Podcasts about PCI

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Latest podcast episodes about PCI

Insight On Business the News Hour
The Business News Headlines 1 December 2022

Insight On Business the News Hour

Play Episode Listen Later Dec 1, 2022 10:52


Welcome to a brand new month and we're glad you are with us.  So did you check the Google Doodle today?  No?  We have a story about that coming up at the tail end of this broadcast.  Also, remember that you can hook up with us all day on Twitter @IOB_NewsHour and on Instagram.  Here's what we've got for you today: Gas Prices and President Biden; What is the PCI? We'll share; Mortgage Rates fall again; This chain is actually lowering prices; McDonald's is conducting a test; Gannett and another round of layoffs; The Wall Street Report; And who is Jerry Lawson?  We'll share! Thanks for listening! The award winning Insight on Business the News Hour with Michael Libbie is the only weekday business news podcast in the Midwest. The national, regional and some local business news along with long-form business interviews can be heard Monday - Friday. You can subscribe on PlayerFM, Podbean, iTunes, Spotify, Stitcher or TuneIn Radio. And you can catch The Business News Hour Week in Review each Sunday Noon on News/Talk 1540 KXEL. The Business News Hour is a production of Insight Advertising, Marketing & Communications. You can follow us on Twitter @IoB_NewsHour. 

Radio Giap Rebelde
Ufo 78 a Macerata, CSA Sisma, 29 ottobre 2022

Radio Giap Rebelde

Play Episode Listen Later Dec 1, 2022 91:47


Wu Ming 1, affiancato da Simone Vecchioni, presenta Ufo 78 al CSA Sisma di Macerata. All'ingresso del centro sociale era parcheggiata una Renault 4 rossa. Si parla di cospirazionismo sugli anni Settanta italiani, inevitabilmente verso la fine si parla del PCI, e forse altrettanto inevitabilmente volano madonne.

MF Economía
Alcances del acuerdo de Paraguay con el FMI/ Proyecto de PGN 2023

MF Economía

Play Episode Listen Later Nov 29, 2022 42:04


Entrevista con el viceministro de Economía del Ministerio de Hacienda, Iván Hass, sobre el acuerdo a nivel técnico del conjunto de políticas macroeconómicas y reformas estructurales que respaldarán el Instrumento de Coordinación de Políticas (PCI). Alcances de las modificaciones al proyecto de Presupuesto General de la Nación para el 2023.

Pass ACLS Tip of the Day
Review The Chain of Survival

Pass ACLS Tip of the Day

Play Episode Listen Later Nov 29, 2022 4:31


The chain of survival for ACLS is the same as was learned in your BLS class.The beginning steps of the Cardiac Emergency and Stroke chain of survival are the same.1. Recognizing the symptoms of a cardiac emergency or stroke;2. Activating an emergency response by calling 9-1-1, or a specialized code team if in the healthcare setting;3. Rapid assessment including 12 lead ECG for cardiac patients or FAST assessment for suspected stroke emergencies; 4. Provide ALS care and transport to the most appropriate facility; for5. Early reperfusion.ACLS's timed goals for first medical contact to PCI for STEMI and door-to-needle for ischemic stroke.Areas with strong EMS relationships, well-defined transport protocols, andspecialized teams that care for the patient in the hospital have significantlybetter patient outcomes. The cardiac arrest chain of survival adds: high quality CPR, early defibrillation, and advanced resuscitation as the next critical links followed by post arrest care and recovery.Connect with me:Website: https://passacls.com@PassACLS on Twitter@Pass-ACLS-Podcast on LinkedInGood luck with your ACLS class!

Infinitum
Nismo dugo ovako dugo

Infinitum

Play Episode Listen Later Nov 27, 2022 104:53


Ep 196Jože Robežnik - JocoHudSpet tipkovnica in ZA RTVAV: Gledam neke polovne iPhone Xs na KP pa ima par oglasa gde piše "Face ID iz čista mira prestao da radi sa iOS 16"Khm, khm...par korisnih linkova šta postoji od iOS 15.2FU na link od ranije, za thread gde ekipa bunari da omogući instalaciju Monterey i Ventura na PCIe 5.0 AM5 chipsetu(potencijalno) objašnjenje otkud problemnovi fix koji ne pačuje ništa nego prosledi custom PCI configuration mask kao boot argsApple Launches Revamped iCloud.com Website With All-New DesignApple Says More about Emergency SOS via Satellite Technology - TidBITSRegulator seizes iPhones from Brazilian retail stores as Apple fails to include charger in boxTim Cook: By 2024, Apple silicon will be manufactured in Arizona | Philip Elmer‑DeWittMajor Apple supplier TSMC's founder confirms advanced 3nm chips will be produced in its new Arizona factoryVMware Fusion 13 released with native support for Apple Silicon MacsMicrosoft Brings Back SwiftKey for iOS, Teases New Features Coming SoonStudy finds nearly 50% of macOS malware comes from one app: MacKeeperSlobodan Marković o važnom novom zakonskom aktuApple close to inking deal for film about Sam Bankman-Fried and FTX collapse'This situation is unprecedented': 10 crazy things detailed in FTX's bankruptcy filingWSJ News Exclusive | Meta Employees, Security Guards Fired for Hijacking User AccountsTekst na Yahoo Finance, za to što je WSJ tekst iza paywalla.Isto na EngadgetuO procenama šta i koliko vrediJust one more good Java engineer is all we needIzvor: Online Platforms and Market Power | U.S. House of Representatives Judiciary Committee (468 kB)A history of ARM, part 2: Everything starts to come togetherPick-Me-Apps: Black Friday Mac Apps Collection 2022ZahvalniceSnimano 26.11.2022.Uvodna muzika by Vladimir Tošić, stari sajt je ovde.Logotip by Aleksandra Ilić.Artwork epizode by Saša Montiljo, njegov kutak na Devianartu.70 x 50 cmulje /oil on canvas2002.

