Podcasts about Jama

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Latest podcast episodes about Jama

DOSIS DIARIA ROKA
Rendirse, Jamás

DOSIS DIARIA ROKA

Play Episode Listen Later Dec 5, 2022 5:13


Rendirse, Jamás by Roka Stereo

TRAIT PHARMACIEN
Parkinson et hospitalisation : quelles questions se poser?

TRAIT PHARMACIEN

Play Episode Listen Later Dec 5, 2022 25:18


Références -Calculatrice en ligne : http://www.parkinsonscalculator.com/ -Calculatrice en ligne : http://pdmedcalc.co.uk/calculator.php -Lignes directrices canadiennes : https://parkinsonguideclinique.ca/guideline/ -Article : Armstrong MJ, Okun MS. Diagnosis and treatment of Parkinson disease: a review. JAMA 2020; 323: 548-60. -Article : Rizek P et al. An update on the diagnosis and treatment of Parkinson disease. CMAJ 2016; 188: 1157-65. http://www.cmaj.ca/content/188/16/1157.full.pdf+html?sid=3206b284- a407-429e-90c1-ad2c55059cf3

DOSIS DIARIA ROKA
Rendirse, Jamás

DOSIS DIARIA ROKA

Play Episode Listen Later Dec 5, 2022 5:13


Rendirse, Jamás by Roka Stereo

Fotbolti.net
Útvarpsþátturinn - Þeir bestu, verstu og skemmtilegustu á HM

Fotbolti.net

Play Episode Listen Later Dec 3, 2022


Elvar Geir og Tómas Þór gera upp riðlakeppni HM í útvarpsþætti vikunnar, velja úrvalsliðið til þessa, mestu vonbrigðin og skemmtilegustu karakterana. Sérfræðingur þáttarins, Kristján Atli Ragnarsson, spáir í viðureignir 16-liða úrslitanna. Fjallað er um vonbrigði Þýskalands. Sæbjörn Steinke ræðir við Guðmund Hreiðarsson, markvarðaþjálfara Jamaíku og sérfræðing um þýska fótboltann. Í lok þáttarins er svo farið yfir fréttir vikunnar í íslenska boltanum.

Fill'Expats

En cette période de fin d'année, Fill'Expats te propose un calendrier de l'avent particulier, toujours dans l'objectif de t'aider dans ta future expatriation ou dans ton expatriation actuelle (désolée mais pas de chocolat !). Fill'Expats va te faire découvrir 1 message vocal par jour de 2 -3 minutes, jusqu'à Noël, sur les choses peu ordinaires dans un pays, et la solution qu'une femme expatriée a trouvé pour s'adapter. ✈️ Aujourd'hui on part à la Jamaïque avec Gilou ✈️  

SUND-FORSKNING
Er kosttilskud spild af penge?

SUND-FORSKNING

Play Episode Listen Later Dec 2, 2022 9:10


Et hold amerikanske forskere har i en artikel i tidsskriftet JAMA kaldt kosttilskud for ”spild af penge”, fordi de mener, at der mangler beviser på præparaternes forebyggende virkning mod hjerte-kar-sygdomme og kræft. Har de ret, eller er de for hurtige på aftrækkeren med deres kritik?

Radio Rodja 756 AM
Karamah Para Wali

Radio Rodja 756 AM

Play Episode Listen Later Dec 1, 2022


Karamah Para Wali adalah bagian dari ceramah agama dan kajian Islam ilmiah dengan pembahasan kitab Syarah Aqidah Ahlus Sunnah wal Jama'ah. Pembahasan ini disampaikan oleh Ustadz Yazid bin ‘Abdul Qadir Jawas pada Sabtu, 27 Syawal 1443 H / 28 Mei 2022 M. Kajian sebelumnya: Setia dan Cinta Kepada Ahlul Bait Karamah Para Wali Karamah para […] Tulisan Karamah Para Wali ditampilkan di Radio Rodja 756 AM.

JAMA Network
JAMA Otolaryngology–Head & Neck Surgery : Risk Factors Associated With Outcomes in Tall Cell Papillary Thyroid Cancer

JAMA Network

Play Episode Listen Later Dec 1, 2022 14:56


Interview with Eric D. Lamarre, MD, author of Risk Factors Associated With Recurrence and Death in Patients With Tall Cell Papillary Thyroid Cancer: A Single-Institution Cohort Study With Predictive Nomogram. Hosted by Paul C. Bryson, MD, MBA. Related Content: Risk Factors Associated With Recurrence and Death in Patients With Tall Cell Papillary Thyroid Cancer

Relentless Health Value
EP387: Medicare Advantage Trends and How Medicare Advantage Plans Will or Will Not Succeed, With Betsy Seals, CEO and Cofounder of Rebellis Group

Relentless Health Value

Play Episode Listen Later Dec 1, 2022 34:50


Here's a big thing that Betsy Seals makes clear in this show: Big companies can be successful in Medicare Advantage (MA)—and I mean success in all of its financial glory—because they have experience and the scale and also the specialized departments who keep track of all kinds of intricacies that are rate critical to MA success. Specifically, things Betsy Seals talks about as critical success factors, for example, are having relationships with brokers and health systems and other provider organizations. She also makes it clear how much local market knowledge is necessary. A benefit design working great in one local market might be a medical trend disaster in another area with different levels of social determinants of health (SDoH) or different disease patterns, so scaling into new areas isn't a matter of just cutting and pasting. History has shown it's easy enough to go down in a flaming ball of unanticipated medical trend and/or OIG/DOJ scrutiny. So, this is one thing that big MA carriers can get right and potentially, for sure, benefit patients in their plans. Now I say this knowing full well that there's a brouhaha afoot in which there are some who are really pro-MA and there are some who are really not. In this show with Betsy Seals today, we do not get into this (ie, Do patients in MA plans fare better than patients in traditional Medicare?). But I have a point to make, and I'm just gonna make it here. Like most “Is this better than that?” questions in healthcare, there is not one answer; and anyone running around espousing pretty much anything as a broad-stroke holy grail is pretty much full of it—and I would say that as a general statement. Whether MA is better than traditional Medicare depends on who the patient is and also which MA plan we're talking about here. So, starting on the “not a fan” side of the house, Wendell Potter has said (with evidence) that if a patient is toward the end of his or her life or acutely ill or needs to go to an NCI-designated cancer center, it could easily be deduced that traditional Medicare is going to be better. On the other hand, there seems to be evidence, including a recent JAMA article by Ravi Parikh, MD, MPP, and Ezekiel Emanuel, MD, PhD, that concludes MA produces a 22% to 26% reduction in costs compared to MSSP (Medicare Shared Savings Program) arrangements. And this is across just a general patient population of all age ranges, if I'm reading the study right. The great results that are discussed in that JAMA article are what can happen when payers and providers align to tackle SDoH and preventative stuff and are willing to go out into the community to curb potentially avoidable downstream acute events. David Carmouche, MD, by the way, on episode 343 talked at length about this. But there are variables here, and let me mention one of them: how good the Medicare Advantage plan is at risk-based contracting with physician groups. How good are they at putting patients into accountable relationships with provider organizations who are getting paid to keep patients healthy, meaning the MA plan is offering budget-based prospective payment contracts to physician groups? This is the case in that Ochsner/JAMA article example that Dr. David Carmouche was talking about. Ochsner, the health system in Louisiana, and MA plans were working together; and both assumed risk for this population. Susan Dentzer, president and CEO over at America's Physician Groups (APG), does a great job at covering a bunch of these topics on the Race to Value podcast. Another thing that will impact care quality is how good the plan leadership is at balancing patient care and shareholder demand for profit. Bottom line, it is not productive to be indiscriminately pie-eyed about pretty much anything in healthcare or throw babies out with bathwater on a regular basis. As Ge Bai, PhD, CPA, has said on this show (and others have said), there's no angels and no devils in healthcare. Everybody is some combination of both. And, in general, the only reason anybody does anything in healthcare is because it appeals to their self-interest. So, not working with some other healthcare stakeholder because we perceive them as greedy or “industry” or whatever is gonna mean that nobody is working with anybody. Just keep your eyes wide open, check the math, and in your contracts, get actual dollar amounts and not discounts. In this healthcare podcast, as mentioned a few times now, I am speaking with Betsy Seals. Betsy Seals is CEO and cofounder of Rebellis Group, a managed care consulting firm working with Medicare Advantage plans. Oh, and one acronym alert before we dive in here: SNP stands for special needs plan. A special needs plan is a Medicare Advantage coordinated care plan that is specifically designed to provide targeted care and limit enrollment to special needs individuals. So, a special needs individual could be any one of the following: An institutionalized individual A dual eligible, meaning somebody who has Medicare and Medicaid An individual with a severe or disabling chronic condition, as specified by CMS SNPs are becoming a bit of thing in the MA space this year, and Betsy talks about this trend. You can learn more at rebellisgroup.com. Betsy Seals is the CEO and cofounder of Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage Organizations (MAOs) and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 20 years of experience. Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the managed care landscape. Betsy's expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that address social determinants of health, and health plan operations. Prior to founding Rebellis Group, Betsy served as the chief consulting officer for Gorman Health Group (GHG). In this role, Betsy managed the Medicare consulting practice, including implementation of strategic initiatives, development of new practice areas, and oversight of day-to-day consulting operations. Prior to her role as chief consulting officer, Betsy served as senior vice president, compliance operations, where she assisted MAOs and Part D sponsors to attain and maintain compliance with the Centers for Medicare & Medicaid Services (CMS) regulations and guidance by conducting risk assessments, preparing organizations for CMS audits, performing mock CMS audits, and creating and implementing internal and delegated entity oversight programs. Before joining GHG, Betsy worked for MAOs, where she served in customer service and compliance with responsibility for creation and implementation of oversight programs, CMS audit preparation, implementation of internal corrective action plans, and the day-to-day management of compliance operations. Betsy has also worked as a CMS subcontractor to conduct CMS Compliance Program audits. 06:16 Is Medicare Advantage still a cash cow? 06:42 Why should Medicare Advantage be the most lucrative line of business? 07:07 “If there weren't a lot of money in it, nobody would do it.” 07:29 What should you know before jumping into the Medicare Advantage market? 14:04 What issues do upstarts overlook when getting into Medicare Advantage? 17:07 What is one of the next areas that Betsy thinks CMS will crack down on? 18:24 “Look at the data.” 19:53 “I think there's a lot of lessons that you could see over the past years in the industry.” 20:52 “That's what we see a lot of times is expansion without enough due diligence and thought put behind it.” 21:02 Why don't common business models always work in healthcare businesses? 22:29 What are the new key trends coming out of the Medicare Advantage space? 26:04 Why is it important to bring in your clinicians when entering a dual market? 27:52 What's going on in the chronic conditions space? 32:14 What's necessary to the infrastructure with any kind of SNP product? 32:56 What's Betsy's forecast for the future of Medicare Advantage? You can learn more at rebellisgroup.com. @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Is Medicare Advantage still a cash cow? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Why should Medicare Advantage be the most lucrative line of business? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “If there weren't a lot of money in it, nobody would do it.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What should you know before jumping into the Medicare Advantage market? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What issues do upstarts overlook when getting into Medicare Advantage? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What is one of the next areas that Betsy thinks CMS will crack down on? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “Look at the data.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “I think there's a lot of lessons that you could see over the past years in the industry.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “That's what we see a lot of times is expansion without enough due diligence and thought put behind it.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Why don't common business models always work in healthcare businesses? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What are the new key trends coming out of the Medicare Advantage space? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Why is it important to bring in your clinicians when entering a dual market? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What's going on in the chronic conditions space? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What's necessary to the infrastructure with any kind of SNP product? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What's Betsy's forecast for the future of Medicare Advantage? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter

