Podcasts about mri

Bieber has Ramsay Hunt Syndrome which is something we covered back in January. It's scary stuff and we hope that it doesn't prevent him from singing, dancing and baking Bimbits for the rest of his life! Don't rub your eyes... Or if you do, don't go watch the MRI video of what it looks like when you rub your eyes. Alopecia is a tough go and there isn't enough access to medication that makes a difference! Brian wants to be VERY clear about his stance on CPR. Finally for this week's edition of WHAT THE HELLTH?! I just saved 15% on car insurance thanks to Geico. I also made 5 million dollars from suing Geico because some guy gave me HPV in the back of his car. Thanks, Geico! Join the post-episode conversation over on Discord! https://discord.gg/expeUDN

Bieber has Ramsay Hunt Syndrome which is something we covered back in January. It's scary stuff and we hope that it doesn't prevent him from singing, dancing and baking Bimbits for the rest of his life! Don't rub your eyes... Or if you do, don't go watch the MRI video of what it looks like when you rub your eyes. Alopecia is a tough go and there isn't enough access to medication that makes a difference! Brian wants to be VERY clear about his stance on CPR. Finally for this week's edition of WHAT THE HELLTH?! I just saved 15% on car insurance thanks to Geico. I also made 5 million dollars from suing Geico because some guy gave me HPV in the back of his car. Thanks, Geico! Join the post-episode conversation over on Discord! https://discord.gg/expeUDN

Bill opens the show discussing his MRI, the Brewers' loss to the Cardinals and the NBA Draft. He then talks NHL Finals controversy, Ohio State trademarking "THE" and Tony Siragusa passing away at the age of 55 See omnystudio.com/listener for privacy information.

Austin Wynns to the rescue! The San Francisco Giants catcher was a triple shy of the cycle, and his three-run homer in the second inning set the tone for the offense in a thrilling 12-10 win for the SF Giants. Wynns has been a fresh air ever since the Giants acquired him from the Phillies, but he wasn't the only offensive star last night. Mike Yastrzemski had a big bases-loaded double, Joc Pederson added a solo shot, and Wilmer Flores had a two-out, two-strike hit that drove in two runs in the ninth. Those runs proved to be essential, as Giants closer Camilo Doval surrendered a two-run homer to Matt Olson in the bottom of the inning. It wasn't all sunshine and roses, however. Brandon Crawford had an injury scare and came out of the game. He's day-to-day and is getting an MRI, but it looks like he was able to avoid a serious injury. Thairo Estrada made another critical error at a very bad time (although Evan Longoria probably should've made a different throw). And Anthony DeSclafani allowed five runs in three innings in his return from the 60-day injured list. To clear a spot on the major league roster, LHP José Álvarez was placed on the 15-day IL with back tightness. Find and follow Locked On Giants on your favorite podcast platforms:

Videos: 1. The great recycling LIE (what really happens to plastic) (10:44) 2. Is It Game Over? New NASA Report (5:30) 2. You won't believe what Justin Trudeau's government just did | Redacted with Clayton Morris (13:26) 3. Neil Oliver – Who pulls the strings – Pandemic Treaty, Wealth & Power? (2:00) 4. He's EXPOSING the truth in Syria and they don't like it | Redacted conversation w/ Kevork Almassian (first 10:00) 5. Russian Ruble now best performing currency in the world this year… another example of how US sanctions have failed. 6. Vanessa Beeley and Eva Bartlett are smeared by the Guardian for reporting the truth (3:07) 7. Kim Iversen: Inside The SECRET Bilderberg Meetings Between Spies, War Hawks And World Leaders (9:28) 8. New Rule: The Misinformation Age | Real Time with Bill Maher (HBO) 9. https://theduran.locals.com/post/2311112/title  10. https://www.youtube.com/watch?v=3maIN4-ZJl8    Strawberry Compound Shown to Protect Against Alzheimer's, Memory Loss Salk Institute for Biological Studies, June 16, 2022  The thought of losing your mind is a frightening one, but one in three Americans die with Alzheimer's or some other form of dementia. Regardless how frightening the possibility is, the chances of it happening to you aren't exactly slim, which means prevention should be at the forefront of your mind. A recent study from the Salk Institute for Biological Studies indicates prevention could be as simple as a natural foods diet—rich in fruits (such as strawberries) and vegetables containing something called fisetin. Fisetin is a flavonol found in strawberries, mangoes, cucumbers, and other vegetables and fruits. Researchers with the Salk Institute found this simple compound can actually reduce the risk of Alzheimer's in mice, and could be effective in humans as well. Maher and her team have documented that fisetin has both anti-inflammatory and antioxidant properties in the brain. It is also able to turn on a cellular pathway related to memory function. The team looked to a type of mouse with mutated genes making them vulnerable to Alzheimer's. At three months old, the researchers began feeding the mice a diet enriched with fisetin. Mice who hadn't received the fisetin began struggling in the mazes at nine months of age, but the fisetin mice performed as well as normal (non-predisposed) mice at both nine and twelve months of age. Avocados may hold the answer to beating leukemia University of Waterloo (Canada), June 16, 2022 Rich, creamy, nutritious and now cancer fighting. New research reveals that molecules derived from avocados could be effective in treating a form of cancer. Professor Paul Spagnuolo from the University of Waterloo has discovered a lipid in avocados that combats acute myeloid leukemia (AML) by targeting the root of the disease – leukemia stem cells. Worldwide, there are few drug treatments available to patients that target leukemia stem cells. “The stem cell is really the cell that drives the disease,” said Professor Spagnuolo, in Waterloo's School of Pharmacy. “The stem cell is largely responsible for the disease developing and it's the reason why so many patients with leukemia relapse. We've performed many rounds of testing to determine how this new drug works at a molecular level and confirmed that it targets stem cells selectively, leaving healthy cells unharmed.” Inability to stand on one leg for 10 seconds in mid to later life linked to near doubling in risk of death Exercise Medicine Clinic-CLINIMEX (Brazil) and University of Eastern Finland, June 21, 2022 The inability to stand on one leg for 10 seconds in mid- to later life is linked to a near doubling in the risk of death from any cause within the next 10 years, finds research published online in the British Journal of Sports Medicine This simple and safe balance test could be included in routine health checks for older adults, say the researchers. The researchers wanted to find out whether a balance test might be a reliable indicator of a person's risk of death from any cause within the next decade, and, as such, might therefore merit inclusion in routine health checks in later life. Participants were asked to stand on one leg for 10 seconds without any additional support.  To improve standardization of the test, participants were asked to place the front of the free foot on the back of the opposite lower leg, while keeping their arms by their sides and their gaze fixed straight ahead. Up to three attempts on either foot were permitted. In all, around 1 in 5 (20.5%; 348) participants failed to pass the test. The inability to do so rose in tandem with age, more or less doubling at subsequent 5 year intervals from the age of 51-55 onwards.  The proportions of those unable to stand on one leg for 10 seconds were: nearly 5% among 51-55 year-olds; 8% among 56-60 year-olds; just under 18% among 61-65 year-olds; and just under 37% among 66-70 year-olds.  More than half (around 54%) of those aged 71-75 were unable to complete the test. In other words, people in this age group were more than 11 times as likely to fail the test as those just 20 years younger. During an average monitoring period of 7 years, 123 (7%) people died: cancer (32%); cardiovascular disease (30%); respiratory disease (9%); and COVID-19 complications (7%). The proportion of deaths among those who failed the test was significantly higher: 17.5% vs. 4.5%, reflecting an absolute difference of just under 13%. Anxious Children have Bigger “Fear Centers” in the Brain Stanford University School of Medicine, June 16, 2022 The amygdala is a key “fear center” in the brain. Alterations in the development of the amygdala during childhood may have an important influence on the development of anxiety problems, reports a new study in the current issue of Biological Psychiatry.

 Researchers at the Stanford University School of Medicine recruited 76 children, 7 to 9 years of age, a period when anxiety-related traits and symptoms can first be reliably identified.  The researchers found that children with high levels of anxiety had enlarged amygdala volume and increased connectivity with other brain regions responsible for attention, emotion perception, and regulation, compared to children with low levels of anxiety. They also developed an equation that reliably predicted the children's anxiety level from the MRI measurements of amygdala volume and amygdala functional connectivity.

The most affected region was the basolateral portion of the amygdala, a subregion of the amygdala implicated in fear learning and the processing of emotion-related information.

 Our study represents an important step in characterizing altered brain systems and developing predictive biomarkers in the identification for young children at risk for anxiety disorders,” Qin said.  New research: Olive oil compound destroys cancer cells in 30 minutes Rutgers University & Hunter College, June 12, 2022  Oleocanthal, a polyphenolic, therapeutic compound found in olive oil is the subject of a new anti-cancer study performed by nutritional science and cancer biology researchers with The School of Environmental and Biological Sciences at Rutgers and Hunter's College in New York City. Programmed cell death, known as apoptosis takes approximately 16-24 hours. Dynamic new research just published in the Journal of Molecular and Cellular Oncology blew scientists away – when exposed to oleocanthal, a polyphenol compound found in olive oil, cancerous cells died within 30 minutes to an hour. While researchers previously understood that compounds in olive oil were capable of killing cancer cells, until now, such short apoptosis had not been observed. Even more fascinating was when the team looked closely to surmise why apoptosis was occurring under such swift circumstances – they discovered that cancer cells were being killed by their own enzymes. And, not only one isolated type of cancerous cell, but all of the cancerous cells they were examining. Unlike chemotherapeutic pharmaceuticals that devastate healthy cellular activity, the therapeutic polyphenolic compound found in olive oil kills cancer while maintaining vitality among healthy cells. As Paul Breslin, one of the study's authors at Rutgers noted, while cancerous cells died, healthy cells were not harmed, but rather the oleocanthal “put them to sleep.” The lifecycle of healthy cells was only temporarily affected in this way, without any negative observations and in approximately 24 hours, the healthy cells resumed their life cycle.  Sports, not screens: The key to happier, healthier children University of South Australia, June 21, 2022 Whether it's sports practice, music lessons or a casual catch up with friends, when children are involved in after-school activities, they're more likely to feel happier and healthier than their counterparts who are glued to a screen. In a new study conducted by the University of South Australia, researchers found that children's well-being is heightened when they participate in extra-curricular activities, yet lowered when they spent time on social media or playing video games. Published in BMC Pediatrics, the study analyzed data from 61,759 school students in years 4 to 9, assessing the average number of days per week children participated in after-school activities (3–6pm), and measure these against well-being factors—happiness, sadness, worry, engagement, perseverance, optimism, emotion regulation, and life satisfaction. It found that most students watched TV about four days of the school week and spent time on social media about three days of the week. Our study highlights how some out-of-school activities can boost children's well-being, while others—particularly screens—can chip away at their mental and physical health. “Screens are a massive distraction for children of all ages. And whether children are gaming, watching TV or on social media, there's something about all screens that's damaging to their well-being. Students in lower socio-economic backgrounds who frequently played sports were 15% more likely to be optimistic, 14% more likely to be happy and satisfied with their life, and 10% more likely to be able to regulate their emotions. Conversely, children who played video games and used social media almost always had lower levels of well-being: up to 9% less likely to be happy, up to 8% to be less optimism and 11% to be more likely to give up on things.

NEW: Support This is HCD by taking one of our courses https://www.thisishcd.com/courses Hello and welcome to Bringing Design Closer. Our goal is to have conversations that inspire and to help move the dial forward for organisations to become more human-centred in their approach to solving complex business and societal problems. This is HCD is almost 5-years old. We've been creating content regularly for that period of time, and if you want to help us out - please leave a review for us wherever you are listening. Those lovely algorithms love reviews, as it helps us grow our community - every little helps. Even if you don't review, you can go one better by telling people you work with about the podcast.  In this episode I speak with Michael Galinsky, a movie director, documentary maker and musician based in North Carolina in the states. For anyone that follows me on Twitter, they might have seen a thread a number of weeks ago where I spoke about back pain. Late last year, I woke with pain in my left hand side of my back, and contributed it to being a Dad, lifting little people, being out of shape, sitting down for larger periods of time etc. I went to my physio and had several sessions before Christmas and to little or no state change. Christmas was sore. I was more grumpy than usual and entered January and had a private MRI scan. That in itself was an interesting experience, and one for another episode, but my GP called me and said “one of your discs is protruding” and possibly on a nerve. I was shocked. I'd heard about herniated discs but now I had one! I actually got stiffer after for a few weeks. Was this what my life was going to be like? Is this what middle age feels like? Sheesh - if it is, then this isn't much fun. Then I Tweeted. What came back was a lot of support and advice. Emma Blomkamp, read something in a newsletter by Kai Brach several months prior and tagged Kai, and Kai mentioned a doctor called Dr John Sarno in the States. He encouraged me to Google and watch some stuff. Sarno's work states that many people have herniated discs but what is the cause for lots of back pain is stress and hidden life traumas. I was instantly skeptical. But I spent 2 hours that night watching lectures of Sarno's in NYU on YouTube. I was shocked. Last year was brutal. Running a business and balancing everything has been hard on me and hard on my own mental health. Maybe, just maybe there was something in this. Then Michael tweeted to me. He's created an awesome documentary called All the Rage several years ago and I bought it on iTunes and watched it. It explores the relationship between the mind and the body. Sarno encourages people to try exercise and ‘watch' for the stressors. I did exactly this. I cut the grass. I went for a short walk with the kids. I gave them a piggy back and to my surprise, nothing.  Was this in my head? In this episode, I speak with Michael about working directly with Dr Sarno in the creation of the documentary and explore deeper about the background to Michaels own journey - something that under pinned the narrative of the documentary. This is a brilliant episode and one for all - even if you don't suffer back pain. You will find this fascinating. Let's go... https://alltheragedoc.com Michael on Twitter: https://twitter.com/mgalinsk https://www.instagram.com/rumurpix Twitter Gerry https://www.twitter.com/gerrycircus Twitter This is HCD https://www.twitter.com/thisishcd See omnystudio.com/listener for privacy information.

Oscar has got the rodent trouble!  Plus, Robb is on pins and needles about his MRI, Mike goes on a Father's Day date that spills into the second location, and Pony is back (which can go both ways).  And a TV recco you don't wanna miss… but please, don't clap.

When Kate Dineen and her husband sought abortion care in the state of Massachusetts, following a devastating MRI revealed that the baby she was carrying had a 50% chance of dying before birth, or shortly thereafter. Dineen shares the nightmarish journey to access a late-term abortion in her very blue town of Boston, even though local abortion laws should have protected her access to abortion care. Listen to All Electorette Episodes https://www.electorette.com/podcast Support the Electorette Rate & Review on iTunes: https://apple.co/2GsfQj4 Also, if you enjoy the Electorette, please subscribe and leave a 5-star review on iTunes. Also, please spread the word by telling your friends, family and colleagues about The Electorette! WANT MORE ELECTORETTE? Follow the Electorette on social media. Electorette Facebook Electorette Instagram Electorette Twitter Learn more about your ad choices. Visit megaphone.fm/adchoices

Accelerator physicist Dr. Suzie Sheehy visits Google to discuss her book "The Matter of Everything: Twelve Experiments that Changed Our World." Her book tells a hopeful story of human ingenuity, creativity and unending curiosity, and introduces us to the people who, through a combination of genius, persistence and luck, staged ground-breaking experiments that shaped the world as we know it. From the physicists who soared in hot air balloons on the trail of new particles, to the serendipitous discovery of X-rays in a German lab; and from the race to split open the atomic nucleus, to the quest to find the third generation of matter, Dr. Sheehy offers a reminder of the thrilling discoveries that have shaped our lives—often without us even knowing it. Radio, TV, the chips in our smartphones, MRI scanners, radar equipment and microwaves, to name a few: these were all made possible by our determination to understand, and control, our world. Moderated by Matt Bongiovi. Visit http://g.co/TalksAtGoogle/MatterofEverything to watch the video.

It's DAY 3! And there were a few surprises! As you know at this point in the mini-series -- we participated in the ALLFTD Study -- Rachael as the participant, and Maria as the study partner... and today's episode recaps our Day 3: The Visit with the Physician to review the Neuropsych testing and the MRI. A long day, but we had a lot of laughs. Everything is an adventure with us, so be sure to listen! Want to learn more about ALLFTD? Visit allftd.org Be sure to connect with us on instagram @remembermepodcast to let us know what you think of today's episode! ------ Special Thanks To Our Sponsor: The Bluefield Project The Bluefield Project to Cure FTD is on a mission to support research to improve our understanding of a genetic form of Frontotemporal Dementia, and to help find a cure for this devastating disease. To achieve our mission, we have supported over 40 researchers at Universities across the world, to understand the science behind FTD caused by mutations in progranulin. We, along with NIH and others, help fund studies of families affected by FTD. These studies are called Natural History Studies and follow participants over time, to better understand how FTD may develop, and to identify clues that may help us treat it. Based in part on our research findings, a number of companies are developing therapeutics that target progranulin FTD. There are now four investigational therapies in clinical trials for progranulin-FTD. So how can you help? If FTD runs in your family, participating in a Natural History Study, or in a therapeutic clinical trial, makes an enormous contribution. To learn more, please go to ftdregistry.org ---- To learn more about Remember Me, visit remembermeftd.com --- Support this podcast: https://anchor.fm/rememberme/support

