Podcasts about Incidence

The February 2023 Neurology Recall showcases four dynamic interviews about Pre-Symptomatic Findings in Neurodegeneration. This episode features conversations with Dr. Sana Aslam on the clinicopathologic correlations of jaw tremor, followed by an interview with Dr. Valeria Iodice on diagnosing pre-motor multiple system atrophy, leading into an interview with Dr. Joe Verghese on olfactory dysfunction and  incidence of motoric cognitive risk syndrome. This month's Recall concludes with a conversation with Dr. Rafael Romero on the correlation between perivascular spaces visible on MRIs and the risk of incident dementia.  Associated Articles:  Clinicopathologic Correlations of Jaw Tremor in a Longitudinal Aging Study Diagnosing Premotor Multiple System Atrophy Natural History and Autonomic Testing in an Autopsy-Confirmed Cohort  Olfactory Dysfunction and Incidence of Motoric Cognitive Risk Syndrome A Prospective Clinical-Pathologic Study  MRI-Visible Perivascular Spaces and Risk of Incident Dementia The Framingham Heart Study 

Commentary by Dr. Valentin Fuster

On this week's podcast, Drs.Feigenbaum and Baraki review sudden cardiac death in sport. Sponsors: https://generalleathercraft.com/ References: 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death https://www.sciencedirect.com/science/article/pii/S0735109717413052?via%3Dihub AHA Exercise-Related Acute Cardiovascular Events and Potential Deleterious Adaptations Following Long-Term Exercise Training https://pubmed.ncbi.nlm.nih.gov/32100573/ Incidence of sudden cardiac death in athletes: a state-of-the-art review https://bjsm.bmj.com/content/48/15/1185 Sudden Cardiac Arrest during Participation in Competitive Sports https://pubmed.ncbi.nlm.nih.gov/29141175/ Myocarditis Cases Reported After mRNA-Based COVID-19 Vaccination in the US From December 2020 to August 2021. https://pubmed.ncbi.nlm.nih.gov/35076665/ Cardiac Complications After SARS-CoV-2 Infection and mRNA COVID-19 Vaccination - PCORnet, United States, January 2021-January 2022. https://pubmed.ncbi.nlm.nih.gov/35389977/ Upper and lower limits of vulnerability to sudden arrhythmic death with chest-wall impact (commotio cordis) https://www.sciencedirect.com/science/article/pii/S0735109702026694?via%3Dihub Sudden death in young adults: a 25-year review of autopsies in military recruits https://pubmed.ncbi.nlm.nih.gov/15583223/ Performance enhancing drugs (doping agents) and sudden death--a case report and review of the literature https://pubmed.ncbi.nlm.nih.gov/9728754/ Upper and lower limits of vulnerability to sudden arrhythmic death with chest-wall impact (commotio cordis) https://www.sciencedirect.com/science/article/pii/S0735109702026694?via%3Dihub 2019 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias https://www.hrsonline.org/guidance/clinical-resources/2019-hrsehraaphrslahrs-expert-consensus-statement-catheter-ablation-ventricular-arrhythmias AHA Screening 2020 https://www.ahajournals.org/doi/10.1161/JAHA.120.016332 Policies to Prevent Sudden Cardiac Death in Young Athletes: Challenging, But More Testing Is Not the Answer https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428526/ Seminars https://www.barbellmedicine.com/seminars/ For more of our stuff: App: https://tinyurl.com/muus5pfn Podcasts: goo.gl/X4H4z8 Website: www.barbellmedicine.com Instagram: @austin_barbellmedicine @jordan_barbellmedicine @leah_barbellmedicine @vanessa_barbellmedicine @untamedstrength @derek_barbellmedicine @hassan_barbellmedicine @charlie_barbellmedicine @alex_barbellmedicine @tomcampitelli @joe_barbellmedicine @rheece_barbellmedicine @cam_barbellmedicine @claire_barbellmedicine @ben_barbellmedicine @cassi.niemann @caleb_barbellmedicine Email: info@barbellmedicine.com Supplements/Templates/Seminars: www.barbellmedicine.com/shop/ Forum: forum.barbellmedicine.com/

Today Claire and Erin discuss the work and teachings of Ray Dorsey, M.D. a professor at the University of Rochester Medical Center. Dr. Dorsey came to speak at Rogue recently to share his research. Parkinson's is now the fastest growing neurologic disease in the world. There are 3 main reasons a person may be more predisposed to getting PD that are modifiable. He wrote a book titled “Ending Parkinson's” and shares the evidence for what causes PD and his views for how to end it. Incidence of Parkinson disease in North America (open access article): https://www.nature.com/articles/s41531-022-00410-y Preventing Parkinson's with Ray Dorsey webcast: https://youtu.be/mqYpE5wEPJE Ending Parkinson's the book by Ray Dorsey: https://endingpd.org

Dr. Juliana H. VanderPluym discusses her paper, "Incidence of Status Migrainosus in Olmsted County, Minnesota, United States: Characterization and Predictors of Recurrence". Show references: https://n.neurology.org/content/early/2022/09/29/WNL.0000000000201382

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Dr. Tesha Monteith talks with Dr. Juliana VanderPluym, about the incidence, recurrence and clinical association of status migrainosus in Olmsted County Minnesota. Read the full article in Neurology.

Featuring perspectives from Drs Erika Hamilton, Sara Hurvitz, Ian Krop, Shanu Modi and Sara Tolaney, including the following topics: Optimizing the Management of Localized HER2-Positive Breast Cancer Introduction (0:00) Case: A woman in her mid 60s with pulmonary hypertension and triple-positive, node-positive infiltrating ductal carcinoma (IDC) after neoadjuvant TCHP and clinical complete remission — Susmitha Apuri, MD (4:31) Case: A woman in her early 60s with a 1.7-cm, triple-positive, clinically node-negative IDC — Ranju Gupta, MD (10:05) Dr Tolaney presentation (18:44) Current Considerations in the Treatment of HER2-Positive Metastatic Breast Cancer (mBC) Case: A woman in her early 60s with an 8-cm, ER-negative, PR-positive, HER2-positive IDC and positive nodes bilaterally after neoadjuvant TCHP and bilateral mastectomies with no residual disease — Henna Malik, MD (31:12) Case: A woman in her late 50s with Stage IIIA, ER/PR-negative, HER2-positive, node-positive IDC with residual disease after neoadjuvant TCHP and mastectomy — Laila Agrawal, MD ()35:29 Dr Krop presentation (42:56) Management of HER2-Positive Breast Cancer with CNS Metastases Case: A woman in her early 90s with “mild” dementia and ER/PR-negative, HER2 IHC 1+ IDC with symptomatic chest wall recurrence after neoadjuvant paclitaxel/trastuzumab and lumpectomy — Alan B Astrow, MD (54:54) Case: A woman in her late 40s with a triple-positive multifocal IDC with a gBRCA2 mutation and HER2-negative axillary nodes after neoadjuvant TCHP and bilateral mastectomies with significant response in the breast but 49 positive nodes — Zanetta S Lamar, MD (1:00:01) Dr Hamilton presentation (1:06:51) Recent Appreciation of HER2 Low as a Unique Disease Subset; Future Directions in the Management of HER2-Positive and HER2-Low Breast Cancer Cases: A premenopausal woman in her late 30s with a triple-positive IDC who develops brain metastases while receiving THP; A woman in her late 60s with an ER/PR-negative, HER2-positive IDC who develops brain metastases after first-line THP and second-line T-DM1 — Kelly Yap, MD & Rohit Gosain, MD (1:20:46) Case: A woman in her mid 60s with ER/PR-negative, HER2-positive mBC treated with paclitaxel/trastuzumab, then T-DXd on progression — Joanna Metzner-Sadurski, MD (1:29:40) Dr Modi presentation (1:40:51) Incidence and Management of Adverse Events Associated with HER2-Targeted Therapy Case: A woman in her early 60s with recurrent triple-positive mBC whose disease converts to HER2-negative, PIK3CA-positive at the time of progression — Dhatri Kodali, MD (2:01:10) Dr Hurvitz presentation (2:05:08) CME information and select publications

While masks might not do much to mitigate the spread of certain illnesses, apparently they can help prevent racism. Yes, this is every bit as crazy as it sounds. So let's look at the article, the research, and discuss the legitimate solutions to these issues. Boston researchers: Masking children in schools can reduce effects of 'structural racism' - Must Read Alaska Lifting Universal Masking in Schools — Covid-19 Incidence among Students and Staff | NEJM --- Support this podcast: https://anchor.fm/factcheckthis/support

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Episode Length: 24:10 Welcome to the KeyLIME Holiday Special “re run” series!  We're going to continue our trip down memory lane by sharing our annual Holiday Specials from the last four years.  Our second holiday special appeared in 2019, and featured the following articles: 1) O'Reilly-Shah VN et al. Is it time to start using the emoji in biomedical literature? BMJ 2018; 363 (Jon Sherbino's pick) 2) Danziger S et al.Extraneous factors in judicial decisions. Proc Natl Acad Sci USA. 2011;108(17):6889-92. (Lara Varpio's pick) 3) Rockwood K et al. Incidence of and risk factors for nodding off at scientific sessions. CMAJ. 2004;171(12):1443-5. (Linda Snell's pick) 4) Fengqin L et al. It takes biking to learn: Physical activity improves learning a second language. PLoS One. 2017;12(5):e0177624. (Jason Frank's pick) Follow our co-hosts on Twitter! Jason R. Frank: @drjfrank  Jonathan Sherbino: @sherbino  Linda Snell: @LindaSMedEd  Lara Varpio: @LaraVarpio Lara Varpio's Disclaimer: The views expressed in this manuscript are solely those of the authors and do not necessarily reflect those of the Uniformed Services University of the Unites States Department of Defense.  Want to learn more about KeyLIME? Click here! Full transcript for this Episode is available upon request.