Invité du matin
Winnie Byanyima (Onusida): «Il faudra une volonté politique pour vaincre le sida»

Invité du matin

Play Episode Listen Later Dec 1, 2022 8:40


Ce 1er décembre marque, comme chaque année, la journée mondiale de lutte contre le sida, épidémie qui tue encore 650 000 personnes par an, et contre laquelle la lutte piétine. Plusieurs régions du monde enregistrent une hausse du nombre de contaminations, mettant à mal des décennies d'efforts. C'est dans ce contexte que l'Onusida publie un nouveau rapport mettant en cause le poids des inégalités qui entravent les politiques sanitaires. Invitée exceptionnelle ce matin sur RFI, Winnie Byanyima, la directrice exécutive de l'agence onusienne, répond aux questions de Simon Rozé. À l'occasion de la journée mondiale contre le sida, l'Onusida publie son nouveau rapport : «Inégalités dangereuses». Pour Winnie Byanyima, sa directrice exécutive, des changements structurels sont à mettre en œuvre pour espérer tenir l'objectif de mettre fin à la pandémie en 2030. RFI : Votre nouveau rapport fait suite à celui publié l'été dernier : « En danger ». Cette fois encore, on lit que la lutte contre l'épidémie n'est pas sur la bonne voie. Qu'est-ce qui ne fonctionne pas ? Winnie Byanyima : Beaucoup de facteurs expliquent cela. Nous n'étions tout d'abord pas bien engagés. Le Covid-19 et ses conséquences économiques ont ensuite compromis de nombreuses choses. Puis la guerre en Ukraine, l'augmentation des prix du carburant, de la nourriture, du coût de la vie, ont laissé de nombreux pays en difficulté. En particulier, ceux les plus touchés par l'épidémie, ceux à bas revenus et à revenus intermédiaires en Afrique. Ils doivent faire face à des remboursements toujours plus élevés de leur dette au détriment des dépenses de santé, d'éducation et de protection sociale. Beaucoup de pays dépendants de l'aide au développement ont également connu des réductions de cette aide. Cela s'explique par la dévaluation de leur monnaie par rapport au dollar, mais également car les montants eux-mêmes des aides ont diminué. Tout cela nous mène donc dans la mauvaise direction. Permettez-moi cependant de dire que nous n'allions pas assez vite avant même ces crises. Nous devons donc simplement nous reprendre et mettre les bouchées doubles. Il faut regarder nos données, les analyser et comprendre que ce sont les inégalités le moteur de l'épidémie. En quoi ces inégalités, et particulièrement celles de genre, nous empêchent-elles de mettre fin au sida ? Les régions Afrique de l'Est et australe, par exemple, constituent l'épicentre de l'épidémie de VIH. 54% de toutes les personnes contaminées y vivent. Lorsque l'on regarde en détail, on voit que chez les 15-24 ans, 3 nouvelles infections sur 4 concernent les filles et les jeunes femmes. C'est une crise d'inégalité de genre. Les femmes et les filles ont plus de risque d'infection. C'est lié aux violences sexuelles, le plus souvent des rapports non désirés. Les causes sont notamment le manque d'accès sûr à l'école, la dépendance économique de ces femmes et ces filles, les rapports sexuels tarifés... Vous voyez : les inégalités sont le moteur de ce risque plus élevé. Je suis en Tanzanie en ce moment. Seuls 30% des jeunes garçons et des jeunes filles vont au lycée. Cela veut dire beaucoup pour une fille. Cette fille qui ne va pas à l'école, qui a 12, 13, 14, 15 ans ; elle risque des rapports sexuels non consentis. Elle sera sur le marché quelque part, elle rapportera de l'eau, elle ramassera du bois de chauffage, elle fera des corvées pour subvenir aux besoins de sa famille. Elle sera probablement seule dans un endroit où elle ne sera pas en sécurité et où un homme, un garçon, la forcera à avoir des rapports sexuels. Elle n'aura aucun contrôle. Nous devons mettre fin à cela. Si nous pouvons garder les filles à l'école, le risque est réduit de moitié. Si on leur donne une éducation à la sexualité, le risque diminue encore plus. Je suis donc heureuse que déjà douze pays aient signé le nouveau programme que nous avons appelé Éducation plus. C'est un plan ambitieux pour développer l'enseignement secondaire et pour y mettre en place des programmes d'éducation sexuelle. Il s'agit notamment de lutter contre la masculinité toxique chez les garçons, les sensibiliser à être des gens respectueux, qui ne forcent pas une fille à faire l'amour. C'est ce genre d'action qui fera reculer les inégalités dont souffrent les filles. Il y a d'autres inégalités, notamment celles qui visent les hommes qui ont des rapports homosexuels. On voit dans les régions d'Afrique de l'Est et australe, en Afrique centrale ou de l'Ouest, que ces dix dernières années ont permis de réduire les nouvelles infections et les décès du sida. Mais pas pour les homosexuels et les autres populations clés. Il n'y a presque pas eu de réduction des nouvelles infections. L'explication est qu'ils souffrent d'inégalités dont on ne s'occupe pas. Ils sont criminalisés, et cela renie leur droit à la santé. Ils se cachent donc de la loi. Ils affrontent le regard de la société, qui ne les laisse pas assumer leur sexualité et obtenir ce dont ils ont besoin. Nous devons donc nous battre contre la stigmatisation et ces lois punitives. Ce ne sera pas facile, mais on avance. Je me réjouis de voir que ces dernières années, certaines de ces lois ont été abandonnées en Afrique : au Gabon, au Botswana, en Angola… Dans les Caraïbes également : Antigue-et-Barbude, Saint-Kitts-et-Nevis… Ces pays et d'autres encore ont décriminalisé l'homosexualité. Il y a une opportunité à saisir et nous continuerons de plaider contre ces lois criminelles. Elles n'ont pas de place dans le monde d'aujourd'hui. Elles renient aux personnes leur droit à la santé. Aussi incroyable que cela puisse paraître, les enfants aussi souffrent des inégalités. Aujourd'hui, 75% des adultes séropositifs suivent un traitement. Ils peuvent vivre comme s'ils avaient une maladie chronique, pour laquelle on prend un médicament et cela suffit. Mais pour les enfants, seulement 52% sont sous traitement. C'est honteux que ceux sans défense, qui ne peuvent porter leur voix, ne puissent bénéficier de ce qu'offre la science. Nous devons donc résoudre cela et fournir un traitement à chaque enfant atteint du VIH. Il faut également arrêter la transmission mère-enfant, car là aussi, nous savons traiter. Il y a des inégalités dans l'accès à la science. Si vous êtes en France, au Royaume-Uni, aux États-Unis, vous pouvez recevoir des injections longue durée. Une simple piqûre dans votre bras vous protégera pendant deux mois. Vous n'avez pas à prendre de médicament et cela vous permet d'avoir des rapports sexuels. Rien ne vous arrivera, vous n'aurez pas le VIH. Tout cela n'est pas disponible dans les pays du Sud, où on en a pourtant le plus besoin. Ces pays en Afrique, où les gens doivent se cacher : une petite piqûre vaudra mieux que de sortir acheter des préservatifs. L'accès aux meilleurs outils de la science est donc inégal. Nous aurons bientôt à disposition des anti-rétroviraux à longue action. Cela pourrait tout changer pour les filles africaines. Vous voyez, aujourd'hui, elles doivent se cacher de leurs parents, de leurs enseignants, de l'Église. Elles font l'amour, et peuvent attraper le VIH. Mais imaginez, si elles pouvaient aller quelque part et avoir cette piqûre. Ce serait efficace pendant six mois. Cela changerait leur vie ! Elles n'auraient plus à se cacher. Tous ces outils ne devraient pas être disponibles uniquement dans les pays riches. Ils devraient être donnés là où le besoin est le plus grand, auprès des personnes stigmatisées et qui en meurent. Pour progresser, il faut certes des programmes comme celui que vous citez, mais il faut également des financements. En septembre dernier, le Fonds mondial contre le VIH, le paludisme et la tuberculose tenait sa conférence de reconstitution. Une somme record a certes été récoltée, mais l'objectif fixé n'a pas été atteint. Comment l'interprétez-vous ? Nous espérions obtenir 18 milliards de dollars, nous en avons eu 16. Ce n'est donc pas une reconstitution complète. Je note que la France est d'ailleurs l'un des principaux contributeurs. C'est impressionnant et c'est un exemple pour d'autres pays. Mais vous savez, chez moi on dit que tout rayon de soleil est bon à prendre. Ce que je veux dire, c'est que nous sommes tout de même parvenus à récolter 16 milliards en période de récession mondiale. De nombreux pays voient les prix du carburant augmenter, cela réduit leurs budgets et malgré ça, beaucoup d'entre eux ont augmenté leur contribution au Fonds de 30%. C'est donc compliqué de ne pas s'en satisfaire. Il faudra alors faire avec et faire des priorités parmi les priorités. Les pays d'Afrique de l'Est, australe, de l'Ouest et centrale ont beaucoup de besoins, notamment car ils sont très endettés. Il y a cette pression sur leurs budgets, et ils vont avoir besoin de toute notre aide pour maintenir en place leurs programmes contre le VIH. C'est pour cette raison qu'avec la France, nous soutenons un certain nombre de pays d'Afrique francophone en difficulté, qui ont besoin d'aide pour continuer le combat. Nous visons un budget de 15 millions de dollars. C'est la troisième région avec le plus de personnes contaminées par le VIH dans le monde. Il faut aussi insister sur le fait qu'il doit y avoir des solutions à la question de la dette. Ce n'est pas juste qu'en pleine crise sanitaire, des pays pauvres doivent rembourser des montants quatre fois supérieurs à ce qu'ils investissent pour la santé de leurs habitants. Dans ce contexte, considérez-vous que la lutte contre le VIH constitue toujours une priorité politique ? Le sida est toujours là. Notre rapport montre même que dans quatre régions du monde, les nouvelles infections ne diminuent pas mais augmentent. C'est dangereux. Jusqu'à maintenant, les nouvelles infections diminuaient en Afrique subsaharienne, en Afrique de l'Est. Elles diminuaient en Asie et dans le Pacifique. Maintenant, on observe des hausses en Amérique latine, en Europe de l'Est et même en Asie et dans le Pacifique. Nous n'allons pas dans le bon sens. Le sida est toujours là : 650 000 personnes en sont mortes l'an dernier. Une toutes les minutes. Nous devons rappeler que ça continue et que cela va empirer si nous relâchons nos efforts. Nous devons poursuivre le combat. Comment faire ? Nous devons tout d'abord nous appuyer sur les données. Elles nous diront où nous devons accentuer nos efforts. Nous devons dépenser l'argent là où il y a le plus grand risque, le plus lourd fardeau. On ne peut pas jeter l'argent partout. Ensuite, il faut identifier les causes : pourquoi des personnes qui commencent leur traitement abandonnent ensuite ? On observe ce phénomène dans plein de pays. Au Mozambique par exemple, c'est le système de santé qui est en cause. Il ne permet pas aux patients de bénéficier du suivi dont ils ont besoin près de chez eux. On voit aussi qu'il y a de nombreux obstacles structurels. La stigmatisation en est un. Elle empêche les gens d'accéder au soin. Nous devons nous en occuper, notamment en réduisant les inégalités qui éloignent les patients des services de soin. C'est une part importante de notre travail. Mais il faut aussi repenser ces services et les mettre dans les mains de ceux qui sont confrontés à la maladie. C'est le meilleur moyen de remettre les choses en ordre, il faut une solution centrée sur les communautés. Il en faut plus. Il faut que les homosexuels, les travailleurs du sexe, les jeunes, aient la main pour retrouver le chemin du soin. Il faut étudier ces services pour comprendre comment les malades les utilisent et régler les problèmes qui les en éloignent. Ce sont ces innovations qui rendront nos actions plus efficaces, plus ciblées. Il faut enfin travailler sur les droits humains, et sur la décriminalisation. Il faut combattre les normes sociales qui rendent le risque acceptable comme les violences sexuelles. Il faut lutter contre le machisme, et la façon dont les garçons et les hommes considèrent le sexe. Ces barrières doivent être levées. Mais cela fait des années qu'on entend parler des solutions basées sur une plus grande implication des communautés. Pourquoi ne sont-elles toujours pas plus répandues ? C'est en fait là que se trouve notre échec. Nous disons mais ne faisons pas. Pays après pays, on le voit : une réticence des gouvernements, un manque de confiance envers ces communautés. C'est à nous de plaider fortement et de présenter les preuves que cette méthode fonctionne. Je reviens de Jamaïque, et j'ai justement vu ça en marche. C'était très fort. Le soin géré par la communauté implique les gens, va vers eux. Celui géré par le gouvernement attend qu'on vienne à lui. Vous voyez la différence ? L'un est motivé par son objectif : atteindre les populations clés. L'autre est plus hospitalier, il reçoit et traite, bien, ceux qui viennent à lui. Ce qui est important, c'est d'avoir un système de santé qui va chercher au sein des communautés, et laisser celles-ci à la manœuvre. Sans ça, non seulement on échouera à vaincre le Sida, mais également d'autres pandémies. C'est cette approche qui fait le travail de prévention. C'est elle qui constitue également la réponse. On ne l'a pas fait et c'est pour cette raison que nous sommes lents. Ou plutôt, on peut le voir ainsi : les pays qui ont mis en place cette approche progressent plus vite que les autres. C'est évident. L'objectif mondial est la fin du sida en 2030. Pensez-vous qu'il soit atteint ? Je suis optimiste. J'aimerais dire que c'est possible, mais il faudra faire différemment. Avec le niveau actuel de financement, avec le manque de progrès sur les droits humains, nous échouerons. Mais si nous décidons de financer, si nous créons un environnement émancipateur, si nous changeons les lois qui empêchent les filles d'avoir les mêmes chances, nous y arriverons. Il n'y a aucune raison de ne pas vaincre le sida en 2030. Nous avons juste besoin de volonté politique.