Partners in cancer care – who are advanced practice providers? In the first episode of ASCO Education's podcast series on Advanced Practice Providers (APPs), co-hosts Todd Pickard (MD Anderson Cancer Center) and Dr. Stephanie Williams (Northwestern University Feinberg School of Medicine), along with guest speaker, Wendy Vogel (Harborside/APSHO), discuss who advanced practice providers are, share an overview of what they do, and why they are important to oncology care teams. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org   TRANSCRIPT Todd Pickard: Hello everyone, and welcome to the ASCO Education Podcast, episode number one of the 'Advanced Practice Providers' series, 'APPs 101: What and Who Are Advanced Practice Providers?' I'd like to introduce my co-host for this series, Dr. Stephanie Williams. My name is Todd Pickard. I'm an advanced practice provider, I'm a PA, and I work at MD Anderson Cancer Center in Houston, Texas. I'm also the Executive Director of Advanced Practice and my clinical practice is in urology. Dr. Williams, how about you introduce yourself? Dr. Stephanie Williams: Thanks, Todd, and thanks for this opportunity to present this incredibly important topic. I am currently retired from clinical practice. I had been in practice for over 35 years both in an academic setting, a private practice, and more recently in a large institutional, multi-specialty institutional type of practice. My primary clinical care has been in stem cell transplants and cellular therapy. And we have used APPs, both PAs and NPs for a couple of decades in our particular area. Todd Pickard: Great, thanks for that. I'd also like to introduce you to our guest panelist today, Wendy Vogel from Harborside, who is a certified oncology nurse practitioner with over 20 years of clinical experience and expertise. We're excited to be chatting with Wendy today about the basics of advanced practice providers and who they are. This will be an introduction for the rest of the upcoming episodes of APP Podcasts. Wendy, why don't you tell us a little bit about yourself and your practice. Wendy Vogel: Thanks, Todd. It is a pleasure to be here. I appreciate you asking me to talk. I am an oncology nurse practitioner as you said. I do a high-risk cancer clinic and do that a couple of days a month. And I am also the executive director of APSHO, the Advanced Practitioner Society for Hematology and Oncology. Todd Pickard: Great! We're looking forward to a robust and informative discussion today between the three of us. So, I'd like to get started with some basics. Wendy, do you want to always start with a definition of advanced practice registered nurse? Wendy Vogel: Okay, great question! So, APRNs or advanced practice registered nurse include nurse practitioners. It can include clinical nurse specialists, nurse anesthetists, and nurse midwives. And generally, APRNs hold at least a master's degree in addition to some initial nursing education as a registered nurse. Some APRNs have doctorates like the DNP or Doctorate of Nursing Practice. But licensure for APRNs generally falls under the State Board of Nursing.   So, we're also required to have a board certification, usually as some sort of generalist as in family medicine, pediatrics, geriatrics, women or acute care. But in oncology, many APRNs also carry oncology certification. Todd Pickard: Excellent! Thanks for that. I'll go ahead and add to the conversation by defining physician assistant. So, physician assistants are individuals who are trained in the medical model and are licensed to practice medicine in team-based settings with physicians. Very much like advanced practice registered nurses, we come from a variety of backgrounds, and our education model is really focused on thinking about the patient the same way that our physician colleagues do. We're trained in really taking a very broad look at patient care, and our education as a generalist model. PAs are certified by the National Commission on Certification of Physician Assistants, which is one national certification that includes all of the content areas in which we will practice. Dr. Stephanie Williams: For those out there who don't know, what are the differences between a physician assistant and an APRN? Or are there differences in practical terms, in terms of how we practice our field? Wendy Vogel: That is a great question, Stephanie, thanks for asking that. We function very much the same. The main difference is just in our educational background, where nurse practitioners come from a nursing background and the nursing model of care, and I'll let Todd speak to where PAs come from, but basically, our functions are very much the same. Todd Pickard: I very much agree. If you are in a clinical setting, and for some reason, Wendy or myself failed to identify who we are, you wouldn't really detect a distinction between the care either of us provide, because we are there in that provider setting and we're really there to assess the conditions you have like appropriate history in physical examination, think through differential diagnosis or a workup, create a diagnosis and then a therapeutic plan and also to educate you as the patient or to make an appropriate referral. So, really, when APPs, PAs, and NPs work side by side, there's really not a lot of difference in what people detect in what we're doing and how we're doing things. But there are some educational differences, which are pretty minimal. So, for example, one small difference is that PAs include surgical assisting as part of our core fundamental training, and our APRN colleagues generally don't. So, in my institution, we do have nurse practitioners that go to the OR and do assisting, but in order to get there, they did a Registered Nursing First Assist Program, it's a certification. So, they learn those fundamentals of sterile technique and surgical technique. So, in essence, there's really not a whole lot of difference. Dr. Stephanie Williams: I think what I was struck with about the difference was the history and the fact that PAs came out of the Mobile Army Surgical Hospitals. To me, that was just fascinating. I think Duke was the first graduating class. Wendy Vogel: You know, the role of the APRN has really changed drastically. It began in the 1960s, because there were not enough primary care providers, particularly for children in the urban and rural areas of the US, and the first nurse practitioner program was in 1965, at the University of Colorado. So, gosh! Have we come a long way since then, both the PA role or the NP role. When was the first PA role, Todd, when was that? Todd Pickard: We were born at the same time in 1965, we just happened to be at Duke University and y'all were in Colorado. You know, I think that the most important thing about working with advanced practice providers is that you look to work with somebody who has the competencies, the skills, interpersonal communication, and the pertinent experiences because honestly, I know fantastic APRNs, I know fantastic PAs, and I know some of either profession that really just don't quite fit a particular role. And so, there is some kind of mythology around PAs and APRNs, and who should work where, like PAs should be more procedural and more in surgery, and nurse practitioners should be more in medicine in the hospital. And really, there's nothing in our training that defines that per se, I think it's just a natural progression of we're over 50 now, so our professions are middle-aged. And we're starting to really have our feet underneath us. And I think people who've worked with PAs or NPs really understand, it's about the individuals and what they bring to the table. It's not really about the initials behind our names, because honestly, that's not what makes me do good work. It's not that I have the PA or NP behind my name. It's my commitment and dedication to my patients and supporting the rest of my team. Wendy Vogel: I think Stephanie, that's why we use the term advanced practitioner, advanced practitioner provider because it doesn't single out either one of us because we are functioning in the same manner. It's easier to say than say, PAs and NPs, so we just say, APPs. Todd Pickard: Yeah. And it doesn't mean that we don't identify as individual professions, because we do. I mean, I'm a PA, but I am part of a larger group. And part of that larger group is identifying as advanced practice provider because, at my institution, there are over 1000 of us, and we are a community of providers, and that's the way that we sense how we function within the team and within the institution. And so, it's really about that kind of joint interprofessional work. And speaking of work, Wendy, tell us a little bit about what are typical things that advanced practice providers do? Wendy Vogel: It might be easier to say what we don't do. I've got a list. Do you want to hear my list? Todd Pickard: Yeah, lay it on us. Wendy Vogel: Okay, here you go. Staff and peer education, survivorship care, palliative care, hospice care, pain management, acute care clinics, case management, research, cancer patient navigator, genetic services, lung nodule clinics, quality improvement. We're writers, we're authors, we're speakers, we mentor, and we do all kinds of public education. We can have clinical roles with faculty and professional organizations. We do procedures like bone marrows, paracentesis and suturing, and all that kind of stuff. We do a lot with all the other things like diagnosing, all the things you said earlier, diagnosing, ordering lab tests, ordering chemotherapy, etc. Todd Pickard: I think what's amazing about advanced practice providers is the flexibility we have to fill in gaps on teams or in service lines, no matter what that is. You know, I like to say and I'm sure everybody thinks that they originated this, but I feel that advanced practice providers are the stem cells of the team because we differentiate into whatever is necessary. At my institution, we recently had a gap in how our peer-to-peers were handled. Many times, you order an MRI or a PET scan, and the payer will, the day of or the day before, say, ‘Oh, I need to talk to somebody.' How that gets to the clinical team and when the clinical team has time to do that, it's really hard to coordinate. So, we created a team of advanced practice providers who spend one day a week doing the regular clinical roles, but then the rest of the time, they are dedicated to facilitating these peer-to-peer conversations. They have over a 95% success rate. And the payers, the medical directors, have actually gotten to know them. And so, they'll say, ‘Hey, I want to talk to so and so because she's fantastic and knows our program, and it's really easy to have these conversations.' And so, patients are taken care of and these business needs are taken care of, and then our clinical teams can really focus on what they're there for, which is to see those patients in and out every day. So, that's the power of advanced practice, its flexibility, filling in gaps; we can bend and morph to whatever we need to do because one of the things that's in our DNA is part of PA and advanced practice RN, we're here to serve, we're problem solvers or doers, too. When we see something, we pick it up and take care of it. That's just in our nature. Stephanie, tell us a little bit about your experience working with an advanced practice provider, is what Wendy and I are saying ringing true, or what's your experience? Dr. Stephanie Williams: Oh, absolutely! As I look back on my career, I'm not certain that I could have accomplished much of what I did, without my team members and advanced practice providers, both PAs and NPs. We also use them in an inpatient setting. And I can't remember Wendy mentioned that to take care of our stem cell transplant patients, because of residency, our requirements were removed from our services, and they became the go-to's to taking care of the patients. It actually improved the continuity of care that the patients received because they would see the same person throughout their 4 to 6-week course in the hospital, they also helped run our graft versus host clinics. I hate that term physician extender because they're really part of our health care team. We are all healthcare professionals working together, as Todd beautifully mentioned, for a common goal to help that patient who's right there in front of us. And not only that, from a kind of selfish viewpoint, they help with a lot of the work, doing the notes, so that we could all split up the work and all get out on time and all have at least some work-life balance. And I think that's a very important part of any team is that we can each find our own work-life balance within the team. So, I feel that they're a very important part of the oncology healthcare team. And I would recommend that everyone who wants to take care of patients, incorporate them into their team. Wendy Vogel: Can I say something right here that you mentioned that I'm so glad you did, which was physician extender. That is a dirty, dirty word in the AP world now because we don't know what part we're extending, that is not what we do. And also, we don't want to be called mid-level providers because – you can't see but I'm pointing from my chest to my belly - I don't treat just the mid-level, nor do I treat in mid-level care. I give superior care. I just give different care. And I give care on a team. And the last one is a non-physician provider. That is also a no-no because I wouldn't describe a teacher as a non-fireman, nor would I describe you, Stephanie, as a non-nurse practitioner. So, I don't want to be a non-physician provider either. Todd Pickard: It is an interesting phenomenon that even after 50 years, so many different places, whether it's the Joint Commission, or the Centers for Medicaid and Medicare Services, whether it's a state legislator, an individual state, an individual institution like Memorial Sloan Kettering or an MD Anderson or a Moffitt, everybody comes up with these different terms. And it's so interesting to me. Physicians are either physicians, doctor, sometimes they're called providers. But as a PA, who's an advanced practice provider, those are the two things that resonate with me: either call me PA or call me advanced practice provider. All these other names seem to just be, it's an alphabet soup, and it really doesn't carry any meaning because some places just come up with these strange terms. And I agree, physician extenders has been the one that always has amused me the most because it reminds me of hamburger helper. Am I some noodles that you add to the main meal so that you can extend that meal out and serve more people? I think what Wendy and I are really trying to get at, I know this has been with a little bit tongue in cheek, but we are part of the team. We work with physicians in a collaborative team-based setting, just like we all work with social workers and schedulers and business people and pharmacists and physical therapists. I think the main message here is that oncology care and taking care of patients with cancer is a team effort because it is a ginormous lift. It's a ginormous responsibility and our patients deserve a full team that works collaboratively and works well and has them in our focus like a laser, and I know that's what APPs do. Dr. Stephanie Williams: I think that's well said, Todd. What I enjoyed in the clinic in particular, was sitting down and discussing patient issues and problems with my APPs. And we worked together to try to figure out how to resolve issues that would come up. But we also learned from each other, you're never too old to learn something from people. I just felt the interaction, the interpersonal interaction was also very satisfying as well. Wendy Vogel: I think that the job satisfaction that comes from being a team player and working together is so much higher and that we're going to experience so much less burnout when we're working together each to the fullest scope of our practice. Todd Pickard: So, Wendy, one of the things that people ask a lot about when they work with advanced practice providers is, ‘Well, gosh! How do I know that they have this training or this experience or this competency?' And then the question arises about certification. So, let's talk a little bit about certification and what that means and what it doesn't mean. So, tell me, are advanced practice providers certified? And are they required to get a variety of certifications throughout their career? Let's talk a little bit about that. Why don't you open up the dialog. Wendy Vogel: Okay, happy to! So, to be able to practice in the United States, I have to have a board certification. And it can vary from state to state, but generally, it has to be either a family nurse practitioner certification, acute care nurse practitioner, geriatrics, women's health, pediatrics, there are about five. So, you are generally certified as one of those. There are a few oncology certifications across the US, board certifications to be able to practice at the state level, but not all states recognize those. So, most of us are educated in a more generalist area, have that certification as a generalist, and then can go on to get an additional certification. So, many nurse practitioners in oncology will also get an advanced oncology nurse practitioner certification. So, that's a little bit different. It's not required to practice. But it does give people a sense that, ‘Hey, she really knows what she's doing in oncology.' Todd Pickard: The PA profession has one national certification, and it is a generalist certification. It's probably similar to USMLE, where you really are thinking about medicine in its entirety. So, whether that be cardiology, orthopedics, family medicine, internal medicine, geriatric, psychiatry, or ophthalmology. I mean it's everything – and oncology is included as well. And that certification really is the entree into getting licensure within the states. It's basically that last examination that you take before you can get that license just to make sure that you have the basic knowledge and fundamentals to practice. And so, I always respond to this kind of question about certification, I say, ‘Well, is it really the experience and the onboarding and the training that one gets on the job and the mentoring and the coaching that one gets from our physician colleagues and other advanced practice providers that brings them the most value? Or is it going through an examination, where basically you're responding to a certain amount of information, and you either pass it or you don't, and you can get a certification? I'm not saying there's not value in that, but I'm also making the argument that if you are working with your APPs well, and they have good mentors, and they have good resources, they're going to be excellent clinicians. And having an additional certification may or may not make some huge difference. Many times I see people use it as a differentiator for privileges or something. It's really an external kind of a pressure or a desire, it doesn't really have anything to do with patient care. I mean, Wendy what has your experience been around that need for additional certification? Wendy Vogel: I've seen it used in practices to merit bonuses, which isn't really fair when a PA does not have that opportunity to have a specialty certification per se. So, I've seen it used negatively. I'm a great believer that any additional education that you can get is beneficial. However, I will say just like you said, if you are getting your mentoring, you have good practice, you're doing continuing education, then it's essentially the same thing. To be able to have an oncology certification, I had to practice for a year and I had to take a test that really measured what I should know after one year. And that's what a certification was for that. Is it beneficial, do I want it? Yeah, I want it. Do I have to have it to practice? No. Todd Pickard: I think that is a great way to segue to having a brief conversation about how you bring APPs in? I mean, just at a very high level, should people expect for an APP to come in right out of school and just hit the ground running without any additional investment? And I could ask the same question about a resident or a fellow who completes an oncology training program. Do you just put those people to work? Maybe that's an older model, and now really mentorship and that additional facilitated work is, I think, critical. So, I'll start with Stephanie, tell us a little bit about what's your experience been with advanced practice providers, or even young physicians as they enter the workforce? What's the role of onboarding or mentoring program? Dr. Stephanie Williams: So, it's important. We had a set process for bringing on our new APPs and it pretty much followed the guidelines from the American Society of Cellular Transplantation in terms of the knowledge base that they would need to know. So, it was a checklist. And we would also have them do modules from ASCO's oncology modules, as well looking at primarily hematologic malignancies, so they could get a background there. And then we would slowly bring them on board. Usually, they would start taking care of autologous patients, a certain subset of patients, and then move on to the more complicated patients. We did the same clinic, whether they were clinic or inpatient APPs. So, it took us about three to four months to onboard our APPs. In terms of a fellow becoming an attending physician, I'd like to say that there's specific onboarding there. Unfortunately, sometimes they're just, ‘Okay, these are your clinic days, this is when you start.' I mean, you're right Todd, we really need to work more on onboarding people. So, that one, they like their jobs, they're not frustrated, and they want to stay and continue to work in this field. I see many times after two or three years, if they're not onboarded properly, they just get frustrated and want to move on to a different area. Wendy Vogel: We know that most of the advanced practitioners who come into oncology don't have an oncology background, PA or NP.  They just don't, and we don't get a lot of that in school. So, it takes months, it would probably, I dare say, take 12 months of full-time practice to feel comfortable in the role. But how many practices particularly in the area that I've practiced in you get this AP, and you throw them in there, and in four weeks, you're supposed to be seeing patients. How can you make those decisions when you haven't been properly mentored? So, absolutely important to have a long onboarding time till that APP feels comfortable. Todd Pickard: Yeah, I think that it is critically important that we set up all of our team members for success, whether they be physicians, or PAs, or nurse practitioners or nurses, or pharmacists, and I think that is the role of onboarding and mentoring, having people who will invest time and energy in what you're trying to accomplish. You know, Wendy is spot on. Advanced practice providers have specific types of training within their educational program. As a PA, my focus in oncology was to screen for and detect it. So, to understand when a patient presents with a mass or some symptoms that may make you think that, oh gosh, maybe they've got acute leukemia or something else and looking at those white counts and, and understanding. But that transition from identifying and screening and diagnosing cancers is very different than how do you care for specific types of tumors and specific disciplines, whether it be radiation oncology, surgical oncology, medical oncology, cancer prevention. There's a lot that folks need to be brought up to speed about the standards of what do we do in this practice and how do we care for these types of cancers? And that really is the role for the onboarding and mentoring. You know, you may be lucky, you might get an advanced practice provider who used to work at a big academic cancer center in the same field, whether it be breast medical oncology or GI, and yeah, that's a much easier task. That person probably really needs mentoring about the local culture, how we get things done, what are the resources, and which hospitals do we refer to. But for the most part, working with an advanced practice provider means that you've got a PA or an NP, who has a strong foundation in medical practice. They know how to care for patients, they know how to diagnose, they know how to do assessments, they know how to critically think, they know how to find resources, and they know how to educate. But they may not know how long does a robotic radical prostatectomy patient going to be in the hospital? And how long does it take to recover and what are some of the things you need to be considering in  their discharge and their postoperative period? That is very detailed information about the practice and the local resources. Every advanced practice provider is going to need to have that kind of details shared with them through mentorship, and a lot of it is just how do we team with each other? What are the roles and responsibilities? Who does what? How do we have backup behaviors to cover folks? So, a lot of this really is just deciding, ‘Okay, we've got a team. Who's doing what? How do they work together and how do we back each other up?' Because at the end of the day, it's all about the team supporting each other and that's what I love about advanced practice. Wendy Vogel: Very well said, yes. I had an AP student yesterday in clinic, who told me - I was asking about her education in oncology and what she got - and she said, ‘Well, so for lymphoma, we treat with R-CHOP. So, a student, of course, raised their hand and said, ‘What's R-CHOP? She's like, ‘Well, the letters don't really line up with what the names of the drugs are, so, just remember R-CHOP for the boards.' So there you go. That's kind of what a lot of our education was like specific to oncology. And again, I'm a little tongue in cheek there also. But Todd, are you going to tell everybody about the ASCO Onboarding tool that's now available? Todd Pickard: Absolutely! ASCO has done a really great job of trying to explore what advanced practice is, and how teams work together. All of us are part of the ASCO Advanced Practice Task Force. One of the things we did was really to look at what are some best practices around onboarding, orientation, scope of practice, and team-based cancer care, and we created a resource that is available on the ASCO website, and I think that it is a great place to start, particularly for practices, physicians, or other hospital systems that don't have a lot of experience with advanced practice. It's a  great reference, it talks about the difference between orientation and onboarding. It gives you examples of what those look like. It talks about what are the competencies and competency-based examinations. So, how you assess people as they're going through the onboarding period. It has tons of references, because ASCO has done a lot of great research in this field, around collaborative practice and how patients experience it, and how folks work on teams, and what do those outcomes look like. So, I highly recommend it. Wendy, thank you for bringing that up. It's almost like you knew to suggest that. Well, this has been a really, really good conversation. I'm wondering, what are some of those pearls of wisdom that we could all provide to the folks listening? So, Stephanie, what are some of your observations that, you know, maybe we haven't just thought about, in your experience working as a physician with advanced practice providers? Dr. Stephanie Williams: One, it's important to integrate them into the team, and, as Wendy mentioned, to mentor them – mentor anybody correctly, in order for them to feel that they're contributing the most that they can to the care of the patient. I think there are other issues that we'll get into later and in different podcasts that come up that make physicians hesitant to have nurse practitioners or physician assistants. Some of those are financial, and I think we'll discuss those at a later time. But really, that shouldn't keep you from employing these particular individuals for your team. It really is a very rewarding type of practice to have. You're not alone. You're collaborating with other providers. I think it's just one of the great things that we do in oncology. Todd Pickard: I wanted to share a moment as a PA, advanced practice provider, when I most felt grateful for the opportunity to work as an advanced practice provider. My clinical practice has been in urology for the past 24 years for the main part. I've had a few little other experiences, but mainly urology, and I'll never forget a patient who was a middle-aged lady who had been working with transitional cell bladder cancer. It was superficial. So, the treatment for that is BCG and repeat cystoscopies and surveillance. And I walked into the room and I was going to give her BCG installation, and she was so angry. I wanted to know what was going on. I thought, gosh, should I make her wait too long or something else? So, I asked her, I said, ‘How are you doing today? You seem to be not feeling well.' And she said, ‘Well, I'm just so tired of this. I don't understand why y'all don't just fix me. Why don't y'all just get this right? Why do I have to keep coming back?' And as I looked at the medical record, this patient had had superficial bladder cancer for years. And I thought, ‘Has nobody ever really kind of sat down and mapped this out for her?' So, I asked her to get off the examining table, and I pulled the little paper forward, so I had someplace to draw. And I drew a big square and I said, ‘This is a field, just think of any big field anywhere near you. And it's full of weeds.' And I drew some weeds on there. And I said, ‘You know we can pull them out and we can pluck them, and we can put some weed killer in that field,' I said,  ‘do you think that if you come back in three months and there will be any weeds on that field?' She said, ‘Of course, there will be. There are always weeds because they always come back. It's very hard to get rid of.' And I said, ‘Well, this field is your bladder. And the type of cancer you have are like these weeds, and we have to constantly look for them, remove them, and then put this treatment down, that's why you come.' And she started crying. And I thought, ‘Well, I've blown it.' Because this was in the first couple of years of working as a PA in urology. And I said, ‘I'm so sorry. I really apologize.' She said, ‘Don't you dare apologize to me.' I said, ‘Man, I've really blown it now.' She said, ‘Todd, I've had this disease now for this many years. This is the first time I've ever fully understood what's happening to me. I am so grateful to you.' I will never forget this patient. I will never forget this experience. And I'm extraordinarily proud. It's not because I'm the smartest person in the world. I just happened to investigate, take the time, and I drew it out. I explained it in the simplest of terms because I wanted her to understand. And then whenever she came back, she always wanted to see me. So, it was great. I really developed a really lovely relationship with this patient. It was very rewarding. Wendy, can you think of a story that you have about an advanced practice provider that makes you particularly happy or where some big lesson was learned? Wendy Vogel: Yeah. I love your analogy. That's a great analogy. I think that part of what I love to do is similar to you, Todd, in that I like to make things understandable because I consider myself an East Tennessee southern simple person, I want to understand things in the language that I understand. So, I like using a language that a patient understands. I think if I was to say about some of the proudest things, or what makes me so excited about oncology is what we've seen in our lifetime. So, Todd, you and I practice probably about the same number of years and we could say we remember when Zofran came out, and how that revolutionized chemotherapy nausea and vomiting – Stephanie's nodding here, too. We all know that. And then wow! When we found out that we could maybe cure CML, that we're having patients live normal lives in our lifetime, that we've seen non-small cell lung cancer patients living past a year that are metastatic – Oh my gosh! This is such an exciting field and we learn something every day. There's new drugs, there's new treatments, there's new hope, every single day, and that's what makes me proud to be a part of that. Todd Pickard: Yeah, I think that oncology and the work that we get to do as a team is so incredibly rewarding. It's challenging, and we have losses, but we also have wins, and those wins are amazing, and transformative, not only for us but for our patients. So, some final pearls of wisdom. I'll share and then Wendy, I'll turn it over to you. One thing that I really want to convey to folks is to know about the state that you work in and what are the practice acts for advanced practice providers. Because, unlike our physician colleagues who have a very standard scope of practice across the country, advanced practice can drastically change from state to state and place to place even from institution to institution. So, be aware of that, so that you can build your team-based practice around what are the constraints, what is the scope of practice, and you can comply with that. It just takes a little bit of pre-work at the beginning. It's not daunting. These things are written in English. We're all smart folks. We can understand them and we can build our teams in the right way. So, just keep that in the back of their mind. It is not an obstacle. It's the instruction manual of how to build your team. That's all it is if you just think about it simplistically like that. So, Wendy, what's one or two things that you would say you really want our listeners to understand about advanced practice? Wendy Vogel: I loved what you said, Todd, both of our PA Associations and our Nurse Practitioner Associations have that information online, so it's very easy to find. But I think I would say, don't be afraid to stand up for yourself as an advanced practitioner or as a physician who wants an advanced practitioner. Don't be afraid to stand up for yourself and your scope of practice, know what you can do, know what you can't do, know and demand the respect that you deserve. I would always say that just don't forget that ‘no' is the first step to a ‘yes,' and keep on trying. Todd Pickard: I think we can all appreciate that sentiment, whether we be a PA an NP or a physician. Many times, we're advocating for our patients within our systems or our practices or with our payers or insurance providers. And yeah, sometimes you start from a place of ‘no' and then you work until you get to that ‘yes', or at least a compromise, if you can get to a 'maybe,' that's a good place too. Stephanie, any particular last words of wisdom or wrap us up with our conclusion? Dr. Stephanie Williams: Thanks, Todd and Wendy, for sharing your insights today. It's always a pleasure chatting with you both. Stay tuned for upcoming episodes where we plan to dig deeper into the various types of APPs, how they are trained, what a day in the life looks like for an oncology APP, their scope of practice, and the importance of team-based care, especially in oncology. Thank you to the listeners as well. Until next time. 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 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.  