Commentary by Dr. Alan Jaffe

On Episode 23 of the Stroke Alert Podcast, host Dr. Negar Asdaghi highlights two articles from the December 2022 issue of Stroke: “Direct, Indirect, and Combined Extracranial-to-Intracranial Bypass for Adult Moyamoya Disease” and “Contemporary Incidence and Burden of Cerebral Venous Sinus Thrombosis in Children of the United States.” She also interviews Drs. Koji Tanaka and Andrew Demchuk about article “Significance of Baseline Ischemic Core Volume on Stroke Outcome After EVT in Patients Age ≥75 Years.” Dr. Negar Asdaghi:         Let's start with some questions. 1) Is direct bypass better than indirect bypass in preventing the future risk of vascular events in adult patients with moyamoya disease? 2) What is the contemporary incidence of cerebral venous sinus thrombosis in the pediatric population? 3) And finally, is endovascular therapy beneficial for patients presenting with a large ischemic core? We have the answers and much more in today's podcast. You're listening to the Stroke Alert Podcast, and this is the best in Stroke. Stay with us. Welcome back to another issue of the Stroke Alert Podcast. My name is Negar Asdaghi. I'm an Associate Professor of Neurology at the University of Miami Miller School of Medicine and your host for the monthly Stroke Alert Podcast. In our final podcast for the year, I'm thrilled to announce that Drs. Nastajjia Krementz and Eric Goldstein have joined our podcast as assistant editors to help us cover the latest and the best in the field of cerebrovascular disorder. And together, here's our article selection to close the year. As part of our Advances in Stroke, in the article titled "Focus on Anticoagulation for Valvular Heart Disease With and Without Atrial Fibrillation," we get an update on current evidence from randomized controlled trials on the use of direct oral anticoagulants or vitamin K antagonists in patients with valvular heart disease that are mechanical valves, moderate to severe mitral stenosis, or bioprosthetic valves from the perspective of stroke physicians. What that means is that data from randomized trials was analyzed based on whether the patient had a prior history of stroke or TIA. In this review, we learned that direct oral anticoagulants may be used in patients with bioprosthetic valves who have atrial fibrillation, although DOACs have never been shown to be superior over vitamin K antagonists. We also learned that vitamin K antagonists should be used in patients with rheumatic moderate to severe mitral valve stenosis or patients with mechanical valves with or without atrial fibrillation and, of course, sometimes during the first few months after either surgical or transcatheter aortic valve replacement in patients without atrial fibrillation. And finally, patients with bioprosthetic valves without AFib don't have any other indications to be treated with anticoagulants should be treated with antiplatelet monotherapy in the long run. In a separate article in this issue of the journal, from Dr. Yang and colleagues from China, we learn about the pathophysiology of radiation-induced brain injury with special attention to radiation-induced vasculopathy. These investigators show that hyperactivity of notch signaling pathway that in normal state is essential in vascular morphogenesis and maintenance of arterial identity actually results in abnormal accumulation and disturbance of vascular smooth muscle cells, resulting in arterial muscularization and arterial dysfunction seen in radiation-induced vasculopathy. What's interesting is that inhibition of the notch signaling pathway in their study resulted not only in a measurable reduction in radiation induced vasculopathy, but also an overall improvement in radiation-induced brain injury as measured by the cognitive function of the mice exposed to radiation in their study. This study takes us a step closer to possible therapeutic options for radiation-induced vasculopathy and radiation-induced brain injury using compounds that can potentially inhibit the notch signaling pathway. As always, I encourage you to review these articles in detail in addition to listening to our podcast. For our interview today, I have a special guest who's not only a prominent researcher and a pioneer in the field of acute stroke therapies, but also, he's an experienced educator who has trained many of the current leaders in the field of vascular neurology and has been influential in shaping the careers of many vascular neurology fellows over the years. Take a listen. Dr. Andrew Demchuk:   I've had the privilege of training fellows. I've been the director since 2004, and we've trained close to 100 fellows in Calgary over 20-some years now. Really, it's frankly an honor and privilege to be able to do that. These individuals come from all over the world. They're here to dedicate themselves to learning a subspecialty really, really well, and it's just a fantastic experience to interact with them all and all their cultures to help them learn those things, and doing it in a fun, enjoyable, comprehensive way. Dr. Negar Asdaghi:         And those are the words of Dr. Andrew Demchuk, who's incidentally my own vascular fellowship director as well. Andrew joins me all the way from Canada to talk about his latest paper on the very hot topic of outcomes of endovascular therapy in patients presenting with a large ischemic core. And true to form, he's accompanied by one of his current vascular fellows. The interview is definitely worth the wait after we review these two articles. Most of us have heard of the term "moyamoya." First described in Japan in 1950s, the term refers to occlusion or stenosis of the terminal portion of the internal carotid artery and is associated with dilated collateral vessels of the proximal middle cerebral artery. These collaterals have a hazy appearance on angiography resembling the puff of smoke, which is Japanese for "moyamoya." Moyamoya is categorized into two broad categories of moyamoya syndrome and moyamoya disease. Syndrome refers to the situations where the occlusion occurs due to another condition. Conditions such as Down syndrome, sickle cell disease, neurofibromatosis type one have all been recognized as associated with moyamoya syndrome. Of course, moyamoya syndrome can occur due to a secondary insult to the blood vessels, anything from radiation vasculopathy, as we reviewed earlier in the podcast, to autoimmune vasculitis, or even good old advanced intracranial atherosclerosis involving the distal ICA region can cause moyamoya syndrome. Now, in contrast to moyamoya syndrome, the term "moyamoya disease" is reserved for individuals with no vascular risk factors or known moyamoya predisposing conditions other than, of course, some potential genetic factors. The most recognized genetic association for moyamoya disease is polymorphism in the ring finger protein 213, or RNF213, gene on chromosome 17. But we also have to keep in mind that the majority of moyamoya disease patients have no identified genetic abnormalities. So, moyamoya is truly a complex condition, and the physicians have to navigate the many possible etiologies that may cause or be associated with this condition. But when it comes to treatment options, we're really limited here. Antiplatelets are generally used and have been shown to reduce mortality in both moyamoya disease and syndrome, and especially cilostazol, which is the favorite antiplatelet therapy of our own assistant editor, Eric, has been shown to be significantly associated with increased survival rate in patients with moyamoya disease. Eric really wanted me to talk about a recently published study out of Korea, which included over 9,000 patients, and that showed that patients treated with cilostazol had a better survival rate than any other antiplatelet therapies. Apart from antiplatelet therapies, medical treatment includes optimizing all other vascular risk factors, which, as we mentioned, are rarely present in this population. So, it all comes down to most cases, at some point, needing surgical treatment, with bypass surgery being the most commonly surgical intervention for this population. Three flavors of bypass are used: indirect, direct, or combination of the two. Indirect bypasses are kind of like long-term investments where the surgeon moves vascular tissue to the surface of the brain in hopes of promoting angiogenesis. Several procedures, such as performing multiple burr holes, pial synangiosis, dural inversion, or omental transposition, among other methods, are used. And broadly speaking, we can think of indirect procedures as angiogenesis-dependent methods, the effect of which takes months to recognize and, in general, are thought to be more efficacious in the pediatric population than the adult population. The direct bypass, in contrast, commonly referred to as extracranial-to-intracranial, or ECIC, bypass, is more of an immediate reward where the surgeon stitches a vessel directly from a donor extracranial branch, typically the superficial temporal artery, to a recipient artery, typically the middle cerebral artery, to provide a direct anastomosis between the two vessels. There are technical variations, of course, especially with regards to the number of donors and recipient arteries used, but essentially this method is an angiogenesis-independent method that results in a quicker revascularization, but it's unclear if this strategy is long lasting. A combination of direct and indirect bypass can also be used. So, the question is, which method is better, especially in the adult population? In this issue of the journal, in the study titled "Direct, Indirect, and Combined ECIC Bypass for Adult Moyamoya Disease," Dr. Nickalus Khan and colleagues report on a meta-analysis and systematic review of those with adult moyamoya disease who underwent either direct, indirect, or a combination bypass. The main study question was whether there's a difference in the rates of early ischemic or hemorrhagic strokes, defined as strokes occurring within 30 days of bypass, or late strokes, defined as strokes occurring after 30 days of bypass, in this population when comparing the different surgical techniques. They also compared the "favorable" outcome rate; however, this outcome was defined in each study between the various broad techniques of direct, indirect, and combined bypass. So, with that, let's take a very quick look at their methodology. They screened more than 4,000 articles and identified 143 articles for their pooled analysis, the majority of articles being from Eastern Asian-based regions, and they had close to 4,000 combined, 4,000 direct, and 4,000 indirect bypass procedures for this analysis. And they had an average follow-up of over three and a half years. So, this is a great sample size for this large, pooled analysis. But they also performed a smaller meta-analysis where they were much more stringent with article selection, excluding pediatric papers, excluding articles containing only one surgical modality, or articles with insufficient outcome data. So, for that meta-analysis, they only had 43 articles qualified and were included in that meta-analysis. So, what did they find? In the larger pooled analysis, a significant benefit in favor of both direct and combined bypass techniques were noted in reduction of early and late ischemic strokes and late intracerebral hemorrhage. Also, a higher rate of that sort of vague favorable outcome was noted with both the direct or combined methods as compared to when indirect bypass techniques were used alone. So, everything in the large, pooled analysis pointed towards the direct bypass or combined technique performing better than all indirect bypass techniques, with only one exception, which was a lower incidence of early intracerebral hemorrhage rate in indirect bypass cases. So, that's one point to keep in mind. The second point was when they compared combined techniques to direct bypass. Overall, these procedures had more or less the same outcomes with the exception that the rate of late ischemic stroke was lower in the combined group than the direct bypass group. So, this is sort of the overall summary of what they found in that large, pooled analysis. When they were much more stringent with their selection criteria, focusing on the smaller meta-analysis portion of the study, what they found was that in the short term, there were no differences in outcomes of any type of stroke between any of these methods. So, basically, people, regardless of the type of bypasses they received, did the same with regards to the risk of intracerebral hemorrhage and ischemic stroke recurrence within the first 30 days after the bypass. But for the late stroke outcomes, whether ischemic or hemorrhagic, those with indirect bypass were nearly twofold more likely to develop late stroke after 30 days compared to those who've undergone the direct bypass. A similar pattern was found comparing combined bypass versus indirect bypass, in general, beyond the 30 days, with combined bypass doing better. Comparing direct versus combined bypass showed no difference regardless of timeframe. So, in summary, overall, it appears that combined or direct bypasses may be the best surgical strategies for treatment of adult patients with moyamoya disease. This study, of course, has many limitations, as does any meta-analysis, but most importantly, the authors focused on moyamoya disease in their analysis. It is presumed, but really unclear if patients with moyamoya syndrome would respond similarly to these different techniques. So, the question is, what surgical procedure are you using at your institution for treatment of adult moyamoya disease patients? And, of course, Eric wanted me to ask if your antiplatelet of choice is cilostazol for this population, yes or no. Leave us your comments, and let us know. Venous sinus thrombosis, or CVST, is a less common form of stroke most commonly affecting women and young individuals. In our past podcast, we've covered many aspects of CVST, especially when it comes to therapy with anticoagulation, anticoagulant of choice, and duration of therapy. In the October podcast, we reviewed a systematic review and meta-analysis comparing direct oral anticoagulants to vitamin K antagonists in the adult patients with CVST. But there are many aspects of this disease that we have not yet covered. For instance, you may ask, how common is this relatively uncommon condition? In the adult population, the incidence of CVST varies depending on the age of individuals studied, and ranges between 1.3 to 2.7 per 100,000 in women between the ages of 31 to 50, which is the adult population at highest risk for this disease. But the incidence of CVST, for instance, in the pediatric population is largely unknown. Some studies suggested an incidence rate of 0.67 per 100,000 in the pediatric population. That's roughly less than half the incidence rate in young female adults, but these reports are from the 1990s and are likely very outdated. Nowadays, many of the pediatric conditions, especially infectious conditions, that can predispose children to CVST are more readily diagnosed and treated. On the other hand, we now perform a lot more imaging than 30 years ago. Our neuroimaging modalities are more accurate, so we are more likely to diagnose CVST than before. So, the question is, what is the contemporary incidence of pediatric cerebral venous sinus thrombosis? In this issue of the journal, in the study titled "Contemporary Incidence and Burden of Cerebral Venous Sinus Thrombosis in Children of the United States," Dr. Fadar Otite and colleagues conducted a retrospective analysis of the New York State Inpatient Database, or SID, from 2006 to 2018, and the National Kids Inpatient Database, referred to as KID, from 2006 to 2019, for all hospitalized CVST cases. KID is the largest publicly-available pediatric inpatient care database in the United States, containing about 3 million pediatric discharges. They included over 700 hospitalized CVST cases from the SID database and 6,100 hospitalizations from the national KID database for the current analysis. And here's what they found. Number one, in terms of significant risk factors associated with CVST, congenital circulatory system anomalies, infections, head trauma, dehydration, and anemia were amongst the top CVST risk factors in the pediatric population. So that's very good to know. Number two, in terms of presentation, seizures were the most common presentation among all pediatric age groups, with close to half of infants with CVST presenting with seizures. Number three, in terms of outcomes, the rate of mortality was twice higher in the infants group as compared to all other age groups. And finally, the overall incidence of CVST, which was the main question of the paper, in this population was 1.1 per 100,000 per year, with a peak incidence during infancy of 6.4 per 100,000 per year. Interestingly, incident admissions also increased annually by 3.8% throughout the study period, which was close to 15 years in this paper. And the national burden of hospitalization dramatically and exponentially grew during the study period. So, here are the top three points from this study. Point one: Girls included less than half of all admissions nationally and statewide, and the overall burden of CVST was higher in boys than girls. That's a dramatic difference between the pediatric and adult populations. Point two: Incidence of CVST in infants was higher than five times that of other age groups at 6.4 per 100,000 compared to overall incidence in children, which was 1.1 per 100,000 people per year. Mortality was also two times higher in infants than in any other age group. And finally, point 3, incident admissions and national burden of hospitalization have dramatically increased over time, but it remains unclear whether true incidence has been on the rise or if simply more cases are recognized nowadays due to heightened awareness of this condition and our advanced neuroimaging capabilities. This study, of course, has some limitations. Data was only obtained on patients admitted, so many patients that may have had CVST but not admitted are not captured in this database. So, in summary, CVST can have catastrophic consequences in children and lead to long-term neurological deficits. Having a high clinical suspicion and early recognition remain crucial for prompt treatment and improved outcomes in this population. Dr. Negar Asdaghi:         Endovascular treatment, or EVT, is an effective method to achieve recanalization and to improve clinical outcomes in ischemic stroke patients with a target vessel occlusion. Both advanced age and having a large infarct volume at the time of presentation are negative predictors of beneficial outcomes post-EVT. Despite this, the neurological benefits of EVT seem to persist across the spectrum of age, and the same has been observed for a range of ischemic core volumes. But it's important to note that, in general, patients presenting with large ischemic core volumes were excluded from the original thrombectomy studies, and currently there's several ongoing trials to determine whether EVT is beneficial for the large core population. Now, the question that everyone is interested in answering is whether there is an actual ischemic core volume beyond which endovascular therapy is either futile or potentially even harmful, and if this magic futile core volume is the same for all patients, or does it differ depending on the age and other factors. In a previous podcast, in an interview with Dr. Osama Zaidat, we learned about that important interaction between the presenting ischemic core volume as measured by ASPECTS score and advanced age in an analysis of patients enrolled in the STRATIS registry. In that study, no one over the age of 75 achieved functional independence post-EVT if the presenting ASPECTS score was under 5 regardless of the angiographic outcomes. In that interview, we also discussed the limitations of STRATIS registry as a non-randomized, single-arm study, and the issues surrounding using ASPECTS score to define ischemic core. In today's podcast, we're going to revisit the important interaction between the presenting ischemic core volume and age while reviewing a pooled analysis of seven endovascular clinical trials in the paper titled "Significance of Baseline Ischemic Core Volume on Stroke Outcome After Endovascular Therapy in Patients Age 75 Years or Older." I'm delighted to be joined today by the first and senior authors of this paper, Drs. Koji Tanaka and Andrew Demchuk. Dr. Tanaka is an Assistant Professor of Neurology at Kyushu University in Japan. With his experience working at the leading center for conducting stroke clinical trials in Osaka, he has now joined the Calgary Stroke Program as a research fellow. And he's accompanied today by his fellowship director, Dr. Demchuk. Dr. Demchuk, of course, needs no introduction to our Stroke readership and our podcast audience. He's a Professor of Neurology at the University of Calgary Cumming School of Medicine. He's a stroke neurologist and a leader in the field of cerebrovascular research who has been involved in multiple clinical studies and randomized trials, including the seminal studies that led to the approval of EVT as the standard of care for treatment of stroke. And, of course, he's a very special guest of this podcast this morning as he was my very own fellowship director. Top of the morning to you both, Andrew and Koji. Welcome to the podcast. Dr. Andrew Demchuk:   Thanks, Negar. It's great to be here. Dr. Koji Tanaka:               Thank you very much for your invitation. That is a great honor to be here. Dr. Negar Asdaghi:         Thank you both. Andrew, let's start with you. Can you please provide us some background on the pooled analysis and the HERMES collaboration, please? Dr. Andrew Demchuk:   Yeah, HERMES is a really, it's been a really fun journey. Years back, when these trials all came out roughly at the same time, right? There was a real quick succession of trials, the MR CLEAN trial was obviously first, and ESCAPE and others quickly followed it. It became very clear to us that it just made total sense to collaborate. And so we got together as a group and decided we will pool the data. We'll do it in a very careful scientific way with basically an independent statistical analysis, and develop a core imaging lab, and really actually share the workload amongst us. I remember one of the really interesting tidbits about HERMES is when we got together, in order, I think, to really build trust in the group, one of the important things we decided early was we were going to have a snake draft. If you don't know what a snake draft is, Negar, it's essentially where you take turns selecting a topic through each of the trials. So, every trialist got an opportunity to pick a topic, and we just went down the list until everyone had their turn, and then we'd start over again and do it again. And I think that really worked very well to be as democratic as possible with this, and as fair. And it really allowed for a lot to get done because whoever was motivated in the collaboration was able to do an analysis. Dr. Negar Asdaghi:         So, what a great summary of this collaboration. So, it's true collaboration between the trialists that basically gave us those seven original randomized trials. Andrew, can I just stay with you, and can you tell us a little bit about the patient population that were enrolled in those trials? Dr. Andrew Demchuk:   Yeah, I think one of the important things to know, and I think a limitation for any kind of analysis like this, is the trials generally were small core trials, right? I mean there are some, MR CLEAN was certainly a more generalized population, but many other trials, including ESCAPE, I mean the "S" and the "C" in ESCAPE is "small core," right? And so a lot of these trials were small core. So, we don't have a lot of data in larger core patients. But, as you can imagine when you do core lab analysis, you realize that some of the stroke patients weren't as small core as we thought they were when we enrolled them. So, there is some sufficient data to hypothesize. I would consider this paper very much hypothesis-generating. So, yeah, it is a limitation to be considered here. I mean, our sample size isn't very large in the big core patients. Dr. Negar Asdaghi:         Perfect. Thank you, Andrew. So, again, a recap for our listeners, that we are looking at pooled analysis of seven original trials of thrombectomy, but keeping in mind that those patients that were enrolled in the trials had, generally speaking, small presenting ischemic core. So, now, Koji, on to you. Can you walk us please through the current study, and what was the premise of it, and who was actually included in this study? Dr. Koji Tanaka:               Yes. In this study, we aimed to evaluate association between baseline ischemic core volume and the benefit of endovascular therapy over the best medical treatment on functional outcomes. Patients were categorized age over 75 years, and less than 75 years old. The primary outcome of interest was a modified Rankin Scale of three or less, and we included 899 patients who underwent this baseline ischemic core volume measurement, which corresponds to 51% of our patients in the HERMES collaboration dataset. Dr. Negar Asdaghi:         All right. So, just a quick recap of what you said. Thank you for this. So, we have 899 patients. Those patients were all included in the HERMES collaboration, but, of course, these are patients in whom we had presenting ischemic core measurements. And that will get me, actually, Koji, to my second question. Can you please walk us through how you did analysis of ischemic core volume measurements in this study? Dr. Koji Tanaka:               In this study, ischemic core volume was measured by CT perfusion in 591 patients and by diffusion-weighted imaging in 309 patients. We defined the ischemic core volume as a relative cerebral blood flow of less than 30% in CT perfusion and diffusion coefficient of less than 620 square micrometers per second in diffusion-weighted imaging. Previous studies showed ASPECTS moderately correlate with ischemic core volume in both CT perfusion and diffusion-weighted imaging. For example, ASPECTS of eight can be considered as ischemic core volume of 20 milliliters. But underlying [inaudible 00:28:21] were different between CT perfusion and diffusion-weighted imaging, and previous studies suggested CT perfusion occasionally overestimates the ischemic core volume was on diffusion-weighted imaging. In this study, the results did not change when analyzing CT perfusion and diffusion-weighted imaging separately. Dr. Andrew Demchuk:   Yeah, that's a really important point Koji makes, is that because we had sort of a, not quite a 50/50 split, we had a 60/40 split of CTP and DWI, we did analyze them separately, and the odds ratios of treatment effect were pretty similar at different core thresholds. So, they're fairly similar when you separate them out, but obviously the methodology is a little different between a CTP and a diffusion. And to Koji's point, he's absolutely right, the CTP has a tendency to slightly overestimate core when you compare to diffusion. Dr. Negar Asdaghi:         Yeah, and thank you. I think you already sort of alluded to what I was going to ask you and Koji, because, in reality, we have different ways of measuring core. We have the ASPECTS score, which is just a quick and dirty way of estimating or guesstimating core, and then we have CT perfusion, and we also have diffusion that sometimes is available to us, but not always. And the question is, in the heat of it, how we're going to measure the volume. With post-processing softwares, with CT perfusion, we get a quick potential ischemic core volume, but we don't have that capability with diffusion even if we did get diffusion. So, I think it's important to know that what Koji mentioned, an ASPECTS of eight can, more or less, in a quick fashion, be thought of as about 20 cc of core. And the other point that Koji raised was that CTP, again, this is sort of ballpark, can tend to overestimate ischemic core if you were to compare that with diffusion-weighted data. So, with that, now we have a study in which we have core volumes, and we're going to look at outcomes from endovascular thrombectomies compared to best medical management and see whether there is a correlation or interaction between ischemic core presentation, especially age. So, my next question would be to Andrew, can you walk us please through the main findings of the paper? Dr. Andrew Demchuk:   The whole goal of this paper was really to understand, are there thresholds in the older patients? When we looked at overall, and Bruce Campbell and the team wrote an important paper with HERMES and the CTP cohort overall, and the sort of message there was if you looked at shift analysis, there wasn't actually a core threshold found at all in HERMES for lack of benefit. There was a benefit across all the core volumes, but, of course, that's all ages. So, we were really interested in looking at the older patients because we felt there's more likelihood the core volume will matter in the elderly than in the younger patient. We know the younger population, it benefits overwhelmingly with EVT, it's hard to even find a core volume threshold. So, that was a premise. Essentially, we had 247 patients over 75 in the overall cohort, of which 98 had EVT. So, it was a decent population, and not a huge sample, but a decent sample. And so we looked at various things. The first thing that was interesting we found was that infarct volumes, the average infarct volume to achieve an mRS three or less, was lower in the older patients, significantly lower, was 23.9 for younger patients under 75 and 10.7 for the older patients. You tend to have much smaller infarcts to achieve good outcome. And so that was kind of interesting, and I think that's been shown by others. Then we got into the weeds to try to figure out, OK, what are these thresholds? And if there's one figure that matters, Negar, you know me to always point out that there's always one figure or table in a paper that's kind of where the money is, where the real learning is, and that's Figure 2 on this paper in my opinion, beautiful figure with four figure A, B, C, and D. And it really sort of nicely highlights these issues and these cutoffs. But what we saw is that in the older patients who received EVT, around 50 mils seemed to be a threshold to achieve zero three, you had to, to see treatment effect, you had to have a baseline infarct volume less than 50 mils for a zero three outcome advantage. For zero four, it was 85 mils. And then we looked at this issue of what we called futility, true futility. And that's a very controversial thing. What is futility, or how do you measure futility? And really, I think, we even had a debate about this as a HERMES group when we were designing the analysis, and we sort of landed on mRS five six. A 90% chance of mRS five six, right? That's quite the bar, right, to say true futility because some people argue mRS four is still not a horrible outcome. Culturally, that is an OK outcome in some situations. But when we did use that five six 90% threshold, it was 132 mils. So, you're getting up to these really large volumes. But here's the catcher in the whole thing, and Koji will probably speak to this a bit more. I don't want to steal his thunder too much, but this issue of reperfusion seemed to matter in this. And we'll come back to that maybe with another question. Reperfusion matters a lot when you think about these thresholds. Dr. Negar Asdaghi:         OK, so, Andrew, a lot of information, I don't know if I need a recap myself to recap, but basically what you mentioned is that for the older patients who received EVT, if we keep our eyes on the outcome of mRS of zero to three, it seems to be the magic core volume for that outcome post-endovascular therapy that it lands on the magic volume of 50 cc core. Did I get that right? Dr. Andrew Demchuk:   That's correct. Dr. Negar Asdaghi:         Then if you're still a bit more lenient with the definitions of what is favorable outcome, what outcomes we're looking at and so on, so forth, for an mRS of five to six, then when we talk about futility of endovascular thrombectomy, the volume that you mentioned, and again I want to ask you this, this volume is for elderly over the age of 75, is 130 mil. Dr. Andrew Demchuk:   132, but yeah, absolutely. But there's a real catcher here, and we need to really emphasize the catcher in this. Dr. Negar Asdaghi:         Okay. I will ask you one more question before I go to Koji, which I'm sure is going to tell us more about that catcher. Andrew, can you please tell us about the factor of time? I feel like that is something that we need to discuss, as well. Your study included patients early on in their stroke onset, but we're talking about an important interaction. The question is, do you think the results of this interaction would be different or impacted by the value of time? Dr. Andrew Demchuk:   Hypothetically? It must, right? I think that that must be the case. We don't have any data specific to this. That would be an interesting Aurora analysis to do. Now, of course, the challenge with late window analysis is, we are really small core in our late window trials, we probably have even a much smaller proportion of large cores. So, to be able to even tackle that question in the late window is, I don't know if we have the data yet, to be honest. But it makes sense that you would expect the thresholds to be a bit lower the later you are in the window. But that is a hypothetical opinion. Dr. Negar Asdaghi:         Right, so, I want to take that and come to Koji. I want to digress a little bit to Koji and see how we can understand the finding of this current analysis of this paper. So, small core patients early on into their onset, we're looking at the interaction between age and their core volume and coming up with numbers 50 cc for the elderly population. If you're looking at the outcome of zero to three or 132, as Andrew pointed out, for an MRS of much higher, four or five. Dr. Andrew Demchuk:   Actually five, six, 90% chance of five, six. So, it's there. It's like almost everybody got five, six, took 132 mils to get there. So, it's like this extreme outcome. Dr. Negar Asdaghi:         Right, so, exactly, and I have to correct it, again, mRS of five or six or dead or almost dead mRS basically. Dr. Andrew Demchuk:   In 90% of patients. Dr. Negar Asdaghi:         90% of patients. So, we have these important numbers here, and I want us to basically understand these numbers in these volumes in the context of the recently published RESCUE-Japan LIMIT study. Can you tell us a little bit about that study and how we can make sense of these volumes in the setting of that paper? Dr. Koji Tanaka:               In the recent RESCUE-Japan LIMIT trial, the median ASPECTS was lower, and baseline ischemic core volume was greater than those in our study. And surprisingly, the median ischemic core volume in that trial was close to our threshold to predict less than 10% of patients achieve a modified Rankin Scale of four or less after endovascular therapy. We thought this is due to much higher complete reperfusion rate in HERMES patient. We have much interest in their additional analysis for outcomes in elderly patients by reperfusion status. This potential benefit of endovascular therapy in the area is promising for the future clinical trials. Dr. Andrew Demchuk:   I think just to add to that, it was actually really interesting, Negar, because when we were analyzing all of this and then the trial came up and it was actually really nice because we're like, OK, how does our data relate to their data? And that's where Table 2 comes in, and it would almost be worth putting on the pod, whatever, I don't know if you have on your podcast website, you have one figure that you can sit there with as you listen to the podcast, because that would be the figure. Dr. Negar Asdaghi:         We'll work on that Andrew, but tell us a little bit more because, really, when I read the trial results, the way I understand it is that people enrolled in RESCUE-Japan that were older than 75, and these are all large core patients, benefited more from endovascular therapy than their younger counterpart. How do I understand that? I don't know how to wrap my head around that finding. Dr. Andrew Demchuk:   You want to try to answer that, and then I'll add? Dr. Koji Tanaka:               As I mentioned previously, we want to know about the exact patient population just only for elderly patients, whether they have a exactly larger ischemic core volume or as well as their functional outcome. How many patients achieved modified Rankin Scale four or less or three or less, or more than five or six? Dr. Andrew Demchuk:   Koji's point's very important. We actually don't have the breakdown of the mRS, so we don't know if they created a lot of fours, or threes, or what. So, that's one issue. But I think that the key to this whole thing is to understand that this is a 2022 trial. HERMES data is essentially a 2015 equivalent where we're looking at a number of clinical trials who roughly ended between 2014, 2016. So, the technology, the technique, the operators, are just at a different level back then than now. And quite frankly, EVT is an improving treatment. We probably don't even fully understand how much, I mean, we're just getting better at it. And I think what's happened here is the reperfusion rates have improved. And our HERMES reperfusion rates, remind me, Koji, I think they're about half, we think, in HERMES, than like the TICI 2bs, threes, are half in HERMES what they got in RESCUE-Japan LIMIT. So, when you achieve successful reperfusion, what were the numbers here? TICI 3 was 43% in the Japan RESCUE LIMIT, and 8.6% in HERMES. Okay, TICI 3s were not ... Now that may be slight differences in core lab interpretation, but we were just starting to get good at 3s. We were getting a lot of 2bs and some 2cs, but we weren't getting a massive number of 3s back in 2015. Well, voilà, now we are, right? We're hitting home runs when we didn't before. And I think that has really shifted the goalposts on the large core. If you open the vessel, they can still do well if they're elderly, but you've got to really open that vessel. And in HERMES, we only did that in a small portion of patients. So, these thresholds are sort of representative of 2015 skill. Dr. Negar Asdaghi:         Golden points, Andrew and Koji, both of you. I want to recap what you mentioned here. A note to all of our audience and listeners that we are looking at an analysis with RESCUE-Japan, an analysis of a 2022 study. And the patient population that were enrolled were also treated much later in terms of time than the patient population that was enrolled in the HERMES collaboration and in all of the trials that contributed to HERMES. So, we've got to remember that EVT is this fluid, ongoing, everyday-improving therapy, from our techniques to everything else, you know, how fast we get patients to the angiosuite. And the point that you raise, I want to repeat that, the percentage or the odds of achieving a perfect reperfusion was, in RESCUE-Japan, was 43% odds of TICI 3 reperfusion, whereas only 8.6%. So, when we're talking about all of these predictive modeling or predictive factors that will tell us who's going to do well, who's not going to do well, it also is predicated on the angiographic success. And perhaps in the earlier trials or even the early study that we covered as part of the STRATIS registry, we put everybody, TICI 3s with TICI 2b or better, whereas nowadays we accept the best, TICI 3s, and maybe that improved percentage in the most recent trial, the RESCUE-Japan, really did what it had to be done for the elderly population to keep that in mind. And Andrew, before we end our interview, I want us to get your top two takeaway messages from this paper. Dr. Andrew Demchuk:   Clearly, elderly patients do better when their strokes are smaller, that we know, compared to younger patients. But it's all about hitting the home run. It's all about hitting the home run. Figure 2C and 2D, you can see that if you achieve that high TICI score, a significant proportion of elderly patients potentially could still benefit, 30–40% reasonable outcomes with bigger cores if you get those high TICI scores. So, it is about hitting the home run in reperfusion in the elderly. You need to go for it, and hopefully you're successful, because if reperfusion isn't successful, then generally the outcomes are not ideal and they certainly worsen as the core volumes become larger, bigger. Dr. Negar Asdaghi:         Before I ended the interview, given Andrew's tremendous experience as a longtime fellowship director and seeing that he was flanked by two of his fellows, one past, myself, and one present, Koji, I had to ask him one final question of what his philosophy is as an educator. Dr. Andrew Demchuk:   I have a sort of philosophy on life with fellows. I always look for the special power in a fellow. I realized a long time ago we're all, we're not perfect, nobody's perfect, I'm not perfect, but there's usually a special power in people, and if you spend the time to get to know them, you identify that special power, and you really help harness it because you know that if they can harness it when they go back to their faculty job, they're going to really contribute something special to their team, right? You can imagine six special powers from six different people in a team. Now you've got a real team, right? If you know what your power is, you know your limitations, but you know where your strengths you can add to the group, and that's what we try to do here when we can. It's not always, you know, special powers, you have to kind of seek them out. But they're there in most people, and that's really important for career down the line. Dr. Negar Asdaghi:         And this concludes our podcast for the December 2022 issue of Stroke. Please be sure to check out this month's table of contents for the full list of publications, including our very interesting Stroke Images series. In this month, we have a case of progressive cervical myelopathy secondary to a dural AV fistula supplied by the anterior inferior cerebellar artery. We also have a separate case of carotid rete mirabile imaged with a four-dimensional flow MRI study. And with these cases, we bring our 2022 Stroke Alert Podcast series to an end. Over the past 12 months, we've ended our podcasts with various inspirational tales. From the moving account of the American runner Steve Prefontaine and the remarkable journey of the Syrian refugee and Olympian swimmer Yusra Mardini, to the discovery of positron and Commander Armstrong's landing on the moon, our podcast stories have but one thing in common, which is the story of human perseverance and consistency in the face of hardship. So, as we end 2022 to start 2023 anew, Andrew's comments on finding that special power in each of us resonate with our resolution to stay alert with Stroke Alert. 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, visit AHAjournals.org.

