church) and Meg Smalley (podcast: Give Grace, owner of Scarlet and Gold Shop)We are beside ourselves to have these killer thought leaders and cannot wait for all the laughing and learning to come! Enjoy this Friday Bonus Episode!

Dr Paul Wang:                   Welcome to the monthly podcast, On the Beat for Circulation: Arrhythmia and Electrophysiology. I'm Dr Paul Wang, Editor-in-Chief, with some of the key highlights from this month's issue. In our first paper this month, Shaan Khurshid and associates determine the frequency of rhythm abnormalities in 502,627 adults in the UK Biobank, a national prospective cohort. They found that 2.35% had a baseline rhythm abnormality. The prevalence increased with age, with 4.84% of individuals aged 65 to 73 years having rhythm abnormalities. During over three million person- years of follow up, nearly 16,000 new rhythm abnormalities were detected. Atrial fibrillation was the most frequent with three per thousand person-years. Bradyarrhythmia with almost one per thousand person-years. Conduction system disease is about one per one thousand years. Supraventricular and ventricular arrhythmias, each about one half per one thousand person-years. Older age was associated with a hazard ratio of 2.35 for each 10 year increase. Male sex, hypertension, chronic kidney disease and heart failure were all associated with new rhythm abnormalities. In our next paper, Fabien Squara and associates evaluated a method of determining the septal or free wall positioning of pacemaker or ICD leads during fluoroscopy. They compared in 50 patients a classical approach using posterior anterior, right anterior oblique 30 degrees, and left anterior oblique 40 degrees fluoroscopic imaging’s to 50 patients undergoing an individualized left anterior oblique or LAO approach. This individualized LAO approach view provided a true view of the interventricular septum. This angle was defined by the degree of LAO that allowed the perfect superimposition of the RV apex, using the tip of the right ventricular lead, temporarily placed at the apex, and one of the superior vena cava, inferior vena cava access using a guide wire. Transthoracic echo was used to confirm position of the right ventricular lead. Septal, or free wall, right ventricular lead positioning was correctly identified in 96% of patients in the individualized group, versus 76% in the classical group. P equals 0.004. For septal lead positioning fluoroscopy had 100% sensitivity, and an 89.5 specificity in an individualized group, versus 91.4% sensitivity, and a 40% specificity in the classical group. In our next paper, Elsayed Soliman and associates examined the lifetime risk of atrial fibrillation based on race and socioeconomic status. In the atherosclerosis risk in communities, ARIC, cohort, of 15,343 participants without atrial fibrillation, patients were recruited in 1987 to 1989, when they were 45 to 64 years of age, and followed through 2014. The authors identify 2,760 atrial fibrillation cases during a mean follow up of 21 years. The authors found that the lifetime risk of atrial fibrillation in the ARIC cohort was approximately one in three among whites, and one in five among African Americans. And, the socioeconomic status was inversely associated with cumulative incidents of atrial fibrillation before the last decades of life. In our next paper, Jonathan Steinberg and associates sought to determine the impact of atrial fibrillation episode duration threshold on atrial fibrillation incidents and burden in pacemaker patients in a prospective registry. In 615 pacemaker patients was device detected atrial fibrillation over a mean follow up of 3.7 years, 599 had one or more atrial fibrillation episodes of 30 seconds duration, with a mean number of 22 episodes. At 12 months, freedom from atrial fibrillation ranged from 25.5% to 73.1%, based on a duration threshold from 30 seconds up to 24 hours. Of patients with a first episode of 30 seconds to two minutes, 35.8% were free from subsequent episodes greater than two minutes at 180 days. The mean atrial fibrillation burden of 0.2% for patients with first episodes between 30 seconds and 3.8 hours, was significantly less than the 9.5% burden for those with greater than 3.8 hours. The authors concluded that small differences in atrial fibrillation episode duration definition can significantly affect the perceived incidents of atrial fibrillation impact reported outcomes, including atrial fibrillation success. An initial atrial fibrillation episode of 30 seconds does not predict clinically meaningful atrial fibrillation burden. In the next paper, Hongwu Chen and Linsheng Shi and associates examined the distinct electrophysiologic features of bundle branch reentrant ventricular tachycardia in patients without structural heart disease. They described nine patients, mean age 29.6 years, with normal left ventricular function and bundle branch reentrant ventricular tachycardia, with a right bundle branch block pattern in one patient, and left bundle branch block patterns in nine patients. In all left bundle branch block pattern ventricular tachycardia, the mean ventricular tachycardia cycling was 329.3 milliseconds, and the median HV interval during tachycardia was longer than that of baseline, 78 versus 71 milliseconds. The H to right bundle interval during ventricular tachycardia was slightly shorter, however, the right bundle to ventricular interval was markedly longer than that during sinus rhythm, 50 versus 30 milliseconds. In six patients with three dimensional mapping of the left ventricle, a slow anterograde, or retrograde conduction over the left His-Purkinje system with normal myocardial voltage was identified. In addition, Purkinje related ventricular tachycardias were also induced in five patients. Ablation was applied to the distal left bundle branch block in patients with baseline left bundle branch block, and in one narrow QRS patient with sustained Purkinje related ventricular tachycardia, while right bundle branch was targeted in other patients. During a mean follow up at 31.4 months, frequent premature ventricular contractions occurred in one patient, and new ventricular tachycardia developed in the other patient. In the next paper, Michel Haissaguerre and associates examined detailed mapping in 24 patients who survived idiopathic ventricular fibrillation. They used multi-electrode body surface recordings to identify the drivers maintaining ventricular fibrillation, and analyze electrograms in the driver regions, using endocardial and epicardial catheter mapping during sinus rhythm. Ventricular fibrillation occurred spontaneous in three patients, and was induced in 16, while VF was non-inducible in five. Ventricular fibrillation mapping demonstrated reentrant and focal activities, 87% and 13% respectively. The activities were dominant in one ventricle in nine patients, while they were biventricular in the others. During sinus rhythm, areas of abnormal electrograms were identified in 15 out of 24 patients, or 62.5%, revealing localized structural alterations, in the right ventricle in 11, the left ventricle in one, in both in three. They covered a limited surface, 13 centimeters squared, representing 5% of the total surface, and recorded predominantly on the epicardium. 76% of these areas were co-located with ventricular fibrillation drivers. In nine patients without structural alterations, the authors observed a high incidence of Purkinje triggers, seven out of nine, versus four out of 15. Catheter ablation resulted in arrhythmia-free outcomes in 15 out of 18 patients at a 17 month follow up. In our next paper, David Spar and associates describe the effectiveness, safety, and compliance of the wearable cardioverter defibrillator in the identification and treatment of life-threatening ventricular arrhythmias in all US pediatric patients who wore a wearable defibrillator from 2009 to 2016, ages less than 18 years. The 455 patients had a median age of 15 years, median duration of wearable cardioverter defibrillator use of 33 days, and median patient wear time of 20.6 hours per day. The study population was divided into two groups, 63 patients with an ICD problem, or 392 patients without an ICD problem. The wear time was greater than 20 hours in both groups. There were seven deaths, or 1.5%. All patients were not wearing the wearable cardioverter defibrillator at the time of death. Eight patients, 1.8%, received at least one wearable cardioverter defibrillator shock treatment. Of the six patients who had appropriate therapy, there were seven episodes of either polymorphic ventricular tachycardia, or ventricular fibrillation, with a total of 13 treatments delivered. All episodes were successfully converted, and the patient survived. In our next paper, Marc Lemoine and associates used human-induced pluripotential stem cell-derived cardiomyocytes to examine differences in repolarization reserve. The authors compared the contribution of IKs and IKr on action potential durations in human left ventricular tissue, and the human induced pluripotential stem cell derived cardiomyocytes, or IPS-derived engineered heart tissue. They found that the IPS-derived heart tissue showed spontaneous diastolic depolarization in action potential duration, which were sensitive to low concentrations of Ivabradine. IKr block by E-4031 prolonged action potential duration 90 with similar EC50 in both the IPS-derived heart tissue and the human left ventricular tissue. But a larger effect size in the IPS-derived heart tissue, 281 milliseconds versus 110 milliseconds, in the human left ventricular tissue. While IKr block alone evoked early after depolarizations, it triggered activity in 50% of the IPS-derived heart tissue. Slow pacing reduced extracellular potassium blocking of IKr, IKs and IK1 were necessary to induce early after depolarizations in human left ventricular tissue. In accordance with their clinical safety, Moxifloxacin and Verapamil did not induce EADs in IPS-derived heart tissue. In both IPS-derived heart tissue and human left ventricular tissue, IKs block by HMR 1556 prolonged action potential duration 90 slightly in the combined presence of E-4031 and isoprenaline. In our next paper, Elizabeth Saarel and associates sought to obtain contemporary digital ECG measurements in healthy children from North America to evaluate the effects of sex and race, and to compare the results to commonly published data sets, using 2400 digital ECGs, collected for children less than 18 years of age with normal electrocardiograms at 19 centers in the pediatric heart network. The authors found that the QTc in lead II was greater for females compared to males for age groups three years or older, for whites compared to African Americans, for ages 12 years or older. The R wave amplitude in V6 was greater for males compared to females for age groups 12 years and greater; for African Americans compared to white or other race categories for age groups three years or greater; and greater compared to commonly used public data set groups for ages 12 years and greater. In our next paper, Pyotr Platonov and associates examined T-wave morphology as a possible predictor of cardiac events in patients with type 2 long QT syndrome mutation carriers with normal QTc intervals. The authors compared 154 LQT2 mutation carriers with QTc less than 360 milliseconds in men, and less than 470 milliseconds in women, with 1007 unaffected family members. Flat, notched, or negative T-waves in leads II or V5 on baseline ECG were considered abnormal. Using Cox regression analysis, the associations between T-wave morphology, the presence in mutations in the poor region of KCNH2, and the risk of cardiac events defined that syncope aborted cardiac arrest, defibrillator therapy, or sudden cardiac arrests were assessed. The authors found that LQT2 female carriers with abnormal T-wave morphology had a threefold increased risk of cardiac events compared to LQT2 female carriers with normal T-waves, while this association was not seen in males. LQT2 males with poor location of mutations had a six-fold increased risk of cardiac events than non-poor location males, while no such association was found in females. In our last paper, Yaniv Bar-Cohen and associates describe a percutaneous pacemaker entirely implanted in the pericardium, using a sheath for sub-xiphoid access to the pericardial space, and a miniaturized camera with fiber optic illumination, the micro-pacemakers were successfully implanted in six pigs. All animals were studied during follow up, survived without symptoms. That's it for this month. We hope that you'll find the Journal to be the go-to place for everyone interested in the field. See you next time!  

The office millennials take the Internet Jargon challenge...can they guess the meaning of these jargony terms? We have a load of fun finding out. IKR?

We asked, and you responded! Season 1 comes to a close with Alli and Latasha answering listener-submitted questions. Conversation topics include communication, dating, and the appropriate time for your child to wear a bikini. Along the way, our hosts discover a shared TV love interest, can't remember the name of Prince William's little brother, and reflect on an incredible first season of IKR?

There are seasons in life when you're just not okay. How do you deal, find hope, choose to get up in the morning when everything inside you is fighting against that? After a year of compounding personal losses, Courtney found her faith shaken to the very core. And yet, her journey toward healing brought her face to face with a God who deals in reality, values honesty, and chooses resurrection. She visits the IKR? team to tell her incredible story.

Another weekend of relaxation and fun has come to an end. Its MONDAY again!! IKR fun times :( .... Dont worry DJ ADAM 2MV got you covered. Introducing the new WEEKLY Podcast series designed to cure the MONDAY Blues. Freestyle mix across different genres and years.... ALL Music is CLEAN & SAFE FOR WORK :)... Soon everyone will be saying its "Just Another 2MV Monday" Mixes will be released Sunday nights so be sure to Follow me on my social media pages below to be notified :) #Happy2MVMonday soundcloud.com/djadam2mvofficial mixcloud.com/djadam2mv instagram.com/djadam2mv twitter.com/djadam2mv facebook.com/djadam2mv

Katelyn was halfway through her freshman calculus class when she had a revelation—this was not the life she wanted to live... and math kind of sucks. She visits the IKR? team to recount her inspiring story of risking everything, letting go of control, and discovering the ultimate business partner.

Jam-packed schedules, growing to-do lists, mounting responsibilities. The pace of modern life is relentless. Is it even possible to slow down? To take a breather? To rest? Courtney visits the IKR team to talk burnout, learning to say "no," and finding hope in pop stars.