Radiation and hormone therapy come with side effects, and while many people are willing to go through whatever it takes to make sure breast cancer is well and truly gone, a new study has shown there may be an easier way.

KSQD 6-15-2022: Recommendations for COVID-19 booster vaccine shots; Suboxone is an important drug to treat pain and opiate drug withdrawal; New studies examine the neurological effects of long COVID disease; Evaluation of toothpaste for temperature-sensitive teeth; Anti-aging supplement strategies are usually anti-inflammatory agents; Cortisol levels are lowered when people are exposed to dogs; What to do about my daughter's tick on her neck; Improve anti-aging benefit of walking exercise by using poles, called Nordic walking; Exercise tolerance is influenced by genetic profiles; Non-alcoholic beer is good for the microbiome; Partial gland ablation using ultrasound under MRI is a new treatment for intermediate-risk prostate cancer

Curly gets a middle of the night MRI. Mark starts a moving band. Jenelle has a 3:20 PM appointment.  TM2 S2 Ep3 Bonus Patreon.com/TrashTalkPodcast Traceycarnazzo.com Tracey Carnazzo @trixietuzzini Noelle Winters @noeygirl_ IG @TeenMomTrashTalk Twitter @TeenMomPodcast YOUTUBE: https://www.youtube.com/channel/UCIukjjTBWOoUezT7LMb9ppQ TM2 S2 Ep2 Bonus Patreon.com/TrashTalkPodcast Traceycarnazzo.com Tracey Carnazzo @trixietuzzini Noelle Winters @noeygirl_ IG @TeenMomTrashTalk Twitter @TeenMomPodcast hellofresh.com/trashtalk16 YOUTUBE: https://www.youtube.com/channel/UCIukjjTBWOoUezT7LMb9ppQ Dameproducts.com Code TEENMOM thrivecausemetics.com/teenmom

Welcome back to our weekend Cabral HouseCall shows!   This is where we answer our community's wellness, weight loss, and anti-aging questions to help people get back on track!   Check out today's questions:    Jenna: I just listened to your podcast explaining Inositol for blood sugar balance and improving insulin sensitivity. I don't have PCOS symptoms, but I do believe I am insulin resistant. However, I trend towards bouts of hypoglycemia once I get that blood sugar crash which happens frequently. I wanted to know if Inositol (or even the EquiLife blood gluco support) would be more beneficial or more harmful for someone dealing with hypoglycemia?   Emily: Hi dr Cabral! I lived in a place for a few years that sprayed insecticides frequently indoors. I now worry about what that could do to my health. Any suggestions on detoxing any harmful effects or anything I should test for?   Jenn: Hi Dr. Cabral, thank you for all you do. I am a huge fan of doing your seven day detox every quarter and have had great results. I was wondering what your thoughts are on Humic extract if you have worked with it and whether or not you find it helpful for gut health. Thank you so much.   Sean: What product for inositol do you recommend?   Stephanie: Hey Dr. Cabral, thank you so much for committing to taking the time to answer our questions. I'm a Vata 26 year old body type and I've had amenorrhea for over 3y since coming off birth control. I'm IHP L2, ran the big 5 labs, did all the protocols over a year ago, progesterone support, all that jaz. My symptoms have dramatically improved and the only issue I'm having is the lack of period. Went to top endocronologists, ran MRI, scans and everything is normal. An an IHP I know all of my hormones are low including estrogen. Took DHEA for 12 weeks as well, progesterone & estrogen support but nothing. It looks like it's an issue with the hypothalamus/pituitary itself whereby my LH is not high enough for me to ovulate thus functional hypothalamic amenorrhea. Eating plenty of calories, and have gained weight since to reach a BMI of 22 but nothing yet. Since I'm not in a rush to get pregnant, the endo recommended to just wait and see what happens but suggested taking a very very small dose of bioidentical estrogen to support bones in the meantime. What are your thoughts? I obviously don't want to take them but I'm concerned about my bones.   Stephanie: Me again! I forgot to mention that my TSH continues to go down which is very weird. I'm fully aware of the root causes as an IHP 2 and it's definitely not heavy metals, fluoride, lack of minerals, etc. It started at 2.3 and now is up to 3.3. Do you think this could due to the hypothalamic amenorrhea?   Thank you for tuning into today's Cabral HouseCall and be sure to check back tomorrow where we answer more of our community's questions!    - - - Show Notes and Resources: StephenCabral.com/2325 - - - Get a FREE Copy of Dr. Cabral's Book: The Rain Barrel Effect - - - Join the Community & Get Your Questions Answered: CabralSupportGroup.com - - - Dr. Cabral's Most Popular At-Home Lab Tests: > Complete Minerals & Metals Test (Test for mineral imbalances & heavy metal toxicity) - - - > Complete Candida, Metabolic & Vitamins Test (Test for 75 biomarkers including yeast & bacterial gut overgrowth, as well as vitamin levels) - - - > Complete Stress, Mood & Metabolism Test (Discover your complete thyroid, adrenal, hormone, vitamin D & insulin levels) - - - > Complete Food Sensitivity Test (Find out your hidden food sensitivities) - - - > Complete Omega-3 & Inflammation Test (Discover your levels of inflammation related to your omega-6 to omega-3 levels) - - - Get Your Question Answered On An Upcoming HouseCall: StephenCabral.com/askcabral - - - Would You Take 30 Seconds To Rate & Review The Cabral Concept? The best way to help me spread our mission of true natural health is to pass on the good word, and I read and appreciate every review!

Videos: 1. Agenda 2030 and the World Economic Forum Plan to Remake the World: Alex Newman (26:00) 2. Pfizer Docs Reveal 800 People Never Finished Trial Due To Death Or Injury (4:39) 3. Vaccines, what are they good for? – Dr Sam Bailey (19:00)  4. Bodily Autonomy is Only Supported When Coupled With The Abortion Agenda (1:00)  5. New Rule: The Misinformation Age | Real Time with Bill Maher (HBO) 6. George Carlin – It's A BIG Club & You Ain't In It!    Active Component of Grape Seed Extract Effective Against Cancer Cells University of Colorado Cancer Center, June 13 2022  A University of Colorado Cancer Center study published online ahead of print in the journal Nutrition and Cancer describes the laboratory synthesis of the most active component of grape seed extract, B2G2, and shows this synthesized compound induces the cell death known as apoptosis in prostate cancer cells while leaving healthy cells unharmed. “We've shown similar anti-cancer activity in the past with grape seed extract (GSE), but now we know B2G2 is its most biologically active ingredient which can be synthesized in quantities that will allow us to study the detailed death mechanism in cancer cells,” says Alpna Tyagi, PhD, of the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. The group pinpointed B2G2 as the most active compound, but, “it's expensive and it takes a long time to isolate B2G2 from grape seed extract,” Tyagi says. This expense related to the isolation of B2G2 has limited the group's further exploration. So instead of purifying B2G2 from GSE, the group decided to synthesize it in the lab. The current study reports the success of this effort, including the ability to synthesize gram-quantity of B2G2 reasonably quickly and inexpensively. In the paper's second half, the group shows anti-cancer activity of synthesized B2G2 similar in mechanism and degree to overall GSE effectiveness. Improving Memory Naturally: Sage Contains Similar Compounds as Modern Alzheimer's Drugs Newcastle and Northumbria Universities, June 14 2022 Sage was named “Herb of the Year” in 2001 by the International Herb Association.  Some of the latest research shows how sage can boost memory and cognitive health. The leaves and stems of sage contain these antioxidant enzymes that protect against free radical oxidative cell damage as well as provide inflammatory relief from ailments such as arthritis and asthma. The Medicinal Plant Research Centre (MPRC) of England conducted studies at Newcastle and Northumbria Universities with sage oil herb pills against placebo pills. Those who took the sage performed much better with a word recall test than those who took the placebo.  In the long run, home-made tinctures are the most economical way to have and use highly effective tinctures for a long time.  Trade the chair for fresh air: Study explores link between sitting time and cardio health Simon Fraser University (Canada), June 15 2022 New research is adding further weight to the argument that prolonged sitting may be hazardous to your health. An international study surveying more than 100,000 individuals in 21 countries found that people who sat for six to eight hours a day had a 12–13 percent increased risk for early death and heart disease, while those who sat for more than eight hours daily increased that to a sobering 20 percent. Their research followed individuals over an average of 11 years and determined that high amounts of sitting time were associated with increased risk of early death and cardiovascular disease.  Not surprising, those who sat the most and were the least active had the highest risk—up to 50 percent—while those who sat the most but were also the most active had a substantially lower risk of about 17 percent. “For those sitting more than four hours a day, replacing a half hour of sitting with exercise reduced the risk by two percent,” Lear notes. “With only one in four Canadians meeting the activity guidelines there's a real opportunity here for people to increase their activity and reduce their chances of early death and heart disease.” Acupuncture Can Treat Alzheimer's Disease Hubei University of Chinese Medicine (China), June 5, 2022  An increasing number of clinical and animal studies have confirmed that acupuncture is effective for the treatment of Alzheimer's disease. Moxibustion is reported to be more effective than electro-acupuncture for improving space-recognizing memory ability in aged mice, suggesting that moxibustion is another alternative or complementary therapy used to treat Alzheimer's disease. Dr. Yanjun Du and team from Hubei University of Chinese Medicine, China only used suspended moxibustion (also named warming moxibustion, scarring moxibustion, or herb-partition moxibustion) on Baihui and Shenshu  acupoints to observe the action of pre-moxibustion on preventing apoptosis in a rat model of Alzheimer's disease. The pre-moxibustion group was treated with moxibustion for eight courses (each course lasting for 6 days) prior to the exposure and 14 days after Aβ1–42 exposure.  Moxibustion prior to Aβ1–42 exposure was more effective than moxibustion after Aβ1–42 exposure in protecting the neuronal structure and lowering the apoptosis rate. Their findings indicate that a combination of preventive and therapeutic moxibustion has a beneficial effect for the prevention of Alzheimer's disease development. Men and women with brain condition could be helped by vitamin E Cangzhou Central Hospital (China), June 15 2022.  Leukoaraiosis is an abnormality in the brain's white matter that appears on magnetic resonance imaging (MRI) as white matter hyperintensities. In an article published in the International Journal of Neuroscience, researchers at Cangzhou Central Hospital in Hebei, China reported improvements in factors related to leukoaraiosis among adults given supplements containing vitamin E. “Leukoaraiosis (LA) is a disease manifested by demyelination and gliosis in white matter, mainly caused by cerebrovascular diseases,” Yan Wang and colleagues wrote.  “Leukoaraiosis is closely related to the expression level of inflammatory factors, oxidative stress, and vascular endothelial dysfunction in patients. Vitamin E may play antioxidant and anti-inflammatory roles in various diseases.” Participants received 200 IU, 400 IU or 600 international units (IU) vitamin E or a placebo daily for 12 weeks. At the end of the treatment period, blood samples were evaluated for the inflammatory factors C-reactive protein, complement C3 and C4, and matrix metalloproteins 2 and 9, as well as for markers of oxidative stress and endothelial function (function of the lining of the arteries, which is impaired in cerebrovascular and cardiovascular disease). Inflammation, oxidative stress and endothelial function improved in all groups that received vitamin E in comparison with the placebo. Cognitive function scores also significantly improved in the vitamin E-treated groups. Improvement in all measured factors was correlated with higher doses of vitamin E. Chlorogenic acid plus chromium improves insulin resistance and lowers obesity in mice University of Toledo, June 10 2022 In an article published in Nutrition & Metabolism, University of Toledo researchers report that a combination of chromium and chlorogenic acid (CGA), a polyphenol occurring in coffee, reversed the development of obesity and insulin resistance in mice caused by the intake of a high-fat diet. Sonia M. Najjar and her associates fed male BL6 mice a standard diet or a high-fat diet for seven weeks. During the last three weeks of the diet, the high-fat group received a daily oral supplement containing water, chlorogenic acid, or a combination of chlorogenic acid and chromium in a base that contained caffeine. Body weight was measured weekly, insulin tolerance was assessed at four and seven weeks, and glucose and glucose tolerance were assessed at the end of the treatment period. At four weeks, animals supplemented with chlorogenic acid and the combination of chlorogenic acid and chromium experienced weight loss within two weeks, and attained weights comparable to those of animals that received a standard diet. While insulin resistance after four weeks was greater among high-fat diet-fed mice compared to those fed a standard diet, supplementation with chlorogenic acid plus chromium reduced this effect, and restored it to a level comparable to that of standard-diet-fed mice. Glucose tolerance and glucose levels were similarly restored in animals that received the supplement combination. 

