Podcasts about recurrences

Link to bioRxiv paper: http://biorxiv.org/cgi/content/short/2023.07.23.550205v1?rss=1 Authors: He, L., Ioannidis, A., Arambula, E., Hoffman, C. J., Joshi, P., Kathiravan, A., Whitelegge, J. P., Liau, L. M., Kornblum, H. I., Pajonk, F. Abstract: Glioblastoma is the deadliest adult brain cancer. Under the current standard of care almost all patients succumb to the disease and novel treatments are urgently needed. Dopamine receptor antagonists have been shown to target cancer cell plasticity in GBM and repurposing these FDA-approved drugs in combination with radiation improves the efficacy of radiotherapy in glioma models. In cells surviving this combination treatment the mevalonate pathway is upregulated at the transcriptional and functional level. Here we report that glioblastoma treatments that converge in the immediate early response to radiation through activation of the MAPK cascade universally upregulate the mevalonate pathway and increase stemness of GBM cells through activation of the Rho-GTPase Rac-1. Activation of the mevalonate pathway and Rac-1 is inhibited by statins, which leads to improved survival in mouse models of glioblastoma when combined with radiation and drugs that target the glioma stem cell pool and plasticity of glioma cells. Copy rights belong to original authors. Visit the link for more info Podcast created by Paper Player, LLC

A Symposium specifically developed for Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Distinguished members and keynote speakers provide insight as to what impacts the patient and families on both quality and economic topics, what role leadership plays in creating the right culture for patient-centered care, and how to identify, evaluate, and prioritize innovations that can quickly touch the lives of patients battling C. diff. infections. Kathy Bischoff, C. diff. Survivor My C. diff. Journey Renata Johnson, C. diff. Survivor My C. diff. Journey Paul Feuerstadt, MD - review Barbara McGovern, MD, “Treatment of recurrent C. difficile infection with SER-109, an investigational microbiome drug.

A Symposium specifically developed for Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Distinguished members and keynote speakers provide insight as to what impacts the patient and families on both quality and economic topics, what role leadership plays in creating the right culture for patient-centered care, and how to identify, evaluate, and prioritize innovations that can quickly touch the lives of patients battling C. diff. infections. Kathy Bischoff, C. diff. Survivor My C. diff. Journey Renata Johnson, C. diff. Survivor My C. diff. Journey Paul Feuerstadt, MD - review Barbara McGovern, MD, “Treatment of recurrent C. difficile infection with SER-109, an investigational microbiome drug.

A Symposium specifically developed for Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Distinguished members and keynote speakers provide insight as to what impacts the patient and families on both quality and economic topics, what role leadership plays in creating the right culture for patient-centered care, and how to identify, evaluate, and prioritize innovations that can quickly touch the lives of patients battling C. diff. infections. Courtney Jones ” Microbiome, Microbiota, and Gut Health.” Denise Cardo, MD “Everyone Has a Role in Antibiotic Awareness.” Larry Kociolek, MD “C. diff. Infections in Pediatrics.” This event was sponsored by Seres Therapeutics. Seres Therapeutics mission is to transform the lives of patients worldwide with revolutionary microbiome therapeutics Enjoy the program!

A Symposium specifically developed for Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Distinguished members and keynote speakers provide insight as to what impacts the patient and families on both quality and economic topics, what role leadership plays in creating the right culture for patient-centered care, and how to identify, evaluate, and prioritize innovations that can quickly touch the lives of patients battling C. diff. infections. Courtney Jones ” Microbiome, Microbiota, and Gut Health.” Denise Cardo, MD “Everyone Has a Role in Antibiotic Awareness.” Larry Kociolek, MD “C. diff. Infections in Pediatrics.” This event was sponsored by Seres Therapeutics. Seres Therapeutics mission is to transform the lives of patients worldwide with revolutionary microbiome therapeutics Enjoy the program!

Welcome to the second episode of a special four (4) part series: A Symposium Created For Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Welcome to a Symposium specifically developed for patients, families, and caregivers. The Patient & Family C. diff. Symposium: where a gathering of healthcare professionals, keynote speakers, health advocates, practitioners, educators, are transforming the patient experience, and changing the way people experience C. diff. infections worldwide. Simon Cutting, Ph. D. “Bacillus, and C. diff. Spore Overview. “ Teena Chopra, MD ” Introduction to Infection Prevention.” Doe Kley, RN, MPH “C. diff. Transitioning from Hospital to Home. This event was sponsored by Seres Therapeutics, Seres Therapeutic's mission is to transform the lives of patients worldwide with revolutionary microbiome therapeutics Enjoy the presentations by the topic leaders joining us!

Welcome to the second episode of a special four (4) part series: A Symposium Created For Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Welcome to a Symposium specifically developed for patients, families, and caregivers. The Patient & Family C. diff. Symposium: where a gathering of healthcare professionals, keynote speakers, health advocates, practitioners, educators, are transforming the patient experience, and changing the way people experience C. diff. infections worldwide. Simon Cutting, Ph. D. “Bacillus, and C. diff. Spore Overview. “ Teena Chopra, MD ” Introduction to Infection Prevention.” Doe Kley, RN, MPH “C. diff. Transitioning from Hospital to Home. This event was sponsored by Seres Therapeutics, Seres Therapeutic's mission is to transform the lives of patients worldwide with revolutionary microbiome therapeutics Enjoy the presentations by the topic leaders joining us!

Go online to PeerView.com/WFC860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In the last two decades, there have been very limited advancements in the treatment of HR+, HER2- early breast cancer, and a particularly marked unmet need has existed for patients at the highest risk of recurrence. Fortunately, there is new hope of improved outcomes for these patients following the recent FDA approval of the first CDK4 and 6 inhibitor for the adjuvant treatment of patients with HR+, HER2-, node+ early breast cancer at high risk of recurrence and a Ki-67 score ≥20%. Shortly thereafter, guideline updates were released that recommended adjuvant CDK4 and 6 inhibitor therapy combined with endocrine therapy to a broader population of patients at high risk of recurrence. The emergence of this new therapeutic option along with varied indications and recommendations has resulted in much uncertainty about which patients should and should not receive adjuvant CDK4 and 6 inhibitor therapy, and how to best integrate it into clinical practice to meaningfully impact outcomes in this challenging patient population. In this educational activity, two leading experts deliver pertinent updates and use patient cases to provide practical guidance for the multidisciplinary team on how to navigate the changing standards of care in HR+, HER2- early breast cancer. Learn how to identify the most appropriate patients who can achieve the highest absolute benefit from adjuvant CDK4 and 6 inhibition, and ensure that those with a particularly poor prognosis are not excluded from this therapy. Additionally, receive guidance on how to recognize and manage treatment-related adverse events so that patients continue to adhere to CDK4 and 6 inhibitor therapy and derive maximum benefit from it in the adjuvant setting. Upon completion of this activity, participants should be better able to: Discuss the evidence, tools, and strategies for risk assessment and stratification in HR+, HER2- early breast cancer to guide treatment selection, including identification of candidates for adjuvant CDK4 and 6 inhibitor therapy, Integrate the latest safety and efficacy data on adjuvant CDK4 and 6 inhibitor therapy into clinical decisions for patients with high-risk, HR+, HER2- early breast cancer, Incorporate modern risk assessment approaches, supporting evidence, regulatory and guideline recommendations, adverse event prevention/management strategies, and shared decision-making into the establishment of individualized treatment plans for patients with HR+, HER2- early breast cancer to improve outcomes in this patient population, including reducing the risk of recurrence in patients with poor prognosis.

Go online to PeerView.com/WFC860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In the last two decades, there have been very limited advancements in the treatment of HR+, HER2- early breast cancer, and a particularly marked unmet need has existed for patients at the highest risk of recurrence. Fortunately, there is new hope of improved outcomes for these patients following the recent FDA approval of the first CDK4 and 6 inhibitor for the adjuvant treatment of patients with HR+, HER2-, node+ early breast cancer at high risk of recurrence and a Ki-67 score ≥20%. Shortly thereafter, guideline updates were released that recommended adjuvant CDK4 and 6 inhibitor therapy combined with endocrine therapy to a broader population of patients at high risk of recurrence. The emergence of this new therapeutic option along with varied indications and recommendations has resulted in much uncertainty about which patients should and should not receive adjuvant CDK4 and 6 inhibitor therapy, and how to best integrate it into clinical practice to meaningfully impact outcomes in this challenging patient population. In this educational activity, two leading experts deliver pertinent updates and use patient cases to provide practical guidance for the multidisciplinary team on how to navigate the changing standards of care in HR+, HER2- early breast cancer. Learn how to identify the most appropriate patients who can achieve the highest absolute benefit from adjuvant CDK4 and 6 inhibition, and ensure that those with a particularly poor prognosis are not excluded from this therapy. Additionally, receive guidance on how to recognize and manage treatment-related adverse events so that patients continue to adhere to CDK4 and 6 inhibitor therapy and derive maximum benefit from it in the adjuvant setting. Upon completion of this activity, participants should be better able to: Discuss the evidence, tools, and strategies for risk assessment and stratification in HR+, HER2- early breast cancer to guide treatment selection, including identification of candidates for adjuvant CDK4 and 6 inhibitor therapy, Integrate the latest safety and efficacy data on adjuvant CDK4 and 6 inhibitor therapy into clinical decisions for patients with high-risk, HR+, HER2- early breast cancer, Incorporate modern risk assessment approaches, supporting evidence, regulatory and guideline recommendations, adverse event prevention/management strategies, and shared decision-making into the establishment of individualized treatment plans for patients with HR+, HER2- early breast cancer to improve outcomes in this patient population, including reducing the risk of recurrence in patients with poor prognosis.

Go online to PeerView.com/WFC860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In the last two decades, there have been very limited advancements in the treatment of HR+, HER2- early breast cancer, and a particularly marked unmet need has existed for patients at the highest risk of recurrence. Fortunately, there is new hope of improved outcomes for these patients following the recent FDA approval of the first CDK4 and 6 inhibitor for the adjuvant treatment of patients with HR+, HER2-, node+ early breast cancer at high risk of recurrence and a Ki-67 score ≥20%. Shortly thereafter, guideline updates were released that recommended adjuvant CDK4 and 6 inhibitor therapy combined with endocrine therapy to a broader population of patients at high risk of recurrence. The emergence of this new therapeutic option along with varied indications and recommendations has resulted in much uncertainty about which patients should and should not receive adjuvant CDK4 and 6 inhibitor therapy, and how to best integrate it into clinical practice to meaningfully impact outcomes in this challenging patient population. In this educational activity, two leading experts deliver pertinent updates and use patient cases to provide practical guidance for the multidisciplinary team on how to navigate the changing standards of care in HR+, HER2- early breast cancer. Learn how to identify the most appropriate patients who can achieve the highest absolute benefit from adjuvant CDK4 and 6 inhibition, and ensure that those with a particularly poor prognosis are not excluded from this therapy. Additionally, receive guidance on how to recognize and manage treatment-related adverse events so that patients continue to adhere to CDK4 and 6 inhibitor therapy and derive maximum benefit from it in the adjuvant setting. Upon completion of this activity, participants should be better able to: Discuss the evidence, tools, and strategies for risk assessment and stratification in HR+, HER2- early breast cancer to guide treatment selection, including identification of candidates for adjuvant CDK4 and 6 inhibitor therapy, Integrate the latest safety and efficacy data on adjuvant CDK4 and 6 inhibitor therapy into clinical decisions for patients with high-risk, HR+, HER2- early breast cancer, Incorporate modern risk assessment approaches, supporting evidence, regulatory and guideline recommendations, adverse event prevention/management strategies, and shared decision-making into the establishment of individualized treatment plans for patients with HR+, HER2- early breast cancer to improve outcomes in this patient population, including reducing the risk of recurrence in patients with poor prognosis.

Go online to PeerView.com/WFC860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In the last two decades, there have been very limited advancements in the treatment of HR+, HER2- early breast cancer, and a particularly marked unmet need has existed for patients at the highest risk of recurrence. Fortunately, there is new hope of improved outcomes for these patients following the recent FDA approval of the first CDK4 and 6 inhibitor for the adjuvant treatment of patients with HR+, HER2-, node+ early breast cancer at high risk of recurrence and a Ki-67 score ≥20%. Shortly thereafter, guideline updates were released that recommended adjuvant CDK4 and 6 inhibitor therapy combined with endocrine therapy to a broader population of patients at high risk of recurrence. The emergence of this new therapeutic option along with varied indications and recommendations has resulted in much uncertainty about which patients should and should not receive adjuvant CDK4 and 6 inhibitor therapy, and how to best integrate it into clinical practice to meaningfully impact outcomes in this challenging patient population. In this educational activity, two leading experts deliver pertinent updates and use patient cases to provide practical guidance for the multidisciplinary team on how to navigate the changing standards of care in HR+, HER2- early breast cancer. Learn how to identify the most appropriate patients who can achieve the highest absolute benefit from adjuvant CDK4 and 6 inhibition, and ensure that those with a particularly poor prognosis are not excluded from this therapy. Additionally, receive guidance on how to recognize and manage treatment-related adverse events so that patients continue to adhere to CDK4 and 6 inhibitor therapy and derive maximum benefit from it in the adjuvant setting. Upon completion of this activity, participants should be better able to: Discuss the evidence, tools, and strategies for risk assessment and stratification in HR+, HER2- early breast cancer to guide treatment selection, including identification of candidates for adjuvant CDK4 and 6 inhibitor therapy, Integrate the latest safety and efficacy data on adjuvant CDK4 and 6 inhibitor therapy into clinical decisions for patients with high-risk, HR+, HER2- early breast cancer, Incorporate modern risk assessment approaches, supporting evidence, regulatory and guideline recommendations, adverse event prevention/management strategies, and shared decision-making into the establishment of individualized treatment plans for patients with HR+, HER2- early breast cancer to improve outcomes in this patient population, including reducing the risk of recurrence in patients with poor prognosis.

