Podcasts about Rhode Island Hospital

DOCKET ALERTS: The Supreme Court stayed a lower court decision out of Texas banning doctors from dispensing the abortion drug mifepristone. The Colorado Supreme Court barred Children's Hospital from cutting gender-affirming care, calling it a denial of treatment on the basis of sex and gender identity.   The DOJ is suing the DC Bar to stop it disciplining upstanding government lawyers like Ed Martin and Jeff Clark. The case has been assigned to Judge Richard Leon!!!   Elon Musk lost his lawsuit against Sam Altman and OpenAI.   MAIN SHOW:   The DOJ's effort to harass trans kids and their medical providers is escalating into a judicial crisis as Judge Reed O'Connor in the Northern District of Texas purports to bar Rhode Island Hospital from seeking redress in any other court or from "aiding and abetting" anyone else in seeking redress. Meanwhile in Rhode Island, Judge Mary McElroy says the Hospital does not have to comply.   Trump purports to "settle" his lawsuit against the IRS over the 2020 disclosure of his tax returns by establishing a $1.8 billion slush fund for the "victims of weaponization" of the DOJ under Biden. Is that legal? (No.)   Danco Labs v. Louisiana [US Supreme Court - mifepristone] https://www.supremecourt.gov/opinions/25pdf/25a1207_21p3.pdf   Boe v. Children's Hospital Colorado [Colorado Supreme Court - gender affirming care] https://www.coloradojudicial.gov/system/files/opinions-2026-05/26SA66.pdf   US v. Fox [DOJ sues DC Bar] https://www.courtlistener.com/docket/73338949/united-states-v-fox/?order_by=desc   In Re: Administrative Subpoena 25-1431-032 [Texas action] https://www.courtlistener.com/docket/73276712/in-re-administrative-subpoena-25-1431-032/   In Re: Motion to Quash Administrative Subpoena to Rhode Island Hospital [Rhode Island action] https://www.courtlistener.com/docket/73290254/in-re-motion-to-quash-administrative-subpoena-to-rhode-island-hospital/   Trump v. IRS [docket via CourtListener] https://www.courtlistener.com/docket/72207870/trump-v-internal-revenue-service/   DOJ Notice of Settlement - administration of "Anti-Weaponization Fund" https://www.justice.gov/opa/media/1441086/dl   OLC Memorandum, "Availability of Judgement Fund in Cases Not Involving a Money Judgment Claim" https://www.justice.gov/file/151086/dl?inline   Show Links: https://www.lawandchaospod.com/ BlueSky: @LawAndChaosPod Threads: @LawAndChaosPod Twitter: @LawAndChaosPod

OA1263 - Two of the most egregiously impeachable things ever to happen in the United States have just occurred on the same day this week:  The so-called “settlement” between Donald Trump and his own IRS which guarantees his immunity from consequences for any financial  a slush fund for his friends and family and  A Texas federal judge forcing a Rhode Island hospital to turn over records for trans kids while also attempting to specifically limit where this order can be challenged--and making absurd threats to anyone who even thinks about talking about challenging it We take a closer look at the alleged legal basis for both actions and how the Trump “settlement” compares to the previous record-holder for Presidential financial corruption set 123 years ago before getting on to much better news in today's footnote: an underdog Boston lawyer who has taken to the mic to call out some much bigger law dogs. “Settlement” Agreement, President Donald Trump et al. v. Internal Revenue Service et al. (5/18/2026) Untitled document, Office of the Attorney General (5/19/2026) Order Closing Case, President Donald Trump et al. v. Internal Revenue Service et al., Southern District of Florida (5/18/2026) Complaint, Harry Dunn and Daniel Hodges v. Donald J. Trump, D.C. District Court (5/20/2026) Order of Court, In RE: Motion to Quash Administrative Subpoena to Rhode Island Hospital, First Cir. (5/19/2026) Emergency Motion to Quash Subpoena In Duces Tecum, In Re: Administrative Subpoena 25-1431-032 to Rhode Island Hospital, Rhode Island District Court (5/4/2026) @joerezlaw on Instagram Check out the OA Linktree for all the places to go and things to do!