Screaming in the Cloud
Security for Speed and Scale with Ashish Rajan

Screaming in the Cloud

Play Episode Listen Later Nov 22, 2022 35:24


About AshishAshish has over 13+yrs experience in the Cybersecurity industry with the last 7 focusing primarily helping Enterprise with managing security risk at scale in cloud first world and was the CISO of a global Cloud First Tech company in his last role. Ashish is also a keynote speaker and host of the widely poplar Cloud Security Podcast, a SANS trainer for Cloud Security & DevSecOps. Ashish currently works at Snyk as a Principal Cloud Security Advocate. He is a frequent contributor on topics related to public cloud transformation, Cloud Security, DevSecOps, Security Leadership, future Tech and the associated security challenges for practitioners and CISOs.Links Referenced: Cloud Security Podcast: https://cloudsecuritypodcast.tv/ Personal website: https://www.ashishrajan.com/ LinkedIn: https://www.linkedin.com/in/ashishrajan/ Twitter: https://twitter.com/hashishrajan Cloud Security Podcast YouTube: https://www.youtube.com/c/CloudSecurityPodcast Cloud Security Podcast LinkedIn: https://www.linkedin.com/company/cloud-security-podcast/ TranscriptAnnouncer: Hello, and welcome to Screaming in the Cloud with your host, Chief Cloud Economist at The Duckbill Group, Corey Quinn. This weekly show features conversations with people doing interesting work in the world of cloud, thoughtful commentary on the state of the technical world, and ridiculous titles for which Corey refuses to apologize. This is Screaming in the Cloud.Corey: This episode is sponsored in part by our friends at Thinkst Canary. Most folks find out way too late that they've been breached. Thinkst Canary changes this. Deploy canaries and canary tokens in minutes, and then forget about them. Attackers tip their hand by touching them, giving you one alert, when it matters. With zero administrative overhead to this and almost no false positives, Canaries are deployed and loved on all seven continents. Check out what people are saying at canary.love today. Corey: This episode is bought to you in part by our friends at Veeam. Do you care about backups? Of course you don't. Nobody cares about backups. Stop lying to yourselves! You care about restores, usually right after you didn't care enough about backups.  If you're tired of the vulnerabilities, costs and slow recoveries when using snapshots to restore your data, assuming you even have them at all living in AWS-land, there is an alternative for you. Check out Veeam, thats V-E-E-A-M for secure, zero-fuss AWS backup that won't leave you high and dry when it's time to restore. Stop taking chances with your data. Talk to Veeam. My thanks to them for sponsoring this ridiculous podcast.Corey: Welcome to Screaming in the Cloud. I'm Corey Quinn. This promoted episode is brought to us once again by our friends at Snyk. Snyk does amazing things in the world of cloud security and terrible things with the English language because, despite raising a whole boatload of money, they still stubbornly refuse to buy a vowel in their name. I'm joined today by Principal Cloud Security Advocate from Snyk, Ashish Rajan. Ashish, thank you for joining me.Corey: Your history is fascinating to me because you've been around for a while on a podcast of your own, the Cloud Security Podcast. But until relatively recently, you were a CISO. As has become relatively accepted in the industry, the primary job of the CISO is to get themselves fired, and then, “Well, great. What's next?” Well, failing upward is really the way to go wherever possible, so now you are at Snyk, helping the rest of us fix our security. That's my headcanon on all of that anyway, which I'm sure bears scant, if any, resemblance to reality, what's your version?Ashish: [laugh]. Oh, well, fortunately, I wasn't fired. And I think I definitely find that it's a great way to look at the CISO job to walk towards the path where you're no longer required because then I think you've definitely done your job. I moved into the media space because we got an opportunity to go full-time. I spoke about this offline, but an incident inspired us to go full-time into the space, so that's what made me leave my CISO job and go full-time into democratizing cloud security as much as possible for anyone and everyone. So far, every day, almost now, so it's almost like I dream about cloud security as well now.Corey: Yeah, I dream of cloud security too, but my dreams are of a better world in which people didn't tell me how much they really care about security in emails that demonstrate how much they failed to care about security until it was too little too late. I was in security myself for a while and got out of it because I was tired of being miserable all the time. But I feel that there's a deep spiritual alignment between people who care about cost and people who care about security when it comes to cloud—or business in general—because you can spend infinite money on those things, but it doesn't really get your business further. It's like paying for fire insurance. It isn't going to get you to your next milestone, whereas shipping faster, being more effective at launching a feature into markets, that can multiply revenue. That's what companies are optimized around. It's, “Oh, right. We have to do the security stuff,” or, “We have to fix the AWS billing piece.” It feels, on some level, like it's a backburner project most of the time and it's certainly invested in that way. What's your take on that?Ashish: I tend to disagree with that, for a couple reasons.Corey: Excellent. I love arguments.Ashish: I feel this in a healthy way as well. A, I love the analogy of spiritual animals where they are cost optimization as well as the risk aversion as well. I think where I normally stand—and this is what I had to unlearn after doing years of cybersecurity—was that initially, we always used to be—when I say ‘we,' I mean cybersecurity folks—we always used to be like police officers. Is that every time there's an incident, it turns into a crime scene, and suddenly we're all like, “Pew, pew, pew,” with trying to get all the evidence together, let's make this isolated as much—as isolated as possible from the rest of the environment, and let's try and resolve this.I feel like in Cloud has asked people to become more collaborative, which is a good problem to have. It also encourages that, I don't know how many people know this, but the reason we have brakes in our cars is not because we can slow down the car; it's so that we can go faster. And I feel security is the same thing. The guardrails we talk about, the risks that you're trying to avert, the reason you're trying to have security is not to slow down but to go faster. Say for example in an ideal world, to quote what you were saying earlier if we were to do the right kind of encryption—I'm just going to use the most basic example—if we just do encryption, right, and just ensure that as a guardrail, the entire company needs to have encryption at rest, encryption in transit, period, nothing else, no one cares about anything else.But if you just lay that out as a framework and this is our guardrail, no one brakes this, and whoever does, hey we—you know, slap on the wrist and come back on to the actual track, but keep going forward. That just means any project that comes in that meets [unintelligible 00:04:58] criteria. Keeps going forward, as many times we want to go into production. Doesn't matter. So, that is the new world of security that we are being asked to move towards where Amazon re:Invent is coming in, there will be another, I don't know, three, four hundred services that will be released. How many people, irrespective of security, would actually know all of those services? They would not. So, [crosstalk 00:05:20]—Corey: Oh, we've long since passed the point where I can convincingly talk about AWS services that don't really exist and not get called out on it by Amazon employees. No one keeps them on their head. Except me because I'm sad.Ashish: Oh, no, but I think you're right, though. I can't remember who was it—maybe Andrew Vogel or someone—they didn't release a service which didn't exist, and became, like, a thing on Twitter. Everyone—Corey: Ah, AWS's Infinidash. I want to say that was Joe Nash out of Twilio at the time. I don't recall offhand if I'm right on that, but that's how it feels. Yeah, it was certainly not me. People said that was my idea. Nope, nope, I just basically amplified it to a huge audience.But yeah, it was a brilliant idea, just because it's a fake service so everyone could tell stories about it. And amazing product feedback, if you look at it through the right lens of how people view your company and your releases when they get this perfect, platonic ideal of what it is you might put out there, what do people say about it?Ashish: Yeah. I think that's to your point, I will use that as an example as well to talk about things that there will always be a service which we will be told about for the first time, which we will not know. So, going back to the unlearning part, as a security team, we just have to understand that we can't use the old ways of, hey, I want to have all the controls possible, cover all there is possible. I need to have a better understanding of all the cloud services because I've done, I don't know, 15 years of cloud, there is no one that has 10, 15 years of cloud unless you're I don't know someone from Amazon employee yourself. Most people these days still have five to six years experience and they're still learning.Even the cloud engineering folks or the DevOps folks, they're all still learning and the tooling is continuing to evolve. So yeah, I think I definitely find that the security in this cloud world a lot more collaborative and it's being looked at as the same function as a brake would have in car: to help you go faster, not to just slam the brake every time it's like, oh, my God, is the situation isolated and to police people.Corey: One of the points I find that is so aligned between security and cost—and you alluded to it a minute ago—is the idea of helping companies go faster safely. To that end, guardrails have to be at least as easy as just going off and doing it cow-person style. Because if it's not, it's more work in any way, shape, or form, people won't do it. People will not tag their resources by hand, people will not go through and use the dedicated account structure you've got that gets in their way and screams at them every time they try to use one of the native features built into the platform. It has to get out of their way and make things easier, not worse, or people fight it, they go around it, and you're never going to get buy-in.Ashish: Do you feel like cost is something that a lot more people pay a lot more attention to because, you know, that creeps into your budget? Like, as people who've been leaders before, and this was the conversation, they would just go, “Well, I only have, I don't know, 100,000 to spend this quarter,” or, “This year,” and they are the ones who—are some of them, I remember—I used to have this manager, once, a CTO would always be conscious about the spend. It's almost like if you overspend, where do you get the money from? There's no money to bring in extra. Like, no. There's a set money that people plan for any year for a budget. And to your point about if you're not keeping an eye on how are we spending this in the AWS context because very easy to spend the entire money in one day, or in the cloud context. So, I wonder if that is also a big driver for people to feel costs above security? Where do you stand on that?Corey: When it comes to cost, one of the nice things about it—and this is going to sound sarcastic, but I swear to you it's not—it's only money.Ashish: Mmm.Corey: Think about that for a second because it's true. Okay, we wound up screwing up and misconfiguring something and overspending. Well, there are ways around that. You can call AWS, you can get credits, you can get concessions made for mistakes, you can sign larger contracts and get a big pile of proof of concept credit et cetera, et cetera. There are ways to make that up, whereas with security, it's there are no do-overs on security breaches.Ashish: No, that's a good point. I mean, you can always get more money, use a credit card, worst case scenario, but you can't do the same for—there's a security breach and suddenly now—hopefully, you don't have to call New York Times and say, “Can you undo that article that you just have posted that told you it was a mistake. We rewinded what we did.”Corey: I'm curious to know what your take is these days on the state of the cloud security community. And the reason I bring that up is, well, I started about a year-and-a-half ago now doing a podcast every Thursday. Which is Last Week in AWS: Security Edition because everything else I found in the industry that when I went looking was aimed explicitly at either—driven by the InfoSec community, which is toxic and a whole bunch of assumed knowledge already built in that looks an awful lot like gatekeeping, which is the reason I got out of InfoSec in the first place, or alternately was completely vendor-captured, where, okay, great, we're going to go ahead and do a whole bunch of interesting content and it's all brought to you by this company and strangely, all of the content is directly align with doing some pretty weird things that you wouldn't do unless you're trying to build a business case for that company's product. And it just feels hopelessly compromised. I wanted to find something that was aimed at people who had to care about security but didn't have security as part of their job title. Think DevOps types and you're getting warmer.That's what I wound up setting out to build. And when all was said and done, I wasn't super thrilled with, honestly, how alone it still felt. You've been doing this for a while, and you're doing a great job at it, don't get me wrong, but there is the question that—and I understand they're sponsoring this episode, but the nice thing about promoted guest episodes is that they can buy my attention, not my opinion. How do you retain creative control of your podcast while working for a security vendor?Ashish: So, that's a good question. So, Snyk by themselves have not ever asked us to change any piece of content; we have been working with them for the past few months now. The reason we kind of came along with Snyk was the alignment. And we were talking about this earlier for I totally believe that DevSecOps and cloud security are ultimately going to come together one day. That may not be today, that may not be tomorrow, that may not be in 2022, or maybe 2023, but there will be a future where these two will sit together.And the developer-first security mentality that they had, in this context from cloud prospective—developers being the cloud engineers, the DevOps people as you called out, the reason you went in that direction, I definitely want to work with them. And ultimately, there would never be enough people in security to solve the problem. That is the harsh reality. There would never be enough people. So, whether it's cloud security or not, like, for people who were at AWS re:Inforce, the first 15 minutes by Steve Schmidt, CSO of Amazon, was get a security guardian program.So, I've been talking about it, everyone else is talking about right now, Amazon has become the first CSP to even talk about this publicly as well that we should have security guardians. Which by the way, I don't know why, but you can still call it—it is technically DevSecOps what you're trying to do—they spoke about a security champion program as part of the keynote that they were running. Nothing to do with cloud security, but the idea being how much of this workload can we share? We can raise, as a security team—for people who may be from a security background listening to this—how much elevation can we provide the risk in front of the right people who are a decision-maker? That is our role.We help them with the governance, we help with managing it, but we don't know how to solve the risk or close off a risk, or close off a vulnerability because you might be the best person because you work in that application every day, every—you know the bandages that are put in, you know all the holes that are there, so the best threat model can be performed by the person who works on a day-to-day, not a security person who spent, like, an hour with you once a week because that's the only time they could manage. So, going back to the Snyk part, that's the mission that we've had with the podcast; we want to democratize cloud security and build a community around neutral information. There is no biased information. And I agree with what you said as well, where a lot of the podcasts outside of what we were finding was more focused on, “Hey, this is how you use AWS. This is how you use Azure. This is how you use GCP.”But none of them were unbiased in the opinion. Because real life, let's just say even if I use the AWS example—because we are coming close to the AWS re:Invent—they don't have all the answers from a security perspective. They don't have all the answers from an infrastructure perspective or cloud-native perspective. So, there are some times—or even most times—people are making a call where they're going outside of it. So, unbiased information is definitely required and it is not there enough.So, I'm glad that at least people like yourself are joining, and you know, creating the world where more people are trying to be relatable to DevOps people as well as the security folks. Because it's hard for a security person to be a developer, but it's easy for a developer or an engineer to understand security. And the simplest example I use is when people walk out of their house, they lock the door. They're already doing security. This is the same thing we're asking when we talk about security in the cloud or in the [unintelligible 00:14:49] as well. Everyone is, it just it hasn't been pointed out in the right way.Corey: I'm curious as to what it is that gets you up in the morning. Now, I know you work in security, but you're also not a CISO anymore, so I'm not asking what gets you up at 2 a.m. because we know what happens in the security space, then. There's a reason that my area of business focus is strictly a business hours problem. But I'd love to know what it is about cloud security as a whole that gets you excited.Ashish: I think it's an opportunity for people to get into the space without the—you know, you said gatekeeper earlier, those gatekeepers who used to have that 25 years experience in cybersecurity, 15 years experience in cybersecurity, Cloud has challenged that norm. Now, none of that experience helps you do AWS services better. It definitely helps you with the foundational pieces, definitely helps you do identity, networking, all of that, but you still have to learn something completely new, a new way of working, which allows for a lot of people who earlier was struggling to get into cybersecurity, now they have an opening. That's what excites me about cloud security, that it has opened up a door which is beyond your CCNA, CISSP, and whatever else certification that people want to get. By the way, I don't have a CISSP, so I can totally throw CISSP under the bus.But I definitely find that cloud security excites me every morning because it has shown me light where, to what you said, it was always a gated community. Although that's a very huge generalization. There's a lot of nice people in cybersecurity who want to mentor and help people get in. But Cloud security has pushed through that door, made it even wider than it was before.Corey: I think there's a lot to be said for the concept of sending the elevator back down. I really have remarkably little patience for people who take the perspective of, “Well, I got mine so screw everyone else.” The next generation should have it easier than we did, figuring out where we land in the ecosystem, where we live in the space. And there are folks who do a tremendous job of this, but there are also areas where I think there is significant need for improvement. I'm curious to know what you see as lacking in the community ecosystem for folks who are just dipping their toes into the water of cloud security.Ashish: I think that one, there's misinformation as well. The first one being, if you have never done IT before you can get into cloud security, and you know, you will do a great job. I think that is definitely a mistake to just accept the fact if Amazon re:Invent tells you do all these certifications, or Azure does the same, or GCP does the same. If I'll be really honest—and I feel like I can be honest, this is a safe space—that for people who are listening in, if you're coming to the space for the first time, whether it's cloud or cloud security, if you haven't had much exposure to the foundational pieces of it, it would be a really hard call. You would know all the AWS services, you will know all the Azure services because you have your certification, but if I was to ask you, “Hey, help me build an application. What would be the architecture look like so it can scale?”“So, right now we are a small pizza-size ten-people team”—I'm going to use the Amazon term there—“But we want to grow into a Facebook tomorrow, so please build me an architecture that can scale.” And if you regurgitate what Amazon has told you, or Azure has told you, or GCP has told you, I can definitely see that you would struggle in the industry because that's not how, say every application is built. Because the cloud service provider would ask you to drink the Kool-Aid and say they can solve all your problems, even though they don't have all the servers in the world. So, that's the first misinformation.The other one too, for people who are transitioning, who used to be in IT or in cybersecurity and trying to get into the cloud security space, the challenge over there is that outside of Amazon, Google, and Microsoft, there is not a lot of formal education which is unbiased. It is a great way to learn AWS security on how amazing AWS is from AWS people, the same way Microsoft will be [unintelligible 00:19:10], however, when it comes down to actual formal education, like the kind that you and I are trying to provide through a podcast, me with the Cloud Security Podcast, you with Last Week in AWS in the Security Edition, that kind of unbiased formal education, like free education, like what you and I are doing does definitely exist and I guess I'm glad we have company, that you and I both exist in this space, but formal education is very limited. It's always behind, say an expensive paid wall sometimes, and rightly so because it's information that would be helpful. So yeah, those two things. Corey: This episode is sponsored in part by our friends at Uptycs. Attackers don't think in silos, so why would you have siloed solutions protecting cloud, containers, and laptops distinctly? Meet Uptycs - the first unified solution prioritizes risk across your modern attack surface—all from a single platform, UI, and data model. Stop by booth 3352 at AWS re:Invent in Las Vegas to see for yourself and visit uptycs.com. That's U-P-T-Y-C-S.com. Corey: One of the problems that I have with the way a lot of cloud security stuff is situated is that you need to have something running to care about the security of. Yeah, I can spin up a VM in the free tier of most of these environments, and okay, “How do I secure a single Linux box?” Okay, yes, there are a lot of things you can learn there, but it's very far from a holistic point of view. You need to have the infrastructure running at reasonable scale first, in order to really get an effective lab that isn't contrived.Now, Snyk is a security company. I absolutely understand and have no problem with the fact that you charge your customers money in order to get security outcomes that are better than they would have otherwise. I do not get why AWS and GCP charge extra for security. And I really don't get why Azure charges extra for security and then doesn't deliver security by dropping the ball on it, which is neither here nor there.Ashish: [laugh].Corey: It feels like there's an economic form of gatekeeping, where you must spend at least this much money—or work for someone who does—in order to get exposure to security the way that grownups think about it. Because otherwise, all right, I hit my own web server, I have ten lines in the logs. Now, how do I wind up doing an analysis run to figure out what happened? I pull it up on my screen and I look at it. You need a point of scale before anything that the modern world revolves around doesn't seem ludicrous.Ashish: That's a good point. Also because we don't talk about the responsibility that the cloud service provider has themselves for security, like the encryption example that I used earlier, as a guardrail, it doesn't take much for them to enable by default. But how many do that by default? I feel foolish sometimes to tell people that, “Hey, you should have encryption enabled on your storage which is addressed, or in transit.”It should be—like, we have services like Let's Encrypt and other services, which are trying to make this easily available to everyone so everyone can do SSL or HTTPS. And also, same goes for encryption. It's free and given the choice that you can go customer-based keys or your own key or whatever, but it should be something that should be default. We don't have to remind people, especially if you're the providers of the service. I agree with you on the, you know, very basic principle of why do I pay extra for security, when you should have already covered this for me as part of the service.Because hey, technically, aren't you also responsible in this conversation? But the way I see shared responsibility is that—someone on the podcast mentioned it and I think it's true—shared responsibility means no one's responsible. And this is the kind of world we're living in because of that.Corey: Shared responsibility has always been an odd concept to me because AWS is where I first encountered it and they, from my perspective, turn what fits into a tweet into a 45-minute dog-and-pony show around, “Ah, this is how it works. This is the part we're responsible for. This is the part where the customer responsibility is. Now, let's have a mind-numbingly boring conversation around it.” Whereas, yeah, there's a compression algorithm here. Basically, if the cloud gets breached, it is overwhelmingly likely that you misconfigured something on your end, not the provider doing it, unless it's Azure, which is neither here nor there, once again.The problem with that modeling, once you get a little bit more business sophistication than I had the first time I made the observation, is that you can't sit down with a CISO at a company that just suffered a data breach and have your conversation be, “Doesn't it suck to be you—[singing] duh, duh—because you messed up. That's it.” You need that dog-and-pony show of being able to go in-depth and nuance because otherwise, you're basically calling out your customer, which you can't really do. Which I feel occludes a lot of clarity for folks who are not in that position who want to understand these things a bit better.Ashish: You're right, Corey. I think definitely I don't want to be in a place where we're definitely just educating people on this, but I also want to call out that we are in a world where it is true that Amazon, Azure, Google Cloud, they all have vulnerabilities as well. Thanks to research by all these amazing people on the internet from different companies out there, they've identified that, hey, these are not pristine environments that you can go into. Azure, AWS, Google Cloud, they themselves have vulnerabilities, and sometimes some of those vulnerabilities cannot be fixed until the customer intervenes and upgrades their services. We do live in a world where there is not enough education about this as well, so I'm glad you brought this up because for people who are listening in, I mean, I was one of those people who would always say, “When was the last time you heard Amazon had a breach?” Or, “Microsoft had a breach?” Or, “Google Cloud had a breach?”That was the idea when people were just buying into the concept of cloud and did not trust cloud. Every cybersecurity person that I would talk to they're like, “Why would you trust cloud? Doesn't make sense.” But this is, like, seven, eight years ago. Fast-forward to today, it's almost default, “Why would you not go into cloud?”So, for people who tend to forget that part, I guess, there is definitely a journey that people came through. With the same example of multi-factor authentication, it was never a, “Hey, let's enable password and multi-factor authentication.” It took a few stages to get there. Same with this as well. We're at that stage where now cloud service providers are showing the kinks in the armor, and now people are questioning, “I should update my risk matrix for what if there's actually a breach in AWS?”Now, Capital One is a great example where the Amazon employee who was sentenced, she did something which has—never even [unintelligible 00:25:32] on before, opened up the door for that [unintelligible 00:25:36] CISO being potentially sentenced. There was another one. Because it became more primetime news, now people are starting to understand, oh, wait. This is not the same as it used to be. Cloud security breaches have evolved as well.And just sticking to the Uber point, when Uber has that recent breach where they were talking about, “Hey, so many data records were gone,” what a lot of people did not talk about in that same message, it also mentioned the fact that, hey, they also got access to the AWS console of Uber. Now, that to me, is my risk metrics has already gone higher than where it was before because it just not your data, but potentially your production, your pre-prod, any development work that you were doing for, I don't know, self-driving cars or whatever that Uber [unintelligible 00:26:18] is doing, all that is out on the internet. But who was talking about all of that? That's a much worse a breach than what was portrayed on the internet. I don't know, what do you think?Corey: When it comes to trusting providers, where I sit is that I think, given their scale, they need to be a lot more transparent than they have been historically. However, I also believe that if you do not trust that these companies are telling you the truth about what they're doing, how they're doing it, what their controls are, then you should not be using them as a customer, full stop. This idea of confidential computing drives me nuts because so much of it is, “Well, what if we assume our cloud provider is lying to us about all of these things?” Like, hypothetically there's nothing stopping them from building an exact clone of their entire control plane that they redirect your request to that do something completely different under the hood. “Oh, yeah, of course, we're encrypting it with that special KMS key.” No, they're not. For, “Yeah, sure we're going to put that into this region.” Nope, it goes right back to Virginia. If you believe that's what's going on and that they're willing to do that, you can't be in cloud.Ashish: Yeah, a hundred percent. I think foundational trust need to exist and I don't think the cloud service providers themselves do a great job of building that trust. And maybe that's where the drift comes in because the business has decided they're going to cloud. The cyber security people are trying to be more aware and asking the question, “Hey, why do we trust it so blindly? I don't have a pen test report from Amazon saying they have tested service.”Yes, I do have a certificate saying it's PCI compliant, but how do I know—to what you said—they haven't cloned our services? Fortunately, businesses are getting smarter. Like, Walmart would never have their resources in AWS because they don't trust them. It's a business risk if suddenly they decide to go into that space. But the other way around, Microsoft may decides tomorrow that they want to start their own Walmart. Then what do you do?So, I don't know how many people actually consider that as a real business risk, especially because there's a word that was floating around the internet called supercloud. And the idea behind this was—oh, I can already see your reaction [laugh].Corey: Yeah, don't get me started on that whole mess.Ashish: [laugh]. Oh no, I'm the same. I'm like, “What? What now?” Like, “What are you—” So, one thing I took away which I thought was still valuable was the fact that if you look at the cloud service providers, they're all like octopus, they all have tentacles everywhere.Like, if you look at the Amazon of the world, they not only a bookstore, they have a grocery store, they have delivery service. So, they are into a lot of industries, the same way Google Cloud, Microsoft, they're all in multiple industries. And they can still have enough money to choose to go into an industry that they had never been into before because of the access that they would get with all this information that they have, potentially—assuming that they [unintelligible 00:29:14] information. Now, “Shared responsibility,” quote-unquote, they should not do it, but there is nothing stopping them from actually starting a Walmart tomorrow if they wanted to.Corey: So, because a podcast and a day job aren't enough, what are you going to be doing in the near future given that, as we record this, re:Invent is nigh?Ashish: Yeah. So, podcasting and being in the YouTube space has definitely opened up the creative mindset for me. And I think for my producer as well. We're doing all these exciting projects. We have something called Cloud Security Villains that is coming up for AWS re:Invent, and it's going to be released on our YouTube channel as well as my social media.And we'll have merchandise for it across the re:Invent as well. And I'm just super excited about the possibility that media as a space provides for everyone. So, for people who are listening in and thinking that, I don't know, I don't want to write for a blog or email newsletter or whatever the thing may be, I just want to put it out there that I used to be excited about AWS re:Invent just to understand, hey, hopefully, they will release a new security service. Now, I get excited about these events because I get to meet community, help them, share what they have learned on the internet, and sound smarter [laugh] as a result of that as well, and get interviewed where people like yourself. But I definitely find that at the moment with AWS re:Invent coming in, a couple of things that are exciting for me is the release of the Cloud Security Villains, which I think would be an exciting project, especially—hint, hint—for people who are into comic books, you will definitely enjoy it, and I think your kids will as well. So, just in time for Christmas.Corey: We will definitely keep an eye out for that and put a link to that in the show notes. I really want to thank you for being so generous with your time. If people want to learn more about what you're up to, where's the best place for them to find you?Ashish: I think I'm fortunate enough to be at that stage where normally if people Google me—and it's simply Ashish Rajan—they will definitely find me [laugh]. I'll be really hard for them not find me on the internet. But if you are looking for a source of unbiased cloud security knowledge, you can definitely hit up cloudsecuritypodcast.tv or our YouTube and LinkedIn channel.We go live stream every week with a new guest talking about cloud security, which could be companies like LinkedIn, Twilio, to name a few that have come on the show already, and a lot more than have come in and been generous with their time and shared how they do what they do. And we're fortunate that we get ranked top 100 in America, US, UK, as well as Australia. I'm really fortunate for that. So, we're doing something right, so hopefully, you get some value out of it as well when you come and find me.Corey: And we will, of course, put links to all of that in the show notes. Thank you so much for being so generous with your time. I really appreciate it.Ashish: Thank you, Corey, for having me. I really appreciate this a lot. I enjoyed the conversation.Corey: As did I. Ashish Rajan, Principal Cloud Security Advocate at Snyk who is sponsoring this promoted guest episode. I'm Cloud Economist Corey Quinn, and this is Screaming in the Cloud. If you've enjoyed this podcast, please leave a five-star review on your podcast platform of choice, whereas if you've hated this podcast, please leave a five-star review on your podcast platform of choice, along with an insulting comment pointing out that not every CISO gets fired; some of them successfully manage to blame the intern.Corey: If your AWS bill keeps rising and your blood pressure is doing the same, then you need The Duckbill Group. We help companies fix their AWS bill by making it smaller and less horrifying. The Duckbill Group works for you, not AWS. We tailor recommendations to your business and we get to the point. Visit duckbillgroup.com to get started.Announcer: This has been a HumblePod production. Stay humble.