Go online to PeerView.com/WFC860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In the last two decades, there have been very limited advancements in the treatment of HR+, HER2- early breast cancer, and a particularly marked unmet need has existed for patients at the highest risk of recurrence. Fortunately, there is new hope of improved outcomes for these patients following the recent FDA approval of the first CDK4 and 6 inhibitor for the adjuvant treatment of patients with HR+, HER2-, node+ early breast cancer at high risk of recurrence and a Ki-67 score ≥20%. Shortly thereafter, guideline updates were released that recommended adjuvant CDK4 and 6 inhibitor therapy combined with endocrine therapy to a broader population of patients at high risk of recurrence. The emergence of this new therapeutic option along with varied indications and recommendations has resulted in much uncertainty about which patients should and should not receive adjuvant CDK4 and 6 inhibitor therapy, and how to best integrate it into clinical practice to meaningfully impact outcomes in this challenging patient population. In this educational activity, two leading experts deliver pertinent updates and use patient cases to provide practical guidance for the multidisciplinary team on how to navigate the changing standards of care in HR+, HER2- early breast cancer. Learn how to identify the most appropriate patients who can achieve the highest absolute benefit from adjuvant CDK4 and 6 inhibition, and ensure that those with a particularly poor prognosis are not excluded from this therapy. Additionally, receive guidance on how to recognize and manage treatment-related adverse events so that patients continue to adhere to CDK4 and 6 inhibitor therapy and derive maximum benefit from it in the adjuvant setting. Upon completion of this activity, participants should be better able to: Discuss the evidence, tools, and strategies for risk assessment and stratification in HR+, HER2- early breast cancer to guide treatment selection, including identification of candidates for adjuvant CDK4 and 6 inhibitor therapy, Integrate the latest safety and efficacy data on adjuvant CDK4 and 6 inhibitor therapy into clinical decisions for patients with high-risk, HR+, HER2- early breast cancer, Incorporate modern risk assessment approaches, supporting evidence, regulatory and guideline recommendations, adverse event prevention/management strategies, and shared decision-making into the establishment of individualized treatment plans for patients with HR+, HER2- early breast cancer to improve outcomes in this patient population, including reducing the risk of recurrence in patients with poor prognosis.

Go online to PeerView.com/WFC860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In the last two decades, there have been very limited advancements in the treatment of HR+, HER2- early breast cancer, and a particularly marked unmet need has existed for patients at the highest risk of recurrence. Fortunately, there is new hope of improved outcomes for these patients following the recent FDA approval of the first CDK4 and 6 inhibitor for the adjuvant treatment of patients with HR+, HER2-, node+ early breast cancer at high risk of recurrence and a Ki-67 score ≥20%. Shortly thereafter, guideline updates were released that recommended adjuvant CDK4 and 6 inhibitor therapy combined with endocrine therapy to a broader population of patients at high risk of recurrence. The emergence of this new therapeutic option along with varied indications and recommendations has resulted in much uncertainty about which patients should and should not receive adjuvant CDK4 and 6 inhibitor therapy, and how to best integrate it into clinical practice to meaningfully impact outcomes in this challenging patient population. In this educational activity, two leading experts deliver pertinent updates and use patient cases to provide practical guidance for the multidisciplinary team on how to navigate the changing standards of care in HR+, HER2- early breast cancer. Learn how to identify the most appropriate patients who can achieve the highest absolute benefit from adjuvant CDK4 and 6 inhibition, and ensure that those with a particularly poor prognosis are not excluded from this therapy. Additionally, receive guidance on how to recognize and manage treatment-related adverse events so that patients continue to adhere to CDK4 and 6 inhibitor therapy and derive maximum benefit from it in the adjuvant setting. Upon completion of this activity, participants should be better able to: Discuss the evidence, tools, and strategies for risk assessment and stratification in HR+, HER2- early breast cancer to guide treatment selection, including identification of candidates for adjuvant CDK4 and 6 inhibitor therapy, Integrate the latest safety and efficacy data on adjuvant CDK4 and 6 inhibitor therapy into clinical decisions for patients with high-risk, HR+, HER2- early breast cancer, Incorporate modern risk assessment approaches, supporting evidence, regulatory and guideline recommendations, adverse event prevention/management strategies, and shared decision-making into the establishment of individualized treatment plans for patients with HR+, HER2- early breast cancer to improve outcomes in this patient population, including reducing the risk of recurrence in patients with poor prognosis.

In this episode of the PRS Global Open Keynotes Podcast, Karen Evans MD and Romina Deldar MD discuss the efficacy of incisional negative pressure wound dressings in patients undergoing combined panniculectomy and ventral hernia repair. This episode discusses the following PRS Global Open article: “Negative Pressure Wound Therapy Prevents Hernia Recurrence in Simultaneous Ventral Hernia Repair and Panniculectomy” by Romina Deldar, Areeg A. Abu El Hawa, John D. Bovill, Dionisio Hipolito, Eshetu Tefera, Parag Bhanot, Kenneth L. Fan and Karen K. Evans. Read the article for free on PRSGlobalOpen.com: https://bit.ly/PreventingHerniaRecurrence Dr. Karen Evans is a Professor, Associate Program Director, and the Vice Chair of Education in the Department of Plastic Surgery at MedStar Georgetown University Medical Centre in Washington DC. Dr. Romina Deldar is a general surgery resident and plastic surgery research fellow at Medstar Georgetown University Hospital in Washington DC. Your host, Dr. Damian Marucci, is a board-certified plastic surgeon and Associate Professor of Surgery at the University of Sydney in Australia. #PRSGlobalOpen #KeynotesPodcast #PlasticSurgery

In this episode of the PRS Global Open Keynotes Podcast, Karen Evans MD and Romina Deldar MD discuss the efficacy of incisional negative pressure wound dressings in patients undergoing combined panniculectomy and ventral hernia repair. This episode discusses the following PRS Global Open article: “Negative Pressure Wound Therapy Prevents Hernia Recurrence in Simultaneous Ventral Hernia Repair and Panniculectomy” by Romina Deldar, Areeg A. Abu El Hawa, John D. Bovill, Dionisio Hipolito, Eshetu Tefera, Parag Bhanot, Kenneth L. Fan and Karen K. Evans. Read the article for free on PRSGlobalOpen.com: https://bit.ly/PreventingHerniaRecurrence Dr. Karen Evans is a Professor, Associate Program Director, and the Vice Chair of Education in the Department of Plastic Surgery at MedStar Georgetown University Medical Centre in Washington DC. Dr. Romina Deldar is a general surgery resident and plastic surgery research fellow at Medstar Georgetown University Hospital in Washington DC. Your host, Dr. Damian Marucci, is a board-certified plastic surgeon and Associate Professor of Surgery at the University of Sydney in Australia. #PRSGlobalOpen #KeynotesPodcast #PlasticSurgery

This week, Scott and Aaron reflect on the American Revolution - and the parallels between that war and today's conflict in Ukraine. The post History Matters: Recurrences and Echoes appeared first on Chapelboro.com.

Federal Workers Compensation Coffee Break Podcast is about all things related to Federal Workers Compensation, FECA, OWCP, DOL & Longshore claim filing as an injured federal worker.  The podcast is an educational and informative training on how to navigate the DOL, OWCP claims filing process for all types of injured US government and federal workers. The podcaster has 27 years in assisting with federal workers compensation as a consultant and trainer. The podcast is free and is educational. If you need help with anything related to a federal workers compensation claim...help is just a cup of coffee away.A DOL - OWCP CA-2a: Recurrences or New Injuries, New Illnesses A DOL - OWCP  Federal Workers Compensation injury known as a recurrence of an injury is described as one of the following:1. A spontaneous return of the symptoms of a previous injury or occupational disease without intervening cause.2. A return or increase of disability due to a consequential injury: Example Something that occurs due to weakness or impairment caused by a work related injury.3. Withdrawal of a specific duty assignment when the employee cannot perform the full duties of the regular or limited duty position.There are two types of recurrences: •A recurrence of the medical condition is the documented need for additional medical treatment after release from treatment for the work related injury.  Continuing treatment for the original condition is not considered a recurrence.•A recurrence of disability is an inability to work after an employee has returned to work, caused by a spontaneous change in a medical condition which had resulted from a previous injury or illness without an intervening injury or new exposure to the work environment that caused the illness. DOL - OWCP form: CA-2A  link: https://www.nalc283.org/pdf/ca-2a.pdfDr. Taylor has a long history working  as an  OWCP -  DOL provider along with years of working as a federal workers comp consultant teaching all things federal workers compensation related. This is an educational short form format for learning how to successfully file federal workers compensation claims. So grab a cup of coffee and lets begin.Dr. Taylor's contact information for more information or assistance is:fedcompconsultants@protonmail.comor you can reach him at 813-877-6900 or make an appointment at https://mrtherapycenter.com/Primary location is at M & R Medical & Therapy Center4150 N. Armenia Avenue, Suite 102Tampa Florida 33607

Go online to PeerView.com/DVD860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, multidisciplinary oncology experts discuss immunotherapy advances, focusing on transitioning immunotherapies to earlier disease settings to improve outcomes, prevent recurrences, and increase curability in early-stage cancers. Upon completion of this CE activity, participants will be able to: Describe the rationale for using neoadjuvant, adjuvant, or perioperative immunotherapy in early-stage cancers, key trials and relevant endpoints, and evolving evidence supporting ICI use in different early-stage solid tumors, Implement best practices for multidisciplinary/interprofessional patient and tumor evaluation as well as coordination of care when managing patients with early-stage cancers, Integrate immunotherapies into individualized, multimodal treatment plans for appropriate patients with early-stage cancers in clinical practice or through clinical trial participation, Assess the risks and benefits associated with neoadjuvant/adjuvant/perioperative immunotherapy use to ensure safe, optimally selected, and appropriately timed delivery of systemic and local multimodal therapies to patients with early-stage solid tumors.

Go online to PeerView.com/DVD860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, multidisciplinary oncology experts discuss immunotherapy advances, focusing on transitioning immunotherapies to earlier disease settings to improve outcomes, prevent recurrences, and increase curability in early-stage cancers. Upon completion of this CE activity, participants will be able to: Describe the rationale for using neoadjuvant, adjuvant, or perioperative immunotherapy in early-stage cancers, key trials and relevant endpoints, and evolving evidence supporting ICI use in different early-stage solid tumors, Implement best practices for multidisciplinary/interprofessional patient and tumor evaluation as well as coordination of care when managing patients with early-stage cancers, Integrate immunotherapies into individualized, multimodal treatment plans for appropriate patients with early-stage cancers in clinical practice or through clinical trial participation, Assess the risks and benefits associated with neoadjuvant/adjuvant/perioperative immunotherapy use to ensure safe, optimally selected, and appropriately timed delivery of systemic and local multimodal therapies to patients with early-stage solid tumors.

Go online to PeerView.com/DVD860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, multidisciplinary oncology experts discuss immunotherapy advances, focusing on transitioning immunotherapies to earlier disease settings to improve outcomes, prevent recurrences, and increase curability in early-stage cancers. Upon completion of this CE activity, participants will be able to: Describe the rationale for using neoadjuvant, adjuvant, or perioperative immunotherapy in early-stage cancers, key trials and relevant endpoints, and evolving evidence supporting ICI use in different early-stage solid tumors, Implement best practices for multidisciplinary/interprofessional patient and tumor evaluation as well as coordination of care when managing patients with early-stage cancers, Integrate immunotherapies into individualized, multimodal treatment plans for appropriate patients with early-stage cancers in clinical practice or through clinical trial participation, Assess the risks and benefits associated with neoadjuvant/adjuvant/perioperative immunotherapy use to ensure safe, optimally selected, and appropriately timed delivery of systemic and local multimodal therapies to patients with early-stage solid tumors.

Go online to PeerView.com/DVD860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, multidisciplinary oncology experts discuss immunotherapy advances, focusing on transitioning immunotherapies to earlier disease settings to improve outcomes, prevent recurrences, and increase curability in early-stage cancers. Upon completion of this CE activity, participants will be able to: Describe the rationale for using neoadjuvant, adjuvant, or perioperative immunotherapy in early-stage cancers, key trials and relevant endpoints, and evolving evidence supporting ICI use in different early-stage solid tumors, Implement best practices for multidisciplinary/interprofessional patient and tumor evaluation as well as coordination of care when managing patients with early-stage cancers, Integrate immunotherapies into individualized, multimodal treatment plans for appropriate patients with early-stage cancers in clinical practice or through clinical trial participation, Assess the risks and benefits associated with neoadjuvant/adjuvant/perioperative immunotherapy use to ensure safe, optimally selected, and appropriately timed delivery of systemic and local multimodal therapies to patients with early-stage solid tumors.

Go online to PeerView.com/DVD860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, multidisciplinary oncology experts discuss immunotherapy advances, focusing on transitioning immunotherapies to earlier disease settings to improve outcomes, prevent recurrences, and increase curability in early-stage cancers. Upon completion of this CE activity, participants will be able to: Describe the rationale for using neoadjuvant, adjuvant, or perioperative immunotherapy in early-stage cancers, key trials and relevant endpoints, and evolving evidence supporting ICI use in different early-stage solid tumors, Implement best practices for multidisciplinary/interprofessional patient and tumor evaluation as well as coordination of care when managing patients with early-stage cancers, Integrate immunotherapies into individualized, multimodal treatment plans for appropriate patients with early-stage cancers in clinical practice or through clinical trial participation, Assess the risks and benefits associated with neoadjuvant/adjuvant/perioperative immunotherapy use to ensure safe, optimally selected, and appropriately timed delivery of systemic and local multimodal therapies to patients with early-stage solid tumors.

Go online to PeerView.com/DVD860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, multidisciplinary oncology experts discuss immunotherapy advances, focusing on transitioning immunotherapies to earlier disease settings to improve outcomes, prevent recurrences, and increase curability in early-stage cancers. Upon completion of this CE activity, participants will be able to: Describe the rationale for using neoadjuvant, adjuvant, or perioperative immunotherapy in early-stage cancers, key trials and relevant endpoints, and evolving evidence supporting ICI use in different early-stage solid tumors, Implement best practices for multidisciplinary/interprofessional patient and tumor evaluation as well as coordination of care when managing patients with early-stage cancers, Integrate immunotherapies into individualized, multimodal treatment plans for appropriate patients with early-stage cancers in clinical practice or through clinical trial participation, Assess the risks and benefits associated with neoadjuvant/adjuvant/perioperative immunotherapy use to ensure safe, optimally selected, and appropriately timed delivery of systemic and local multimodal therapies to patients with early-stage solid tumors.