Ligne de MIR
Ligne de MIR n°104 - Le Pr Antoine Guillon nous parle de la prise en charge de la personne âgée en réanimation.

Ligne de MIR

Play Episode Listen Later Dec 1, 2022 9:24


Le Pr Antoine Guillon, qui est PUPH au service de Médecine Intensive Réanimation du CHU de Tours, nous parle de la prise en charge de la personne âgée en réanimation. Aucun conflit d'intérêt n'est déclaré. Sommaire Que représente actuellement en termes de population les personnes âgées en réanimation ? Existe-il une ou des stratégies de sélection en vue d'une admission des patients âgés en réanimation ? Quelles sont les spécificités de la prise en charge des personnes âgées en réanimation ? Quel est le devenir des patients âgés après leur hospitalisation en réanimation ? Bibliographie Nielsson MS, Christiansen CF, Johansen MB, Rasmussen BS, Tønnesen E, Nørgaard M. Mortality in elderly ICU patients: a cohort study. Acta Anaesthesiol Scand. 2014 Jan;58(1):19-26. doi: 10.1111/aas.12211. Epub 2013 Oct 13. PMID: 24117049. Guidet B, Leblanc G, Simon T, Woimant M, Quenot JP, Ganansia O, Maignan M, Yordanov Y, Delerme S, Doumenc B, Fartoukh M, Charestan P, Trognon P, Galichon B, Javaud N, Patzak A, Garrouste-Orgeas M, Thomas C, Azerad S, Pateron D, Boumendil A; ICE-CUB 2 Study Network. Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France: A Randomized Clinical Trial. JAMA. 2017 Oct 17;318(15):1450-1459. doi: 10.1001/jama.2017.13889. PMID: 28973065; PMCID: PMC5710364. Guillon A, Hermetet C, Barker KA, Jouan Y, Gaborit C, Ehrmann S, Le Manach Y, Dequin PF, Grammatico-Guillon L. Long-term survival of elderly patients after intensive care unit admission for acute respiratory infection: a population-based, propensity score-matched cohort study. Crit Care. 2020 Jun 29;24(1):384. doi: 10.1186/s13054-020-03100-4. PMID: 32600392; PMCID: PMC7325055.

The GP Show
#166 Interval Weight Loss with Dr Nick Fuller

The GP Show

Play Episode Listen Later Nov 30, 2022 70:40


Dr Nick Fuller is a leading obesity researcher in Australia and has been running the clinical research program at the Boden Institute, Charles Perkins Centre at the University of Sydney for the past decade. Nick holds a Doctorate of Philosophy (PhD) in obesity treatment, a Bachelor's Degree in Human Movement and a Master's Degree in Nutrition and Dietetics.  Nick is the founder of the Interval Weight Loss Method, the author of “Interval Weight Loss”, “Interval Weight Loss for Life” and “Interval Weight Loss for Women". He has published in top ranked journals in the medical field including JAMA, Lancet, International Journal of Obesity, Obesity and Metabolism and the American Journal of Clinical Nutrition. You can find more information at Interval Weight Loss. Interested in studying lifestyle medicine, health coaching and new models of care in health and wellbeing?  Check out the JCU postgraduate courses: Grad Cert, Grad Diploma, and Master.  If you find this podcast valuable then subscribing, sharing, rating it 5 stars and leaving a review is appreciated. If you would like to send in your thoughts, insights, opinions, provide feedback or request a topic, please contact me via thegpshow.com  Thank you for listening and your support.

Albayan Radio - ASWJ Australia - Islam: Qur'an & Sunnah
018 An Explanation of Al-Haaiyah | Sh. Mohamad Doar

Albayan Radio - ASWJ Australia - Islam: Qur'an & Sunnah

Play Episode Listen Later Nov 30, 2022 25:41


Al-Haaiyah is a poem written about the Creed of Ahlus-Sunnah wal-Jama'ah by Imam Abu Bakr Ibn Abi Dawud As-Sijistani (d. 316AH) may Allah have mercy upon him. Watch on YouTube: https://youtu.be/J7jNP6CcYwQ Watch The Whole Series: https://youtube.com/playlist?list=PLWRcONNViMipeVQzVoY9N-AF7wq_pL0R5 You can also listen LIVE on Albayan Radio: http://albayan.com.au/ Please Support Albayan Radio: http://albayan.com.au/#donate

Radio Rodja 756 AM
Setia dan Cinta Kepada Ahlul Bait

Radio Rodja 756 AM

Play Episode Listen Later Nov 29, 2022


Setia dan Cinta Kepada Ahlul Bait adalah bagian dari ceramah agama dan kajian Islam ilmiah dengan pembahasan kitab Syarah Aqidah Ahlus Sunnah wal Jama'ah. Pembahasan ini disampaikan oleh Ustadz Yazid bin ‘Abdul Qadir Jawas pada Sabtu, 23 Sya’ban 1443 H / 26 Maret 2022 M. Kajian sebelumnya: Berpegang Teguh kepada Sunnah Setia dan Cinta Kepada […] Tulisan Setia dan Cinta Kepada Ahlul Bait ditampilkan di Radio Rodja 756 AM.

Radio Rodja 756 AM
Ahlus Sunnah Memuliakan Para Sahabat

Radio Rodja 756 AM

Play Episode Listen Later Nov 29, 2022


Ahlus Sunnah Memuliakan Para Sahabat adalah bagian dari ceramah agama dan kajian Islam ilmiah dengan pembahasan kitab Syarah Aqidah Ahlus Sunnah wal Jama'ah. Pembahasan ini disampaikan oleh Ustadz Yazid bin ‘Abdul Qadir Jawas pada Sabtu, 16 Sya’ban 1443 H / 19 Maret 2022 M. Kajian sebelumnya: Berpegang Teguh kepada Sunnah Ahlus Sunnah Memuliakan Para Sahabat […] Tulisan Ahlus Sunnah Memuliakan Para Sahabat ditampilkan di Radio Rodja 756 AM.