Circulation on the Run
Circulation November 22, 2022 Issue

Circulation on the Run

Play Episode Listen Later Nov 21, 2022 19:50


This week, please author Jung-Minh Ahn and Associate Editor Emmanouil Brilakis as they discuss the article "Everolimus-Eluting Stents or Bypass Surgery for Multivessel Coronary Artery Disease: Extended Follow-Up Outcomes of Multicenter Randomized Controlled BEST Trial." Dr. Greg Hundley: Welcome, listeners to this November 22 issue of Circulation on the Run. And I am Dr. Greg Hundley, Director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr. Peder Myhre: And I am Dr. Peder Myhre from Akershus University Hospital and University of Oslo in Norway, and also a social media editor interpolation. Dr. Greg Hundley: Well Peder, our feature this week, we are reviewing a comparison between drug eluting stents and bypass surgery for multi vessel coronary artery disease. Really an extended follow up from the Vest trial. Dr. Peder Myhre: I can't wait, Greg. Dr. Greg Hundley: Right. But before we get onto that, how about we grab a cup of coffee and jump into some of the other articles in the issue? Would you like to go first? Dr. Peder Myhre: Sure, I'd love to. And the first paper today is a clinical one and it is entitled, “Efficacy of a Drug Eluting Stent Versus Bare Metal Stents for Symptomatic Femoropopliteal Peripheral Artery Disease: Primary Results of the Eminent Randomized Trial.” And it comes to us from the corresponding author Yann Gouëffic from Groupe Hospitalier Paris St. Joseph in France. So Greg, a clear patency benefit of a drug eluting stent over bare metal stents for treating peripheral artery disease of the femoropopliteal segment has not been definitely demonstrated. But today's paper publishes the primary results of the eminent randomized trials, which was designed to evaluate the patency of the Eluvia drug eluting stent. And this stent is a polymer based paclitaxel eluting stent and it was compared with bare metal stents for the treatment of femoropopliteal artery lesions. In fact, with 775 patients, Eminent is the largest randomized trial of drug eluting stent treatment for symptomatic femoropopliteal arterial disease to report patency to dates. Dr. Greg Hundley: Very nice, Peder. So describe for us, what were the results of this very large randomized clinical trial? Dr. Peder Myhre: Sure, Greg. So the primary effectivity outcome was primary patency at 12 months, defined as independent core laboratory assessed duplex ultrasound peak systolic velocity ratio less than or equal to 2.4 in the absence of clinically driven target lesion revascularization or surgical bypass of the target lesions. And primary effectiveness analysis from the Eminent randomized study demonstrated superior one year primary patency for the Eluvia drug eluting stent versus bare metal stent. And that is 83.2% versus 74.3% with a P value less than 0.01. And this treatment was associated with a greater incident of Rutherford classification improvement without the need for re-intervention, and functional parameters demonstrated improvements in both groups, and there were no statistical difference observed in one year mortality between patients treated with the Eluvia drug eluting stents and bare metal stents. So in summary, this high level evidence supports the one year benefit of polymer based paclitaxel elusion over bare metal stents to treat superficial femoral artery and/or proximal popliteal artery lesions. What'd you think of that, Greg? Dr. Greg Hundley: Very nice. So sounds like for peripheral arterial interventions, a benefit from the polymer based paclitaxel eluting stents. Dr. Peder Myhre: Exactly. And there's also an editorial putting these results in context from Doctors Mosarla and Secemsky entitled, “From Imperialism to Eminence: The Noble Rise of the Second Generation Peripheral Drug Eluting Stents.” Dr. Greg Hundley: Excellent, Peder. Well, my article comes to us, Peder, from the world of preclinical science. And Peder, these investigators led by Professor Volker Spindler from University of Basel evaluated arrhythmogenic cardiomyopathy. And as you know, arrhythmogenic cardiomyopathy is characterized by progressive loss of cardiomyocytes with fibrofatty tissue replacement, systolic dysfunction, and life threatening arrhythmias. So a substantial proportion of arrhythmogenic cardiomyopathy is caused by mutations in genes of the desmosomal cell to cell adhesion complex, but the underlying mechanisms are not well understood. So to address this, the team mutated the binding site of desmoglein two, a crucial desmosomal adhesion molecule in cardiomyocytes. This desmoglein two W2A mutation abrogates the tryptophan swab, a central interaction mechanism of desmogenin two based on structural data. Now, the impaired adhesive function of this DSG2W2A was confirmed by cell to cell dissociation assays and for spectroscopy measurements by atomic force microscopy. Dr. Peder Myhre: Wow. We continue to learn more about this disease, arrhythmogenic cardiomyopathy. And this sounds so interesting. Greg, please tell me what did they find? Dr. Greg Hundley: Right, Peder. So they found that the DSG2W2A mutation impaired binding on the molecular level and compromised intercellular adhesive function. Now, mice bearing this mutation, developed a severe cardiac phenotype recalling the characteristics of arrhythmogenic cardiomyopathy including cardiac fibrosis, impaired systolic function, and arrhythmia. Now, a comparison of the transcriptome of the mutant mice with arrhythmogenic cardiomyopathy patient data suggested deregulated integrin alpha V beta six and subsequent TGF beta signaling as a driver of cardiac fibrosis. Now accordingly, blocking integrin alpha V beta six led to reduced expression of pro-fibrotic markers and reduced fibrosis formation in the mutant animals in vivo. Dr. Peder Myhre: Oh, this is so important mechanistically. And Greg, can you please tell us something about the clinical importance of these findings? Dr. Greg Hundley: Right Peder, just like Carolyn always driving at that clinical significance. So these authors show now that disruption of desmosomal adhesion is sufficient to induce a phenotype which fulfills the clinical criteria to establish the diagnosis of arrhythmogenic cardiomyopathy confirming the dysfunctional adhesion hypothesis. Now mechanistically, deregulation of integrin alpha V beta six and TGF beta signaling was identified as a central step in the process toward developing fibrosis. And then finally, a pilot in vivo drug test revealed this pathway as a promising target to ameliorate fibrosis. So perhaps, new information leading to future therapeutic strategies to halt myocardial fibrosis in patients with arrhythmogenic cardiomyopathy. Dr. Peder Myhre: Oh wow. What an amazing issue this is, Greg, and we actually have even more in the mail bag. We have a Perspective piece by Dr. Prystowsky entitled “Rate versus Rhythm Control for Atrial Fibrillation, Has the Debate Been Settled?” And we have some Cardiology News by Bridget Kuehn entitled, “Fitness Rather than BMI Appears to be Better Predictor of Survival for Women with Heart Disease.” I'm sure Carolyn would love to read that one. And in this paper, Bridget Kuehn discusses a new study published in European Journal of Preventive Cardiology. Dr. Greg Hundley: Very nice, Peder. Well, I've got a couple other articles in the issue. First, Dr. Tonelli has a Primer entitled, “Increasing Societal Benefit from Cardiovascular Drugs.” And then Professor Januzzi has a Research Letter entitled, “Association Between Sacubitril/Valsartan Initiation in Mitral Regurgitation Severity and Heart Failure with Reduced Ejection Fraction: The PROVE HF Study.” Well, now let's get on to that feature discussion in this issue to discuss PCI versus CABG for multi vessel coronary artery disease. Dr. Peder Myhre: Let's go. Dr. Greg Hundley: Welcome listeners to this November 22nd feature discussion and we have with us today Dr. Jung-Min Ahn from Seoul, South Korea and our own associate editor, Dr. Manos Brilakis from Minneapolis, Minnesota. Welcome gentlemen. Jung-Min, we'll start with you. Can you describe for us some of the background information that went into the preparation of your study and what was the hypothesis that you wanted to address? Dr. Jung-Min Ahn: Thank you, Greg. So the everolimus-eluting stent Freedom trial, showed a higher mortality after PCI than after bypass surgery in multi vessel disease. However, these findings maybe delimited predictability in the contemporary practice because such trials use the first generation drug stent which may have higher rate of stent thrombosis. The Press trial is the first randomized trial using the second-generation drug eluting stent. The initial approach was published in New England Journal of Medicine five years ago. So they showed that the 4.6 years of follow the PCI with everolimus-eluting stents showed a significantly higher rate of prime endpoint deaths, MI, the target revascularization, but overall mortality, there was no significant difference. So the hypothesis that, in a long term follow, more than 10 years follow, so we want to see the mortality difference between the PCI with the second generation everolimus-eluting stent versus bypass surgery. So we designed this extended follow trial best studies. Dr. Greg Hundley: Very nice, Jung-Min. And can you describe for us the study design, and who was your study population, and how many subjects did you enroll? Dr. Jung-Min Ahn: Actually, this study is the extended follow original Press trial, enrolled 880 patients from mostly Korea, China, Malaysia, and Thailand. So the study population was Asian population with a symptomatic or symptomatic coronary artery disease with angiopathy confirming the multi vessel coronary artery disease population. One additional criteria is the patient with coronary artery disease should report PCI and bypass surgery decided by the attending physicians and surgeons. Dr. Greg Hundley: Thank you, Jung-Min. And so, can you describe for us your study results? Dr. Jung-Min Ahn: Yes. During the extended follow-up study we found that there is no significant difference between the PCI with everolimus-eluting stent and bypass surgery regarding prime endpoint deaths, MI, vascularization. In addition, more importantly, we reduced the compost endpoint of death, MI, stroke. There was no significant difference in addition regarding the mortality. Also, there is no significant difference during the long term follow. Dr. Greg Hundley: Really interesting results, Jung-Min. Did you notice any differences in men versus women or in younger versus older individuals? Dr. Jung-Min Ahn: In our sub-group analysis, there is no interaction according to the sub-groups except the diabetic sub-groups. In diabetics and long term outcomes, have interaction with the treatment assignment regarding the primary endpoint, prime endpoints, death, MI, target vascularization. Even though contrary to the Freedom trial, the overall mortality rate, there is no significant difference between the PCI versus the bypass surgery even in diabetic populations. Dr. Greg Hundley: Well thank you so much, Jung-Min. And now listeners, we're going to turn to our Associate Editor, our expert in the area of advanced percutaneous coronary artery interventions, Dr. Manos Brilakis from Minneapolis, Minnesota. Manos, you have many papers come across your desk. What attracted you to this particular paper and how do you put its results in the context of other studies that have been performed to compare multi vessel percutaneous coronary artery intervention versus coronary artery bypass grafting? Dr. Manos Brilakis: Yeah, thank you, Greg. And again, congratulations to Jung-Min for a great paper. And the reason we were very interested in this paper is because it is an area that is still debated clinically quite extensively. As Jung-Minh mentioned, there is the Syndex trial showing that there was higher mortality amongst the PCI group over long term, but that was done a long time ago with previous generation drug diluting stents, and the data, the contemporary data with recently the currently used DS, is much more limited. So I think the appeal for us, and I think frankly for the practicing interventionalist, is that this paper provides long term outcomes with contemporary drug eluting stents over a fairly large patient population, and it does so fairly well, but there are plus and minuses. There was no difference in mortality, which continues to be debated. But this paper is fairly equivalent on this respect. And if we see the coupled myo curves, they also look very similar. And there was some differences in death in myocardial infarction to be taken into consideration. But all this information is important for deciding for each patient we treat right now, which is the best way to go in terms of coronary devascularization. Dr. Greg Hundley: Very nice. And so, let's circle back next to Jung-Min. What do you see as the next research study really to be performed in this sphere of investigation? Dr. Jung-Min Ahn: Thank you, Greg. So I'd like to talk about the future study, but I'd like to say something about the how to do PCI. So what is the difference between the Press trial and previous randomized trial? In the Pres trial, we used the intracoronary imaging in 72% of PCI population. This is a huge higher rate than what was used compared with the previous randomized trial. Only 10% or less than 10% PCI population used intracoronary imaging. So I think to get the comparable research to the bypass surgery, I think we have to optimize the PCR region. What is the best way shortcut to get optimizing PCR region? It could be intracoronary imaging guided PCI, could be one important way to get optimized PCR region. I think this is very important to take a message from the first trial. Dr. Greg Hundley: Well, Jung-Min, it sounds like from your description that the application of intracoronary imaging was very important in this study. Do you want to expand on that for our listeners? You know, what were maybe some subgroup analysis results of using intracoronary ultrasound? And then, how would you recommend to our listening audience that that particular technique be applied? Dr. Jung-Min Ahn: Thank you, Greg. So I mentioned that the Press trial used the intravascular ultrasound in 72% of PCI. So we analyzed the the PCI with I, without I. PCI with I showed a very comparable primary endpoint and overall mortality rate to the bypass surgery group. But PCI without I showed a significantly higher rate of primary endpoint and overall mortalities. So intravascular ultrasound guided PCI may improve the PCI outcomes and we can compare our clinical outcomes to the bypass surgery. Dr. Greg Hundley: Very nice. And Manos, do you have anything to add? Dr. Manos Brilakis: Yeah, I think the era of doing multiple huge mega trials may be tough to find these days. I think we may not have big trials comparing those two modalities, but I do agree with Junh Minh. I think the conclusion from this study as well as the previous studies is that you can choose which way to go. But if you're going to go with PCI for example, you do want to make sure that you do the best possible outcome so that you use intravascular imaging, you use physiology. We know from phase three, that use of intravascular imaging was very limited. So if you're going to go with PCI for a specific patient, the decision of course depends on the study's results and the previous studies and the patients' specific preferences. But if you're going to do PCI, you want to take your time to get the best possible result, make sure you can get as complete revascularization as possible because that will translate into better clinical outcomes as well. Dr. Greg Hundley: Very nice. Well listeners, we want to thank our main author today, Dr. Jung-Min Anh, and our own associate editor, Dr. Manos Brilakis, for bringing us this important study highlighting that in patients with multi vessel coronary artery disease, there were no significant differences between PCI and coronary artery bypass grafting in the incidence of major adverse cardiac events, the safety composite endpoint, and all cause mortality during an extended follow up period. Well, on behalf of Peder, Carolyn, and myself, we want to wish you a great week and we will catch you next week On the Run. Dr. Greg Hundley: This program is copyright of the American Heart Association 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

Weiss Advice
Set Realistic Expectations In Partnerships With Anthony Pinto

Weiss Advice

Play Episode Listen Later Nov 17, 2022 32:51


Anthony Pinto owns and manages Pinto Capital Investments (PCI), a real estate investment firm focused on acquiring affordable and workforce multifamily properties and apartment buildings through syndications. Since 2019, PCI has gone full cycle on 2 large apartment complexes (+100 units) with IRR in excess of 85%.[00:01 - 07:18] Opening SegmentWe welcome, Anthony Pinto!Anthony started looking into real estate investing in 2019 and found that the apartment-building model was more scalable than buying single-family homesHis journey to becoming a real estate investor[07:19 - 25:44] Set Realistic Expectations In PartnershipsThe importance of timeline and financial freedomPrioritization is key when it comes to becoming a successful real estate investorUnderstanding who your partners areIt's important to set realistic expectations for yourself when partnering with others in a syndicationHave a lead sponsor who is doing their job well[25:45 - 32:50] THE FINAL FOURWhat's the worst job that you ever had?Working at a pizza shopWhat's a book you've read that has given you a paradigm shift?“Blue Ocean Strategy” by W. Chan KimWhat is a skill or talent that you would like to learn?He wants to learn how to fly a helicopter or a planeWhat does success mean to you?Anthony says, “Success is being able to not have to worry about money and being able to have the time freedom to go spend a day with my daughter.”Connect with Anthony PintoLinkedIn: Anthony PintoFacebook: Anthony PintoYouTube: Pinto Capital InvestmentsSpotify: The Lessons In Real Estate ShowLEAVE A 5-STAR REVIEW by clicking this link.WHERE CAN I LEARN MORE?Be sure to follow me on the below platforms:Subscribe to the podcast on Apple, Spotify, Google, or Stitcher.LinkedInYoutubeExclusive Facebook Groupwww.yonahweiss.comNone of this could be possible without the awesome team at Buzzsprout. They make it easy to get your show listed on every major podcast platform.Tweetable Quotes:“You need to really understand who you're getting into bed with. Even if you've done multiple deals with them, even if you've done all these things with them.” – Anthony Pinto“You need to figure out what their values are and make sure that they match yours rather than trying to fill a hole for each other.” – Anthony PintoSupport the show

Partially Redacted: Data Privacy, Security & Compliance
Inside PCI DSS and Privacy for Payments with Skyflow's Bjorn Ovick

Partially Redacted: Data Privacy, Security & Compliance

Play Episode Listen Later Nov 16, 2022 49:10


The Payment Card Industry Data Security Standard (PCI DSS) is an information security standard for organizations that handle branded credit cards from the major card schemes. It was introduced to create a level of protection for card issuers by ensuring that merchants meet minimum levels of security when they store, process, and transmit cardholder data and ultimately reduce fraud. Merchants that wish to accept payments need to be PCI compliant. Without PCI compliance, the merchant not only risks destroying customer trust in the case of a data breach, but they risk fines and potentially being stopped from being able to accept payments. Payment processors like Stripe, Adyen, Braintree, and so on, help offload PCI compliance by providing PCI compliant infrastructure available through simple APIs.  Bjorn Ovick, Head of Fintech at Skyflow, formerly of Wells Fargo, Visa, Samsung, and American Express, holds over 20 patents related to payment applications. He joins the show to share his background, thoughts on the evolution of technology in this space, break down PCI DSS, payment processors, and how Skyflow helps not only offload PCI compliance but gives businesses flexibility to work with multiple payment processors. Topics: Can you share a bit about your background and how did you end up working in the financial industry? You also have over 20 patents for payment applications, what are some of those patents? So you are Head of Fintech Business and Growth at Skyflow, what does that consist of and how did you come to work at Skyflow? Can you talk a bit about the evolution and change of the fintech market from when you started your career to today? What is PCI DSS and where did it come from? How does a company achieve PCI DSS compliance? What's a company's responsibilities with respect to PCI compliance? What's it take to build out PCI compliant infrastructure? What happens if you violate PCI compliance? How do you offload PCI compliance and still accept payments? What is PCI tokenization? What patterns do you see in payments and what should someone consider as they build their payment stack? Why would a merchant use multiple payment processors? How does a company use multiple payment processors? What is network tokenization and how does that improve privacy and security? What is 3D secure? What are the big gaps in terms of payment processing today? What problems still need to be solved? Where do you see the payment technology industry going in the next 5-10 years? Where should someone looking to learn more about the payments space go? Resources: Network Tokenization: Everything You Need to Know Multiple Payment Gateways: The Why and How

HeartTalk
Ballonudvidelse (PCI)

HeartTalk

Play Episode Listen Later Nov 14, 2022 24:38


I Danmark laves ca. 9500 ballonudvidelser årligt. Hvad er en ballonudvidelse og hvornår er ballonudvidelse nødvendig? Overlæge Lene Holmvang forklarer om indgrebet, om blodfortyndende medicin og om den første tid efter udskrivelsen. Læge Marie Bayer Elming er vært.

The Gavel Podcast
Veteran's Day and Military Service with Josh Causey (Middle Tennessee State)

The Gavel Podcast

Play Episode Listen Later Nov 9, 2022 49:25


The Gavel Podcast is the official podcast of Sigma Nu Fraternity, Inc. and is dedicated to keeping you updated on the operations of the Legion of Honor and connecting you to stories from our brotherhood. To find out more from the Fraternity, you can always check out our website at www.sigmanu.org. Also consider following us on: Facebook | Instagram | LinkedIn | Twitter | YouTube | FlickrHave feedback or a question about this episode? Want to submit an idea for a future topic you'd like to see covered? Contact the Gavel Podcast team at news@sigmanu.org. Hosts for this EpisodeChristopher Brenton (North Carolina State) - Director of CommunicationsAdam Girtz (North Dakota State) - Director of Chapter ServicesGuests for this EpisodeJosh Causey (Middle Tennessee State) - Brigade Operations Officer; United States ArmyPlugs and ResourcesRegistration for College of Chapters - College of Chapters is an intense, interactive program for our collegiate chapter and colony Commanders focusing on chapter management, leadership, and core competencies.Registration for Grand Chapter - The Grand Chapter is the Fraternity's legislative conclave taking place every two years. Work for Sigma Nu Fraternity as a Leadership Consultant - Applications are due each year by October 15 (the early decision deadline) and March 1.Our Story: The Oral History Project of Sigma Nu Fraternity - The Fraternity has partnered with Publishing Concepts (PCI) to help collect stories from our brothers. PCI will contact alumni via mailed postcard, phone, and email asking them to participate by updating their contact information and sharing their Sigma Nu experience. These stories will be preserved in a book that celebrates Sigma Nu's impact.

Pass ACLS Tip of the Day
Prehospital Capabilities and EMS Destination Protocols for STEMI & Stroke

Pass ACLS Tip of the Day

Play Episode Listen Later Nov 9, 2022 5:34


The chain of survival for a cardiac emergency and stroke start the same:1. preparedness & recognition of an emergency; 2. activation of EMS; 3. delivery of Advanced Life Support; and4. transporting to the most appropriate facility.Depending on where you live, Emergency Medical Services (EMS) may provide prehospital Advanced Life Support (ALS).ALS ambulances are staffed with paramedics who have training in ACLS skills. Paramedics can perform an assessment, obtain a medical history, and provide life-saving care within minutes of recognition.Why EMS "Destination Protocols" for suspected stroke and STEMI make adifference. ACLS's timed benchmarks for:point of first medical contact to PCI for ST elevation MI;door to tPA for ischemic stroke; andonset of symptoms to EVT for LVO strokes.EMS may bypass a close hospital to transport a STEMI or suspected stroke patient to a more appropriate hospital - one capable of 24/7 PCI or a certified stroke center; because time is heart muscle or brain cells.Check out the Pod Resource page at passacls.com for links to the "EMS On Air" podcast for links to episodes that look at EMS's role in stroke outcomes in the rural vs urban area. Connect with me:Website: https://passacls.com@PassACLS on Twitter@Pass-ACLS-Podcast on LinkedInGood luck with your ACLS class!

Cybersecurity Sense
PCI SSC Community Meeting Top Takeaways

Cybersecurity Sense

Play Episode Listen Later Nov 8, 2022 28:45


In this podcast, Host William Parks discusses with LBMC Information Security Senior Managers Andy Kerr and Kyle Hinterberg some of the top takeaways at this year's PCI SSC Community Meeting. Topics discussed during this episode include changes to the “In-Place with Remediation” reporting option which was added in PCI DSS v4.0, what to do if you miss an ASV Scan, new ways to interact with the PCI Council, SAQ updates, and much more!