Nicholas Acuna discusses research showing that incidence of liver cancer increases over time in people of Mexican descent living in Los Angeles, the “Latino paradox” in health outcomes, and the next steps for this research.

Featuring a slide presentation and related discussion from Dr Eric Sherman, including the following topics: Incidence and mortality of thyroid cancer and the thyroid cancer treatment pyramid (0:00) Available and emerging data with targeted therapies for thyroid cancer (9:01) Optimal genomic screening and selection of treatment for medullary thyroid cancer (26:58) CME information and select publications

Dustin Greenhill from St. Luke's in Pennsylvania discusses femur fractures, subspecialty consultation before high-risk spine surgery, forearm fractures in obese children, and a variety of hip-related issues from recent publications. Your hosts are Julia Sanders from Children's Hospital Colorado, Carter Clement from Children's Hospital of New Orleans, Craig Louer from Vanderbilt, and Josh Holt from University of Iowa. This episode is sponsored by OrthoFix. Music by A. A. Aalto.   Papers discussed:   Greenhill, Allred, Feldman, Herman. Vascular Safe Zone During Percutaneous Pinning of the Distal Femur. JPO 2022.   Greenhill, Herman. Treatment of Pediatric Femoral Shaft Fractures. JAAOS 2022.   Bauer, Sienko, Roy, et al. The incidence of avascular necrosis in children with cerebral palsy after hip containment surgery. JCO 2022.   Visser, Lehman, Armstrong. Does Routine Subspecialty Consultation Before High-Risk Pediatric Spine Surgery Decrease the Incidence of Complications? JPO 2022.   Murphy, Howells, Gallagher, et al. Children's Hip Predictive (CHiP) Score: A Triage Tool for Hip Dislocation in Children Referred With Suspected Hip Dysplasia. JPO 2022.   Lyons, McGregor, Hoyt, et al. Do Forearm Fracture Characteristics and Outcomes Differ Between Obese and Non-Obese Children? Original Research. JPOSNA 2022.   Smith, Block, Eisenberg, Shoenecker, Clohisy, Nepple. Characterizing the Residual SCFE Deformity: Utility of the 45-degree Dunn View. JPO 2022.

Featuring an interview with Dr Eric Sherman, including the following topics: Changes in the incidence, mortality, and management of thyroid cancer in the past 20 years (0:00) Clinical presentation and histologic characteristics of thyroid cancer; genomic alterations associated with each histology (5:55) Initial management of thyroid cancer; current role of surgery and radioactive iodine in treatment algorithms (14:56) Current and future role of tumor biomarkers in treatment selection; emerging role of liquid biopsies in anaplastic thyroid cancer (20:23) Incidence and optimal treatment of brain metastases in patients with thyroid cancer; biologic rationale for tyrosine kinase inhibitors (TKIs) targeting VEGF and BRAF in thyroid cancer (24:20) Safety and tolerability of sorafenib and lenvatinib; management of BRAF-mutated disease (34:49) Management of tumors in patients with RET alterations or NTRK fusions; therapies for medullary tumors (39:28) Case: A woman in her early 60s with metastatic papillary thyroid cancer; ongoing research combining TKIs and immunotherapy for anaplastic thyroid cancer (50:35) Case: A man in his early 40s presenting with severe diarrhea and metastatic medullary thyroid cancer (1:00:54) CME information and select publications

In this session we will examine Exertional Heat Injury (EHI) within individuals undertaking endurance races, military exercises, or extreme activity. We will draw contrast and parallels to acute behavioural disturbance, what is happening both at the physiological level and some of the autonomic positive feedback mechanisms within EHI. To do this I have Harvey Pynn with me, Harvey is a Lieutenant colonel within the British Military and an Emergency Medicine and air ambulance consultant with GWAAC. In the episode we examine: · Definitions, spectrum of disease – EHI as a broad definition and spectrum of states · How are thinking has changed on heat illness and what is happening on a physiological level · Incidence of EHI; anecdotal and empirical · The hierarchy of ‘exercise-state' heat loss – evaporative, convective, conduction, then radiation. · Heat acclimatisation: Salt concentration (aldosterone mediated), sweating initiation and rate. · Risk factors (individual, environmental)- concomitant disease or drugs (dehydration, alcohol, co-morbid disease, medication) · Subtle and not so subtle prodromal signs and symptoms of heat injury & why urine colour isn't a great marker (lack of micturition during dehydration). · Preventative measures and treatment modalities in severe EHI · Analogues of comparison and symptomatology – ABD, drug induced hyperthermia. · Differential diagnosis and an anecdotal case from Harvey Please find some related research produced by Harvey pertaining to measuring dehydration and the sequlae of EHI: https://www.researchgate.net/publication/327822126_The_Compensatory_Reserve_Index-potential_uses_in_a_military_context Please also see relevant empirical literature that is congruent with the podcast: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5819979/ Please enjoy this episode with an engaging and informative guest.