Go online to PeerView.com/DVD860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, multidisciplinary oncology experts discuss immunotherapy advances, focusing on transitioning immunotherapies to earlier disease settings to improve outcomes, prevent recurrences, and increase curability in early-stage cancers. Upon completion of this CE activity, participants will be able to: Describe the rationale for using neoadjuvant, adjuvant, or perioperative immunotherapy in early-stage cancers, key trials and relevant endpoints, and evolving evidence supporting ICI use in different early-stage solid tumors, Implement best practices for multidisciplinary/interprofessional patient and tumor evaluation as well as coordination of care when managing patients with early-stage cancers, Integrate immunotherapies into individualized, multimodal treatment plans for appropriate patients with early-stage cancers in clinical practice or through clinical trial participation, Assess the risks and benefits associated with neoadjuvant/adjuvant/perioperative immunotherapy use to ensure safe, optimally selected, and appropriately timed delivery of systemic and local multimodal therapies to patients with early-stage solid tumors.

Go online to PeerView.com/DVD860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, multidisciplinary oncology experts discuss immunotherapy advances, focusing on transitioning immunotherapies to earlier disease settings to improve outcomes, prevent recurrences, and increase curability in early-stage cancers. Upon completion of this CE activity, participants will be able to: Describe the rationale for using neoadjuvant, adjuvant, or perioperative immunotherapy in early-stage cancers, key trials and relevant endpoints, and evolving evidence supporting ICI use in different early-stage solid tumors, Implement best practices for multidisciplinary/interprofessional patient and tumor evaluation as well as coordination of care when managing patients with early-stage cancers, Integrate immunotherapies into individualized, multimodal treatment plans for appropriate patients with early-stage cancers in clinical practice or through clinical trial participation, Assess the risks and benefits associated with neoadjuvant/adjuvant/perioperative immunotherapy use to ensure safe, optimally selected, and appropriately timed delivery of systemic and local multimodal therapies to patients with early-stage solid tumors.

Go online to PeerView.com/DVD860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, multidisciplinary oncology experts discuss immunotherapy advances, focusing on transitioning immunotherapies to earlier disease settings to improve outcomes, prevent recurrences, and increase curability in early-stage cancers. Upon completion of this CE activity, participants will be able to: Describe the rationale for using neoadjuvant, adjuvant, or perioperative immunotherapy in early-stage cancers, key trials and relevant endpoints, and evolving evidence supporting ICI use in different early-stage solid tumors, Implement best practices for multidisciplinary/interprofessional patient and tumor evaluation as well as coordination of care when managing patients with early-stage cancers, Integrate immunotherapies into individualized, multimodal treatment plans for appropriate patients with early-stage cancers in clinical practice or through clinical trial participation, Assess the risks and benefits associated with neoadjuvant/adjuvant/perioperative immunotherapy use to ensure safe, optimally selected, and appropriately timed delivery of systemic and local multimodal therapies to patients with early-stage solid tumors.

Go online to PeerView.com/DVD860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, multidisciplinary oncology experts discuss immunotherapy advances, focusing on transitioning immunotherapies to earlier disease settings to improve outcomes, prevent recurrences, and increase curability in early-stage cancers. Upon completion of this CE activity, participants will be able to: Describe the rationale for using neoadjuvant, adjuvant, or perioperative immunotherapy in early-stage cancers, key trials and relevant endpoints, and evolving evidence supporting ICI use in different early-stage solid tumors, Implement best practices for multidisciplinary/interprofessional patient and tumor evaluation as well as coordination of care when managing patients with early-stage cancers, Integrate immunotherapies into individualized, multimodal treatment plans for appropriate patients with early-stage cancers in clinical practice or through clinical trial participation, Assess the risks and benefits associated with neoadjuvant/adjuvant/perioperative immunotherapy use to ensure safe, optimally selected, and appropriately timed delivery of systemic and local multimodal therapies to patients with early-stage solid tumors.

Go online to PeerView.com/DVD860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, multidisciplinary oncology experts discuss immunotherapy advances, focusing on transitioning immunotherapies to earlier disease settings to improve outcomes, prevent recurrences, and increase curability in early-stage cancers. Upon completion of this CE activity, participants will be able to: Describe the rationale for using neoadjuvant, adjuvant, or perioperative immunotherapy in early-stage cancers, key trials and relevant endpoints, and evolving evidence supporting ICI use in different early-stage solid tumors, Implement best practices for multidisciplinary/interprofessional patient and tumor evaluation as well as coordination of care when managing patients with early-stage cancers, Integrate immunotherapies into individualized, multimodal treatment plans for appropriate patients with early-stage cancers in clinical practice or through clinical trial participation, Assess the risks and benefits associated with neoadjuvant/adjuvant/perioperative immunotherapy use to ensure safe, optimally selected, and appropriately timed delivery of systemic and local multimodal therapies to patients with early-stage solid tumors.

Go online to PeerView.com/DVD860 to view the activity, download slides and practice aids, and complete the post-test to earn credit. In this activity, multidisciplinary oncology experts discuss immunotherapy advances, focusing on transitioning immunotherapies to earlier disease settings to improve outcomes, prevent recurrences, and increase curability in early-stage cancers. Upon completion of this CE activity, participants will be able to: Describe the rationale for using neoadjuvant, adjuvant, or perioperative immunotherapy in early-stage cancers, key trials and relevant endpoints, and evolving evidence supporting ICI use in different early-stage solid tumors, Implement best practices for multidisciplinary/interprofessional patient and tumor evaluation as well as coordination of care when managing patients with early-stage cancers, Integrate immunotherapies into individualized, multimodal treatment plans for appropriate patients with early-stage cancers in clinical practice or through clinical trial participation, Assess the risks and benefits associated with neoadjuvant/adjuvant/perioperative immunotherapy use to ensure safe, optimally selected, and appropriately timed delivery of systemic and local multimodal therapies to patients with early-stage solid tumors.

Kellar's in hell, Strenk's doing improv, Joe Briggs wants to be happy, and Pedro looms large. Help Kelly pay for a new alternator so they can get to work. Watch Joe's YouTube video and sound off in the comments. Ending song: Bug Mane "Kokopelli (Steel Drum Remix)"  

A Symposium specifically developed for Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Distinguished members and keynote speakers provide insight as to what impacts the patient and families on both quality and economic topics, what role leadership plays in creating the right culture for patient-centered care, and how to identify, evaluate, and prioritize innovations that can quickly touch the lives of patients battling C. diff. infections. Kathy Bischoff, C. diff. Survivor My C. diff. Journey Renata Johnson, C. diff. Survivor My C. diff. Journey Paul Feuerstadt, MD - review Barbara McGovern, MD, “Treatment of recurrent C. difficile infection with SER-109, an investigational microbiome drug.

A Symposium specifically developed for Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Distinguished members and keynote speakers provide insight as to what impacts the patient and families on both quality and economic topics, what role leadership plays in creating the right culture for patient-centered care, and how to identify, evaluate, and prioritize innovations that can quickly touch the lives of patients battling C. diff. infections. Kathy Bischoff, C. diff. Survivor My C. diff. Journey Renata Johnson, C. diff. Survivor My C. diff. Journey Paul Feuerstadt, MD - review Barbara McGovern, MD, “Treatment of recurrent C. difficile infection with SER-109, an investigational microbiome drug.

A Symposium specifically developed for Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Distinguished members and keynote speakers provide insight as to what impacts the patient and families on both quality and economic topics, what role leadership plays in creating the right culture for patient-centered care, and how to identify, evaluate, and prioritize innovations that can quickly touch the lives of patients battling C. diff. infections. Kathy Bischoff, C. diff. Survivor My C. diff. Journey Renata Johnson, C. diff. Survivor My C. diff. Journey Paul Feuerstadt, MD - review Barbara McGovern, MD, “Treatment of recurrent C. difficile infection with SER-109, an investigational microbiome drug.

A Symposium specifically developed for Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Distinguished members and keynote speakers provide insight as to what impacts the patient and families on both quality and economic topics, what role leadership plays in creating the right culture for patient-centered care, and how to identify, evaluate, and prioritize innovations that can quickly touch the lives of patients battling C. diff. infections. Courtney Jones ” Microbiome, Microbiota, and Gut Health.” Denise Cardo, MD “Everyone Has a Role in Antibiotic Awareness.” Larry Kociolek, MD “C. diff. Infections in Pediatrics.” This event was sponsored by Seres Therapeutics. Seres Therapeutics mission is to transform the lives of patients worldwide with revolutionary microbiome therapeutics Enjoy the program!

A Symposium specifically developed for Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Distinguished members and keynote speakers provide insight as to what impacts the patient and families on both quality and economic topics, what role leadership plays in creating the right culture for patient-centered care, and how to identify, evaluate, and prioritize innovations that can quickly touch the lives of patients battling C. diff. infections. Courtney Jones ” Microbiome, Microbiota, and Gut Health.” Denise Cardo, MD “Everyone Has a Role in Antibiotic Awareness.” Larry Kociolek, MD “C. diff. Infections in Pediatrics.” This event was sponsored by Seres Therapeutics. Seres Therapeutics mission is to transform the lives of patients worldwide with revolutionary microbiome therapeutics Enjoy the program!

A Symposium specifically developed for Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Distinguished members and keynote speakers provide insight as to what impacts the patient and families on both quality and economic topics, what role leadership plays in creating the right culture for patient-centered care, and how to identify, evaluate, and prioritize innovations that can quickly touch the lives of patients battling C. diff. infections. Courtney Jones ” Microbiome, Microbiota, and Gut Health.” Denise Cardo, MD “Everyone Has a Role in Antibiotic Awareness.” Larry Kociolek, MD “C. diff. Infections in Pediatrics.” This event was sponsored by Seres Therapeutics. Seres Therapeutics mission is to transform the lives of patients worldwide with revolutionary microbiome therapeutics Enjoy the program!

Welcome to the second episode of a special four (4) part series: A Symposium Created For Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Welcome to a Symposium specifically developed for patients, families, and caregivers. The Patient & Family C. diff. Symposium: where a gathering of healthcare professionals, keynote speakers, health advocates, practitioners, educators, are transforming the patient experience, and changing the way people experience C. diff. infections worldwide. Simon Cutting, Ph. D. “Bacillus, and C. diff. Spore Overview. “ Teena Chopra, MD ” Introduction to Infection Prevention.” Doe Kley, RN, MPH “C. diff. Transitioning from Hospital to Home. This event was sponsored by Seres Therapeutics, Seres Therapeutic's mission is to transform the lives of patients worldwide with revolutionary microbiome therapeutics Enjoy the presentations by the topic leaders joining us!

Welcome to the second episode of a special four (4) part series: A Symposium Created For Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Welcome to a Symposium specifically developed for patients, families, and caregivers. The Patient & Family C. diff. Symposium: where a gathering of healthcare professionals, keynote speakers, health advocates, practitioners, educators, are transforming the patient experience, and changing the way people experience C. diff. infections worldwide. Simon Cutting, Ph. D. “Bacillus, and C. diff. Spore Overview. “ Teena Chopra, MD ” Introduction to Infection Prevention.” Doe Kley, RN, MPH “C. diff. Transitioning from Hospital to Home. This event was sponsored by Seres Therapeutics, Seres Therapeutic's mission is to transform the lives of patients worldwide with revolutionary microbiome therapeutics Enjoy the presentations by the topic leaders joining us!

Welcome to the second episode of a special four (4) part series: A Symposium Created For Patients Diagnosed With a C. diff. Infection, Being Treated For a Clostridioides diffiicile infection, Recovering From a Clostridioides difficile Infection and Recurrences with Family Members and Caregivers. Welcome to a Symposium specifically developed for patients, families, and caregivers. The Patient & Family C. diff. Symposium: where a gathering of healthcare professionals, keynote speakers, health advocates, practitioners, educators, are transforming the patient experience, and changing the way people experience C. diff. infections worldwide. Simon Cutting, Ph. D. “Bacillus, and C. diff. Spore Overview. “ Teena Chopra, MD ” Introduction to Infection Prevention.” Doe Kley, RN, MPH “C. diff. Transitioning from Hospital to Home. This event was sponsored by Seres Therapeutics, Seres Therapeutic's mission is to transform the lives of patients worldwide with revolutionary microbiome therapeutics Enjoy the presentations by the topic leaders joining us!