Cardionerds
240. CardioNerds Rounds: Challenging Cases – Antithrombotic Management with Dr. Deepak Bhatt

Cardionerds

Play Episode Listen Later Nov 3, 2022 46:54


It's another session of CardioNerds Rounds! In these rounds, Dr. Priya Kothapalli (Interventional FIT at University of Texas at Auston, Dell Medical School) joins Dr. Deepak Bhatt (Dr. Valentin Fuster Professor of Medicine and Director of Mount Sinai Heart) to discuss the nuances of antithrombotic therapy. As one of the most prolific cardiovascular researchers, clinicians, and educators, CardioNerds is honored to have Dr. Bhatt on Rounds, especially given that Dr. Bhatt has led numerous breakthroughs in antithrombotic therapy. Come round with us today by listening to the episodes of #CardsRounds! Audio editing by CardioNerds Academy Intern, Dr. Christian Faaborg-Andersen. This episode is supported with unrestricted funding from Zoll LifeVest. A special thank you to Mitzy Applegate and Ivan Chevere for their production skills that help make CardioNerds Rounds such an amazing success. All CardioNerds content is planned, produced, and reviewed solely by CardioNerds. Case details are altered to protect patient health information. CardioNerds Rounds is co-chaired by Dr. Karan Desai and Dr. Natalie Stokes.  Speaker disclosures: None Challenging Cases - Atrial Fibrillation with Dr. Hugh Calkins CardioNerds Rounds PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Show notes - Antithrombotic Management with Dr. Deepak Bhatt Case #1 Synopsis: A woman in her early 70s with a history of hypertension, hyperlipidemia, and paroxysmal atrial fibrillation presented with sudden-onset chest pressure and diaphoresis while at rest and was found to have an acute thrombotic 99% mid-LAD occlusion. The patient received OCT-guided PCI with a single drug-eluting stent. We discussed what the appropriate antithrombotic strategy would be for a patient with recent acute coronary syndrome and atrial fibrillation. Case #1Takeaways According to the recent 2021 revascularization guidelines, in patients with atrial fibrillation undergoing PCI and taking oral anticoagulant therapy, it is recommended to discontinue aspirin after 1 to 4 weeks while maintaining P2Y12 inhibitors in addition to a non-vitamin K oral anticoagulant or warfarin.There are two recent trials – AUGUSTUS and the ENTRUST-AF PCI trial – that evaluated regimens of apixaban and edoxaban, respectively, that support earlier findings reporting lower bleeding rates in patients maintained on oral anticoagulant plus a P2Y12 inhibitor compared to triple therapy.Of note, none of these trials were specifically powered for ischemic endpoints, but when pooling data from these trials, rates of death, MI and stent thrombosis with dual therapy were similar to those seen in patients on triple therapy.Additionally, all of these patients enrolled in these trials were briefly treated with triple therapy after PCI before the aspirin was discontinued. In the 2021 guidelines, it is noted that analyses of stent thrombosis suggest that 80% of events occur within 30 days of PCI. Thus, it is reasonable to consider extending triply therapy to 1 month after PCI in high risk patients to reduce risk of stent thromboses.In AUGUSTUS, 90% of patients received clopidogrel as their P2Y12 inhibitor Case #2 Synopsis: A man in his mid-50s with a history of peripheral vascular disease with prior SFA stent for chronic limb ischemia, hyperlipidemia, tobacco use, diabetes, and chronic kidney disease presented with a two day history of “reflux” that was worse with exertion and that improved with rest and associated with diaphoresis. He was diagnosed with an NSTEMI. His LHC revealed 99% mid-RCA thrombotic occlusion with moderate disease in the LAD. He underwent thrombectomy and PCI with a single drug-eluting stent to the RCA. We discussed his short-term and long-term antithrombotic therapy Case #2 Takeaways

Circulation on the Run
Circulation November 1, 2022 Issue

Circulation on the Run

Play Episode Listen Later Oct 31, 2022 23:38


This week, please join authors Kevin Roedl and Sebastian Wolfrum, as well as Associate Editor Mark Link as they discuss the article "Temperature Control After In-Hospital Cardiac Arrest: A Randomized Clinical Trial." Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary, and backstage pass to the Journal and its editors. We are your cohosts. I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center, and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, Associate Editor and Director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Well, Carolyn, this week's feature, very interesting, a randomized clinical trial of temperature control after in-hospital cardiac arrest. But before we get to that exciting study, let's grab a cup of coffee, and jump in and discuss some of the other articles in the issue. Carolyn, would you like to go first? Dr. Carolyn Lam: Yes. Starting with a great quiz. So Greg, which is better? How about this? It's multiple choice. Is it A; transradial, or B; transfemoral access, in terms of post-procedural mortality? Dr. Greg Hundley: I'm going to go with transradial. It has been, hopefully, I'm okay on this. It just seems so many fewer complications. Dr. Carolyn Lam: But that's exactly that we need to meta-analyze the studies that have been done. Exactly what this paper did, led by Professor Valgimigli, from USI in Lugano, Switzerland. So what they did is, they performed an individual patient data meta-analysis of 21,600 patients, enrolled in seven multi-center randomized control trials, comparing the transradial with transfemoral access, among patients undergoing coronary angiography with or without PCI. And they found that transradial access was associated with a lower incidence of the primary outcome of all-cause mortality, and the co-primary outcome of major bleeding at 30 days, compared to transfemoral access. There was also evidence for reductions in major adverse cardiac and cerebral vascular events, net adverse clinical events, vascular complications, excess site bleeding, and blood transfusion. MI, stroke, and stent thrombosis, did not differ. And crossover was higher in the transradial access group. At predefined subgroup analysis, the authors confirmed that the benefit observed the transradial group was generally consistent across the majority of pre-specified subgroups, except for those with significant baseline anemia. Patients with baseline anemia appear to derive a substantial mortality benefit with transradial access rather than transoral access, compared to those with mild or no anemia. So, the authors concluded, that the meta-analysis provides evidence that transradial access should be considered the preferable access site for PCI, in patients with acute coronary syndrome, supporting most recent recommendations on the preferential use of this radial approach. So you were right, Greg. Dr. Greg Hundley: Very nice, Carolyn. A really important piece of science to disclose to our listeners, in that hurried state, and moving quickly door to balloon times, et cetera. And here we find another positive outcome in study result for transradial approaches. Well Carolyn, as we know, my next paper, it's really going to come to us from the world of preclinical science. And it pertains to hypertension, which is a common cardiovascular disease, and is related to both genetic and environmental factors. But the mechanisms linking the interplay between the domains of genetics and the environment have not been well studied. Now, DNA methylation, a classical epigenetic modification, not only regulates gene expression, but is also quite susceptible to environmental factors. Thereby, linking environmental factors to genetic modifications. So therefore, Carolyn, these authors, including Professor Jingzhou Chen, from Fuwai Hospital, National Center for Cardiovascular Diseases, and the Chinese Academy of Medical Sciences, and the Peking Union Medical College, and their colleagues, felt that screening differential genomic DNA methylation, in subjects with hypertension, would be important for investigating this genetic environment interplay in hypertension. So this study, Carolyn, like many from the world of preclinical science and circulation, incorporated both human and animal model subjects. Methodologically differential genomic DNA methylation in hypertensive, pre-hypertensive, and healthy control individuals, was screened using the Illumina 450K BeadChip, and then verified by pyrosequencing. Plasma oviduct glycoprotein 1, or OVGP1 levels, were determined using an enzyme-linked immunosorbent assay. And OVGP1 transgenic and knockout mice were generated to analyze the function of OVGP1. Dr. Carolyn Lam: Wow. Nice approach, Greg. And what did the authors find? Dr. Greg Hundley: Right, Carolyn. These authors found a hypomethylated site at cg20823859 in the promoter region of OVGP1, and the plasma OVGP1 levels were significantly increased in hypertensive patients. This finding indicates that OVGP1 is associated with hypertension. Now Carolyn, in OVGP1 transgenic mice, OVGP1 over expression caused an increase in blood pressure. Also, dysfunctional vasoconstriction, and vasodilation, remodeling of the arterial walls, and increased vascular superoxide stress and inflammation. And these phenomenon were exacerbated by angiotensin II infusion. In contrast, OVGP1 deficiency, attenuated angiotensin II induced vascular oxidase, stress, inflammation, and collagen deposition. Now pull down, and co-immunoprecipitation assays showed that myosin heavy chain 2A, or MYH9, interacted with OVGP1. Whereas, inhibition of MYH9 attenuated OVGP1 induced hypertension and vascular remodeling. Dr. Carolyn Lam: So Greg, let me try to summarize, is that okay? So hypomethylation, at that specific site in the promoter region of the OVGP1 gene, is associated with hypertension, and induces its upregulation. The interaction of this OVGP1 with myosin heavy chain 2A contributes to vascular remodeling and dysfunction. And so, OVGP1 is a pro hypertensive factor, that promotes vascular remodeling by binding to this myosin heavy chain. So, really cool stuff. Thanks for teaching us. Dr. Greg Hundley: Very good. Dr. Carolyn Lam: Well thanks so much, Greg. And we go back to the clinical world now, and ask the question, what is the efficacy and safety of prophylactic full dose anticoagulation and antiplatelet therapy, in critically ill COVID-19 patients? So I'm going to tell you the results of the COVID-PACT trial. And this was a multi-center, two-by-two factorial, open label, randomized controlled trial, with blinded endpoint adjudication in 390 ICU level patients. So, severely ill patients with COVID-19, from 34 US centers. Patients were randomized to a strategy of full dose anticoagulation, or standard dose prophylactic anticoagulation. And in the absence of an indication for antiplatelet therapy, patients were additionally randomized to either clopidogrel or no antiplatelet therapy. Dr. Greg Hundley: Ah, Carolyn. So what did they find? Dr. Carolyn Lam: Full dose anticoagulation substantially reduced the proportion of patients experiencing a venous or arterial thrombotic event, and there was no benefit from treatment with clopidogrel. Severe bleeding events were rare, but numerically increased in patients on full dose versus standard dose prophylactic anticoagulation, without any fatal bleeding events, GUSTO moderate or severe bleeding was so significantly increased with full dose anticoagulation, but with no difference in all-cause mortality. So in summary, in a population of critically ill patients with COVID-19, a strategy of prophylaxis with full dose, versus standard dose prophylactic anticoagulation, but not the addition of clopidogrel, reduced thrombotic complications, with an increased risk of bleeding, driven primarily by transfusions in hemodynamically stable patients, with no apparent excess in mortality. Dr. Greg Hundley: Very nice, Carolyn. What a important piece of information, as many of us around the world are taking care of critically ill patients with COVID-19. Well, how about we see what is in the mail bag this week? So first, Carolyn, there's a Frontiers piece by Dr. Packer, entitled, “Critical Reanalysis of the Mechanisms Underlying the Cardiorenal Benefits of SGLT2 inhibitors, and Reaffirmation of the Nutrient Deprivation Signaling Autophagy Hypothesis.” Next, there's a Research Letter, from Professor Airaksinen entitled, “Novel Troponin Fragmentation Assay to Discriminate Between Troponin Elevations in Acute Myocardial Infarction and End-stage Renal Disease.” Carolyn, there's another Research Letter, from Professor Solomon, entitled, “Aptamer Proteomics for Biomarker Discovery in Heart Failure with Reduced Ejection Fraction.” Also, Carolyn, [a] wonderful Cardiovascular News summary from Tracy Hampton, reviewing three articles. First, “Mechanisms Behind Cannabis Effects on Heart Health.” The second, “Exercise Inducible Metabolite Suppresses Hunger.” And then lastly, “Piezo1 Initiates the Cardiomyocyte Hypertrophic Response to Pressure Overload.” Dr. Carolyn Lam: Cool. There's also an exchange of letters between Doctors Jha and Borlaug on latent pulmonary vascular disease in therapeutic atrial shunt. And finally, an On My Mind, by Dr. David Kass entitled, “What's EF Got To Do, Got To Do With It.” I love it. You must read it. It's so, so cool. All right. But now, let's go on to our feature discussion, shall we? Dr. Greg Hundley: You bet, Carolyn.   Welcome listeners, to our feature discussion today, and really delving into the world of in-hospital cardiac arrest, and how we manage those patients. And we have with us today, Dr. Kevin Roedl from Hamburg, Germany, Dr. Sebastian Wolfrum from Lubeck, Germany, and our own associate editor, Dr. Mark Link from University of Texas Southwestern in Dallas, Texas. Welcome gentlemen. Kevin, we're going to start with you. Can you describe for us, some of the background information that went into the construct of your study, and what was the hypothesis that you wanted to address? Dr. Kevin Roedl: Thank you, Greg. We thank you for the kind invitation to this podcast. We're very likened to do this podcast with you. And so, talking about the background of hypothermia in-hospital cardiac arrest, we have to go back like two decades almost, because there were two studies in New England Journal of Medicine published 2002, who introduced mild therapeutic hyperthermia to the treatment in post cardiac arrest. Primary, these two studies show the benefit of the therapy in this kind of patients. And then, 2003, it was introduced in also the international guidelines. However, these studies only addressed out-of-hospital cardiac arrest patients, and also, only shockable rhythms. And so, the question arised over the years, what about other patients like non shockable rhythms, or also in-hospital cardiac arrest? And so, that's basically was the primary aim of our study to address this special population. Because when you see the states, the numbers, there are 290,000 in-hospital cardiac arrests a year. So it's actually, a very large population. And there's no randomized control trial to show any benefit, or maybe harm, in this group. There were some observational studies, 2016 in China published. From China, in this group, they looked at the Get With The Guidelines registry, and actually, they saw that there was probably a negative influence of hypothermia in the study. However, it was only observational. So actually, there were no randomized control trials. And that primary hypothesis was, that we wanted to know actually, does thus mild therapeutic hyperthermia work in this group of patients in the in-hospital cardiac arrest setting? And what is the outcome? Is it like in the out-of-hospital cardiac arrest setting, or not? Dr. Greg Hundley: Wonderful, Kevin. And so, can you describe for us then, your study population and your study design? Dr. Kevin Roedl: Yes, of course. We did a randomized control trial. There were over 1000 people screened, and overall, we included 242. So you see how hard it is to get people in there. And actually, in terms of hypothermic temperature control, we are 120 about, and long term at 118, and the final others of the endpoints. And when we look at the baseline characters of these patients, they were well balanced actually, about 72 years. When we look at the initial cardiac arrest rhythm, that's interesting because about 70% non-shockable rhythms, and 25% shockable rhythms. And probably also interesting, the location of the cardiac arrest. Medical boards about 50%, and ICU or ED was 22%. So that's probably summed up the baseline characteristics of our study. Dr. Greg Hundley: Perfect. And so Kevin, can you describe for us what was the hypothermic target for the group that was going to have their temperature recused? Dr. Kevin Roedl: Yes, hypodermic target was 32 degrees to 44. And so two degrees Celsius, basically the same target like in earlier trials. Dr. Greg Hundley: Very nice. Well listeners, now we're going to turn to our second co-author, Dr. Sebastian Wolfrum. And Sebastian, can you share with us the study results? Dr. Sebastian Wolfrum: Yes, Greg. Thank you very much for the opportunity to participate in this podcast. Only wanted to include unconscious patients, and therefore, we took a time and took 45 minutes after their cardiac arrest, to let the patients get away if they did so. We also excluded patients that had severe functional deficit before the cardiac arrest; since we could not really define the neurological outcome if we would've included those. And we didn't see any differences. Neither in mortality, not in the functional outcome, either when they're treated with 33 degrees Celsius, or whether normothermia was used. The death rate after six month was in a range which is comparable to other in-hospital cardiac arrest studies, and higher than those performed in the out-of-hospital cardiac arrest studies. It was about slightly over 70% in both groups. And the number of patients with the good functional recovery after six months was 23% of the patients in the hypothermia group, and 24% of the patients in the normothermia group. And if we look at only the survivors, we see that the ones which are worse functional outcome, were most of them dead after six months. We then also focused on the temperature curves in our patients, and to see whether we have achieved our goal. And we saw that we have reached the target temperature within four and a half hours after cardiac arrest in our hypothermia group. Which is not as fast that we had expected, but still in the range, which is comparable to other studies on this field. And we also saw that our control group was about 37 degrees, within the first 12 and 48 hours. So we truly avoided fever, which has not been done in every previous study on cardiac arrests. Dr. Greg Hundley: Very nice. And any differences between the hypothermia and normothermia groups, related to the age of the patient? Or, whether or not they had a shockable rhythm at the time of presentation? Dr. Sebastian Wolfrum: We saw as a result of our study, that age is a predictive factor for mortality. But age did not differ between our treatment groups, and therefore, did not interfere with our results. And we didn't see differences in the shockable or non-shockable rate in our patients in the different treatment groups.   Dr. Greg Hundley: Thank you. Well listeners, now we're going to turn to our associate editor, Dr. Mark Link, one of our expert electrophysiologists at Circulation. And Mark, you have many papers come across your desk, and what attracted you to this particular paper? Dr. Mark Link: There were a number of things. One, it's hard to do RCTs in resuscitation, and I thought they did a very nice job with this RCT. Two, the subject of hypothermia, or therapeutic temperature management, is a very hot one in resuscitation. It's one of the few treatments in the past that have been shown to make a difference in outcome. And so, all of those trials were done in out-of-hospital arrest. So to have a trial done in in-hospital arrest was very intriguing also. And I think we're all disappointed that it wasn't a positive trial, but we have to take the negative trials also. And I think, part of the reason it may have been a negative trial is because the normal thermic group avoided hyperthermia. And I think that's something that's coming out of a lot of these trials is avoid fever. It may not be so important to get hypothermic targets, actually, looks like it's probably not, but it looks like it's very important to avoid fever. Dr. Greg Hundley: Very nice. Well listeners, we're going to turn back to our expert panel here really, and start with you Kevin. Kevin, what do you think is the next study that needs to be performed in this sphere of research? Dr. Kevin Roedl: Thank you for this interesting question. Yeah, a bunch of studies could be performed, especially maybe in the out-of-hospital cardiac arrest study, because we don't know. This fever harmful, we have to find certain subgroups in which this treatment works. So maybe in this subgroups there is data on this and it could be a benefit. So these are, I think, the two main topics that should be done in the future. Dr. Greg Hundley: Thank you. Sebastian, what are your thoughts? Dr. Sebastian Wolfrum: As Mark said, the hypothermic treatment was, for decades, maybe the only treatment which we could give to cardiac arrest patients, which has been proven to reduce mortality. And all other studies following didn't see any be benefit of hypothermia, not even in a subgroup. Also, the TTM trials did not. So I'm questioning myself, where is the original HACA study group that benefits? Where did this hide in the other studies? So I would think, to do another study in out-of-hospital cardiac arrest patients, whether in ventricular fibrillation that had shown in the HACA trial to reduce mortality. This should be done in a similar way to the original study, to see whether there is this subgroup. People who support the idea of hypothermia also focus very much on the fast onset of their hypothermic treatment. And they say we saw a difference in mortality in the HACA trial, and we could very fast. And I think the other studies have to show that they cool as fast as the HACA study. So the main focus should be on the time calls of hypothermia after cardiac arrest, cooling very fast to a target temperature of 33 degrees, maybe holding on for 24, maybe 48 hours. Dr. Greg Hundley: Very nice, Sebastian. So focusing on the speed and the timing of that cooling. And Mark, anything to add? Dr. Mark Link: Yeah, so if I sit here with my writing group hat on for the HA and say, "What are we going to do for the resuscitation guidelines in 2025?" I think you look at the totality of the data for targeted temperature management. And I think, the main thing you say, walking away from this, is avoid fever. Don't let your patients get hot. I'm not sure you can say much more than that right now, until we get more data. Dr. Greg Hundley: Very nice. Well listeners, a really interesting provocative discussion today. And we want to thank Dr. Kevin Roedl from Hamburg, Germany, Dr. Sebastian Wolfrum from Lubeck, Germany, and our own associate editor, Dr. Mark Link from Dallas, Texas, bringing us the results of this study highlighting that hypothermic temperature control is compared with normothermia did not improve survival, nor functional outcome, at 180 days in patients presenting with coma after in-hospital cardiac arrest. Well, on behalf of Carolyn and myself, we want to wish you a great week, and we will catch you next week On The Run. This program is copyright of the American Heart Association 2022. The opinions expressed by speakers in this podcast are their own, and not necessarily those of the editors, or of the American Heart Association. For more, please visit ahajournals.org.

Level-up Engineering
How to Choose the Right Tech Stack - A Leader's Guide to Digital Transformation

Level-up Engineering

Play Episode Listen Later Oct 26, 2022 53:16


Interview with Steven Lopez, VP of Engineering, Technology and Operations at Deem. We go through real life examples and take a deep dive into choosing the right tech stack for your business and team, especially while leading a digital transformation. https://codingsans.com/engineering-management-newsletter?utm_source=Podcast&utm_medium=platforms (Sign up to the Level-up Engineering newsletter!) In this interview we're covering: Parts of a tech stack Choosing a tech stack for a project vs. digital transformation Other tools to consider when choosing a tech stack How to choose a tech stack connected to company values The process of digital transformation Common mistakes in digital transformation Story of choosing Deem's tech stack Excerpt from the interview: "You need to make sure to customize the tech stack according to the company's industry. Each industry has different needs when it comes to choosing the right tech stack. For example, in fields that use credit cards, you have to take PCI security standards into account. Ten to 15 years ago, digital transformations were different. People came up with a tech stack, and they would implement it right away. Technologies are moving so fast nowadays that I recommend defining the tech stack only after you do your due diligence and digital transformation experts have looked at your company thoroughly. In the age of agile implementations, we have to be flexible enough to try new things. We set hypotheses, and we try out whether they work, and we make necessary updates." https://codingsans.com/blog/how-to-choose-tech-stack?utm_source=Podcast&utm_medium=platforms (Click here to read the full interview!)