In a Hectic Life, Systems Keep You Sane In a world full of chaos, systems keep you sane. Music by Tommy Walker My weekly newsletter is on Substack (download here for Apple, coming soon for Android/Google). It will still come to your inbox via email, so if you don't want to use the app, you'll still be good!Substack combines all the things I'm doing online into one place, gives me the opportunity to bring additional content to paid subscribers, and will make my online life a lot more efficient.You can sign up for my Substack letter here. (Note: There are options to sign up for free, or to become a paid subscriber in this link. The normal newsletter will always be free!)   (Music shared on The Dr. Lee Warren Podcast is authorized under BMI license #61063253 and ASCAP license #400010513 )   Go to my website www.wleewarrenmd.com for more information about my letter, this show, my books, and more.   John to Know, James to Grow bible study   Transcript: Hey friend, have you ever lost your keys? It's an irritating way to start the day. You can't find your car keys. You already lost your spare set, so you have to search your house, you finally find them in the pants you wore yesterday, and by the time you get to work, you're ten minutes late. And that morning, you had a big meeting. Since you were late, the boss gave a sale to your rival, who you were trying to beat for associate of the quarter, and you really needed that bonus. You get to your desk, and spend an hour looking for the folder you need for your conference call, and finally remember that you left it in the copy room yesterday. When you get there, it's buried under a stack of other stuff and it takes you ten minutes to find it. You're now five minutes late to the conference call, and as a result the manager tells you she's going a different direction on the project. Your whole day is shot, because of lost keys and misplaced folders. Does this sound familiar? If so, this episode is for you. I've got a question for you: What's your system? What's your strategy for getting things done in the most efficient way, always having the things you need to do your work and live your life?  I'm going to tell you twelve reasons why you need to be more organized, and then I'm going to share six secrets to developing life-proof systems to help you avoid days like the one we just talked about. Disorganization and chaos can make our lives much more stressful than they already are. And who wants that? I'm here to tell you, friend: in my world I cannot survive without a solid organizational plan. Why? Because systems keep you sane. I need to confess that as intelligent as I am, as accomplished as I am, at my baseline my mind is a disorganized mess. I struggle with being easily distracted, and I learned a long time ago that if I was going to be successful, I had to get organized. Now I'm not alone in this. In fact, a huge percentage of type-A, hyper-performing people have what today is called "Adult ADD." When I was a kid, the teachers called us 'hyperactive,' but fortunately I had parents and teachers who were wise enough to let me be myself. They never let me feel like something was wrong with me because I paced a lot, tapped my pencil when I had to sit still for a long time, or seemed to be distracted when they were trying to teach me. Instead of assuming I wasn't listening, they learned to say, "Did you hear me?" And I had, every time. I just didn't need to look at them to hear. The big surprise for me was when I got to medical school and found myself in a school full of people just like me. Parents, be patient with your kids, learn how they learn, and try to maximize their opportunities before you let someone label or medicate them when they're not acting exactly like everyone else. Sure, some people need help and have real problems with learning and behavior.  But a lot of folks just need to develop a system to manage their minds, their lives and their behaviors.  If you struggle with keeping your mind on track long enough to get off to work without forgetting your cell phone, then you need a system.  If you have a hard time focusing on one task because a lot of things are vying for your attention, you need a system. If you feel like you waste a lot of time during the day, and you're not as productive as you need to be, you need a system. It's really cute when your five-year-old forgets something and shrugs, smiles adorably, and asks for your help. It's not cute when your classmate has to borrow your calculator, every day. Or when your forty-five-year-old lawyer gets to your deposition and forgot your case files. Systems keep you sane. For me it works like this: I put everything I need to have with me in the same place, every day. My keys, glasses, wallet, watch, anti-Zombie spray, and hand grenades in a certain place, all together, every day when I get home from work. I'm just kidding about the hand grenades. Those are illegal. But seriously, all my stuff is right next to my sock and underwear drawer, and unless I want to leave the house without underwear and socks on, all my important stuff is right in front of me where I'd have to work hard to forget it.   I promise, if I ever get out of sequence in how I dress, or if I leave my wallet somewhere else, I will absolutely get to work without it. What's amazing to me is how I can literally have no idea I've forgotten my wallet, and then as soon as I realize it my brain can absolutely feel its absence in my pocket. I'll feel my not-wallet in there like a splinter under my skin until I go home and get it.  Why don't I feel the not-wallet sensation until later in the day when I need my wallet? No idea. But it's true.  No system, no wallet. Or keys, etc. The same thing is true at work. If I don't discipline myself I'm the total absent-minded professor. I'll get to surgery without my MRI scans, with no prescription pad, and my reflex hammer is still in the car. It's true. I have learned of myself over the course of my life that if I do not enforce a strict organizational system I am stunningly capable of Alzheimer's-level forgetfulness. Listen: if you struggle with disorganization, frequently forgetting things, not having what you need, etc., you need systems. As Henry Kissinger said, if you don't know where you're going, every road will lead you nowhere. Systems keep you sane. Here are twelve reasons you need systems: (These were inspired by a great article on evancarmichael.com) 1. Systems help you be more focused on what you want to achieve. You can stop getting sidetracked by the things you forgot and instead keep knocking out the things you need to do. 2. Systems help you be more productive. You increase your brain power by eliminating a lot of stuff you've always worried about- you'll know where things are, when things need to happen, and you'll have a system in place to keep track of your work and your life. 3. Systems help you manage your time more effectively.  4. Systems help you do your work more economically. No more rushing out on the business trip to replace the cell phone charger you left at home. 5. Systems help you reduce the clutter in your workspace and reduce your stress levels. Systems improve your brain chemistry. 6. Systems help you achieve more balance in your life. 7. Systems help you set and achieve your goals in a more efficient manner. 8. Systems help you present a more positive business image. Scrub techs have amazing systems to prepare for a case. Imagine a scrub that didn't strategically design how they prepared the instruments for your brain surgery. Chaos... when I see a messy scrub tech, I look for a new one.  9. Systems help you prioritize your tasks. 10. Systems help you be more flexible and more creative. Your brain power isn't being sapped by worrying where you left your briefcase, so it's got the juice to think up new things. 11. Systems help you achieve more energy and enthusiasm. Confidence soars when you know you're squared away. 12. Systems help you achieve freedom from chaos.  Doesn't it sound like you need systems in your life? I hope by now that you're convinced that developing and maintaining organizational systems will help your life. Now we know the why, and I'm going to give you the how. Here are my six secrets to developing life-proof systems: 1. Create backups for things you need. I have a 'go bag.' It's a bag full of stuff that will ruin a trip if we forget it. It's got backup power cords for our phones, certain medicines and supplies that will get us through a couple of days if the airline loses our bags or if somehow I forget something. It stays in my carryon bag all the time, and if I ever have to use it, I immediately make a note to myself with a calendar reminder to replace the used item. This might sound silly, but the first time you have a lost bag or a migraine or an allergy attack in a distant town where you can't get to a pharmacy, you'll thank me. It's a backup, to my tendency to forget some things, and to protect us from someone else losing our luggage. Of course, this does not only apply to travel. If there's anything that your successful day at work depends on, your safety or happiness is frequently at risk over, etc., build a system with backups to handle it. I'm not saying that you should keep blank anniversary, birthday and Valentine's Day cards in your sock drawer in case you forget... but could that sort of thing save the day for you once in a while? It's part of my system to have a backup in place. Don't just have a plan A. Life is too great of an offensive coordinator for you to think that you can run the same play over and over and win. You have to be ready, and backups help a lot. 2. Create failsafes for important data. This sounds similar, but it's different. Failsafes are subsystems I put in place in case of some major problem arising. If I'm giving a talk, what if the computer doesn't have the right kind of port for my memory card? I have a failsafe: all my books, talks, blog posts, everything I write is backed up online via Dropbox.com, and on an external hard drive I can take with me in case my laptop decides to die, and on my computer's hard drive and an SD card. Sounds excessive, until you've given enough talks to know that sometimes you get somewhere and their WiFi isn't working so you can't get to Dropbox, your computer is a Mac and they don't have the right connections for the projector, even though they said they would, and their old Dell laptop doesn't have an SD card slot. Failsafe: my presentation is also on a USB hard drive, so we're still good. Oh, and POW, they don't have Keynote on their PC, so my presentation isn't compatible! Disaster? No. I also saved in Powerpoint format in case I ran into any dinosaurs, I mean PC people who haven't yet seen the Keynote light... Failsafes keep you from, well, failing. They're an essential part of the systems that keep me successful at all times. And no just with data. Can you think of areas of your life that would be improved if you implemented backups and failsafes?  3. Use repetition to create synapses, muscle memory, improve brain power by removing conscious thought from frequently needed items/tasks/etc. 4. Never rely on memory. It's unreliable, no matter how smart you are. Make checklists, and develop a discipline and practice of using them. Save your brain for the important stuff, not remembering the toothpaste. Set phone alarms. If you use Gmail, you already have a free calendar that will send you alerts on your cell phone. Why keep letting the same issues hold you back? Use systems. 5. Use Evernote. In this day and age, it's silly to keep bumping into the same problems over and over again when there are so many, and often free, powerful tools to help us organize our lives.  I use Evernote everyday. It's the note keeping, digital information organizer that's made a huge difference in my life. Even the free version is super-powerful. Lisa and I use the pro version and it's awesome. I actually write podcasts and blog posts in Evernote first. It syncs across all my devices, works offline, and saves me tons of frustration. Check it out at Evernote.com. Michael Hyatt has a vast number of blog posts about how to maximize Evernote to help you. Please do yourself a favor and check them out.  6. Care about it. The most important aspect of successfully implementing systems into your life is to care that you don't forget things. To have it bother you when you're late, when you can't find something, or when you underperform because you had to scramble to manage something a system would have prevented. Let me tell you a secret: my systems kept me alive and kept our business running when my son died. I have so much of the mechanical parts of my life systematized that in those months after we lost Mitch, I didn't have to think about where my keys were. Muscle memory kept me hanging them in the same spot, reaching for them the next day without having to think about it. I didn't have to wonder where my prescription pad or coffee cup were, or my when my bills were going to be paid, or anything like that, because of having systems in place. In those weeks when all we could do was breathe in and out, having the calendar pop up and remind me to pay the mortgage was a lifesaver. Systems keep you sane. They can save your life.  We're grownups now, and it's time to stop struggling over things that can be automated and systematized.  Systems keep you sane and they set you free. And let me just add this: Not having a system IS a system. It's just a terrible one. Now you might be wondering what all this has to do with starting today? I'm glad you asked.  1. Past losses can teach us, but they can't define us. Labels are rarely true, and when they are, they can be changed. "That's just the way I am," isn't cute anymore when it costs you your job. We aren't stuck with "I'm just ADD, and it makes me forgetful," or "I'm just a messy person." It if keeps hurting you, change it. 2. Massive change requires massive action. It takes at least three weeks to make a new habit. If you want to make a system that will really stick in your life and make a difference, you have to massively engage with it. It won't set in and become a part of your life if you don't fully embrace it. 3. If you want to feel better, do better.  If you're really tired of the consequences of being disorganized, stop wallowing in it. Change it with systems, backups, failsafes, lists, software. Care about it. 4. Peace is achievable in spite of circumstance. No matter what, if you divorce circumstance and marry the idea that you get to decide how you feel, you'll be happier.  Decide, purpose in your heart that disorganization and chaos are NO LONGER ACCEPTABLE TO YOU, Embrace the peace systems offer you. Embrace the sanity of systems. 5. The time to start is today. You start today. You can't change yesterday, and you can't control tomorrow. But you can decide that today you will become more organized and therefore more successful in your life.  Someone I love recently said, "Creative types are just messy people. It's how we are." I would submit to you, dear one, that organized, disciplined systems in your life, including housekeeping, cleanliness, orderliness in how your life and your things and your work environment will lead you to having more available brain power to be creative. It will improve your work and your life. Systems keep you sane. My friend, if you're not using systems, you're leaving a lot of your life on the table.  I hope this conversation has motivated you to look for places in your life where you can be more systematized. But motivation is useless unless you act on it.  Take massive action. Systems will help your brain, help your heart, and keep you sane. Take massive action. Embrace systems in your life. Get Evernote. Make lists, set alarms, automate things. Take massive action.  Stay safe, get smarter, and keep your sanity by embracing the idea that systems keep you sane. And start today. If you want to become healthier, feel better, and be happier, you have to start today. (Updated YST034 from the old You Start Today Podcast)

Radiologists are describing a crisis across the country of short staffing, old scanning machines and millions spent on outsourcing. The extra taxpayer dollars being spent sending outpatients for private CT, MRI and ultrasound scans, are not necessarily denting the public hospital queues. Phil Pennington reports.