Commentary by Dr. Valentin Fuster

SGLT2 inhibitors, publishing choices, second and third order effects of interventions, decision support, and patient selection for preventive procedures are the topics John Mandrola, MD, discusses in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. EMPA Kidney - EMPA-Kidney Seals SGLT2 Inhibitors as 'Foundational' for CKD https://www.medscape.com/viewarticle/984439 - EMPA-Kidney Moves the Needle for SGLT2 Inhibitors in Kidney Disease https://www.medscape.com/viewarticle/983521 - Empagliflozin in Patients with Chronic Kidney Disease https://www.nejm.org/doi/pdf/10.1056/NEJMoa2204233 - Canagliflozin and Renal Outcomes in Type 2 Diabetes and Nephropathy https://www.nejm.org/doi/10.1056/NEJMoa1811744 - Dapagliflozin in Patients with Chronic Kidney Disease https://www.nejm.org/doi/full/10.1056/NEJMoa2024816 - Impact of diabetes on the effects of sodium glucose co-transporter-2 inhibitors on kidney outcomes: collaborative meta-analysis of large placebo-controlled trials https://doi.org/10.1016/S0140-6736(22)02074-8 II. Publishing Choices - Motorcycle Rallies Linked to Spike in Organ Transplants https://www.medscape.com/viewarticle/984623 - Organ Donation and Transplants During Major US Motorcycle Rallies https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2798550 III. Second and Third Order Effects - Heart Disease Deaths Spiked During COVID After 10-Year Decline https://www.medscape.com/viewarticle/984605 IV. Decision Support - Patient App Aids Decisions on Anticoagulants: ENHANCE-AF https://www.medscape.com/viewarticle/984253 - A Randomized Clinical Trial to Evaluate an Atrial Fibrillation Stroke Prevention Shared Decision‐Making Pathway https://www.ahajournals.org/doi/10.1161/JAHA.122.028562 V. Percutaneous Left Atrial Appendage Closure - Consider Life Expectancy When Referring for LAA Closure? https://www.medscape.com/viewarticle/981117 - Transcatheter Left Atrial Appendage Occlusion: A Multi-Center Real Life Experience https://www.mdpi.com/2077-0383/11/23/6944 - Incidence and Predictors of Early Death in Patients Undergoing Percutaneous Left Atrial Appendage Closure https://www.jacc.org/doi/full/10.1016/j.jacep.2022.06.012 - Indications for Left Atrial Appendage Occlusion in the United States and Associated In-Hospital Outcomes: Results From the NCDR LAAO Registry https://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.121.008418 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

Dr. Xuejing Chen discusses her group's retrospective analysis of the incidence and risk factors of delayed retinal breaks following a symptomatic posterior vitreous detachment. Discussed article: Jindachomthong KK, Cabral H, Subramanian ML, Ness S, Siegel NH, Chhablani J, Hsu SX, Chen X. Incidence and risk factors for delayed retinal tears following an acute, symptomatic posterior vitreous detachment. Ophthalmol Retina. 2022 Oct 25:S2468-6530(22)00514-0. doi: 10.1016/j.oret.2022.10.012. Epub ahead of print. PMID: 36307014.

Survey: https://bit.ly/feedback_UltraSounds Theresa and Rachel discuss postpartum hemorrhage with Dr. Luke Burns. 00:30 Dr. Burns Biography 01:50 Case 1: 35 year old G4P4 with polyhydramnios, boggy uterus 09:17 Case 2: 35 year old G4P4 with postpartum hemorrhage and chronic hypertension 16:53 Case 3: hemodynamically unstable 35 year old G4P4 with postpartum hemorrhage 23:59 Case 4: 35 year old G4P4 with no return of menstruation Transcript: https://bit.ly/Ultrasounds_PPH Trends in maternal mortality: 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2019. ACOG Practice Bulletin No. 183: Postpartum Hemorrhage. Obstet Gynecol 2017, 30(4). Wormer KC, Jamil RT, Bryant SB. Acute Postpartum Hemorrhage. StatPearls Publishing; 2022 Jan. ACOG Committee Opinion No. 794: Quantitative blood loss in obstetric hemorrhage. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;134. Bell, S. F., et al (2020). Incidence of postpartum haemorrhage defined by quantitative blood loss measurement: a national cohort. BMC pregnancy and childbirth, 20(1), 271. Parry Smith WR, et al. Uterotonic agents for first‐line treatment of postpartum haemorrhage: a network meta‐analysis. Cochrane Database of Systematic Reviews 2020, Issue 11. Vogel JP, et al. WHO recommendations on uterotonics for postpartum haemorrhage prevention: what works, and which one? BMJ Global Health 2019. A. Borovac-Pinheiro, et al. (2018). Postpartum hemorrhage: new insights for definition and diagnosis. American Journal of Obstetrics and Gynecology, 219(2):162-8. A. Leleu, et al. (2021). Intrauterine balloon tamponade in the management of severe postpartum haemorrhage after vaginal delivery: Is the failure early predictable?. European Journal of Obstetrics & Gynecology and Reproductive Biology, 258:317-323. Schury MP, Adigun R. Sheehan Syndrome. StatPearls Publishing; 2022 Jan.

Playlist for this show :- 1 Standing Stones .. Dawnwalker ( House Of Sand 2022 ) 2 Adrift .. 25 Yard Screamer ( Nemesis 2022 )( Album Of The Week ) 3 Arcane Knowledge .. Falling Edge ( Final Dissent 2022 ) 4 Incidence .. 25 Yard Screamer ( Nemesis 2022 )( Album Of The […]

Episode 120: Immune Reconstitution Inflammatory Syndrome (IRIS) Abeda Faharti and Dr. Schlaerth present the definition, diagnosis, and treatment of IRIS. Moderated by Dr. Arreaza. Written by Abeda Farhati, MS4, Ross University School of Medicine. Editing and comments by Katherine Schlaerth, MD, and Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Definition.Have you heard of IRIS? No, not the color portion of our eyes. IRIS is short for Immune Reconstitution Inflammatory Syndrome. This condition occurs in immunocompromised patients with HIV/AIDS due to an overactive inflammatory response. In most cases, it occurs after initiating antiretroviral therapy (ART). To understand IRIS in HIV patients, we must first understand HIV.HIV.The Human Immunodeficiency Virus (HIV) infection was first reported in 1981. The virus attacks the immune system, destroying white blood cells called CD4+ T lymphocytes, which are part of our body's defense mechanism. These cells are also known as "helper T cells" and are responsible for destroying viruses, bacteria, and other germs that make us sick.When your CD4+ count is low, you are more likely to get serious infections from viruses, bacteria, and fungi, which usually do not cause problems in otherwise healthy individuals. These infections are called Opportunistic infections, and they can be deadly. To restore CD4+ T lymphocytes, HIV patients are started on ART to normalize their immune response to pathogens. As a result of these treatments, HIV patients' lives have been significantly improved and prolonged. [Comment by Dr. Arreaza: It is paradoxical, but some HIV patients are among the healthiest patients I have seen.]Despite this, no treatment is guaranteed to be without side effects. Increases in CD4+ T lymphocytes trigger the immune system to respond to any persisting antigen, regardless of whether it is fragments or intact organisms. As a result, a hyperinflammatory response may occur.Diagnosis.There are no established criteria for diagnosing IRIS. It is generally accepted that IRIS requires the worsening of an existing infection or an unrecognized, preexisting infection in the context of improved immune function. For a diagnosis to be made, most, if not all of the following features must be present:The presence of a low CD4 count (less than 100 cells) before initiating treatment with ART (Except IRIS secondary to preexisting TB infection can occur with CD4 counts >200 cells).The presence of an inflammatory condition, especially after ART is initiated.The absence of drug-resistant infection, bacterial superinfection, drug allergy, or other adverse drug reactions.The absence of patient noncompliance or reduced drug levels due to drug-drug interactions or malabsorption.Clinical Manifestations.IRIS can be presented in patients in 2 ways:Patient's with a preexisting infectious disease that has NOT been treated, getting paradoxically worse after initiating treatment with ART ---this is known as “unmasking IRIS” ORPatient's with a preexisting infectious disease that has been previously diagnosed and treated but regained capacity after treatment with ART, causing it to mount an inflammatory response – this is known as “paradoxical IRIS.”In summary: Unmasking IRIS and paradoxical IRIS.Patients with IRIS have clinical features that vary widely. The presentations are strongly dependent on the type of preexisting opportunistic infection. For example, about 75% of patients with a mycobacterial or cryptococcal-related infection will develop a fever. In contrast, fever is rarely seen in cytomegalovirus (CMV) infections.Risk & Prevention.Researchers have found that lower CD4 cell counts or high HIV RNA levels at the time of anti-retroviral treatment initiation increase the risk of developing IRIS. One way to prevent IRIS development is to treat opportunistic infections prior to starting ART. Although this reduces the risk of IRIS development, it does not guarantee it.Treatment.In “unmasking IRIS,” patients can be treated with antibiotics, antivirals, or antifungals against the underlying infectious organism. In severe cases, steroids can also be used to suppress inflammation until the infection has been eradicated. Unfortunately, there is no treatment for paradoxical IRIS. Most patients who experience “paradoxical IRIS” reactions will get better spontaneously without additional therapy.Incidence of IRIS.The overall incidence of IRIS is unknown; however, studies have shown that anywhere from 25 to 30% of HIV patients who start antiretroviral treatment develop IRIS in the first six months. You may ask, which preexisting infections can lead to patients developing IRIS?Pathogens associated with IRIS.Different pathogens have been associated with the development of IRIS. The leading pathogens include:Mycobacterium tuberculosisMycobacterium avium complexCytomegalovirusCryptococcus neoformansPneumocystis jiroveciiHerpes simplex virusHepatitis B virusHuman herpes virus 8 (associated with Kaposi sarcoma)Non-HIV etiologies.IRIS can also be seen in other immunocompromised conditions, such as:Solid organ transplant recipients Postpartum period – 3 to 6 weeks after giving birthNeutropenic patients – with an absolute neutrophil count of less than 500Patients on Tumor Necrosis Factor Antagonists (TNF antagonists)- are used to treat chronic conditions such as ulcerative colitis, Crohn's disease, or sarcoidosis.In summary, Immune Reconstitution Inflammatory Syndrome (IRIS) is a hyper-inflammatory state seen after initiating ART in HIV patients whose improved immune system responds to previously acquired opportunistic infection, whether treated or not.The treatment is directed to the unmasked specific opportunistic infection or support therapy if no active infection is found.____________________________Conclusion: Now we conclude episode number 121, “Immune Reconstitution Inflammatory Syndrome (IRIS).” This syndrome presents in about 30% of HIV patients when they start ART. A stronger immune system means a stronger immune reaction. So, keep in mind this diagnosis when your HIV patients get sicker when they are supposed to get better after starting ART. This week we thank Hector Arreaza, Abeda Farhati, and Katherine Schlaerth. Audio edition by Adrianne Silva.Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week! _____________________Links:“CD4 Lymphocyte Count: MedlinePlus Medical Test.” Medlineplus.gov, accessed on November 4, 2022.https://medlineplus.gov/lab-tests/cd4-lymphocyte-count/#:~:text=A%20CD4%20count%20is%20mostly,have%20trouble%20fighting%20off%20infections.Sun HY, Singh N. Immune reconstitution inflammatory syndrome in non-HIV immunocompromised patients. Curr Opin Infect Dis. 2009 Aug;22(4):394-402. doi: 10.1097/QCO.0b013e32832d7aff. PMID: 19483618. https://pubmed.ncbi.nlm.nih.gov/19483618/Thapa, Sushma, and Utsav Shrestha. “Immune Reconstitution Inflammatory Syndrome.” PubMed, StatPearls Publishing, 2022, www.ncbi.nlm.nih.gov/books/NBK567803/.Wolfe, Cameron. Immune reconstitution inflammatory syndrome, UpToDate. ww.uptodate.com, https://www.uptodate.com/contents/immune-reconstitution-inflammatory-syndrome. Accessed November 14, 2022.Royalty-free music used for this episode: “Keeping Watch,” New Age Landscapes. Downloaded on October 13, 2022, from https://www.videvo.net/royalty-free-music-albums/new-age-landscapes/. 

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In his weekly clinical update Dr. Griffin discusses the four things to know about RSV, the burden of respiratory syncytial virus in healthy term-born infants in Europe, the diagnostic accuracy of rapid diagnostic tests for Ebola virus disease, evaluating the accuracy of self-collected swabs for the diagnosis of monkeypox, tecovirimat is effective against human monkeypox virus in vitro at nanomolar concentrations, acute and postacute sequelae associated with SARS-CoV-2 reinfection, clinical course of SARS-CoV-2 infection and recovery in lung transplant recipients, effectiveness of a third BNT162b2 mRNA COVID-19 vaccination during pregnancy, maternal antibody response and transplacental transfer following SARS-CoV-2 infection or vaccination in pregnancy, impact of community masking on COVID-19, Lifting Universal Masking in Schools – Covid-19 Incidence among Students and Staff, systematic review of the clinical effectiveness of Tixagevimab/Cilgavimab for prophylaxis of COVID-19 in immunocompromised patients, comparative effectiveness of sotrovimab and molnupiravir for prevention of severe COVID-19 outcomes in patients in the community, early adoption of anti–SARS-CoV-2 pharmacotherapies among us veterans with mild to moderate COVID-19, evaluation of viral and symptom rebound differences between Paxlovid and untreated COVID-19 participants, monoclonal antibodies for treatment of SARS-CoV-2 infection during pregnancy, twice daily oral zinc in the treatment of patients with COVID-19, cognitive deficits in long Covid-19, severe Neuro-COVID is associated with peripheral immune signatures, autoimmunity and neurodegeneration, and long-lasting symptoms after an acute COVID-19 infection and factors associated with their resolution. Subscribe (free): Apple Podcasts, Google Podcasts, RSS, email Become a patron of TWiV! Links for this episode Four things to know about RSV (Gates Foundation) The burden of RSV in healthy term-born infants in Europe (The Lancet) Diagnostic accuracy of rapid tests for Ebola (CMI) Accuracy of self-collected swabs for diagnosis of Monkeypox (CID) Tecovirimat is effective against human monkeypox virus in vitro (Nature) Acute and postacute sequelae associated with SARS-CoV-2 reinfection (NatureMedicine) SARS-CoV-2 infection and recovery in lung transplant recipients (Transplant Infectious Diseases) Effectiveness of third COVID-19 vaccination during pregnancy (Nature Communications) Maternal antibody response and transplacental transfer following infection or vaccination (CID) Impact of community masking on COVID-19 (Science) Lifting universal masking in schools (NEJM) Bebtelovimab fact sheet for providers (FDA) Effectiveness of Tixagevimab/Cilgavimab for prophylaxis of COVID-19 (medRxiv) Effectiveness of Sotrovimab and Molnupiravir for prevention of severe COVID-19 outcomes (BMJ) Early adoption of Anti–SARS-CoV-2 pharmacotherapies among US veterans (JAMA) PAXLOVID patient eligibility screening checklist (FDA) Viral and symptom rebound differences between Paxlovid and untreated COVID-19 participants (medRxiv) Monoclonal antibodies for treatment of SARS-CoV-2 during pregnancy (Annals of Internal Medicine) Remdesivir fact sheet for providers (Veklury)  Twice daily oral zinc in the treatment of patients with COVID-19 (CID)  Cognitive deficits in long COVID-19 (NEJM) Severe Neuro-COVID associated with peripheral immune signatures, autoimmunity and neurodegeneration (Nature Communications) Long-lasting symptoms after an acute COVID-19 Infection (JAMA) Contribute to our MicrobeTV fundraiser at PWB Dr. Griffin's treatment guide (pdf) Letters read on TWiV 955 Timestamps by Jolene. Thanks! Intro music is by Ronald Jenkees Send your questions for Dr. Griffin to daniel@microbe.tv

Zoe Russell discusses ankle sprain assessment and treatment, and how to return your patients to sport. You'll discover how to help your ankle sprain patients fully recover as quickly as possible, and avoid long term issues, such as chronic ankle instability, osteoarthritis or other lower limb injuries.  Zoe is a Specialist Sports Physiotherapist (FACP), APA Titled Musculoskeletal and Sports Physio, as well as a Clinical Edge Senior Educator and Presenter, and in this Physio Edge podcast hosted by David Pope, we discuss the latest evidence and practical strategies for ankle sprains, including:    Assessment  Common issues therapists face when rehabilitating ankle sprain patients.  Questions you need to ask your ankle sprain patients.  How a previous history of ankle sprains impacts your assessment & treatment. Why patients with inversion injuries may have medial ankle pain. How to avoid stirring up patients pain during your assessment.   Diagnosis Common mechanisms of injury, and how this guides your diagnosis.  Structures that are likely to be injured with different ankle injuries.   Treatment  10 key elements to include in your assessment & treatment. How to help reduce swelling quickly after an ankle sprain, and why this is important. Immediate sideline management for ankle sprains at sporting events. Whether manual therapy has a role in acute ankle injuries or persistent ankle pain and swelling.  How to explain ankle sprains, recovery & rehab to your patient. What you're looking to achieve with your early rehab.  How to set rehab targets or goals with your patients. The role of taping in ankle rehab. Taping compared to bracing. Whether long term taping or bracing is a useful long term injury prevention strategy.  The latest surgical procedures for patients with chronic ankle instability (CAI).   Links Zoe Russell David Pope on Twitter Improve your musculoskeletal and sports injury assessment & treatment results with a free trial Clinical Edge membership Explain acute and persistent pain to your patients, without giving them the message “It's all in your head” with the Making sense of pain training module Comprehensive low back pain assessment & treatment training module David Pope at Clinical Edge References CLICK HERE to download the article associated with this podcast Bestwick-Stevenson, T., Wyatt, L. A., Palmer, D., Ching, A., Kerslake, R., Coffey, F., Batt, M. E., & Scammell, B. E. (2021). Incidence and risk factors for poor ankle functional recovery, and the development and progression of posttraumatic ankle osteoarthritis after significant ankle ligament injury (SALI): the SALI cohort study protocol. BMC musculoskeletal disorders, 22(1), 362. https://doi.org/10.1186/s12891-021-04230-8 Delco ML, Kennedy JG, Bonassar LJ, Fortier LA. Post-traumatic osteoarthritis of the ankle: A distinct clinical entity requiring new research approaches. J Orthop Res. 2017 Mar;35(3):440-453. doi: 10.1002/jor.23462. Epub 2016 Nov 8. PMID: 27764893; PMCID: PMC5467729. Herzog MM, Kerr ZY, Marshall SW, Wikstrom EA. Epidemiology of Ankle Sprains and Chronic Ankle Instability. J Athl Train. 2019 Jun;54(6):603-610. doi: 10.4085/1062-6050-447-17. Epub 2019 May 28. PMID: 31135209; PMCID: PMC6602402. van Ochten, J. M., de Vries, A. D., van Putte, N., Oei, E., Bindels, P., Bierma-Zeinstra, S., & van Middelkoop, M. (2017). Association between Patient History and Physical Examination and Osteoarthritis after Ankle Sprain. International journal of sports medicine, 38(9), 717–724. https://doi.org/10.1055/s-0043-109554     Chapters: 03:47 - Untreated ankle sprains 05:27 - Latest evidence 07:04 - Subjective questions 09:45 - Common mechanisms of injury 11:47 - Plantarflexion/inversion injury with medial ankle pain 15:22 - Dorsiflexion eversion injuries 15:54 - Swelling 21:11 - Objective tests 26:32 - Irritability 26:47 - Figure of 8 taping technique 28:56 - Inferior and superior tib-fib joint assessment 32:14 - Treatment 42:41 - Change of direction 43:17 - Tape or brace? 50:06 - Mobilise or immobilise?