FOCUS
Episode 503: Driving Innovation within the Higher Ed Community

FOCUS

Play Episode Listen Later Oct 25, 2022 19:54


In the world of higher education, innovation is the constant goal. Institutions and solution developers continuously work together to create the best and most efficient experiences possible for both students and staff. But identifying where to start in the process of innovation can be difficult. Lauren Ipsen, CEO of Ellucian, sheds light on this topic as she joins the FOCUS podcast and discusses supporting student success, and how partnerships throughout the higher ed tech community have become the driving forces toward innovation. How Ellucian Helps Higher Ed Institutions Ellucian is a mission-based technology company focused on creating better outcomes for institutions and transforming that into student success. They provide institutions with operating systems from administration to HR and all student systems and help maximize the success capabilities for students. Ellucian serves 3,200 customers globally, taking out the friction in campus financial processes. Ipsen believes their capabilities will, in turn, solve some of the toughest challenges in higher ed. Supporting Student Success Institutions that work to find solutions and create processes that support student success will be at the forefront of innovation. Ipsen reveals that while being a user of campus interfaces is integral in understanding the user experience, schools should focus on the software-as-a-service ( SaaS) experience too. Many institutions are still working from on-premise systems that are more difficult than cloud systems to enhance and maintain. Ellucian is transforming both the institution experience and the student experience by helping institutions transition to a SaaS model with technology solutions delivered through the cloud. This newer approach allows teams to hone in on financial data, financial aid, and make sure transactions are PCI compliant and friction-free so students can make better decisions. At the core of student success, Ipsen believes that financial success, mental health, and community all need to come together on a platform level—and keeping students enrolled. The majority of students who drop out of higher education do so because of financial or mental health issues. If schools work to simplify and reduce stressors in students' lives, they will be able to focus on the bigger picture of their education. Ipsen is driven to help campuses provide new opportunities to make the student experience better on- and off-campus. One opportunity to aid students is to expand AI advising, so all students can access academic support whenever they need it. When it comes to enrollment, Ipsen suggests that schools also look at retention data rather than just new enrollees. To keep retention up, explore payment plans that can be flexible for students. Then, if they go through issues with financial aid, mental health, or their health, students do not need to worry as much about the burden of paying their bill. The most important thing is to implement support that will bring back students who have dropped out, which will raise retention while helping students in need. Better Together In the last few years, institutions have seen how beneficial the right technology can be for them. Technology is quickly becoming thought of as part of “the staff,” with AI and more integrations creating a new digital transformation toward the Cloud. But even though technology is ever-expanding and infiltrating the higher ed space, we must not forget the valuable roles humans play. Schools need to understand how business processes and roles are going to change with new tech and how they can make sure they have the right staff in the right places. For Ellucian, Ipsen says that they also had to start with their people, going from delivering best-in-class capabilities on-premises to operating through the cloud. She believes moving from on-premises to SaaS is one of the hardest things to do, but with partners like TouchNet, it can be made possible. “There is more of an urgency now more than ever. You [have] to be resilient. It's hard to get all the technical stuff that you need. You think tech companies are challenged [by] what institutions are dealing with, but you can't innovate in the future unless you're in a platform that lets you build your own future,” says Ipsen. Tech companies and institutions have to work together in order for schools to be successful. Within that partnership, it's also important to focus on data privacy and building in compliance with different policies and regulations. Ipsen also notes how much Ellucian values its partnership with TouchNet because of PCI compliance integrated into solutions. With the right partner, institutions can be assured their students' data will be protected. What's next for Ellucian Ipsen explains that Ellucian has brought back their user conferences, with ELive 2023 coming up soon. In these conferences, which will take place at various locations around the world, Ellucian will show the tech community how they can come together to overcome new challenges. Ipsen believes community is the higher ed and technology worlds' superpower, and in the future focusing on creating solutions that enhance student experiences—not just that of the institution—will be the key to success. Special Guest: Laura Ispen.

Circulation on the Run
Circulation October 25, 2022 Issue

Circulation on the Run

Play Episode Listen Later Oct 24, 2022 30:24 Very Popular


This week, please join Circulation's Associate Editor Marc Ruel and Executive Editor James de Lemos as they summarize all of the articles found in Circulation's annual Cardiovascular Surgery-Themed Issue for 2022. Dr. James de Lemos: Hi, welcome to Circulation on the Run. Greg and Carolyn are off today. My name is James de Lemos. I'm the executive editor for Circulation and I'm delighted to be joined today by Marc Ruel, who's the editor of our themed issue on cardiac surgery and leads the development and curation of all of the cardiac surgery content in Circulation. Marc, congratulations to you, to Mike Fischbein, to the whole Circ team on another spectacular effort to pull together this issue. Glad to have you here today. Dr. Marc Ruel: Well, thank you very much, James. It's really a team effort. I want to salute and thank the vision of Circulation to really give an important component to surgical science. As you often hear me say, your surgery provides the most durable and robust solution for advanced heart disease, right? So it's a very important part of the mission of Circulation as the premier cardiovascular journal. I want to thank you and also Joe Hill, our Editor-in-Chief and obviously the entire team of Circulation as well as all staff. Augie [Rivera], who is helping us on this call as well as Nick [Murphy] and many others who have made this issue possible. Dr. James de Lemos: Well, great. Well, let's get to this. And you recognize as well Mike Fischbein, who's the Cardiac Investor surgeon at Stanford who helps to edit the themed issue and really helps us to think about basic science into surgical specialties. Let me start, Marc, with cardiac bypass surgery. We have actually three papers in this issue that cover various aspects of CABG. The first one is one that you and I really resonated with, I know, because we talked about this. It's a paper by Ono from the SYNTAX Extended Survival study titled "Impact of Patient Reported and Pre-Procedural Physical and Mental Health on 10 year Mortality after PCI or CABG." And this is a really fascinating paper, looked at obviously patients with left main or multi vessels coronary disease, but used objective measures of physical and mental function from the SF-36 score and calculated summary physical and mental component scores. And then used those scores to evaluate whether there were treatment interactions based on physical and mental performance metrics with regard to the benefit of CABG over PCI. And really fascinating, first that there was an interaction and that the magnitude of benefit of CABG over PCI for multi vessel disease was substantially greater among individuals that had higher physical performance as well as mental health performance. What did you think of this paper and data? I know you wrote a tremendous editorial to this. So this is something that you thought about as we were bringing the paper in, but also had to think about in terms of putting this paper in the context of this daily decision for patients with multi vessel disease. Dr. Marc Ruel: Thanks James. And I agree with you. I think this is a bit of a new paradigm, right, to really think of the individual patient decision. It's a form of precision medicine if you will, with regards in this case to physical functioning and mental functioning prior to something as invasive as undergoing CABG. So I want to thank you, the Circulation leadership for inviting Anne Williams who's a cardiologist and yours truly to write a tutorial on this piece because I do think you, that is really, it is something that's quite intriguing and it makes sense. I think it is intuitive. I think clinicians who send patients to CABG and see them come back and hopefully in a good state, the very vast majority of the time, do realize nevertheless that CABG is a very invasive procedure. So the patient has to be actively involved in her or his recovery. And interestingly as you pointed out, there's quite a effect modification if you will, between the benefits of CABG over PCI in the SYNTAX trial, which many will remember as having randomized either left main or three vessel disease, coronary artery disease patients to PCI versus CABG. So there was an effect modification in those patients who had better functioning, not only physical, but interestingly, even more so mental component score of the SF-36 prior to operation. These patients would derive a greater benefit from having been randomized to CABG over PCI. So I think this is obviously logical, it makes sense and the converse will be true, but it's nice to see it formalized, to my knowledge, for the first time in the context of a rigorous randomized control trial such as SYNTAX with a long-term follow up. Now obviously this, like any study, there are a few caveats. Not every single patient had their SF-36 at baseline, but roughly about 90 plus percent of patients did. And I think that is quite an important clinical lesson in terms of allocating PCI versus CBG... I've often said over the years as a division head and someone who performs this operation often to my more junior colleagues, "Don't perform bypass surgery if someone's not going to live five years." That might be a bit of a simplistic approach but the data and the conclusions from this paper would support that. It's probably not too farfetched to think as such. Dr. James de Lemos: I think that's a great point and your clinical experience is so valuable for us here. One question I have is, do you think that it would be advantageous to objectively measure these parameters or is this something that the heart team or the surgeon at the bedside can assess intuitively? Because I think that's the question, right? Is this something... It certainly fits with what we would expect intuitively, that the more complete and durable procedure works better in people that are more robust physically, mentally. But should we be measuring this preoperatively to help make that decision or should this be a intuitive decision by expert clinicians? Dr. Marc Ruel: It's a great question and I think it's one that's not yet answered. I mean, the data from the paper would suggest that it has to be a formalized physical component score and mental component score and then ready allocate according to turnstiles. But that being said, we all know that we can address those issues by an end of bed type of eyeball test, right? So I think you're absolutely right. It may be that a clinical expert may provide the same type of information. Unfortunately we don't have that from the paper but I think there will be several subsequent papers that will look at this. I think we are in the era of precision medicine and one would even think, why has this not been done before considering how invasive bypass surgery is? You guys, you cardiologists and primary care physicians all know that it takes patients six to 12 months to be recover from sternal bypass surgery. Surgeons all be, I'll say that with a blink in my eye, don't always necessarily always see that, right? And think that's more like a one to three months but the data would suggest including that from randomized controlled trials such as Feedem, that it takes six to 12 months. So it's been one of my career long quest if you will, to make bypass surgery less invasive. And I think this type of paper really provides the impetus to do so. Dr. James de Lemos: Well, thanks. Let's shift gears from a study that makes perfect sense and fits our preconceived notions to maybe one that doesn't. And this is a research letter from a group led by Steve Goldman at University of Arizona looking at long term mortality from the VA study comparing radial arteries with saphenous vein conduits in CABG. And this looked at long term mortality from this study, which included over 700 individuals that had extended follow up beyond 10 years. At one year, the cath data had not shown differences in patency in this study, I think important to interpret, but they find absolutely no difference in mortality within similar median survival of 14 to 15 years after CABG in this study. This was controversial among the editors when we discussed it, but what are your thoughts about these data and how this informs the radial artery question in CABG? Dr. Marc Ruel: Absolutely. You are so right in seeing that this was controversial because there are in fact two ways to look at this paper, right? You can drain the information that's in there or you can be a naysayer. And there's credence to both approaches, in my opinion. One could say, "Well, there was no difference at one year in terms of graph patency, so why would there be one at 14-15 years?" Well, the answer to that would be the durability of the compared conduits would be potentially different, right? One to five years is what we call the "golden age of saphenous vein grafts." And beyond that time period, one could perhaps expect that the radial artery would do better and start translating into clinical benefits. But that was not seen in this long-term analysis of the VA RCT that compared the use of a saphenous vein versus a radial artery. The other way to perhaps find why the data is discrepant versus the methodology that had been performed before showing an advantage for the radial artery, would be that this is more perhaps of a real world type of experience. It comes from VA centers. Perhaps the expertise or the level of penetrance if you will, of use of the radial artery was not the same as other centers that maybe more "academic" and more vested into using the radial. So it's possible that those could have played a difference in nullifying if you will, the results of radial artery. But I nevertheless think that it's very important data. It makes us think and it is the largest single series data available that compares the radial to saphenous vein in a randomized control setting. So one cannot ignore it, and I think it's a very important piece of information that strengthens the surgery themed dish. Dr. James de Lemos: Thank you, Marc. And then the last CABG related article that I'd like to talk about is the prospective piece by Mario Gaudino and Bruce Lytle discussing the right internal thoracic artery for bypass. Asking the question, did we get it wrong? And this is really a very interesting piece. I encourage our readers to look at. That attempts really to reconcile the strong promise of the RITA with the disappointing results from art and the higher than expected failure rates in other trials. And what the authors do here really resonates with, Marc some of your points about individualizing treatment. They point out that some of the worse than expected RITA results may reflect the artery to which the RITA has been anecimosed, simply that results when an anecimosed to non-LED targets aren't as good and potentially the experience of the operators. Their final conclusion really isn't that, the reader's not a superior conduit but that perhaps more individualization, both at the patient level but also based on physician experience, maybe what's needed to achieve the optimal selection of conduits and bypass results. What did you think of this? How did their conclusions and interpretation resonate with you? Dr. Marc Ruel: I agree with your summary James and I think you are spot on. What's interesting in addition from this frame of reference is that it unites the opinions of two key opinion leaders, i.e Mario Gaudino, who's essentially behind much of the data favoring the radial artery over the use of the saphenous vein. And Bruce Lytle, who historically was behind really proposing the use of the right internal thoracic artery and this bilateral ITA grafting if you will, and they are really coming together and putting their thoughts in a really sensible manner with regards to the points that you raised already. I would add in my own opinion, it's twofold. One, there's nothing biologically wrong with the right internal thoracic artery. So if the LITA works, the RITA should work as well from a biologic point of view. In fact, surgeons know that it's often bigger than the left internal thoracic artery and even more suitable or suited as account with. What might be wrong is the applicability of it and that question really goes in a couple of important manners. Let's remember surgery is a craft, right? And it's a bit different. It's something I like to repeat, and it's not always captured. It's not really a pure science, like for instance, giving atorvastatin 40 milligrams would be this much more variability. And if you allow me a ten second example, if you were to take one of the bronze tools from Rodin, a grape sculptures, and take it away from him, the sculptures would not be as good. But if you were to give that tool to all semi-professional sculptures around the globe, the United States or France for instance, you may not see any benefit from that tool. So again, the crafty example of surgery is something that we have to compose with all the time. So the RITA is a great conduit, but it's often not onto the LED per se. And we know that LED in an average patient, which doesn't exist, it's probably about 50% of the left heart profusion. So really the LITA has an advantage from that point of view. And when we compare studies that have used the RITA on a non LED target, there are in some cases bound to fail or at least be neutral. So I think the jury's still out but really the perspective that's denoted here, as you said, is a fascinating one coming from two key opinion leaders, each in their camp of radial versus right internal thoracic artery use. Dr. James de Lemos: Well, fabulous discussion, Marc. I really appreciate your insights. I think as cardiologists, the decision making about conduits can often be opaque, and this is really insightful. Let's switch gears and talk about valve surgery. We have two papers on valve surgery. First, an original research article by Johan Wedin from Uppsala on bicuspid aortic stenosis demonstrating adverse ventricular remodeling and impaired cardiac function prior to surgery with a heightened risk of postoperative heart failure. This is a really interesting study that looked at 271 patients that were undergoing surgical aortic valve replacement. About half with bicuspid valves and half with tricuspid aortic valves, and they did comprehensive preoperative echo-cardiography and then followed the patients for four to five years after followup. And despite the expected finding that the bicuspid patients for younger, they had a substantially worse LV echo parameters pre-op with greater LV wall fitness, greater LV mass, worse preoperative LV function. And that translated even after successful AVR into increased risks for postoperative heart failure hospitalizations when compared to individuals with tricuspid aortic valves. And so the authors conclude that at least in contemporary practice, perhaps individuals are undergoing surgery for bicuspid aortic valve stenosis relatively later in the natural history, and they might merit closer civilians and possibly earlier intervention. What did you think of these data and do they make you think about your timing of recommendation for surgery with bicuspid aortic stenosis? Dr. Marc Ruel: Absolutely, and thank you James. I think this is very much in line with the current precision medicine led trends of operating earlier on patients with aortic stenosis. I think this is another subgroup that really deserves our attention. I think there are two things at play here with regards to patients who would have a comparable degree of hemodynamic aortic stenosis, either coming from a bicuspid aortic valve phenotype versus a normal tricuspid aortic valve phenotype. And I think the two important differences are, first, often the bicuspid valves are more prone to have a mixed disease and being more calcified as well. We often see surgery, what I call these black valves, like the valve is so calcified and necrotic that it actually turns black or navy blue in color. And this is not an uncommon finding in younger patients typically than tricuspid aortic valve patients. The second thing is that we have to remember that bicuspid aortic valve disease is a lifelong illness. So these patients often go undetected for a very long time. They may be 55 years old compared to someone who's 68 and have the same degree of hemodynamic aortic stenosis and even AI. But the disease has really, in the bicuspid aortic valve patient, has probably been there for decades, sometimes even the whole life. So I think the effects on the left ventricle are destined to be worse, and also in terms of recovery after resection and after aortic valve replacement. So I think these are humbling tidbits that come from this paper that really even allow us in this era of early TAVR and now two randomized trials that have looked... One from Europe and one from Korea that have looked at asymptomatic aortic valve replacement interventions with favorable results towards early intervention. That really tell us that we should pay even closer attention to those patients with bicuspid aortic valve phenotypes. Dr. James de Lemos: Thanks, Marc. And the second valve related paper is a prospective piece by [Rebecca] Becky Hahn, Vincent Chan and David Adams, evaluating current indications for a transcatheter edged edge repair of the mitral valve for primary mitral regurgitation. I thought this was a really well done piece and one that I appreciated focus specifically on primary micro-regurgitation. The piece includes a terrific algorithm for clinicians that really helps to guide decision making through a multidisciplinary approach. They talk about the importance of specialized valve imagers, given the complexity of evaluating even the etiology of micro-regurgitation. The importance of excellence in determining the quantitation of severe MR, valve morphology and dimensions. And then really take it a step further to drive decision makings based on risk assessment of the patient. Obviously for primary MR for adequate surgical risk patients surgery is recommended, but then it walks through the decision making for which of the patients that are not surgical candidates might be optimal candidates for transcatheter techniques. How do you think this field's moving and how did this perspective change your thinking? Dr. Marc Ruel: This is such an excellent piece as you denoted. I think it really comes from three experts in the field representing different school of thoughts, if you will. One, more hybrid, more catheter based and more surgery based. And I think the jury's still out on transcatheter edge to edge repair, especially for primary marginal regurgitation. It's paradoxical as we're hoping that edge to edge repair would be primarily used in secondary MR and have great results. We now know and somewhat humbling, that it works not as great as we were hoping for secondary MR and it seems to be working pretty well where we already had a fantastic surgical therapy for it, which is essentially primary MR and Fibroelastic Deficiency type of lesions. Now, as you know, these patients do extremely well with surgery. There are several series of 800, 900, a thousand patients operated either conventionally or minimal invasively with maybe one death. Still one too much I would argue, but extremely low risks. These are the healthiest patients that a cardiac surgeon often can operate because I would argue this probably an inverse correlation with coronary artery and peripheral vascular disease in those patients. It's hard to know. There's some elements of the answer that we don't have yet. What about the very long term follow up? What about 10 years? What happens when an edge to edge repair fails and it was for primary MR in a younger patient? And I think the authors really captured those very important caveats quite elegantly and provide a very balanced view. So like you, I'm very happy with this piece. Lastly, I'll conclude by saying there's even controversy as to sub-clinical parameters with edge to edge versus surgical mitral valve pair for primary MR. What does two plus mitral regurgitation that is post-procedure, What does that mean? Is this something that's going to impact the patient at 10 years, at 20 years and perhaps churn, what was it initially, a great therapeutic solution into one that's not so desirable? So again, as I said, the jury's still out on this and I think these really captures the main element of the answer as we know them in 2022. Dr. James de Lemos: Excellent points. I think really, I love your conclusion that hopefully there will be a better transcatheter solution than this for patients that aren't surgical candidates, obviously, because it doesn't, unlike TAVR, this doesn't come close to matching the surgical option. The last couple of papers in the issue focus on putting cardiac surgery in the greater context of the patient experience and the healthcare system experience and are in the health services research phase. The first one is from multi-centered team led by Amgad Mentias at Cleveland Clinic and Ambarish Pandey at UT Southwestern. And it focuses on a new performance metric that they're calling, 90 day risk standardized home time for cardiac surgery hospitals in the US. And this group has done several studies with this new metric that basically is attempting to evaluate performance at the patient level with a very patient-centric metric of how much time they spend at home. They've published previously using data from heart failure patients and post MI patients and now are extending this to cardiac surgery and using risk adjustment of time outside the hospital in the 90 days after surgery to evaluate the variability among cardiac surgical programs. And they find that the metric correlates with mortality and readmission, that higher volume surgical centers are associated with more time spent out of the hospital. And then when they compare it more directly with approaches that are used to currently rank performance, they see that this results in some reclassification of performance categories versus the other metrics. It's early in the life of this new metric but I'm interested to see intuitively is a cardiac surgeon, how does another tool to evaluate your performance, your team's performance and your hospital's performance resonate? And does this have any intrinsic advantages to you over the other risk standardized tools that are currently being used? Certainly in the US I don't know what's happening in Canada. Dr. Marc Ruel: Great points, James and I agree, this is an impressive data set. It's almost on 1 million patients from more than 1000 centers in the US. And as you said, it is a new patient based metric. It's a bit of a patient before the outcome if you will, those PROs that are so more commonly now the object of research with regards to outcomes. I would somewhat simplistically say that there are three possible outcomes to any heart surgery, patient survives and feels better. That's number one, that's what we want to achieve for everybody. Unfortunately, there are two other outcomes that can happen. Patient survives but patient is not improved by the surgery or has a complication as a result of it and quality of life does not improve. And third, obviously the one that is the obvious, highly detrimental is that patient does not make it from the surgery. But I think really what this paper highlights is the importance of really focusing on the first one by the number of days spent at home during the first 90 days post intervention, post-surgery itself. So I think it is really a marker of how well the patient's doing. It closes the loop, if you will, with the first paper that we looked at, in an observational large data set type of way. But it again calls to, how was the patient functioning pre-op? And that data, as we know, is not available from this series. So it could be three things essentially. It could be performance and definitely it pleases the mind to think that the performance of the institution i.e, the quality of the care provided has a huge impact. But it could also be two other things. It could be the level of functioning of the patient. The ability to get back and spend many of those first 90 days at home versus not, of the patient himself or herself, depending on the various populations that are served by those institutions. And third, it could also be a little bit of a recurrent theme of mine and I apologize for that, but it could be the degree of invasiveness that's provided if you out of surgeries offered to these patients. So I think these are interesting paradigms. They are very important. Again, they're completely in line with precision medicine and I think that this performance measure, as you alluded to, is an important point because a patient who survives but doesn't go back home really is not deriving a benefit from any operation. Dr. James de Lemos: Yeah, great points. And I think this discussion really leads us into our discussion, the last paper, which is another paper that attempts to put surgery in the greater context of the population and environment in which patients come. And this is led by Aditya Sengupta and her team from Boston Children's Hospital evaluating contemporary socioeconomic and childhood opportunity disparities in congenital heart surgery. This is a really next level analysis of associations between socioeconomic status and outcomes after congenital heart disease surgery in children focusing in one high volume quaternary center in Boston. And what they did is developed a novel predictor that was a US census tract based nationally normed composite metric of contemporary childhood, what they called neighborhood opportunity. And this comprised 29 indicators across three domains. The three domains were education, health, and environment and socioeconomic domains. And they classified the patients into very low, low, moderate, high and very high neighborhood opportunity. And then they looked at evaluations across multiple outcomes. They did not see any association of neighborhood opportunity with early deaths, which I think is encouraging, but they did see that children with lower neighborhood opportunity had longer length of stay, higher healthcare costs and then significantly higher late deaths following surgery when the multiple components of long term care of these children probably have time to operationalize. I found this sobering and a complex message that excellent cardiac surgery can deliver superb outcomes across all levels of opportunity but if these issues aren't addressed, there are financial implications, but more importantly, the long term benefits of the cardiac surgical procedures aren't fully realized. Interested to hear your thoughts on this and how this might apply more broadly even to adult surgery. Dr. Marc Ruel: I agree, James and I too, really love this paper. As you say, it is sobering. It's a paper for physicians, but I would argue it's probably bedtime reading for Mr. Biden, any other country leaders as well. Whether it's Mr. Macron or Mr. Trudeau. Definitely something that is shows that what happens after the hospital stay, even in something as complex as congenital heart surgery, performed at Boston children, obviously a great institution. But what is shown here is that the institution with its top quality outcomes as we know them to be, is a fantastic societal and outcome equalizer, if you will. But once that passage through the tertiary or coronary institution has occurred, then reality sets in. And the childhood opportunity index that the authors had previously published in JAMA proves to be, again, a very important predictor of how these kids do later on. So this refers really to the societal contract that we're all part of as physicians. And we obviously, a big part of our mission is to improve the outcomes in hospital, but also beyond it. And I think this paper illustrates this very nicely as you so eloquently summarized. Dr. James de Lemos: Well, thanks. And I'll just, before I hand it over to you to conclude and wrap up, just compliment you and Mike and the entire team, as well as the authors who have submitted not just these but so many other superb papers covering the full spectrum of surgical sciences Circulation. I'm proud for us to have the opportunity to share these terrific papers with our readers and with researchers. And congratulations again to you for pulling this together. Dr. Marc Ruel: Well, you're very kind and thank you, James. To you and Joe, Darren and our and entire editorial leadership for the important place given to surgery within Circulation. It's something that I believe is important and resonates with surgeons but also non-surgeons who are part of the greater cardiovascular community. So it's tremendously important and we're very thankful for that opportunity. Dr. James de Lemos: Well, I'd like to thank all our listeners for joining us today and remind you to tune in next week when Greg and Carolyn will be back for their regularly scheduled podcast. Dr. Greg Hundley: This program is copyright of the American Heart Association 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