On Episode 17 of the Stroke Alert Podcast, host Dr. Negar Asdaghi highlights two articles from the June 2022 issue of Stroke: “Vitamin D Enhances Hematoma Clearance and Neurologic Recovery in Intracerebral Hemorrhage” and “Acute Ischemic Stroke, Depressed Left Ventricular Ejection Fraction, and Sinus Rhythm: Prevalence and Practice Patterns.” She also interviews Dr. Bruce Campbell on his article “Role of Intravenous Thrombolytics Prior to Endovascular Thrombectomy.” Dr. Negar Asdaghi:         Let's start with some questions. 1) Is vitamin D that golden key to recovery from intracerebral hemorrhage? 2) Endovascular therapies seem to have prevailed where thrombolytics have failed. In the era of fast and furious thrombectomy, what is the role of pre-thrombectomy thrombolysis? 3) And finally, 20 years of clinical research has failed to demonstrate the superiority of anticoagulation over antiplatelet therapies for treatment of patients in sinus rhythm with low left ventricular ejection fraction, and yet, our practice patterns have not changed. Why do we remain resolute in prescribing anticoagulation despite the lack of evidence? We're back here to tackle the toughest questions with our Stroke Alert Podcast because this is the latest in Stroke. Stay with us. Dr. Negar Asdaghi:         Welcome back to another extremely motivating 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 June 2022 issue of Stroke contains a number of interesting articles. As part of our Advances in Stroke, we have two articles, one on the topic of cost-effectiveness of stroke care to inform health policy and the second on the current state and the future of emerging stroke therapies. As part of our Original Contributions category, we have an interesting study by Dr. [Ben] Assayag and colleagues from the Department of Neurology at Tel Aviv Sourasky Medical Center, where we learned that just over 10% of patients with TIA and stroke developed post-traumatic stress disorder, or PTSD. Higher presenting stroke severity, preexisting white matter disease, and having anxious coping styles are risk factors for development of post-stroke PTSD. Dr. Negar Asdaghi:         In another Original Contribution, by Dr. Daehoon Kim and colleagues from Yonsei University College of Medicine in Seoul, South Korea, we read with interest on the topic of whether or not we should be anticoagulating frail patients with atrial fibrillation. In this large population-based cohort, which included patients with atrial fibrillation older than 65 years of age with frailty as defined by a score of equal or greater than five on Hospital Frailty Risk Score, we learned that despite their frailty, patients with atrial fibrillation still significantly benefit from oral anticoagulation therapy. In this study, those treated with anticoagulation had lower net adverse clinical events as compared to those untreated. We also learned that direct oral anticoagulants provided lower incidence of stroke, bleeding, and mortality over Coumadin. This paper really provided practical information on treatment of frail patients with atrial fibrillation. So, I encourage you to review these papers in addition to listening to our podcast today. Later in the podcast, I have the great pleasure of interviewing Dr. Bruce Campbell from University of Melbourne in Australia on an especially timely topic, that is the role of intravenous thrombolytics prior to endovascular therapy. Dr. Campbell is a leading authority on the topic, and his interview does not disappoint. But first, with these two articles. Dr. Negar Asdaghi:         In the setting of intracerebral hemorrhage, or ICH, aside from the primary brain insult that occurs at the time of hemorrhage, secondary brain injuries continue for days and sometimes to months mostly due to the pathological response of the brain to byproducts of hematoma lysis or RBC degradation products. Today, the majority of spontaneous ICH cases are not surgically evacuated, so we rely on the body's own ability to clear blood for hematoma clearance, and obviously the faster the clearance, the better the outcome. Erythrophagocytosis by monocyte-derived macrophages contributes to hematoma clearance and ultimately to the functional recovery from ICH. So, it's conceivable that therapeutic approaches to enhance the endogenous erythrophagocytosis can potentially improve ICH outcomes. Vitamin D has been known to have variety of functions within the central nervous system, and it turns out that it may also be one such therapeutic option to improve the much needed erythrophagocytosis in intracerebral hemorrhage. Dr. Negar Asdaghi:         In the current issue of the journal, in the study titled "Vitamin D Enhances Hematoma Clearance and Neurologic Recovery in Intracerebral Hemorrhage," a group of researchers led by Dr. Jiaxin Liu from the Department of Surgery at Queen Mary Hospital at the University of Hong Kong studied the effects of oral vitamin D administered two hours after the induction of hematoma in a rodent model of ICH using direct collagenase injection into the striatum of the mouse. Eighty-nine young mice and 78 middle-aged mice were included in the study and randomly divided into three groups. Group one were sham-operated mice; group two, ICH mice treated with vehicle, which was corn oil; and group three, vitamin D-treated ICH mice. In the third group, 1000 international unit per kg of vitamin D diluted in corn oil was administered orally using a pipette two hours after the induction of ICH to mice, and then daily afterwards. And here are their top three findings of this study. Dr. Negar Asdaghi:         Number one, vitamin D-treated mice did better than vehicle on two neurobehavioral tests that were completed in the study. On the cylinder test, treatment with vitamin D significantly alleviated the asymmetric usage of four limbs at day seven, and vitamin D elongated the duration that the mice could run on the accelerated rod at day 10 on the rotarod test. Dr. Negar Asdaghi:         Number two, in terms of hematoma resolution and perihematoma edema, it's an issue that we deal with, with ICH, they used MRI imaging for edema measurement on T2-weighted images, and then sacrificed the mice and used digital quantification of hematoma volume with fresh brain specimens. And they found that treatment with vitamin D significantly alleviated both the ICH-associated brain swelling on MR and resulted in significant reduction in hematoma volume on the fresh brain specimens when compared with the vehicle-treated group at day three and day five. Dr. Negar Asdaghi:         And finally, their third main finding is in terms of erythrophagocytosis. So, the pathway that is mediated by the monocyte-derived macrophages is an endogenous pathway, that is, PPAR-γ (which stands for peroxisome proliferator-activated receptor γ) and its downstream scavenger receptor CD36 mediated. This pathway is essential for directing the endogenous erythrophagocytosis. Using flow cytometry, they found that vitamin D-treated mice had more mature macrophages expressing the scavenger receptor CD36, which was not expressed by the undifferentiated monocytes. Dr. Negar Asdaghi:         Western blot analysis confirmed that vitamin D treatment increased the tissue levels of CD36 and the upstream PPAR-γ levels in the brain at day five after collagenase model. Locally, vitamin D-enriched phagocytes that were positive for PPAR-γ and CD36 in the perihematoma regions. So, in summary, vitamin D increased the number of mature macrophages rather than undifferentiated monocytes in the perihematoma region and accelerated the differentiation of reparative macrophages from bone marrow-derived monocytes. So, bottom line is that in vitamin D, we have a simple, accessible, and well-tolerated agent to improve both the ICH outcomes and enhance hematoma resolution, but this we all observed in rodents. So, we stay tuned with interest to find out whether the same success will be seen in humans treated with vitamin D after intracerebral hemorrhage. Dr. Negar Asdaghi:         Patients with depressed left ventricular ejection fraction, or low EF, are at risk of development of ischemic stroke even if they remain in sinus rhythm. The optimal antithrombotic treatment for these patients is still unknown. Over the past two decades, we have a number of randomized trials studying the efficacy of oral anticoagulation, predominantly Coumadin, over aspirin therapy in prevention of all forms of stroke, that is ischemic and hemorrhagic, and death in patients with a low EF in sinus rhythm. Dr. Negar Asdaghi:         The meta-analysis of WASH, HELAS, WATCH, and WARCEF trials showed that treatment of low ejection fraction patients in sinus rhythm with Coumadin does reduce the subsequent risk of stroke, but it comes at the cost of a higher major bleeding risk in this population. The COMMANDER HF clinical trial published in New England Journal of Medicine in October 2018 studied whether low-dose rivaroxaban at 2.5 milligram BID was superior to placebo in patients with recent worsening of chronic heart failure, reduced ejection fraction, coronary artery disease, but no atrial fibrillation, and very similar to its prior counterparts, it did not show that rivaroxaban was associated with a lower rate of combined death, myocardial infarction, or stroke as compared to placebo. But very similar to prior studies, it also showed that rivaroxaban-treated patients had a lower risk of subsequent ischemic stroke. This poses a conundrum for stroke neurologists treating patients with this condition, especially after they present with an embolic-appearing stroke. So, the question is, how often do we encounter this situation, and what do we do in routine practice? We know that when there is equipoise, there's practice variation. Dr. Negar Asdaghi: In the current issue of the journal, in the study titled "Acute Ischemic Stroke, Depressed Left Ventricular Ejection Fraction, and Sinus Rhythm," Dr. Richa Sharma from the Department of Neurology at Yale School of Medicine and colleagues examined the prevalence of heart failure with sinus rhythm among hospitalized patients with acute ischemic stroke and the physician's practice patterns with regard to the choice of antithrombotics in this population. Dr. Negar Asdaghi:         So, let's look at their study. The study was comprised of five separate study cohorts of hospitalized acute ischemic stroke patients in the Greater Cincinnati Northern Kentucky Stroke Study for the year 2005, 2010, and 2015, and then four additional academic hospital-based cohorts in the United States during different timeframes. These were the Massachusetts General Hospital from 2002 to 2016, Rhode Island Hospital from 2016 to 2018, Yale-New Haven Hospital 2015 to 2017, and Cornell Acute Stroke Academic Registry from 2011 to 2018. All of these cohorts combined contributed to the 19,155 total number of patients in this study, which included over 14,000 patients that had documented left ventricular ejection fraction. Amongst those, 1,426 had a depressed EF and were included in this study. The investigator obviously excluded those with documented atrial fibrillation and flutter. And so the sample size for this analysis was 805 patients. And here are their main results. Dr. Negar Asdaghi:         The overall prevalence of this condition, that is low ejection fraction and sinus rhythm, among hospitalized acute ischemic stroke patients was 5%. It varied slightly between the different cohorts in this study from 4 to 6%. In terms of the antithrombotic treatment patterns, this information was available in close to 500 patients in the cohort. Overall, 59% of patients were discharged on an antiplatelet treatment alone, and 41% on anticoagulation. But these percentages significantly varied between the different institutions and was as low as 22% in one of the cohorts and as high as 45% in another cohort. Dr. Negar Asdaghi:         So, what were the factors that were associated with the use of anticoagulation at discharge? They found that the absolute percentage of left ventricular ejection fraction and the presenting NIH Stroke Scales were associated with anticoagulation use. That is, the lower the percentage of EF and the higher the presenting NIH Stroke Scale, the more likely physicians were to discharge the patients on an anticoagulation in univariate analysis, but in multivariate analysis, only the study site and presenting NIH Stroke Scale over eight were independently associated with anticoagulation use. Dr. Negar Asdaghi:         Now, interestingly, 2002 to 2018, which was their overall study period, was a time during which some of the largest and neutral randomized trials on the topic of anticoagulation versus antiplatelet were published, including the WATCH and the WARCEF trial. But the authors found no temporal variation in anticoagulation practice patterns before and after the publication of the results of these trials. So, it appears that we didn't change our minds. So, overall, we have some important takeaway messages from this study. We learned that 5% of hospitalized acute ischemic stroke patients have low left ventricular ejection fraction and remain in sinus rhythm without atrial fibrillation. Today, over 40% of patients with this condition are anticoagulated at discharge despite the results of the randomized trials, but the practice is widely variable among different institutions, and a higher presenting NIH Stroke Scale is a significant predictor of anticoagulation use at discharge in this population. Dr. Negar Asdaghi:         Almost 20 years after the approval of intravenous thrombolysis for treatment of patients with acute ischemic stroke, endovascular therapy was approved for treatment of select ischemic stroke patients with a large vessel occlusion. The two treatments are, therefore, entangled, as one was the standard of care while the second one was being tested. Therefore, all endovascularly treated patients enrolled in randomized trials would've received intravenous thrombolysis if eligible. Now, with the overwhelming success of endovascular therapy in achieving reperfusion in areas where IV thrombolysis has drastically failed, there're still critical questions regarding the added value of IV thrombolysis to endovascularly treated patients. The critical question remains as to whether eligible ischemic stroke patients who have immediate access to endovascular thrombectomy should receive prior IV thrombolysis, or should we skip the thrombolysis step altogether and just move to the angio suite as fast as possible. And there are, of course, arguments for and against each approach. Dr. Negar Asdaghi:         In this issue of the journal, in an invited topical review titled "The Role of Intravenous Thrombolytics Prior to Endovascular Thrombectomy," we learn about these arguments as the authors go through a comprehensive review of the current literature on this issue. I'm joined today by the first author of this review, Dr. Bruce Campbell, to discuss this paper. Dr. Campbell absolutely needs no introduction to our Stroke listeners. He's a professor of neurology and head of neurology and stroke at Royal Melbourne Hospital, University of Melbourne, in Australia. He's a pioneer in the field of acute stroke therapies and acute neuroimaging. He has served as the lead investigator of multiple landmark randomized trials, including EXTEND-IA and EXTEND-IA TNK, and holds multiple leadership roles. He's the clinical director of the Stroke Foundation and co-chairs the Australian Stroke Guidelines Working Party and the coordinator of the National Brain School Training Program for Neurologists in Training. And, of course, last but not least, he's my friend. So, I'm delighted to welcome him to our podcast today. Top of the morning to you, Bruce, 6:00 a.m. in Melbourne. That's quite some dedication. Thank you for being here. Dr. Bruce Campbell:       It's great to be with you. Thanks for the invitation. Dr. Negar Asdaghi:         Congrats on the paper, really exciting topic. So, let's just start with this question as part of a case. We have a patient with an M1 occlusion, a large clinical syndrome presenting two hours out from their symptom onset, and we are at a hospital where the angio suite is ready. What are some of the benefits of basically spending time in giving IV thrombolytics first rather than quickly going to the angio suite? Dr. Bruce Campbell:       I think a key element of this case is that the patient has presented directly to a hospital with immediate access to thrombectomy. Thrombolytic used in drip-and-ship transfer patients really isn't controversial, and the recent randomized trials excluded them. So, the debate's all about this context of bridging thrombolytics in patients presenting directly to a comprehensive stroke center. And you mentioned spending time giving lytics, but in fact, if you do things in parallel, that shouldn't be the case. It shouldn't delay thrombectomy if you go and give thrombolysis. Dr. Bruce Campbell:       So, the general principle is that getting the artery open faster by any means is better, and IV thrombolytic certainly has the potential to open the artery before thrombectomy in a proportion of patients, perhaps not that many, but it may also facilitate the thrombectomy. So, in the randomized trials, reperfusion after the thrombectomy was significantly better when patients had had bridging thrombolytic despite a low rate of pre-endovascular reperfusion. Other reasons for giving the lytics are the potential safety net it provides if the thrombectomy procedure is unexpectedly delayed or fails to get the artery open, and there's also this potential for lytics to dissolve distal embolic fragments and perhaps improve microvascular reperfusion. Dr. Negar Asdaghi:         So, great. So, let me summarize for our listeners what you mentioned. First off, so these are arguments in favor of giving lytics. As you mentioned, we're not really wasting time. These processes occur in parallel, so it's not like we're wasting time in giving a therapy that is potentially not as efficacious as thrombectomy is. And number two, we have improved the possibility of early reperfusion, perhaps, with the lytics. And if there are some fragments or distal clots that thrombectomy wouldn't have reached, then the lytics would. And then also there is also the chance that the thrombectomy might have failed in difficult access, and so on and so forth, and at least the patient has some chance of revascularization with the lytics. So, if these are the arguments for giving lytics, what are the arguments against giving lytics in this scenario? Dr. Bruce Campbell:       The main argument is the potential to reduce both the intracerebral and systemic hemorrhagic complications. There's also potential cost saving by skipping thrombolytics. That's probably more relevant in low-resource settings, particularly when relatives may have to pay for the thrombolytic before treatment is initiated, and that can be burdensome and also potentially delay the thrombectomy. There's a theoretical concern about thrombus fragmentation with lytics and potential migration of the clot out of reach of the thrombectomy or to new territories. But final reperfusion, as I mentioned, was, on average, better with the patient having a lytic on board in the randomized trials. Dr. Negar Asdaghi:         Perfect. And I want to highlight this issue of thrombus fragmentation because I think our readers will read more and more about this idea of, as you mentioned, fragmentation will potentially make an accessible clot for thrombectomy inaccessible. But I see that later in our questions, we're going to address that as part of the findings of randomized trials as well. So, these are some of the arguments for and against. And before we go to the randomized trials, I'd like to get an overview of what we knew as part of observational studies and non-randomized studies prior to more recent randomized trials on this topic. Dr. Bruce Campbell:       There've been a couple of nice systematic reviews and meta-analyses of the observational data, and notably in most of these studies, the direct thrombectomy patients had contraindications to lytics, and that introduces confounding factors that are difficult to adjust for. For what that's worth, the functional independence, mortality outcomes were better in the bridging patients. Hemorrhage rates weren't always higher with the lytic, and one study by Jonathan Coutinho in JAMA Neurology for the SWIFT and STAR studies showed the opposite despite them having really careful adjustment for all the confounders they could think of. And the meta-analysis by Eva Mistry in Stroke did not detect a difference in symptomatic ICH between the direct and bridging strategies. One thing that should be less affected by the patient characteristics would be the technical efficacy outcomes, and it was interesting that in the observational data, the patients who'd had bridging lytic had higher mTICI 2b-3 rates and also fewer device passes. Dr. Negar Asdaghi:         Okay. And now we do have further information with all of these new randomized trials. So, why don't we start with some of the earlier studies, the three, SKIP, DEVT, and DIRECT-MT, and start with those studies first before we move to some more recent European trials. Dr. Bruce Campbell:       SKIP was performed in Japan, and it used the lower 0.6 milligram per kilogram dose of alteplase that's standard there, and DEVT and DIRECT-MT were performed in China. All three of them showed numerically similar functional outcomes with slight trends favoring direct thrombectomy. SKIP had a smaller sample size and did not meet its non-inferiority criteria, and the other two trials did meet their specified non-inferiority margin, but it could be argued those margins were overly generous. If you think about non-inferiority trials, we generally try to set a margin for non-inferiority such as lower 95% confidence interval for the trial intervention would sacrifice up to 50% of the reference treatment effect. And it's difficult to estimate the effect of alteplase in this specific population. But if you think of the Emberson meta-analysis of alteplase, overall zero to three hours alteplase versus placebo has a 10% effect size and mRS 0-1, three to four and a half hours of 5% effect size. And we regard that as clinically important. So, half of 5%, 2.5%, is a lot tighter margin than any of the direct randomized trials employed. Dr. Negar Asdaghi:         So, Bruce, let me recap what you just mentioned. Two out of the three earlier trials seem to suggest that perhaps skipping IV therapy is the way to go rather than bridging as these two trials met the non-inferiority criteria if we believe that non-inferiority margins you mentioned. And now we have a couple of more trials, more recent trials. Can you tell us about these trials please? Dr. Bruce Campbell:       MR CLEAN-NO IV in a European population did not demonstrate non-inferiority, and the point estimate slightly favored bridging. Interestingly, in that trial, the symptomatic intracerebral hemorrhage risk, which was one of the main drivers for trying this strategy, was 5.9% in the direct and 5.3 in the bridging group. So, there's no hint of benefit from dropping the lytic on that metric. SWIFT-DIRECT was more selective in only enrolling internal carotid and M1 occlusions, which had a lower chance of early recanalization with lytic. But the protocol also specified giving the full dose of lytic. In the other trials, it seems the alteplase infusion was often stopped once the patient was in the angio suite, so the full dose may not have been delivered. And despite very low pre-endovascular recanalization in that selected group in SWIFT-DIRECT, the end of procedure reperfusion was significantly better in the bridging group, which is a consistent finding across the trials and suggests that the lytic may improve the thrombectomy outcome. Dr. Bruce Campbell:       DIRECT-SAFE, the final of those trials, was interesting in that the patients were enrolled roughly 50:50 from Australia, New Zealand, versus Asia. And in contrast to the original three randomized trials in Asian patients, DIRECT-SAFE found a significant benefit of bridging lytic in Asian patients. So, it'd be very interesting to see the results of the IRIS individual patient data meta-analysis, but we may not find a difference in Asian versus Caucasian patients despite those initial trials and despite substantial differences in the prevalence of intracranial atherosclerosis, which has often been proposed as something that would increase the risk of having bridging thrombolytic on board. Dr. Bruce Campbell:       The original study level estimate of symptomatic hemorrhage had a borderline significant 1.8% absolute reduction in the direct group. Whether those data were not all core lab adjudicated and the final analysis may show a smaller difference than that. Notably, given that trend with symptomatic intracerebral hemorrhage, mortality did not differ significantly, and, in fact, the trend favored bridging patients. So, the symptomatic hemorrhage slight trend into increase did not translate into any hint of increased mortality. Dr. Negar Asdaghi:         So, Bruce, a lot of information, and I need a recap for me. So, let me try to recap some of the things you said, and please jump in. So, so far, the newer data really basically don't show us any convincing evidence that skipping is the way to go, and direct endovascular we really don't have data in favor of going directly to the angio suite. And the jury is still out regarding an increase in the symptomatic intracerebral hemorrhage rate amongst those that actually are pre-treated with IV therapy. Is that correct? Dr. Bruce Campbell:       That's correct. So, none of the three recent trials met their non-inferiority margins. And again, we had this issue of relatively generous non-inferiority margins, and the symptomatic hemorrhage, it would make sense that there's a small difference, but it's not really been borne out in the data to be statistically significant at this stage. And again, this individual patient data meta-analysis is keenly awaited to get the most accurate estimate on that. Dr. Negar Asdaghi:         So, while we wait that, I'm going to digress a little bit and ask you a question that's not addressed in the paper that you have in this issue of the journal, and that's the CHOICE trial. So, by now, we have the results of CHOICE trial. Do you mind first give us a brief overview of what CHOICE was and how you feel that the results of CHOICE would affect this field of direct versus bridging in general? Dr. Bruce Campbell:       CHOICE is a very interesting study in that it tested giving the intra-arterial lytic at the end of a thrombectomy procedure that had achieved an mTICI 2b or better, which is what we traditionally regarded as angiographic success. The idea was to improve microvascular flow, and that may be the case. The trial was terminated early due to logistic reasons and showed a very large effect size that requires replication. The subgroup analyses are interesting in that the benefits seem to mostly accrue in patients who'd not already had intravenous lytic. Dr. Bruce Campbell:       So, perhaps giving the IV lytic before thrombectomy can still benefit patients after the thrombectomy, as well as achieving early recanalization in a proportion of patients and perhaps facilitating the thrombectomy. The other issue to address with the DIRECT trials is that with the exception of a few patients in DIRECT-SAFE, the comparator was alteplase and not tenecteplase. And we have data from EXTEND-IA TNK that tenecteplase bridging is not just non-inferior, but superior to alteplase bridging. There's an ongoing Brazilian trial of exactly that, tenecteplase versus the direct approach, which will be very interesting. Dr. Negar Asdaghi:         So, great, Bruce. I just want to repeat this segment again for our listeners. So, CHOICE is a very interesting study, looked at giving intraarterial alteplase to patients after endovascular therapy was completed and after they'd already achieved the complete and successful revascularization, and the trial was terminated early because of logistic reasons. So, we have to keep in mind, this was a smaller study, early termination, but the effect size was pretty large in favor of giving lytics. Dr. Negar Asdaghi:         So, what you mentioned is interesting, and I think that it's really worth paying attention to, that the majority of the benefits seem to have occurred from intraarterial thrombolytics in patients that have not been given intravenous lytics prior to endovascular therapy. So, in other words, you need some sort of lytics either before or after the endovascular thrombectomy to achieve that ultimate improved outcome. So, moving forward now from the randomized trials that we have on bridging versus direct thrombectomy, you have mentioned in the paper some interesting subgroups that may benefit or not benefit as much from bridging versus direct thrombectomy. Do you want to elaborate a little more about those subgroup analyses? Dr. Bruce Campbell:       The idea of precision selection or individualized treatment is being talked about a lot given there didn't seem to be much overall difference between strategies in the randomized trials, but it's important to note that the randomized trial actually disadvantages the bridging group by delaying lytic until the patient was firstly confirmed eligible for thrombectomy and then consented and randomized. Putting that aside, if we could identify a subgroup who clearly benefit from skipping lytic and, importantly, identify them without delaying lytic for those who likely benefit, that's clearly attractive. Dr. Bruce Campbell:       Currently, I'd say we have not identified that kind of subgroup, and the planned IRIS individual patient data meta-analysis will be critical for that. Patients with a large ischemic core are one potential group where there's a high risk of bleeding hypothesized. To date, there is no definitive data to indicate the risk is lower with the direct approach. Patients who need stents certainly may benefit from not having a lytic on board because they often need adjuvant antithrombotics that could increase the bleeding risk. But the question there is whether we can confidently identify those patients before the procedure, and I think that's unclear at this stage. Patients with really large clot burdens and proximal occlusions have sometimes been said not to benefit from IV lytic based on the low rates of pre-endovascular reperfusion, but the randomized trials really hinted other benefits like this potential facilitative thrombectomy. So, that hypothesis may be insecure as well. Dr. Negar Asdaghi:         And how about age? Have you come across and has there been any signal towards an impact or interaction between age and benefit from pre-endovascular thrombectomy and thrombolytics? Dr. Bruce Campbell:       It's an interesting question because age has not generally been a treatment effect modifier in previous stroke studies with thrombolytics and thrombectomy, and the individual direct thrombectomy trials that have reported subgroups haven't shown any convincing heterogeneity by age. There's certainly no indication that older patients are at risk from bridging in what I've seen so far. Dr. Negar Asdaghi:         So, this question comes up in clinical practice all the time, that a person's older, perhaps more atrophy, more vascular risk factors and white matter disease, and they're more prone, so to speak, of having a symptomatic intracerebral hemorrhage. So, what you're saying is, from the data we have, there's really no signal in favor of withholding pre-thrombectomy lytics in this population. So, it's important to know this. Bruce, what should be our final takeaway message from this study? Dr. Bruce Campbell:       I tend to agree with the recent European Stroke Organization and ESMINT guideline that for now, patients should receive lytic as early as possible and in parallel with the decision to perform thrombectomy such that neither treatment delays the other. I think if we can identify a subgroup that benefits from direct thrombectomy, and that's confirmed in the individual patient data and meta-analysis, and we can identify them without disadvantaging the majority of patients, and also that the ongoing improvements in IV lytic strategies don't render the existing trial data obsolete, then we may, in future, skip lytic for some patients, but we are not there yet. Dr. Negar Asdaghi:         So, that's amazing, Bruce. We look forward to reviewing the paper and individual data meta-analysis and interviewing you, hopefully at a better hour your time, on that. Thank you very much for joining us on the podcast today. Dr. Bruce Campbell:       Thanks again for the invitation. It's been great talking to you. Dr. Negar Asdaghi:         Thank you. Dr. Negar Asdaghi:         And this concludes our podcast for the June 2022 issue of Stroke. Please be sure to check out this month's table of contents for the full list of publications, including three very interesting images that are presented as part of a new article type, Stroke Images, and a special report in Comments and Opinions section on "Bias in Stroke Evaluation: Rethinking the Cookie Theft Picture." June is the month of Pride, and in spirit of equality, we hope to do our part to reduce all biases in stroke processes of care, diagnosis, and outcomes as we continue to stay alert with Stroke Alert. Dr. Negar Asdaghi:         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.

“But if you step back and you're the parent, what do you want to teach that kid? You want to teach the kid that it's ok to fall. So, when the kid falls, you smile and say ‘Oops! That was fun, you're ok buddy! Let's do it again!' Right? And that's what you're doing to your brain. Because your brain is looking to you; your brain is giving you pain and you're either freaking out or you're going ‘Oops that's silly! I'm ok!” - Dr. Howard Schubiner, Internist and Pediatrician, Director of the Mind Body Medicine Center at Ascension Providence Hospital in Southfield, Michigan   Dr. Jen Barna discusses recent breakthroughs in curing chronic pain with esteemed guest, Dr. Howard Schubiner. Dr. Schubiner and colleagues developed Pain Reprocessing Therapy and Emotional Awareness and Expression Therapy, chronic pain treatments that focus around curing pain rather than managing pain. Dr. Howard Schubiner offers listeners his key insights as to what he has learned is the best way to confront pain that may be stopping you or your patients from living freely. In today's episode, Dr. Schubiner discusses neuroplasticity and the effective process in which you can ultimately retrain your brain to move away from pain, rather than continue to be stuck in a negative feedback loop. As physicians, it is often your job to find the source of you or your patients' pain. Being able to offer solutions to patients in chronic pain can be life-changing for patients and can be very fulfilling to clinicians. Dr. Barna and Dr. Schubiner also discuss the effectiveness of cognitive-behavioral based therapy and other practices that have proven to help manage pain, to cope with pain, but not to cure it. The paradigm shift that is now occurring is to recognize that research has demonstrated with randomized, controlled trials that chronic pain, even pain that has lasted for decades, can be alleviated in a short amount of time with lasting results using Pain Reprocessing Therapy and Emotional Awareness and Expression Therapy.  Links to Podcast episodes mentioned:   - Episode 163: Part 1: Emotional Awareness & Expression Therapy for You & Your Patients with Dr. David Clarke   - Episode 164: Part 2: Emotional Awareness & Expression Therapy for You & Your Patients with Dr. David Clarke   -Episode 172: Healthcare Burnout & PTSD with Dr. James Zender     Documentary:    This Might Hurt- https://www.thismighthurtfilm.com/   “This Might Hurt is a documentary that offers solutions to reduce and unlearn chronic pain. The film follows three chronic pain patients who have spent years searching for answers. Desperate for relief, they enter a new medical program — run by Dr. Howard Schubiner — that focuses on uncovering hidden causes of pain, and retraining their brains to switch the pain off.” Books:   Unlearn Your Pain: A 28-day Process to Reprogram Your Brain by Howard Schubiner, MD with Michael Betzold Unlearn Your Anxiety and Depression by Howard Schubiner, MD Hidden From View by Allan Abbass, MD and Howard Schubiner, MD Websites:    Unlearn Your Pain - https://unlearnyourpain.com/ The Psychophysiological Disorders Association- https://ppdassociation.org/ The Tension Myositis Syndrome Wiki: The PPD/TMS Peer Network- https://www.tmswiki.org/w/index.php?page=The_Tension_Myositis_Syndrome_Wiki The Pain Reprocessing Therapy Center- https://www.painreprocessingtherapy.com/ Videos:    “What is Pain?”- Animated Series by Dr. Howard Schubiner English: https://www.youtube.com/playlist?list=PLsJVYZbo6uWrKc57MDUL1vGciEGnPYrV9 Spanish: https://www.youtube.com/playlist?list=PLsJVYZbo6uWoBAVQxNhQhz618T_HHwfDX Online Programs & Apps:  Freedom From Chronic Pain Curable lin.health The DOC Journey   Other Recommended Authors:  Dr. David Clarke Alan Gordon, LCSW David Hanscom, MD Georgie Oldfield, Pain Specialist David Schechter, MD   Dr. Howard Schubiner is an internist and the director of the Mind Body Medicine Center at Ascension Providence Hospital in Southfield, Michigan. He is a Clinical Professor at the Michigan State University College of Human Medicine and has authored more than 100 publications in scientific journals and books. He lectures regionally, nationally, and internationally. Dr. Schubiner has consulted for the American Medical Association, the National Institute on Drug Abuse, and the National Institute on Mental Health. Dr. Schubiner is the author of three books: Unlearn Your Pain, Unlearn Your Anxiety and Depression, and Hidden From View, written with Dr. Allan Abbass.   Dr. Schubiner has collaborated extensively with colleagues such as Mark Lumley, Tor Wager, Yoni Ashar and Alan Gordon to develop two novel psychological treatments for chronic pain: Emotion Awareness and Expression Therapy (EAET) and Pain Reprocessing Therapy (PRT), which have  been shown to be highly effective in randomized, controlled trials. EAET is now listed as a treatment option in the U.S. Department of Health and Human Services Pain Management Best Practices Inter-agency Task Force Report.   Dr. Schubiner is part of the team that conducted the Boulder back pain study, along with Tor Wager, Yoni Ashar, Alan Gordon, Christie Uipi and Mark Lumley. This study demonstrated that 75% of the people with chronic back pain treated with a novel therapy called Pain Reprocessing Therapy recovered fully. The study also documented the changes in the brain that occurred with this treatment using function MRI scans.   The documentary This Might Hurt, follows Dr. Schubiner and several of his patients through treatment that focuses on uncovering hidden causes of pain, and retraining their brains to switch the pain off. “The film had its world premiere at Austin Film Festival and is now in the midst of a two-year community screenings campaign. If you're interested in hosting a virtual live screening, we encourage you to reach out to us at tmhfilm@gmail.com. 100% of the proceeds for This Might Hurt go towards creating affordable community screenings for diverse audiences around the globe.” -https://www.thismighthurtfilm.com/   Dr. Schubiner lives in the Detroit area with his wife of thirty-eight years and has two adult children.   Find full transcripts of DocWorking: The Whole Physician Podcast episodes on the DocWorking Blog  The past few weeks have been busy at DocWorking! We have been working behind the scenes to add even more CME credits to the THRIVE memberships.    Let your CME budget help you prioritize your own wellness so you can get on with living your best life on your own terms, as defined by you, with DocWorking THRIVE.   You can take the first step today by taking our 2 Minute Balance to Burnout Quiz! Where are you on the Balance to Burnout Continuum? Take the quiz and find out today!   DocWorking empowers physicians and entire health care teams to get on the path to achieving their dreams, both in and outside of work, with programs designed to help you maximize life with minimal time.   Are you a physician who would like to tell your story? Please email Amanda Taran, our producer, at podcast@docworking.com to be considered.   And if you like our podcast and would like to subscribe and leave us a 5 star review, we would be extremely grateful!   We're everywhere you like to get your podcasts! Apple iTunes, Spotify, iHeart Radio, Google, Pandora, Stitcher, PlayerFM, ListenNotes, Amazon, YouTube, Podbean   You can also find us on Instagram, Facebook, LinkedIn and Twitter.    Some links in our blogs and show notes are affiliate links, and purchases made via those links may result in payments to DocWorking. These help toward our production costs. Thank you for supporting DocWorking: The Whole Physician Podcast!   Occasionally, we discuss financial and legal topics. We are not financial or legal professionals. Please consult a licensed professional for financial or legal advice regarding your specific situation.   Podcast produced by: Mara Heppard