Joining Brian and myself in our virtual studio we are delighted to have Dr Emily Hall, one of our lecturers in Veterinary Education here at the RVC. Emily has been working with the VetCompass group looking at Heat Related Illness in the UK and we thought we'd talk to her to about her research in this field and the questions that left unanswered.  We hope that you enjoy. Emily has her own blog on this topic too, where you can find links to the papers. http://heatstroke.dog/ There is even an infographic: https://www.rvc.ac.uk/Media/Default/VetCompass/210324%20EH%20Heat%20Stroke%20infographic.pdfAnd Congress abstract recordings to watch:  https://www.rvc.ac.uk/vetcompass/audio-visual-resources/conference-presentations Some references of interest: Hall, Hall, E. J., Carter, A. J., & O’Neill, D. G. (2020). Incidence and risk factors for heat related illness (heatstroke) in UK dogs under primary veterinary care in 2016. Scientific Reports, 10(1), 9128. https://doi.org/10.1038/s41598-020-66015-8Hall, E. J., Carter, A. J., & O’Neill, D. G. (2020). Dogs Don’t Die Just in Hot Cars—Exertional Heat-Related Illness (Heatstroke) Is a Greater Threat to UK Dogs. Animals, 10(8), 1324. https://doi.org/10.3390/ani10081324Hall, E. J., Carter, A. J., Bradbury, J., Barfield, D., & O’Neill, D. G. (2021). Proposing the VetCompass clinical grading tool for heat-related illness in dogs. Scientific Reports, 11(1), 6828. https://doi.org/10.1038/s41598-021-86235-wE. J., Carter, A. J., Chico, G., Bradbury, J., Gentle, L. K., Barfield, D., & O’Neill, D. G. (2022). Risk Factors for Severe and Fatal Heat-Related Illness in UK Dogs—A VetCompass Study. Veterinary Sciences, 9(5), 231. https://doi.org/10.3390/vetsci9050231Carter, A. J., & Hall, E. J. (2018). Investigating factors affecting the body temperature of dogs competing in cross country (canicross) races in the UK. Journal of Thermal Biology, 72, 33–38. https://doi.org/10.1016/j.jtherbio.2017.12.006 To Cite this podcast as: Dom Barfield. RVC Clinical Podcast 136 Heat Related Illness with Emily Hall. Published on November 18 2022 If you have any comments about this podcast, please get in touch: email dbarfield@rvc.ac.uk; tweet @dombarfield. We would greatly appreciate your time to rate us on Apple podcast, podbean or Acast and kindly write us a review.  