CISO Tradecraft
#101 - SaaS Security Posture Management (with Ben Johnson)

CISO Tradecraft

Play Episode Listen Later Oct 24, 2022 40:07


Special Thanks to our podcast sponsor, Obsidian Security.   We are really excited to share today's show on SaaS Security Posture Management.  Please note we have Ben Johnson stopping by the show so please stick around and enjoy.  First let's go back to the basics: Today most companies have already begun their journey to the cloud.  If you are in the midst of a cloud transformation, you should ask yourself three important questions:   How many clouds are we in? What data are we sending to the cloud to help the business? How do we know the cloud environments we are using are properly configured? Let's walk through each of these questions to understand the cyber risks we need to communicate to the business as well as focus on one Cloud type that might be forecasting a major event.  First let's look at the first question.   How many clouds are we in?  It's pretty common to find organizations still host data in on premises data centers.  This data is also likely backed up to a second location just in case a disaster event occurs and knocks out the main location.  Example if you live in Florida you can expect a hurricane.  When this happens you might expect the data center to lose power and internet connectivity.  Therefore it's smart to have a backup location somewhere else that would be unlikely to be impacted by the same regional event.  We can think of our primary data center and our backup data center as an On-Premises cloud.  Therefore it's the first cloud that we encounter.   The second cloud we are likely to encounter is external.  Most organizations have made the shift to using Cloud Computing Service providers such as Amazon Web Services, Azure, Google Cloud Platform, or Alibaba.  Each of these cloud providers has a multitude of offerings designed to help organizations reduce the need to host IT services on premises.  Now if you are using both on-premises and a cloud computing provider such as AWS, congratulations you are in what is known as a hybrid cloud environment.  If you use multiple cloud computing providers such as AWS and Azure then you are in a multi-cloud environment.  Notice the difference between terms.  Hybrid cloud means you host on premises and use an external cloud provider, whereas multi-cloud means you use multiple external cloud providers.  If you are using a Common Cloud platform like AWS, Azure, or GCP then you can look into a Gartner Magic Quadrant category known as Cloud Workload Protection Platforms.  Here you might encounter vendors like Palo Alto Prisma Cloud, Wiz, or Orca who will provide you with recommendations for your cloud configuration settings. So let's say your organization uses on premises and AWS but not Azure or GCP.  Does that mean you only have two clouds?  Probably not.  You see there's one more type of cloud hosted service that you need to understand how to defend.  The most common cloud model organizations leverage is Software as a Service commonly pronounced as (SaaS). Frankly we don't hear about SaaS security being discussed much which is why we are doing a deep dive on its security in this episode.  We think there's a real danger of SaaS clouds turning from a nice cloud that gently cools down a hot summer day into a severe weather storm that can cause an event.  So let's look at SaaS Security in more depth.   SaaS refers to cloud hosted solutions whereby vendors maintain most everything.  They run the application, they host the data, they host runtime environments, middleware, operating systems, virtualization technologies, servers, storage, and networking.  It can be a huge win to run SaaS solutions since it minimizes the need to have IT staff running all of these IT services.  Example: Hiring HVAC folks to ensure we have proper heating and cooling for servers on premises won't add new sales revenue to the business.   Now that you understand why SaaS is important you should ask yourself.  How many external SaaS providers are we sending sensitive data to?  Every company is different but most can expect to find dozens to hundreds of SaaS based solutions.  Examples of external SaaS solutions commonly encountered by most businesses include:  Service Now or Jira in use as a ticketing service,  Salesforce for customer relationship management Workday for HR information G Suite or Microsoft Office 365 in use to send emails and create important documents Github as a source code repository for developers Zoom for virtual teleconferences Slack for instant messaging like conversations Okta for Identity and Access Management Once you build out an inventory of your third parties hosted SaaS solutions, you need to understand the second question.  What kind of data is being sent to each service?  Most likely it's sensitive data.  Customer PII and PCI data might be stored in Salesforce, Diversity or Medical information for employees is stored in Workday, Sensitive Algorithms and proprietary software code is stored in GitHub, etc.  OK so if it is data that we care about then we need to ensure it doesn't get into the wrong hands.  We need to understand why we care about SaaS based security which is commonly known as SaaS Security Posture Management.  Let's consider the 4 major benefits of adopting this type of service.   Detection of Account Compromise.  Today bad actors use man in the middle attacks to trick users to give their passwords and MFA tokens to them.  These attacks also provide the session cookie credentials that allow a website to know a user has already been authenticated.  If attackers replay these session cookie credentials there's no malware on the endpoints.  This means that Antivirus and EDR tools don't have the telemetry they need to detect account compromise.  Therefore, you need log data from the SaaS providers to see anomalous activity such as changing IP addresses on the application.  Note we talked about this attack in much more detail on episode 87 From Hunt Team to Hunter with Bryce Kunze.   In addition to detecting account compromises, we see that SaaS security posture management solutions also improve detection times and response capabilities.  Let's just say that someone in your organization has their login credentials to Office 365 publicly available on the dark web.  So a bad actor finds those credentials and logs into your Office 365 environment.  Next the bad actor begins downloading every sensitive file and folder they can find.  Do you have a solution that monitors Office 365 activity for Data Loss Prevention?  If not, then you are probably going to miss that data breach.  So be sure to implement solutions that both log and monitor your SaaS providers so you can improve your SaaS incident detection and response capabilities. A third benefit we have seen is improvements to configuration and compliance.  You can think of news articles where companies were publicly shamed when they lost sensitive data by leaving it in a Public Amazon S3 bucket when it should have been private.  Similarly there are settings by most SaaS solutions that need to be configured properly.  The truth is many of these settings are not secure by default.  So if you are not looking at your SaaS configurations then access to sensitive data can become a real issue.  Here's an all too common scenario.  Let's say your company hires an intern to write a custom Salesforce page that shows customer documents containing PII.  The new intern releases updates to that webpage every two weeks.  Unfortunately the intern was never trained on all of the Salesforce best practices and creates a misconfiguration that allows customer invoices to be discovered by other customers.  How long would this vulnerability be in production before it's detected by a bad actor?  If you think the answer is < 90 days, then performing yearly penetration tests is probably too slow to address the brand damage your company is likely to incur.  You need to implement a control that finds vulnerabilities in hours or days not months.  This control might notify you of compliance drift in real time when your Salesforce configuration stopped meeting a CIS benchmark.  Now you could pay a penetration testing provider thousands of dollars each week to continually assess your Salesforce environment, but that would become too cost prohibitive.  So focus on being proactive by switching from manual processes such as penetration testing to things that can be automated via tooling The fourth major benefit that we observe is proper access and privilege management. Here's one example.  For critical business applications you often need to enforce least privilege and prevent the harm that one person can cause.  Therefore, it's common to require two or more people to perform a function.  Example: One developer writes the new code for a customer facing website, another developer reviews the code to detect if there's any major bugs or glaring issues that might cause brand damage.  Having a solution that helps mitigate privilege creep ensures that developers don't increase their access.  Another example of the importance to proper access management occurs when bad employees are fired.  When a bad employee is fired, then the company needs to immediately remove their access to sensitive data and applications.  This is pretty easy when you control access via a Single Sign On solution.  Just disable their account in one place.  However many SaaS providers don't integrate with SSO/SAML.  Additionally the SaaS website is generally internet accessible so people can work from home even if they are not on a corporate VPN.  Therefore it's common to encounter scenarios where bad employees are fired and their account access isn't removed in a timely manner.  The manager probably doesn't remember the 15 SaaS accounts they granted to an employee over a 3 year time frame.  When fired employees are terminated and access isn't removed you can generally expect an audit finding, especially if it's on a SOX application.   OK so now that we talked about the 4 major drivers of SaaS Security Posture Management (detection of account compromise, improved detection and response times, improvements to configuration and compliance, and proper access and privilege management) let's learn from our guest who can tell us some best practices with implementation. Now I'm excited to introduce today's guest:  Ben Johnson Live Interview Well thanks again for taking time to listen to our show today.  We hoped you learning about the various clouds we are in (On Premises, Cloud Computing Vendors, and SaaS), Understanding the new Gartner Magic Quadrant category known as SaaS Security Posture Management.  So if you want to improve your company's ability on SaaS based services to: detect account compromise,  improve detection and response times,  improve configuration and compliance, and  proper access and privilege management  Remember if you liked today's show please take the 5 seconds to leave us a 5 star review with your podcast provider.  Thanks again for your time and Stay Safe out there.  