The Supreme Court stayed a lower court decision out of Texas banning doctors from dispensing the abortion drug mifepristone.The Colorado Supreme Court barred Children's Hospital from cutting gender-affirming care, calling it a denial of treatment on the basis of sex and gender identity.The DOJ is suing the DC Bar to stop it disciplining upstanding government lawyers like Ed Martin and Jeff Clark. The case has been assigned to Judge Richard Leon!!!Elon Musk lost his lawsuit against Sam Altman and OpenAI.MAIN SHOW:The DOJ's effort to harass trans kids and their medical providers is escalating into a judicial crisis as Judge Reed O'Connor in the Northern District of Texas purports to bar Rhode Island Hospital from seeking redress in any other court or from “aiding and abetting” anyone else in seeking redress. Meanwhile in Rhode Island, Judge Mary McElroy says the Hospital does not have to comply.Trump purports to “settle” his lawsuit against the IRS over the 2020 disclosure of his tax returns by establishing a $1.8 billion slush fund for the “victims of weaponization” of the DOJ under Biden. Is that legal? (No.)Danco Labs v. Louisiana [US Supreme Court - mifepristone]https://www.supremecourt.gov/opinions/25pdf/25a1207_21p3.pdfBoe v. Children's Hospital Colorado [Colorado Supreme Court - gender affirming care]https://www.coloradojudicial.gov/system/files/opinions-2026-05/26SA66.pdfUS v. Fox [DOJ sues DC Bar]https://www.courtlistener.com/docket/73338949/united-states-v-fox/?order_by=descIn Re: Administrative Subpoena 25-1431-032 [Texas action]https://www.courtlistener.com/docket/73276712/in-re-administrative-subpoena-25-1431-032/In Re: Motion to Quash Administrative Subpoena to Rhode Island Hospital [Rhode Island action]https://www.courtlistener.com/docket/73290254/in-re-motion-to-quash-administrative-subpoena-to-rhode-island-hospital/Trump v. IRS [docket via CourtListener]https://www.courtlistener.com/docket/72207870/trump-v-internal-revenue-service/DOJ Notice of Settlement - administration of “Anti-Weaponization Fund”https://www.justice.gov/opa/media/1441086/dlOLC Memorandum, “Availability of Judgement Fund in Cases Not Involving a Money Judgment Claim”https://www.justice.gov/file/151086/dl?inlineShow Links:https://www.lawandchaospod.com/BlueSky: @LawAndChaosPodThreads: @LawAndChaosPodTwitter: @LawAndChaosPodSee Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

Ballistic missiles overhead at 2 a.m. Surgeons back in the OR at sunrise. A city buying groceries and sending kids to school while medevacs arrive around the clock. That contrast is the setting for our conversation with Dr. Roman Hayda, Chief of Orthopaedic Trauma at Rhode Island Hospital and a retired US Army colonel who has traveled to Ukraine repeatedly to support frontline trauma hospitals.We trace how his Ukrainian roots and military surgical career shaped a calling for war surgery, then zoom in on what makes the current conflict medically different. With contested airspace and relentless drone surveillance, traditional evacuation assumptions collapse. When you can't fly a helicopter and you can't safely drive into the kill zone, the “golden hour” becomes a moving target and the downstream impact shows up in limb salvage decisions, prolonged tourniquet times, infection risk, and a growing need for amputation care and complex reconstruction.We also dig into leadership lessons for any orthopaedic surgeon considering humanitarian work: arrive with humility, listen first, adapt to limited resources, and treat teaching as a two-way exchange. Finally, we talk practical ways to help even if you never get on a plane, from donating external fixation resources to supporting reputable NGOs and advocating for sustained support.Subscribe for more conversations on the future of orthopaedic surgery, share this with a colleague who cares about trauma systems and global surgery, and leave a review with your biggest takeaway or question.