On Episode 22 of the Stroke Alert Podcast, host Dr. Negar Asdaghi highlights two articles from the November 2022 issue of Stroke: “Estimating Perfusion Deficits in Acute Stroke Patients Without Perfusion Imaging” and “Five-Year Results of Coronary Artery Bypass Grafting With or Without Carotid Endarterectomy in Patients With Asymptomatic Carotid Artery Stenosis.” She also interviews Dr. George Ntaios about his article “Incidence of Stroke in Randomized Trials of COVID-19 Therapeutics.” Dr. Negar Asdaghi:         Let's start with some questions. 1) What is the actual incidence of stroke after COVID-19? 2) In the setting of acute ischemic stroke, can the volume of ischemic penumbra be estimated with just a regular MRI study of the brain without any vascular or perfusion imaging? 3) And finally, can a patient with significant carotid stenosis go through coronary artery bypass graft surgery? We're back here to answer these questions and bring us up to date with the latest in the world of cerebrovascular disorders. You're listening to the Stroke Alert Podcast, and this is the best in Stroke. Stay with us. Welcome back to another issue of the Stroke Alert Podcast. My name is Negar Asdaghi. I'm an Associate Professor of Neurology at the University of Miami Miller School of Medicine and your host for the monthly Stroke Alert Podcast. The November issue of Stroke is packed with a range of really exciting and exceedingly timely articles. As part of our Original Contributions in this issue of the journal, we have a post hoc analysis of the Treat Stroke to Target, or the TST, randomized trial by Dr. Pierre Amarenco and colleagues. We've talked about this trial in our past podcast, and the main study results that were published in New England Journal of Medicine in January of 2020. TST randomized patients with a recent stroke or TIA to either a low target of LDL cholesterol of less than 70 milligram per deciliter or a target LDL of 90 to 110. The main study showed that the low LDL target group had a significantly lower risk of subsequent cardiovascular events without increasing the risk of hemorrhagic stroke. So, from this, we know that achieving a low target LDL is possible and is actually better than the LDL target of 90 to 110 post-stroke. But in the new paper, in this issue of the journal, in a post hoc analysis of the trial, the TST investigators showed that it's not just achieving that magic low target LDL of less than 70 that's important in a reduction of cerebrovascular disorders, but it's also how we achieve it that determines the future of vascular outcomes. So, in this analysis that compared patients on monostatin therapy to those treated with dual cholesterol-lowering agents, that would be a combination of statin and ezetimibe, and showed that in the low LDL target group, only those patients treated with dual therapy had a significant reduction of subsequent vascular events as compared to those in the higher LDL category. But the same was not true for patients on statin monotherapy, even though they had all achieved a low target LDL. Think about this for a moment. Both groups, whether on statin monotherapy or on dual anti-cholesterol treatments, achieved the same low target of LDL, but only those on dual therapy had a lower risk of subsequent vascular events as compared to those that were in the higher LDL target group. Very thought-provoking study. In a separate paper by Dr. Shin and colleagues out of Korea, we learned that survivors of tuberculosis, or TB, are at a significantly higher risk of ischemic stroke than their age- and risk factors–matched non-TB counterparts. The authors used data from the Korean National Health Insurance Services and studied over 200,000 cases diagnosed with TB between 2010 and 2017 and compared them to a pool of over one million non-TB cases for matching. And they found that the risk of ischemic stroke was 1.2 times greater among TB survivors compared to matched non-TB cases after adjusting for the usual confounders, health behavioral factors, and other comorbidities. Now, why would TB increase the risk of stroke? The authors talk about the pro-inflammatory state of this condition, thrombocytosis, that is a known complication of chronic TB amongst other putative and less clear mechanisms. But what is clear is that findings from a large-scale population-based cohort such as the current study support an independent association between TB and ischemic stroke. As always, I encourage you to review these papers in addition to listening to our podcast today. My guest on the podcast today, Dr. George Ntaios, joins me all the way from Greece to talk to us about the much discussed topic of the risk of stroke in the setting of COVID-19. Dr. Ntaios is the President of the Hellenic Stroke Organization and an experienced internist who has been fighting this pandemic in the front lines since the beginning. In an interview, he talks about his recently published paper, his experience, and the lessons learned on balancing scientific rigor against the urgency of COVID-19. But first, with these two articles. In the setting of a target vessel occlusion in patients presenting with an acute ischemic stroke, distinguishing the ischemic core from the ischemic penumbra is of outmost importance. The success of all of our reperfusion therapies heavily lies on our ability to differentiate between the tissue that is already dead, which would be the ischemic core, from the tissue that is not dead yet but is going to die unless revascularization is achieved. That is the ischemic penumbra. Over the past two to three decades, there's been lots of debate over how these entities of dead tissue versus going-to-die tissue are best defined, especially when we're making these distinctions under the pressure of time. We don't even agree on the best imaging modality to define them. Should we rely on CT-based imaging? Do we stop at CT, CT angiogram? Should we do single-phase CTA or multiphase CTA? When do we perform CT perfusion, and what perfusion parameters best define core and penumbra, or should we rely on MRI-based modalities altogether? These questions have all been asked and extensively studied, which is why, as a field, I think, we have at least some agreements today on the basics of core and penumbra definitions. And I also think that overall we are becoming better at doing less imaging to be able to predict tissue outcomes in real time. And there's definitely a growing interest in trying to estimate tissue fate based on a single-imaging modality. So, I think you're going to find an Original Contribution in this issue of the journal, titled "Estimating Perfusion Deficits in Acute Stroke Patients Without Perfusion Imaging," really interesting. In this paper, Dr. Richard Leigh from the National Institute of Neurological Disorders and Stroke, National Institutes of Health, in Bethesda and colleagues evaluated patients with acute ischemic stroke enrolled between 2013 to 2014 in the NINDS Natural History of Stroke study. A little bit about the study: It enrolled stroke patients presenting to three hospitals in Washington, DC, and Maryland with serial MRI scans during the acute and subacute time period after ischemic stroke. For this particular paper, they included patients who received MRI and perfusion-weighted imaging and included only those who were thrombolized. That was their way of ensuring that all patients in their study were in the hyperacute stage of stroke. They then looked at their MR imaging, specifically the fluid-attenuated inversion recovery, or FLAIR, images, for a presence of something called hyperintense vessels in the ischemic territory. Now, this is an audio-only podcast, so unless you're Googling FLAIR hyperintense vessels on MRI, to follow along, I have to take a bit of time explaining this entity. What do we mean by FLAIR hyperintense vessels? We are not just talking about the T2 hyperintense signal that's sometimes noticeable at the site of proximal occlusion. For example, in the setting of an M1 occlusion, we may be able to detect a T2 hyperintense signal at the site of M1 on FLAIR. That's not the point of this paper. The point is to look throughout the area supplied by that said target occlusion, in this case all of the MCA, and see whether there is hyperintense signal in all arteries in that potentially ischemic tissue and how the area delineated by these FLAIR hyperintense vessels could potentially correspond to the area of perfusion deficit on conventional perfusion imaging. It turns out that these hyperintense vessels actually map a pretty large area. So, this is the point of this study. The investigators developed a FLAIR hyperintense vessel scoring system and called it NIH, obviously, because this was a National Institutes of Health study, FHV, which stands for FLAIR hyperintense vessel, scoring system. And the score is based on presence of these hyperintense vessels in three vascular territories: ACA, MCA, or PCA. Now, seeing that MCA is a larger territory, they had to further divide it into four sub-regions: frontal, insular, temporal, and parietal. So, in total, we have six regions now. Each of them would get a score of zero if there were no hyperintense vessels in them, and a score of two if there were three or more FLAIR hyperintense vessels in a single slice, or if there were three or more slices that contained FLAIR hyperintense vessels. And, of course, a score of one would be anything in between. So, we have six regions in total, each maximum getting two points, to give us a composite score of maximum 12 for this scoring system. So, they wanted to see whether there's a correlation between the FLAIR hyperintense vessel score and the volume of perfusion deficits that is detected by conventional perfusion imaging, which is their main study result. But before we go there, it does seem like a lot of work to learn all these regions and count all these hyperintense vessels in these six regions and come up with an actual score. So, they had to do an interrater reliability to see how easy it is to score and how reliable are these scores. So, they had two independent reviewers for their study. On average, the scores of these two independent reviewers differed by one point for a κ of 0.31, which is quite a low interrater reliability. But when they looked at a more liberal way of assessing interrater reliability, where partial credit was given, when the raters were at least close in their scoring, the κ improved to 0.65 for a moderate degree of agreement. So, what that means is that it's not easy to learn the score, and potentially I can give a score and another colleague can give a different score. So, we have to keep that in mind. But I want to emphasize that in the field of stroke neurology, we are kind of used to these poor interrater reliability agreements in general. For example, the interrater reliability of the ASPECTS score, a score that is commonly used in our day-to-day practice, and especially in the acute phase, we communicate the extent of early ischemic changes by using the ASPECTS score, has a pretty poor interrater reliability, especially in the first few hours after the ischemic stroke. So, we can make due with a κ of 0.65. Now on to the results of this study. They had a total of 101 patients. Their median age was 73. The median FHV, which is that FLAIR hyperintense vessel score, in their entire cohort was four. And close to 80% of patients enrolled in their study had some perfusion abnormalities on their concurrent perfusion-weighted imaging. Now, briefly, they defined perfusion deficits as areas with delay in the relative time to peak map, or TTP maps, after applying a six-second threshold to these TTP maps. Of note, half of those patients with a perfusion deficit had a significant perfusion deficit, which meant that they had 15 cc or more of perfusion deficit. OK, now on to the main study results. Number one, the score obtained by NIH FLAIR hyperintense score highly correlated with the volume of perfusion deficit. In fact, every one point increase on the NIH-FHV score was approximately equal to 12 cc of perfusion deficit. That's a really useful way of thinking about this score. Each score translated in 12 cc of perfusion deficit. Number two, when they looked at the predictive ability of this score in predicting the presence of significant perfusion deficit, that is 15 cc or more of perfusion delay, the area under the curve was 0.9, which is quite high. This is quite reassuring that the FHV score was sensitive and specific in predicting the presence of significant perfusion deficit. Next finding, how does this score do in predicting a significant mismatch? They calculated mismatch ratio by dividing the perfusion volume to that of ischemic core as measured by diffusion volume as it's done conventionally, and then did the same for the score with the exception that instead of using the perfusion volume, they actually used this score and divided it by diffusion volume. And it turns out that FLAIR hyperintense mismatch ratio had a strong predictive capability in predicting the mismatch ratio of 1.8. So, in summary, if this score is validated in larger studies, it can potentially be used as a quick and dirty way of calculating the amount of perfusion deficit in the setting of target vessel occlusion. And, of course, it can also be used as a predictive way of presence of significant perfusion deficit, which is perfusion deficit of over 15 cc. This is all without the need to do actual perfusion imaging. Now, all we've got to do is to get comfortable with this scoring system and, of course, be able to multiply it by 12 to give us a quick guesstimate of the perfusion volume. And one final word on this is that I think the future of stroke imaging is not in doing more images, but to be able to extract more information from less imaging in the acute setting. Stroke physicians were frequently consulted to see patients that are scheduled to undergo coronary artery bypass graft surgery, or CABG. The stroke consult would be for the optimal perioperative management of an often incidentally found carotid disease. Now, why do I say we were frequently consulted? Because at least anecdotally in my own practice, I feel that over the past decade, the number of these consults has substantially reduced. Why is that? Well, let's dive into this topic and review some of the literature. First off, around 40% of patients who have active coronary artery disease and are scheduled to undergo CABG have concurrent carotid disease, and about 10% of CABG patients have evidence of hemodynamically significant carotid disease. And seeing that the risk factors for coronary artery disease are similar to those causing carotid disease, these high percentages are not surprising at all. But the question to ask is, can we put a patient with significant carotid disease through cardiac surgery? What is the perioperative risk of stroke in this situation? And importantly, should the carotid disease be surgically treated during carotid surgery? This is referred to as synchronous carotid endarterectomy, or CEA plus CABG. Or the carotid disease should be treated either surgically or endovascularly before CABG? We refer to this as staged carotid surgery or post-CABG. This is known as reverse staged carotid surgery. All of these questions are asked from the stroke physicians in that consult, and, like many of you, I have struggled to find the evidence to answer some of them. So, let's briefly review some of the current literature on this topic. The CABACS trial, the acronym stands for the Coronary Artery Bypass Graft Surgery in Patients With Asymptomatic Carotid Stenosis, was a randomized controlled trial that included patients undergoing CABG who are found, exactly like that consult, to have an asymptomatic carotid disease of equal or greater than 70% stenosis. The carotid disease for this trial had to be amenable to carotid endarterectomy, or CEA, and the patients were randomized to either receive synchronous CEA plus CABG or just go through with the CABG alone. The trial started in 2010 and planned to enroll over a thousand patients, but was stopped, unfortunately, prematurely in 2014 due to slow recruitment and withdrawal of funding after only 129 patients were enrolled from 17 centers in Germany and Czech Republic. The original study was published in this journal in 2017. So, what did it find? In their intention-to-treat analysis, the primary outcome of any stroke or death at 30 days was 18% in patients receiving synchronous CEA plus CABG as compared to only 9% in patients receiving isolated CABG. Ouch, a double risk of stroke in those who had concurrent surgical treatment of their carotid disease in addition to CABG. Now, this was an underpowered study, and the results should be understood in that context, but it really didn't appear that synchronous CEA plus CABG would decrease the rate of stroke in the first 30 days. Now, how about the long-term outcomes of these patients? We know that asymptomatic carotid disease carries a cumulative annual risk of stroke, and it's important to see if the risk of subsequent stroke was lower downstream if the carotid was already fixed early on. So, in the current issue of the journal, the CABACS trial investigators, led by Dr. Stephan Knipp from the Department of Thoracic and Cardiovascular Surgery in Essen, Germany, and colleagues are back with the five-year results of this trial. How did synchronous CABG plus CEA do as compared to CABG alone? Well, by five years, the rate of stroke or death was 40% in the combined group and 35% in the CABG-only group. This was not a statistically significant difference. Now, when they broke down the primary outcomes, the rate of death from any cause was similar in the two groups. By five years, the mortality rate was 25% in the combined group and 23% in the CABG-only group. And the same was true for the rate of nonfatal strokes. And also the cumulative rate of nonfatal strokes from year one to year five was similar between the two groups, which meant that the higher stroke risk early on in the CABG plus CEA group was not counterbalanced by decreased rate of stroke later on during the long-term follow-up. And finally, they looked at the rate of disability-producing stroke. First of all, after the first year, no new disabling strokes were observed in either group. That's great news. However, in the early period, unfortunately, close to half of strokes that had happened after the combined CEA and CABG were disability-producing, and about a third of strokes that happened after CABG alone were also disability-producing. So, in summary, even though this study is quite underpowered, it appears that performing synchronous CEA plus CABG increases the preoperative morbidity and mortality in patients with asymptomatic carotid disease without providing any long-term benefits to these patients. Coronaviruses are important human and animal pathogens. By now, I think it's safe to say that most of the population of the world has heard of at least one of the members of the coronavirus's family, which was first identified in late 2019 as the cause of a cluster of cases of pneumonia in Wuhan, China. In the early months of 2020, COVID-19, the disease caused by this novel coronavirus, would rapidly spread to involve much of the world. And on March 11 of the same year, the World Health Organization declared COVID-19 a pandemic. Today, over two and a half years have passed since that day, and an avalanche of scientific papers have since been published about COVID-19, not just in medicine, but in each and every imaginable field of life. Neurology's, of course, no exception. The clinical presentation of COVID-19 largely depends on the severity of the disease and may range from a simple asymptomatic infection to a severe, lethal, multi-organ disease. In the world of neurology, a myriad of neurological symptoms, from loss of sense of taste and smell to headache, all the way to encephalopathy and seizures, have been reported in association with this disease. Early in the pandemic, some studies suggested that COVID-19 is indeed a risk factor for stroke. Like many severe infections, COVID-19 can potentially cause a prothrombotic state and can be associated with thromboembolic events. But most of these earlier studies were smaller observational studies that were completed in an inpatient setting, including those with severe COVID. In fact, to date, we still don't have an accurate and reliable estimate of stroke incidence among patients with COVID-19. On the other hand, stroke is the second leading cause of death globally and the fifth cause of death in the US. In the United States, every 40 seconds, someone has a stroke, and every four minutes, someone dies of a stroke. So, I think the question that everyone should be asking is, has COVID-19 changed this statistic? In this issue of the journal, in the study titled "Incidence of Stroke in Randomized Trials of COVID-19 Therapeutics: A Systematic Review and Meta-Analysis," Dr. Ntaios and colleagues aim to get us a step closer to answering this very important question. Dr. Ntaios is an Associate Professor of Medicine at the University of Thessaly in central Greece, and he's the current President of the Hellenic Stroke Organization. It is my great honor to have Dr. Ntaios today in our podcast to discuss this paper and all things stroke-related COVID-19. Good afternoon, George, and welcome to our podcast. Dr. George Ntaios:          Thank you for the invitation, Negar, and for highlighting our work. It's a pleasure to be here with you today. Dr. Negar Asdaghi:         Thank you for being here, and congrats on the paper. George, can you start us off by discussing the pathophysiological mechanisms through which COVID can potentially cause a stroke? Dr. George Ntaios:          Well, one of the most attractive things about stroke, which makes it fascinating for all of us, is its complexity. So many different pathologies can cause stroke, and, quite frequently, identifying the actual cause of stroke can be really challenging. And in a similar way, the pathophysiological association between COVID and stroke seems to be, again, complex. Different pathways have been proposed. Internal, we talk about two broad mechanisms. One is the vascular inflammation and thrombosis, and the other is cardioembolism. And there are several pathways which are involved in vascular inflammation and thrombosis: activation of the complement, activation of the inflammasome, activation of thrombin, increased production of [inaudible 00:24:47] constriction, state of stress, platelet aggregation, vascular thrombosis. So, collectively, this thromboinflammation could lead to damage of the neurovascular unit and consequently to stroke. And in a similar way, there are several cardiac pathologies which can cause stroke in a COVID patient, like acute left ventricular dysfunction, which can be caused, again, by several mechanisms, like coronary ischemia, stress-induced takotsubo cardiomyopathy, myocarditis inflammation, or also as a result of direct effect of the coronavirus at the myocardial cell. And, of course, we should not forget about atrial fibrillation, which seems to be more frequent in COVID patients. So, we see that the proposed mechanisms behind the association between COVID and stroke, that is, vascular thromboinflammation on one hand, or cardioembolism on the other hand, are complex, but whether these derangements they have a clinically relevant effect or they are just biochemical derangements without any clinical effect is a debate. For example, the incidence of myocarditis in COVID is about 0.2%. That is, in every 500 COVID patients, you have one patient with myocarditis. But myocarditis has a very wide clinical spectrum ranging from subclinical elevation of myocardial enzymes to full and life-threatening disease. So, obviously, the incidence of severe myocarditis is even lower than 0.2%. And the same is true also for the incidence of myocarditis after COVID vaccination. The CDC estimates that one case of myocarditis occurs every 200,000 vaccinations, with the number being slightly higher in young men after the second dose. And this is extremely rare, and the huge majority of these myocarditis cases, they're mild. So, this is about ischemic stroke. Now, with regard to hemorrhagic stroke and its association with COVID, again, it seems to be, again, very rare. The best estimate that we have comes from the Get With The Guidelines – Stroke Registry and is about 0.2% and involves mainly patients who are already on anticoagulants. So, they had already a risk factor for ICH. So, again, whether all these pathophysiologic derangements in COVID patients, they have a clinical meaningful association with stroke risk or not, I think it's a matter of debate. Dr. Negar Asdaghi:         Wow, George, it was a simple question, but it seems like the answer was not that straightforward. Let me just recap some of the things you mentioned. So, first of all, the answer is not straightforward and depends on whether we're talking about ischemic stroke or hemorrhagic stroke. There seems to be a lot of connecting points, at least, so to speak, between COVID and either forms of stroke. But you touched on two major sort of broad mechanisms. One is the idea of vascular thromboinflammation that goes along the lines of many sort of hyperacute, hyperinflammatory processes that can occur, especially in the setting of severe COVID. You touched on activation of thrombin, complement activation, platelet aggregation, sort of an activation of that microvascular or vascular unit in a sense. And then a second mechanism you touched on is the impact of COVID on the myocardium on sort of many different pathways. Again, you talked about acute left ventricular dysfunction, stress-induced myocarditis, and the impact of COVID on perhaps increasing the rate of atrial fibrillation. Again, these are all very complex associations, and some could be already present in a patient who is perhaps of an older age, and COVID is just a modifier of that risk factor that was already present in that particular person. And you also touched on how COVID can potentially increase the risk of hemorrhagic stroke, but the study seems to suggest that those patients already had risk factors for the same. And perhaps, again, COVID is a modifier of that risk factor. All right, so with that information, a number of studies early on, especially, in the pandemic and later, some meta-analyses, have aimed to estimate the incident rate of stroke post-COVID. Can you please briefly tell us what were their findings, and how is your current paper and current meta-analysis different in terms of methodology from those earlier studies? Dr. George Ntaios:          Yes. Well, it all started from this letter to the editor at the New England Journal of Medicine. It was published very early in the pandemic during the outbreak in New York. And in this letter, the authors had reported that within a period of two weeks, they had five young patients with COVID and large artery stroke, which they commented that it was much higher than their typical, actually their average, of 0.7 cases during a two-weeks period within the last year. And remember that back then, we knew literally nothing about COVID. So, this letter was really a huge, loud alert that something is going on here and that perhaps our hospitals would be flooded with COVID patients with stroke. So, subsequently, several reports were published aiming to estimate the incidence of stroke in COVID. Rather contradictory with the incidence, estimates are ranging from as low as 0.5% to even 5%. However, these estimates could well be inaccurate. They were observational studies. Most of them were limited to the inpatient setting. Most of them were single-center studies. Most of them, if not all, were retrospective studies. So, there was really a high risk of registration and assessment bias, as well as reporting bias. And also remember that back then during the outbreak, people were really reluctant to visit the hospital, even if they had a serious condition like stroke, an urgent condition, which means that the real incidences could be even higher. So, it was our feeling that these estimates were perhaps inaccurate. And there are also some meta-analyses of these studies which estimate that the incidence of stroke in COVID is about 1.5%. But, of course, any meta-analysis is as good as the studies it includes. So, we tried to find a way to have a more accurate estimate than these estimates. And we followed a different methodology. We studied randomized trials of COVID therapeutics, and we looked for strokes reported as adverse events or as outcome events. And the good thing about randomized trials is the rigorous assessment and reporting of outcomes in adverse events. So, we think, we believe, that this methodology provides a more reliable and a more robust estimate of stroke incidence in COVID patients. Dr. Negar Asdaghi:         OK. George, it's very important what you just mentioned, so I wanted to recap for our listeners some of the things you mentioned. It all started with a letter to the editor of New England Journal of Medicine on a report of five young patients that had large vessel occlusion in the setting of COVID. And then, basically, the floodgates opened in terms of all these observational studies that basically reported the same. And subsequent to that, meta-analyses that were completed containing those observational studies predominantly gave us an incident rate of 0.5 to 5%. That's much, much higher than basically the non-COVID–associated incidence rate of stroke in the population-based studies, and basically suggested that COVID-19 is indeed a major risk factor for all types of stroke. So, that's where it all started. And, as you alluded to, these numbers had to be reverified in bigger settings, more controlled setting. And you already answered my next question, which is the difference between those studies and prior meta-analyses to the current meta-analysis is that you basically took the simple question and started looking at it in a controlled setting of randomized trials. And you already answered this question of the methodology, but I want to recap. You took basically patients included in randomized trials of therapeutics for COVID-19, various therapies for COVID-19, and you did a meta-analysis to see what were the incident rate of stroke as an outcome in these trials. So, with that, could you please tell us a little more about the population that you had in this meta-analysis in terms of their age, the types of therapies that these randomized trials had looked at, and the duration of the follow-up, please? Dr. George Ntaios:          The follow-up included 77 randomized trials, which corresponds to more than 38,000 COVID patients. The mean age of these patients was about 55 years of age, and they were followed for an average of 23 days after study enrollment. With regard to the set strategy, I think it was not strict at all. I would rather say it was very liberal. We allowed trials of any drug in COVID patients of any age, of any severity, coming from any setting: outpatient, inpatient, either general ward or intensive care unit. And from any country. I don't think that we could achieve a wider inclusion than this strategy did. And the huge majority of patients, more than 95%, they were hospitalized patients. So, by definition, they had severe COVID disease. And the drugs studied in these trials included everything that was actually tried in COVID, including tocilizumab, IL-6R inhibitors, steroids, remdesivir, chloroquine, azithromycin, ritonavir, interferon, ivermectin, and many other drugs. So, I think we tried to include as many trials as possible. Dr. Negar Asdaghi:         OK. So, let me see if I got it. You basically included 77 randomized trials. It is a younger population of patients in these trials, median aged 55. You had a total of over 38,000 patients. It's a great sample size for this meta-analysis. And importantly, the duration of follow-up is median of 23 days. And it's just about any treatments we've heard that have been tried for COVID, from dexamethasone to remdesivir and ivermectin. And a rigorous methodology. So, I think we're ready to hear the primary results of this meta-analysis. How many strokes happened in these patients? Dr. George Ntaios:          In the overall population, that is both in the hospital and in the outpatient setting, there were totally 65 strokes in these 38,000 COVID patients, which corresponds to one stroke every 600 COVID patients or else an incident of only 0.16%, 0.16%. This is very low, much lower than the previous estimates. And, of note, all strokes occurred in hospitalized patients. There were no strokes at all in the ambulatory COVID patients. So, just to repeat the result, we just found that only one patient will have a stroke every 600 COVID patients who are either hospitalized or are ambulatory. Dr. Negar Asdaghi:         OK. So, I need to have these numbers, I think, committed to memory, especially when we speak to family members and patients in the hospital. Ninety-five percent of the patient population of this meta-analysis were inpatient COVID. So, by definition, they must be sicker in terms of the severity of their COVID disease. Out of 38,000 patients, you had 65 events of stroke. So, these are very, very important numbers, a lot basically lower than the incidence rate reported from prior studies. So, I wanted to ask you about the sensitivity analysis that was done in the meta-analysis. Dr. George Ntaios:          Yes. When we designed the analysis, we were expecting that we would find numbers was similar to those reported before. So, we thought that perhaps a sensitivity analysis would be able to increase the confidence and the robustness of the results. That's why we did this sensitivity analysis. However, it proved that the number of strokes, the number of outcome events was much lower than what expected. So, the power for those sensitivity analysis to show a meaningful conclusion was low. So, actually, that's why we don't comment at all on those sensitivity analysis because there were so few strokes to support such an analysis. Dr. Negar Asdaghi:         OK. So, basically, you had a priori design the meta-analysis based on the assumption that the incidence rate of stroke would be a lot higher, but then later on, when the incidence rates was lower, then the sensitivity analysis didn't really give any meaningful data to us. So, I mean, I think we already talked about this, but I want to ask you, why do you think that the incidence rates were so much lower in your analysis than the prior meta-analysis? Dr. George Ntaios:          I believe that our estimate is quite accurate. I think that the reports of stroke incidence published during the pandemic possibly overestimated the association. I think that the early concern that we all had in the beginning, that we would be flooded with strokes during the pandemic, was not confirmed. I think that we can support with decent confidence that stroke is a rare or perhaps very rare complication of COVID. Dr. Negar Asdaghi:         Right. That's great news. That really is great news, and we take every bit of good news in these trying times. George, something that was not touched on in the paper, but I want to ask you and basically get your opinion on this matter, is a much talked about concept in the COVID literature of how COVID could potentially modify certain risk factors. There are much talk about how people with pre-existing diabetes or obesity can potentially develop more severe COVID and, hence, have more complications of COVID, including stroke. What is your clinical experience on this matter, and do you think there are certain predictors of development of COVID-associated stroke? Dr. George Ntaios:          That's a very good point. For the last two years, I was involved in the hospitalization management of COVID patients. So, what we see is what is also described in the literature, that there are certain patient characteristics that predispose them to severe COVID. For example, obesity, for example, older age, pregnancy. Perhaps our analysis was not designed to respond to this question. The data available on the studies that were included, they could not support such an analysis. So, I cannot provide information from our study. But the fact that all strokes in our study, they occurred in hospitalized patients and none of them occurred in ambulatory patients, confirms what is known, that those strokes occurred in patients who, by definition, they have severe COVID disease. So, they confirm this putative association that perhaps severe COVID is associated with stroke rather than just mild COVID. Dr. Negar Asdaghi:         All right. Thank you. And I just want to end with this simple question that I get asked often, and I want to see how you respond to patients or their loved ones when you're asked this question: "Doctor, did COVID give me a stroke?" How should we answer that question? Dr. George Ntaios:          Yes. As we discussed, I think that stroke is a rather rare or perhaps very rare complication of stroke and certainly less frequent than we initially thought. And in those stroke patients who had already other pathologies which can cause stroke, I would be rather reluctant to attribute it to COVID. I would be perhaps more willing to do so in younger patients, but again, only after exhaustively looking for another cause, like PFO, dissection, etc. I mean, the concern is that if we as the treating stroke physicians assume that the stroke is caused by COVID, then we might discourage patients from doing the necessary diagnostic workup to find the actual cause of stroke. And if it happens, then perhaps an underlying pathology may be missed, which means that the patient will remain vulnerable to stroke recurrence. So, in general, I'm rather very reluctant to say that the stroke is caused by COVID unless a really thorough diagnostic workup shows nothing else at all. Dr. Negar Asdaghi:         All right. Very important message now to all practicing clinicians is don't stop at COVID. Don't just say simply, "Oh, this is COVID. COVID gave you a stroke." Keep looking for potential causes of stroke. Still do put that patient in the category of potentially ESUS or cryptogenic stroke if no other causes are found. And keep in mind that stroke is rare or, as George said, a very rare complication of COVID. Dr. George Ntaios, this is an exceedingly timely topic and a very important contribution to the field. Congratulations again on your paper, and thanks for taking the time to chatting with us today. Dr. George Ntaios:          Thank you for the wonderful discussion, Negar, and for the focus of our work. Dr. Negar Asdaghi:         Thank you. And this concludes our podcast for the November 2022 issue of Stroke. As always, please be sure to check out the table of contents for the full list of publications, as we can only cover a fraction of the incredible science published in this journal each month. And don't forget to check our fantastic Literature Synopsis. In this month's issue, we read a short summary of the ACST-2 trial published in Lancet on the results of a randomized comparison of stenting versus endarterectomy in asymptomatic carotid disease patients with over 60% of carotid stenosis. We also have the results of the CASSISS randomized trial, which was published in JAMA earlier this year, and it studied the effect of stenting plus maximal medical therapy versus maximum medical therapy alone on the risk of subsequent stroke and death in patients with symptomatic intracranial stenosis, either in the anterior or in the posterior circulation. CASSISS did not show that stenting was superior to maximum medical therapy, and sadly, these patients remain at a substantial risk of recurrent stroke despite being on best medical therapy. But I wouldn't be too despondent about the future of interventional therapy for intracranial atherosclerotic disease. After all, we've come a long way since Dr. Charles Thomas Stent, an English dentist, started experimenting with products to advance the field of denture making around 1865. The work that Dr. Stent had started would be continued by his two sons, both dentists, to eventually make its way to products to create surgical tools. But it would be another 100 years before the first percutaneous coronary procedure was completed in 1964. And in honor of Dr. Stent's pioneering work, the device used to keep the coronaries open was named, you guessed it, stents. Today's stroke care cannot be imagined without the use of various stents, and there's no doubt the future is promising for ways in which we will be able to safely treat intracranial atherosclerotic disease amongst all other vascular disorders. And what better way to keep our enthusiasm than staying alert with Stroke Alert. 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, visit AHAjournals.org.