Dr Wong:             Welcome to the monthly podcast, "On The Beat, for Circulation: Arrhythmia, and Electrophysiology." I'm doctor Paul Wong, editor in chief, with some of the key highlights from this month's issue. We'll also here from Dr. Suraj Kapa reporting on new research from the latest journal articles in the field.                                 In our first article, Mathew Daly and associates examine whether a high-resolution, 9 French, infrared thermography catheter can continuously image esophageal temperatures during atrial fibrillation catheter ablation. The infrared temperature catheter was inserted nasally or orally into the esophagus, adjacent to the left atrium. Endoscopy was performed within 24 hours to document esophageal injury. Thermal imaging showed that 10 out of 16 patients experienced one or more events where the peak esophageal temperature was greater than 40 degrees centigrade. Three patients experienced temperatures greater than 50 degrees centigrade and one experienced greater than 60 degrees centigrade. Analysis of temperature data from each subject's maximal thermal event revealed high radius, 2.3 degrees centigrade per millimeter and rates of change 1.5 degrees centigrade per second, with an average length of esophageal involvement of 11.0 millimeters.                                 Endoscopy identified three distinct thermal lesions, all in patients with temperatures greater than 50 degrees centigrade, all resolving within two weeks. The authors concluded that infrared thermography, high-resolution mapping of esophageal temperatures during catheter ablation may be performed. Esophageal thermal injury occurs with temperatures greater than 50 degrees centigrade, and was associated with large spacial-temporal gradients.                                 In our next article, Nitesh Sood and associates reported on the real-world incidence and predictors of perioperative complications in transvenous lead extractions involving ICD leads in the NCDR ICD registry. Lead extraction was defined as removal of leads implanted for greater than one year. Predictors of major perioperative complication for all extraction procedures, 11,304, and for high voltage leads, 8,362, or 74% across 762 centers were analyzed, using univariate and multivariate logistic regression. Major complications occurred in 258, or 2.3% of the extraction procedures. Of these, 258 procedures with a complication, 41 or 16% required urgent cardiac surgery. Of these, 14 or 34% died during surgery. Among the total 98, or 0.9% deaths reported, 18 or 0.16% of the total occurred during extraction.                                 In multivariate, logistic regression analysis of all extractions, female sex, admission other than electively for the procedure, three or more leads extracted, longer implant duration, dislodgement of other leads, patients' clinical status, requiring lead extraction, such as infection or perforation, were associated with increased risk of complications. For high voltage leads, smaller lead diameter, a flat versus round coil shape, in greater proximal surface coil area, were multivariate predictors of major perioperative complications.                                 The rate of major complications and mortality with transvenous lead extraction is similar in the real world compared to single center studies from high volume centers. There remains a significant risk of urgent cardiac surgery with a very high mortality, and planning for appropriate cardiothoracic surgical backup is imperative.                                 In our next paper, Bence Hegyi and associates, have reported on the repolarization reserve in failing rabbit ventricular myocytes, and the role of calcium and beta-adrenergic effects on delayed and inward rectifier potassium currents. The authors measured the major potassium currents, IKr, IKs, IK1, and their calcium and beta-adrenergic dependence in rabbit ventricular myocytes, in chronic pressure, in volume overload, induced heart failure, and compared them to age-matched controls.                                 The authors made a number of observations. One, action potential duration was significantly prolonged only at lower pacing rates, 0.2 to 1 Hertz, in heart failure under physiological ionic conditions and temperature. Two, beat to beat variability of action potential duration was also significantly increased in heart failure. Three, both IKr and IKs were significantly regulated in heart failure under action potential clamp but only when cytosolic calcium was not buffered. Four, CaMKII inhibition abolished IKs upregulation in heart failure, but did not affect IKr. Five, IKs response to beta-adrenergic stimulation was also significantly diminished in heart failure, and, six, IK1 was also decreased in heart failure regardless of calcium buffering, CaMKII inhibition or beta-adrenergic stimulation.                                 These observations changed when cytosolic calcium was buffered. The action potential prolongation in heart failure was also significant in higher pacing rates. The authors concluded that in heart failure, calcium dependent up regulation of IKr and IKs counter-balances the reduced IK1, maintaining the repolarization reserve, especially at higher heart rates. In physiologic conditions, unlike conditions of strong cytosolic calcium buffering. Under beta-adrenergic stimulation, reduced IKs responsiveness, severely limits the integrated repolarizing potassium current in repolarization reserve in heart failure, increasing the arrhythmia propensity.                                 In the next paper, Christopher Piorkowski and associates report on the feasibility of a combined endo-epicardial catheter approach for mapping the ablation of atrial fibrillation. The authors studied 59 patients with permanents pulmonary veins isolation and had further symptomatic recurrences of paroxysmal atrial fibrillation, persistent atrial fibrillation, or atrial tachycardia. These patients underwent repeat ablation using bi-atrial endo- and epicardial mapping and ablation. Identification of arrhythmia substrates and selection of ablation strategy were based on sinus rhythm voltage mapping. In all patients, endo-epicardial mapping ablation were feasible using standard technologies of catheter access, three dimensional mapping, and radiofrequency ablation.                                 Epicardial mapping and ablation did not add procedural risk. Exclusively, epicardial low voltage substrate were found in 14% of patients. For the first time, novel epicardial conduction abnormalities located in the epicardial fiber network were described in human patients, 19% of the cohort. Epicardial ablation was needed in 80% of the patients. Over 23 months of follow up, freedom from arrhythmia recurrence was 73%. The authors used continuous monitoring and three months blanking period. Freedom from ATR of greater than two minutes was defined as the primary end-point.                                 The authors concluded that endo-epicardial mapping ablation was feasible and safe. Epicardial ablation increases transient mortality of ablation lesions. Further studies will be needed to demonstrate reproducibility and long-term outcomes, and how the technique compares to other methods.                                 In the next article, Michael Wolf and associates examined the long-term results of substrate modification for ablation of ventricular tachycardia using substrate elimination, targeting local, abnormal ventricular activities, or LAVA, post-myocardial infarction. They reported on 159 consecutive patients undergoing first ablation, age 65, 92% with ICDs, 54% with storms, and 73% with appropriate shocks. LAVA were identified in 92% and VT was inducible in 73%. Complete LAVA elimination after ablation was achieved in 64% and non-inducibility was achieved in 85%. During a median follow-up of 47 months, single procedure, ventricular free survival was 55%, 10% storms, and 19% shocks. The ventricular arrhythmia free survival was 73% after one year and 49% after five years.                                 Complete LAVA elimination was associated with improved outcomes, ventricular arrhythmia free survival of 82% at one year and 61% at five years. The subgroup treated with multi-electrode mapping and real-time image integration had improved ventricular arrhythmia free survival, 86% at one year and 65% at four years. Repeat procedures were also performed in 18% of patients. The outcomes improved, 69% ventricular arrhythmia free survival during a median follow-up of 46 months.                                 In a single center study, substrate modification, targeting LAVA for post myocardial infarction ventricular tachycardia resulted in a substantial reduction in ventricular tachycardia storm and ICDs shocks with up to 49% of patients free of arrhythmias at five years after a single procedure. Complete LAVA elimination, multi-electrode mapping, and real-time integration were associated with improved ventricular arrhythmia free survival.                                 In the next paper, Jean-Baptiste Gourraud and associates examined the safety and feasibility of transvenous lead extraction in adults with congenital heart disease over a 20 year period at a single center. The authors reported on 71 transvenous lead extraction procedures in 49 patients with adult congenital heart disease, mean age 38 years in which a total of 121 leads were extracted. The primary indication for extraction were infection in 48%, lead failure in 31%. A laser sheath was required in 46% and a femoral approach in 8%. Complete transvenous lead extraction was achieved in 92% of the leads. 49% of the patients had transposition of the great arteries. In multivariate analysis, lead duration was predictive of transvenous lead extraction failure. No perioperative death or pericardial effusion was observed. Subpulmonary, atrioventricular valve regurgitation increased in eight patients, five of whom had TGA and were independently associated with ICD leak or valvular vegetation.                                 After a median of 54 months of follow up after the first lead extraction, three deaths occurred independently from lead management. The authors concluded that despite complex anatomical issues, transvenous lead extraction can be achieved successfully in most adult congenital heart disease patients using advanced extraction techniques. Subpulmonary AV valve regurgitation is a prevalent complication, particularly in patients with transposition of the great arteries.                                 In the next paper, Gabriela Orgeron and associates examined the incidence of ventricular arrhythmias and follow-up in ARVC patients grouped by the level of indication for ICD placement, based on the 2015 International Task Force Consensus Statement Risk Stratification Algorithms for ICD Placement in arrhythmogenic right ventricular dysplasia/cardiomyopathy. In 365 of arrhythmogenic right ventricular dysplasia/cardiomyopathy patients, the authors found that the algorithm accurately differentiates survival from any sustained VT/VF among the four risk groups, p < 0.001. Patients with a Class I indication had significantly worst survival from VT/VF than patients with a Class IIa indication or a Class IIb. However, the algorithm did not differentiate survival free from VF or V flutter between patients with Class I and Class II indications. Adding Colter results, less than 100 PVCs per 24 hours to the classification, helps differentiate the risk.                                 Patients with a high PVCs burden, greater than 1000 PCVs per 24 hours had a poor survival from both VT/VF and VF and V flutter.                                 In the next paper, Takeshi Kitamura and associates studied eight patients that had bi-atrial tachycardia, a rare form of atrial macroreentrant tachycardia, in which both atria form a critical part of the circuit and were mapped using an automatic, high resolution, mapping system. 708 patients had a history of persistent atrial fibrillation, including septal or anterior left atrial ablation before developing bi-atrial tachycardia. One of the patients had a history of atrial septal path closure with a massively enlarged right atrium. The authors found that 9 atrial tachycardias, with a median cycle length of 334 milliseconds had three different types. Three were peri-mitral and peri-tricuspid reentrant circuit, three utilized the right atrial septum in a peri-mitral circuit, and three utilized only the left atrium and the left right atrial septum.                                 Catheter ablation successfully terminated eight of the nine bi-atrial tachycardias. The authors found that all patients who developed bi-atrial tachycardia had an electrical obstacle on the intraseptal left atrium, primarily from prior ablation lesions.                                 In our next paper, Kwang-No Lee and associates randomized 500 patients with paroxysmal atrial fibrillation to one of two strategies after pulmonary vein isolation. One, elimination of non-PV triggers in 250 patients, group A, or, two, step-wise substrate modification using complex fractionated atrial electrogram or linear ablation until non-inducibility of atrial tachyarrhythmias was achieved, 250 patients in group B. Recurrence of atrial tachyarrhythmias was higher in group B compared to group A. 32% of patients in group A experienced at least one episode of recurrent atrial tachyarrhythmia after the single procedure, compared to 43.8% in group B. P-value of 0.012 after a median follow-up of 26 months. Competing risk analysis showed that the cumulative incidence of atrial tachycardia was significantly higher in group B compared to group A (p= 0.007).                                 The authors concluded that elimination triggers as the end-point of ablation in paroxysmal atrial fibrillation patients decreased long-term recurrence of atrial tachyarrhythmias compare to non-inducibility approach achieved by additional empiric ablation.                                 In our final paper of the month, Roland Tilz and associates reported on 10 year outcome after circumferential pulmonary vein isolation using a double lasso and three dimensional electro anatomic mapping technique. From 2003 to 2004, 161 patients with symptomatic drug refractory paroxysmal atrial fibrillation underwent electro-anatomical mapping guided circumferential pulmonary vein isolation. The procedure end-point was absence of pulmonary vein spikes thirty minutes after isolation, after a single procedure and a median follow up of 129 months, stable sinus rhythm was present in 32.9% of patients based on Holter-ECGs and telephonic interviews. After multiple procedures, mean 1.73 and median follow up of 123.4 months, stable sinus rhythm was seen in 62.7% of patients. Progression towards persistent atrial fibrillation was observed in 6.2%.                                 The authors concluded that although the 10-year single procedure outcome in patients with paroxysmal atrial fibrillation was low, 32.9%, it increased to 62.7% after multiple procedures and the progression rate to persistent atrial fibrillation was remarkably low.                                 That's it for this month but keep listening. Suraj Kapa will be surveying all journals for the latest topics of interest in our field. Remember to download the podcast, "On the beat." Take it away Suraj. Dr Kapa:               Thank you Paul, and welcome back everybody to Circulation’s “On the Beat”, where we'll be discussing hard hitting articles across the electrophysiology literature.                                 Today, we'll be reviewing 22 separate articles of particular interest, published in January 2018. The new year saw plenty of articles that are of particular interest either for the future of our field of for present management of our patients. First, within the realm of atrial fibrillation, we'll review several articles within the realm of anticoagulation and left atrial appendage occlusion.                                 The first article we'll review is by Yong et al in the American Heart Journal, volume 195, entitled "Association of insurance type with receipt of oral anticoagulation in insured patients with atrial fibrillation: A report from the American College of Cardiology NCDR PINNACLE registry." In this publication, the author sought to evaluate the effect of insurance type on the appropriate receipt of anticoagulant therapy, specifically looking at warfarin versus NOACs. They reviewed retrospectively over 360,000 patients and found significant differences in appropriate prescription of anticoagulants, irrespective of which anticoagulant was considered. Medicaid patients received less appropriate anticoagulant prescription than those who were privately insured on Medicare or military insured. Furthermore, those on military or private insurances had a higher rate of NOAC prescription than those with Medicare.                                 Furthermore, there was an even wider disparity in NOAC use than warfarin use amongst differently insured patients. These data are important in that they highlight potential variability in appropriate management of patients based on insurance type. Of course, there are many issues that might impact this, such as health care access or available pharmacy coverage of specific medications. Furthermore, the authors do not dive into the impact on outcomes based on the therapy availability.                                 The next article we'll review is by Jazayeri et al, entitled "Safety profiles of percutaneous left atrial appendage closure and lysis: An analysis of the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database from 2009 to 2016" published in the Journal of Cardiovascular Electrophysiology in volume 29 issue 1. Here, the authors sought to evaluate the overall safety profiles of procedures performed with different percutaneous left atrial appendage occlusion devices, including LARIAT and WATCHMAN. They review 356 unique reports and compared outcomes pre- and post- approval of the WATCHMAN device. The look at the specific composite outcome of stroke, TIA, pericardiocentesis, cardiac surgery, and death. They noted that this composite outcome occurred more frequently with WATCHMAN than with LARIATs, and this is irrespective of pre- or post- approval status.                                 These findings highlight the importance of postoperative monitoring in evaluation of overall outcomes. The reason by which there was more frequent negative outcomes in the WATCHMAN than LARIATs need to be considered. Obviously there's several limitations in the MAUDE database, similar with all large databases. However, it does highlight the importance of considering the mechanisms or sure decision making necessary, not just amongst patients and their providers but amongst operators of the staff or amongst physicians and industry executives. To determine how to optimize devices going forward.                                 Speak of left atrial appendage occlusion devices and the potential future of these, we next review an article by Robinson et al, entitled "Patient-specific design of a soft occluder for the left atrial appendage" published in nature biomedical engineering, in volume two in the year 2018. Robinson et al used 3D printing to create a soft, immunocompatible, biocompatible, endocardial implant to occlude the left atrial appendage. They use the individual CT of an in vivo pig to three D print using a specialized material, a left atrial appendage occlusion device, and demonstrated feasibility of achieving adequate occlusion. This paper is important and is one of the initial [inaudible 00:22:03] to how three D printing may be used to optimize patient care. In fact, three D printing has the potential to overturn medical manufacturing and device development.                                 