8:05PM: Heart disease is by far the leading cause of death in the U.S. Recent medical data indicate a significant and troubling rise in stroke rates among younger Americans (those under 65). What you need to know and how you survive a stroke!- Survive Stroke Week 2026 is coming up May 3–9. It aims to raise awareness of stroke symptoms (BE FAST) and ensure immediate, lifesaving emergency treatment to improve survival and recovery rates. Guest: Mahesh V. Jayaraman, MD – Chief of Diagnostic Imaging, Brown University Health; Director, Neurovascular Center, Rhode Island Hospital 8:15PM: Even with $100 fines, many in no-tow Cambridge aren’t moving their cars for street sweeping! Guest: John Fitzgerald – Cambridge DPW Environmental Services Manager 8:30PM: Massachusetts eases teacher licensing rules to tackle teacher shortage. Guest: Samantha Drysdale – State House News Reporter 8:45PM: More than 30 million people have unclaimed money or assets. Are you one of them? How you can find out! Guest: Bill Dendy - CPA and money manager with Raymond JamesSee omnystudio.com/listener for privacy information.

In this episode of the Brown Surgery Podcast, host Ryan Desrochers and co-host Ken Lynch sit down with a panel of medical students to discuss the realities of the third-year surgery clerkship experience at The Warren Alpert Medical School of Brown University. The panel, featuring Lauren McNeil (MD '27), Timmy Jeng (MD '27), and Elleen Kim (MD '27), share their diverse perspectives on transitioning into the surgical environment.The conversation dives into the structure of a typical day—from morning rounds to navigating the operating room (OR)—and offers practical advice on balancing clinical duties with shelf exam preparation. Whether you are a rising MS3 or just curious about life in the OR, this episode provides a grounded look at the challenges and rewards of surgical education.Key Topics Discussed:The Daily Grind: A breakdown of the early morning start times, rounding with the team, and managing floor tasks vs. OR time.Site-Specific Advice: Insights into rotating at different locations, including Rhode Island Hospital, Miriam Hospital, and ACS (Acute Care Surgery).Resource Recommendations: The panel's favorite tools for success, including UWorld, Anki, OnlineMedEd, and surgical videos (JOMI).OR Etiquette: How to introduce yourself to the scrub techs and residents, manage sterility, and stay engaged as a "team sport" player.Wellness & Expectations: Debunking myths about "mean" surgeons and sharing tips for meal prepping and maintaining mental health during long weeks.

In this episode, Alan H. Daniels, MD, Professor of Orthopaedics and Chief of Spine Surgery at The Miriam Hospital and Rhode Island Hospital, discusses balancing private practice autonomy with academic medicine, navigating reimbursement pressures, and growing complex spine programs. He also shares insights on innovations in spinal deformity care, including data driven decision making, specialized teams, and alignment focused technologies.

In this episode, Alan H. Daniels, MD, Professor of Orthopaedics and Chief of Spine Surgery at The Miriam Hospital and Rhode Island Hospital, discusses balancing private practice autonomy with academic medicine, navigating reimbursement pressures, and growing complex spine programs. He also shares insights on innovations in spinal deformity care, including data driven decision making, specialized teams, and alignment focused technologies.

In this episode, Alan H. Daniels, MD, Professor of Orthopaedics and Chief of Spine Surgery at The Miriam Hospital and Rhode Island Hospital, discusses balancing private practice autonomy with academic medicine, navigating reimbursement pressures, and growing complex spine programs. He also shares insights on innovations in spinal deformity care, including data driven decision making, specialized teams, and alignment focused technologies.