Stuff You Missed in History Class
Charles Drew & Blood Banks

Stuff You Missed in History Class

Play Episode Listen Later Nov 28, 2022 43:18


Dr. Charles Drew was once described as “one of the most constructively active figures in the medical profession.” His work as a key figure in the development of blood banking continues to impact lives today, long after his tragic death.  Research: "Charles R. Drew." Notable Black American Men, Book II, edited by Jessie Carney Smith, Gale, 1998. Gale In Context: U.S. History, link.gale.com/apps/doc/K1622000127/GPS?u=mlin_n_melpub&sid=bookmark-GPS&xid=3948f072. Accessed 21 Oct. 2022. "Drew, Charles Richard (1904-1950)." Encyclopedia of World Biography, Gale, 1998. Gale General OneFile, link.gale.com/apps/doc/A148418612/GPS?u=mlin_n_melpub&sid=bookmark-GPS&xid=a6aa993c. Accessed 21 Oct. 2022. “Charles Richard Drew.” https://www.acs.org/content/acs/en/education/whatischemistry/african-americans-in-sciences/charles-richard-drew.html Biswas, Saptarshi and Dannie Perdomo. “Charles Drew: An extraordinary life.” CC2017 Poster Competition. https://www.facs.org/media/u3xhtqz0/01_charles_drew.pdf Cobb, W. Montague. “Charles Richard Drew, 1904-1950.” The Journal of Negro History , Jul., 1950, Vol. 35, No. 3 (Jul., 1950). Via JSTOR. https://www.jstor.org/stable/2715713 Diamond, Louis K. “History of Blood Banking in the United States.” JAMA, July 5, 1965. Eschner, Kat. “The First-Ever Blood Bank Opened 80 Years Ago Today.” Smithsonian. 3/15/2017. https://www.smithsonianmag.com/smart-news/first-ever-blood-bank-opened-80-years-ago-today-180962486/ Giangrande, Paul L.F. “The history of blood transfusion.” British Journal of Hematology. 12/24/2001. https://onlinelibrary.wiley.com/doi/10.1046/j.1365-2141.2000.02139.x Gordon, Ralph C. “Charles R. Drew: Surgeon, Scientist, and Educator.” Journal of Investigative Surgery, 18:223–225, 2005. Grimes, William T. Jr. “The History of Kate Bitting Reynolds Memorial Hospital.” Journal of the National Medical Association. July 1972. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2608830/pdf/jnma00500-0084.pdf Guglielmo, Thomas A. “'Red Cross, Double Cross': Race and America s World War II-Era Blood Donor Service. The Journal of American History , June 2010, Vol. 97, No. 1 (June 2010). https://www.jstor.org/stable/40662818 Love, Spencie. “'Noted Physician Fatally Injured': Charles Drew and the Legend That Will Not Die.” Washington History , Fall/Winter, 1992/1993. Via JSTOR. https://www.jstor.org/stable/40073067 Love, Spencie. “Blood: The Death and Resurrection of Charles R. Drew.” University of North Carolina Press. 1996. Love, Spencie. “One Blood: The Death & Resurrection of Charles R. Drew (Book).” American Visions. Oct/Nov95, Vol. 10 Issue 5, p28-31. National Library of Medicine. “Charles R. Drew: The Charles R. Drew Papers.” https://profiles.nlm.nih.gov/spotlight/bg/feature/biographical-overview Pilgrim, David. “The Truth about the Death of Charles Drew.” June 2004. https://www.ferris.edu/HTMLS/news/jimcrow/question/2004/june.htm Thomas, Heather. “Dr. Charles R. Drew: Blood Bank Pioneer.” Library of Congress. 2/16/2021. https://blogs.loc.gov/headlinesandheroes/2021/02/dr-charles-r-drew-blood-bank-pioneer/ University of Chicago. “Dr. Bernard Fantus: Father of the Blood Bank.” 2004. https://storage.lib.uchicago.edu/pres/2011/pres2011-0100.pdf Wallace, Rob. “Medical Innovations: Charles Drew and Blood Banking.” National World War II Museum. 5/4/2020. https://www.nationalww2museum.org/war/articles/medical-innovations-blood-banking Woo, Susie. “When Blood Won't Tell: Integrated Transfusions and Shifting Foundations of Race.” American Studies, Vol. 55/56, Vol. 55, No. 4/Vol. 56, No. 1 (2017). Via JSTOR. https://www.jstor.org/stable/44982617 See omnystudio.com/listener for privacy information.

Frankly Speaking About Family Medicine
Selecting Medication for Depression: Do Genomics Matter? - Frankly Speaking Ep 304

Frankly Speaking About Family Medicine

Play Episode Listen Later Nov 28, 2022 10:27


Credits: 0.25 AMA PRA Category 1 Credit™   CME/CE Information and Claim Credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-304 Overview: Pharmacogenomic testing has been suggested as a way to personalize medicine, particularly where the metabolism of medications can vary significantly. Unfortunately, despite increasing use of this testing, there has been little evidence showing a benefit in clinical outcomes. Listen to this podcast to explore the data on clinical outcomes for pharmacogenetic testing and how to best select medication for patients with depression. Episode resource links: Oslin DW, Lynch KG, Shih MC, et al. Effect of Pharmacogenomic Testing for Drug-Gene Interactions on Medication Selection and Remission of Symptoms in Major Depressive Disorder: The PRIME Care Randomized Clinical Trial. JAMA. 2022;328(2):151-161. Guest: Alan Ehrlich MD, FAAFP   Music Credit: Richard Onorato

Radio Rodja 756 AM
Mengikuti Sunnah Rasulullah Shallallahu ‘Alaihi wa Sallam

Radio Rodja 756 AM

Play Episode Listen Later Nov 28, 2022


Mengikuti Sunnah Rasulullah Shallallahu ‘Alaihi wa Sallam adalah bagian dari ceramah agama dan kajian Islam ilmiah dengan pembahasan kitab Syarah Aqidah Ahlus Sunnah wal Jama'ah. Pembahasan ini disampaikan oleh Ustadz Yazid bin ‘Abdul Qadir Jawas pada Sabtu, 18 Rajab 1443 H / 19 Februari 2022 M. Kajian sebelumnya: Menegakkan Syari'at Allah Subhanahu wa Ta'ala Mengikuti […] Tulisan Mengikuti Sunnah Rasulullah Shallallahu ‘Alaihi wa Sallam ditampilkan di Radio Rodja 756 AM.

Radio Rodja 756 AM
Berpegang Teguh kepada Sunnah

Radio Rodja 756 AM

Play Episode Listen Later Nov 28, 2022


Berpegang Teguh kepada Sunnah adalah bagian dari ceramah agama dan kajian Islam ilmiah dengan pembahasan kitab Syarah Aqidah Ahlus Sunnah wal Jama'ah. Pembahasan ini disampaikan oleh Ustadz Yazid bin ‘Abdul Qadir Jawas pada Sabtu, 25 Rajab 1443 H / 26 Februari 2022 M. Kajian sebelumnya: Mengikuti Sunnah Rasulullah Shallallahu ‘Alaihi wa Sallam Berpegang Teguh kepada […] Tulisan Berpegang Teguh kepada Sunnah ditampilkan di Radio Rodja 756 AM.

Conspirituality
Bonus Sample: The Super Best Most Pure Immune-Boosting Supplement Ever (Until Next Week)

Conspirituality

Play Episode Listen Later Nov 28, 2022 6:02


Are you ready for the bestest, purest immunity-boosting supplement in the history of the world? No, not that one. Only I have discovered what really works, and I'll share it with you this week.Ok, not quite, but Derek looks at a recent JAMA study that found many of the top 30 supplements sold on Amazon don't contain what they claim. He opens by looking at Mikki Willis's latest best supplement ever, as well as a naturopath and her binder filled with detoxing supplement protocols. Show NotesWellness influencers don't understand history Does Z-Stack multivitamin work to boost the immune system, and is it safe? Analysis of Select Dietary Supplement Products Marketed to Support or Boost the Immune System -- -- --Support us on PatreonPre-order our bookFollow us on Instagram | Twitter: Derek | Matthew | JulianOriginal music by EarthRise SoundSystem

Pri-Med Podcasts
Selecting Medication for Depression: Do Genomics Matter? - Frankly Speaking Ep 304

Pri-Med Podcasts

Play Episode Listen Later Nov 28, 2022 10:27


Credits: 0.25 AMA PRA Category 1 Credit™   CME/CE Information and Claim Credit: https://www.pri-med.com/online-education/podcast/frankly-speaking-cme-304 Overview: Pharmacogenomic testing has been suggested as a way to personalize medicine, particularly where the metabolism of medications can vary significantly. Unfortunately, despite increasing use of this testing, there has been little evidence showing a benefit in clinical outcomes. Listen to this podcast to explore the data on clinical outcomes for pharmacogenetic testing and how to best select medication for patients with depression. Episode resource links: Oslin DW, Lynch KG, Shih MC, et al. Effect of Pharmacogenomic Testing for Drug-Gene Interactions on Medication Selection and Remission of Symptoms in Major Depressive Disorder: The PRIME Care Randomized Clinical Trial. JAMA. 2022;328(2):151-161. Guest: Alan Ehrlich MD, FAAFP   Music Credit: Richard Onorato

She Slays the Day
184 - This is What Being Present Feels Like! - Mindfulness and Gratitude feat. Kirby

She Slays the Day

Play Episode Listen Later Nov 27, 2022 59:05


Dr. Lauryn has Kirby back on the podcast to talk about all things mindfulness and gratitude. They dive into the JAMA study that inspired this discussion, the usefulness of tracking your mood, if technology has made us less happy, why you should introduce silence into your day, Kirby's recommendations for where to start if you are brand new, and so much more! – – – – – Journal of American Medical Association study that is referenced can be found here.Kirby's three book recommendations related to today's topic matter are:Golden: The Power of Silence in a World of Noise, which can be found here.Authentic Happiness, which can be found here.The Happiness Hypothesis, which can be found here. To learn more about Sked visit their website. To learn more about the Multipassionate Chiropreneur Program and join the waitlist for access, visit here.Rate & subscribe wherever you get your podcasts!To learn more about CLA and the INSiGHT scanner go to: https://insightcla.com/psa/ and enter code SHESLAYS when promptedTo check out all the great products from Well Aligned: https://wellaligned.com/ To hear all the great stuff happening on patreon go to: https://www.patreon.com/sheslayspodcast Join the Weekly Slay mailing list HEREIf you have a question or feedback, make sure to tell us:Website | Instagram | Facebook Get bonus content on Patreon Hosted on Acast. See acast.com/privacy for more information.

Le jazz sur France Musique
Repassez-moi l'standard ... "Many Rivers to Cross" composé par le chanteur jamaïcain Jimmy Cliff (1969)

Le jazz sur France Musique

Play Episode Listen Later Nov 27, 2022 58:19


durée : 00:58:19 - "Many rivers to cross" (Jimmy Cliff) (1969) - par : Laurent Valero - "Jimmy Cliff est assurément un des artistes jamaïcain les plus connus au monde. Il a commencé sa carrière à l'époque du ska un style musical florissant sur l'île. Et la particularité de son parcours artistique réside dans le fait qu'il pratique d'autres styles musicaux que le reggae" Laurent Valero - réalisé par : Patrick Lérisset

Repassez-moi l'standard
Repassez-moi l'standard ... "Many Rivers to Cross" composé par le chanteur jamaïcain Jimmy Cliff (1969)

Repassez-moi l'standard

Play Episode Listen Later Nov 27, 2022 58:19


durée : 00:58:19 - "Many rivers to cross" (Jimmy Cliff) (1969) - par : Laurent Valero - "Jimmy Cliff est assurément un des artistes jamaïcain les plus connus au monde. Il a commencé sa carrière à l'époque du ska un style musical florissant sur l'île. Et la particularité de son parcours artistique réside dans le fait qu'il pratique d'autres styles musicaux que le reggae" Laurent Valero - réalisé par : Patrick Lérisset