Join us with our guest: Candida Fratazzi, MD, Consulting Medical Director at Vedanta Biosciences, focused on pioneering rational design of drugs, made of defined consortia of bacteria, to Modulate the Human Microbiome. Dr. Fratazzi will be discussing and explaining Microbiome functions and how its changes impact our health. How bacteria colonies’ equilibrium is supported and supports our immune system. Thus, the need to correct imbalance of bacteria colonies not with untargeted pull of bacteria such as fecal transplant or with a single strain of bacteria such as probiotics. Dr Fratazzi will certainly be educating us on this episode, Why Bacterial Consortia May Stop C. diff. Recurrences”

Join us with our guest: Candida Fratazzi, MD, Consulting Medical Director at Vedanta Biosciences, focused on pioneering rational design of drugs, made of defined consortia of bacteria, to Modulate the Human Microbiome. Dr. Fratazzi will be discussing and explaining Microbiome functions and how its changes impact our health. How bacteria colonies' equilibrium is supported and supports our immune system. Thus, the need to correct imbalance of bacteria colonies not with untargeted pull of bacteria such as fecal transplant or with a single strain of bacteria such as probiotics. Dr Fratazzi will certainly be educating us on this episode, Why Bacterial Consortia May Stop C. diff. Recurrences”

Paul J. Wang: Welcome to the monthly podcast, On the Beat for Circulation: Arrhythmia and Electrophysiology. I'm Dr. Paul Wang, Editor-in-chief, with some of the key highlights from this month's issue. In our first paper, Zak Loring and associates examined 3,139 patients undergoing atrial fibrillation (AF) ablation, between 2016 and 2018 in the Get With The Guidelines-Atrial Fibrillation Registry from 24 US centers. Patients undergoing AF ablation were predominantly male (63.9%) and Caucasian (93.2%) with a median age of 65. Hypertension was the most common comorbidity (67.6%), and persistent atrial fibrillation patients had more comorbidities than paroxysmal AF patients. Drug refractory, paroxysmal AF was most common ablation indication (class I, 53.6%) followed by drug refractory, persistent AF (class I, 41.8%). Radio-frequency, RF ablation, with contact force sensing was the most common ablation modality (70.5%) and 23.7% of patients underwent cryoballoon ablation. Pulmonary vein isolation was performed in 94.6% of de novo ablations. The most common adjunctive lesion included left atrial roof or posterior/inferior lines and cavotricuspid isthmus ablation. Complications were uncommon (5.1%) and were life-threatening in 0.7% of cases. In our next paper, Brian Howard and associates hypothesize that pulse field ablation (PFA) would reduce pulmonary vein stenosis risk and collateral injury compared to irrigated radiofrequency ablation (IRF). IRF and PFA deliveries were randomized in eight dogs with two superior pulmonary veins (PVs), ablated with using one technology and two inferior PVs ablated with the other technology. IRF energy (25-30 watts) or PFA with delivered (16 pulse trains) at each PV in a proximal and in a distal site. Contrast computed tomography (CT scans) were collected at 0, 2, 4 and 8, and 12 week, including termination time points to monitor PV cross-sectional area at each PV ablation site. Maximum average change in normalized cross-sectional area at 4 weeks was 46.1%±45.1% post IRF compared to -5.5±20.5% for PFA (P≤ to 0.001). Necropsy showed expansive PFA lesions without stenosis in the proximal PV sites compared to more confined and often incomplete lesions after IRF. At the distal PV sites only IRF ablations were grossly identified based on focal fibrosis. Mild pulmonary chronic parenchymal hemorrhage was noted in three left superior pulmonary vein lobes after IRF. Damage to vagus nerves, as well as evidence of esophagus dilation, occurred at sites associated with IRF. In contrast, no lung, vagal nerve, or esophageal injury was observed at PFA sites. In our next paper, Mohamed Diab and associates aimed to assess the safety of ablation for atrial fibrillation (AF) with trans-esophageal (TEE) screening on intracardiac echocardiography (ICE) imaging of the appendage in direct oral anticoagulant (DOAC) compliant patients. They studied 900 patients with a medium CHA2DS2-VASc score of two. Interquartile range one to three. All consecutive patients presenting with AF or atrial flutter on DOAC were included. All were on DOACs (333 Rivaroxaban, 285 Dabigatran, 281 Apixaban and one Edoxaban). Thromboembolic complications occurred in four patients (0.3%), two ischemic strokes, one transient ischemic attack without residual deficit and one splenic infarct, all with no further complications. Bleeding complications incurred in 5 patients (0.4%), including 2 pericardial effusions (1 intraoperative, 1 after 30 days, both drained), and 3 groin hematomas (1 due to needing heparin for venous thrombosis, none requiring intervention). No patients required emergent surgeries. In our next paper, Alexios Hadjis and associates aim to explore the role of complete diastolic pathway activation mapping on ventricular tachycardia (VT) recurrence. They studied 85 consecutive patients who underwent VT ablation using and guided by high-density mapping. During activation mapping, the presence of electrical activity in all segments of diastole defined the evidence of having had recorded the whole diastolic interval. Patients were categorized as having recorded the full diastolic pathway, partial diastolic pathway or no diastolic pathway map performed. Recurrences of VT were defined as appropriate IC therapies or on the basis of EC documented arrhythmia. Complete recording of the diastolic pathway was achieved in 36 of 85 (42.4%). Partial recording of the diastolic pathway of clinical VT was achieved in 24 of 85 (28.2%). No recording of the diastolic pathway of clinical VT was feasible in 25 of 85 patients (29.4%). At a mean of 12.8 months, freedom from VT recurrences was 67% in the overall cohort. At a mean of 12.8 months, freedom from VT recurrence was 88% in patients who had full diastolic activity recorded, 50% of partial diastolic activity recorded and 55% in those who underwent substrate modification (P=0.02). The authors concluded that mapping of the entire diastolic pathway was associated with a higher freedom from VT occurrence compared to partial diastolic pathway recording and substrate modification. The use of multielectrode mapping catheters in recording diastolic activity may help predict those VTs employing intramural circuits and further optimize ablation strategies. In our next paper, Hui-Nam Pak and associates investigated whether electrical posterior box isolation (POBI) may improve rhythm outcome of catheter ablation in patients in whom persistent atrial fibrillation changes to paroxysmal atrial fibrillation after antiarrythmic drug medication and cardioversion. They prospectively randomized 114 patients, 75% male, 59.8 years old to circumferential pulmonary vein ablation (CPVI) alone (n=57) and an additional POBI group (n=57). Primary endpoint was AF recurrence after a single procedure, and secondary endpoints were recurrence pattern, cardioversion rate and response to antiarrhythmic drugs (AAD). After a mean follow-up of 23.8 months, the clinical recurrence rate did not significantly differ between the CPVI alone and additional POBI group (31.6% versus 28.1%; P=0.682). The recurrence rate as atrial tachycardias, 5.3% versus 12.3% (P=0.14) and cardioversion rates, 5.3% versus 10.5% (P=0.25) were not significantly different between the CPVI and POBI group. At the final follow-up, sinus rhythm was maintained without antiarryhthmic drug in 52.6% of CPVI group and 59.6% of the POBI group (P=0.45). No significant difference was found in major complications between the two groups, 5.3% versus 1.8% (P=0.618). But the total ablation time was significantly longer in the POBI group (4187 seconds versus 5337 seconds; P

From the Rumble Seat brings you a new way to experience Georgia Tech sports — through your earholes. Join Jake and Akshay as they talk Georgia Tech sports news, break down games, and banter away during your commute to work or your workout. On this week’s episode: WBB and MBB get wins! Recapping the action around the ACC Last week: L 56-33 @ NCST - bleh Next week: 12/10 vs Pitt (TV: 7pm, RSN) Looking ahead to Week 14 (13? who knows) in the ACC Subscribe to the pod via anchor.fm/scions or add us to your podcatcher using anchor.fm/s/5aa2e7c/podcast/rss. You can also find us on Apple Podcasts, Google Podcasts, Spotify, Pocket Casts, and Stitcher Radio! We hope you enjoy! Please let us know what you think via email (fromtherumbleseat@gmail.com) or on Twitter (@FTRSBlog)!

Join us with our guest: Candida Fratazzi, MD, Consulting Medical Director at Vedanta Biosciences, focused on pioneering rational design of drugs, made of defined consortia of bacteria, to Modulate the Human Microbiome. Dr. Fratazzi will be discussing and explaining Microbiome functions and how its changes impact our health. How bacteria colonies' equilibrium is supported and supports our immune system. Thus, the need to correct imbalance of bacteria colonies not with untargeted pull of bacteria such as fecal transplant or with a single strain of bacteria such as probiotics. Dr Fratazzi will certainly be educating us on this episode, Why Bacterial Consortia May Stop C. diff. Recurrences”

Join us with our guest: Candida Fratazzi, MD, Consulting Medical Director at Vedanta Biosciences, focused on pioneering rational design of drugs, made of defined consortia of bacteria, to Modulate the Human Microbiome. Dr. Fratazzi will be discussing and explaining Microbiome functions and how its changes impact our health. How bacteria colonies’ equilibrium is supported and supports our immune system. Thus, the need to correct imbalance of bacteria colonies not with untargeted pull of bacteria such as fecal transplant or with a single strain of bacteria such as probiotics. Dr Fratazzi will certainly be educating us on this episode, Why Bacterial Consortia May Stop C. diff. Recurrences”

Join us with our guest: Candida Fratazzi, MD, Consulting Medical Director at Vedanta Biosciences, focused on pioneering rational design of drugs, made of defined consortia of bacteria, to Modulate the Human Microbiome. Dr. Fratazzi will be discussing and explaining Microbiome functions and how its changes impact our health. How bacteria colonies’ equilibrium is supported and supports our immune system. Thus, the need to correct imbalance of bacteria colonies not with untargeted pull of bacteria such as fecal transplant or with a single strain of bacteria such as probiotics. Dr Fratazzi will certainly be educating us on this episode, Why Bacterial Consortia May Stop C. diff. Recurrences”

Dr. Auwaerter covers the following topics: *Recurrences of COVID-19 symptoms *Hydroxychloroquine study from Michigan *Sarilumab (anti-IL6) monoclonal antibody *Operation Warp Speed update *Differences in mortality rates among States *Nasal vs. nasopharyngeal test accuracy. The post UPDATE 7/8/2020 – COVID-19: Keeping Up With A Moving Target appeared first on DKBmed Radio.

Productivity Tip of the DayⓇ: Use recurrences in your calendar Extreme Time Blocking Workshop: https://extremetimeblocking.com --- Send in a voice message: https://anchor.fm/productivitytip/message

SHOW #199 Mission Impossible Fallout, Chronic Recurrences, The Meaning Of Your Recurring Dreams, What Happened to YumYum YuiYum, and more. Fabulous!