Anatomy tends to be more often patient-specific than not. That's one size fits all implant designs may not be optimal, and resulting exclusion or inadequate occlusion amongst many patients. Decide of three D printable patient specific rapidly prototype soft devices that are biocompatible and hemocompatible, holds the potential to revolutionize the occlusion.                                 Staying in the field of left atrial appendage occlusion, we next review an article by Lakkireddy et al entitled "left atrial appendage closure and systemic homeostasis: The LAA homeostasis study" published in JACC. The authors sought to evaluate the effect of epicardial-versus endocardial left atrial appendage occlusion on systemic homeostasis, including effects on neuro-hormonal profiles of patients. They performed a prospective, single center, observational study, including 77 patients, about half of whom received endocardial versus epicardial device. Interestingly, they noted that the epicardial left atrial appendage occlusion cohort exhibited significant decrease in blood adrenaline, noradrenaline and aldosterone levels. Those are not seen with endocardial devices. Internal epicardial devices are associated with increases in adiponectin and insulin levels as well as a decrease in free fatty acids and consistently lower systemic blood pressure.                                 These data suggest a significant difference in the effect of epicardial versus endocardial closure left atrial appendage on neurohormonal profile. The authors propose several mechanisms for these findings but not the exact mechanisms as yet unclear. Several factors potentially could lead to these findings. One is that epicardial ligation may result in more total ischemia of the left atrial appendage than endocardial closure. Another potential mechanism maybe that the presence for material in the pericardial space versus in the bloodstream may have different effects on neuro-hormonal profile. However, these significant differences in outcomes highlight the importance of considering whether all approaches of left atrial appendage occlusion are considered equal. Many flaws of this study is that it's observational and not randomized. Does it possible those receiving epicardial closure may have been perceived to be lower risk for epicardial puncture, in this, as result, had better long-term outcomes.                                 Changing gears now but staying within the realm of atrial fibrillation, we next review elements for cardiac mapping and ablation. The first article we review is one that has received significant press, published by Marrouche et al entitled "Catheter ablation for atrial fibrillation with heart failure" in the New England Journal of Medicine, volume 378. It is well recognized that morbidity and mortality are higher in heart failure patients who also have atrial fibrillation. Marrouche et al published the results of the CASTLE-AF trial, which attempted to determine if catheter ablation [inaudible 00:24:46] better outcomes among patients with heart failure and atrial fibrillation. They randomized 179 patients to ablation and 184 to medical therapy, which consisted of either rate or rhythm control. Inclusion criteria were those with NYHA class II to IV heart failure, LVEF of 35% or less, and an ICD.                                 The primary endpoint was a composite where the death from many causes or hospitalizations for worsening heart failure. They noted over a median of three as a follow up, the end-point was reached in 28.5% of the ablation group and 44.6% of the medical therapy group, accounting for a significant hazard ratio of 0.62. Furthermore, fewer patients that in the ablation group died from any cause, were hospitalized for worsening heart failure, or died from cardiac causes. These data made a big splash because they're highly supportive of the premise that catheter ablation may be beneficial in some patients with atrial fibrillation and heart failure, often beyond that of medical therapy alone.                                 One major strength of this paper is that the actual AF burden was tracked by the ICD, so we know for sure whether or not the procedure was successful and how controlled the atrial fibrillation was. One thing to note however, is that subgroup analysis suggest that those with more symptomatic heart failure, namely NYHA class III to IV, not benefit as much from ablation. Furthermore, it's also important to note that the five years expected mortality in patients was higher than predicted in the CASTLE-AF trial, however overall these trials highly suggest that the potential benefit that ablation may hold over conventional medical therapy. Extrapolation to comparison with the utility of interventions such as biventricular pace with AV node ablation, however, remains to be considered.                                 Next, we review an article by Chugh et al entitled "Spectrum of atrial arrhythmias using ligament of Marshall in patients with atrial fibrillation" published in Heart Rhythm volume 15, issue 1. They reviewed the spectrum of presentations associated with arrhythmogenesis attributed to the ligament of Marshall, amongst patients with atrial fibrillation. They demonstrate that nearly a third of those patients, ligament of Marshall associated arrhythmias had a pulmonary vein ligament connection, that variously required ablation, the left lateral ridge, the mitral annulus, or alcohol ablation. In addition, they noted about a quarter of patients had atrial tachycardia attributable to the ligament, and the remaining had periatrial reentry requiring either ablation or alcohol injection of the ligament to attain a conduction block.                                 The relevance of this publication, albeit it is of a small number of patients and a small center, lies in highlighting on the right mechanisms by which the ligament of Marshall may contribute to arrhythmogenesis. Namely, can include direct venous connections, inhibition to inaudibility to attain mitral block, and directly attributed atrial arrhythmias. Recognition of the various ways and situations under which the ligament of Marshall may play a role in arrhythmogenesis in atrial fibrillation patients, may optimize physician decisions to look for identify and target the ligaments. What is not as well understood however is the frequency with which ligament of Marshall plays a significant role in arrhythmogenesis in atrial fibrillation.                                 Moving gears, we next review an article by Pathik et al entitled "Transient rotor activity during prolonged three-dimensional phase mapping in human persistent atrial fibrillation" published in a special issue of JACC Clinical Electrophysiology, that focus on atrial fibrillation specifically, in volume 4 issue 1. Pathik et al sought to validate three-dimensional phase mapping system for persistent atrial fibrillation. Commercially available rotor mapping systems project the heart into two dimensions based on a three-dimensional catheter. Instead, Pathik et al used a combination of basket catheters along with the non-left atrial surface geometry to construct three D representations of phase progression. Amongst 9 out of 14 patients, they identified 34 rotors, with all these rotors being transients. Of particular interest, the rotors were only seen in areas of high electric density, where internal electric distances were shorter. They also noted the single wave front is also the most common propagation pattern. The importance of this publication lies in considering two things. First is the three dimensional representation of rotor position and the feasibility of this, and the second is really the high electro-density necessary to observe for others.                                 This has been one of the main problems in rotor analysis, namely what the spacial and temporal density is, that is required to identify rotors, especially given how transient they often are. The presence of rotors does not necessarily mean they're ablation targets in all patients. However, the question still remains regarding the optimal approach to mapping rotors, it needs to be remembered that rotors actually are meant to represent three dimensional scrollway phenomena, that cannot necessarily always be reflected in traditional two D mapping schema. Furthermore, to be remembered that when we claim three-dimensional mapping, this just reflects a two-dimensional surface being wrapped in three dimensions to reflect overall internal surface geometry but it does not take into account transmural activation.                                 Thus, taking into account all these elements it should be remembered as sometimes, it is possible that a rotor might exist but it's just not evident based on the two-dimensional representation or a two-dimensional representation that looks like a rotor may in fact not be a rotor when you consider it in a three-dimensional media.                                 Our last article within the realm of cardiac mapping and ablation we will consider is by Zghaib et al, entitled "Multimodal examination of atrial fibrillation substrate: Correlation of left atrial bipolar voltage using multielectrode fast automated mapping, point by point mapping, and magnetic resonance imaging intensity ratio", published in JACC Clinical Electrophysiology, in the same volume as the previous article. The authors sought to compare fast automated mapping with multiple electrodes versus point by point mapping and correlate with weighed gadolinium enhancement as seen by MRI, termed the image intensity ratio.                                 We all recognize that bipolar voltage is critical to recognizing and evaluating substrate. It's traditionally used in decay regions of substrate in both the atrium and ventricles. However, whether a newer automated approach used to characterize substrate perform equally well in comparison with traditional point to point mapping is still unknown. Thus, the authors in 26 patients perform cardiac MRI and mapping endocardial using both voltage mapping techniques. They noted that for each unit increase in image intensity ratio on MRI, in other words, increasing late enhancement, there was 57% reduction of bipolar voltage. They also noted that the bipolar voltage using other fast elevating mapping or point by point was significantly related with actual differences in calculated voltage, becoming more dissimilar in the extreme of high and low voltage areas.                                 The relevance of this publication is highlight in the potential utility of fast automated mapping in creating accurate voltage maps. The correlation of voltage values with image-intensity ratios suggest the utility of either approach. In turn, correlation with MRI suggest a pathologic correlate for all of these findings. However, whether substrate characterization guide ablation carries incremental benefit remains to be seen.                                 Changing gears but staying in the realm of atrial fibrillation, we next review elements of risk stratification and management. The first article we review is by Friedman et al, entitled "Association of left atrial appendage occlusion and readmission for thromboembolism amongst patients with atrial fibrillation undergoing concomitant cardiac surgery", published in JAMA, volume 319, issue four. Friedman et al sought to evaluate whether surgical left atrial appendage occlusion let to a reduction in long-term thromboembolic risk in a large database of Medicare recipients. They included the primary outcome as readmission for thromboembolism, including stroke, TIA, or systemic embolism, in up to three years of follow-up. With secondary end-points including hemorrhagic stroke, all-cause mortality, and a composite end-point of all outcomes.                                 Amongst more than 10,000 patients, there were almost 4,000 patients receiving surgical occlusion of left atrial appendage. Surgical occlusion was associated with a reduction in thromboembolic risk, OR of 6%, all cause mortality, 17 versus 24%, and the composite end-point, 21 versus 29%. However, interestingly, surgical occlusion was only associated with reduction in thromboembolic risk compared with no occlusion amongst those discharged without anticoagulation and those discharge with it. Namely, the thromboembolic risk reduction was primarily seen in those where the surgical occlusion, those who were sent home without any sort of anticoagulation. These data suggest that surgical occlusion leads to reduction of thromboembolic risk overall. As any large database based study, there are massive flaws in the database itself. Namely, we're relying on the coding of hospitals and operators. To know exactly what was done and what happens latter.                                 However, these data are hypothesis generating. One key element is the fact that surgical left atrial appendage occlusion was only superior in reducing thromboembolic risk amongst those discharged without anticoagulation. This raises the question as why. Was left atrial appendage completely closed in these patients? In which case, they may be at further increased risk or that the operators felt that there is a high risk for other reasons that cannot be cleaned from an administrative datasets? While the data support consideration of the benefit of left atrial appendage occlusion in a surgical manner, a kin to what has been seen in papers on WATCHMEN and other approaches, and how is the critical nature of randomized trials in this regard.                                 We next review an article published in JAMA Cardiology, volume three issue one by Inohara et al, entitled "Association of atrial fibrillation clinical phenotypes with treatment patterns and outcomes: A multicenter registry study." Traditionally classification of AF has depended largely on factors such as the nature of AF, paroxysmal versus persistent, LA size, and other factors such as extend of the late enhancement. Inohara et al sought to evaluate whether cluster analysis could better define heterogeneity of AF in the population. They included an observational cohort of almost 10,000 patients admitted to 124 sites in the United States in the ORBIT-AF registry.                                 Outcome was a composite major address cardiovascular and neurological events or major bleeding. Amongst these patients, they identified four clusters, including one those with lower rates of risk factors and comorbidities than other clusters, two, those with AF at younger ages and with comorbid behavior disorders. Three, those with AF with tachycardia-bradycardia type syndromes and had devices for sinus node dysfunction, and four, those with AF with other risk factors such as a coronary disease. Those in the first cluster had significantly lower risks of major events. All clusters were noted to have symptom dissociation to specific clinical outcomes.                                 These data are interesting and highlight the highly heterogeneous nature of classifying risk attributable to atrial fibrillation. When broad datasets associated atrial fibrillation with specific outcomes. Maybe suggest an attribution to all patients with atrial fibrillation. However, this single relationship was specific to the outcomes suggest the limitation of applying outcome as approach to understand atrial fibrillation impacts and outcomes, namely depending on clusters that may take into account patient age or comorbidities, it may be irrelevant in discriminating patient outcomes than the traditional paradigm in the same paroxysmal versus persistent or depending on the left atrial size.                                 These data also highlight the importance of considering the inclusion criteria in randomized trials of atrial fibrillation before stripling real world outcomes to patients who don't fit within that trial.                                 Next, we will be reviewing an article by Chou et al entitled "Relationship of aging and incident comorbidities to stroke risk in patients with atrial fibrillation," published in JACC, volume 71 issue two. Chou et al sought to evaluate the effect of aging and evolving instant comorbidities to stroke risk in patients with atrial fibrillation. Many large database studies or trials where added baseline CHADSVASC score and the then ensuing follow up period to define risk over time of ischemic stroke.                                 The authors hypothesized that as patients age, develop new comorbidities that would change the score, may be more predictable of long-term outcomes than the score itself. They included over 31,000 patients who do not have comorbidities to CHADSVASC aside from age and sex but had atrial fibrillation. They didn't calculate a delta score defined as the difference between the baseline and follow up scores. The mean baseline score was 1.29 with an increase in 2.3 during follow up, with an average delta of one. The score may not change over follow up in 41% of patients. Interestingly, significantly more patients had a delta CHADSVASC of one or more and develop ischemic stroke than non-ischemic stroke. The delta CHADSVASC was shown to better predictor of ischemic stroke than either baseline or follow up CHADSVASC score. This data suggest that additive shifts in the CHADSVASC score over time may be more predictive of stroke risk than the actual score itself.                                 These findings are thoughtful and logical. They indicate the potential impact of continued aging or acquisition identification of new comorbidities. In some patients, potential discovery or new comorbidities or follow-up; for example, hypertension and coronary artery disease may lead to reclassification of stroke risk. That is important to maintain close follow up of atrial fibrillation patients, and not to show a continued need or lack of need of anticoagulation on the basis of a baseline evaluation. This also holds relevance single center long-term outcomes in patients specific scores. Whether is acquisition of new comorbidities or presence of baseline comorbidities or predict a long-term score, should we consider when assessing the need for anticoagulation, particularly in perceived initially low risk cohorts who go on to develop ischemic stroke.                                 Lastly, within the realm of atrial fibrillation, we review an article by Hussain et al, entitled "Impact of cardiorespiratory fitness on frequency of atrial fibrillation, stroke, and all-cause mortality" published in the American Journal of Cardiology, volume 121 issue one. Hussain et al review the effect of cardiorespiratory fitness on overall outcomes and incidence of atrial fibrillation and outcomes amongst patients with atrial fibrillation. Amongst over 12,000 individuals prospectively followed up after treadmill exercise test, they noted 1,222 had a incidence of AF, 1,128 developed stroke, and 1,580 died. For every 10% increase in functional layover capacity, there was a 7% decrease in risk of incident AF, stroke, or death.                                 Similarly, in those who developed AF, stroke was lower in those with higher functional aerobic capacity. These findings support the notion known to other areas of cardiovascular disease that better cardiorespiratory fitness is associated with better outcomes, in this case to stroke, incident AF, or mortality. Furthermore, even on the presence of AF, those with better functional capacity had a lower risk of stroke. These data highlight the continued importance of counseling patients on the benefits of physical fitness even in the setting of already present AF.                                 Moving on to a different area of electrophysiology, we review the realm of ICD pacemakers and the CRT.                                 