Ta de Clinicagem
Episódio 163: 7 Armadilhas de Tromboembolismo Pulmonar

Ta de Clinicagem

Play Episode Listen Later Nov 25, 2022 38:26


CUPOM: BLACKFRIDAYGUIA www.tadeclinicagem.com.br/guia - Conheça o Guia TdC com 7 dias grátis Um serviço de revisão e atualização continuados em clínica médica. A informação que você precisa, do jeito que você prefere. Junte-se aos mais de 800 assinantes. Assine o Guia, ganhe tempo e atualize-se sem esforço. Joanne, Kaue e Lucca conversam sobre armadilhas no tromboembolismo pulmonar (TEP): Quando pedir d-dímero e ajuste, em que momento iniciar a anticoagulação, como fazer a estratificação, quando trombolisar, qual anticoagulante iniciar, anticoagular ou não o TEP subsegmentar/assintomático e um pouco de TEP na gestante. Referências: 1. Kahn SR, de Wit K. Pulmonary Embolism. N Engl J Med. 2022 Jul 7;387(1):45-57. doi: 10.1056/NEJMcp2116489. PMID: 35793208. 2. Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J 2019; 54. 3. Raja AS, Greenberg JO, Qaseem A, et al. Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2015; 163:701. 4. Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest 2021; 160:e545. 5. Kucher N, Goldhaber SZ. Management of massive pulmonary embolism. Circulation 2005; 112:e28. 6. Aujesky D, Obrosky DS, Stone RA, et al. A prediction rule to identify low-risk patients with pulmonary embolism. Arch Intern Med 2006; 166:169. 7. Becattini C, Casazza F, Forgione C, et al. Acute pulmonary embolism: external validation of an integrated risk stratification model. Chest 2013; 144:1539. 8. Righini M, Van Es J, Den Exter PL, Roy PM, Verschuren F, Ghuysen A, Rutschmann OT, Sanchez O, Jaffrelot M, Trinh-Duc A, Le Gall C, Moustafa F, Principe A, Van Houten AA, Ten Wolde M, Douma RA, Hazelaar G, Erkens PM, Van Kralingen KW, Grootenboers MJ, Durian MF, Cheung YW, Meyer G, Bounameaux H, Huisman MV, Kamphuisen PW, Le Gal G. Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014 Mar 19;311(11):1117-24. doi: 10.1001/jama.2014.2135. Erratum in: JAMA. 2014 Apr 23-30;311(16):1694. PMID: 24643601. 9. Ortel TL, Neumann I, Ageno W, Beyth R, Clark NP, Cuker A, Hutten BA, Jaff MR, Manja V, Schulman S, Thurston C, Vedantham S, Verhamme P, Witt DM, D Florez I, Izcovich A, Nieuwlaat R, Ross S, J Schünemann H, Wiercioch W, Zhang Y, Zhang Y. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv. 2020 Oct 13;4(19):4693-4738. doi: 10.1182/bloodadvances.2020001830. PMID: 33007077; PMCID: PMC7556153. 10. Duffett L, Castellucci LA, Forgie MA. Pulmonary embolism: update on management and controversies. BMJ. 2020 Aug 5;370:m2177. doi: 10.1136/bmj.m2177. PMID: 32759284. 11. van der Hulle T, Cheung WY, Kooij S, Beenen LFM, van Bemmel T, van Es J, Faber LM, Hazelaar GM, Heringhaus C, Hofstee H, Hovens MMC, Kaasjager KAH, van Klink RCJ, Kruip MJHA, Loeffen RF, Mairuhu ATA, Middeldorp S, Nijkeuter M, van der Pol LM, Schol-Gelok S, Ten Wolde M, Klok FA, Huisman MV; YEARS study group. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet. 2017 Jul 15;390(10091):289-297. doi: 10.1016/S0140-6736(17)30885-1. Epub 2017 May 23. Erratum in: Lancet. 2017 Jul 15;390(10091):230. PMID: 28549662.

Relentless Health Value
INBW36: Will Healthcare Stakeholders Who Don't Collaborate Wind Up With a Business Problem?

Relentless Health Value

Play Episode Listen Later Nov 24, 2022 19:00


We got two new reviews this week on the podcast, which I was thrilled to see. The first was from, it turns out, Dave Chase from Health Rosetta, who wrote that “with so many people in healthcare practicing ‘innovation theater' and bloviating versus driving real change, it's a breath of fresh air to listen to Relentless Health Value.” Thank you so much for saying that, Dave. We try really hard to get guests who are actually doing great things such as yourself. And then there's another review from mattiw2002, who says, “For anyone trying to stay abreast of developments in the healthcare space, there's none better than … Relentless Health Value.” Thank you so much to the two of you who took the time to write a review—could not appreciate it more. There have been two inbetweenisodes this year where I get deep into the why behind the “why collaborate.” And when I say collaborate, what I mean is anybody in the healthcare industry working together with and for the patients that we're supposed to be serving here. It's creating alignment amongst stakeholders around what's best for the patient. Here is the nutshell version of the two previous shows. First point: Patients fall into one care gap after another. You hear this from any PCP you talk to who's working in a care setting when there's little, if any, collaboration effort on the front end to ensure a non-fragmented patient journey. So then, all these care gaps wind up getting surfaced, which, by the way—let's not forget this—these care gaps were there all along negatively affecting patient outcomes. It's just, in the past, we didn't know about them. But now that we know about them, it becomes the fee-for-service PCPs' job to mop up all the care gaps while the faucet is still running. So, that's the situation analysis, and if we're going to put an end to this, it means that payers have to align with providers and give enough incentive for those providers to create a non-fragmented patient journey (ie, making sure that the care gaps don't happen to begin with). This also means providers need to talk amongst themselves and collaborate. Keep in mind that a multi-morbid Medicare patient sees something like 5 to 13 doctors, on average, depending on what study you look at … 13! If anybody thinks that a patient can see 13 doctors not collaborating with each other and coordinating care and not wind up with some polypharmacy adverse event or materially conflicting advice … I don't know. Call me. I just do not understand how consistent excellence in patient outcomes or patient care even could be achieved. That whole cliché the left hand doesn't know what the right hand is doing? That's a cliché for a reason, and I seriously suspect the entire field of medicine isn't weirdly excluded from it. So, first point: Collaboration/alignment is required amongst healthcare stakeholders for patients to get decent outcomes, especially patients with multiple chronic conditions. Payers gotta pay for the right stuff, and providers have to coordinate care. Otherwise, you wind up with all of the care gaps that PCPs currently working in systems with fragmented patient journeys are seeing. Here's the second point from earlier episodes: Financial toxicity is clinical toxicity. Patients are forgoing care they need and not taking drugs they need because they cannot afford them. This is not speculation. Trilliant Health just released a report that showed this. Healthcare utilization, if you subtract COVID care and behavioral health, might be permanently down. Other reports speculated that by 2030, a leading cause of death might be nonadherence due to cost concerns. Wayne Jenkins, MD, in episode 358, talks about a whole constellation of negative effects when patients can't afford care; and yeah … here we are. Patients cannot afford their care. They cannot afford premiums, deductibles, out-of-pockets. These are insured patients a lot of times we're talking about here. Also, this is not a “Medicaid” problem, as Dan Mendelson put in episode 385. So, go back and listen to the earlier shows for the who and the what and the why of the above and much more context; but nothing I've just said is stuff that I personally would regard as my personal opinion. There is one study after another that bears all this out. There is just one anecdote after another. Fragmented patient care and care that is way more expensive than a patient can afford is going to result in outcomes that are not, let's just say, super. Alright, all of this being said, does then aligning payers and providers, and providers collaborating with each other and coordinating care … if these things are done, do patient outcomes improve? Do care gaps reduce? Are patients more satisfied with their care? Said another way, when physician practices get paid to deliver health and not paid for sick care, does patient health actually improve? Why, yes. Yes, it does. Why do I say this? First of all, this very much seems to be the conclusion of CMS. Here's from the Center for Medicare & Medicaid Innovation (CMMI). They released a report updating their strategic vision for implementing value-based care. One of the key new strategies focuses on creating greater care coordination between primary care doctors and specialists. What might be some of the success stories that precipitated the CMMI focusing their strategy on exactly what I've been running around squawking about for one to three years now? The ChenMed Case Study: ChenMed focuses on the most vulnerable patients and dramatically improves access for those patients, which has led to a 30% to 50% reduction in hospitalizations. They published there's been a 20% to 30% reduction of stroke. They've doubled six-month cancer survival rates and, in some cases, reduced heart failure readmissions by 50%, 70%, up to 90%. They see evidence that they are extending lives five or more years. How? By the providers being aligned with the payers and then also making sure that there is very coordinated care going on there. Johns Hopkins has a paper in JAMA that concluded that a care coordination model can be associated with improved outcomes, including substantial cost reduction. I was talking to Larry Bauer from FMEC, the Family Medicine Education Consortium; and he sent me probably a 40-page PDF of really great patient results when care is coordinated and payers are aligned to pay for health. As just one example, Dr. Daniel Hoefer from Sharp HealthCare, they have created what they call their Transitions program. And the idea is by moving aggressive care upstream via community-based palliative medicine, they have proven that the vast majority of people never need to see the inside of a hospital during the last year-ish of their life. The revolving door of hospitalization should be considered an archaic residual of a bygone era, as they put it. Again, this is very well-coordinated care with payer alignment. Do patients actually want this stuff? Before I get into our evidence here, just let me remind you that Kaiser is a payvider with a narrow network and also that Centivo is an innovative TPA (third-party administrator) pulling together narrow networks. On the podcast the other week, Dan Mendelson (EP385) from Morgan Health said that 40% of new employees are choosing lower-premium plans with either Kaiser or Centivo benefit designs. They are choosing lower-cost plans just as much for the lower premiums as for the care coordination and the “I don't want anybody between me and my doctor” messages. This is what happens when payers and providers are aligned. Nobody gets in the middle there. Heard a similar story from Nick Stefanizzi (EP383) from Northwell Direct. They're doing direct contracting with customers like Whole Foods. Everybody I talk to here is surprised how many employees are electing these kinds of plans. So, yeah … The Nuka System of Care in Alaska (EP312), where I get into this with Doug Eby, MD, MPH, CPE, in great detail. But wow, just wow there. With the Nuka ecosystem, they went from basically a failing mess into the health system that many consider to be the best or one of the best in the country at something like half the price per patient than in mainland US. They have this whole thing where they integrate specialty care into primary care. They have established an agreed-upon referral patterns and also an agreed-upon way to work with specialists that very much involves PCPs talking to specialists so that the whole person, the whole patient can be considered. They structure their whole program around paying for health and getting paid for health. Also, Nuka has a 96% patient satisfaction rate. So again, patients are certainly on board with this. If I was gonna sum up these five examples, I would certainly say that any physician practices looking to take better care of patients, rediscover clinical excellence and focus … get aligned with payers (CMS or otherwise). That's step one and certainly easier said than done. After that, work to collaborate with fellow providers. All of these entities that we just talked about who can brag about their patient outcomes and care quality are doing both of the stuff that we just talked about: aligning and collaborating with payers and other providers. They are also, at the same time, folding three other things into their strategy. And this other stuff is required because you kinda can't align with payers and you can't collaborate unless you're doing these three things at the same time: standardizing best-practice care, getting and using data, and using good technology in conjunction with that data. All of this in the service of this last thing, which is turning transactions into relationships. Human relationships. Relationships with patients. As Rebecca Etz, PhD, and her team at The Larry A. Green Center have shown quite crisply (discussed in episode 295), no relationship with a patient means worse outcomes for patients. End of sentence. But then there's also having relationships with colleagues and relationships with other docs who have patients in common. It is really tough to coordinate care without relationships, and it's also not very fulfilling. Alright, moving on to another question: Are doctors happy in these models where payers are paying for health and where it's a must-have to coordinate across the continuum of care? Well, I can tell you a couple of things. ChenMed has been named to Newsweek's “Most Loved Workplaces” list. Nuka System has a 93% employee satisfaction rating. Considering that elsewhere one out of two family practice docs are burned out, this is pretty striking in contrast. Also, here's another quote from a physician leader about good accountable care where health is being paid for. He said, “This has changed our physicians' lives … the idea that we can get paid to actually take care of people. To actually have data to send people to the best for follow-up care, who we know will continue and contribute to the patients' well-being in the same way. Burnout reduces here because burnout is moral injury in a cheap Halloween costume.” I'm really sorry I can't remember who said that because it's a great quote and so true. Larry Bauer from FMEC also told me the other day that DPC (Direct Primary Care) conferences have never had a session on burnout. Larry says he tells people if they want to see what 350 happy primary care docs look like, they need to come to a DPC summit. They're happy as clams. Now, while DPC isn't the “be entirely responsible for downstream costs” kind of accountable care, what is going on in DPC is, these docs are accountable to their patients and for the care that they are providing. Here's another anecdote which I think, in sum, adds up to a “yes” if the question is “Do docs really like this stuff?” I had a long conversation with Scott Conard, MD, the other day about his work with clinics in Queens. What I learned was, these clinics, they used to have waiting rooms overflowing with patients who had been waiting the entire day to be seen and just ... it wasn't good for anybody. Fast-forward a few years—high-risk patients get seen fast, and there's time for care coordination. Patients are happy; outcomes are better. But here is why I inferred that the docs are happy in this model: There was a new office manager. New office manager starts trying to go back to the old way, the “normal” way that practices are run. And it was mutiny on the bounty. No way no how were those docs going back. I took that as a pretty solid testimonial if I ever heard one. So, I don't know if anybody has done any sort of global physician satisfaction studies to determine if physicians who are in pay-for-health models where they're collaborating with one another are happier and less burned out than doctors in the current fee-for-service (FFS) environment. But I can tell you that if somebody did do this, there's gonna be one really big confounding factor … and this is what it is: There's a world of difference between a well-functioning accountable care model and a very terrible one. I have had a series of (as I said earlier) pretty heartbreaking, honestly, conversations with PCPs around the country who think value-based care pretty much sucks. For the big why on this, listen to the show with Dan O'Neill (EP359). But in short, in “not quite there yet” value-based care models, one's still in the two canoes messy middle (ie, they've got one foot in the value-based care world and one foot firmly in the FFS world). Life can get really hard for PCPs especially because they get the worst of both. They get to be care gap cowboys and cowgirls while, at the same time, having to do all of the FFS coding; and they still have seven-minute visits and RVU targets. There's not really great population health. Nobody's figured out how to defragment the care journey. And then there's the whole measurement industrial complex that gets piled on top of their day. I cannot stress this enough. Alright, so let's just check off our last big question here for the money motivated. This especially comes up when talking with especially specialists, who are doing very well, thank you very much—financially, I mean—in the current FFS status quo. So, let's not avoid the elephant in the room. Is taking on risk, getting paid for value, being accountable to deliver great results, deliver health … is it worth it from a financial standpoint? Alright, let's take a look at this. Here's from show 343 with David Carmouche, MD, when he was at Ochsner. He said, “Anything that we can do to convert the effective reimbursement in the Medicare space to something greater than Medicare fee-for-service rates, we think that this is in our best interest. So, we have gone very heavy into moving as much of our Medicare business into risk as we can. And we will take full capitation under a couple of Medicare advantage contracts.” So, that includes primary care as well as specialist care. Let's talk about One Medical for a moment. Five percent of One Medical members account for 51% of the company's revenue. You know which 5% account for that 51% of revenue? Right, the at-risk ones that are part of the Iora value-based medical group with a capitated model. That is a pretty strong financial endorsement there. There's a whole show with Brian Klepper, PhD (EP335), about why private equity is willing to pay $55,000 per patient in a capitated model. So, some actuaries somewhere think this is a very financially sound way to go. I am not sure if I would die on this hill, but I'd also say there's likely a downside to making zero effort on the accountable care front and banking on FFS being a forever cash cow. Everything I've just said, not a secret. Not at all. You see CMS moving in the “making providers accountable” direction. I already mentioned this and what CMMI is up to. But this is very much an overall strategy. Currently, 44% of traditional Medicare beneficiaries with parts A and B are in a care relationship with some accountability for quality and total cost of care. CMS aims to boost that number to 60% by 2024 and 100% by 2030. In sum across the industry, it looks like 19.6% of healthcare payments were risk-based in APMs (Alternative Payment Models) that include upside and downside. This is a couple points higher than in 2020, but it's not like it's skyrocketing. So, that might be a curb to our enthusiasm. However, in 2022 here, looking forward to 2023, you know who besides CMS is going heavy on trying to pay for health and not sick care? I have never seen my entire career more CEOs of Fortune 500 companies—CEOs!—who are actively taking a role in their employee health benefits. I think it's because they can't afford not to at this point. Again, financial toxicity is very, very real for employed individuals. Here's something that Jeff Hogan called out from a McKinsey report: “VBC [value-based care] models that show promise in the employer context include high-performance provider networks with cost- and quality-based metrics, episode-based payments for standardized patient-care journeys … , and risk-based contracts for end-to-end management of high-cost conditions.” You know what all those things have in common that I just rattled off? Only high-performing docs are in network—and this includes specialists. I say all this to say, I don't know, if I were a practitioner of healthcare and I knew that all this data was floating around about my practice patterns and given that doctors that don't perform well as per that data are being excluded from networks … I don't know, just given all of the signs that are pointing in a risk-based direction, learning to take on risk just seems like—I was never a Boy Scout, but the whole “Be prepared” seems pretty sound advice right now, especially given how long it takes to get good at this.   For more information, go to aventriahealth.com. To listen to the playlist of the mentioned episodes, click here. Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry. In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups.   05:03 When physician practices get paid to deliver health and not paid for sick care, does patient health actually improve? 05:46 What is the ChenMed Case Study? 06:26 Can a care coordination model be associated with improved outcomes, including substantial cost reduction? 06:38 Are there examples of really great patient results when care is coordinated and payers are aligned to pay for health? 07:29 Do patients actually want this stuff? 07:46 Are employees choosing lower-cost plans just as much for the lower premiums as for the care coordination and the “I don't want anybody between me and my doctor” messages? 08:29 What is the Nuka System of Care in Alaska? 09:25 “I would certainly say that any physician practices looking to take better care of patients, rediscover clinical excellence and focus … get aligned with payers (CMS or otherwise). That's step one and certainly easier said than done.” 10:45 Are doctors happy in these models where payers are paying for health and where it's a must-have to coordinate across the continuum of care? 11:16 “This has changed our physicians' lives … the idea that we can get paid to actually take care of people. To actually have data to send people to the best for follow-up care, who we know will continue and contribute to the patients' well-being in the same way. Burnout reduces here because burnout is moral injury in a cheap Halloween costume.” —Physician leader 13:25 “There's a world of difference between a well-functioning accountable care model and a very terrible one.” 13:59 “Life can get really hard for PCPs especially because they get the worst of both. They get to be care gap cowboys and cowgirls while, at the same time, having to do all of the FFS coding; and they still have seven-minute visits and RVU targets.” 14:43 Is taking on risk worth it from a financial standpoint? 16:05 “There's likely a downside to making zero effort on the accountable care front and banking on FFS being a forever cash cow.” 17:11 “I have never seen my entire career more CEOs of Fortune 500 companies—CEOs!—who are actively taking a role in their employee health benefits. I think it's because they can't afford not to at this point. Again, financial toxicity is very, very real for employed individuals.” 17:54 “Only high-performing docs are in network—and this includes specialists.”   For more information, go to aventriahealth.com. To listen to the playlist of the mentioned episodes, click here.   Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast When physician practices get paid to deliver health and not paid for sick care, does patient health actually improve? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast What is the ChenMed Case Study? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast Can a care coordination model be associated with improved outcomes, including substantial cost reduction? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast Are there examples of really great patient results when care is coordinated and payers are aligned to pay for health? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast Do patients actually want this stuff? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast Are employees choosing lower-cost plans just as much for the lower premiums as for the care coordination and the “I don't want anybody between me and my doctor” messages? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast What is the Nuka System of Care in Alaska? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast “Are doctors happy in these models where payers are paying for health and where it's a must-have to coordinate across the continuum of care?” Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast “There's a world of difference between a well-functioning accountable care model and a very terrible one.” Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast Is taking on risk worth it from a financial standpoint? Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast “There's likely a downside to making zero effort on the accountable care front and banking on FFS being a forever cash cow.” Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast “Only high-performing docs are in network—and this includes specialists.” Our host, Stacey, discusses #collaboration on our #healthcarepodcast. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington  