Paul Wang:         Welcome to the monthly podcast “On The Beat”, for Circulation: Arrhythmia and Electrophysiology. I am Dr. Paul Wang, Editor-in-Chief, with some of the key highlights from this month's issue. We'll also hear from Dr. Suraj Kapa, reporting on new research from the latest journal articles in the field.                                 In our first article, Adetola Ladejobi and associates studied 1,433 patients, between 2000 and 2012, who were discharged alive after sudden cardiac arrest. A reversible and correctable cause was identified in 792 patients, or 55%. A reversible cause for sudden cardiac arrest was defined as significant electrolyte or metabolic abnormality, evidence of acute myocardial infarction or ischemia, recent initiation of antiarrhythmic drug, or illicit drug use, or other reversible circumstances.                                 Of the 792 sudden cardiac arrest survivors, due to reversible or correctable cause, 207 or 26% of the patients received an ICD after their indexed sudden cardiac arrest. During a mean follow-up of 3.8 years, 319 or 40% of patients died. ICD implantation was highly associated with a lower all-cause mortality, p < 0.001, even after correcting for unbalanced baseline characteristics.                                 In subgroup analyses, only patients with sudden cardiac arrest, were not associated with myocardial infarction, extracted benefit from the ICD, p < 0.001.                                 The authors concluded that in survivors of sudden cardiac arrest, due to a reversible and correctable cause, ICD therapies associated with lower all-cause mortality, except if the sudden cardiac arrest was due to myocardial infarction.                                 Further prospect of multi-center randomized control trials will be needed to confirm this observation.                                 In our next study, Carlo Pappone and associates, studied 81 patients with persistent atrial fibrillation, randomized to undergo high density electrophysiological mapping, to identify repetitive regular activities, before modified circumferential pulmonary vein ablation, or modified circumferential pulmonary vein ablation alone. The primary endpoint was freedom from arrhythmia recurrence at one year.                                 In the 81 patients with persistent atrial fibrillation, there were 479 regions exhibiting repetitive regular activities in these patients, or 5.9 repetitive regular activities per patient. There were 232 regions in the mapping group, which consisted of 41 patients, and 247 regions in the control group, consisting of 40 patients. Overall, 39% of the repetitive regular activities were identified within pulmonary veins, whereas 61% were identified in non-pulmonary vein regions.                                 Mapping-guided ablation resulted in higher arrhythmia termination rate, as compared to conventional strategy, 61% vs. 30%, p < 0.007. Total RF duration, mapping, and fluoroscopy times were not significantly different between the groups. No major procedure related adverse events occurred.                                 After one year, 73% of the mapping group of patients were free of recurrences, compared to 50% of the control group, p = 0.03.                                 The authors concluded that targeted ablation of regions showing repetitive regular activities provided adjunctive benefit in terms of arrhythmia freedom at one year in treatment of patients with persistent atrial fibrillation. These findings should be confirmed by additional larger randomized multi-centered studies.                                 In the next article, Maciej Kubala and associates examine repolarization abnormalities in 40 patients with arrhythmogenic right ventricular cardiomyopathy, comparing extent and location of abnormal T-waves of one millimeter or greater in depth, downsloping elevated ST segment in two or more adjacent leads to the area and location of endocardial bipolar and unipolar, and epicardial bipolar voltage abnormalities. They found an abnormal unipolar right ventricular endocardial area of 33.4% with presence in eight patients without negative T-waves. Patients with negative T-waves extending beyond V3, seen in 20 patients, had larger low bipolar and unipolar endocardial areas, and larger epicardial low bipolar areas, compared to those with negative T-waves limited to leads V1 to V3.                                 ECG localization of negative T-waves regionalized to the location of substrate. Patients with downsloping elevated ST segment, all localized to leads V1, V2 had more unipolar endocardial abnormalities involving outflow in mid-right ventricle, compared to patients without downsloping elevated ST segment.                                 The authors concluded that in arrhythmogenic right ventricular cardiomyopathy, abnormal electric current areas were proportional to the extent of T-wave inversion on the 12 lead electrocardiogram. Marked voltage abnormalities can exist without repolarization changes. Downsloping elevated ST segment patterns in V1 and V2 occurs with more unipolar endocardial voltage abnormalities, consistent with more advanced trans neural disease.                                 In the next manuscript, Teresa Oloriz and associates examine the timing and value of program stimulation after catheter ablation for ventricular tachycardia. They performed 218 program ventricular stimulations six days after ablation in 210 consecutive patients, 48% with ischemic cardiomyopathy in the median left ventricular ejection fraction of 37%. After ablation, ICDs were programmed according to NIPS results. Class A were noninducible, Class B non documented inducible VT, and Class C documented inducible VT. Concordance between the programmed ventricular stimulation at the end of the procedure and at six days was 67%. The positive predictive value and negative predictive value were higher for the programmed ventricular stimulation at day six. Ischemic patients and those with preserved ejection fraction showed the highest negative predictive value.                                 Among noninducible patients at the end of the procedure, but inducible at day six, 59 patients had VT recurrence at one year follow-up. Recurrences were 9% when both studies were noninducible. There were no inappropriate shocks, incidents of syncope with 3%, none harmful. The rate of appropriate shocks per patient per month according to NIPS was significantly reduced, comparing the month before and after the ablation.                                 The authors concluded that programmed ventricular stimulation at day six predicts VT recurrence.                                 In the next study, Tor Biering-Sørensen and associates examined ECG global electrical heterogeneity, GEH, in its longitudinal changes, are associated with cardiac structure and function, in their Atherosclerosis Risk and Community study, ARIC, consisting of 5,114 patients, 58% which were female and 22% African Americans. Using the resting 12-lead ECGs, and echocardiographic assessments of left ventricular ejection fraction, global strain, left ventricular mass index, end diastolic volume index, end systolic volume index at visit five.                                 Longitudinal analysis included ARIC participants with measured GEH at visits one to four. GEH was quantified by spatial ventricular gradient, the QRST angle, and the sum of the absolute QRST integral. Cross sectional and longitudinal regressions were adjusted for manifest subclinical cardiovascular disease.                                 Having four abnormal GEH parameters was associated with a 6.4% left ventricular ejection fraction decline, a 24.2 gram/meter square increase in left ventricular mass index, a 10.3 milliliter/meter square increase in left ventricular end diastolic volume index, and a 7.8 milliliter/meter square increase in left ventricular end systolic index. All together, clinical and ECG parameters accounted for approximately one third of the left ventricular volume in 20% of the systolic function variability.                                 The associates were significantly stronger in patients with subclinical cardiovascular disease. The QRST integral increased by 20 millivolts/meter second for each three year period participants who demonstrated left ventricular dilatation at visit five. Sudden cardiac death victims demonstrated rapid GEH worsening, while those with left ventricular dysfunction demonstrated slow GEH worsening.                                 The authors concluded that GEH is a marker of subclinical abnormalities in cardiac structure and function.                                 In the next manuscript, Takumi Yamada and associates studied 19 patients with idiopathic ventricular arrhythmias, originating in the parietal band in 14 patients, in the septal band in 5 patients. Among 294 consecutive patients with right ventricular arrhythmia origins, parietal band and septal band ventricular arrhythmias exhibited a left bundle branch block, with left inferior in 12 patients', superior in 2 patients' axes, in left or right inferior axis pattern in four and one patients respectively.                                 In Lead 1, all parietal band ventricular arrhythmias exhibited R-waves, while septal band ventricular arrhythmias often exhibited S-waves. A QS pattern in lead AVR, in the presence of a knock in the mid QRS were common in all infundibular muscle ventricular arrhythmias. During infundibular muscle ventricular arrhythmias, a far-field ventricular electrogram, with an early activation, was always recorded in the His bundle region, regardless of the location of ventricular arrhythmia regions. With 9.2 radiofrequency applications in a duration of 972 seconds, catheter ablation was successful in 15 of the 19 patients. Ventricular arrhythmias recurred in four patients during a fallout period of 43 months.                                 In the next paper, Uma Mahesh Avula and associates examine the mechanisms underlying spontaneous atrial fibrillation, in an Ovine model of left atrial myocardial infarction. The left atrial myocardial infarction was created by ligating the atrial branch of the left anterior descending artery. ECG loop recorders were implanted to monitor atrial fibrillation episodes.                                 In seven sheep, Dantrolene, a Ryanodine receptor blocker, was administered in vivo, during the observation period. The left atrial myocardial infarction animals experienced numerous episodes of atrial fibrillation during the eight day monitoring period, that were suppressed by Dantrolene. Optical mapping showed spontaneous focal discharges originating through the ischemic/normal-zone border. These spontaneous focal discharges were calcium driven, rate dependent, and enhanced by isoproterenol, but suppressed by Dantrolene.                                 In addition, these spontaneous focal discharges initiated atrial fibrillation-maintaining reentrant rotors anchored by marked conduction delays at the ischemic/normal-zone border. Nitric oxide synthase one protein expression decreased in ischemic zone myocytes, or NADPA oxidase in xanthine oxidase enzyme activities in reactive oxygen species increased. Calmodulin aberrantly increased, Ryanodine binding to cardiac Ryanodine receptors in the ischemic zone. Dantrolene restored the physiologically binding of Calmodulin to the cardiac Ryanodine receptors.                                 The authors concluded that atrial ischemia causes spontaneous atrial fibrillation episodes in sheep, caused by spontaneous focal discharges that initiate re-entry. Nitroso redox imbalance in the ischemic zone is associated with intensive reactive oxygen species production, and altered the Ryanodine receptor responses to Calmodulin. Dantrolene administered normalize the Calmodulin response and prevents left atrial myocardial infarction, spontaneous focal discharges in atrial fibrillation initiation.                                 In the next study, Wouter van Everdingen and associates examine the use of QLV for achieving optimal acute hemodynamic response to CRT with a quadripolar left ventricular lead. 48 heart failure patients with left bundle branch block were studied. Mean ejection fraction 28%, mean QRS duration 176 milliseconds. Immediately after CRT implantation, invasive left ventricular pressure volume loops were recorded during biventricular pacing, with each separate electrode at four atrial ventricular delays.                                 Acute CRT response, measured as a change in stroke work compared to intrinsic conduction, was related to the intrinsic interval between the Q on the electrocardiogram and the left ventricular sensing delay, that is the QLV, normalized for the QRS duration, resulting in QLV over QRS duration in the electrode position.                                 QLV over QRS duration was 84% and variation between the four electrodes was 9%. The change in stroke work was 89% and varied by 39% between the electrodes. In univariate analysis, an anterolateral or lateral electrode position in a high QLV to QRS duration ratio had a significant association with a large change in stroke work, all P less than 0.01.                                 In a combined model, only QLV over QRS duration remained significantly associated with a change in stroke work, P less than 0.5. However, a direct relationship between QLV over QRS duration in stroke work was only seen in 24 patients, while 24 other patients had an inverse relation.                                 The authors concluded that a large variation in acute hemodynamic response indicates that the choice of stimulated electrode on the quadripolar electrode is important. Although QLV to QRS duration ratio was associated with acute hemodynamic response at a group level, it cannot be used to select the optimal electrode in the individual patient.                                 In the next study, Antonio Pani and associates conducted a multi-centered prospective study evaluating the determinance of zero-fluoroscopy ablation of supraventricular arrhythmias. They studied 430 patients with an indication for EP study and/or ablation of SVT. A procedure was defined as zero-fluoroscopy when no fluoroscopy was used. The total fluoroscopy time inversely was related to number of procedures previously performed by each operator since the study start. 289 procedures, or 67%, were zero-fluoro. Multi-variable analyses identified as predictors of zero-fluoro was the 30th procedure for each operator, as compared to procedures up to the ninth procedure, the type of arrhythmia, AVNRT having the highest probability of zero-fluoro, the operator, and the patient's age. Among operators, achievement of zero-fluoro varied from 0% to 100%, with 8 operators, or 23%, achieving zero-fluoro in 75% of their procedures. The probability of zero-fluoro increased by 2.8% as the patient's age decreased by one year. Acute procedural success was obtained in all cases.                                 The authors concluded that the use of 3D mapping completely avoided the use of fluoroscopy in most cases, with very low fluoro time in the remaining, and high safety and effectiveness profiles.                                 In the next paper, Demosthenes Katritsis and associates examine the role of slow pathway ablation from the septum as an alternative to right-sided ablation. Retrospectively, 1,342 undergoing right septal slow pathway ablation for AV nodal reentry were studied. Of these, 15 patients, 11 with typical and 4 with atypical AVNRT, had a left septal approach following unsuccessful right sided ablation, that is, the righted left group. In addition, 11 patients were subjected prospectively to a left septal only approach for slow pathway ablation, without previous right septal ablation, that is, left group. Fluoroscopy times in the right and left group, and the left groups were 30.5 minutes and 20 minutes respectively, P equals 0.6. The rate of [inaudible 00:18:24] current delivery time for comparable, 11.3 minutes and 10.0 minutes respectively.                                 There are no additional ablation lesions at other anatomical sites in either group, and no cases of AV block were encountered. Recurrence rate for arrhythmias in the right and left group was 6.7% and 0% in the left group, in the three months following ablation.                                 The authors concluded that the left septal anatomical ablation of the left inferior nodal extension is an alternative to ablation of both typical and atypical AV nodal reentry when ablation at the right posterior septum is ineffective.                                 In our next study, Mark Belkin and associates reported prior reports of new-onset device-detected atrial tachyarrhythmias. Despite the clear association between atrial fibrillation and the risk of thromboembolism, the clinical significance of new-onset device-detected atrial tachyarrhythmias and thromboembolism remains disputed.                                 The authors aim to determine the risk of thromboembolic events in these patients. Using the Ovid Medline, Cochrane, SCOPUS databases to identify 4,893 reports of randomized control trials, perspective or retrospective studies of pacemaker and defibrillator patients reporting the incidence of device detected atrial tachyarrhythmias.                                 The authors examine 28 studies, following a total of 24,984 patients. They had an average age of 69.9 years and a mean study duration of 21.8 months. New-onset device-detected atrial tachyarrhythmias was observed in 23% of patients. Among nine studies, consisting of 8,181 patients, reporting thromboembolism, the absolute incidence was 2.1%. Thromboembolic events were significantly greater among patients with new-onset device-detected arrhythmias, with a relative risk of 2.88, compared to those who had less than one minute of tachyarrhythmias, 1.77 risk ratio.                                 The authors concluded that new-onset device-detected atrial tachyarrhythmias is common, affecting close to one quarter of all patients with implanted pacemakers and defibrillators.                                 In our last paper, Sanghamitra Mohanty and associates performed a meta-analysis systematically evaluating the outcome of pulmonary vein isolation with and without thermoablation in patients with atrial fibrillation. For pulmonary vein ablation alone, only randomized trials conducted in the last three years reporting single procedure success rates, off antiarrhythmic drugs at 12 months or greater follow-up were included. In the PVI plus FIRM group, all public studies reporting a single procedure off antiarrhythmic drug success rate with at least one year follow-up were identified.                                 Meta-analytic estimates were derived, using the DerSimonian and Laird Random-effects Models, and pooled estimates of success rates. Statistical heterogeneity was assessed using the Cochran Q test and I-square. Study quality was assessed with the Newcastle-Ottawa Scale.                                 15 trials were included, 10 with PVI plus FIRM, with 511 patients, non-randomized perspective design, and 5 pulmonary vein isolation-only trials, consisting of 295 patients, all randomized.                                 All patients in the pulmonary vein only trials had 100% non paroxysmal atrial fibrillation, except for one study, and no prior ablations. About 24% of the PVI plus FIRM patients had paroxysmal atrial fibrillation.                                 After 15.9 months of follow-up, the off antiarrhythmic drug pooled success was 50% with FIRM plus PVI, compared to 58% in the PVI alone. The difference in the effect size between the groups was not statistically significant. No significant heterogeneity was observed in this meta-analysis.                                 The authors concluded that the overall pooled estimate did not show any therapeutic benefit of PVI FIRM over PVI alone.                                 That's it for this month, but keep listening. Suraj Kapa will be surfing all journals for the latest topics of interest in our field. Remember to download the podcast On The Beat. Take it away, Suraj. Suraj Kapa:          Thank you, Paul, and welcome back to “On The Beat”. Again, my name is Suraj Kapa and I'm here to review with you articles across the cardiac electrophysiology literature that were particularly hard hitting in the month of February.                                 To start, we review the area of atrial fibrillation, focusing on anticoagulation. Reviewing an article published in this past month's issue of the Journal of the American Heart Association, by Steinberg et al., entitled Frequency and Outcomes of Reduced Dose Non-Vitamin K Antagonist Anticoagulants, results from ORBIT AF II. The ORBIT AF II registry, also called the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation, is a prospective national observational registry of AF patients.                                 The author sought to describe the frequency, appropriateness, and outcomes of patients prescribed reduced doses of NOACs in the community practice. They reviewed the records of almost 8,000 patients receiving NOACs and noted that the vast majority, nearly 84%, received a standard dose of NOACs, consistent with the U.S. FDA labeling. While only 16% received a reduced dose, only 43% of these were consistent with labeling instructions. Those who received reduced dose NOACs inappropriately more often tended to be younger and have, interestingly, lower overall bleeding risks scores.                                 Furthermore, compared with those appropriately receiving dosing, patients receiving inappropriately reduced dose NOACs had a higher unadjusted rates of thromboembolic events and death.                                 These data are important to understand, in that, discussion with patients, that inappropriate reduction of NOACs does not necessarily offer appropriate protection against long-term risk of thromboembolic events. Thus, close attention must be paid to consideration of the use cases and instructions for use.                                 While the registry cannot get into the details of why the dose was reduced in the spectrum of patients, it does highlight the fact that this continues to be a problem in general practice.                                 Further data is needed to understand what leads to inappropriate dose reduction, which could include factors such as patient preference, or physician education.                                 Staying within the realm of anticoagulation and understanding individual needs, we next review an article published in this past month's issue of Circulation, by Nielsen et al., entitled Female Sex Is a Risk Modifier Rather Than a Risk Factor for Stroke in Atrial Fibrillation. Should we use a CHA2DS2-VA score rather than CHA2DS2-VASc? In this review, the authors sought to evaluate whether female sex is truly an overall risk factor, as opposed to a risk modifier.                                 Using three nationwide registries, they identified patients with nonvalvular atrial fibrillation between 1997 and 2015, and they calculated two sets of scores. The first score, they termed a CHA2DS2-VA score, calculated for men and women with follow-up of one year in the Danish National Patient Registry. They wanted to calculate the risk based on this pseudo-value method. They then reviewed female sex as a prognostic factor by inclusion as an interaction term on the CHA2DS2-VA score, to calculate overall thromboembolic risk.                                 Amongst over 200,000 patients with atrial fibrillation, almost half of whom are women, they noted that the mean CHA2DS2-VA score, where sex is excluded, was a tad higher in women than men, namely 2.7 vs. 2.3. However, women had an overall higher one year thromboembolic rate of 7.3 vs. 5.7 per 100 person-years. Interestingly, with a CHA2DS2-VA score of zero, the absolute risk of thromboembolism was equal amongst men and women, around .5%. Once overall points increased above one, however, women exhibited a higher stroke risk. This interaction was statistically significant.                                 Thus, the authors indicated that female sex is a risk modifier for stroke in patients with atrial fibrillation, rather than a risk factor. The terminology is important to consider. Essentially, what they are noting is that at the lower risk level, female sex, in and of itself, is not something that necessarily puts somebody in the higher risk cohorts. Instead, at higher risk levels, because of other factors, a woman may have a higher overall risk of stroke than men. Thus, stroke risk is accentuated in women, who would have been eligible for oral anticoagulating treatment anyway, on the basis of a CHADS score above one.                                 These data highlight the importance of thinking about the fact that at the lower risk score level, female sex alone might not be sufficient to say that a patient has reached the CHA2DS2-VASc score of one and above. But, really, you need an overall CHA2DS2-VA score, or a risk score, inclusive of at least two other risk factors to indicate that now, being a female is going to modify the risk and further accentuate it.                                 Now, one thing to note is, these data are very consistent with the guidelines. The European guidelines indicates that female sex alone, which in the CHA2DS2-VASc score would confer a risk score of one, should not, by itself, construe the need to put somebody on anticoagulation.                                 However, it's important to highlight that these data show that at a CHA2DS2-VASc score of one in females, they should really be construed as equivalent to a CHA2DS2-VASc score of zero in men.                                 Using the CHA2DS2-VA score, where sex is excluded, but considering that women overall have a higher incidence of stroke at any given CHA2DS2-VA level above one, will help better counsel women about the importance of being on anticoagulants.                                 The next article we review relates to long-term risk related to atrial fibrillation, published in February's issue of Heart Rhythm, by Nishtala et al., entitled Atrial Fibrillation and Cognitive Decline in the Framingham Heart Study. While there's much out there about the potential long-term role of cognitive decline in atrial fibrillation patients, longitudinal research investigating the relationship is relatively sparse. Thus, the authors sought to investigate the association between atrial fibrillation and cognitive performance, cross-sectionally and longitudinally.                                 They chose patients within the Framingham study who are dementia and stroke-free at the time of baseline neuropsychological assessments. They evaluated atrial fibrillation status as a two level variable, namely prevalent atrial fibrillation vs. no atrial fibrillation in cross-sectional analyses. And they also separated into prevalent atrial fibrillation at baseline, interim development of atrial fibrillation, and those who didn't develop any atrial fibrillation in longitudinal analysis.                                 They studied 2,682 participants in the Framingham Heart study, including original and offspring cohorts. They noted that a baseline of about 4% had diagnosed atrial fibrillation. Prevalent AF was noted to be significantly associated with poorer attention. Interestingly, sex differences were noted, with men performing worse on test of abstract reasoning and executive function than women.                                 They noted that prevalent atrial fibrillation was significantly associated with the longitudinal decline in executive function, in both the original cohorts, as well as interim atrial fibrillation being significantly associated with longitudinal decline in executive function of the offspring cohorts. Thus, they noted that atrial fibrillation is associated with a profile of long-term change in cognitive function.                                 The importance of these data are to further highlight the potential contribution of atrial fibrillation to cognitive decline. While the exact mechanisms remain to be fully elucidated, the question of how to get ahead of the cognitive decline associated with atrial fibrillation is further put out by these data.                                 Whether the relationship between atrial fibrillation and cognitive decline is due to recurrent thromboembolic events vs. the therapies used vs. other factors such as humid anatomic factors resulting in poor brain perfusion, are relatively unclear.                                 Certainly it is also possible that atrial fibrillation simply reflects a process associated with other factors that might lead to cognitive decline. However, again, further mechanistic studies and potential treatment interventions to mitigate the risk of cognitive decline are still needed.                                 Speaking of this, we next review a paper published in the European Heart Journal this past month, by Friberg and Rosenqvist, entitled Less Dementia with Oral Anticoagulation in Atrial Fibrillation.                                 Speaking of treatments to avoid long-term cognitive decline, the authors sought to evaluate if oral anticoagulant treatment might offer protection against long-term dementia risk in atrial fibrillation.                                 These retrospective registry studies of patients with the hospital diagnoses of atrial fibrillation and no prior diagnosis of dementia in Sweden, including patients between 2006 and 2014. The study included a total of 444,106 patients over 1.5 million years. They noted that patients who were on anticoagulant treatment at baseline were associated with a 29% lower risk of dementia than patients without anticoagulant treatments. Thus, there is an overall 48% lower risk on treatments with the appropriate anticoagulation. There is no difference on whether Warfarin or the newer oral anticoagulants were used.                                 