The first article review is by Sze et al entitled "Impaired recovery of left ventricular function in patients with cardiomyopathy and left bundle branch block" published in JACC volume 71 issue 3. Patients with left bundle branch block and cardiomyopathy are known to respond to CRT therapy. Thus the investigators sought to evaluate whether guideline medical therapy in patients with reduced LVEF and left bundle branch block, afford a beneficial first line approach therapy. The reason for this currently guidelines suggest waiting at least three months before consideration of CRT has had as some patients may recover on guideline directed medical therapy without the need for device implantation.                                 They review patients with a LVEF of less or equal than 35% and baseline ECG showing left bundle branch block. In evaluating left ventricular ejection fraction at follow up of three to six months. They excluded patients with severe valvular disease, and already present cardiac device, an LVAD, or heart transplant. Among 659 patients meeting criteria, they notice 74% had a narrow QRS duration of less than 120 whereas 17% had QRS duration greater than 120, and the remainder had a QRS duration greater 120 but was not left bundle branch block. The mean increase in the left ventricular ejection fraction on guideline directed medical therapy was in those with a narrow QRS duration and least in those with left bundle branch block, 8.2%.                                 Furthermore, when comparing mean LVEF improvement, those with on versus non-on guideline directed medical therapy, there was virtually no difference in rates of recovery. Furthermore, composite end-point of heart failure hospitalization mortality was highest in those with left bundle branch block. These data suggest that those with bundle branch block and cardiomyopathy received less overall benefit from guideline directed medical therapy over the three to six months follow up period. Whether this is due to already more severe myopathic process to start with or due to the CRT is unclear. However, it may suggest that in some patients, left bundle branch block may benefit from inclusion of CRT early in their disease course as known the significant number of patients up to three to six months guideline directed medical therapy with insufficient DF recovery may then benefit from CRT. As well as intervening earlier may result in better outcomes, especially knowing the high and term raise mortality in heart failure hospitalization remains to be seen.                                 A trial studying early implantation of CRT on these patients may be relevant.                                 The next article review is by Gierula et al entitle "Rate-response programming tailored to the force-frequency relationship improves exercise tolerance in chronic heart failure" published in JACC Heart Failure, in volume six, issue two. The authors sought to evaluate whether tailored rate-response programming improved exercise tolerance in chronic heart failure. The double blinded, randomized, control, crossover study, they compared the effects of tailored programming on the basis of calculated force-frequency relationship, defined as including critical heart rate, peak contractility, and the slope, multidimensional programming and exercise time and maximal oxygen consumption. They demonstrate amongst 98 enrolled patients that rate-response settings limiting heart rate raise to below the critical heart rate led to create exercise timing and higher peak oxygen consumption.                                 These data suggest that personalizing rate-response therapies may improve exercise time and oxygen consumption values in patients with heart failure and pacing devices. The main limitation of the study is that the number of patients was small, 90, and then the number of patients crossing over was even smaller, 52. However, highlights the potential of working closely between device programmers and consideration of individual's characteristics and their exercise needs in determining optimal programming strategy.                                 Finally, within the realm of devices, we review an article by Hawkins et al, entitled "Long-term complications, reoperations, and survival following cardioverter defibrillator implant" published in Heart, volume 104 issue three. Hawkins et al sought to evaluate the long-term complications and risk of reoperation associated with defibrillator implantations in a large [inaudible 00:41:56] population of 300,410 patients, they noted over a 30-month follow up period there was a 12% reoperation rate within the year of implant. This is most prominent for CRT devices, with a risk of 18% in one year post-implant. Furthermore, CRT had the highest rate of early complications, with device complexity, age, or the presence of atrial fibrillation being significantly associated with complication risk.                                 Mortality also increased over time from 5% within the first year to nearly a third after five years. However, younger patients exhibited five years survival similar to the general population with a progressive decline of this as older patients were considered. These findings highlight several critical issues. First, they report a high one year reoperation rate for a variety of reasons. This finding highlights the importance of considering protocols to minimize the need for reoperation. Furthermore, they note the higher rate amongst CRT patients, with seems logical given the likely longer associated procedural risk and need for more leads. Finally, the impact of age on expectant survival are to be taken into consideration with the device and the life-saving potential of the defibrillator.                                 Moving on to cellular electrophysiology, review one article by Zhang et al, entitled "Reduced N-type calcium channels in atrioventricular ganglion neuron are involved in ventricular arrhythmogenesis" published at the journal of the American Heart Association, in volume seven issue two. Zhang et al reported a rat model of ventricular arrhythmogenesis and characterized the role of atrioventricular ganglion neurons in risk of arrhythmogenesis as well as the mechanism for this risk this model relates in humans to the attenuated cardiac vagal activity in heart failure patients, which is known to relate to their arrhythmic risk. The demonstrated reduced N-type calcium channel in these AV ganglion neurons, which project innervating systems to the myocardium, resulting in increased risk of PVCs, and increased susceptibility to induction of ventricular arrhythmias with programmed stimulation.                                 The relevance of the intrinsic cardiac nervous system arrhythmogenesis has become increasingly prominent as methods to study it have improved. Understanding the direct and most relevant inputs may facilitate better understanding of risk of arrhythmias in patients. In the case of this study by Zhang et al, the critical finding is that disorder of the atrioventricular ganglion neurons may lead to increased susceptibility for ventricular arrhythmogenesis. Clinical relevance includes consideration of effects on this specific ganglion when performing ablation on for other conditions, and potential long-term effect on arrhythmogenic risk, as well as potentially relevant functional explanations for arrhythmogenesis.                                 Moving on to the genetic channelop, these are considered two separate articles. The first one by Bilmayer et al, entitled "ExomeChip-Wide analysis of 95,626 individuals identified ten novel loci associated QT and JT intervals" published in Circulation: Genomic and Precision Medicine, in volume 11 issue 1. This whole exome study reviewed several novel loci that modified the QT and JT intervals. They include over 100,000 individuals and identified ten novel loci not previously reported in the literature. This increases the number of known loci that impact from ventricular portal adjacent by nearly one third. These loci appear to be responsible for myocyte and channel structure and interconnections that internally impact the ventricular repolarization.                                 While long QT syndrome be characterized amongst the known genes in 75% of affected individuals, that also means one fourth long QT syndrome cannot be characterized based on known genes impacting ventricular repolarization. The identification of novel loci or novel that may be affect repolarization kinetics to unique means are critical to define novel therapies as well as in genetic counseling the patients in potential effects on family members when screening them for potential disease risk. These findings should assess an opportunity for further studying the mechanisms by which these loci modulate QT and JT intervals and the potential contribution to phenotypic risk.                                 The second paper within this realm we review is by Zumhagen et al, entitled "Impact of presynaptic sympathetic imbalance on long QT syndrome by positron emission tomography" published in Heart, volume 104. The authors sought to evaluate by a PET scan the impact of sympathetic heterogeneity on long-QT syndrome risk. Amongst 25 patients with long-QT syndrome, including long-QT type I and II, and 20 ostensibly healthy controls, they noted that regional retention in disease were similar between affected patients and controls. However, regional washout rates were higher in the lateral left ventricles in patients with long-QT syndrome. Internal global washout rates were associated with greater frequency of clinical symptoms. That's there seem to be some relationship between regional and global sympathetic heterogeneity, particularly during washout, with overall risk in long-QT syndrome patients.                                 These findings report the notion for sympathetic imbalance, partly mediating the risk attributable to long-QT syndrome. The findings on PET suggest regional imbalance of presynaptic cathecholamine and reuptake and release, being one mechanisms. This was most prominent in long-QT I patients who also often drive most benefit from left sided sympathectomy. The novelty of these findings is in the potential role of imaging to determine basic contributors to congenital long-QT syndrome in given patients. The larger prospect of size would really need to be evaluated this further.                                 Moving on to the realm of ventricular arrhythmias, we review three different articles. The first one, by Hamon et al, entitled "Circadian variability patterns predict and guide premature ventricular contraction ablation, procedural disability, and outcomes" published in Heart Rhythm, volume 15 issue one. Hamon et al sought to evaluate whether circadian variability of PVC frequency can predict optimal drug response intraprocedurally during PVC ablation. One of the main problems of PVC ablation is when PVC are infrequent and tend to disappear during the procedure, achieving procedural success or attaining sufficient frequencies of PVCs to map becomes very difficult. Next, they use Holter monitoring in the ambulatory stripe to define three groups. Those of higher PVC burden during faster heart rates, those with higher PVC burden during slower heart rates, and those with no correlation between their PVCs burden and their heart rate.                                 More than half the one hundred and one patients included a high burden of PVCs at fast rate while 40% had no correlation between the two and 10% had higher burden in slower heart rates. Almost one third of patients taken for ablation have infrequent PVCs during a procedure, while the best predictor of this being a low ambulatory PVC burden of less than 120 per hour. Isoproterenol infusion was only useful in lessening PVCs in those with PVCs associated with fast heart rates. The isoproterenol washout or phenylephrine where used with those associated with slower heart rates.                                 Interestingly, not a single drug was effective in inducing PVCs in those with infrequent PVCs that have not heart rate correlation in the ambulatory stages. They noted that outcomes ablates were similar amongst those with higher heart rate associated PVCs and non-heart rate correlated PVCs previously responded to a drug. But, [inaudible 00:48:08] noted only a 15% success rate from ablation in infrequent PVCs in patients who lacked correlation between PVC burden and heart rate and who were unresponsive to drug previously. These data are important highlighting the potential for further defining idiopathic PVC ablation needs and likelihood of success based on ambulatory data, by correlating PVC burden with heart rate and their circadian variability, it's possible to predict likelihood specific intraoperative drugs working when dealing with infrequent intraprocedural PVCs.                                 Furthermore, the finding of lack of correlation with slower or fast heart rate in terms of PVC burden is associated with the poor success rate unless those PVCs are drug responsive. Highlights the potential benefit of performing preoperative antiarrhythmic drug testing to get likelihood of ablation success in this patients.                                 The next article we review is by Lee et al, entitled "Incidence and significance of the lesions encountered during epicardial mapping and ablation of ventricular tachycardia in patients with no history of prior cardiac surgery or pericarditis" published in Heart Rhythm, volume 15 issue one. Lee et al sought to determine the frequency of pericardial lesions, impeding mapping in patients without prior surgery, operative procedure, or pericarditis, in other words virgin hearts. Amongst 155 first time attempts of access, 8% had pericardial lesions. The only clinical predictor was the presence of severe renal impairment.                                 In addition, no patients with supposedly normal hearts had a lesions. Notably, those with a lesion had more frequent impairment in mapping and lower overall success rates; there were similar complication rates as those without the lesions. These data are relevant in highlighting the ease of mapping of pericardial access may not always be present, even when dealing with inversion of pericardial space. A lesion may be present in patients, particularly with severe renal disease. Advising patients of this possibility prior to the procedure and considering that epicardial access may be impaired in a fair number of patients, even the absence of prior history of surgery, epicardial access or pericarditis isn't important.                                 The final article we'll review within the realm of ventricular arrhythmias is by Kumar et al, published in Journal of Cardiovascular Electrophysiology, volume 29 issue one, entitled "Right ventricular scar-related ventricular tachycardia in nonischemic cardiomyopathy: Electrophysiological characteristics, mapping, and ablation underlying heart disease." Kumar et al sought to evaluate the substrate and outcomes associated with right ventricle scar related ventricular tachycardia ablation in nonischemic patients at large, but particularly in those with neither stroke or coronary artery disease as potential explanations for this scar. They reviewed 100 patients consecutively over half of whom had ARVC and the remainder was sarcoid or RV scar of unclear origin. Those with RV scar of unknown origin tend to be older compared to the ARVC patients, and had more severe LV dysfunction compared with saroid patients.                                 However, the scar distribution extend was similar within all these groups. Furthermore VT/VF survival was higher in those with RV scar of unknown origin. The velocity of survival free or death or cardiac transplant and VT/VF survival seen in sarcoid patients. These data suggest that close to one third of patients, RV scar related VT may have VT of unknown cause. Total outcome was superior overall to those with defined myopathic processes. What's most interesting is, over follow up, none of those with RV scar of unknown origin develop any further findings to reclassify them as sarcoid or ARVC. It is possible this group reflects some mild form of either disease however. Again, the exact pathophysiologic process remains unclear. These findings may help in counseling patients who are in long-term expected outcomes from ablation intervention.                                 The final article we'll review this month is within the realm of other EP concepts that may be broadly applicable, published by van Es et al, entitled "Novel methods for electrotissue contact measurement with multielectrode catheters", published in Europace, volume 20 issue one. In this publication, the authors sought to evaluate the potential utility of a novel measure on evaluating electro tissue contact. With multielectrode catheters it is known that one of the problems with assessing contact is a contact force that cannot be used. Electro with coupling index is often used but even this has fragile problems, especially when you get into high impedance areas, that can be affected by surrounding ion impedance structures. Due to the fact that measuring contacts forces challenging in such multielectrode catheters, the authors measure electric interface resistance by applying a low level electrical field, pushing neighboring electrodes. They compared the effectiveness of assessing contact by this approach without using contact force in a poor side model.                                 They know that this measure was directly correlated with contact force in measuring tissue contacts. These findings support a role for aversion of an active electrode location and determining tissue proximity and contact-based on the coupling between the electrodes on multipolar catheters in the tissue. These findings may be highly useful when there is a variety of catheters where contact force cannot be implemented. Further studies on the methods and cutoff to establish tissue proximity on the end of contact will be also needed.                                 To summarize, however, as a term was brilliant here that was not well explained, active electrical location is actually a phenomenon that occurs in nature. This is seen in deep sea fish, which actually have multiple electrodes oriented around its body. They emit a small electrical field that results in a general impedance field surrounding the fish. This essentially is the way of visualizing the world around them. Perturbations based on proximity to different structures, whether they are live or death, and based on whether they are live or death, results in changes in the perturbations of this resistive fields, resulting in proximity determination by the fish. Several individuals are looking into potential applications of this to understanding tissue proximity when using catheters in the body. This consideration of impedance is fundamentally different than the traditional measure impedance were used by traditional generator.                                 I appreciate everyone's attention to this key and hardening articles that we've just focus on or this past month of cardiac electrophysiology across literature. Thanks for listening. Now back to Paul. Dr Wong:             Thanks Suraj, you did a terrific job surveying all journals for the latest articles on topics of interesting in our field. There's not an easier way of staying in touch with the latest advances. These summaries and the list of all major articles in our field for month can be downloaded from the Circulation: Arrhythmia and Electrophysiology website. We hope that you find the journal to be the go to place for everyone interested in the field.                                 See you next month.  