Albayan Radio - ASWJ Australia - Islam: Qur'an & Sunnah
017 An Explanation of Al-Haaiyah | Sh. Mohamad Doar

Albayan Radio - ASWJ Australia - Islam: Qur'an & Sunnah

Play Episode Listen Later Nov 24, 2022 27:05


Weekly lesson from Masjid Al-Azhar, Belmore. Al-Haaiyah is a poem written about the Creed of Ahlus-Sunnah wal-Jama'ah by Imam Abu Bakr Ibn Abi Dawud As-Sijistani (d. 316AH) may Allah have mercy upon him. Watch on YouTube: https://youtu.be/W7Lc5dYbI-g Watch The Whole Series: https://youtube.com/playlist?list=PLWRcONNViMipeVQzVoY9N-AF7wq_pL0R5 You can also listen LIVE on Albayan Radio: http://albayan.com.au/ Please Support Albayan Radio: http://albayan.com.au/#donate

MONEYFITMD PODCAST
Episode 110: Kicking Fulfillment Down the Road with Dr. Sunny Smith

MONEYFITMD PODCAST

Play Episode Play 34 sec Highlight Listen Later Nov 22, 2022 21:46


In this episode, Dr. Sunny Smith shared  "Kicking fulfillment down the road" with us.This is part of the Recession IRX series that I did where I interviewed humans that are doing amazing things and sharing how they are prepping themselves for the recession.Here is the deal. This is a gift of love. And I have three to ask of you. 1. listen, enjoy, and take action. 2. I want you to take this information and share it with those that you like. Share itwith your friends. Share it with your neighbors. Share with your colleagues. Let's get the word out because we are going to be prepped. Not panicked.3.  I want you to leave us a review and let us know exactly what you love about this episode. This is a 100% free gift to you but I would love it if you do all those three things. Don't forget to tag me @MoneyFitMDSunny Smith is the Founder & CEO of Empowering Women Physicians which hosts a Facebook group, podcast, retreats, and the most comprehensive, collaborative, and effective coaching program for physicians. She is a Master Certified Coach, a member of the Forbes Coaches Council, and in the top 1% of female-founded companies in the United States. She spent her academic career as a Clinical Professor in the Department of Family Medicine and Public Health at UC San Diego School of Medicine, co-directing and teaching several courses spanning the medical school curriculum. She is co-medical director of the UC San Diego Student-Run Free Clinic Project and an Academic Community Director where she advises one-sixth of each medical school class regarding their personal and professional development.  Dr. Smith has been featured in documentaries on medical student and physician wellness for over twenty years – including The Residents, Suffering in Silence, and Do No Harm - and cares deeply about these issues. Her work has been featured on PBS, Discovery Health, TLC, and Amazon video. She has received numerous teaching awards and honors including the Excellence in Teaching award, Humanism in Medicine award, and Outstanding Community Leader award. Her work has been published in many peer-reviewed journals including JAMA and she is a Fellow of the American Academy of Family Physicians.To download a Recap of The Recession Rx and to join The Money School for women physicians where we combine the Power of education, coaching, and community, visit https://www.moneyfitmd.com/work-with-me to schedule a callEnjoyed the episode? Leave us a review on Apple Podcasts.⁣Ready to liberate yourself and become the CEO of your money & life? Join the only community exclusively for women physicians. The doors are open https://www.moneyfitmd.com/msbDo you have questions/ topics you want addressed in an upcoming episode? Fill out this form.https://www.moneyfitmd.com/podcast-questionsAccess our FREE 5- Day Video Mini-Series will change how you handle your finances. Visit  https://www.moneyfitmd.com/cashflow to learn how to cash flow. As physicians, it's important that we are prepped for any economic downturn. This is why I am sharing the steps I am taking to be prepped. That way we can be well together. www.moneyfitmd.com/prep⁣Don't miss an episode, subscribe to THE MONEYFITMD PODCAST, where we help women Physicians curate their rich life.⁣⁣⁣Thank you so much for sharing this episode with those around you and helping change the money of women physicians all around the

JAMA Editors' Summary: On research in medicine, science, & clinical practice. For physicians, researchers, & clinicians.
Regular Use of Morphine for Chronic Breathlessness in COPD, Treatment Time and In-Hospital Mortality With STEMI, Change in Travel Time to US Abortion Facilities After Dobbs Decision, and more

JAMA Editors' Summary: On research in medicine, science, & clinical practice. For physicians, researchers, & clinicians.