In this inspiring episode of Living The Good Life, the hosts share an extraordinary story of compassion, science, and second chances. Dr. Rachel Gilardetti a Rhode Island dentist, used her professional expertise in an unexpected way — performing a life-saving dental-style repair on a peregrine falcon's broken beak. Using dental acrylic and composite bonding, Dr. Gilardetti restored the bird's ability to eat and preen, giving it a new lease on life.The falcon, rescued near Rhode Island Hospital and identified as a tagged local bird, is now recovering at The Congress of the Birds in Chepachet, RI. Under the leadership of Sheida Soleimani the organization rehabilitates more than 2,000 wild birds each year and depends on community volunteers and donations to continue its vital work.In the second half of the episode, the hosts shift gears to discuss the growing risks associated with “Buy Now, Pay Later” financing services — a trend that's leaving many consumers trapped in mounting debt despite its convenience. The conversation emphasizes the importance of mindful spending, budgeting, and awareness of fine print before clicking “pay later.”

In this week's episode, Brain & Life Podcast host Dr. Daniel Correa is joined by Tiffany Kairos, an epilepsy advocate and founder of the Epilepsy Network, and her husband Chris Kairos. Tiffany shares her journey of living with epilepsy and her recent diagnosis of Functional Neurologic Disorder (FND). Tiffany and Chris delve into their experience managing both conditions, the impact on daily life, and the support systems that help her navigate these experiences. Dr. Correa is then joined by Dr. W. Curt LaFrance, Inaugural Director of Neuropsychiatry and Behavioral Neurology at Rhode Island Hospital, Director of the VA Mind Brain program, and Professor of Psychiatry and Neurology at Brown University. Dr. LaFrance discusses the complexities of FND, the importance of integrating neurology and psychiatry for effective diagnosis and treatment, and the evolution of terminology to reduce stigma and improve patient engagement.   Additional Resources The Epilepsy Network (TEN) What is Functional Neurologic Disorder? Taking Control of Your Seizures Epilepsy Foundation The Anita Kaufman Foundation   Other Brain & Life Podcast Episodes on These Topics JenVon Cherry on Educating Communities of Color About Epilepsy Actor Cameron Boyce's Legacy and Raising Awareness About SUDEP Tiffany Kairos on Finding Her Voice in Epilepsy Advocacy   We want to hear from you! Have a question or want to hear a topic featured on the Brain & Life Podcast? ·       Record a voicemail at 612-928-6206 ·       Email us at BLpodcast@brainandlife.org   Social Media:   Guests: Tiffany Kairos @TiffanyKairos @theepilepsynetwork; Chris Kairos @ka1ro5; Dr. W. Curt LaFrance @brownuniversityhealth Hosts: Dr. Daniel Correa @neurodrcorrea; Dr. Katy Peters @KatyPetersMDPhD