Author Jenny Baker visits with the IKR team to talk body image, finding freedom when you look in the mirror, and what she learned by choosing afternoon sex.

Hosts Alli and Latasha give an introduction to IKR? by sharing their stories, revealing why they decided to start a podcast for women, and admitting they're bad at understanding text abbreviations.

  Paul Wang:         Welcome to the monthly podcast On the Beat for Circulation, Arrhythmia, and Electrophysiology. I'm Dr. Paul Wang, Editor in Chief, with some of the key highlights from this month's issue. We'll also hear from Dr. Suraj Kapa, reporting on new research from the latest journal articles in the field.                                 In our first study, Boris Schmidt and associates studied 134 patients with persistent atrial fibrillation, randomized to laser balloon or wide area circumferential pulmonary vein isolation using irrigated radiofrequency current ablation and 3D mapping.                                 They found that 71% of patients in the laser balloon group had freedom from atrial fibrillation between 90 and 365 days after a single ablation, similar to 69% of patients in the radiofrequency group, p=0.40. In the laser balloon group, one patient developed stroke, one had false aneurysm and one had phrenic nerve palsy. In the radiofrequency group, two patients developed a false aneurysm and one patient needed surgical repair. Procedure and fluoroscopy times were similar between the two groups. The authors concluded that the two methods were associated with similar efficacy in patients with persistent atrial fibrillation.                                 In the next study, Kairav Vakil and associates examined the success of VT ablation in elderly patients who were part of the International VT Center Collaborative Study Group Registry. Of the 2,049 patients in the registry, 33% or 681 were greater than or equal to 70 years of age with a mean age of 75 years.                                 Compared to patients less than 70 years, patients 70 years or greater had higher in-hospital, 4.4% versus 2.3%, p=0.1 mortality, and also a higher one year mortality, 15% versus 11%, p=0.002. But they had a similar instance of VT recurrence, 26% versus 25% and a similar time to recurrence, 280 versus 289 days.                                 The authors concluded that VT ablation in elderly is feasible with reasonable safety and modestly higher in-hospital and one year mortality with similar rates of VT recurrence at a one year compared to younger patients.                                 In the next study, Angel Ferrero-de Loma-Osorio and associates studied the optimal dosage of cryotherapy using cryoballoon ablation of pulmonary veins. The study the prospective, randomized, multicenter, non-inferiority study including 140 patients with paroxysmal atrial fibrillation which was refractory to antirrhythmic drugs.                                 Patients were randomly assigned to a conventional strategy group of 180 seconds cryoablation applications per vein with a bonus freeze 70 patients or a shorter time application protocol with one application that lasted the time required for a electrical time to effect plus 60 seconds and a 120 second freeze bonus, 70 patients.                                 At one year followup there was no difference in freedom from atrial fibrillation 79.4% of the control group versus 78.3% in the study group, p=0.87. The time to effect was detected in 72% of the veins. The study and control group had similar mean number of applications per patient, 9.6 versus 9.9. compared to controls the study group had a significantly shorter cryotherapy time, 28.3 versus 19.4 minutes, p80 or >90, especially when one refers to the appropriate use criteria where appropriateness was reclassified based on what the age range was and what the indication was from a primary prevention defibrillator. Further study is need to understand whether we really should apply an age cutoff to the benefit of ICDs but it is an important thing to consider when counseling patients, especially in light of evolving evidence in this area.                                 Still staying in the realm of heart failure but now going to more basic electrophysiology, we review a paper published in Circulation this past month by Cho et al., entitled Delayed Repolarization Underlies Ventricular Arrhythmias in Rats With Heart Failure and Preserved Ejection Fraction.                                 Increasingly, heart failure with preserved ejection fraction is being diagnosed to the point where it is now approximately half of all diagnosed heart failure with incidences that continue to increase nevertheless. One of the leading causes of mortality in heart failure with preserved ejection fraction is sudden death but the underlying mechanisms for this is less clear.                                 Thus in a rat model, Cho et al., sought to evaluate why heart failure with preserved ejection fraction might result in an increase risk of sudden death. They exposed salt sensitive rats to a high salt diet and evaluated the effect on systolic and diastolic function. After verifying, some rats that suffered from HFpEF at this point versus control rats, they underwent programmed electrical stimulation and they measured corrected QT interval from surface ECG as well. Furthermore they did optical mapping, whole-cell patch clamping and quantitative polymerase chain reaction and Western blotting to evaluate ion channel expression.                                 They noted that 31 of 38 rats exposed to a high salt diet demonstrated diastolic dysfunction and preserved ejection fraction along with signs of heart failure. There was an increased susceptibility to ventricular arrhythmias amongst these particular rats when compared to controls. They also noted that the corrected QT interval was significantly longer. Interestingly optical mapping showed that these rats had prolonged action potentials and multiple reentry circuits during induced ventricular arrhythmias. Furthermore there was confirmed a delay of repolarization based on patch clamping with a downregulation of transient outward potassium currents or ITO. Finally they noted that there was a downregulation of IK1 as well as IKR.                                 Thus they felt that the susceptibility to ventricular arrhythmias was indeed markedly increased, at least in a rat model of HFpEF. These could be caused by QT prolongation, which is associated with delayed repolarization from downregulation of potassium currents and also associated multiple reentry circuits which can mediate ventricular arrhythmia. These findings are significant in that they highlight both potential targets for sudden death risk in the setting of HFpEF as well as potential targets for treatments that might prevent ventricular arrhythmias in the long term.                                 Staying within the realm of ventricular arrhythmias, we next review an article by Do et al., published in the Journal of the American Heart Association this past month, entitled Thoracic Epidural Anesthesia Can Be Effective for the Short‐Term Management of Ventricular Tachycardia Storm.                                 Similar to the earlier discussed article, of optogenetic stimulation of left stellate ganglion, even short term management options for VT storm are important. Some inject lidocaine or bupivacaine into the left stellate ganglion or into both stellate ganglia in order to get control. However, depending on comfort level, the utility of this may be variable at different institutions.                                 Thus, novel therapies aimed at modulating the autonomic nervous system that might be available at other institutions such as thoracic epidural anesthesia are important to consider. The group sought to evaluate via multicenter experience what the effect on VT storm was with thoracic epidural anesthesia.                                 They noted amongst 11 patients reviewed between July 2005 and March 2016 that the majority who underwent thoracic epidural anesthesia had incessant VT with a minority of them being polymorphic VT. Furthermore almost half of them had nonischemic cardiomyopathies. Almost half of the patients had a complete response to thoracic epidural anesthesia where the VT became quiescent. And one patient had a partial response.                                 Thus, they suggested that thoracic epidural anesthesia may be effective and should be considered as a therapeutic option in patients with VT storm, especially those with incessant VT, who are refractory to initial management. They also noted clinically that improvement in VT burden associated with deep sedation may suggest a higher likelihood of responding to thoracic epidural anesthesia. For a clinical electrophysiologist especially in community hospitals where rapid utilization of ablation may not be possible or other advanced methods of autonomic modulation might not be feasible, options such as thoracic epidural anesthesia are important to be considered. They exist in an armament that includes intravenous drugs, left stellate ganglion injections, general anesthesia and use of IV beta blockers. These findings are highly suggestive and the fact that certain clinical characteristics might suggest those that are more likely to benefit might just to clinicians exposed to a patient of VT storm what the next step should be.                                 Changing gears a little bit we will now review an article by Rafaat in the Journal of the American Heart Association entitled Swine Atrioventricular Node Ablation Using Stereotactic Radiosurgery: Methods and In Vivo Feasibility Investigation for Catheter‐Free Ablation of Cardiac Arrhythmias.                                 The group sought to demonstrate using a linear accelerator based stereotactic radiosurgery system whether or not atrioventricular node ablation could be safely performed with minimal damage to surrounding structures. They used the linear accelerator to apply energy in a pig model after implantation of a pacemaker using a CT scan to guide therapy. They also performed pathologic evaluation of the region of the AV node and the surrounding tissues. They found that all animals included had disturbances of AV conduction with progressive transition into complete heart block. There was no damage to the surrounding myocardium and all pigs had preserved systolic function echocardiography.                                 Thus they suggested that catheter free radioablation using this approach might be feasible in an intact swine. These findings are important because they build on other studies done by groups at other centers suggesting that noninvasive linear accelerator based therapies either using stereotactic radiosurgery with existing technologies, proton beams, carbon beams or other approaches, might offer feasible methodologies for noninvasive treatment for cardiac arrhythmias. Further study is indeed needed to validate what the effect on surrounding tissues actually is.                                 Next we will review an article published by Williamson et al., in JACC Clinical Electrophysiology this past month entitled Real-World Evaluation of Magnetic Resonance Imaging in Patients With a Magnetic Resonance Imaging Conditional Pacemaker System.                                 Results of four year prospective followup in over 2,600 patients, while MRI conditional pacemakers are more increasingly used, long term longevity as well as effects of multiple MRI scans in terms of MRI functioning the devices is unclear. Thus, the study was sought to be a large scale, real world evaluation of MRI in patients with MRI conditional pacemakers. They included over 2,600 patients in multiple centers and all these patients had a SureScan pacing system. They noted that there were no MRI related complications occurring during or after the MRI, meeting the primary objective. In fact, almost a third of the patients underwent two or more scans and even then there was no cumulative increase in problems in these patients. The pacing capture thresholds stayed stable throughout all patients.                                 Thus this report constituted the largest longitudinal MRI experience in patients implanted with an MRI conditional device. The importance of this is to be able to highlight to patients that in fact even multiple MRIs despite having a device in place is safe. There is an increasing body of data that suggests that however, MRIs might be safe in a controlled setting, even in patients with legacy pacemakers. Whether MR conditional pacemakers actually offer incremental safety over legacy pacemakers however, is less clear and will likely require randomized trials of a large scale given the low number of events to really come to a conclusion. However, in most centers where it's not possible to do MRIs in legacy pacemakers, this offers some level of certainty that patients will likely be safe even undergoing multiple MRIs in a setting of having chronic pacemakers that are MRI conditionally safe.                                 Staying within the realm of looking at large multicenter experiences, we review an article by Hosseini et al., entitled Catheter Ablation for Cardiac Arrhythmias, Utilization and In-Hospital Complications, 2000 to 2013, published in JACC Clinical Electrophysiology this past month.                                 In this study, Hosseini et al., sought to investigate the overall utilization and in-hospital complications associated with catheter ablation in of all types in the United States between 2000 and 2013 using the National Inpatient Sample and Nationwide Inpatient Samples. They included all patients 18 years of age and older who underwent inpatient catheter ablation over this time period.                                 They estimated total a total of almost 520,000 inpatient ablations performed in this time period with a median age of 62 years amongst patients. Interestingly the annual volume of ablations and the number of hospitals performing ablations increased year over year but the rate of complications and length of stay also increased. A large number, almost more than a quarter of inpatient ablation procedures were actually performed in low volume hospitals and in turn were associated with an increased risk for complications with an odds ratio 1.26. Independent predictors of in-hospital complications and in-hospital mortality included complex ablations for atrial fibrillation and ventricular tachycardia, older age and a greater number of comorbidities. In addition to this, lower hospital volumes was an independent predictor of complications.                                 Thus the authors note that there has been a steady progressive in the number of in-hospital catheter ablation procedures. However, despite the increasing number, the number of periprocedural complications is increasing which may be partly mediated by taking in sicker patients from a complex procedures but also to performing these at lower volume centers. These findings are critical when considering the future of ablation strategies and ablation performance when we consider multicenter experiences or when we consider where certain procedures might be performed based on the experience of the operator or the institution. Why exactly it is that lower volume centers of higher complication rates still needs to be evaluated. However, it should be understood that ablations are  complex procedures and thus require a certain amount of experience in order to allow for procedural efficacy and safety similar to any cardiac surgery or other procedure. It remains to be understood what the number of procedures to be able to be felt to be competent and safe should be. But, these findings should be considered by all providers based on their own personal experience and based their own personal numbers.                                 Staying with the realm of catheter ablation, we will next review an article by Haldar et al., published regarding Catheter ablation vs electrophysiologically guided thoracoscopic surgical ablation in longstanding persistent atrial fibrillation: The CASA-AF Study in last month's edition of Heart Rhythm.                                 In this article, they sought to evaluate catheter ablation outcomes for longstanding persistent atrial fibrillation as compared with those of thoracoscopic surgical ablation. There's a limited amount of data comparing these two methodologies for ablation. They included 51 patients with de novo symptomatic atrial fibrillation. 26 underwent thoracoscopic surgical ablation and the remainder underwent stepwise left atrial ablation with a primary end point being single-procedure freedom from atrial fibrillation and atrial tachycardia lasting >30 seconds without antiarrhythmic drugs at 12 months. They noted that single- and multi procedure freedom from atrial fibrillation was higher in the surgical ablation group than in the catheter ablation group. Namely the overall success rate from the surgical ablation group was 73% versus 32% in the catheter ablation group. It should be noted that there was testing of the surgical ablation lesion set by electrophysiologists that was felt increased success rate in achieving acute conduction block by 19%. It also should be noted that the complication rate in the surgical ablation group, was significantly higher than the catheter ablation group, namely 27% versus 8%. This did not reach statistical significance however, possibly due to the low numbers considered.                                 The conclusion from the authors was that meticulous electrophysiologically guided thoracoscopic surgical ablation as a first line strategy in long standing persistent atrial fibrillation, may provide excellent single procedure success rates as compared with traditional catheter ablation. However again, there is an increased upfront risk of nonfatal complications. These considerations are important when thinking about what strategy to use in specific patients. Whether at a large level, thoracoscopic surgical ablation should be routinely used is still unclear and larger studies are likely needed to compare different modalities of ablation to better evaluate which is the right one for which patients.                                 Again staying in Heart Rhythm in 2017, we next review an article by Sheldon et al., published regarding Catheter ablation in patients with pleomorphic, idiopathic, premature ventricular complexes.                                 