Play Episode Listen Later Nov 22, 2022 8:26


Editor's Summary by Anne Cappola, MD, ScM, Associate Editor of JAMA, the Journal of the American Medical Association, for the November 22/29, 2022, issue. Related Content: Audio Highlights

What I Meant to Say
Special Release - The Future of Health and Healing with Dr. Kent Holtorf

What I Meant to Say

Play Episode Listen Later Nov 18, 2022 85:40


Key Points, Top Takeaways and Memorable Quotes - “Everyone is sick now with chronic muliti-system illnesses that our system is not set up to fix.” 1:31“I also found that fast food, the body acts like it's an infection.” 6:14“Even the CDC says that 80% of people have at least one chronic illness due to the involution of the thymus.” 7:44“A peptide is basically a chain of amino acids, right, and if it's longer, by arbitrary definition if it's longer than 40 amino acids, it's a protein and if it's less, it's a peptide.” 9:19“We're finding that emotional stress is probably the worst thing for your immune system, for your aging.” 12:44 “An addiction has to do with inflammation of the brain.” 22:45“The days of just relying on your doctor are gone, you are going to get terrible care.” 27:40“Everything has its place, but they want to give it to everybody.” 30:45“Mass cells are the cells that, one of the cells, or main cell that cause inflammation.” 34:34“If a Doctor says ‘I don't know,' stay with them because I'm telling you that means they're a good doctor.” 39:34“JAMA said it takes, on average, a proven new concept, let's just say peptides, it takes on average 17 years to get accepted into mainstream medicine.” 59:14“One of the best ways to prevent breast cancer, take progesterone.  One of the best ways to cause breast cancer, take progestin.”  1:11:50“The number one thing we can do is stay curious about our own health and keep asking questions and finding the right doctors.” -Wendy @1:13:53“Kaiser will bonus a Doctor at the end of the year for the least amount of money they spend on a patient.” 1:18:58“Doctors are miserable, right, in the insurance model, so I mean, they're not really the problem; and they want to get out, but they don't know how.” 1:23:50 Guest Bio - Dr. Holtorf's desire to help those suffering from undiagnosed health concerns stems from his own personal health journey. In medical school, he suffered from terrible fatigue, barely able to function. He was told by numerous specialists that he was depressed or stressed, and simply needed to get more sleep and exercise more. As he discovered a treatment protocol that helped his symptoms, he knew there were many others suffering the same way he had. As a result, he opened centers treating patients with similar issues, who had seen countless physicians only to be told that nothing was wrong with them, yet they felt horrible. Show Notes - 0:00 - WIMTS Podcast Intro0:32 - Introducing Dr. Kent Holtorf0:47 - Welcome to Dr. Holtorf1:46 - What's the Focus of Your Practice?4:24 - Immune Dysfunction is at the Core of Chronic Illness & Aging8:38 - What is a Peptide?10:38 - Dr. Holtorf's Personal Health Crisis13:58 - Getting to the Root Cause17:23 - Testing & Diagnosing the Thyroid & Uses of T321:18 - STAR Report on Anti-Depressants & Bipolar Patients23:37 - Health Care Reform Discussion29:35 - Guise of ‘Evidence Based Medicine'30:50 - Contrasting Pharmaceutical Drugs & Peptides37:01 - Treating Autistic Kids39:46 - Doctors & How They Use Or Don't Use Available Research45:55 - BB Commercial46:04 - The Keys to Longevity48:02 - Elite Culture & Peptide Access for the Masses49:40 - Type of Patients that Peptides Help59:44 - Practical Ways You Are Informing Other Doctors About Peptides1:01:50 - What Questions Should Patients Be Asking Their Doctors?1:04:17 - Recommendations for Finding Doctors Like You & Politics in Medicine1:07:59 - Hardest Part is Delivering the Peptide1:10:41 - The Hormone Discussion on Progesterone Vs. Progestin1:12:52 - Removing the Ego & Money1:14:38 - How to Connect with Dr. Holtorf1:19:34 - Treating Vets with PTSD1:21:09 - Ask Simple Questions, then Go Find Integrative Medicine1:24:42 - Thank You 1:25:26 - WIMTS Podcast Closing Links & Where to Find Dr. Kent Holtorf - https://holtorfmed.com/Integrative PeptidesIG - @holtorfmedicalgroup 

Breathe Easy
Critical Perspective: Emergency Abortion Care

Breathe Easy

Play Episode Listen Later Nov 18, 2022 33:48


In this “Breathe Easy Critical Perspective” podcast, Dr. Dominique Pepper interviews Dr. Andrea MacDonald and Dr. Deepshikha Ashana. The authors discuss their November 1, 2022 JAMA article entitled "The Challenge of Emergency Abortion Care Following the Dobbs Ruling.' Drs. Ashana and MacDonald are affiliated with the Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University, Durham, North Carolina.

Stroke Alert
Stroke Alert November 2022

Stroke Alert

Play Episode Listen Later Nov 17, 2022 44:15


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.

JAMA Network
JAMA Dermatology : Diversity and Goals of Graduating Medical Students Pursuing Careers in Dermatology

JAMA Network

Play Episode Listen Later Nov 16, 2022 19:48


Interview with Matthew D. Mansh, MD, author of Diversity and Career Goals of Graduating Allopathic Medical Students Pursuing Careers in Dermatology. Hosted by Adewole S. Adamson, MD, MPP. Related Content: Diversity and Career Goals of Graduating Allopathic Medical Students Pursuing Careers in Dermatology

Room for Lovely
E039: Brave Boundaries-- Dr. Sasha Shillcutt

Room for Lovely

Play Episode Listen Later Nov 15, 2022 31:23


About Dr. Sasha ShillcuttSasha K. Shillcutt, MD, MS, FASE is a tenured and endowed Professor and the Vice Chair of Strategy in the Department of Anesthesiology at the University of Nebraska Medical Center in Omaha, Nebraska. Sasha is CEO & Founder of Brave Enough, a well-published researcher in cardiac anesthesiology and gender equity, author, and international speaker. Sasha has taught thousands of women to achieve work-life control through her courses and conferences. She speaks frequently to executives and leaders on the topics of professional resilience and gender equity. Her TEDx talk titled Resilience: The Art of Failing Forward has been viewed by thousands of people. Her writing has been published in both the prestigious New England Journal of Medicine and JAMA. She leads conferences and retreats for professional women through her organization, Brave Enough. A best-selling author, her first book Between Grit and Grace: How to be Feminine and Formidable, has sold thousands of copies and her second book, Brave Boundaries: Strategies to Say No, Stand Strong and Take Control of Your Time, is available now.Connect with Dr. Sasha ShillcuttWebsite:https://www.becomebraveenough.com/Social Media:Facebook: @becomebraveenoughIG: @becomebraveenoughTwitter: @rubraveenoughLinkedin: @becomebraveenoughBook Links:Brave BoundariesFinally, be sure to SUBSCRIBE to the podcast and SHARE!  Make sure you don't miss a thing by subscribing on your favorite podcast platform and share so that all your friends can find us too! Connect with ErinIG @erincucciowww.erincuccio.comJoin my COMMUNITY Simply text LOVELY to 936.253.6555 or click HERE. You'll receive exclusive content right to your mobile device, and the best part is it's FREE.

JAMA Editors' Summary: On research in medicine, science, & clinical practice. For physicians, researchers, & clinicians.
Decontamination of the Digestive Tract in Critically Ill Patients, Predicting Ascending Aortic Diameter, USPSTF Recommendation Statement on Sleep Apnea, and more

JAMA Editors' Summary: On research in medicine, science, & clinical practice. For physicians, researchers, & clinicians.

Play Episode Listen Later Nov 15, 2022 11:04


Editor's Summary by Kirsten Bibbins-Domingo, PhD, MD, MAS, Editor in Chief of JAMA, the Journal of the American Medical Association, for the November 15, 2022, issue. Related Content: Audio Highlights

ASCO eLearning Weekly Podcasts
Oncology, Etc. – In Conversation with Dr. David Steensma (Part 2)