Circulation on the Run
Circulation October 18, 2022 Issue

Circulation on the Run

Play Episode Listen Later Oct 17, 2022 22:48


This week, please join author Sunil Rao and Guest Editor and Editorialist Gregory Lip as they discuss the article "A Multicenter, Phase 2, Randomized, Placebo-Controlled, Double-Blind, Parallel-Group, Dose-Finding Trial of the Oral Factor XIa Inhibitor Asundexian to Prevent Adverse Cardiovascular Outcomes After Acute Myocardial Infarction" and the editorial "Factor XIa Inhibition: Is It a Novel Alternative Antithrombotic Strategy for High-Risk ACS Patients?" Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts. I'm Dr. Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, Associate Editor Director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Dr. Carolyn Lam: Greg, today's feature paper is about the factor XI inhibitor asundexian. It's the trial that we've been waiting for the PACIFIC-AMI trial. You really have to listen to it because these factor XI inhibitors are super interesting. What? We're going to tell you about the other papers in today's issue first. Aren't we, Greg? Do you want to go first? Dr. Greg Hundley: You bet, Carolyn. Thank you so much. Carolyn, did you ever consider the genetic underpinnings of venous thromboembolism? Well, as you know, venous thromboembolism is a complex disease with environmental and genetic determinants. And in this study, this large investigative team represented by Dr. Nicholas Smith from the University of Washington in Seattle, and their colleagues present new cross-ancestry meta-analyzed genome-wide association study results from 30 studies with replication of novel loci and their characterization through in silicone genomic interrogations. Dr. Carolyn Lam: Wow. Sounds like a really large effort, Greg. What did they find? Dr. Greg Hundley: Right, Carolyn. In the author's initial genetic discovery effort that included 55,330 participants with venous thromboembolism: 47,000 were European, 6,000 African, and a little over 1000 Hispanic ancestry. They identified 48 novel associations of which 34 are replicated after correction for multiple testing. In their combined discovery replication analysis, so that's 81,669 venous thromboembolism participants and ancestry stratified meta-analyses from the European, African and Hispanic ethnic groups. They identified another 44 novel associations, which are new candidate venous thromboembolism associated loci requiring replication. And many of the replicated loci were outside of known or currently hypothesized pathways to thrombosis. Carolyn, in summary, these findings from this very large GWAS analysis highlight new pathways to thrombosis and provide novel molecules that may be useful in the development of anti-thrombosis treatments with reducing the risk of bleed. Dr. Carolyn Lam: Wow. Super interesting and very related to that feature paper that we just discuss. But nonetheless, this next paper I love as well, if I may say so myself. It deals with frailty and as we know, frailty is increasing in prevalence. And because frail patients are often perceived to have a less favorable benefit risk profile, they may be less likely to receive new pharmacological treatments. And so, we and led by Professor John McMurray from the University of Glasgow, decided to investigate the efficacy and tolerability of dapagliflozin according to frailty status in the DELIVER trial. Dr. Greg Hundley: The DELIVER trial. Carolyn, tell us about the DELIVER trial? Dr. Carolyn Lam: Sure. In deliver dapagliflozin compared to placebo, reduced the risk of worsening heart failure events or cardiovascular death and improved symptoms in more than 6,000 patients with heart failure and mildly reduced and preserved ejection fraction, so ejection fraction above 40%. Now in this pre-specified analysis, we examine the efficacy and safety of dapagliflozin according to frailty status. That was determined using the Rockwood cumulative deficit approach. And so, what we found was that greater frailty was associated with more impairment of health status and worse clinical outcomes in patients with heart failure and ejection fraction of 40%. The beneficial effects of dapagliflozin compared to placebo on clinical outcomes were consistent regardless of frailty class. But interestingly, the improvement in symptoms, physical function and quality of life were larger in the frailest patients. Adverse events were not more common in individuals randomized to receive dapagliflozin compared to placebo irrespective of frailty class. And so, the take home message is the benefit risk balance related to frailty in patients with heart failure with mildly reduced and preserved ejection fraction is favorable for dapagliflozin. And so, these findings should challenge any clinical reluctance to introduce dapagliflozin in patients perceived to be frail. Dr. Greg Hundley: Wow. Carolyn, really interesting. You could see with the diuretic effect in someone that's frail, the potential hesitancy, but very interesting study results in this world of frailty and the use of dapagliflozin. Well, Carolyn, this next study is very interesting and it comes to us from the world of preclinical science that takes a very interesting approach to a scientific question. Now, as you may know, RNA-binding proteins or RBPs are master orchestrators of genetic expression regulation. They regulate hundreds of transcripts at once by recognizing specific motifs, thus characterizing RBPs targets is critical to harvest their full therapeutic potential. However, such investigation has often been restricted to a few RBP targets, thereby limiting our understanding of their function. Carolyn, these investigators led by Dr. Grégoire Ruffenach from UCLA were interested in assessing pulmonary arterial hypertension and they turned to the world of cancer research. Carolyn, in cancer, the RNA-binding protein hnRNPA2B1, and we're going to abbreviate that as A2B1, promotes a pro proliferative anti-apoptotic phenotype. The same phenotype is present in pulmonary arterial smooth muscle cells and is responsible for the development of pulmonary arterial hypertension. However, the A2B1 function that's never really been investigated in pulmonary arterial hypertension. Dr. Carolyn Lam: Oh, Greg, that's not only fascinating, but so beautifully described. Thank you. What did they find? Dr. Greg Hundley: Right, Carolyn. These authors found that A2B1 expression and it's nuclear localization are increased in human pulmonary arterial hypertension, pulmonary arterial smooth muscle cells. Using bioinformatics, they identified three known motifs of A2B1 and all mRNAs carrying them and demonstrated the complimentary non-redundant function of A2B1 motifs as all motifs are implicated in different aspects of the cell cycle. In addition, they showed that pulmonary arterial smooth muscle cells and A2B1 promote the expression of its targets. Additionally, in vivo A2B1 inhibition in the lungs rescued pulmonary hypertension in rats. And so, Carolyn, through the integration of computational and experimental biology, this team study revealed the role of A2B1 as a master orchestrator of pulmonary arterial smooth muscle cells in pulmonary hypertension and that phenotype and its relevance as a therapeutic target in pulmonary arterial hypertension. Dr. Carolyn Lam: Wow, that's super, Greg. Thanks. Shall we go through what else is in today's issue? Dr. Greg Hundley: You bet, Carolyn. There's a Research Letter from Professor Mustroph entitled, “Empagliflozin Inhibits Cardiac Late Sodium Current versus Calcium Calmodulin‐dependent Kinase II.” Dr. Carolyn Lam: There's also an exchange of letters between Doctors Omarjee and Diederichsen regarding vitamin K2 and D in patients with aortic valve calcification: [an] absence of evidence might not be evidence of absence? And finally, there's an On My Mind paper by me and Scott Solomon and it's entitled, “Delivering Therapeutic Efficacy Across the Ejection Fraction Spectrum of Heart Failure.” But let's go on now to talk about the Factor XI inhibitor, shall we, Greg? Dr. Greg Hundley: You bet. Well, listeners, welcome to this feature discussion on October 18th at a very special article today. And we have with us the lead author, Dr. Sunil Rao from NYU in New York City and also our associate guest editor as well as editorialist, Dr. Gregory Lip from Liverpool. Welcome, gentlemen. Sunil, we'll start with you. Can you describe for us some of the background information that went into the preparation of your study and what was the hypothesis that you wanted to address? Dr. Sunil Rao: Yeah, great. Thanks so much, Greg. It's a real pleasure to be here with you. The background of the PACIFIC-AMI study is really rooted in the fact that patients who have acute myocardial infarction are really at risk for recurrent thrombotic events, even after their event. And this risk continues despite the fact that we have evidence based therapies that are really around targeting the platelet as well as aspects of the coagulation cascade. There have been studies that have looked at the use of dual antiplatelet therapy plus an anticoagulant or single antiplatelet therapy plus an anticoagulant. And those studies have shown a benefit. However, their clinical use is limited because of the bleeding risk. Factor XI is an interesting target, because factor XI is likely involved in the amplification of thrombin generation after plaque rupture. But it really doesn't play much of a role in hemostasis. And so, as a target in reducing events after acute coronary syndrome, activated factor XI is a very attractive one. And so, the hypothesis of this study was that a highly bioavailable oral, direct, selective activated factor XI inhibitor called asundexian would be safe and effective in the treatment of patients who experience acute coronary syndrome at reducing adverse events. Now, this is a phase two study, so it really wasn't powered for clinical events. It was really a dose-finding study, so it was really looking at adverse events and sort of bleeding complications. Dr. Greg Hundley: Very nice. Asundexian, a new factor XI inhibitor. And Sunil, can you describe for us your study design and then maybe a little bit more about the study population, how many subjects? Dr. Sunil Rao: Sure. Again, this is a phase two study. It was a randomized, double-blind, parallel-group design where patients, who were admitted with acute coronary syndrome were randomized to three different doses of asundexian and or placebo in a one-to-one to one-to-one fashion. Patients who met criteria for enrollment were: patients who were admitted with a diagnosis of acute MI; if they were older than or equal to 45 years of age; they were hospitalized in acute coronary syndrome that did not occur in the context of revascularization, so it was not a type 4 event; and they were planned to be treated with dual antiplatelet therapy after hospital discharge. Dr. Greg Hundley: Sunil, thank you for describing this very interesting study design. Now, how many subjects did you include and could you just describe for us the study population? Dr. Sunil Rao: We had a total of 1,601 patients that were randomized at 157 centers in 14 countries between June 2020 and July 2021. And in order to be eligible for enrollment into the study: patients had to be admitted with a diagnosis of acute MI, they had to be greater than or equal to 45 years of age, and be hospitalized with that acute MI that did not occur in the context of revascularization, so type 4 MIs were excluded. The other inclusion criteria was that they had to be planned to be treated with dual antiplatelet therapy after hospital discharge. Now, we allowed randomization up to five days after hospital admission and randomization occurred after patients were clinically stabilized and any planned PCI was performed. We included both patients with STEMI as well as non-ST segmental elevation ACS, but we capped the number of patients with STEMI that were included to no more than 50%. Now, the main exclusion criteria were things that you would expect for a phase two trial. Obviously, hemodynamic instability at the time of randomization, active bleeding or bleeding dialysis, severe renal dysfunction, planned use of full-dose anticoagulation. Dr. Greg Hundley: Very nice. And so, we have several doses of this new factor XI inhibitor. Describe for us your study results? Dr. Sunil Rao: Again, this was a phase two trial that was really looking at safety and adverse events as you would expect. The study groups were pretty balanced across all of the dosing arms. When we looked at the pharmacokinetic and pharmacodynamic data, we found something really interesting, which was that there was a dose relationship between the dose of asundexian and the factor XIa activity. Factor XIa is activated factor XI. The higher the dose, the more suppression of factor XI activity. In fact, the highest dose nearly eliminated factor XI activity. The drug clearly works in the way that it was intended. Now again, the clinical data, it wasn't powered for clinical data. But when we look at the bleeding results, we found that there was in fact an increase in bleeding as the dose of asundexian increased. The overall rate of bleeding in the highest dose of asundexian was in 50 milligrams was 10.5% with type 2 or 3 or 5 BARC bleeding, a placebo is about 9.02%. Again, the efficacy outcomes, very, very low rates of overall events. Again, not powered to show a difference. Essentially, very similar across all the arms. Dr. Greg Hundley: And did you find the same results for the men and the women? And what about older individuals and younger individuals? Dr. Sunil Rao: Yeah. We did look at some subgroups. And you had to be a little bit cautious because again, the trial itself is relatively small. I mean, we didn't notice any significant patterns across these subgroups. And the overall interaction p-values were really non-significant. But I think what this does show is like a phase two trial that the drug works as in the way that it's intended. Overall, safety was as expected. And I think it really sets up data for a larger study. Dr. Greg Hundley: Well, listeners, what a fantastic presentation. And now, we're going to turn to our guest editor and editorialist, Dr. Gregory Lip from Liverpool. Greg, I know working for circulation, you have many papers come across your desk. What attracted you to this particular paper? And then maybe secondly, can you help us put the results of this study in the context of other studies that have been evaluating these factor XI therapies? Dr. Gregory Lip: Thanks, Greg. Well, I think this is an important paper, because it is a phase two trial with a novel, orally bioavailable inhibitor factor XI. And this is intriguing because factor XI efficiency in humans and experimentally in animals is associated with a reduced risk of thrombotic events like stroke or venous thromboembolism. But spontaneous bleeding is rare and also bleeding in response to trauma or surgery is much milder. Really it's the holy grail of trying to get an anticoagulant that reduces thrombosis but doesn't cause an excess of bleeding. Now, this was the quest with different anticoagulants. And I think it was very exciting to see this particular paper in the patients who've had an acute coronary syndrome, because there was a lot of interest in the use of anticoagulants, particularly in combination with antiplatelet therapy from trials such as ATLAS and COMPASS, where there was certainly a reduction in adverse cardiovascular events. But a downside with those drugs and when using combination, was an excess of bleeding by the combination of the available anticoagulants now plus antiplatelets. The factor XIs agents offered the possibilities we might have combination therapy to reduce cardiovascular events but not causing an excess of bleeding. Dr. Greg Hundley: Well, listeners, what a wonderful discussion that we've had here. Let's circle back with both individuals. Sunil, we'll start with you. What do you see as the next study to really be performed in this sphere of research? Dr. Sunil Rao: I think that factor XI is a very attractive target in patients with acute coronary syndrome. Again, the rationale for why we did this phase two trial was to show that inhibition of activated factor XI should result in a low rate of ischemic events without a significant increase in bleeding. This phase two trial was really to try and decide which doses result in potent inhibition of factor XIa and potentially which doses should be carried forward into a larger study. What we found in the PACIFIC-AMI trial was that the doses of asundexian and the factor XIa inhibitor were very, very well tolerated with a low rate of adverse events. It resulted in a dose-dependent near complete inhibition of factor XIa activity without a significant increase in bleeding and a low rate of ischemic events. I think, again, it's a very attractive target in patients with ACS and this really provides support for a larger adequately powered clinical trial in patients with acute coronary syndrome that is really looking at clinical events such as MACE as well as bleeding. Dr. Greg Hundley: And Greg as an editorialist, what did you see with this paper? Maybe some unanswered questions that we'd like to pursue further? Dr. Gregory Lip: Well, I think this does raise a lot of questions in the sense that it'll be interesting because as a phase two trial, it's a relatively moderate sized trial. It's not like a phase three large outcome trial and phase two trials also testing different doses of the novel agent. We need to see the definitive phase three trial and to look at the magnitude of benefit versus potential for bleeding if in the large phase three trial and obviously, the net clinical benefit and importantly are some of the subgroups: ST elevation, myocardial infarction, undergoing primary PCI, for example, those with renal impairment. And I think particularly intriguing would be looking at the patients in this scenario who get the new antiplatelet drugs such as ticagrelor and prasugrel. And the reason I say that is what we have with warfarin or Coumadin and from the current DOACs or NOACs, depending on the risk side upon. We refer to them, that's the direct oral anticoagulants or non-vitamin K antagonist or anticoagulants. Well, if you give a more potent antiplatelet like prasugrel or ticagrelor, the risk of bleeding not surprisingly is higher. Hence, the guidelines recommend that if you use an anticoagulant or a DOAC, you use it with a P2Y 12 inhibitor clopidogrel as opposed to the more potent ones. If this new class of drugs, the factor XI inhibitors can work well in combination with one of the more potent antiplatelets without causing an excessive bleeding, again, this is going to be a substantial advance. Well, with these new class of anticoagulants, will be really interesting to see the phase three trials when applied to other chronic conditions. For example, stroke prevention and atrial fibrillation. And the other category of patients would be those who've had an embolic stroke of uncertain source or ESUS or in old terminology cryptogenic stroke. With the ESUS group of patients, they're currently treated with aspirin because the trials which tried a NOAC or DOAC, they were not showing a positive result. They'll be interesting again with the factor XI inhibitors, whether we are going to see this benefit with the reduction in recurrence stroke with no excessive bleeding. Dr. Greg Hundley: Very nice. Well, listeners, we want to thank Dr. Sunil Rao from NYU in New York City and Dr. Gregory Lip from the University of Liverpool for bringing us this study highlighting that in patients with recent acute myocardial infarction, three doses of asundexian when added to aspirin plus a P2Y 12 inhibitor resulted in dose-dependent near complete inhibition of factor XIa activity without a significant increase in bleeding and a low rate of ischemic events. And certainly, the data from this study support the investigation of asundexian at a dose of 50 milligrams daily in an adequately powered clinical trial of patients following acute myocardial infection. Well, on behalf of Carolyn and myself, we want to wish you a great week and we will catch you next week On the Run. This program is copyright of the American Heart Association 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

The Gavel Podcast
The LEAD Program with Scott Smith (Central Arkansas)

The Gavel Podcast

Play Episode Listen Later Oct 14, 2022 77:16


The Gavel Podcast is the official podcast of Sigma Nu Fraternity, Inc. and is dedicated to keeping you updated on the operations of the Legion of Honor and connecting you to stories from our brotherhood. To find out more from the Fraternity, you can always check out our website at www.sigmanu.org. Also consider following us on: Facebook | Instagram | LinkedIn | Twitter | YouTube | FlickrHave feedback or a question about this episode? Want to submit an idea for a future topic you'd like to see covered? Contact the Gavel Podcast team at news@sigmanu.org. Hosts for this EpisodeChristopher Brenton (North Carolina State) - Director of CommunicationsAdam Girtz (North Dakota State) - Director of Chapter ServicesGuests for this EpisodeScott Smith (Central Arkansas) - Director of Leadership DevelopmentEpisode Mentions and ReferencesThe LEAD Program - Overview of the LEAD Program, Sigma Nu's award-winning ethical leadership development program.George Mason Assessment - Overview of the research showcasing the significant benefits members receive when they experience the LEAD Program.Officer Resources for the LEAD Chairman - Webpage dedicated to providing resources for LEAD Chairmen; collegiate chapter officers tasked with the implementation of the LEAD Program. Work for Sigma Nu Fraternity as a Leadership Consultant - Applications are due each year by October 15 (the early decision deadline) and March 1.Our Story: The Oral History Project of Sigma Nu Fraternity - The Fraternity has partnered with Publishing Concepts (PCI) to help collect stories from our brothers. PCI will contact alumni via mailed postcard, phone, and email asking them to participate by updating their contact information and sharing their Sigma Nu experience. These stories will be preserved in a book that celebrates Sigma Nu's impact.

Cardionerds
238. Cardio-Oncology: Radiation-Associated Cardiovascular Disease with Dr. Eric Yang

Cardionerds

Play Episode Listen Later Oct 13, 2022 62:34 Very Popular


CardioNerds (Dr. Patrick Azcarate, Dr. Teodora Donisan, and Amit Goyal) discuss Radiation-Associated Cardiovascular Disease (RACD) with Dr. Eric Yang, cardio-oncologist, assistant professor of medicine, and associate fellowship program director at UCLA. RACD is a consequence of radiation treatment for various mediastinal tumors (breast, lung, lymphoma). It is the second most common cause of morbidity and mortality in patients treated with mediastinal radiation for cancer. While novel techniques decrease radiation exposure during cancer treatment, the incidence is expected to increase because of historical practices and delayed onset of symptoms. The prevalence of RACD is difficult to estimate given under-recognition. Additionally, most of the data comes from patients treated with radiation techniques from decades ago. In this discussion we review every nook and cranny of RACD to help guide you the next time you see a patient with a history of chest radiation. Review this CardioNerds Case Report of radiation associated cardiovascular disease for more: Episode #169. Chest pain in a Young Man – “A Gray (Gy) Area” – UC San Diego. Audio editing by CardioNerds Academy Intern, student doctor Yousif Arif. This episode is supported by a grant from Pfizer Inc. This CardioNerds Cardio-Oncology series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Giselle Suero Abreu, Dr. Dinu Balanescu, and Dr. Teodora Donisan.  Pearls • Notes • References • Production Team CardioNerds Cardio-Oncology PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes - Radiation-Associated cardiovascular disease Due to the legacy effect, the incidence of RACD will continue to increase in the next few years.When treating patients with a history of mediastinal radiation, we should remember to ask:     How much radiation was given?Could the heart have been exposed?Radiation can affect every part of the heart by causing coronary artery disease (CAD), valvulopathy, myocardial disease, conduction disease, and pericardial disease.Exposure to ~25-30 Gy or more significantly increases the risk but RACD can occur at lower doses.Try to delay surgery as much as possible and do all you can in one operation to avoid re-operation in the future.For revascularization, percutaneous coronary intervention (PCI) is typically preferred over coronary artery bypass grafting (CABG) but the choice should be individualized in consultation with a multidisciplinary heart team experienced in the management of RACD.In general, for aortic valve disease, transcatheter replacement is recommended over surgical aortic valve replacement. For mitral valve disease, surgical replacement is recommended over repair. Every decision should be made with a heart team approach and made unique to that specific patient. Show notes - Radiation-Associated cardiovascular disease Notes were drafted by Dr. Patrick Azkarate. 1. Understand the pathophysiology of RACD Ionizing radiation has the potential to damage DNA. Both normal cells and cancer cells get damaged, but cancer has less effective DNA repair mechanisms and therefore malignant cells are more vulnerable to radiation therapy.After radiation causes acute damage, this sets off an inflammatory cascade leading to myofibroblast activation, fibrosis and collagen deposition, and subsequent stiffening of the myocardium and vessels. 2. What may increase one's risk of developing RACD? Young age (30 Gy) or high dose of radiation fractions (>2 Gy/day)Anterior or left chest radiation (breast cancer, lung cancer, lymphoma)Pre-existing cardiovascular diseaseTumor in or next to t...

NEJM This Week — Audio Summaries
NEJM This Week — October 13, 2022

NEJM This Week — Audio Summaries

Play Episode Listen Later Oct 12, 2022 30:06 Very Popular


Featuring articles on PCI for ischemic left ventricular dysfunction, endovascular treatment of basilar-artery occlusion, five-year outcomes of the Danish Cardiovascular Screening trial, and a report on twin boys with excessive caloric intake but low body weight; a review article on the treatment and prevention of heat-related illness; a case report of a man with heartburn, nausea, and inability to eat; and Perspective articles on access to treatment for opioid use disorder, on repealing state drug-paraphernalia laws, and on new federal incentives for diversity in trials.

Weaver: Beyond the Numbers
Confessions of a QSA: PCI DSS Version 4.0

Weaver: Beyond the Numbers

Play Episode Listen Later Oct 12, 2022 12:27


In March of 2022, the Security Standard's Council released version 4.0 of its Payment Card Industry Data Security Standard (PCI DSS.) Weaver's IT Advisory Services' Kyle Morris, Senior Manager, and Brittany George, Partner, spoke to Tyler Kern about the new standard and what people need to know.PCI DSS 4.0 applies to entities storing, processing, and transmitting cardholder data or could affect the security of cardholder data. Kyle said this includes merchants who sell goods and services and get paid with a credit or debit card, like a Visa or Mastercard as well as service providers and other entities that support these merchants. “So, that can affect many different types of organizations.”Version 4.0 came out this past March, but the new standards do not take effect until March 31, 2024. This will give merchants and service providers time to prepare for the latest compliance standard. There is also a transitional period, said Kyle. “Entities will have another year on top of 2024, to March 31, 2025, to implement some of the new requirements going into place.”“You can opt-in early for version 4.0,” Brittany said. “It is fine for organizations that are ready to do that. It is actually considered a best practice.”What are some of the changes in the latest version? “One key difference is the approach to implementing PCI,” Brittany said. “We currently have the defined approach, the traditional method of implementing the requirements as stated. Version 4.0 will introduce the customized approach, which is an alternative way of implementing the requirements.”This customized approach offers the ability to implement the controls in an advanced way, for example through machine learning. “Organizations, including many or our clients, have been asking for this for years, especially those who have been on the leading edge of technology,” Kyle said.

Weaver: Beyond the Numbers
Confessions of a QSA: PCI DSS Version 4.0

Weaver: Beyond the Numbers

Play Episode Listen Later Oct 12, 2022 12:27


In March of 2022, the Security Standard's Council released version 4.0 of its Payment Card Industry Data Security Standard (PCI DSS.) Weaver's IT Advisory Services' Kyle Morris, Senior Manager, and Brittany George, Partner, spoke to Tyler Kern about the new standard and what people need to know.PCI DSS 4.0 applies to entities storing, processing, and transmitting cardholder data or could affect the security of cardholder data. Kyle said this includes merchants who sell goods and services and get paid with a credit or debit card, like a Visa or Mastercard as well as service providers and other entities that support these merchants. “So, that can affect many different types of organizations.”Version 4.0 came out this past March, but the new standards do not take effect until March 31, 2024. This will give merchants and service providers time to prepare for the latest compliance standard. There is also a transitional period, said Kyle. “Entities will have another year on top of 2024, to March 31, 2025, to implement some of the new requirements going into place.”“You can opt-in early for version 4.0,” Brittany said. “It is fine for organizations that are ready to do that. It is actually considered a best practice.”What are some of the changes in the latest version? “One key difference is the approach to implementing PCI,” Brittany said. “We currently have the defined approach, the traditional method of implementing the requirements as stated. Version 4.0 will introduce the customized approach, which is an alternative way of implementing the requirements.”This customized approach offers the ability to implement the controls in an advanced way, for example through machine learning. “Organizations, including many or our clients, have been asking for this for years, especially those who have been on the leading edge of technology,” Kyle said.