When a patient presents with idiopathic PVCs that are a single monomorphic focus, it is often considered reasonable to ablate them. However when patients have pleomorphic PVCs or polymorphic PVCs, the role of ablation is less clear and often considered more complex. Thus in this study, Sheldon et al., sought to evaluate patients who underwent ablation with pleomorphic PVCs. They reviewed about 100 consecutive patients 31% of whom had pleomorphic versus 69% who had monomorphic PVCs, however all of who were considered idiopathic. They noted the overall success rate was lower in patients with pleomorphic PVCs, namely 71% versus 90%. In fact, the presence of pleomorphic PVCs was independently associated with unsuccessful ablation. Also, pleomorphic PVCs more often had an epicardial origin than did monomorphic PVCs. And repeat ablation procedures were required in almost 20% of the cohort. Interestingly, three of the patients who came back for another procedure, had an increase of a nonpredominant PVC and one patient had a newly emerged PVC focus.                                 The conclusion by Sheldon et al. Was the presence of pleomorphic PVCs can affect ablation outcomes but it's still possible to achieve successful elimination of the predominant PVC even if not all PVCs are targeted. Furthermore, they suggested that most recurrences are due to reemergence of the originally targeted predominant PVC morphology though sometimes other PVC morphologies may arise. Larger scale evaluation is still necessary to understand when a patient should be taken to ablation and when not. We recognize that sometimes the presumption of idiopathic might be due to a lack of consideration of other ideologies such as subclinical inflammation that can be related to myocarditis or sarcoidosis or other finding. Thus it should always be considered what the actual underlying substrate is with rigorous imaging such as MRI or PET scanning. However, the findings by Sheldon et al. suggest that just because there are multiple PVC morphologies present, does not necessarily mean that they cannot be ablated.                                 Switching gears away from PVCs, we next review an article by Romero et al. published in Heart Rhythm this past month entitled Emergence of atrioventricular nodal reentry tachycardia after surgical or catheter ablation for atrial fibrillation: Are we creating the arrhythmia substrate?                                 They reviewed patients who had AVNRT ablation performed and sought to evaluate how many of them had prior surgical or catheter ablation for atrial fibrillation. They reviewed cases of ablation for specifically persistent atrial fibrillation who eventually required a repeat ablation procedure and had a diagnosis of AVNRT at that time. A total of nine patients were identified meeting these characteristics. All of these patients were noted to have evidence of atrial fibrosis in the septum or proximal CS, and in fact six had undergone ablation either at the septum or the coronary sinus ostium or body and the other three had inferior mitral lines at a surgical MAZE approach. All had typical AVNRT inducible that was abolished with slow pathway ablation, though five required ablation in the roof of the coronary sinus or on the mitral valve annulus.                                 Thus Romero et al. concluded that ablation involving the septum or proximal CS may create a substrate that can induce AVNRT. These findings are important when we consider ablation. Oftentimes when we do ablation, we think of a targeting substrate without thinking about the substrate we might create. Thus, rigorous evaluation for other mechanisms of tachycardia that one might not think of because of the absence of it during the index ablation should always be considered such as the creation of substrate for AVNRT. While most of us will consider atrial flutters or focal atrial tachycardias or macro reentry atrial tachycardias as the principle mechanisms of tachycardia in patients returning after prior atrial fibrillation ablation should also be considered that we might be creating substrate for other types of arrhythmias such as AVNRT.                                 The next article we will review is published in the American Journal of Physiology, Heart and Circulatory Physiology by Yang et al., entitled Effect of ovariectomy on intracellular calcium regulation in guinea pig cardiomyocytes.                                 It is believed that long-term deficiency of ovarian hormones after ovariectomy can alter cellular calcium handling mechanisms in the heart that can in turn result in the formation of a proarrhythmic substrates. This is important when considering possible arrhythmogenic mechanisms in women who might be undergoing ovariectomy or who might be in a post menopausal state. Thus in a series of animals, they evaluated the effective of ovariectomy as well as estrogen supplementation to ovariectomized animals on calcium handling at the level of the heart. They demonstrated that the ovariectomized guinea pig cardiac myocytes had higher frequencies of calcium waves and isoprenaline challenged cells displayed more early after depolarizations after ovariectomy. In addition to this, they noted the observations of calcium regulation alternations were not observed in myocytes from ovariectomized guinea pigs who were supplemented with 17β-Estradiol suggesting that in fact, these changes in the arrhythmogenic substrate were due to ovarian hormone deficiency resulting in dysregulation of cardiac calcium.                                 While this was all performed at the level of guinea pigs, it is an important consideration again, as a potential mechanisms of cardiac arrhythmogenesis in women who might be undergoing ovariectomy or who might be post menopausal. In some cases ovarian hormones might be beneficial in regulating the arrhythmogenic substrate.                                 The next article we review is published in Heart this past month by Stewart et al., entitled Nitric oxide synthase inhibition restores orthostatic tolerance in young vasovagal syncope patients.                                 Syncope is probably one of the most difficult things that we treat in electrophysiology. In particular, vasovagal syncope. People have looked at different pacing maneuvers and specialized pacemakers for treatments. However, there's improving body of knowledge regarding other mechanisms, specific physiologic mechanisms that might underlie vasovagal syncope. This group in question had previously demonstrated that impaired post synaptic adrenergic responsiveness in those who have vasovagal syncope may be reversed by blocking nitric oxide synthase. Thus, they sought to evaluate volunteers who either had vasovagal syncope or were otherwise healthy, what the effect of a nitric oxide synthase inhibitor would be.                                 They demonstrated that arterial vasoconstriction is impaired in young vasovagal syncope patients but inhibiting nitric oxide synthase could correct this problem. Namely, that this might provide a potential mechanism of avoiding the changes in blood pressure associated with orthostatic intolerance resulting in vasovagal syncope. Whether or not this proves to be an ambulatory therapy still remains to be seen but at least in the acute study state within which these patients were evaluated, it suggests to be a potential promising target.                                 The next paper we review is also published in Heart this past month by Lazzerini et al., entitled Systemic inflammation as a novel QT-prolonging risk factor in patients with torsades de pointes.                                 There is increasing evidence of the role systemic inflammation can play in arrhythmogenesis and particularly in acquired long QT syndrome in patients with sarcoid or myocarditis and other disease states is well recognized that ventricular arrhythmias that are potentially life threatening can happen. What the role of correcting this inflammatory state is, is less clear. However, this group decided to evaluate whether systemic inflammation may represent a currently overlooked risk factor contributing to torsades de pointes in the general population. They looked at 40 consecutive patients who experienced torsades and enrolled them to evaluate circulating levels of different inflammatory biomarkers and compared them with patients with active rheumatoid arthritis, comorbidity or healthy controls. They demonstrated that in the torsades group, 80% of patients showed an elevated inflammatory markers and in fact a definite inflammatory disease was identifiable in 18 of the 40 patients with 12 having acute infections, five having immune mediated diseases and one described as other.                                 Thus they proposed that systemic inflammation via elevated IL-6 levels could represent a novel QT-prolonging risk factor that can contribute to torsades. In their group they showed that CRP reduction was associated with IL-6 level decrease and resulted in QTC shortening. It remains to be seen whether this increased inflammatory pathway might be due to the torsades event itself or the cause. However, it does bring up the interesting question of whether or not systemic inflammation may in fact be causing untoward effects on normal arrhythmic profiles resulting in a greater risk of ventricular arrhythmias.                                 The next article we review is published by Kottkamp et al., entitled Global multielectrode contact mapping plus ablation with a single catheter: Preclinical and preliminary experience in humans with atrial fibrillation in this past month's issue of the Journal of Cardiovascular Electrophysiology.                                 Within the realm of catheter ablation for atrial fibrillation, There's a constant search for new approaches to achieve either more durable or quicker or safer pulmonary vein isolation. It is well recognized that pulmonary vein isolation is the cornerstone of atrial fibrillation ablation. In this particular paper, they sought to evaluate the utility of a catheter, namely a basket catheter that could allow for both diagnostic mapping as well as targeted ablation. This novel catheter has a distal multielectrode array with 16 ribs with 122 gold-plated electrodes. With each electrode being able to ablate, pace and able to measure tissue contact, temperature, current, and intracardiac electrograms. They noted in three patients that complete pulmonary vein isolation was achieved in all 12 and in most veins, PVI was achieved with a single placement in front of that respective vein though in one case there was a single gap requiring reapplication.                                 This suggests a new technique for quote unquote, single shot pulmonary vein isolation. Furthermore, the fact that multiple electrodes could be used to map at the same time as performing ablation, suggest that there might be opportunities for mapping more than just the veins themselves. What the safety and utility of this approach would be over other quote unquote, single shot approaches, such as laser and cryo based balloon systems, is unclear. Furthermore, whether or not they actually reflect a paradigm that offer additional utility due to the ability for more mapping, also remains to be seen. However, the critical portion of understanding these different tools is being able to differentiate them in practice and understanding what their relative values and opportunities are will be critical as one makes selections of which technologies to use.                                 The next article we review is published in Europace this past month by Hellenthal et al., entitled Molecular autopsy of sudden unexplained deaths reveals genetic predispositions for cardiac diseases among young forensic cases.                                 While we recognize that coronary artery disease causes the majority of sudden cardiac deaths in the older population. When we have a young patient who experiences sudden cardiac death, we always have to be concerned about the role of a genetic component. This is not just important for the patient themselves but also for family members who might still be alive. In this study they sought to determine the portion of underlying genetic heart disease among unexplained putative sudden cardiac death cases from a large German forensic departments.                                 The number included were only 10 patients who had sudden unexplained death aged 19 to 40 years. DNA was analyzed for 174 candidate genes and also genetic testing was offered to affected families. Amongst 172 forensic cases again, 10 cases of sudden unexplained death were identified and a genetic disposition was found in eight of 10 cases, with pathogenic mutations in three and variants of uncertain significance in five. Furthermore, subsequent selective screening of the family members revealed two additional mutation carriers in family members who had not suffered from a sudden death event yet.                                 The role of molecular autopsy in patients is evolving. However, the amount of molecular autopsies that are sent are still too low. All patients who are young and die unexpectedly, might benefit from molecular autopsy beyond just traditional forensic pathology to understand whether or not there's a genetic predisposition that led to their event. This might help the family members of that affected individual, especially in understanding whether or not they may also be at risk.                                 The next article we review is by Constantino et al., entitled Neural networks as a tool to predict syncope risk in the Emergency Department in Europace this past month.                                 Many patients when they pass out immediately come into the emergency department. However, it can be very difficult to understand what the risk of that syncope patient is and thus many are automatically admitted to the hospital despite the fact that history might provide a lot of data. In this study, Constantino et al., sought to evaluate the utility for artificial neural networks in stratifying risk in patients presenting with syncope to the hospital. They analyzed individual level data from three prior prospective studies and included a a cumulative sample of 1,844 patients. They included ten variables from patient history, ECG, and the circumstances of syncope to train and test the neural network. They actually had two different approaches used for training and validating neural network given the exploratory nature of the study. They found that they could identify adverse events after syncope with a sensitivity if 95% if they used one approach versus 100% if they used an approach that considers more factors.                                 Thus the study suggested that artificial neural networks could effectively predict the short-term risk of patients with syncope after presenting to the emergency departments. They did not seek to address what the predictive capability of the artificial neural network would be when compared with traditional clinical judgment and existing rule sets that might exist in various emergency departments. The reason this study's important is that as artificial neural networks become more robust we might find that their role in complementing physician decision making might become more and more important. This is especially true on the front lines amongst emergency department physicians or in other groups and consideration of employment of novel technologies or rule sets or methodologies to augment decision making on risk of patients who are being evaluated might need to be considered. It also might help individual stratify patients into those that require sooner evaluation.                                 The final article we review is published in the Journal of Interventional Cardiac Electrophysiology this past month by Schmier et al., entitled Effect of battery longevity on costs and health outcomes associated with cardiac implantable electronic devices: a Markov model-based Monte Carlo simulation.                                 Economic effects of increasing utilization of cardiac implantable electronic devices is of increasing concern. We also note that a lot of focus goes on what the battery life of a device is. However, how that battery longevity might affect overall cost and health outcomes is less clear. Thus in this study, Schmier et al., sought to develop a Monte Carlo Markov model simulation model to evaluate what happens to patients based on the battery longevity. They sought evaluations such as infection and non-infectious complication rates as well as overall costs over the lifetime of that individual patient. These outcomes were largely derived from Medicare data. They noted that an increase in battery longevity was an associated reduction in the number of revisions needed by 23%, the number of battery changes needed by 44%, the number of infections by 23%, the number of non-infectious complications by 10% and total costs per patient by 9%.                                 Thus, they demonstrated that using batteries that have longer longevity could be associated with fewer adverse outcomes and reduced healthcare costs. The understanding of the magnitude of the cost benefits of extended battery life is critical and how to optimize the battery life is also critical. It might be that as we move forward, when encountering a situation or a patient in which the battery life is far less than expected, consideration of the reasons why that battery life was limited will be critical in order to optimize the ongoing chronic care of that patient. Both to reduce the burden on the healthcare system and to improve that individual patient's long term outcomes in terms of infectious risk or other issues.                                 This is primarily simulation model and was not necessarily tested in a prospective fashion though this would be quite difficult given the long duration over which would be required to see a lot of these beneficial costs and complication rate effects. However, it is provocative in the fact that it allows us to understand that there might be benefits from taking further care in selecting not just the right device based on indication but the right device based on patient age, the number of general changes one expects a patient to have and what the longevity of that patient is expected to be.                                 I appreciate everyone's attention in these key and hard hitting articles that we have just focused on from this past months of cardiac electrophysiology across the literature. Thanks for listening. Now back to Paul. Paul Wang:         Thanks Suraj. You did a terrific job surveying all journals for the latest articles on topics of interest in our field. There's not an easier way to stay in touch with the latest advances. These summaries and a list of all major articles in our field each month can be downloaded from the Circulation, Arrhythmia and Electrophysiology website. We hope you'll find the journal to be the go to place for everyone interested in the field. See you next month.    