ASCO eLearning Weekly Podcasts

Play Episode Listen Later Nov 15, 2022 18:01


In Part Two of this Oncology, Etc. episode, hosts Patrick Loehrer and David Johnson continue their chat with hematologist-oncologist Dr. David Steensma. They explore his views of key opinion leaders and a lifelong passion – collecting rare stamps, including medical stamps. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org.   TRANSCRIPT Pat Loehrer: Hi, I'm Pat Loehrer, Director of Global Oncology and Health Equity at Indiana University. I'm here with Dave Johnson, a Medical Oncologist from The University of Texas, Southwestern in Dallas, Texas. Welcome to the second half of our Oncology, Etc. conversation with Dr. David Steensma. He's a highly accomplished physician and scientist in the field of Hematology/Oncology. In the first part of this episode, Dr. Steensma told us about his Dutch immigrant roots, and how a single college biology course changed his career interests from astronomy into medicine. Today, we'll explore his views on Key Opinion Leaders and another passion of his, and an interest of ours - collecting rare stamps, including medical stamps. Dave Johnson: So, David, in addition to your scientific writing, you've been a prolific writer in many other sort of viewpoints and opinion pieces. There's a lot to choose from, but I know you've been interviewed in the past about your column called ‘The Raven', which I won't ask you about, as an Edgar Allen Poe fan. You also wrote a wonderful piece called, ‘Key Opinion Leaders', which I thought might be quite interesting to ask you about, now that you might be calling upon KOLs. Do you want to tell us a little about that? Dr. David Steensma: Yeah, that's not my favorite term. Thought Leaders is another kind of silly term, but we know what we mean when people are talking about it. Yeah, I've had a chance to write on a lot of different things over the years, and that's been great fun. And when I first heard that term, I couldn't figure out what it meant, KOL. And then, a pharmaceutical representative actually accidentally left a list of KOLs in my office and I realized that not only are KOLs cultivated very carefully, those relationships, but there's a hierarchy of KOLs. They were people who influenced the local formulary and local practice at the institution, there were those who had a regional impact, and then there were those who were on the NCCN guideline committees, and had, you know, much broader impact that they really wanted to make sure to influence the heart and minds of-- in my interactions now, this opinion piece was a sort of tongue-in-cheek about Key Opinion Leaders and Thought Leaders. And with Thought Leaders, I was reminded of Sherlock Holmes's brother Mycroft Holmes, who, by Conan Doyle's fiction, was a brilliant man, but unwilling to stir his ample backside from his Chair in the Diogenes Club to actually get out there, and do some real work, and solve mysteries. And so, it fell to his slightly less brilliant brother, Sherlock, to become the consulting detective. So, that was fun. Now, we're sort of on the receiving end of wisdom from people who are experts in the area. And it's very important what doctors think, and in different geographies about how they think their patients will be potentially treated in a year or two, five years down the road, what the issues they have with current approaches are, where they see opportunity for some of our new compounds, for some of those of other companies, and it's different in Europe versus the US versus Australia. And so, there's a lot that we gain from advisory boards. There's an arc to an advisory board. You don't want to convene an advisory board when there's no data, because then, everybody is just speculating. You don't want to do it too late after something is already on the doorstep of FDA approval because then not anything can be changed at that point. So, you know, doing it at an in-between point where there's some initial data, but where we can really be guided by academic, clinical, and other experts, is really helpful. Pat Loehrer: I'd encourage people to pull this article out. It is really, really good. 2015, I think it came out there. The end of it, I also love it. You're talking about Kanti Rai who came up with the Rai classification and he was at this Meet the Expert session at the ASH meeting, and he said at the meeting, and this is your quote from it, and I love it, he said, “I don't like the name of this session because no one's an expert in chronic lymphocytic leukemia. I've been studying this disease for decades, and still too many of my patients die. If I was truly an expert, the disease would've been cured by now." I just love it, but it's a great read. Dave Johnson: Let me ask you, very seriously, if a younger colleague were to come to you, David, what advice would you give him or her about being invited to be on an advisory board? We'll skip the term KOL or Thought Leader. What advice would you give him or her, and what should they look for, and how should they prepare for that activity should you think they should do it? Dr. David Steensma: Well, I think getting back to imposter syndrome, people should feel, if they're invited to be in such a meeting, that they're there for a reason because their opinion does matter. And sometimes, younger physicians are reluctant to speak up in this setting, especially when there maybe leaders in the field there that have been doing it for decades, and may have very strong opinions. So, not being afraid to share their perspective and realizing that they're invited for a reason. On the other hand, I found it very helpful when I was a young faculty member and, on these panels, to listen to how colleagues were assessing data, and the recommendations they were making, and their perspective. And I learned a lot from some of those advisory boards earlier on. Many of the people who are the senior leaders in leukemia and MDS, you know, Rich Stone, Peter Greenberg, you know, John Bennett, in MDS, Marty Tallman, Hagop Kantarjian, Clara Bloomfield, just people who had decades of experience. And in part, I think it's some of my comments at advisory boards that helped get me my job at Dana-Farber, because I'd been in a number of meetings with Rich Stone, and he apparently liked some of the things I'd said about approaching patients. And so, you know, when a faculty position came open, he invited me out to come visit. And so, they can have benefits that you don't anticipate. Dave Johnson: Yeah, I would definitely agree with that. And there's pros and cons to being involved in those activities, but there are an awful lot of good that comes from it. And I think you've just touched on some of those. I'm going to shift gears a little bit because Pat has been waiting anxiously to hear all about your stamps. So, out of the many, many things that you've done and written about, I would say you've got close to 100 publications on medical stamps. It's an extraordinary productivity, David. So, tell us a little about your interest in medical stamps. How did you get involved in this, and where do you find time to write about them, and how do you decide which ones you're going to write about? Dr. David Steensma: Yeah. Bob Kyle, is really the driver on that, and we continue to do these together. Bob turned 94 this year, and he continues to be intellectually engaged. He's fun to talk to, if it weren't for COVID, he'd still be traveling and coming into the office, you know, which he was doing until just a few years ago. So, I met Bob as an intern when I was at Mayo. Somebody said, "Oh, you should meet this guy, he's really fun to talk to." And we just hit it off. And when I was a boy, my grandfather and my great-grandfather had collected stamps. And my grandfather really got me interested in it, partly given our family history, those of The Netherlands and former colonies, but also just more generally. And then as often happens, I got to be a teenager and other things took over in terms of interest, and there was less time, so, I had fallen away from it a bit. But somehow in this conversation, Bob had mentioned this, and that they were looking for someone younger who had this kind of background, to help with this series that has been running. Initially, it was running in JAMA with a guy named John Mirt, beginning around 1960, and then about a decade later, moved to the Mayo Clinic proceedings when they published six stamp vignettes on medical science per year, and Bob has done over 500 of these going back decades. And so, I got involved in that, and writing about-- thus far, it's mostly focused on individuals, but I have done a few also about more general trends in Philately. I will say that there are fewer of us, certainly those under 50, who are involved in the hobby. There's so much other distractions, but I still find it interesting and fun. And I've learned a lot, putting those vignettes together. Pat Loehrer: I started collecting stamps when I was young, I still have my Scott's album down. And now it's not stored, in properly, but I remember US Number One, I could have bought for $35, but I was only like 10 years old, and that was, you know, like $500 to me. So, I still regret that. Are you collecting stamps yourself now, still that you've resumed the collection part of it? Dr. David Steensma: Yeah. I would say, only a little bit. So, my Netherlands and Colonies collection is now actually complete, except there's one elusive. There's always one, right? Can't find this thing, even at auctions and such. And I also collected coins as a kid, and you know, still have some involvement in that. It's hard to find the time because I do do so many other things, and my wife and I have children, they're now college and PhD age, so I do woodworking, I have a telescope, so I never lost the love of astronomy. It seems like there's always other things to do. But I still have my collection over there on the shelf. Pat Loehrer: Did you inherit it from your grandfather too? Dr. David Steensma: Some of it I did. Yep. The core of it, I inherited from my grandfather and my great-grandfather. And then once I paid off my substantial medical school debt to the University of Chicago with the help of, in part, from advisory boards, but also mostly from moonlighting in emergency rooms around rural Minnesota-- during fellowship, I was like a full-time ER doc who happened to be doing a Hem/Onc Fellowship on the side, and finally got it paid off and then I could start on filling in some of the gaps. Pat Loehrer: Before we change this thing, what is your most cherished stamp that you own? Dr. David Steensma: Oh, my most cherished stamp is not a Dutch one. It is a set of national park stamps from 1934, authorized by James Farley, who was the Postmaster General at that point. 10 stamps, different colors about, you know, Zion and Acadia-- and it was my grandfather's favorite, and he was a big fan of the national parks, took two big trips there back in the '50s out West. And so, at his funeral, I put together a little display of those hanging with the photographs of other things from his life. I have that display, it's very meaningful to me - it's a connection with him. He was certainly very influential in my life. I never imagined I'd be working for a Basel-based pharmaceutical company, like he did for his whole career. Never thought that that would happen, but life has some unexpected twists. He worked for Roche in Nutley, New Jersey for much of his career as a research chemist. And ironically, when my grandmother was diagnosed in the 1990s, pancreatic cancer, and she saw the oncologist and was offered a 5-FU infusion after surgical, he said, "5-FU. I worked on that in 1959, 1960, that's still the best that we have to offer?" He was shocked by that. I was a fellow at the time. I said, "We need better drugs." Dave Johnson: For sure. So, do you have a favorite medical stamp, David? Dr. David Steensma: A favorite medical stamp? Gosh, that one's I think a little bit harder. I certainly have medical stamps that have piqued my interest. One of the sort of most moving is one of the US stamps that came out in the 1950s that has the Sir Luke Fildes' ‘The Doctor', on it. You know, with this concerned physician at the bedside of a young boy, and I actually wrote a vignette about the history and background there, and I think that connection with patients at the end of the day when we don't have good drugs, that connection with patients is still so meaningful, isn't it? As you guys really know. So, and as many of our listeners know, and so much of what medicine remains despite the molecular glue degraders and CAR T and gene therapy, is still that human connection, and being there for our patients. And so, I would say that that is probably one of the most meaningful. There's some real quirky ones, too. Austria's come out with some stamps in the last few years; one made of toilet paper, when the toilet paper shortage was happening, another, made of the mask material and the shape of the mask to remind people to mask up. You know, there's been a lot of creativity. And the Dutch are very good about design. They come up with just some brilliant innovations in postage stamps. Dave Johnson: I mean, stamps are really quite artful, by the way, the Fildes painting hangs on the wall of my office. You can't see it, but it's on the wall. And then behind me, you can perhaps see a couple of framed stamps that are some of my favorites. One was a gift to me from a former Group of Chief Residents, of an Osler stamp that Canada put out, and the other is one I received actually as a gift, as part of an award. It's the first cancer stamp that was produced in the United States. So, I love them both. They're quite nice. The Fildes stamp is actually my favorite of all, so I think that's a great stamp. Pat Loehrer: I have actually looked behind me. I've got a stamp collection on the frame that was given to me too that I love. It's stamps of medicine. There was one, a Dag Hammarskjöld stamp, that was famous because they printed it upside down when they put the color in, and I think it created a huge controversy from-- you know this better than I do because they decided then just to overprint them. Instead of making a few sheets that were incredibly valuable, they ended up printing out thousands of these things, which I have one now. It's only worth 7 cents, but at the time, it seemed really cool to have a misprinted stamp in your collection. Dr. David Steensma: Dag Hammarskjöld, there's an interesting connection with what I was talking about a little bit earlier with St. Elizabeth's Hospital. So, this relatively small teaching hospital had, at one point, a very strong hematology research program led by a guy named Fred Stallman. And in 1974, Fred Stallman, who was coming back from ISH, International Society Hematology, which was in Tel Aviv that year, and his plane exploded somewhere over the Aegean Sea, ultimately thought to be related to the PLO, and so he died. There was a big painting on the wall, in the hospital of him. And Dag Hammarskjöld also, at the peak of his career, you know, as the UN Secretary-General, was killed in a plane crash. But the interesting thing about Fred Stallman is, here, you have somebody who was so important in hematology. None of the fellows had any idea who he was or their connection to hematology. You know, it shows how fleeting fame is, unless you're an Einstein or Babe Ruth level. So, that was a good thing to keep in mind as well. Pat Loehrer: We could talk for another hour or two on this. Dave, we really appreciate it. But unfortunately, this is all the time we have for today. And I really want to thank you for joining us, Dave. This has been a wonderful conversation. I also want to thank all our listeners for tuning in to Oncology, Etc. This is an ASCO Education broadcast where we will talk about anything and everything, as you can imagine. If you have an idea for a topic or a guest you'd like to see on the show, just email us at: education@asco.org. Thanks, again. And, Dave, I've got a quiz for you here. Do you know why pirates don't take a shower before they walk off the plank? Dr. David Steensma: I do not. Dave Johnson: I have no idea. Pat Loehrer: It's because they wash up on shore. Dave Johnson: Oh boy.   Thank you for listening to the ASCO Education podcast. To stay up-to-date with the latest episodes, please click, "Subscribe." Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at: education.asco.org.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy, should not be construed as an ASCO endorsement.