Thus, the authors concluded that the risk of dementia is higher without oral anticoagulant treatment in patients with atrial fibrillation, suggesting that early initiation of anticoagulant treatment in patients with atrial fibrillation could be of value to preserve long-term cognitive function.                                 This relates directly back to the previous paper, which focused more on the epidemiologic risk, while this paper focuses on elements that might construe mechanism or treatment options.                                 Many authors have concluded the incredible importance of early recognition of the need for anticoagulant initiation in patients with atrial fibrillation. While the exact mechanism of cognitive decline and dementia in atrial fibrillation remains to be completely elucidated, certainly recurrent thromboembolic events that might be relatively silent as they occur, but result in a long-term cumulative risk might be helped by placing patients on anticoagulants.                                 This becomes another reason to counsel patients on the importance of long-term anticoagulant therapy. Certainly, the limitations of these studies, however, are the retrospective nature and the fact that there might be some subtle differences that may not be otherwise able to be construed from retrospective registry data regarding the relative role of anticoagulants in truly protecting against long-term cognitive decline. However, the data are certainly provocative.                                 Continuing within realm and discussing outcomes associated atrial fibrillation, we next review an article by Leung et al., entitled The Impact of Atrial Fibrillation Clinical Subtype on Mortality, published in JACC: Clinical Electrophysiology this past month.                                 The author sought to investigate the prognostic implications of a subtype of atrial fibrillation, paroxysmal or persistent, on long-term prognosis. They sought to evaluate differences in mortality between paroxysmal or persistent atrial fibrillation amongst 1,773 patients. They adjusted for comorbid diseases associated with atrial fibrillation, as well as CHA2DS2-VASc score. In the study, a total of about 1,005 patients or about 57% had persistent atrial fibrillation. Over the follow-up period, about 10% of those with paroxysmal atrial fibrillation and 17% of those with persistent atrial fibrillation died.                                 They noted that persistent atrial fibrillation, after correcting for other comorbidities, was independently associated with worse survival. Thus, they concluded that persistent atrial fibrillation is independently associated with increased mortality in the long term.                                 These data are relevant in that they highlight that persistent atrial fibrillation in its nature might construe an overall higher risk cohort. It remains to be fully understood what are the true mechanistic differences between persistent and paroxysmal atrial fibrillation. Overall, however, the community grossly agrees that persistent atrial fibrillation likely suggests a higher degree of atrial myopathy. If we believe this, then it is reasonable to believe that the risk associated with this specific form of atrial fibrillation might result in higher long-term harm.                                 Of course, these data are subject to the same limitations of all retrospective data. Namely, these persistent atrial fibrillation patients might have received different therapies or been more sick to start with that cannot be construed by comorbidities alone.                                 Furthermore, these data do not necessarily get to the point of whether treating atrial fibrillation in the persistent patient more aggressively necessarily reduces the risk equivalent to that of paroxysmal patients. Thus, further understanding is needed to understand how to use these data to reduce this mortality difference.                                 Continuing within the realm of epidemiology of atrial fibrillation, we next review an article published in this past month's issue of Circulation, by Mandalenakis et al., entitled Atrial Fibrillation Burden in Young Patients with Congenital Heart Disease. It is assumed that patients with congenital heart disease are vulnerable to atrial fibrillation because of multiple factors. These include residual shunts, hemodynamic issues, atrial scars from previous heart surgery, valvulopathy and other factors.                                 However, there's limited data on the overall risk of developing atrial fibrillation and complications associated with it, especially in children and young adults with congenital heart disease. Furthermore, these children and young adults with congenital heart disease have never been compared with overall risk and control subjects.                                 The authors use the Swedish Patient and Cause of Death Registries to identify all patients with diagnoses of congenital heart disease born from 1970 to 1993. They then matched these patients with control subjects from the Total Population Register in Sweden. They noted amongst almost 22,000 patients with congenital heart disease and almost 220,000 matched control subjects that 654 patients amongst the congenital heart disease cohort developed atrial fibrillation, while only 328 amongst the larger control group developed atrial fibrillation. The mean follow-up overall was 27 years.                                 They noted the risk of developing atrial fibrillation was almost 22 times higher amongst patients with congenital heart disease than control subjects. They noted the highest risk with a hazard ratio of over 84 was noted in patients with conotruncal defects. Furthermore, at the age of 42 years, over 8% of patients with congenital heart disease had a recorded diagnosis of atrial fibrillation.                                 Interestingly, heart failure was a particularly important complication in patients with congenital heart disease and atrial fibrillation, with over 10% of patients developing atrial fibrillation and [inaudible 00:38:20] congenital heart disease developing a diagnosis of heart failure as well.                                 These data are important in that they help in counseling the importance of close follow-up of patients with congenital heart disease and their long-term risk of other complications. Even if patients might be perceivably well managed, incident atrial fibrillation might increase risk of stroke in these patients. It is further important to note that many of these patients cannot be evaluated according to traditional risk or evaluations. Thus, it is important to consider whether or not a patient should be treated with anticoagulation once they develop atrial fibrillation.                                 The high risk of overall atrial fibrillation incidents, particularly in patients with more complex congenital defects, needs to be taken into consideration when advising on the frequency of follow-up.                                 It is important to further note that we must think of this overall risk as the minimum possible risk, namely, counseling a congenital heart disease patient that up to one in ten of them may develop atrial fibrillation by the age of 42 years, is likely the minimum amount. The reason for this is many patients, due to either lack of follow-up or lack of sufficient monitoring, and the asymptomatic nature of atrial fibrillation in many patients might have not been diagnosed.                                 Implications or treatments remain to be seen, and whether or not there are methods to reduce the overall risk of atrial fibrillation is unclear. However, engaging congenital heart disease experts and advising patients, especially at younger ages, on the importance of close electrocardiographic monitoring for a potential atrial fibrillation risk is critical.                                 Next within the realm of atrial fibrillation, we switch to the topic of ablation. And review an article by Pallisgaard et al., published in this last month's issue of European Heart Journal, entitled Temporal Trends in Atrial Fibrillation Recurrence Rates After Ablation, between 2005 and 2014: a nationwide Danish cohort study.                                 Ablation has been increasingly used as a rhythm control strategy for patients with atrial fibrillation. Over this time, we have all noted evolution in both the experience and the techniques used. Thus, the authors sought to evaluate whether recurrence rate of atrial fibrillation has changed over the last decade. They included all patients with first-time AF ablation done between 2005 and 2014 in Denmark. They then evaluated recurrent atrial fibrillation based on a one year follow-up. They included a total of 5,425 patients undergoing first-time ablation.                                 They noted, interestingly, that the patient median age increased over time, and the median AF duration prior to ablation decreased over time. However, the rates of recurrent atrial fibrillation decreased from 45% in 2005 to 31% in the more recent years of 2013, 2014. With the relative risk of recurrent atrial fibrillation almost being cut in half.                                 They noted that female gender, hypertension, atrial fibrillation duration more than two years, and cardioversion with one year prior to ablation were all associated with an increased risk of recurrent atrial fibrillation, regardless of year.                                 These data, again, are retrospective and thus must be taken in the context of that consideration. However, they highlight that it is possible either our selection of appropriate patients for atrial fibrillation ablation or our techniques have improved overall success.                                 The fact that atrial fibrillation ablation is still a relatively young field, with evolving approaches and evolving techniques, needs to be taken into consideration when advising patients on success rates. Using data from many years prior to informed discussion today is fraught with potential error, especially as our catheter design and mapping system use and understanding of appropriate lesion set changes.                                 Of course, some criticism is required as well. While the patients included were relatively older in more recent years, the total AF duration prior to ablation decreased over the years. This suggests that patients are being ablated earlier than they were in the early days of atrial fibrillation ablation.                                 There is some data out there to suggest that earlier ablation for atrial fibrillation might result in a lower long-term recurrence rate. Thus, this might account for some of the difference. However, it is unlikely that it accounts for all of it, given the degree of reduction in overall risk of occurrence.                                 Staying within the trend of talking about changes in techniques for atrial fibrillation ablation, we next review an article published in this past month's issue of Heart Rhythm, by Conti et al., entitled Contact Force Sensing for Ablation of Persistent Atrial Fibrillation: A Randomized, Multicenter Trial. Contact force sensing is one of the newer techniques being used to optimize the success rates for atrial fibrillation ablation. It is generally felt that understanding when one is in contact will optimize atrial fibrillation ablation outcomes by ensuring the physician knows each time they are in contact, and also potentially reducing complications by avoiding excessive contact.                                 Thus, the authors designed the TOUCH AF trial to compare contact force sensing-guided ablation vs. contact force sensing-blinded ablation. They included a total of 128 patients undergoing first-time ablation for persistent atrial fibrillation, and thus randomized them to a situation where the operator was aware of the contact force vs. blinded to the contact force. While the force data was hidden in the blinded cohort, it was still recorded on the backend.                                 In all patients, wide antral pulmonary vein isolation plus a roof line was performed, and patients were followed at 3, 6, 9, and 12 months, with clinical visits, ECGs, and 48-hour Holter monitoring.                                 The primary endpoint was cumulative radio frequency time for procedures, and atrial arrhythmia is greater than 30 seconds after three months is considered a recurrence.                                 They noted that average force was higher in the contact force-guided arm than contact force-blinded arm, though not statistically significant, with an average of 12 grams in the latter and 14 grams in the former.                                 Interestingly, the total time of ablation did not differ between the two groups. Furthermore, there was no difference in the single procedure freedom from atrial arrhythmia, computing to about 60% in the contact force-guided arm vs. the 63% in the contact force-blinded arm. They did notice, however, that lesions with associated gaps were associated with significantly less force and less force-time integral.                                 The authors concluded from this, the contact force-guided ablation did not result in significant decrease in total radio frequency time or 12-month outcomes in terms of freedom from atrial arrhythmias.                                 These data are important to help guide us in terms of thinking about how the tools we use, as they change, actually alter outcomes. Sometimes we may perceive benefits based on logical thinking that's knowing more about what is happening when we are performing a procedure should optimize that procedure. However, this is not necessarily always the case, and thus highlights the importance of randomized trials to directly compare different situations, such as awareness of contact force vs. lack of awareness of contact force.                                 The relevance of these particular articles is that when we compare catheters with different designs, it does not necessarily highlight the importance of the force number itself. Namely, comparing a contact force catheter vs. non-contact force catheter implicates use of essentially two completely different catheters. To understand the incremental utility of force in making decisions, it is important to consider the same catheter, but simply with awareness or lack of awareness of the actual force number.                                 One of the limitations, however, is that individuals who might have been trained on using the same force sensing catheter might have some degree of tactile feedback and understanding of the amount of force being applied to the tip of the catheter, based on having been repeatedly exposed to contact force numbers during use of said catheter. Thus, there might be a difference in being blinded to contact force in early stage operators than in later stage operators who might have been trained based on repeated feedback.                                 Thus, it's difficult to conclude, necessarily, that contact force is not offering mental benefit. In fact, there's a fair chance that it does. However, offering a skeptical viewpoint to help guide the importance of continually evolving technology in actually improving outcomes is important.                                 Finally, within the realm of atrial fibrillation, we review an article published by Pathik et al., in this past month's issue of Heart Rhythm, entitled Absence of Rotational Activity Detected Using 2-Dimensional Phase Mapping and the Corresponding 3-Dimensional Phase Maps in Human Persistent Atrial Fibrillation.                                 Current clinically used phase mapping systems involve 2-dimensional maps. However, this process may affect accurate detection of rotors. The authors sought to develop 3-dimensional phase mapping technique that uses a 3D location of the same basket electrodes that are used to create the currently available 2-dimensional maps. Specifically, they wanted to determine whether the rotors detected in 2D phase maps were present in the corresponding time segments and anatomical locations in 3D phase maps.                                 They used one minute left atrial atrial fibrillation recordings obtained in 14 patients, using the basket catheter, and analyzed them offline, using the same phase values, based on 2-dimensional vs. 3-dimensional representations.                                 They noted rotors in 3.3% using 2D phase mapping, 9 to 14 patients demonstrated about 10 transient rotors, with a mean rotor duration of about 1.1 seconds. They noted none of the 10 rotors, however, were seen at the corresponding time segments and anatomical locations in 3D phase maps. When looking at 3D phases maps, 4 of the 10 corresponded with single wavefronts, 2 of 10 corresponded with simultaneous wavefronts, 1 of 10 corresponded with disorganized activity, and 3 of 10 had no coverage by the basket catheter at the corresponding 3D anatomical locations.                                 These data are important, in that they highlight the importance of when we consider reflecting 2-dimensional systems in a 3-dimensional world of atrial fibrillation. The role of ablating rotors is still in question. However, it is still an important question, and it requires continued study. The best way of identifying a rotor, knowing a rotor is a rotor, and understanding where the rotor is, are going to be critical to further evaluating whether actual ablation of these rotors has any relevance to long-term atrial fibrillation ablation.                                 The truth is, that we need to be sure that we are properly identifying all the rotors in order to help guide whether or not we are actually being successful in ablating atrial fibrillation. The importance of the study is in reflecting whether 2-dimensional representations of the 3-dimensional geometry is sufficient to reflect what is actually happening in that 3-dimensional geometry. These authors suggest that it is not.                                 One of the limitations, however, might be that when we wrap a 2-dimensional framework into 3 dimensions and perform additional post-processing, this might result in some degree of attenuation of the data. However, it does highlight the importance for continued rigorous evaluation of current approaches to phase mapping.                                 Several articles have been published in recent months as well, about different single processing techniques to evaluate whether or not a rotor is, in fact, a rotor and to help optimize identification of them.                                 The jury is still out on whether or not targeted ablation of rotors will, in fact, improve overall long-term atrial fibrillation ablation outcomes. The limitations might not necessarily be that rotors are not an appropriate target, but that we just don't understand entirely where rotors are, based on limited single processing options, or based on limitations of anatomical localization.                                 Next, delving into the realm of ablation at large, we review an article by Iwasawa et al., published in this past month's issue of Europace, entitled Trans Cranial Measurement of Cerebral Microembolic Signals During Left-Sided Catheter Ablation with the Use of Different Approaches - the Potential Microembolic Risk of a Transseptal Approach.                                 The authors note the importance of considering microemolization in subclinical brain damage during catheter ablation procedures. They evaluated microembolic signals detected by transcranial Doppler during ablation of supraventricular or ventricular arrhythmias with the use of either a transseptal or a retrograde approach.                                 The study set was small, only including 36 patients who underwent catheter ablation. They noted in about 11 patients left-sided ablation was done with transaortic approach, and in 9 patients a transseptal approach was used. The other 16 patients were not included, as they only had right-sided ablation.                                 The total amount of microembolic signature, based on transcranial Doppler were counted throughout the procedure and then analyzed offline. There is no significant difference in number of radio frequency applications, total energy delivery time, total application of energy, or total procedure time between the different groups. However, they did note that the mean total number of microembolic signals was highest in those undergoing transseptal approach to left-sided ablation. It was significantly lower in those having retrograde aortic approach, and lowest in those having right-sided only ablation.                                 Interestingly, many of the microembolic signals were detected during the transseptal puncture period, and then during the remainder of the procedure there was relatively even distribution of emboli formation. A frequency analysis suggested that the vast majority of microembolic signals are gaseous, in particularly Group 1 and Group 3, though only 91% in Group 2. No neurological impairment was observed in any of the patients after the procedure.                                 Recently, there's been a lot of focus on the potential long-term risk of cognitive impairments due to microembolic events in the setting of ablation. At least one recent paper in ventricular arrhythmias and several recent papers in atrial fibrillation ablation have suggested a fairly high risk of incidence cerebral emboli noted on MRI post ablation. While these results do not necessarily get at MRI lesions, they do suggest microembolic events. And what is most interesting, they look at microembolic events that occur throughout the entire ablation period with different approaches.                                 Interestingly, there is a massive spike in overall microembolic signals during the transseptal puncture period, and relatively even distribution throughout ablation, irrespective of application of radio frequency or not. Furthermore, while nearly all microembolic signals are gaseous, based on frequency analysis, with retroaortic approach or in those having right-sided only ablation, significantly less seem to be due to gaseous events in those having a transseptal approach.                                 It is known that there's possible damage to the internal dilation system when exposing it to transseptal needles or wires. Thus, one has to wonder whether some of the embolization could be from material associated with the actual transseptal puncture, either from portions of the punctured septum itself, or perhaps from the plastic material that which is being pushed transseptally.                                 These data still need to be considered and we have yet to see what the long-term applications of these kinds of findings are. It may be possible that while transseptal approach seems to offer more instant microembolic signals, if the long-term risk is no different, does it really matter?                                 However, these findings are provocative in the sense that they highlight potential significant differences and the risk of silent cerebral damage, based on the approach we use to ablation.                                 Changing gears, we next focus on the role of devices. And the first paper review is in the last month issue of JACC: Heart Failure, by Gierula et al., entitled Rate Response Programming Tailored to the Force Frequency Relationship Improves Exercise Tolerance in Chronic Heart Failure.                                 The authors sought to examine whether the heart rate at which the force frequency relationship slope peaks can be used to tailor heart rate response in chronic heart failure patients with cardiac pacemakers, and to see whether this favorably influences exercise capacity.                                 They performed an observational study in both congestive heart failure and healthy subjects with pacemaker devices. They then evaluated in a double-blind, randomized, controlled crossover study, the effects of tailored pacemaker rate response programming on the basis of a calculation of force frequency relationship based on critical heart rate, peak contractility, and the FFR slope.                                 They enrolled a total of 90 patients with congestive heart failure into the observational study cohorts, and 15 control subjects with normal LLV function. A total of 52 patients took part in the crossover study. They noted that those who had rate response settings limiting heart rate rise to below the critical heart rate were associated with greater exercise time and higher peak oxygen consumption, suggesting the tailored rate response program can offer significant benefit, particularly in congestive heart failure patients.                                 The importance of this trial is in that it highlights the importance of thoughtful decision-making in programming devices, and that group decision-making involving exercise physiologists, alongside pacemaker programming, and involving our congestive heart failure specialists might be the most critical in optimizing the approach to programming.                                 It might be that more aggressive measures are needed in congestive heart failure patients to decide on what optimal programming is, than it is in otherwise normal patients.                                 Staying within the realm of devices, we next focus on a publication by Sanders et al., published in this past month's issue of JACC: Clinical Electrophysiology, entitled Increased Hospitalizations and Overall Healthcare Utilization in Patients Receiving Implantable Cardioverter-Defibrillator Shocks Compared With Antitachycardia Pacing.                                 The authors sought to evaluate the effect of different therapies and healthcare utilization in a large patient cohorts. Specifically comparing antitachycardia pacing with high voltage shocks. They used the PROVIDE registry, which is a prospective study of patients receiving ICDs for primary prevention in 97 U.S. centers. They categorized these patients by type of therapy delivered, namely no therapy, ATP only, or at least one shock. They then adjudicated all ICD therapies, hospitalizations, and deaths.                                 Of the 1,670 patients included, there was a total follow-up of over 18 months. The vast majority, 1,316 received no therapy, 152 had ATP only, and 202 received at least one shock.                                 They noted that patients receiving no therapy and those receiving only ATP had a lower cumulative hospitalization rate and had a lower risk of death or hospitalization. The cost of hospitalization was known to be significantly higher for those receiving at least one shock than for those receiving only ATP therapy.                                 They noted no difference in outcomes or cost between patients receiving only ATP and those without therapy. Thus, the authors concluded that those receiving no therapy or those receiving only ATP therapy had similar outcomes, and had significantly reduced hospitalizations, mortality, and costs compared to those who received at least one high voltage shock.                                 The relevant findings from this study is similar to prior studies that suggest that any shock over follow-up is associated with potential increase in long-term mortality. The difficulty in assessing this, however, is the fact that it might be that those who have VT that can be appropriately ATP terminated, might be at a somewhat lower risk than those who need to be shocked to get out of their VT. Thus, the presumption of needing a shock to restore normal rhythm might suggest a higher risk cohort, it cannot be gleaned from traditional evaluation of morbid risk factors.                                 This is why the importance of considering how devices are programmed and whether or not a patient who has received shocks can be reprogrammed to offer ATP only therapy to terminate those same VTs, needs to be taken into consideration. How to best tailor this therapy, however, is still remaining to be determined, though more and more clinical trials are coming out to suggest in terms of optimal overall population-wide programming for devices.                                 Staying with the realm of devices, we next review an article by Koyak et al., in this past month's issue of Europace, entitled Cardiac Resynchronization Therapy in Adults with Congenital Heart Disease.                                 Heart failure is one of the leading causes of morbidity and mortality amongst patients with congenital heart disease. But there's limited experience in the role of cardiac resynchronization therapy amongst these patients. Thus, the authors sought to evaluate the efficacy of CRT in adults with congenital heart disease.                                 They performed a retrospective study on a limited number of 48 adults with congenital heart disease who received CRT, amongst four tertiary referral centers. They have defined responders as those who showed improvement in NYHA functional class or improvement in systemic ventricular ejection fraction. The median age at CRT implant was 47 years, with 77% being male. There was a variety of syndromes included.                                 They noted that the majority of patients, nearly 77%, responded to CRT, either by definition of improvement of NYHA functional class, or systemic ventricular function, with a total of 11 non-responders.                                 They noted that CRT was accomplished with a success rate comparable to those with acquired heart disease. However, the anatomy is much more complex and those technical challenges in achieving success o