Professional philanders and side hustles are being discussed on this episode. Joan’s new man that she met at work (IKR) has a wife? Or is it Toni’s bae? Lynn found her entrepreneurial stride in jewelry making and it potentially saved several lives. HAPPY BIRTHDAY TRACEE ELLIS ROSS! Girlfriends – The Importance of Being Frank  – … Continue reading "The Importance of Being Frank (S1E11)"

Today, I talk about living in gratitude in how sepsis kills. Ikr, what a combo, lol! --- This episode is sponsored by · Anchor: The easiest way to make a podcast. https://anchor.fm/app

This weeks episode the crew get together and hit on topic of Mother's day, Derek Fishers' fishy behavior, KFC new chicken flavored nail polish, Harriet Tubman on new money as well as color changing condoms. Ikr! Lol enjoy.

European Lab forum 6e édition Europe de la culture : année zéro 4 — 8 mai 2016 Vers une ville ouverte, Séoul Dans le cadre des années croisées France-Corée en collaboration avec l'Institut français. Notre vie à l’intérieur comme à l’extérieur des la ville s’articule autour du vivre ensemble autant que de l’expérimentation de l’architecture et de la technologie. Parfois les villes, comme les ordinateurs, peuvent paraître froides, cryptées ou inaccessibles, comme dans une boîte noire. Les citadins n’ont qu’un contrôle limité sur la façon dont leurs espaces sont pensés, construits et l’utilisation qui leur est proposée. L’infrastructure des villes reflète les dynamiques de pouvoirs de la société contemporaine, ses inégalités et son hostilité. Comment déconstruire la technocratie qui ne cesse d’accélérer les programmes d’urbanisation ? Comment apprendre du passé pour imaginer la ville du futur? En réponse aux inquiétudes grandissantes concernant la privatisation, la gentrification et le réaménagement des espaces urbains ; artistes, architectes et activistes regorgent de propositions créatives. Cette conférence sera l’occasion pour un groupe de professionnels sud-coréens d’échanger sur la nécessité de repenser le commun, de créer des espaces et des communautés alternatives afin de rapprocher les espaces urbains d’un monde où nous aimerions habiter. Intervenants : Binna Choi • Unmake Lab I KR Taeyoon Choi • School for Poetic Computation I KR  Seung Yoon Choi • Chorégraphe I KR ------------------------------------------------------------------------------------------------ European Lab forum 6th edition Europe of culture : year zero 4 — 8 may 2016 Towards an open city, Seoul Our life in and out of the city revolve around technology, architecture and built environment. Cities, like the computers, are often enclosed, encrypted and abstracted in a black box. This condition results the city inhabitants having a limited control of how the spaces are made and used. The infrastructure of cities reflect the power dynamics of contemporary society, and the inequalities and intolerable hostilities. How to deconstruct technocracy that accelerates urban programs? How to learn from the past to envision the future city? In response to the growing concerns about privatization, gentrification, and redevelopment in urban space, there’s a burst of creative activities by artists, architects, activists in South Korea. In this panel, a group of practitioners will discuss ways of creating alternative spaces and communities to make urban spaces closer to the world we want to live. Speakers : Binna Choi • Unmake Lab I KR Taeyoon Choi • School for Poetic Computation I KR Seung Yoon Choi • Chorégraphe I KR

Dalsland har liknats vid ett Sverige i miniatyr - här finns bördig jordbruksbygd, karga sprickdalslandskap och kalkrika skifferområden. Det omväxlande landskapet ger också upphov till en varierad svampflora och under veckan kommer mykologer från hela landet att finkamma trakterna runt den berömda akvedukten i Håverud i jakt på intressanta fynd och rariteter. Vår fältreporter Elin Lemel sände direkt ifrån mykologiveckan i Håverud. Guidade gjorde bland andra Jan Olsson från Göteborgs svampklubb. Mitt i centrala Tromsø i Norge ligger Prestvannet, som på många sätt är en typisk parkdamm. Längs stranden går en promenadslinga, här finns parkbänkar och pensionärer som matar änder med brödsmulor. Samtidigt ligger Prestvannet - precis som hela Tromsø - på en nordnorsk holme mellan höga fjäll. Änder och pensionärer spatserar mellan knotiga fjällbjörkar, gångvägen löper längs en hjortronmyr och här och där lyser fjällvioler gult i grönskan. Sjön är en märklig mix av kommunalt rekreationsområde och arktisk tundra, och just här häckar en mycket speciell fågel - smålommen. Den sover långa stunder, eller sitter stilla och låtsas vara en trädrot, men rätt vad det är kan den resa sig upp och dansa balett under höga tjut. Biologen och fotografen Fredrik Broms tog oss med på urban fågelskådning i Nordnorge. Döda ekar är som bekant till nytta för många organismer. En sådan art är den bredbandade ekbarkbocken. Ett långt namn, men själva skalbaggen är en vacker historia i svart och gult. Ekbarkborren för en tynande tillvaro på Djurgården i Stockholm, men på Nordens Ark i Bohuslän är man i färd med att försöka föda upp fler för att förstärka beståndet. I Kråkvinkeln denna vecka hörde vi Erik Kohlström - om något man kan bränna sig på! Programledare var Lasse Willén.