“My mom was like ‘Absolutely not, we are not telling a child he has 6 months left to live,' which I think played a huge role in [me] staying positive.” David is one of the longest surviving patients of glioblastoma in America, beating all the odds stacked against him since he was a child. He is joining Amber Barbach on Glioblastoma aka GBM to talk about his experience as a three-time survivor, how the support of his friends and family pushed him through, and the importance of being your own advocate. Hear us talk about: David's first diagnosis. David was a healthy child who never got sick, until he got sick. When he was 10, he started getting headaches and deja vu so bad they caused him to vomit - even touching his head induced severe pain. A CT scan that showed a brain tumor. After taking many other tests and being admitted to the hospital, David was scheduled for a surgery to remove his tumor, and it was successful - so successful that the neurosurgeon claimed it was the easiest surgery he had ever done because the tumor fell out of his skull due to its fully encapsulated nature. The pathology of the tumor revealed that it was stage four glioblastoma, and the doctor's diagnosis was that David would only have six more months to live. His mother informed him of his cancer but refused to let the doctor tell David that his days were numbered. The return of the tumor. David's headaches and deja vu episodes came back with a vengeance, and it was discovered that the tumor had returned, bigger than it was before. Surgery was performed, but his chance of survival was even lower this time. Not one to be deterred, David's mother thanked the doctors and respectfully decided to get a second opinion. He was put in a clinical trial at Duke for a new type of treatment, and the positive attitudes of everyone around him kept him grounded and stable. He gradually got better. More cancer. The year was 2019, and David started getting pain in his jaw. At first thinking it was TMJ, he went to a specialist who told him he had a severe underbite and needed total jaw realignment surgery. Knowing that underbites were either hereditary or caused by a severe contact injury, none of which applied to him, he got a second opinion, which led to an MRI. The MRI showed that there was a tumor the size of a baseball at the base of his skull. He had a biopsy done, and it revealed that it was radiation-induced osteosarcoma. Experiencing chemotherapy as an adult was a stark difference from when he was a child. There were moments where he faltered in spirit, but he quickly snapped out of the ‘why me' spiral. Being your own advocate. If a surgeon or doctor says something to you that you don't agree with, just know that there are millions of them on the planet - you are bound to find one that's willing to help you. Don't just roll over and accept whatever you're told.  Finding positivity. It is absolutely essential in the midst of any adversity to find positivity, David shares. Some people might handle it through humor, meditation, exercise - as long as you find an outlet to channel what you're feeling into something positive, you will feel more complete. “Cancer is already going to change your life as it is through your health, but it doesn't have to change who you are spiritually or mentally, emotionally.” What's Next? David Fitting is an ambassador for the Glioblastoma Research Organization, who has given hope to people all around the world. He's passionate about motivational speaking and sharing his story to inspire others. As always, the information that is discussed in Glioblastoma AKA GBM is not meant to treat or diagnose any disease. What we and our guests share are personal stories of what has worked for the individuals in question, and should not be taken as medical advice or opinion, and is not a substitute for medical advice. If you have any questions about your own situation, always consult with your medical provider and healthcare team.

Cousin Frank returns to the podcast after two years. We recorded this episode in Wisconsin outside his garage. He shares his story having brain surgery immediately after being pulled from an MRI machine. He explains what was going through his mind and what actions he took after being shown there was a tumor the size of a walnut in his head. He shares how the experience has changed his perspective, including seeing his daughter grow older. Rich and Frank discuss the rapid advancement of technology “these days.” Rich asks about how to raise children with the proliferation of screen addiction. Frank shares his trip to Memphis and Nashville. Towards the end of their conversation, Frank shares advice on life as someone who has to battle each day with the challenges of having cancer brings   Episode 40. Cousin Frank on Wisconsin Culture  

Wellington hospital is being forced to spend millions of extra dollars sending patients to private hospitals for MRI and CT scans as its old scanning machines fail to cope. The average waiting time for outpatient scans has grown by a third since March, to four weeks for a CT and seven weeks for an MRI, with hundreds of people in the queue. Phil Pennington has the story.

Bio:   Shari Short is a patient advocate, a professional in healthcare communications and naturally, a standup comedian. As Senior Director of Insights and Strategy at Bionical Solutions, she has over 20 years of experience in patient education from behavior change to clinical trial recruitment. A developmental psychologist by training, Shari has held positions with the National Cancer Institute, Centers for Disease Control, Virginia Department of Health, Fox Chase Cancer Center, and various healthcare marketing firms. Shari received her M.A. in developmental psychology from Columbia University Teachers College.    Shari has been living with Multiple Sclerosis for 14 years. As a Patient Advocate, Shari has shared insights from living with Multiple Sclerosis to the New Jersey statewide advocacy committee of the National MS Society as well as written for their national magazine, Momentum. She incorporated her experience with MS into a sold-out one-woman show called “It's My Mother's MS, I just Have It” and a satire letter series from “The Crazy Cane Lady”. Shari has been featured on multiple podcasts. She has been performing standup comedy since her teen years (read: the 80s) and has opened for performers such as Shawn Colvin and Sandra Bernhard.   Questions:   Welcome to the program, Shari, and thanks so much for joining us on Living Well with MS. You have a very eclectic background, from standup comedy to developmental psychology. Can you tell us a bit about how that all ties together and has helped you forge your current path focused on behavior change? We know humor is important to you, an essential part of your personal and even professional identity. And we'll dig into that in a moment. But first, I'd like to understand your experience with MS. Can you give us a bit of an intro to that, anything you feel comfortable sharing? Was there a point when you developed a philosophy or even a methodology for using humor to cope with some of the challenges of MS? Can you tell our audience about that journey? You've produced a lot of humorous output about MS. Some notable things to mention (incidentally links to many of these can be found in the show notes, so I encourage everyone to have a look): a one woman show called “On My Nerves”; a satirical piece for Momentum, the National MS Society magazine; presentations at the University of Pennsylvania; various podcast appearances, including this one. Do any of these stand out for you, and if so, how? I understand that humor has personally helped you deal with scary situations, reframe your current physical abilities, and not take yourself too seriously. How transferable are these “benefits” to the broader MS community, and how would you advise people who don't have the same organic relationship with humor that you do tap into them? How do you overcome the discomfort some people may feel when you apply a humorous or jokey spin to a “serious” topic such as MS? There's a principle I understand you have called “laughing on purpose”. Can you tell us a little more about that? So I'm getting the sense that humor can be many things as applied to MS: a coping tool, a teaching tool, or even a defense mechanism. What's your best advice for how Joe Q. Public with MS can harness humor to its maximum positive advantage? Thanks so much for being our guest on Living Well with MS, Shari. We are thrilled to learn about the amazing work you're doing to help people with MS ease their burdens and get the most out of life using humor. And I encourage everyone to learn more about you and your work by checking out the links and more in our show notes for this episode. Thanks again, Shari.   Links:   Connect with Shari on LinkedIn Read Shari's humorous piece in Momentum Magazine, the official magazine of the National MS Society Check out Shari's satirical take on pharma marketing Here's a collection of Shari's videos connected to the 2021 Tody Awards Check out selections from Shari's 2011 one-woman show, "It's My Mother's MS, I Just Have It" – clip 1 and clip 2   Coming up next:   Starting June 27, please join us for the 33rd installment of our Living Well with MS Coffee Break series. On this journey into the lives of our global OMS community, we have a special surprise for you – a mystery guest. Their location won't be disclosed until the episode because you'd likely guess who it is it were. But we assure you that you'll relish some of the behind-the-scenes details of this person's life and OMS journey.   Don't miss out:   Subscribe to this podcast and never miss an episode. You can catch any episode of Living Well with MS here or on your favorite podcast listening app. For your convenience, a full episode transcript is also available on all platforms within 72 hours of each episode's premiere. If you like our program, don't be shy and leave a review on Apple Podcasts or wherever you tune into the show. And feel free to share your comments and suggestions for future guests and episode topics by emailing podcast@overcomingms.org.   S4E53 Transcript Laughter is the Best Medicine   Geoff Allix (00:00): Welcome to Living Well with MS, the podcast from Overcoming MS, the world's leading multiple sclerosis healthy lifestyle charity, celebrating its 10th year of serving the MS community. I'm your host, Geoff Allix. The goal of our organization and this podcast is to inform, support, and empower people with MS to lead full and happy lives. We're excited you could join us for this new episode.   Make sure to check out this episode's show notes for more information and useful links. You can find these on our website at www.overcomingms.org/podcast or on whichever podcast platform you use to tune into our program. If you enjoy the show, please spread the word about us on your social media channels or leave a review wherever you tune into our podcast. Have questions or ideas to share? Email us at podcast@overcomingms.org or you can reach out to me directly on Twitter, @GeoffAllix. We'd love to hear from you. Finally, don't forget to subscribe to Living Well with MS on your favorite podcast platform so you never miss an episode. And now, let's meet our guest for this episode.   Welcome to the Living Well with MS podcast. This episode is Laughter is the Best Medicine, with guest, Shari Short. Shari is a patient advocate, a professional in healthcare communications, and naturally, a stand-up comedian. As senior director of insights and strategy at Bionical Solutions, she has over 20 years of experience in patient education, from behavior change to clinical trial recruitment. A developmental psychologist by training, Shari has held positions with the National Cancer Institute, Centers for Disease Control, Virginia Department of Health, Fox Chase Cancer Center, and various healthcare marketing firms. Shari received her MA in Developmental Psychology from Columbia University Teacher's College.   Shari has been living with multiple sclerosis for 14 years. As a patient advocate, Shari has shared insights from living with multiple sclerosis to the New Jersey Statewide Advocacy Committee of the National MS Society, as well as written for their national magazine, Momentum. She incorporated her experience with MS into a sold-out one-woman show called, It's My Mother's MS, I Just Have It, and a satire letter series from The Crazy Cane Lady. Shari has been featured on multiple podcasts. She had been performing stand-up comedy since her teen years and has opened for performers such as Shawn Colvin and Sandra Bernhard. Welcome to the program, Shari, and thanks so much for joining us on Living Well with MS.   Shari Short (02:34): Thank you for having me.   Geoff Allix (02:37): You have a very eclectic background, from stand-up comedy to developmental psychology. Can you tell us a bit about how that all ties together and has helped you forward your current path focused on behavior change?   Shari Short (02:51): Sure. I mean, doesn't it sound like such a natural path, from stand-up comedy to developmental psychology. It's like a board game, really, it's like a party game. I basically started out really wanting to be in the arts and especially stand-up, I preferred stand-up to acting. I sing, I act, whatever, but stand-up was my favorite. And I for some reason had the guts to start it at 14 years of age when I had braces and was in high school and was able to go into the comedy clubs and just watch, watch and learn. And the older comics there just, they adopted me and took really good care of me. I read John Belushi's book, a book about John Belushi by Woodward, at a young age, and it scared me to have to depend on my sense of humor for finances.   So I said, "Well, I want to have like a solid degree and a solid job and do stand-up." And of course, when you're a teenager, you think that all works. I was eager to at least get academic credentials behind me, so I went to film school, went to NYU, and there I minored in psychology, spent a lot of time during the summers, working with young kids and parents in theater camps, and just absolutely fell in love with... Excuse me... The way that our lives changed when we become parents. And it wasn't me, I was watching people become parents, and I was helping parents and I wasn't even a parent yet. So when I chose developmental psychology for my graduate work, I felt like that's what I'm going to go into. I want to create resources for parents.   I became concerned with... like we talked about Microsoft earlier, I was like, "Are there books for parents on how to use the computer?" I interned with Sesame Street. I was very focused on being creative within this academic psych setting. But once you go to grad school, nothing's really funny, so I stopped doing comedy. I had opened for Sandra Bernhard, I'd opened for Shawn Colvin, I'd had a wonderful time, but you got to commit. If you want to do stand-up, you have to commit and you have to want it, you have to want that life and I preferred giving lectures.   I preferred making the audience laugh that they had to be there, I had to grade them or they had to be graded, they had to show up. And I tipped my hat off to everybody I know that's successful now, that just put in those hours and put in that amount of travel to live the life of a stand-up comic, especially in the 90s, and the early 2000s, because that was way before MS for me, but something I knew I didn't have the stamina for. And I was so nervous to not get paid and have it all depend on my sense of humor, that was a big thing for me.   Geoff Allix (06:14): We'll come back to the humor in a bit because it's obviously an essential part of your personal and professional identity. But first, because this is a Living Well with MS Podcast, we want to understand a bit about your experience with MS. Could you give us a bit of an intro, anything that you feel comfortable sharing about your MS journey?   Shari Short (06:35): Sure. I was diagnosed in the summer of 2008. I had become a runner a year or so before that, and was training pretty intensely for a 10k, and I suddenly had vision loss and pain behind my eye. It presented as the optic neuritis, but I didn't know that. For me it was, "Oh, there's pain, there's my eye, there's my head. Clearly it's a brain tumor." And I panicked and went to the urgent care center and they sent me to the ER, and I got an emergency eye doctor appointment the following morning. And the eye doctor just said, "Oh, this is really classic optic neuritis." And I was like, "Great, give me some eye drops." I didn't know what that meant, and he just kept sitting there and I'm like, "Oh, you have more to tell me, don't you?"   He got me into a pretty quick appointment with a neurologist. And I don't have a slow, drawn-out diagnosis story, like so many. They had a neuroradiologist at my MRI, they saw lesions, I was diagnosed really quickly, all based on that one event with the optic neuritis.   Geoff Allix (07:53): I think there is a difference in different health care systems around the world, it does seem to me the Americans I've spoken to, do get diagnosed typically quite quickly, whereas in the UK we often get diagnosed quite slowly. But on the flip side, we get lots of free medication.   Shari Short (08:10): Yes, it's quite the flip side.   Geoff Allix (08:13): Definitely tradeoffs between the different-   Shari Short (08:13): It's quite the flip side.   Geoff Allix (08:16): If someone were to come up with the best of both worlds, it'd be pretty good. But yeah. Yeah, I would never say anything bad about our system, our system is fantastic.   Shari Short (08:24): I'm a fan of your system.   Geoff Allix (08:25): But yeah, there are downsides to how quickly things happen occasionally, but anyway, we can live with that.   Shari Short (08:30): Yeah [inaudible 00:08:33].   Geoff Allix (08:33): Was there a point when you developed a philosophy or methodology even of using humor to cope with some of the challenges that came up because of MS?   Shari Short (08:45): It was pretty organic, I think, for me to be using my humor to cope. And I just didn't realize how naturally it would be until I was actually in a situation where I had to really tap into my coping skills. At my very first MRI where they diagnosed me, and the neuroradiologist is literally showing me my scan so I'm seeing my skull, the first thing out of my mouth, Geoff, was, "Do I look fat?" Right? It's like, "What?" Like, "Where'd that come from?" Like okay, I'm nervous and I'm processing, and clearly I'm going to try to lighten the mood. And to just see myself consistently doing that, when I got my first handicap tag and I was very sad about it, I remembered I had a dress the same color and I'm like, "I can finally accessorize."   So things were just coming to me in a way to get me off of the morbid train, to get me off of the "Okay, I could really [inaudible 00:09:53] because of this particular situation, but I'm going to find the humor in it." And the more I did that, the more my friends would say to me, "You've got a collection of stuff here. You've got stories, you've got strangers who've said ridiculous things to you, you've got just funny conversations, you've had funny interactions." People would see me, and I didn't mention this before, but eventually after the optic neuritis, eventually I lost feeling on my left side and now I walk with a cane and two leg braces. And I've had people just approach me, like I'm some sort of former athlete and then they'd be like, "Oh, was it soccer?" They just made up sports and they're strangers, I started telling people it was a Quidditch injury.   Geoff Allix (08:45): Well Quidditch is very dangerous. I mean, the altitude and...   Shari Short (10:48): Well, yeah, this is my little PSA. Yeah, so Quidditch causes MS, so yeah. I had a lot of time to not only see how I was using my humor to cope, but also to just see humor in situations. I was watching it unfold and gave myself the project of putting together a one woman show. And in doing so, in writing and in taking every Sunday to just sit and write and write, it was really, it was a deep dive into my own perspective. And from there I did the show, but I also then put together presentations and different types of creative outlets and tools for coping, that could hopefully help other people. Because this is not a mindset that just comes easily to a lot of people.   Geoff Allix (11:39): You've produced a lot of content, which you've touched on there, and it is mentioned in the show notes, so do have a look, there's links to a lot of that content. Some of the things are shows, like On My Nerves, as well as a satirical piece for Momentum, the National MS Society magazine in the States. Presentations at the University of Pennsylvania, various podcast appearances, including this one. Could you tell us if there's any of those experiences that stand out for you?   Shari Short (12:11): The one-woman show was phenomenal, and it was called On My Nerves, but the working title for me was, It's My Mother's MS, I Just Have It, because I had so many stories about how mom was dealing with my diagnosis or dealing with my disease, as opposed to me. And then that dovetailed into how everybody else was dealing with my situation, and the stories that I had on that. To have so many people come out and see that, and then be asked, "Do you want to do this for fringe festivals and stuff like that?" And to have to say, "Actually, no, I can't, that took all the energy I have." It was amazing, I'm glad I had it taped, I'm glad I have my binder. I could do it again, but I couldn't do it on a show basis.   To have a night at the theater where 140 people came out and it was sold out, was a really wonderful way to honor how I've used the humor. And also I got just emails and responses from people with other chronic illnesses, and a lot of people with more silent, hidden chronic illness that were like, "Thank you for that, because you just touched on stuff that no one's talking about, and you did it in a way that was safe." And I just realized that the humor can help people and it's not just helping me. Yeah, and then just the Crazy Cane Lady letter series that I started a couple of years ago was just a little creative advocacy project for me, where I would just write letters, fake letters, very real feelings, but fake letters to different entities, like hotels or restaurants, or back to school night, or Broadway theaters, about how they could be more accommodating to people like me.   I definitely honed in on the cane part of my existence because I see that there are tremendous accommodations, and we could still improve for people in wheelchairs, but the cane, it gets a little middle child treatment sometimes. And there's a ramp that it'll take me a year to get up the ramp on the cane when I could just go up the steps and then be there. So I just feel like there's a lot to learn and people have a lot to learn in terms of event planning and in terms of accommodating people with canes. I did this series of letters during MS Week here in the States, it was in March a couple of years ago. And I made those public, and that took off really nicely. People responded really well to that, and I need to write more of them. I was going to do it again the following year, but the following year was COVID and I just felt like we all had bigger fish to fry than if I can find a bench near a movie theater, right? So I didn't continue with that. I did a video series, like an Oscars version of just thanking different entities within the MS community that have helped me cope. I feel like if I can't perform it or if I can't write it and put it out there in a satirical way, I'm not processing. I don't do the serious stuff and process; it has to be creative for me to feel like it's healing.   Geoff Allix (15:37): You've mentioned that humor's helped you deal with situations you've had and help with your physical abilities and not take yourself too seriously, so how transferable are those benefits to the broader MS community? And how would you advise people to try to tap into that relationship you have with humor?   Shari Short (16:03): Yeah, no, that's a great question. I think that it comes down to the lens that you're seeing life through and the lens that you're seeing your mobility issues through, or whatever it is that MS has affected for you. And the lens I used to see my slow gait and my balance issues, I used to just... Well, I went from being a runner to the negative and it was, "Oh, great. This is what I get, and this isn't fair." And all of those very, very normal feelings, to, "All right, I'm going to rock a cane." Or "All right, with these assistant orthotic devices, they make me look like a Jedi." Or not, they made me look like a storm trooper actually, because they were white.   I also, I have to say I had a small child during this time, so I really felt the need to be creative about what was happening to mommy, because he saw me go from a runner to, I can't walk well, and that kind of pushed me along. There might be something for other people, when they consider, "Well, am I looking through it in the glass half full lens, or am I looking through it in the glass half empty? And what lens am I looking at it through? And are there things that I think are funny that, if I tell people I think they're funny, they're going to judge me?" And I'm here to say, embrace all of it. It's your lens, you're seeing it through. I did a lot of acceptance of dark humor. I did a lot of acceptance of the fact that humor is a language and some people will be put off if you're joking about your condition. And some people will feel like, "Oh, okay, good [inaudible 00:17:53]."   Geoff Allix (17:53): How do you deal with that discomfort if people are not comfortable with you talking in a humorous way about something as serious as MS?   Shari Short (18:03): Sure. Well, it's always know your audience, right? If I'm talking to other people who have MS, to the best of my ability I gauge where they are, like that talk I gave at Penn here in the States, they knew they were logging on to see a comedian, they knew what they were getting, so I wasn't too scared to read the Crazy Cane Lady letters or whatever. But I mean, to this day... look, last week I dealt with COVID and I knew I had COVID not because of a cold or a cough, but because I collapsed, and my husband had to pick me up off the floor. It triggered something in the MS and I'm like, "Oh, I've got a virus that my body wants me to know about."   And I could tell people and I get the "Oh." You know, I get the face. And I'm like, "Yeah, but I didn't hurt myself." Or "Yeah, my husband was right there." Or "My COVID's more fun than your COVID." I feel the need to keep going with the story instead of letting it halt and let them know I'm okay. And not everybody can do that, and I get that. And that's why, when I do workshops or anything like that, I get personal and talk about, "Okay, what's in your toolbox? What can you grab onto at that moment that is going to help you get either through telling the story or through what you're doing?" Almost in a cognitive behavioral way, "What's a great image you have in your head to just move you through the situation?"   And that's all just been because that's worked for me, and I know from research that humor is healing and laughing is really good for the body. There have definitely been situations in my life where the instinct is to cry, but I know it I've always felt better if I set the situation up so I could laugh at it.   Geoff Allix (20:10): You've got a principle, I believe, called laughing on purpose, which you've almost touched on there, I think. But could you tell us a bit of more about that?   Shari Short (20:18): Laughing on purpose?   Geoff Allix (20:19): Yes.   Shari Short (20:22): Laughing on purpose, I mean, when I hear that phrase, I mean, I feel like it's making a conscious choice to keep your sense of humor about you when things are challenging. And that looking at things with humor is not a weakness, it's like, if I don't laugh, I'll cry, that phrase that's out there. It's like if you laugh, it's actually going to help the situation a little bit. And it's for you, it's personal for you. It's not like, "Oh, somebody else is suffering, so laugh at them." I'm only talking about when one is dealing with one's own stuff. That would be horrible advice to give to anybody to just laugh at other people's challenges.   Geoff Allix (21:04): I just think all the best humor is when it's the comedian laughing at themselves, I think that's the funniest humor, isn't it?   Shari Short (21:10): Of course. Yeah, and I felt like sometimes I had to be jostled into it, I had to be jostled back. And I had this wonderful story in the show whereby I got that handicap tag and I was sad about it. And my boss at the time was like, "Well, can I borrow it? I have Springsteen tickets, and I would love to use your handicap tag." Here I was feeling really bad for myself, and then people were like, "You've got the golden ticket." I have this motto or whatever, or this creed or this way of looking at things, like if I don't try to find the humor in this, then I haven't really processed it, like I mentioned before. And it's not a pressure, it's just how can I help myself?   Occasionally they'll be like, "Oh no, no, no, it's not working yet. It's not working yet." And in my toolbox, I have things that make me laugh. I have old Blackadder episodes, I have the best of Bits of Fry and Laurie, I have comedians like David Mitchell and things on the BBC that make me laugh, or American comedians like Kathleen Madigan. And I just go there, I'm like, "They're going to make me laugh and it's going to reset me." The things that are dark, the things that I've had to deal with with MS, the intimate, discreet ways in which the central nervous system wreaks havoc, MS wreaks havoc on it, I don't want to share with everybody, but I've become a little bit more like, "I've got to advocate for me or no one else will."   So if we're all going into a restaurant, I'm like, "Excuse me, but the seat near the bathroom. Yeah, that would be me. That is mine." Right? Yeah. And it's just like, I'm 51 years old, people might think, "Oh, oh, women do that." No, no, no, it is totally because of the MS. But I've just grown a little bit more comfortable with the uncomfortable because I communicate with my humor. And when you have MS, I mean, everybody's got it differently, but there's uncomfortable things about it.   Geoff Allix (23:33): Sense of humor can apply to many things in MS. It can be coping tool, teaching tool, defense mechanism, so just for general member of the public who's got MS, how can they harness humor to make a positive benefit to themselves?   Shari Short (23:55): I think, first of all, you have to ask how you're processing any aspect of where you are in your patient journey, is the term that's used most often. How are you processing? Are you talking about it a lot? Are you thinking about it a lot? Are you down on yourself because of it? Or are you trying to give yourself pep talks? Are you worried about the future? Where are you with it? And then ask yourself in that processing, "Okay, what kind of lens should I look at this through so it's going to help me move forward?"   The toolbox is something I come back to a lot. What makes you laugh, as you, your own person with MS, what makes you laugh is not what makes me laugh, is not what makes everybody else laugh, it's you. So write it down, actually acknowledge your sense of humor. What makes you laugh? And start to collect those things, whether it's books or whether it's links on the internet, whether it's the cat video or the guy who says, "I'm not a cat," to the lawyer, you know those things that went viral last year. There are things that can immediately make you laugh so just be more aware of them because they're tools for you to reset. And I use humor to communicate, not everybody does. You may find in your dealing with MS, that you've got two friends that will get your dark humor, that will get your jokes, or will support you on that, then they're part of your toolbox too.   I've found that I've had, like we talked about earlier, there's people that get uncomfortable or they make faces and I don't stop too long in their party. I just go, "Okay, yeah, yeah, no, I know it sucks." I can't take care of anybody else but me, so I think that's really important, is to just look where you are, what lens are you looking at it through? Where can you find, is there humor in this situation? Do you want to write about it? Do you want to tell a good close friend about it? Do you want to tell your doctor about it? But collect those things, because at other times it's going to make you laugh when no one else knows what you're thinking, and it's going to be part of your own collection of stories that you can go back to and say, "This is how I dealt. This is how I helped myself." Because to find humor in situations, it's not self-defeating, it's empowering.   Geoff Allix (26:26): With that, I'd like to thank you so much for being our guest on Living Well with MS. We're thrilled to learn about the amazing work you've been doing to help people with MS, to ease their burdens and get the most out of life using humor. And I would absolutely encourage everyone to learn more about you and your work by checking out the links in the show notes, they're available on every platform. Have a look at the show notes of the episode. And thank you much for joining us again, Shari.   Shari Short (26:52): Thank you so much for having me, this was great.   Geoff Allix (27:01): Thank you for listening to this episode of Living Well with MS. Please check out this episode's show notes at www.overcomingms.org/podcast. You'll find all sorts of useful links and bonus information there. Do you have questions about this episode or ideas about future ones? Email us at podcast@overcomingms.org. We'd love to hear from you. You can also subscribe to the show on your favorite podcast platform, so you never miss an episode.   Living well with MS is kindly supported by a grant from The Happy Charitable Trust. If you'd like to support the Overcoming MS charity and help keep our podcast advertising free, you can donate online at www.overcomingms.org/donate. To learn more about Overcoming MS and its array of free content and programs, including webinars, recipes, exercise guides, OMS Circles, our global network of community support groups, and more, please visit our website at www.overcomingms.org. While you're there, don't forget to register for our monthly e-newsletter so you can stay informed about the podcast and other news and updates from Overcoming MS. Thanks again for tuning in and see you next time.   The Living Well with MS family of podcasts is for private, non-commercial use, and exists to educate and inspire our community of listeners. We do not offer medical advice. For medical advice please contact your doctor or other licensed healthcare professional. Our guests are carefully selected, but all opinions they expressed are solely their own and do not necessarily reflect the views or opinions of the Overcoming MS charity, its affiliates, or staff.