You might not think it's possible, but there are enough different flu viruses circulating this season that you could actually get the flu again before Spring! H3N2 is the most common form around this year, but late season flus like Influenza B could bring you down again before things warm up. Joe and Amy talk about their recovery from a nasty case of the flu and give you some important advice. Plus, how to deal with nosebleeds with limited supplies. Nosebleeds, also known as epistaxis can occur in young or old, and for a dozen different reasons. Learn all you need to know about this common, but scary, medical problem. Also, survival settings require your people to be at 100% efficiency, but what happens when people get pregnant? Back pain, nausea and vomiting, and much more can intervene to take out a productive member of your crew. Dr. Alton tells you about some of the issues that might complicate what is usually a normal and natural process. All this and more in the latest Survival Medicine Hour Podcast with Amy Alton, ARNP and Joe Alton MD! To learn more about survival medicine, get a copy of the award-winning Third Edition of the Survival Medicine Handbook!

You might not think it's possible, but there are enough different flu viruses circulating this season that you could actually get the flu again before Spring! H3N2 is the most common form around this year, but late season flus like Influenza B could bring you down again before things warm up. Joe and Amy talk about their recovery from a nasty case of the flu and give you some important advice. Plus, how to deal with nosebleeds with limited supplies. Nosebleeds, also known as epistaxis can occur in young or old, and for a dozen different reasons. Learn all you need to know about this common, but scary, medical problem. Also, survival settings require your people to be at 100% efficiency, but what happens when people get pregnant? Back pain, nausea and vomiting, and much more can intervene to take out a productive member of your crew. Dr. Alton tells you about some of the issues that might complicate what is usually a normal and natural process. All this and more in the latest Survival Medicine Hour Podcast with Amy Alton, ARNP and Joe Alton MD! To learn more about survival medicine, get a copy of the award-winning Third Edition of the Survival Medicine Handbook!