Det ska komma att bli en av Säkerhetspolisens största publika framgångar någonsin; avslöjandet i april 1977 om att en svensk terrorgrupp, ledd av västtysken Norbert Kröcher, har planerat att kidnappa före detta statsrådet Anna-Greta Leijon. Bakgrunden är Leijons medverkan i utvisningen av de fem överlevande terroristerna från Västtyska ambassaddramat två år tidigare. Det är en utvisning som blir starkt ifrågasatt då en av ockupanterna, Siegfried Hausner, avlider efter ankomsten till Västtyskland. I Kröchers ögon bär Anna-GretaLeijon ansvaret för Hausners död och tiden efter ambassaddramat ska planläggningen av ”Operation Leo” växa till enorma proportioner och även involvera flera svenskar och utländska ”revolutionärer” i Kröchers närhet. Men när polisen gör sitt omfattande tillslag, grips även flera personer som ska visa sig vara helt oskyldiga. Bland dem den blivande riksdagsledamoten Juan Fonseca som trots frikännandet ska tvingas dras med terroriststämpeln en lång tid framöver. Producent: Fredrik Johnsson

De kallas pseudoskorpioner, bokskorpioner eller klokrypare - i Sverige känner vi till 21 olika arter av de här små rovdjuren. De liknar sina släktingar skorpionerna bortsett från att de saknar gifttagg på bakkroppen. Främsta sätt att transportera sig är liftning! Naturmorgons fältreporter Lena Näslund träffar entomologen och fotografen Stanislav Snäll på Södertörn för att portättera några mycket spännande små djur. Klicka på länken nedan för att se en film från inspelningen, och höra reportaget igen! Ett betydligt större djur besöker regelbundet Hunnebostrand i Bohuslän. Han har fått namnet Herbert, och han gillar att äta fiskrens. Hör Sara Malmcrona berätta mer! Pyttesmå fåglar ska vi också stifta närmare bekanskap med: kolibrier. Dessa små och skimrande nektarätare är världsmästare på att hovra - de kan inte bara stå alldeles stilla i luften och besöka blommor, utan också flyga baklänges! Elin Lemel har träffat kolibriforskare på University of California Berkely. Reportaget och Elins bilder hittar du nedan! I Kråkvinkeln denna vecka hör vi Jenny Berntson Djurvall berätta om en imponerande blomsterbok. Programledare är Lasse Willén.

Ventrikuläre Tachyarrhythmien sind die Hauptursachen für den plötzlichen Herztod, der eine bedeutende Todesursache in der westlichen Welt darstellt. Dabei sind, neben strukturellen Veränderungen im Myokard wie Narben, Hypertrophie oder Ventrikeldilatation, elektrophysiologische Veränderungen der Repolarisationsphase ursächlich. Für die Repolarisation essentielle Kanäle sind die delayed rectifier Kaliumkanäle IKr und IKs; Mutationen in diesen Kanälen sind ursächlich für das angeborene Long QT-Syndrom, das mit lebensbedrohlichen Herzrhythmusstörungen assoziiert ist. Pharmakologische Wirkungen und Nebenwirkungen auf die repolarisierenden Kaliumkanäle können ebenfalls Herzrhythmusstörungen auslösen; man spricht dabei vom erworbenen oder Medikamenten-induzierten Long QT-Syndrom. Auch bei Herzinsuffizienz zum Beispiel aufgrund einer dilatativen Kardiomyopathie wird oft eine QT-Zeit Verlängerung und Rhythmusstörungen beobachtet. Dabei ist die Herunterregulation von Kaliumkanälen wie Ito ein oft beobachtetes Phänomen; in tierexperimentellen Untersuchungen wird teilweise auch eine Reduktion von IKr und IKs beschrieben. Für viele Ionenkanäle sind Unterschiede in der transmuralen Verteilung bekannt, so dass die Messung der delayed rectifier Kaliumkanäle in vorliegender Untersuchung getrennt nach subepikardialen, mittleren und subendokardialen Arealen des linksventrikulären Myokards durchgeführt wurde. Ein weiterer Aspekt der Arbeit ist der Vergleich der Repolarisation in verschiedenen Spezies, was bei der Interpretation von tierexperimentell gewonnenen Ergebnissen von großer Bedeutung ist. Dazu wurden IKr und IKs in verschiedenen Tiermodellen (Meerschweinchen, Schwein und Hund) unter Berücksichtigung der transmuralen Verteilung gemessen und mit den aus humanem Myokard gewonnenen Ergebnissen verglichen. Die porenbildenden alpha-Untereinheiten von IKr und IKs, KCNH2 und KCNQ1, wurden im heterologen Zellsystem exprimiert und deren Sensitivität auf IKr bzw. IKs spezifische Kanalblocker überprüft. Methodisch wurde für oben genannte Fragestellungen die patch clamp Technik in Ganzzellkonfiguration verwendet; zur Aufzeichnung von Aktionspotentialen und zum Nachweis von IKs in humanem Myokard wurde die perforated patch Methode verwendet, um eine Veränderung des intrazellulären Milieus mit Dialyse von Botenstoffen zu vermeiden. Auf molekularbiologischer Ebene wurde die mRNA-Menge der IKr und IKs alpha-Untereinheiten KCNH2 und KCNQ1, sowie deren (potentielle) beta-Untereinheiten KCNE1 und KCNE2 mit Hilfe der quantitativen real-time PCR bestimmt. Dabei konnten folgende Ergebnisse erzielt werden: IKr ließ sich im Menschen in allen Zellen in relevanter Größe nachweisen; der Strom ließ sich sowohl durch den spezifischen IKr-Blocker Dofetilide, aber auch durch Pharmaka aus nicht-kardiologischen Anwendungsgebieten wie das Neuroleptikum Haloperidol inhibieren. Dabei wies der Kanal eine Abhängigkeit von der extrazellulären Kaliumkonzentration auf, die sich umgekehrt zum elektrochemischen Gradienten verhielt: höhere extrazelluläre Kaliumkonzentrationen bewirkten eine Steigerung von IKr. IKs (definiert als HMR 1556 sensitiver Strom) ließ sich in humanem Myokard nur unter speziell optimierten Bedingungen (perforated patch Technik, adrenerge Stimulation mit Isoproterenol) nachweisen. Er hatte dann eine sehr kleine Stromdichte, die eine weitere elektrophysiologische und pharmakologische Charakterisierung nicht erlaubte. In Meerschwein, Schwein und Hund war IKr und IKs nachweisbar; dabei hatte das Meerschweinchen die höchsten Stromdichten von delayed rectifier Kaliumkanälen, das Schwein kleinere, aber robuste IKr und IKs-Ströme. Beim Hund fanden sich deutlich geringere Stromdichten für IKr und IKs; IKs war nicht in allen Zellen nachweisbar. IKr wies in allen Spezies epikardial eine kleinere Stromdichte auf als in mittleren und endokardialen Arealen. Dieser transmurale Gradient mit geringerer Stromdichte in epikardialen Arealen war nur in nicht-insuffizienten humanen Herzen nachweisbar; bei Herzinsuffizienz kam es zur Angleichung der Stromdichten in allen drei untersuchten Schichten. KCNH2 und KCNQ1 generierten im heterologen Zellsystem IKr bzw. IKs ähnliche Ströme, die jeweils typische Sensitivität für IKr bzw. IKs Blocker aufwiesen. Für KCNH2 und KCNQ1 mRNA waren keine transmuralen Gradienten und keine Regulation bei Herzinsuffizienz nachweisbar; KCNE1 und KCNE2 zeigten bei Herzinsuffizienz höhere Expressionslevel. Somit ließ sich das Vorhandensein und die Bedeutung von IKr und IKs in humanem Myokard belegen, wobei IKs nur in sehr geringer – in Ruhe gerade noch nachweisbarer – Stromdichte vorkommt. Dennoch lässt sich seine Bedeutung am Vorhandensein von Mutationen in KCNQ1, die lebensbedrohliche Rhythmusstörungen verursachen können, ablesen. Auch für KCNH2, das für die alpha-Untereinheit von IKr kodiert, sowie für die (potentiellen) beta-Untereinheiten KCNE1 und KCNE2 sind Mutationen beschrieben, die ursächlich für das angeborene Long QT-Syndrom sind. Damit scheinen IKr und IKs für die Repolarisation des humanen Aktionspotentials essentiell zu sein, wobei IKr aufgrund der relativ großen Stromdichte die wesentliche Rolle bei der Repolarisation des Aktionspotenials in humanem Myokard zukommt. IKs hat große Bedeutung als „Repolarisationsreserve“ zur Stabilisierung der Repolarisation unter Bedingungen erhöhter Katecholaminspiegel, bei tachykarden Herzfrequenzen und bei verzögerter Repolarisation wie durch Hypokaliämie, IKr-Blocker oder IKr-Mutationen und Polymorphismen. Mutationen in Proteinuntereinheiten von IKs können zur Störung dieser Repolarisationsreserve führen und somit Rhythmusstörungen auslösen, die charakteristischerweise in Situationen erhöhter sympathischer Aktivierung auftreten. Die Ausstattung der unterschiedlichen Spezies mit repolarisierenden Kaliumströmen wies erhebliche Unterscheide auf, was bei der Interpretation tierexperimentell gewonnener Daten zu berücksichtigen ist. Insbesondere korreliert eine Abnahme der Ruheherzfrequenz der Spezies mit einer deutlichen Reduktion der repolarisierenden Ströme entsprechend dem Konzept der speziesabhängigen Variabilität der repolarisierenden bei Konstanz der depolarisierenden Ströme (INa und ICa). Transmurale Unterschiede in der Expression von Ionenkanälen scheinen notwendig für den Ablauf der Erregungsbildung und Erregungsrückbildung zu sein. Die epikardial geringeren Stromdichten für IKr waren in allen untersuchten Spezies nachweisbar. Die Beobachtung einer geringeren Stromdichte der repolarisierenden Kaliumströme epikardial bedeutet, dass andere Ionenkanäle als IKr und IKs für die dort kürzere Aktionspotentialdauer verantwortlich sein müsssen. Eine Reduktion der Stromdichte bei Herzinsuffizienz, wie sie beispielsweise für Ito beschrieben ist, konnte für IKr nicht nachgewiesen werden. Jedoch fand sich eine Nivellierung des physiologischerweise Vorhandenen transmuralen Gradienten, was grundsätzlich zu einer Störung des physiologischen Erregungsablaufes mit Begünstigung von Rhythmusstörungen in insuffizienten Herzen beitragen könnte. Aus dem dualen Repolarisationsmechanismus im menschlichen Ventikelmyokard werden klinische Konstellationen mit Rhythmusstörungen verständlich, insbesondere in Hinblick auf die Variabilität der Empfindlichkeit gegenüber Medikamenten mit blockierender Wirkung auf IKr. Dabei stellt IKs in unterschiedlichem Maße eine Kompensation im Sinne einer Repolarisationsreserve bereit.