Gifts don't always come when we need them.Sometimes, they're already there…We just don't know it yet!Bridget Picard has always valued vitamins, supplements, essential oils, healthy foods, among other natural resources – readily available on the market – but she saw them in a different (even more positive) light after Christmas day.Prior the holidays, Bridget was already suffering from what she thought were symptoms of an auto-immune disease, one of which was a break out of rashes, starting from her feet and ankles, which made its way around her body. Worried about her condition, she got herself tested.Come December 26, she still had not heard from her physician. Impatient and anxious about the results, she took it upon herself to check the healthcare portal – that's where she discovered her MRI that was suspiciously showing lymphoma.It was a life-shattering moment for Bridget. It was during the holidays, and during covid (where it was difficult to get appointments), and she only had an MRI (that didn't show stages, prognosis, nor treatment plans) to go on.Truly, the unknown was overwhelming.It didn't help when she was finally diagnosed with gray zone lymphoma, a rare type of lymphoma, cancer of a part of the immune system called the lymph system.At that point, the “ship was sinking fast” and all she could do was plug the holes with medical treatments, without giving a thought towards alternative solutions.That's when her clean eating habits and healthy lifestyle choices became the gift she wasn't expecting. It was through these natural remedies that Bridget was able to maximize the positive effects of chemotherapy, and minimize the harmful effects of said treatment.What other natural resources did she leverage to support her healing process? How were these integrated into her medical treatments? What was the overall impact of this holistic approach to the life she leads today?Tune in to learn more about clean and healthy living habits, food and supplement choices, and other natural resources you need to become a thriving survivor.Integrative Cancer Solutions was created to instill hope and empowerment. Other people have been where you are right now and have already done the research for you. Listen to their stories and journeys and apply what they learned to achieve similar outcomes as they have, cancer remission and an even more fullness of life than before the diagnosis. Guests will discuss what therapies, supplements, and practitioners they relied on to beat cancer. Once diagnosed, time is of the essence. This podcast will dramatically reduce your learning curve as you search for your own solution to cancer. For more information about products and services discussed in this podcast, please visit www.integrativecancersolutions.com. To learn more about the cutting-edge integrative cancer therapies Dr. Karlfeldt offer at his center, please visit www.TheKarlfeldtCenter.com.

In this bonus episode, Peter Bandettini talks to four co-authors from a recent Nature paper on “Reproducible brain-wide association studies require thousands of individuals.” Scott Marek, Brenden Tervo-Clemmens, Damien Fair and Nico Dosenbach discuss their work, demonstrating that to make reproducible associations between MRI measures (both structural and functional) and behavioral measures, upwards of 2000 subjects are required. The panel discuss the strong reaction across the field to this paper, and how the results fit with the known strong and robust signal from fMRI. They consider why the effect size is essentially three orders of magnitude smaller when trying to pull out differences between subjects. In this insightful, clarifying, and ultimately optimistic conversation about fMRI and the implications of this paper, Peter and his guests go over possible reasons for these extremely small effects, and discuss ways forward.

Aram and Peter answer your mailbag questions for this week with topics ranging all over the league! Download the Loupe app for 24/7 baseball cards at your fingertips + $20 credit! What are your thoughts on the guardians and what should they do for the remainder of the year? go for it and add another bat/ arm? retool and keep most of the core? or full rebuild? - @DavidDOlivo3 Cards record prediction and will they win the division? I reckon they will win the league pennant. They are playing well now, but half the team seems to be second half players. - @Eduardo54978750 Is Luis Arraez an all star? And can the Twins actually compete with the best teams? @ouunioon What is one move that will shake up the league at the deadline - @Dodgerfanpage1 Is this the year that Edwin Diaz becomes a top 3 closer? - @Dhils Is Dansby Swanson an All Star this year? What do the Braves do at second base? - LWundy Is the Padres solid start without Nando sustainable (still no word on his MRI scan so may be out longer)? How do they prevent a catastrophic collapse like last year? What moves are realistic at the DL? - JoshuaDLandis What player has shocked you the most this year? For me, Luis Gonzalez as he is putting up good at bats and getting results - LilDj030 on IG  Learn more about your ad choices. Visit megaphone.fm/adchoices

Yoga teacher Jenni Rawlings and Exercise Science professor Travis Pollen discuss the ins and outs of pigeon pose.Points of discussion include:A description of the anatomy and biomechanics of pigeonThe different variations of pigeon pose and their unique effects on the bodyIs pigeon pose risky for the front knee?The relationship between pigeon pose and the piriformis muscle of the hipDo we ever realistically stretch one muscle in isolation?Is pigeon pose a good treatment for sciatica?Should the front shin be parallel to the front edge of the mat in pigeon?Should we flex the foot to protect the knee in pigeon?Are active variations of pigeon superior to traditional passive pigeon?Is pigeon pose the main form of “hip opener” that we practice in yoga?…And much more!Enjoy this engaging and eye-opening discussion for yoga, movement, and fitness geeks!Resources mentioned in this episode:Free yoga class from Jenni: “Pigeon is Our Friend”! (Through 6/30/22)Jenni's email newsletterStrength for Yoga Remote Group Training – ongoing, interactive monthly strength program for yogis created by Jenni & TravisYouTube video: Does Flexing the Foot Protect the Knee in Pigeon Pose?Research article: Is it painful to be different? Sciatic nerve anatomical variants on MRI and their relationship to piriformis syndromePodcast episode: Do We Store Emotions in Our Hips?Podcast episode: Stretching Myths & Stretching Facts w/ Greg LehmanBlog Post: Physical Touch in Yoga: Do Teachers & Students Agree?Blog Post: End-Range Training: Does Closing the Gap Between Active and Passive ROM Prevent Injuries?Online yoga classes & continuing ed workshops with JenniTo find out more about Travis Pollen: website / InstagramMusic used with generous permission from Dischord A Cappella.

Monday was an awful/no good day for the Nats from start to finish as they lost 9-5 to Atlanta. Mark & Al update the latest on Juan Soto as he missed his final at bat after banging his knee in the dugout prior to the top of the 9th. (05:14) Pregame it was announced that Stephen Strasburg is back on the IL due to discomfort after his Saturday bullpen session. We still don't know the results of the MRI, but it seems difficult to maintain an optimistic outlook. He had been previously scheduled to start on Tuesday night. (18:40) Josiah Gray did not start because just before 1st pitch there was a sudden rain delay and the game did not begin until after 8:30pm. Gray had already warmed up just before the rain and so the decision was made to pitch a bullpen game instead. Erasmo Ramirez filled in and made his first start since 2018. (23:20) Jackson Tetreault will take the mound on Tuesday in place of Strasburg. Mark explains the delicate situation Washington is in with their pitching as there is no off-day this week. Learn more about your ad choices. Visit podcastchoices.com/adchoices

It's MRI Day! Our FTD Research mini-series continues! As you know at this point in the mini-series -- we participated in the ALLFTD Study -- Rachael as the participant, and Maria as the study partner... and today's episode recaps our Day 2: The MRI. A long day, but we had a lot of laughs. Everything is an adventure with us, so be sure to listen! Want to learn more about ALLFTD? Visit allftd.org Be sure to connect with us on instagram @remembermepodcast to let us know what you think of today's episode! ------ Special Thanks To Our Sponsor: The Bluefield Project The Bluefield Project to Cure FTD is on a mission to support research to improve our understanding of a genetic form of Frontotemporal Dementia, and to help find a cure for this devastating disease. To achieve our mission, we have supported over 40 researchers at Universities across the world, to understand the science behind FTD caused by mutations in progranulin. We, along with NIH and others, help fund studies of families affected by FTD. These studies are called Natural History Studies and follow participants over time, to better understand how FTD may develop, and to identify clues that may help us treat it. Based in part on our research findings, a number of companies are developing therapeutics that target progranulin FTD. There are now four investigational therapies in clinical trials for progranulin-FTD. So how can you help? If FTD runs in your family, participating in a Natural History Study, or in a therapeutic clinical trial, makes an enormous contribution. To learn more, please go to ftdregistry.org ---- To learn more about Remember Me, visit remembermeftd.com --- Support this podcast: https://anchor.fm/rememberme/support

Feel Good From Within with Yvette Le Blowitz - #SPAITGIRL Podcast  EP.176 - The Awakened Brain with Dr Lisa Miller, Ph.D., Leading Psychologist & Scientist, Columbia Professor and  NYT Bestselling Author The Psychology of Spirituality and our Search for Meaning  Dr Lisa Miller, Ph.D., is the New York Times bestselling author of The Spiritual Child and a professor in the Clinical Psychology Program at Teachers College, Columbia University. Dr Lisa Miller, Ph.D., is a Leading Psychologist and Scientist on Spirituality, Mental Health and Flourishing. She is the founder and director of the Spiritual Mind Body Institute, the first Ivy League program in spirituality and psychology, and has held over a decade of joint appointments in the Department of Psychiatry at Columbia University Medical School. Here innovative research has been published in more than one hundred peer-reviewed articles in leading journals, including Cerebral Cortex, The American Journal of Psychiatry, and the Journal of the American Academy of Child and Adolescent Psychiatry. Dr. Miller is Editor of the Oxford University Press Handbook of Psychology and Spirituality, Founding Co-Editor-in-Chief of the APA Journal Spirituality in Clinical Practice, an elected Fellow of The American Psychological Association (APA) and the two-time President of the APA sOCIETY FOR Psychology and Spirituality. A graduate of Yale University and University of Pennsylvania, where she earned her doctorate under the founder of positive psychology, Martin Seligman, she has served as Principal Investigator on multiple grant funded studies. Dr. Lisa Miller,Ph.D. has spent decades researching the effects of spirituality on the brain. In her book The Awakened Brain, she draws on her clinical experience and award-winning research to show how an active spiritual life can transform our physical and psychological wellbeing. Bringing scientific rigour to the most intangible aspect of our lives, Miller offers insights into the neurological basis for the increased resilience that comes with nurturing spirituality and highlights its measurable positive effects: decreasing the likelihood of depression and substance abuse, and shifting the course of recovery in many other clinical settings. Woven throughout is miller's personal story of how, while confronting her own challenges, her professional pragmatism gave way to a greater appreciation of insights that are important to so many people and yet so often dismissed as unscientific. Brimming with inspiration and compassion, this landmark book will revolutionize your understanding of spirituality, mental health and how we find meaning and purpose in life. Whether it's an uplifting walk in nature, meditation or prayer, there are many ways to experience heightened awareness and escape the relentless demands of modern life. The range of opportunities of this kind suggest that it isn't dependent on faith or religion, but that it's about a different mode of living; an innate spirituality. The Awakened Brain, combines cutting-edge science (from MRI studies to genetic research, epidemiology, and more) with on-the-ground application for people of all ages and from all walks of life, illuminating the surprising science of spirituality and how to engage it in our lives. Absorbing, uplifting, and ultimately enlightening, The Awakened Brain is a conversation-starting saga of scientific discovery packed with counterintuitive findings and practical advice on concrete ways to access your innate spirituality and build a life of meaning and contribution. Yvette Le Blowitz Podcast Host sits down with Dr Lisa Miller, Ph.D., Author of The Awakened Brain  to find out about the ground-breaking exploration of the neuroscience of spirituality a bold new paradigm for health, healing and resilience. In Podcast Episode - EP.176 Dr Lisa Miller,Ph.D. shares: - a little bit about herself - insights into her new book - The Awakened Brain - the neuroscience of spirituality - how an active spiritual life can transform our physical and psychological wellbeing - insights into how spirituality can help to decrease the likelihood of depression and substance abuse - shifting from mental illness recovery to mental health renewal - her own personal story of the power of pray and ancient traditions - the benefits of spending time in nature for our mental health and wellbeing - how to access your innate spirituality - how to build a life of meaning and contribution - her own self-care rituals Plus we talk about so much more........ Get Ready To TUNE IN --- Get Ready to TUNE IN  Episode 176 - #spaitgirl Podcast with Yvette Le Blowitz  available on Apple, Spotify, Google, Audible, Libysn - all podcast apps search for #spaitgirl on any podcast app or on google  -------- Available to watch on Youtube Channel - Spa it Girl or Yvette Le Blowitz Press the Play Button Below and subscribe ------ JOIN OUR #SPAITGIRL BOOK CLUB Buy a copy of The Awakened Brain by Lisa Miller**pre-order through the spaitgirl podcast affiliated BookTopia link *any book purchase via this link will result in a small commission paid by BookTopia to spaitgirl **thanks for your support for more books search via Booktopia our affiliated online book store  *click here Hashtag #spaitgirlbookclub //#spaitgirl + tag @spaitgirl - when reading your book  --- STAY IN TOUCH   Podcast Guest Dr Lisa Miller, Ph.D.   Leading Psychologist and Scientist on Spirituality, Mental Health and Flourishing Columbia Professor NYT Bestselling Author Website www.lisamillerphd.com Instagram: @dr.lisamiller ------ Podcast Host  Yvette Le Blowitz  Instagram @yvetteleblowitz Website www.yvetteleblowitz.com Youtube Channel: Yvette Le Blowitz  TikTok: @yvetteleblowitz ------- Become a Podcast Show Sponsor #SPAITGIRL  www.spaitgirl.com Email: info@spaitgirl.com with your sponsorship offer -- JOIN OUR #SPAITGIRL Community  Instagram: @spaitgirl TikTok: @spaitgirl Sign Up to my Mailing List: www.spaitgirl.com Search for #spaitgirl on any podcast app, youtube and subscribe  ---- HOW TO SUPPORT The #SPAITGIRL Podcast Show  Practice a Little Random Act of Kindness  - subscribe to the #spaitgirl podcast show on any podcast app or youtube channel  - leave a 5* rating and review  - tell someone about the #spaitgirl podcast show - share your favourite episode - tag @spaitgirl in your stories - hashtag #spaitgirl to share the show &  Together "Let's Feel Good From Within" and #makefeelinggoodgoviral ---- Please note - Affiliated Links included in this spaitgirl.com blog post includes affiliated links with Amazon.com and booktopia.com.au- should you order any books from Amazon.com or Booktopia.com.au via the links contained in this blog post spaitgirl.com will receive a small paid commission fee from the online book stores.  Please note - The information in this podcast is a general conversation between the podcast host and podcast guest and is not intended to replace professional medical advice and should not be considered a substitute for medical treatment or advice from a mental health professional or qualified medical doctor or specialist.  Use of any of the material in this podcast show is always at the listeners discretion.   The podcast host and guest accept no liability arising directly or indirectly from use or misuse of any of the information contained in this podcast show and podcast episode conversation, or any trauma triggered or health concerns associated with it. 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Hey Sjogies! It's a HOT minute since you've heard from me and I'm here to fill you in! FYI.... FIREMAN are HOT... shhh... don't tell Brian I said that!Let's SocializeFacebook https://www.facebook.com/SjogrensStrong/Instagram https://www.instagram.com/sjogrens_strong/Twitter https://twitter.com/SjogrensStrongFind us on the Web at https://sjogrensstrong.com/