In this episode Dr. Chastain and Abby give advice on defense against dog bites, including:Incidence of serious dog bitesPreventive steps for dog bitesProactive defenses compared to reactive defenses against dog bitesLink to show notes: BetterAnimalHandling.com

• Host Austin Beason, MD • Guest interviewees Loretta B. Chou, MD, FAAOS; Lisa K. Cannada, MD, FAAOS; Antonia F. Chen, MD, MBA, FAAOS discussing their research article “Increased Prevalence of Breast and All-cause Cancer in Female Orthopaedic Surgeons” from the JAAOS Global May 2022 issue (https://journals.lww.com/jaaosglobal/Fulltext/2022/05000/Increased_Prevalence_of_Breast_and_All_cause.10.aspx) • Article summarized from the November 1, 2022 issue (https://journals.lww.com/jaaos/toc/2022/11010) o Research article “Incidence, Timing, and Predictors of Hip Dislocation After Primary Total Hip Arthroplasty for Osteoarthritis” • Article summarized from the November 15, 2022 issue (https://journals.lww.com/Jaaos/toc/2022/11150) o Research article “Delay in Knee MRI Scan Completion Since Implementation of the Affordable Care Act: A Retrospective Cohort Study” Follow this link to download these and other articles from the November 1, 2022 issue of JAAOS (https://journals.lww.com/jaaos/toc/2022/11010) and the November 15, 2022 issue of JAAOS (https://journals.lww.com/Jaaos/toc/2022/11150). The JAAOS Unplugged podcast series is brought to you by the Journal of the American Academy of Orthopaedic Surgeons and the AAOS Resident Assembly.

Synopsis: Every first and third Wednesday of the month, The Straits Times helps you make sense of health matters that affect you. In this episode, we look at why you should start insuring yourself against critical illnesses when you are in your 20s or early 30s. Cancer, heart attacks and stroke are three common critical illnesses in Singapore. We are living longer but we may be spending more time in poor health. Looking at government statistics, we can see that in Singapore, cardiovascular disease accounted for 32 per cent of all deaths in 2021. This means that almost one out of three deaths in Singapore is due to heart disease or stroke. Spotting a stroke early can help to save a life. Recovery after a stroke, however, may take a long time.. Most millennials and Gen Z are busy establishing their careers. Growing their wealth is likely to take priority over protecting their health, but this is the time to think about health insurance. ST senior health correspondent Joyce Teo finds out more from neurosurgeon Dr Chou Ning from Chou Neuroscience Clinic and Eddy Lim, who is the head of Propositions and Portfolio Management, at Great Eastern. This episode is brought to you by Great Eastern: https://str.sg/w9qr Highlights (click/tap above): 1:15 Incidence of stroke among younger age groups is about 10-15% of entire stroke cohort 3:15 Among survivors of stroke, 50% would still be chronically disabled after one year 4:10 Risk of recurring stroke within the next five years 6:39 Avoiding placing financial burden on your parents; plans that can cost as low as $20 a month to cover critical illnesses 9:11 Dr Chou on a recent case of a healthy 46-year-old patient who came in with some weakness in his left hand; eventually diagnosed with a small ischaemic stroke 11:54 Tip: Consider cover critical illnesses one time, and covering recurrence with a rider for a second payout More about Great Eastern's Great Critical Cover Series: https://str.sg/w9qV Help cancer survivors in their rehab journey: https://str.sg/w9qC About Great Eastern: https://str.sg/w9qy Produced by: Joyce Teo (joyceteo@sph.com.sg), Ernest Luis, Teo Tong Kai and Eden Soh Edited by: Eden Soh Follow Health Check Podcast here and rate us: Channel: https://str.sg/JWaN Apple Podcasts: https://str.sg/JWRX Spotify: https://str.sg/JWaQ Google Podcasts: https://str.sg/J6Wv  SPH Awedio app: https://www.awedio.sg/ Website: http://str.sg/stpodcasts Feedback to: podcast@sph.com.sg Read Joyce Teo's stories: https://str.sg/JbxN --- Discover ST's special edition podcasts: The Unsolved Mysteries of South-east Asia: https://str.sg/wuZ2 Stop Scams: https://str.sg/wuZB Singapore's War On Covid: https://str.sg/wuJa Invisible Asia: https://str.sg/wuZn --- Discover more ST podcast series: Asian Insider: https://str.sg/JWa7 Green Pulse: https://str.sg/JWaf In Your Opinion: https://str.sg/w7Qt Your Money & Career: https://str.sg/wB2m SG Extra: https://str.sg/wukR #PopVultures: https://str.sg/JWad ST Sports Talk: https://str.sg/JWRE Bookmark This!: https://str.sg/JWas Lunch With Sumiko: https://str.sg/J6hQ Discover ST Podcasts: http://str.sg/stpodcasts Discover BT Podcasts: https://bt.sg/pcPL Follow our shows then, if you like short, practical podcasts! #healthcheckSee omnystudio.com/listener for privacy information.

Synopsis: Every first and third Wednesday of the month, The Straits Times helps you make sense of health matters that affect you. In this episode, we look at why you should start insuring yourself against critical illnesses when you are in your 20s or early 30s. Cancer, heart attacks and stroke are three common critical illnesses in Singapore. We are living longer but we may be spending more time in poor health. Looking at government statistics, we can see that in Singapore, cardiovascular disease accounted for 32 per cent of all deaths in 2021. This means that almost one out of three deaths in Singapore is due to heart disease or stroke. Spotting a stroke early can help to save a life. Recovery after a stroke, however, may take a long time.. Most millennials and Gen Z are busy establishing their careers. Growing their wealth is likely to take priority over protecting their health, but this is the time to think about health insurance. ST senior health correspondent Joyce Teo finds out more from neurosurgeon Dr Chou Ning from Chou Neuroscience Clinic and Eddy Lim, who is the head of Propositions and Portfolio Management, at Great Eastern. This episode is brought to you by Great Eastern: https://str.sg/w9qr Highlights (click/tap above): 1:15 Incidence of stroke among younger age groups is about 10-15% of entire stroke cohort 3:15 Among survivors of stroke, 50% would still be chronically disabled after one year 4:10 Risk of recurring stroke within the next five years 6:39 Avoiding placing financial burden on your parents; plans that can cost as low as $20 a month to cover critical illnesses 9:11 Dr Chou on a recent case of a healthy 46-year-old patient who came in with some weakness in his left hand; eventually diagnosed with a small ischaemic stroke 11:54 Tip: Consider cover critical illnesses one time, and covering recurrence with a rider for a second payout More about Great Eastern's Great Critical Cover Series: https://str.sg/w9qV Help cancer survivors in their rehab journey: https://str.sg/w9qC About Great Eastern: https://str.sg/w9qy Produced by: Joyce Teo (joyceteo@sph.com.sg), Ernest Luis, Teo Tong Kai and Eden Soh Edited by: Eden Soh Follow Health Check Podcast here and rate us: Channel: https://str.sg/JWaN Apple Podcasts: https://str.sg/JWRX Spotify: https://str.sg/JWaQ Google Podcasts: https://str.sg/J6Wv  SPH Awedio app: https://www.awedio.sg/ Website: http://str.sg/stpodcasts Feedback to: podcast@sph.com.sg Read Joyce Teo's stories: https://str.sg/JbxN --- Discover ST's special edition podcasts: The Unsolved Mysteries of South-east Asia: https://str.sg/wuZ2 Stop Scams: https://str.sg/wuZB Singapore's War On Covid: https://str.sg/wuJa Invisible Asia: https://str.sg/wuZn --- Discover more ST podcast series: Asian Insider: https://str.sg/JWa7 Green Pulse: https://str.sg/JWaf In Your Opinion: https://str.sg/w7Qt Your Money & Career: https://str.sg/wB2m SG Extra: https://str.sg/wukR #PopVultures: https://str.sg/JWad ST Sports Talk: https://str.sg/JWRE Bookmark This!: https://str.sg/JWas Lunch With Sumiko: https://str.sg/J6hQ Discover ST Podcasts: http://str.sg/stpodcasts Discover BT Podcasts: https://bt.sg/pcPL Follow our shows then, if you like short, practical podcasts! #healthcheckSee omnystudio.com/listener for privacy information.

Comorbidities in Axial Spondyloarthritis Dr. Antoni Chan discusses Abstract 1609 at ACR22 Convergence. Diffuse alveolar hemorrhage in antiphospholipid syndrome Dr. Eric Dein discusses Abstract 0675 at ACR22 Convergence. Abstract 0675: Clinical Characteristics and Factors Associated with Relapse and Mortality in Diffuse Alveolar Hemorrhage Among Patients with Antiphospholipid Syndrome: A Multi-Center Retrospective Cohort Eosinophilia in systemic JIA patients after exposure to biologics Dr. Bella Mehta discusses Abstract 0872 at ACR22 Convergence. Abstract 0872: Incidence, Risk Factors, and Outcomes of Eosinophilia on IL-1 and IL-6 Inhibitors in Systemic and Non-Systemic Juvenile Idiopathic Arthritis Gender differences in Axial Spondyloarthritis Dr. Antoni Chan covered abstracts 0497 and 1614 at ACR22 Convergence in Philadelphia, PA. Inadequate Dosing of Hydroxychloroquine Leads to Hospitalizations in SLE Dr. Sheila Reyes discusses abstract 1654 at ACR22 Convergence.  Abstract 1654: Hydroxychloroquine Dosing Less Than 5 Mg/kg/day Leads to Increased Hospitalizations for Systemic Lupus Erythematosus Flares Oligoarticular PsA: FOREMOST Study Dr. Peter Nash discusses abstract 1018 at ACR22 Convergence.  Abstract 1018: Characterization of Joint Distribution and Disease Burden in Patients with Early Oligoarticular Psoriatic Arthritis: Results from the Ongoing FOREMOST Study Sensor-engineered glove evaluates hand function in RA Dr. David Liew discusses abstract 0904 at ACR22 Convergence.  Abstract 0904: Testing the Hand Function with a Sensor-engineered Glove in Patients with Rheumatoid Arthritis

Featuring an interview with Dr Brady Stein, including the following topics: Case: A man in his late 70s with myelofibrosis (MF) presenting with fatigue and night sweats (0:00) Incidence and severity of fatigue and other symptoms; use of symptom scales to measure severity (3:43) Rapidity of symptom response to ruxolitinib; emerging data with momelotinib (7:34) Novel therapeutic targets for MF: BET, PI3K and BCL2 (13:25) Available data on JAK inhibitors for essential thrombocytosis and polycythemia vera; pathogenesis of pruritus and optimal management (20:31) Clinical pearls on managing splenomegaly, weight loss and other MF symptoms (26:34) Risks of localized therapy for splenomegaly; splenic progression among patients receiving ruxolitinib (30:14) Prevention and management of withdrawal rebound from ruxolitinib; factors to consider in choosing JAK inhibitors for different risk groups (34:17) Myths and misperceptions about MF among community general oncologists (38:26) Management algorithms for transplant-eligible and transplant-ineligible patients (44:32) Current understanding of MF pathophysiology; end-of-life care for patients with MF (50:13) CME information and select publications