November is National Bladder Health Awareness Month.  According to the Urology Care Foundation the cost of treating bladder problems in the United States is 70 billion dollars annually. For National Bladder Health Awareness Month, we are talking about bladder cancer. Bladder cancer is the 5th most common non-skin cancer in the United States. It is the 4th most common cancer diagnosed in men and by the Veterans Affairs Health System. Nearly 600,000 Americans live with bladder cancer today and 75-80,000 people will be diagnosed in the United States with bladder cancer this year. An estimated 16-17,00 people will die from bladder cancer this year. In the last episode, we talked about bladder cancer growing as a papillary tumor. It begins on the surface of the bladder, in the lining cells of the bladder called transitional cells. Most bladder cancers then grow into the inside of the bladder on a stalk. As tumors grow, however, they can grow roots and invade into the deeper layers of the bladder. As tumors invade the chance that the cancer metastasizes and spreads to organs beyond the bladder increases. Superficial tumors can be resected from the surface of the bladder as their only treatment. Higher stage and recurrent tumors will need to be treated with other treatments such as instillation of BCG, chemotherapy, or even removal of the bladder. This year the American Urologic Association, in collaboration with other oncologic societies, published guidelines for the treatment of muscle invasive bladder cancer. The guidelines were presented at the 2017 Annual Meeting. You can find the guidelines as well as other AUA guidelines at http://www.auanet.org/guidelines/muscle-invasive-bladder-cancer-new-(2017). Muscle invasive bladder cancer is a challenging problem in urology. The introductory paragraphs of the AUA guidelines gives the scope of the problem that muscle invasive bladder cancer is for patients and physicians: “Although representing approximately 25% of patients diagnosed with bladder cancer, muscle-invasive bladder cancer (MIBC) carries a significant risk of death that has not significantly changed in decades…In patients who undergo cystectomy, systemic recurrence rates vary by stage…Most recurrences will occur within the first two to three years…and…most patients with recurrence after cystectomy are not curable. …There is also a significant impact of treatment choices on outcome with the type and timing of therapy playing an important role.”  I am going to repeat that statement. “There is also a significant impact of treatment choices on outcome with the type and timing of therapy playing an important role.” Losing one's bladder, even if it is lifesaving, causes significant impact in a person's quality of life, and many patients and physicians choose to delay or defer surgery when it could be curative. Urologists, as we will discover, have always sought ways to restore or retain the quality of life for patients whose bladder must be removed because of cancer. If we choose the right treatment at the right time we can make progress in treating muscle invasive bladder cancer. I am going to go through the AUA guidelines.  There are 35 of them. Don't worry, I will not be going through each guideline individually but rather group them together into brief discussion points that patients who have muscle invasive bladder cancer and their physicians must think about before, during, and after the removal of the bladder. Guidelines 1-5 concern the initial evaluation and counseling. Full history and physical examination should be performed, the patient should have a staging evaluation with imaging and laboratory evaluation, and the patient should have a full discussion of curative treatment options. A complete discussion with regard to implications for quality-of-life should be discussed with the patient, including the type of urinary diversion. A multidisciplinary approach including surgical, chemotherapy and/or radiotherapy options should be discussed with patient. Guidelines 6-9 discuss either preoperative or postoperative chemotherapy. Chemotherapy should be offered to eligible patients prior to radical cystectomy although the best regimen for neo-adjuvant chemotherapy remains undefined. Guidelines 10-12 concern the radical cystectomy operation. Radical cystectomy should be offered to patients along with bilateral lymphadenectomy for surgically eligible patients. Standard radical cystectomy in the males includes removal of the bladder, prostate, and seminal vesicles. In females, the operation includes removal of the bladder, uterus, fallopian tubes, ovaries and anterior vaginal wall. The potential impact of sexual function and other quality of life issues after surgery for both men and women should be discussed prior to the operation. Guidelines 13 and 14 relate to urinary diversion. When the bladder is removed, an alternative to store and drain the urine must be created. Options for urinary diversion after removal of the bladder including ileal conduit, continent cutaneous diversions and ortho-topic neo-bladders. The choice of urinary diversion has a significant impact on long-term quality of life for patients who undergo radical cystectomy. Each type of diversion is associated with its own unique potential complications. Your surgeon will help you decide what type of urine diversion is right for you. I am not trying to be cute here but speaking of diversion, I want to take a step away from the guideline statements at this time and look at one of the articles from the 100th anniversary of the Journal of Urology published this year, a collection of reprints that highlight different eras and advances in Urology over the last 100 years. You can find the articles at JU100.org. I've highlighted some of these reprinted articles over my last few episodes. We have also been highlighting how “otherwise cautious urologists are also adventurous surgeons,” a phrase that struck me from the editor's introduction to the anniversary edition. One of the articles that was reprinted was a 25-year retrospective for one type of procedure for urinary diversion no longer used today called the Camey procedure. The original article was published in the Journal in 1984. Camey began doing his procedure in the late 1950s.  The Camey procedure is a type of urinary diversion isolating a 40-cm segment of ileal small bowel, attaching the ureters to either end and sewing the mid-segment of the isolated ileum to the remaining urethra after the bladder is removed. 84 patients were reviewed by Camey in his 25 year-experience. Dr. Camey's review paper is fascinating to read. In his paper Dr. Camey gives details about his experience, both his success as well as his failures. Let's hear him tell us about his first five patients. “The historical evolution of the current technique of bladder replacement can be divided into intervals of error, analysis, and correction. The first patient bladder replacement was attempted achieved continence. The second patient, operated upon a few days after the first, died within 15 days postoperatively…. The first functional enterocystoplasty in which total continence was a seen was performed in 1959 (patient #3). Pelvic lymphadenectomy revealed positive nodes and the patient died of carcinoma in 18 months… In an attempt to minimize infection, foreign body reaction and so forth, ureteral were not used in patient number four. This procedure proved disastrous when the patient became anuric secondary to edematous obstruction of the bilateral implants. As a consequence, bilateral ureteral stents delivered through the urethra and held in place by attachment to an indwelling urethrovesical 22 French straight catheter sutured to the penis have been used in all subsequent procedures. As a consequence of patient 5 the final U-shaped enterocystoplasty emerged. The error in this case was a graph design in which both ureters where anastomosed to the isoperistaltic end of the ileal loop with the distal end anastomosed to the urethra. This procedure resulted in peristaltic waves abutting against the urogenital diaphragm causing urinary frequency and leakage. Despite this deficiency the patient was the first long-term survival (15 years) with preservation of excellent renal function and electrolyte balance.” I will stop reading from Camey's article. It just gives us some idea of how this otherwise cautious urologist needed to be an adeventurous surgeon to make his breakthrough. As I said, the Camey procedure is no longer performed. This has been replaced by other types of urinary diversion and neo-bladder with other names such as Indiana, Hauttman, Studer, and Koch. The newer diversions use de-tubularized segments of bowel. The bowel is designed to contract in a coordinated peristalsis and move contents through it. Because of the coordinated peristalsis the pressures within a tubular segment of bowel will push urine through it rather than store the urine.  By de-tubularizing the bowel, we disrupt the peristaltic waves of the bowel and it begins to store the urine under low pressure. The different types of diversion deserve a whole podcast to themselves. Let's return to this podcast and the guidelines. Guidelines 15-18 relate the perioperative management of patients. Optimization of patient performance status and health prior to cystectomy and optimized recovery pathway protocols will enhance recovery. Guidelines 19 and 20 discuss the role of extended lymphadenectomy during the procedure. Guidelines 21through 29 discuss bladder sparing protocols for those patients not eligible for radical cystectomy or who choose to keep their bladder. For these patients, maximal trans-urethral resection of the bladder tumor should be performed. This is typically combined with a combination of radiation along with chemotherapy and close follow-up. Recurrences after bladder sparing techniques should be treated aggressively. Guidelines 30-34 relate to patient surveillance and long-term quality of life issues. Frequent imaging and laboratory assessment are appropriate for those who have undergone treatment to check for recurrence. For those patients struggling with their diagnosis there are number of bladder cancer support groups that would love to speak with you. The last guideline number 35 relates to unique, less common cancer types that may require variance from any of the above guidelines. Your surgeon will help you understand if you fall into one of these categories. The radical cystectomy, lymphadenectomy and the urinary diversion is one of the longest and most complicated procedures that a urologist does. In his conclusion, Dr. Camey wrote, “As a cautionary note the successful performance of this operation depends on an unusual degree of commitment to meticulous technique. The procedure is tedious and stressfully long, and requires a team approach that is logistically complex and not universally feasible.” Dr. Camey's operations routinely took 9 hours. He employed two sets of surgeons for the operation, one to remove the bladder and the other to do the urinary diversion. As urologists have gained surgical experience, operative times have improved.  For my partners and I it takes 2-4 hours to remove the bladder, perform the lymphadenectomy, and create the simplest urinary diversion, the ileal conduit. The current standard in my practice is to perform the removal of the bladder robotically using the daVinci system. But the urologic oncologist's long-term success and survival for patients with muscle invasive bladder cancer have not changed in the last 30 years. In his conclusion Dr. Camey writes, “The ancillary modalities, such as chemotherapy, immunotherapy, radiotherapy, antibiotic prophylaxis and nutritional supplementation, which may improve survival further must be perfected….” By creating the guidelines listed above the AUA and other various societies have for the first time come to an agreement about the best approach for these patients to give the highest chance of long-term success. I will end with some of the websites where you can find more information or support if you find yourself with this disease. Helpful websites include the Bladder Cancer Advocacy Network (http://www.bcan.org), Cancer Support Community (https://www.cancersupportcommunity.org), Cancer Care (https://www.cancercare.org), the American Bladder Cancer Society (https://bladdercancersupport.org), the American Cancer Society (https://www.cancer.org), and the Urology Care Foundation (http://urologyhealth.org). Support groups help reduce the three most significant stressors associated with cancer: unwanted aloneness, loss of control, and loss of hope. For those patients who are not interested in a support group, individual counseling may be available through an oncology social worker, psychologist, or local religious organizations. Lastly, if you have any questions, need my support, or have any feedback you can contact me at drbrandt@whyurologypodcast.com.

A new podcast reviewing a review of the Ghostbusters (2016) movie.

Q.  How can you avoid taking Nexium and what Fruit and Vegetables are best to avoid Heartburn?  A.  If you really want to heal the damage that has been done, and to get rid of the Medicinal Residues that the Nexium has left in your body, then you need to go on 1. a Diet of Apples and Water for 14days 2. a Diet of Fermented foods (It will be tough, but it's better than having a heart attack, having a stroke or some other problem) or 3. Organic milk, Aged Cheese with Vegetable Enzymes, Live Cultured Yogurts, Kefirs, Sauerkraut, Apple Cider Vinegar with a bit of Honey and Lemon in it, and this will Re-establish the gut. Honey is a very very Healthy, brilliant Nutritional Component of mother nature.  Our first bite of food is what the ancients thought to be an Offering and called 'The Widows Mite' which basically stands for 'Less is More'. You should always chew your first bite into liquid form before gulping down the rest of it.  Same goes for liquids, if you swish your drink in your mouth before you swallow it, it is a prefatory affect of electrical frequency that sets the body up for whats to follow. Fruit acids (apples and lemons) cause the body to Produce Alkaline, if you just eat things that are alkaline then the body has to Over Produce Acids to Digest it, this can cause Reflux and Ulcerations. Meat is alkaline, so your body has to produce a lot of acid to break down meat. Don shares about a baby he helped at the age of 2 1/2 yrs old, that couldn't walk or talk because it had never Consumed any Whole foods or been given Water. It was just fed junk food.  We should Drink good Organic Milk. Don's realised that we have Lost the very phrases of a 'Land of Milk and Honey'. The land of our Inheritance. Milk and Honey used to be mixed and Consumed in a very special Time of year. It was a Drink of the Gods which they believed lead to Health and Reconstruction. Q.  After taking a course of Antibiotics and Nasal sprays from Flu symptoms, I have lowered my Immune system and now it reoccurs often. How can I get my System Naturally back on track?  A. If you Eat Sweets with Meat there's a Fermentation and Rot that takes place so fast that your body wants to puke, have the runs and develop fevers.  This usually happens at Holiday Seasons so Avoid eating dead animal with sweets, and you will Avoid the flu!  A Flu is all Functional Systems of your own Physiology trying to get rid of an Extreme Offence, it's not from a bug that floated through the air. If you go on Raw Food and Drink Water for 28days, you won't have the Flu or Recurrences or any kind of Infections. A Flu is a Functional Disorder of the Body trying to throw out an Offence that has been taken in by you.  It was finally later admitted that the swine flu vaccine was what actually killed over 100,000 people.

Among more than 2,000 patients with an invasive cancer, more than 5% had a mutation in PTEN and almost half of these patients had a second malignancy. This observation has implications for patients with breast, endometrial and thyroid cancer, and those with known PTEN mutations.

Faranda, D (CEA/Saclay) Tuesday 29 October 2013, 14:50-15:25

In Lecture 15, Gusfield finishes the discussion of interval selection, and then introduces the RNA folding problem and talks about recurrences for it.

Tue, 1 Jan 2008 12:00:00 +0100 http://bjo.bmj.com/content/92/9/1298.short https://epub.ub.uni-muenchen.de/14973/1/How_to_treat_recurrences_after_avastin.pdf Haritoglou, Christos; Kampik, Anselm; Strauss, R.; Kook, Daniel; Wolf, Armin

The Stanley Foundation Bipolar Network (SFBN) is an international, multisite network investigating the characteristics and course of bipolar disorder. Methods (history, ratings and longitudinal follow-up) are standardized and equally applied in all 7 centres. This article describes demographics and illness characteristics of the first 152 German patients enrolled in them SFBN as well as the results of 2.5 years of follow-up. Patients in Germany were usually enrolled after hospitalisation. More than 72% of the study population suffered from bipolar I disorder and 25% from bipolar 11 disorder. The mean +/- SD age of the study participants was 42.08 +/- 13.5 years, and the mean SD age of onset 24.44 +/- 10.9 years. More than 40% of the sample reported a rapid-cycling course in history, and even more a cycle acceleration overtime. 37% attempted suicide at least once. 36% had an additional Axis I disorder, with alcohol abuse being the most common one, followed by anxiety disorders. During the follow-up period, only 27% remained stable, 56% had a recurrence, 12.8% perceived subsyndromal symptoms despite treatment and regular visits. 27% suffered from a rapid-cycling course during the follow-up period. Recurrences were significantly associated with bipolar I disorder, an additional comorbid Axis I disorder, rapid cycling in history, a higher number of mood stabilizers and the long-term use of typical antipsychotics. Rapid cycling during follow-up was only associated with a rapidcycling course in history, a higher number of mood stabilizers and at least one suicide attempt in history. Copyright (c) 2003 S. Karger AG, Basel.