This week, please join author Christan Mueller, editorialist Christopher deFilippi, and Associate Editor Torbjørn Omland as they discuss the research article "Skeletal Muscle Disorders: A Non-cardiac Source of Cardiac Troponin T" and the editorial "Skeletal Muscle Disorders: A Non-cardiac Source of Cardiac Troponin T." Dr. Greg Hundley: Welcome, listeners, to this June 14, 2022, version of Circulation on the Run. I am Dr. Greg Hundley, associate editor and director of Poly Heart Center at VCU Health in Richmond, Virginia. This week I don't have my good friend Carolyn with me, but we will grab a cup of coffee and work through several of the articles in the issue. Dr. Greg Hundley: Well, first, I want to tell you about the feature discussion today, and we're going to interview with Christian Mueller and talk about the utility of cardiac troponin T and its association with an elevation in those individuals with skeletal muscle disorders, but, before we get to that, let's go through some of the other articles in this issue. Dr. Greg Hundley: Listeners, the first study comes to us from Professor Haidong Kan from Fudan university. These investigators conducted a time stratified, case crossover study among 1,292,000 acute coronary syndrome patients from 2,239 hospitals across 318 Chinese cities between January 1 of 2015 and September 30 of 2020 to determine the associations between sub-daily or hourly levels of criteria air pollutants with the onset of an acute coronary syndrome. Dr. Greg Hundley: Now, hourly concentrations of fine particulate matter, coarse particular matter, nitrogen dioxide, sulfur dioxide, carbon monoxide and ozone were collected, and the hourly onset data of acute coronary syndrome and its subtypes including ST segment elevation myocardial infarction, non-ST segment elevation myocardial infarction and unstable angina were obtained. Dr. Greg Hundley: Listeners, what did the investigators find? Well, their results indicated that transient exposure to the air pollutants of fine particulate matter, nitrogen dioxide, sulfur dioxide, and carbon monoxide, but not coarse particular matter or ozone may trigger the onset of acute coronary syndrome even at concentrations below the World Health Organization Air Quality Guidelines. Now, greater magnitude of associations were observed among patients that were older than 65 years in age or those without a history of smoking or chronic cardiorespiratory diseases and those in the cold seasons. Dr. Greg Hundley: Listeners, next, we're going to move from the study of air pollution to the world of preclinical science. Listeners, this study comes to us from Dr. Ming-Hui Zou from Georgia State University. Indoleamine 2,3-dioxygenase 1 or IDO1 is the rate limiting enzyme for tryptophan metabolism. IDO1 malfunction is involved in the pathogenesis of atherosclerosis, and vascular smooth muscle cells with an osteogenic phenotype promote calcification and features of plaque instability, but it remains unclear whether aberrant IDO1-regulated tryptophan metabolism causes vascular smooth muscle cell osteogenic reprogramming and arterial calcification. Dr. Greg Hundley: Listeners, what did this study find? Well, this investigative team and their results revealed the previously unrecognized protective role of IDO1 in arterial calcification in that vascular smooth muscle cells defective of IDO1 result in enhanced runt-related transcription factor 2 and ectopic calcium deposition in plaques. In contrast, administration of kynurenine via intraperitoneal injection markedly delayed the progression of intimal calcification in parallel with decreased RUNX2 expression. Dr. Greg Hundley: Also, listeners, the authors found that patients with coronary artery calcification have abnormal tryptophan metabolism, and serum IDO1 activity was inversely associated with calcification development in clinical settings, so, listeners, what are the clinical implications here? Well, this work reveals a protective role for IDO1 in mitigating arterial intimal calcification through kynurenine production and then, secondly, developing interventions toward the IDO1 kynurenine RUNX2 access may prevent the pathogenesis of arteriosclerotic complications. Dr. Greg Hundley: Well, listeners, a really interesting article, and now let's turn our attention to some of the other articles in the issue. Well, first, there's a Research Letter from Professor Modarai entitled “A Higher Incidence of Chromosomal Aberrations in Operators Performing a Large Volume of Endovascular Procedures,” and then, also, there is an AHA Update from our exiting AHA president who addresses “What Does the American Heart Association Do (and How Can You Help)?” Well, now, listeners, let's turn now to our feature related to a discussion of the utility of troponin T as well as troponin I in those with skeletal muscle disorders that may also present with acute coronary syndromes. Dr. Greg Hundley: Welcome, listeners, to this June 14 issue, and we're very excited today. We have with us Dr. Christian Mueller from the University Heart Center at Basel, Switzerland, Dr. Torbjorn Omland from the University of Oslo in Oslo, Norway, and Dr. Chris deFilippi from Inova Heart and Vascular Institute in Falls Church, Virginia. Dr. Greg Hundley: Welcome, gentlemen, and, Christian, we'll start with you. Could you describe for us some of the background information that went into your study, and what was the hypothesis that you wanted to address? Dr. Christian Mueller: Thank you very much for giving me the opportunity in this podcast to discuss our study with you and together with Torbjorn and Chris, who both contributed so enormously to the field with their own research. It's about cardiac troponin, cardiac troponin, an essential pillar in our early diagnosis of myocardial infarction. In this specific study, we tried to address possible non-cardiac causes of cardiac troponin T. In our clinical practice, we use and guidelines recommend both cardiac troponin T and I more or less as equivalent in providing identical information and, when going back from the clinical practice to biology, we have learned that, the troponin complex, that it is composed of three isoforms, T, I, and C. Dr. Christian Mueller: While they are very similar in their function, they are distinct regarding amino acid sequence in configuration in cardiac and skeletal muscle. As the cardiac form, of course, is the one that we are interested in, cardiac-specific assays have been developed both for cardiac troponin T and cardiac troponin I. As with any other tests in medicine, they are very good, but they may have limitations, and the specific questions that we had set for this study is whether skeletal muscle disease might be non-cardiac source for cardiac troponin T as measured in blood, therefore, with the possible harm of having false positive increases that could lead to a misdiagnosis of acute myocardial infarction. Dr. Greg Hundley: Very nice. We're trying to understand the utility of cardiac troponin T measures in those individuals that may have concomitant skeletal muscle disorders. Christian, what was your study population, and describe for us your study design? Dr. Christian Mueller: Our study had two components, a clinical component and a translational component. The clinical component included 211 consecutive patients that presented with active and chronic muscle symptoms to a workup either with a rheumatologist or a neurologist or internal medicine specialist, so more or less elective workup for muscle, skeletal muscle symptoms, to have a population that is broad and reflects all possible skeletal muscle disorders, their possible impact on cardiac troponin T concentration. Dr. Christian Mueller: In this population, we quantified cardiac involvement as this is common in some of these musculoskeletal disorders to be either major, minor or are not. They're according to patient history, according to … ECG and cardiac imaging, and we did the measurement of high sensitivity cardiac troponin using the high sensitivity cardiac troponin T assays used all over the world and three high sensitivity cardiac troponin I assays to look for mismatches, the percentage of patients that might have elevated T concentration, but not I as a possible sign that the T might be from the muscle, not the heart, particularly in those patients that didn't have any imaging evidence of cardiac involvement, and then we correlated the amount of high sensitivity cardiac troponin T with the amount of muscle injury as quantified by CK. Dr. Christian Mueller: In the translational part, those patients who have received a skeletal muscle biopsy with quantified by differential gene expression, the MRNA of the cardiac isoform of cardiac troponin T as well as of I in those patients who had the biopsy and matched it and compared it to controls to see whether the cardiac isoform would be upregulated in those with the cases of skeletal muscle disease. Dr. Greg Hundley: Very nice, and so, Christian, was this one single measurement at one point in time or did you have a series of measures over time? Dr. Christian Mueller: In fact, this is a large, ongoing project where patients will receive followup appointments. The current study reports the first phase versus single measurement at a single time point was performed. Dr. Greg Hundley: Very good. Christian, what did you find? Dr. Christian Mueller: We first found that even in those patients with active skeletal muscle disease, cardiac troponin T still reflected the presence of cardiac disease. Those patients with severe cardiac disease did have significantly higher concentration than those patients with mild or with no cardiac disease. That was the good thing. However, the more challenging one for this biomarker in this setting is that high sensitivity cardiac troponin T was significantly higher in these patients as compared to controls. We had the chance to have a couple of thousand controls from another study that presented with non-cardiac chest and no skeletal muscle disease and, while high sensitivity troponin I concentrations were similar, cardiac troponin T was elevated, resulting in a much higher prevalence of elevated T concentration versus elevated I concentration and corresponding mismatches in these patients. Dr. Christian Mueller: In the second part, we were able to show that there was a significant correlation between high sensitively cardiac troponin T with CK quantifying somehow muscle damage while this was not seen in the correlation with high sensitivity I, and that signaled that some of the systemic cardiac troponin T concentration seems to be derived from the muscle. It was confirmed in the translational part of the study in which the differential gene expression showed an eightfold over-expression of cardiac troponin T in skeletal muscle biopsies of those patients with disease, so with active skeletal muscle disease. This … expression correlated with disease activity, a pathological score that quantifies the extent of damage in the skeletal muscle history and correlated with the high sensitivity cardiac troponin T plasma concentration measured with the immunoassay. Dr. Greg Hundley: Very nice. Listeners, it sounds as if, in patients with skeletal muscle disorders, Christian's team observed an elevation in cardiac troponin T, but not necessarily cardiac troponin I, and you've got mechanistic understanding from the biopsies where you see this cardiac troponin T expression in the damaged skeletal muscles. Well, Torbjorn, you have many papers come across your desk. What attracted you to this particular paper? Torbjorn Omland: Thank you, Greg. I think, in general, when I receive papers from circulation, there are three main criteria I consider. The first is whether this is an interesting research question and then, second, whether the study is well-designed and the third is whether they're in themselves are novel, robust and interesting with potential clinical implications. Torbjorn Omland: For this specific papers, I must say it seemed to me to fulfill all these criteria and that it would be able to bring this field forward. The study of re-expression of troponin T in skeletal muscle is not entirely novel because it has been done in small samples, but mainly with rare and neuromuscular diseases previously, but this study broadened that or generalized that to a much more clinically relevant population. The clinical implications also seemed to be much greater than what has been reported by previous papers. Dr. Greg Hundley: Very nice. Listeners, we have in addition to Dr. Omland, we have another expert with us today, Dr. Chris deFilippi, really in the area of biomarkers particularly as they pertain to cardiac injury. Dr. Greg Hundley: Chris, now turning to you, how do we put the context of the results today really with the broader scope of what we have learned about cardiac troponin I and cardiac troponin T and then their use in diagnosing acute ischemic syndromes or even forecasting future cardiovascular events down the road? Dr. Christopher deFilippi: Thank you, Greg, and thank you Circulation for inviting me to participate in this podcast and to write this editorial. First, Christian, this was a terrific paper and one that was probably great to review during the pandemic because, as I spent a good Sunday peeling back layers of the onion and reiterating what Torbjorn said, this paper makes a tremendous contribution where there already was some knowledge to maybe the expression of the cardiac specific troponin T and skeletal muscle, but there's something there for everyone just to get the takeaway message, but for those who really want to delve in, there are supplemental tables that contribute a huge amount of nuance and detail that I think will help guide researchers in the future in maybe how to optimally use cardiac troponin T and troponin I both in the evaluation for acute myocardial infarction and then in a variety of chronic conditions, so first putting this in context of how you would evaluate patients with acute myocardial infarction, and that's the predominant indication for measuring a high sensitivity troponin T or troponin I. Dr. Christopher deFilippi: As Christian in an earlier study has shown and others have shown, actually, the correlation between a high sensitive troponin I by a variety of commercial assays. Troponin T is really pretty good. I think in one study from Christian's group, it was measured at 0.89. Now, the issue that's relevant is more around the edges. People who come in with just a low elevation and, as Christian pointed out and colleagues pointed out in the paper, using the ESC algorithm, a number of those patients would have qualified for myocardial infarction with the skeletal myopathies particularly the myositis or the non-inflammatory myopathy. If there is an index of suspicion for these disorders I think particularly around the cutoff for troponin T, one has to be cautious. Whether one can actually look at serial changes and try to differentiate that way I think is an open question. It may be. Dr. Christopher deFilippi: I think the other thing that gets quite interesting for me in an area that we've delved in over the past decade is the use of high sensitive troponin T or troponin I as a measure of chronic injury that's been codified in the fourth universal definition of MI published four years ago to identify individuals at risk. These can be individuals who are living in the community without known cardiovascular disease or actually without, perhaps, a lot of other comorbidities other than advanced age, for example, who an elevated troponin I or troponin I can be indicative of an increased risk for incident heart failure over the next five to 10 years. It can be patients with other chronic comorbidities. Dr. Christopher deFilippi: Actually, what drew me to this paper and thinking along these lines was a paper that Torbjorn had published back in 2013 where, using the key study which are individuals who have chronic ischemic heart disease without heart failure, he measured both troponin I and troponin T and found there was quite a discordance. There, we're looking at … value of about 0.4 and found that troponin I was a great predictor for the risk of coronary heart disease event and an acute myocardial infarction in the future, but T was not, but both T and I were good predictors of incident heart failure in the future. Dr. Christopher deFilippi: Other investigators, the … investigators, investigators from Scotland have also found this discordance between I and T in chronic ambulatory populations with or without comorbidities, and so it opens an interesting question in individuals with maybe conditions of pre-frailty or frailty or some element of sarcopenia, subclinical skeletal muscle disease. Does this cause this discordance? Ultimately, we know particularly with heart failure, with preserved ejection fraction, it is a systemic disorder, and measures of skeletal muscle disease may be relevant in ultimately determining who's going to have symptomatic heart failure. Dr. Christopher deFilippi: I think it really opens things wide open potentially to further investigation. Is this modifiable? Is it through intervention simply like physical activity? Could you see changes in cardiac troponin T that may be reflecting cardiovascular changes and skeletal muscle changes, but maybe not so much with I, and does this have relevant prognostic implications? I think I was really excited about it based on the defined pragmatic findings with respect to evaluating patients for myocardial infarction who have these underlying skeletal muscle diseases, but also implications, what this might mean in chronic disease populations as well. Dr. Greg Hundley: Very nice. Well, Chris, you've led us really to our next series of questions, and maybe we'll circle back with each of you, first, Christian. What do you see, Christian, as the next study to be performed in this space? Dr. Christian Mueller: I think the next study should address two aspects. The first one is I think we already, with the current population have found that skeletal muscle disease includes various pathologies, and as indicated by Torbjorn, the cardiac troponin T re-expression seems to be at least of our current understanding limited to the two groups of myositis and the muscular dystrophies, whereas the other skeletal muscular disorders at least in those that we have currently investigated did not seem affected. However, we were limited by the number of patients in this subgroup, and so for sure need a larger population to cover all aspects or all classifications of skeletal muscle disease in more detail. Dr. Christian Mueller: The second point that I'd like to highlight is the followup and to look for cardiac events and to look for cardiac changes, functional or anatomical changes in cardiac imaging, because it still may be that some of the T that is more commonly seen in this patient, that the majority of this is derived from the heart, so it's not a black and white, it's only from the muscle or only from the heart. It's still possible that some of the higher concentration of T found in these patients, as in many of the skeletal muscle systemic disorders, they have cardiac involvement which may not be identifiable by current imaging techniques at the first visit. This may become apparent during followup, and so these studies will help us to get a better quantitative understanding, so ideally to understand is it just a tiny amount, I don't know, 10, 20% of the systemic T concentration that is derived from the muscle? Then it would have a very different clinical implication as compared to if, I don't know, more than 50% of the systemic concentration would be derived from the skeletal muscle rather than the heart. Dr. Greg Hundley: Very nice. Torbjorn, I would like to turn to you. What do you see as the next study to be performed in this space? Torbjorn Omland: Oh, I agree with Christian that the serial assessment of changes of disease activity versus troponin changes would be very interesting to study in more detail and also correlate that to changes, for instance, by cardiac MRI if you can see whether there are actually correlations there. Long-term prognostic implications of skeletal muscle derived cardio troponin is another subject, and then, finally, I think that we do need to know even more accurately what is the impact of these alterations on the diagnostic workup in the acute coronary syndrome setting. Is it really a clinically important confounder? I think studies that could address that will be important. Dr. Greg Hundley: Very nice, and then finally Chris, and, Chris, I want to add just another question. Just from my listening to this, if I'm trying to identify someone with an acute ischemic syndrome and then they may also have an underlying skeletal muscle disorder, both Christian was talking about inflammation, but you brought in frailty and things of that nature. Should we really then turn clinically to measuring cardiac troponin I in this setting when we're trying to rule out, for example, acute myocardial infarction? Dr. Christopher deFilippi: Yeah. I don't want to overstate that. I mean, Christian's work and others have shown actually a high sensitive troponin T and a variety of different high sensitive troponin Is in a very heterogeneous chest pain population have been equivalent, looking at receiver operator curves area under the curbs, and so they're probably our people at the margins where this will make a difference, but it should be. Listeners should be reassured at this point because troponin T is a very common assay that it's still quite efficacious and accurate for the diagnosis of acute myocardial infarction from what we know, and a lot of Christian's work has identified this. Dr. Christopher deFilippi: Again, moving into the more chronic disease population outside the evaluation of acute myocardial infarction, maybe where we can use it as a differentiator, it could be helpful in some instances to look at interventions. Earlier work has shown in just small numbers of patients have been published, but patients with hypothyroidism, patients with statin-induced skeletal myopathies, the treatment of these has actually led to a decrease in high sensitive troponin I corresponding with decreases in CK, so there may be opportunities for lifestyle interventions like physical activity, and you could see that response and whether that has prognostic implications. This could be of interest for future research. Dr. Greg Hundley: Very nice. Well, listeners, what an incredible discussion today. We want to thank Dr. Christian Mueller from Universi