More than a million people in the United States have been killed by COVID-19 in the past 3 years. The numbers would be much higher, but the vaccines were developed with amazing speed. Time and again, the vaccines have been shown to be safe and effective. Yet some people persist in claiming the mRNA vaccines are causing an epidemic of stroke. The data is clear. They do not. If you want to reduce your chances of stroke, get the vaccine. The new thing that causes stroke over the past few years is COVID-19 itself. If you want to decrease your chances of having a stroke (or another stroke) don't get a severe COVID-19 infection. And the simplest thing you can do to reduce your chances of getting a severe COVID-19 infection is to get the COVID-19 vaccine. If you do catch COVID-19 despite the vaccine, the data shows it will be much less severe and much less likely to be fatal.  In addition to protecting yourself, you are also helping to protect others who may not be medically eligible to get the vaccine. The COVID-19 mRNA vaccines are saving lives every day. In this episode ... In this episode, I talk with data scientist and epidemiologist Dr. Remle Crowe about the research studies coming out now that show what we already knew from earlier research: the COVID-19 vaccine does not increase your risk stroke. We talk about several studies, and we talk about how you can do your own research on the credibility of these studies and evaluate how well they reflect the scientific reality of our world. In this post, you'll also find links to a bunch of these studies that you can read for yourself. Start by listening to this conversation. If you don't seed the audio player below visit http://Strokecast.com/MSN/vaccine to listen to the whole conversation.   Click here for a machine-generated transcript   I got my Bivalent COVID-19 booster and my 2022 Flu shot on the same day in October. Who is Dr. Remle Crowe? Dr. Remle Crowe is an expert in EMS research and quality improvement. From truck clutches to clinical care, she has shown how research and improvement science work to solve problems across fields. Prior to earning a PhD in Epidemiology, her EMS career began with the Red Cross in Mexico City as a volunteer EMT. She has authored numerous peer-reviewed publications related to prehospital care and the EMS workforce. Now, as a research scientist with ESO, Dr. Crowe routinely uses EMS data to improve community health and safety. Dr. Crowe previously appeared on the Strokecast in episode 132 to discuss the AHORA pneumonic to help Spanish speakers recognize and respond to a stroke. When it comes to stroke, Time is Brain regardless of which language you speak. A Sampling of the Studies When we claim the data indicates that the vaccine doesn't cause an increase in stroke, what data are we talking about? How did "they" analyze it? Who reviewed the studies to ensure they were accurate? Where can you read the details yourself? As Dr. Crowe explained, there are currently a whole bunch of studies that are coming out. That makes sense; it's roughly 18 months since the vaccines against COVID-19 became widely available. To conduct sound research, you need a large pool of people to look at. You need to take some time to see the results. You need to write up those results. Then you need to submit them for publication. Publications will then need to review before publishing them. That brings us to where we are today with all these studies now becoming available. Let's take a look at a few of them, and I encourage you to click through to the details and read them yourself. Click the study titles for more. Surveillance for Adverse Events After COVID-19 mRNA Vaccination This study published in JAMA (Journal of the American Medical Association) looked at nearly 12 million doses of the mRNA vaccine given to more than 6 million people. This is what they learned: "The incidence of events per 1 000 000 person-years during the risk vs comparison intervals for ischemic stroke was 1612 vs 1781 " In other words, the time period at greatest risk for stroke did not see an increased risk. They concluded: "In interim analyses of surveillance of mRNA COVID-19 vaccines, incidence of selected serious outcomes was not significantly higher 1 to 21 days postvaccination compared with 22 to 42 days postvaccination. While CIs were wide for many outcomes, surveillance is ongoing." COVID-19 Incidence and Death Rates Among Unvaccinated and Fully Vaccinated Adults with and Without Booster Doses During Periods of Delta and Omicron Variant Emergence — 25 U.S. Jurisdictions, April 4–December 25, 2021 We talked about this report from the CDC Morbidity and Mortality Weekly Report during the episode. This study looked at infections and deaths among vaccinated folks and unvaccinated folks. The rate of infection and death from COVID-19 was much higher among unvaccinated folks than among vaccinated or vaccinated and boosted folks. The report says: "Rates of COVID-19 cases were lowest among fully vaccinated persons with a booster dose, compared with fully vaccinated persons without a booster dose, and much lower than rates among unvaccinated persons during October–November (25.0, 87.7, and 347.8 per 100,000 population, respectively) and December 2021 (148.6, 254.8, and 725.6 per 100,000 population, respectively) (Table 2). Similar trends were noted for differences in the mortality rates among these three groups (0.1, 0.6, and 7.8 per 100,000 population, respectively) during October–November." Even though the vaccine does not guarantee a person will avoid COVID-19, it greatly increases their chances of avoiding infection. And if they do become infected, the vaccine greatly increases their chances of survival. Acute ischemic stroke and vaccine-induced immune thrombotic thrombocytopenia post COVID-19 vaccination; a systematic review This study in the Journal of Neurological Sciences looked throughout the published literature and found just 43 incidents of stroke following the vaccine administration. "AIS has been reported as a rare complication within 4 weeks post COVID-19 vaccination, particularly with viral vector vaccines. Health care providers should be familiar with this rare consequence of COVID-19 vaccination in particular in the context of VITT to make a timely diagnosis and appropriate treatment plan." The report specifically called out the risk of “viral vector vaccines” (and, again, it's a shockingly small risk). The most common viral vector COVID-19 vaccines are those from Johnson & Johnson and from Oxford-AstraZeneca. The mRNA vaccines from Moderna and Pfizer are not viral vector vaccines., indicating that those appear to be even safer. The recommendation is not to avoid vaccination. It's an extremely rare complication. The recommendation is to watch for signs of stroke, which is something we should be doing all the time anyway. Association Between Vaccination and Acute Myocardial Infarction and Ischemic Stroke After COVID-19 Infection This article, published in JAMA looked at what happens after a COVID-19 infection for both vaccinated and unvaccinated folks. If someone does get infected and, does their vaccination status reduce the impacts of infection? Yes, it does. In fact, folks who got the vaccine and the got COVID were LESS likely to have a stroke or heart attack after their COVID infection. "This study found that full vaccination against COVID-19 was associated with a reduced risk of AMI [heart attack] and ischemic stroke after COVID-19. The findings support vaccination, especially for those with risk factors for cardiovascular diseases." Risk of thrombocytopenia and thromboembolism after covid-19 vaccination and SARS-CoV-2 positive testing: self-controlled case series study This study in the UK looked at patients who had been infected with COVID-19 or who had received the vaccine. More than 30 million people were part of the study. The conclusions were clear: "Increased risks of haematological and vascular events that led to hospital admission or death were observed for short time intervals after first doses of the ChAdOx1 nCoV-19 and BNT162b2 mRNA vaccines. The risks of most of these events were substantially higher and more prolonged after SARS-CoV-2 infection than after vaccination in the same population." Even if there is a slight risk from vaccination, the risk from the actual disease is much higher. COVID-19 vaccine not linked to increased risk of stroke Not all research becomes available without a subscription. Researchers at Cedars-Sinai have found similar results to other studies though and have come to the same conclusion. "Newly compiled data evaluated by researchers in the Department of Neurology and the Smidt Heart Institute at Cedars-Sinai shows that COVID-19 vaccines do not raise stroke risk--but that severe COVID-19 infection does. Physician-scientists hope this growing body of evidence, highlighted today in an editorial in the peer-reviewed journal Neurology, will ease the minds of individuals still hesitant to be vaccinated." Risk of Myocarditis After Sequential Doses of COVID-19 Vaccine and SARS-CoV-2 Infection by Age and Sex We talked about this study in the conversation with Dr. Crowe. At first glance it is concerning. This is the conclusion: "Overall, the risk of myocarditis is greater after SARS-CoV-2 infection than after COVID-19 vaccination and remains modest after sequential doses including a booster dose of BNT162b2 mRNA vaccine. However, the risk of myocarditis after vaccination is higher in younger men, particularly after a second dose of the mRNA-1273 vaccine." That does seem scary for young men, and there are a couple things to keep in mind. First, the number of events was so small that it's tough to draw firm conclusions. When you get down to such low numbers, that stats can do weird things. Second, this was based on the adverse event reporting system. That does not prove causality. It just flags something to look at more closely if there are large numbers. Which there are not. The point of all this research, though, is to learn more and compile more and more evidence. And ultimately to let the body of evidence guide decision making and recommendations. What we know at this point is that the risk of stroke after a COVID-19 infection is much higher than the risk of stroke following a vaccination. And the risk of stroke after COVID-19 infection is much lower in folks that have been vaccinated than it is in those who have not been vaccinated. COVID-19 is not gone. It is still out there in the world infecting people, killing people, and giving people strokes. Billions of vaccinations later, this is what the data tells us. The simplest way to reduce your risk of stroke is to get the vaccine and stay boosted. Do Your Own Research We talked about a bunch of research in the podcast, and we looked at a bunch of reports above. You don't have to just accept my commentary or Dr. Crowe's. You can read the reports yourself and look at the data and see why the vast majority of medical professionals have concluded the vaccines are safe and effective. Dr. Crowe offered a number of tips to help you do your research. You'll find them and more in this list. Tip 1 Search research focused search engines and directories to find studies and resources. Google Scholar and PubMed are great places to start. Tip 2 Look at the Publication that publishes the research. Is it well known for scientific rigor? Does it have a strong requirement for peer review of articles? Or can someone publish in it by simply paying a fee? Tip 3 Search for the publication's Impact Factor. The more other publications that cite its work, the higher the number. A publication with a higher impact factor is likely more credible. Tip 4 When you get to the actual study, look at what type it is. If it was a case study, that's interesting. If it was a randomized, double-blind, placebo-controlled study on a large scale, that's even better. If it was a systemic review evaluating hundreds of other studies, that's stronger still. Tip 5 Look at how many people were part of the study. A few dozen is interesting. A few million is much more likely to yield credible results. Tip 6 Look at the results of the study, relative to the size of the study. A few results out of a dozen is one thing. A few results out of millions of subjects is another matter altogether. Tip 7 Look at the goal of the study. What were the authors hoping to demonstrate? Did they succeed? Why or why not? Tip 8 Consider confounding. Studies generally deal with a subset of the population -- a limited number of people -- and seek to extrapolate those results and draw conclusions about the broader population.  For those conclusions to be valid, though, the group studied needs to be similar to the group the study extrapolates to. The more different the groups are, the less reliable the results. Tip 9 Finally, does the study demonstrate causality or just coincidence? There's a reason folks will often say, “Correlation does not equal causation.” For example, the FDA Adverse Event Reporting System (FAERS) Public Dashboard is a collection of negative things that happen to a person after they get a vaccine. It's not a list of events caused by the vaccine. If a person gets hit by a bus after getting the vaccine, that can go in the database. It's an adverse event. That doesn't mean the vaccine caused the bus accident. Read the study carefully to see if the authors claim a causal relationship and if that relationship is supported by the evidence in the study. AHORA The last time Dr. Crowe was on the show was to talk about the AHORA messaging to help Spanish speakers recognize and respond to stroke. It's basically the equivalent of the BEFAST messaging we talk about a lot in English. Here is the stroke warning pneumonic device in Spanish. Download it and share it far and wide. Reconocer los signos de un accidente cerebrovascular y responder rápidamente. ¡Llame a una ambulancia si observa estas señales! Let's look at a translation. Letter Abbreviation for Spanish Description In English A Andar Tiene dificultad para andar? Tiene problemas con el equilibrio? Do they have difficulty walking? Do they have problems with balance? H Hablar Tiene dificultad para hablar o entender? Usa palabras que no tienen sentido? Do they have difficulty speaking or understanding language? Do they use words that don't make sense? O Ojos Tiene algün cambio de vista? Tiene visiön doble? Tiene dificultad para ver con ambos ojos? Do they have some change in vision? Do the have double vision? Do they have difficulty seeing with both eyes? R Rostro Tiene la mitad del rostro caido? Tiene un repentino dolor de cabeza como nunca se ha sentido? Do they have one-sided facial droop? Do they suddenly have the worst headache of their life? A Ambos Brazos Tiene dificultad para levantar un brazo o una pierna? Tiene debilidad en un brazo o una pierna? Do they have difficulty lifting an arm or a leg? Do they have weakness in an rm or a leg? And, of course, here is the BE FAST messaging for English speakers. Recognize the signs of a stroke and respond quickly. Call an ambulance if you observe these signs! Both sets of symptoms look for the same thing. The AHORA messaging includes legs and headaches. The BE FAST messaging specifically calls out calling an ambulance. Regardless, the more people that can recognize a stroke as it is happening, the better off we will all be. Pop Culture Moment During the conversation, Remle mentioned she is a big fan of the movie Sliding Doors. It's an examination of how simple moment can change the course of your life. What path lies ahead if we catch that train or miss it? https://www.youtube.com/watch?v=Da-Mizk86AE&ab_channel=Shout%21Factory Or what happens if we turn right instead of turning left? https://www.youtube.com/watch?v=YnzbuU5I7RI&ab_channel=DoctorWho In reflecting on the past, it's easy to get fixated on thing were so much better back then, but it's never that simple, is it? Billy Joel reminds us that: "The good old days weren't always good, and tomorrow ain't as bad as it seems." https://www.youtube.com/watch?v=ph7oZnBH05s&ab_channel=billyjoelVEVO Other Shows Journal Club Remle mentioned her show, PCRF Journal Club, which is a journal review webinar that meets each month. They go deep into looking at the latest research studies that are coming out. The focus is on research around EMS -- the ambulance and transport industry. If you'd like to learn more, check out its site here: https://www.cpc.mednet.ucla.edu/pcrf Successful and Disabled I was also recently featured on another podcast focused on being successful as a person with disabilities. I joined host Christ Mitchell on the Successful and Disabled podcast to share my story and discuss how I use mindset to drive my recovery and other goals in life. Listen to it here. If you don't see the audio player below, visit http://Strokecast.com/MSN/Vaccine to listen to the conversation: Hack of the Week Reading a paper book can be challenging with one functional hand. It's even harder if you try to do that while eating a meal. Why? Because books don't always want to stay open on their own. You have to hold them open, which makes it harder to pick up your cheeseburger. I use my phone to address this problem. I open the book and then lay my phone across the open pages. It's just heavy enough to keep the book from snapping shut so I can enjoy feeding my belly as I also enjoy feeding my mind. Give it a try. Links  Where do we go from here? Check out the links above to learn more about why getting the vaccine is safer than not getting the vaccine Share this episode with someone you know by giving them the link http://Strokecast.com/vaccine Do you have a recent win or victory in your recovery? Share it by calling 321-5 STROKE Get your vaccine and booster to protect against COVID if your doctor advises it Don't get best…get better

Interview with Tianjing Li, MD, MHS, PhD, author of Prevalence and Incidence of Dry Eye and Meibomian Gland Dysfunction in the United States: A Systematic Review and Meta-analysis. Hosted by Neil Bressler, MD.

Interview with Tianjing Li, MD, MHS, PhD, author of Prevalence and Incidence of Dry Eye and Meibomian Gland Dysfunction in the United States: A Systematic Review and Meta-analysis. Hosted by Neil Bressler, MD.

Featuring an interview with Dr Justin Gainor, including the following topics: Ongoing Phase III trials of selective RET inhibitors for non-small cell lung cancer (NSCLC): Potential effects on survival (0:00) Significance of non-fusion RET abnormalities in NSCLC (3:33) Clinical impact of tumor-agnostic targeted therapy (5:11) Incidence and management of chylothorax in patients undergoing treatment with RET inhibitors (8:46) Therapeutic approach for patients with RET-rearranged NSCLC and brain metastases (15:24) Appropriate use of checkpoint inhibitors for patients with RET-rearranged NSCLC and disease progression on a RET inhibitor (16:45) Adjuvant therapy for RET-rearranged NSCLC (26:23) Case: A woman in her mid 60s with no smoking history with NSCLC with a RET fusion and disease progression after a response to carboplatin and pemetrexed (31:07) Case: A woman in her early 50s with no smoking history with NSCLC with a RET fusion and liver lesions who previously received cisplatin/pemetrexed and pembrolizumab (36:40) Case: A woman in her late 60s with NSCLC with a RET fusion and liver and brain metastases (43:28) CME information and select publications

Interview with Brent S. Rose, MD, author of Association of Prostate-Specific Antigen Screening Rates With Subsequent Metastatic Prostate Cancer Incidence at US Veterans Health Administration Facilities. Hosted by Jack West, MD. Related Content: Association of Prostate-Specific Antigen Screening Rates With Subsequent Metastatic Prostate Cancer Incidence at US Veterans Health Administration Facilities

Interview with Brent S. Rose, MD, author of Association of Prostate-Specific Antigen Screening Rates With Subsequent Metastatic Prostate Cancer Incidence at US Veterans Health Administration Facilities. Hosted by Jack West, MD. Related Content: Association of Prostate-Specific Antigen Screening Rates With Subsequent Metastatic Prostate Cancer Incidence at US Veterans Health Administration Facilities

LINKS BELOW | OUR EPISODE THIS WEEK INCLUDES:Where Brazilian Jui Jitsu and Physical Therapy OverlapSpecificity of BJJ AthletesEnhancing Injury IQPower of Graded ExposureIncidence of InjuriesMismanagement of Expectations in AthletesWith Much More⏱ Time Stamps:0:00 Introduction1:45 Mike Background5:34 Overlap in BJJ and PT9:03 Beginning Career10:53 How To Treat Combat Athletes13:40 Helping Combat Athletes Receive Care15:27 Specificity of BJJ17:57 Factors To Consider When Treating the Combat Athlete21:25 Different Types of Grapplers24:16 Performance Buckets for Combat Athletes28:45 Where Do Combat Athletes Go Wrong33:40 Improving Injury IQ in the Combat Athlete35:35 Importance of Graded Exposure40:06 Mismanagement of ACL Patients and Return to Sport43:11 Incidence of Injuries in BJJ44:07 Research and Social Media Endeavors48:56 Separating Experience in Clinical Decision Making51:45 Addressing Fads In Physical Therapy54:42 Test and Re-test56:11 Biggest Surprise Working with Combat Athletes1:01:52 Health Me,  Health You

In this podcast, Gary S. Marshall, MD, summarizes the burden of meningococcal disease and the importance of immunization, including: The unpredictability and severity of meningococcal diseaseDifferences between meningococcal serogroups and available vaccines Current meningococcal vaccine recommendations, distinguishing between routine vs shared clinical decision-making recommendations Vaccine recommendations in high-risk populations Use of immunization platforms to help complete age-appropriate vaccines, including the MenACWY and MenB vaccine, in adolescents and young adultsFaculty:Gary S. Marshall, MDProfessor of PediatricsDivision of Pediatric Infectious DiseasesUniversity of Louisville School of MedicineLouisville, KentuckyLink to full program:https://bit.ly/3T0GLG2