Not Boring
Social vs. Science Experiments

Not Boring

Play Episode Listen Later Oct 10, 2022 19:27


Social vs. Science Experiments: We talk a lot about progress here in Not Boring. Progress can be difficult and messy and winding, and importantly, progress moves at different speeds and follows different paths for different kinds of products. Today's essay is my thinking on two types: science experiments and social experiments. Successful science experiment products clearly move the world forward; social experiment products are less obviously beneficial and messier in the short-run, but I think they're every bit as important in the long run, especially in combination with science experiment products. Sponsored by Secureframe: Secureframe is the leading, all-in-one platform for security and privacy compliance. Secureframe makes it fast and easy to get and stay compliant so you can focus on what matters: Scaling your business, customers, and revenue. With Secureframe, hypergrowth organizations can: Get SOC 2 audit ready in weeks, not months Stay compliant with the latest regulations Scale compliance with your business to meet ISO 27001, GDPR, HIPAA, PCI, and other requirements Plus, Secureframe helps sales teams respond to RFPs and security questionnaires quickly and easily with AI so they can close more deals, faster. Click here to set up a demo. Mention “Not Boring” during your demo to get 20% off your first year of Secureframe. Promotion available through October 31, 2022. --- Send in a voice message: https://anchor.fm/notboring/message

Dark Rhino Security Podcast
SC S8 E1 A Self-taught Cybersecurity Consultant

Dark Rhino Security Podcast

Play Episode Listen Later Oct 7, 2022 49:51


#SecurityConfidential #darkrhinosecurity New Month, New Season! Boyd is a self-taught cybersecurity consultant who helps entry-level IT professionals upskill and land six-figure jobs. He was formerly at American Airlines and is the Co-founder, of Baxter Clewis Cybersecurity. Boyd is the Author of “Corporate Security: Proven Ways to Reduce Cybersecurity Breaches” and a Highly-Respected International Expert and Speaker on Cybersecurity featured on Forbes, NBC, ABC, FOX, and CBS. 00:00 Introduction 01:50 Boyds Beginning 07:00 Avoid playing the victim 10:20 Being Motivated 15:00 Mythbusting: Jumping into Cyber with no experience 17:11 Cyber-hero Rule #25 18:05 Cyber-hero Rule #24 21:02 Cyber-hero Rule #26 21:30 Cyber-hero Rule #1 22:24 Cyber-hero Rule #2 23:33 Cyber-hero Rule #3 25:13 Cyber-hero Rule #4 26:31 Cyber-hero Rule #5 28:17 It's not just about completing the program 30:42 KPIs and Activation points 33:50 PCI and DSS 35:10 If you're complaint does that mean you have significant cybersecurity? 37:02 What should companies be doing to better safeguard the privacy of that information? 40:18 Thoughts on not using a credit card and using PayPal/Android/Apple Pay instead? 41:30 Boyds Book: Proven ways companies can reduce cybersecurity breaches 47:26 Upcoming News for Boyd To learn more about Boyd visit https://www.linkedin.com/in/boydclewis/ https://www.baxterclewis.com/ To learn more about Dark Rhino Security visit https://www.darkrhinosecurity.com SOCIAL MEDIA: Stay connected with us on our social media pages where we'll give you snippets, alerts for new podcasts, and even behind the scenes of our studio! Instagram: https://www.instagram.com/securityconfidential/ Facebook: https://m.facebook.com/Dark-Rhino-Security-Inc-105978998396396/ Twitter: https://twitter.com/darkrhinosec LinkedIn: https://www.linkedin.com/company/dark-rhino-security Youtube: https://www.youtube.com/channel/UCs6R-jX06_TDlFrnv-uyy0w/videos

VOV - Việt Nam và Thế giới
Tin trong nước: Cần Thơ coi doanh nghiệp là động lực phát triển kinh tế

VOV - Việt Nam và Thế giới

Play Episode Listen Later Oct 5, 2022 3:55


- Ngày 5/10, Thành ủy Cần Thơ tổ chức Hội nghị tổng kết 10 năm thực hiện Nghị quyết số 11 ngày 09/7/2012 của Thành ủy “Về cải thiện môi trường đầu tư, nâng cao chỉ số năng lực cạnh tranh cấp tỉnh (PCI) của thành phố Cần Thơ”. Qua 10 năm thực hiện chỉ số năng lực cạnh tranh cấp tỉnh của Cần Thơ được cải thiện, góp phần đạt mục tiêu, nhiệm vụ về cải thiện môi trường đầu tư, nâng cao chỉ số năng lực cạnh tranh cấp tỉnh của thành phố. Tác giả : Phạm Hải/VOV ĐBSCL Chủ đề : cần thơ, doanh nghiệp, phát triển kinh tế --- Support this podcast: https://anchor.fm/vov1tintuc/support

Podcasts from the Presbyterian Church in Ireland
S2022 Ep64: 064 – Urban and Estates Ministry

Podcasts from the Presbyterian Church in Ireland

Play Episode Listen Later Oct 5, 2022 49:53


Ministry in urban centres and housing estates presents unique challenges and opportunities for the church to show and share the love of Christ to a community in need. PCI's Urban Mission Network seeks to support and encourage those ministering in these areas. To explore this we hear from Felix Aremo (Training Manager, London City Mission), Rev Richard McIlhatton (Christchurch, Dundonald) and Jason Sime (Community Outreach Worker, Alexandra). At the end of this conversation is a short interview with Mary Leshi from PCI's congregation in Galway, who was part of PCI's Impact programme in August which sent teams to serve different urban churches around Belfast.

The Future of Security Operations
TripAction's Aaron Cooper: Why Understanding Broader Company Culture Is Critical to a Security Operation Team's Success

The Future of Security Operations

Play Episode Listen Later Oct 4, 2022 33:36


Aaron Cooper is the Security Operations Manager at TripActions with 20+ years of experience working in a variety of enterprise infrastructures. He specializes in managing and designing secure network environments to meet the needs of financial and corporate customers, managing security operations centers, designing and implementing highly secure and available data networks while maintaining HIPAA, SOX, and PCI compliance.  In this episode, Thomas and Aaron discuss why understanding company culture is a critical component to successful security teams, how he helps his team manage burnout, and more!  In this episode, Thomas and Aaron discuss why understanding company culture is a critical component to successful security teams, how he helps his team manage burnout, and more!    Topics in this episode include:  His journey from hardware, to a vendor, to healthcare, to banking, to a cloud first tech company – how security posture and challenges differ across industries and companies  Why it's critical to understand the culture of the company to run a successful security team  Why the state of security today is in flux and how security teams are changing how and what they respond to  Why the ‘onion model' no longer exists so it's critical to put on your ‘black hat'  The tools and strategies that help Aaron with risk reduction and analyzing indicators  The one thing IT managers can do to maintain the uptime of their environment How Aaron works to prevent burnout among his team and what drives him to help his team succeed  How Aaron evaluates AI tools  How his major in psychology gives him insight into the minds of security analysts, how resilient they can be, and how to hold space for them  Resources mentioned:  Year Up: https://www.yearup.org/job-training/cyber-security Hunter: https://www.hunters.ai/

The History of Computing
Taiwan, TSMC, NVIDIA, and Foundries

The History of Computing

Play Episode Listen Later Sep 30, 2022 31:03


Taiwan is a country about half the size of Maine with about 17 times the population of that state. Taiwan sits just over a hundred miles off the coast of mainland China. It's home to some 23 and a half million humans, roughly half way between Texas and Florida or a few more than live in Romania for the Europeans. Taiwan was connected to mainland China by a land bridge in the Late Pleistocene and human remains have been found dating back to 20,000 to 30,000 years ago. About half a million people on the island nation are aboriginal, or their ancestors are from there. But the population became more and more Chinese in recent centuries. Taiwan had not been part of China during the earlier dynastic ages but had been used by dynasties in exile to attack one another and so became a part of the Chinese empire in the 1600s. Taiwan was won by Japan in the late 1800s and held by the Japanese until World War II. During that time, a civil war had raged on the mainland of China with the Republic of China eventually formed as the replacement government for the Qing dynasty following a bloody period of turf battles by warlords and then civil war. Taiwan was in martial law from the time the pre-communist government of China retreated there during the exit of the Nationalists from mainland China in the 1940s to the late 1980. During that time, just like the exiled Han dynasty, they orchestrated war from afar. They stopped fighting, much like the Koreans, but have still never signed a peace treaty. And so large parts of the world remained in stalemate.  As the years became decades, Taiwan, or the Republic of China as they still call themselves, has always had an unsteady relationship with the People's Republic of China, or China as most in the US calls them. The Western world recognized the Republic of China and the Soviet and Chines countries recognized the mainland government. US President Richard Nixon visited mainland China in 1972 to re-open relations with the communist government there and relations slowly improved. The early 1970s was a time when much of the world still recognized the ruling government of Taiwan as the official Chinese government and there were proxy wars the two continued to fight. The Taiwanese and Chinese still aren't besties. There are deep scars and propaganda that keep relations from being repaired.  Before World War II, the Japanese also invaded Hong Kong. During the occupation there, Morris Chang's family became displaced and moved to a few cities during his teens before he moved Boston to go to Harvard and then MIT where he did everything to get his PhD except defend his thesis. He then went to work for Sylvania Semiconductor and then Texas Instruments, finally getting his PhD from Stanford in 1964. He became a Vice President at TI and helped build an early semiconductor designer and foundry relationship when TI designed a chip and IBM manufactured it. The Premier of Taiwan at the time, Sun Yun-suan, who played a central role in Taiwan's transformation from an agrarian economy to a large exporter. His biggest win was when to recruit Chang to move to Taiwan and found TSCM, or Taiwan Semiconductor Manufacturing Company. Some of this might sound familiar as it mirrors stories from companies like Samsung in South Korea. In short, Japanese imperialism, democracies versus communists, then rapid economic development as a massive manufacturing powerhouse in large part due to the fact that semiconductor designers were split from semiconductor foundry's or where chips are actually created.  In this case, a former Chinese national was recruited to return as founder and led TSMC for 31 years before he retired in 2018. Chang could see from his time with TI that more and more companies would design chips for their needs and outsource manufacturing. They worked with Texas Instruments, Intel, AMD, NXP, Marvell, MediaTek, ARM, and then the big success when they started to make the Apple chips. The company started down that path in 2011 with the A5 and A6 SoCs for iPhone and iPad on trial runs but picked up steam with the A8 and A9 through A14 and the Intel replacement for the Mac, the M1. They now sit on a half trillion US dollar market cap and are the largest in Taiwan. For perspective, their market cap only trails the GDP of the whole country by a few billion dollars.  Nvidia TSMC is also a foundry Nvidia uses. As of the time of this writing, Nvidia is the 8th largest semiconductor company in the world. We've already covered Broadcom, Qualcomm, Micron, Samsung, and Intel. Nvidia is a fabless semiconductor company and so design chips that vendors like TSMC manufacture.  Nvidia was founded by Jensen Huang, Chris Malachowsky, and Curtis Priem in 1993 in Santa Clara, California (although now incorporated in Delaware). Not all who leave the country they were born in due to war or during times of war return. Huang was born in Taiwan and his family moved to the US right around the time Nixon re-established relations with mainland China. Huang then went to grad school at Stanford before he became a CPU designer at AMD and a director at LSI Logic, so had experience as a do-er, a manager, and a manager's manager.  He was joined by Chris Malachowsky and Curtis Priem, who had designed the IBM Professional Graphics Adapter and then the GX graphics chip at Sun.   because they saw this Mac and Windows and Amiga OS graphical interface, they saw the games one could play on machines, and they thought the graphics cards would be the next wave of computing. And so for a long time, Nvidia managed to avoid competition with other chip makers with a focus on graphics. That initially meant gaming and higher end video production but has expanded into much more like parallel programming and even cryptocurrency mining.   They were more concerned about the next version of the idea or chip or company and used NV in the naming convention for their files. When it came time to name the company, they looked up words that started with those letters, which of course don't exist - so instead chose invidia or Nvidia for short, as it's latin for envy - what everyone who saw those sweet graphics the cards rendered would feel.  They raised $20 million in funding and got to work. First with SGS-Thomson Microelectronics in 1994 to manufacture what they were calling a graphical-user interface accelerator that they packaged on a single chip. They worked with Diamond Multimedia Systems to install the chips onto the boards. In 1995 they released NV1. The PCI card was sold as Diamond Edge 3D and came with a 2d/3d graphics core with quadratic texture mapping. Screaming fast and Virtual Fighter from Sega ported to the platform.  DirectX had come in 1995. So Nviia released DirectX drivers that supported Direct3D, the api that Microsoft developed to render 3d graphics. This was a time when 3d was on the rise for consoles and desktops. Nvidia timed it perfectly and reaped the rewards when they hit a million sold in the first four months for the RIVA, a 128-bit 3d processor that got used as an OEM in 1997. Then the 1998 RIVAZX with RIVATNT for multi-texture 3D processing. They also needed more manufacturing support at this point and entered into a strategic partnership with TSMC to manufacture their boards. A lot of vendors had a good amount of success in their niches. By the late 1990s there were companies who made memory, or the survivors of the DRAM industry after ongoing price dumping issues. There were companies that made central processors like Intel. Nvidia led the charge for a new type of chip, the GPU. They invented the GPU in 1999 when they released the GeForce 256. This was the first single-chip GPU processor. This means integrated lightings, triangle setups, rendering, like the old math coprocessor but for video. Millions of polygons could be drawn on screens every second. They also released the Quadro Pro GPU for professional graphics and went public in 1999 at an IPO of $12 per share.  Nvidia used some of the funds from the IPO to scale operations, organically and inorganically. In 2000 they released the GeForce2 Go for laptops and acquired 3dfx, closing deals to get their 3d chips in devices from OEM manufacturers who made PCs and in the new Microsoft Xbox. By 2001 they hit $1 billion in revenues and released the GeForce 3 with a programmable GPU, using APIs to make their GPU a platform. They also released the nForce integrated graphics and so by 2002 hit 100 million processors out on the market. They acquired MediaQ in 2003 and partnered with game designer Blizzard to make Warcraft. They continued their success in the console market when the GeForce platform was used in the PS 3 in 2005 and by 2006 had sold half a billion processors. They also added the  CUDA architecture that year to put a general purpose GPU on the market and acquired Hybrid Graphics who develops 2D and 3D embedded software for mobile devices. In 2008 they went beyond the consoles and PCs when Tesla used their GPUs in cars. They also acquired PortalPlayer, who supplies semiconductors and software for personal media players and launched the Tegra mobile processor to get into the exploding mobile market. More acquisitions in 2008 but a huge win when the GeForce 9400M was put into Apple MacBooks. Then more smaller chips in 2009 when the Tegra processors were used in Android devices. They also continued to expand how GPUs were used. They showed up in Ultrasounds and in 2010 the Audi. By then they had the Tianhe-1A ready to go, which showed up in supercomputers and the Optimus. All these types of devices that could use a GPU meant they hit a billion processors sold in 2011, which is when they went dual core with the Tegra 2 mobile processor and entered into cross licensing deals with Intel.  At this point TSMC was able to pack more and more transistors into smaller and smaller places. This was a big year for larger jobs on the platform. By 2012, Nvidia got the Kepler-based GPUs out by then and their chips were used in the Titan supercomputer. They also released a virtualized GPU GRID for cloud processing.  It wasn't all about large-scale computing efforts. The Tegra-3 and GTX 600 came out in 2012 as well. Then in 2013 the Tegra 4, a quad-core mobile processor, a 4G LTE mobile processor, Nvidia Shield for portable gaming, the GTX Titan, a grid appliance. In 2014 the Tegra K1 192, a shield tablet, and Maxwell. In 2015 came the TegraX1 with deep learning with 256 cores and Titan X and Jetson TX1 for smart machines, and the Nvidia Drive for autonomous vehicles. They continued that deep learning work with an appliance in 2016 with the DGX-1. The Drive got an update in the form of PX 2 for in-vehicle AI. By then, they were a 20 year old company and working on the 11th generation of the GPU and most CPU architectures had dedicated cores for machine learning options of various types.  2017 brought the Volta, Jetson TX2, and SHIELD was ported over to the Google Assistant. 2018 brought the Turing GPU architecture, the DGX-2, AGX Xavier, Clara, 2019 brought AGX Orin for robots and autonomous or semi-autonomous piloting of various types of vehicles. They also made the Jetson Nano and Xavier, and EGX for Edge Computing. At this point there were plenty of people who used the GPUs to mine hashes for various blockchains like with cryptocurrencies and the ARM had finally given Intel a run for their money with designs from the ARM alliance showing up in everything but a Windows device (so Apple and Android). So they tried to buy ARM from SoftBank in 2020. That deal fell through eventually but would have been an $8 billion windfall for Softbank since they paid $32 billion for ARM in 2016.  We probably don't need more consolidation in the CPU sector. Standardization, yes. Some of top NVIDIA competitors include Samsung, AMD, Intel Corporation Qualcomm and even companies like Apple who make their own CPUs (but not their own GPUs as of the time of this writing). In their niche they can still make well over $15 billion a year.  The invention of the MOSFET came from immigrants Mohamed Atalla, originally from Egypt, and Dawon Kahng, originally from from Seoul, South Korea. Kahng was born in Korea in 1931 but immigrated to the US in 1955 to get his PhD at THE Ohio State University and then went to work for Bell Labs, where he and Atalla invented the MOSFET, and where Kahng retired. The MOSFET was an important step on the way to a microchip.  That microchip market with companies like Fairchild Semiconductors, Intel, IBM, Control Data, and Digital Equipment saw a lot of chip designers who maybe had their chips knocked off, either legally in a clean room or illegally outside of a clean room. Some of those ended in legal action, some didn't. But the fact that factories overseas could reproduce chips were a huge part of the movement that came next, which was that companies started to think about whether they could just design chips and let someone else make them. That was in an era of increasing labor outsourcing, so factories could build cars offshore, and the foundry movement was born - or companies that just make chips for those who design them.  As we have covered in this section and many others, many of the people who work on these kinds of projects moved to the United States from foreign lands in search of a better life. That might have been to flee Europe or Asian theaters of Cold War jackassery or might have been a civil war like in Korea or Taiwan. They had contacts and were able to work with places to outsource too and given that these happened at the same time that Hong Kong, Singapore, South Korea, and Taiwan became safe and with no violence. And so the Four Asian Tigers economies exploded, fueled by exports and a rapid period of industrialization that began in the 1960s and continues through to today with companies like TSMC, a pure play foundry, or Samsung, a mixed foundry - aided by companies like Nvidia who continue to effectively outsource their manufacturing operations to companies in the areas. At least, while it's safe to do so.  We certainly hope the entire world becomes safe. But it currently is not. There are currently nearly a million Rohingya refugees fleeing war in Myanmar. Over 3.5 million have fled the violence in Ukraine. 6.7 million have fled Syria. 2.7 million have left Afghanistan. Over 3 million are displaced between Sudan and South Sudan. Over 900,000 have fled Somalia. Before Ukranian refugees fled to mostly Eastern European countries, they had mainly settled in Turkey, Jordan, Lebanon, Pakistan, Uganda, Germany, Iran, and Ethiopia. Very few comparably settled in the 2 largest countries in the world: China, India, or the United States.  It took decades for the children of those who moved or sent their children abroad to a better life to be able to find a better life. But we hope that history teaches us to get there faster, for the benefit of all.