Your Health First: Advancements in Robotic Surgery & Live Liver Donation at Houston MethodistJoin Dr. Joe Galati on this episode of "Your Health First" as he speaks with leading surgeons from Houston Methodist Hospital, Dr. Simon and Dr. Yee Lee Cheah. Broadcasting live from 740 KTRH in Houston and worldwide on the iHeartRadio app every Sunday at 7:00 PM Central, this insightful discussion delves into the groundbreaking work being done in robotic surgery and the current status of the live donor liver transplant program at Houston Methodist.Dr. Simon and Dr. Cheah share their expertise on the numerous benefits of robotic surgery, highlighting the significant advantages for patients and the remarkable advancements in technology over the past 5-10 years. They also provide a comprehensive overview of the meticulous patient selection process for live liver donors and detail the structured program at Houston Methodist Hospital.Don't miss this opportunity to learn about the cutting-edge surgical techniques and life-saving transplant procedures making a difference in patient care.For more information:Dr. Simon & Dr. Cheah: www.houstonmethodist.orgDr. Joe Galati: www.drjoegalati.comGuest Biographies:Dr. Simon:Dr. Simon is a highly accomplished surgeon with a specialization in abdominal transplantation and hepatobiliary surgery. She earned her medical degree with honors from University College Cork Faculty of Medicine in Ireland in 2002 and completed her general surgery residency at Brown University Program, Rhode Island Hospital. Dr. Simon further honed her expertise with a research fellowship in Diagnostic Imaging at Brown University and an ASTS-certified fellowship in Abdominal Transplantation and Hepatobiliary Surgery at Lahey Hospital & Medical Center. Her clinical interests are extensive, encompassing both benign and malignant tumors of the liver, bile duct, and pancreas, including hepatocellular carcinoma and Klatskin tumors. She is also deeply involved in kidney transplantation, living and deceased donor liver transplantation, pancreatic carcinoma, robotic surgery, and surgery for portal hypertension. Dr. Simon is board-certified in general surgery by the American Board of Surgery and is a Fellow of the American College of Surgeons (FACS).Dr. Yee Lee Cheah:Dr. Yee Lee Cheah is a distinguished surgeon who joined the J.C. Walter Jr. Transplant Center at Houston Methodist Hospital in 2022. She graduated with honors from the Royal College of Surgeons in Ireland in 2000 and completed her General Surgery Residency at the Brown University Program. Dr. Cheah further specialized with an ASTS-accredited fellowship in Transplantation & Hepatobiliary Surgery at the Lahey Clinic. Prior to Houston Methodist, she played a pivotal role at the Asian American Liver Centre at Gleneagles Hospital, the largest adult living donor liver transplantation (LDLT) center in Southeast Asia, before returning to LHMC to develop their LDLT and robotic surgery programs. Her expertise lies in living donor liver transplantation, robotic transplantation, HPB surgery for benign and malignant disorders, and nutrition therapy for surgical patients. Dr. Cheah's main research interests are centered on living donor safety and robotic surgery. She has held faculty positions at Brown University and Tufts University and served as an Adjunct Assistant Professor at the National University of Singapore. Hosted on Acast. See acast.com/privacy for more information.

What happens when the doctor becomes the patient?

Send us a textWelcome to part one of a special two-part conversation featuring distinguished neonatologist and physician-scientist, Dr. Phyllis A. Dennery. In this “At the Bench” episode, hosts Drs. David McCulley and Misty Good, along with guest co-host Ben Courchia, delve into Dr. Dennery's remarkable journey—spanning from her early fascination with molecular biology to her influential roles as Chair of Pediatrics at Brown University and Pediatrician-in-Chief at Rhode Island Hospital. Throughout the discussion, she reflects on the challenges of investigating bilirubin as a possible antioxidant, pioneering new insights into newborn lung injury, and unraveling the complexities of oxidative stress.Dr. Dennery also opens up about building vibrant research programs at leading institutions, underscoring the value of mentorship, collaboration, and taking bold risks in pursuit of groundbreaking discoveries. She offers candid perspectives on balancing clinical demands with scientific innovation, and how she has navigated multiple leadership positions to foster deeper community engagement in pediatric health. This episode highlights not only her scientific achievements, but her passion for cultivating new talent and forging interdisciplinary partnerships. Don't miss this engaging opening segment of our two-part series. Be sure to tune into The Incubator's Sunday Interview for part two, where Dr. Dennery's inspiring story continues!As always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below. Enjoy!

When Luke Messac began his emergency medicine residency at Rhode Island Hospital in 2018, he noticed his patients often came to him concerned about costs. Some worried about his recommendations for them to stay in the hospital overnight. Others questioned his motives when he asked them to undergo a test, like an X-ray or MRI. A few came in way too late in the course of their illnesses out of fear of the cost. He'd heard about aggressive debt collection practices at hospitals around the country that put people at risk of profound financial and legal consequences. It made him wonder: Was his hospital doing that, too? After a quick trip to the country courthouse to examine the case files, what he found troubled him. “I was inundated with what I thought were pretty horrific cases,” said Messac, author of the 2023 book, Your Money or Your Life: A History of Medical Debt Collection in the United States. “Low-income single moms, people living on disability, recent immigrants, were facing thousands of dollars of bills and court fees and interest fees. And if they did not pay and if they did not settle their suits quickly, then they could have their wages garnished. They would be charged double-digit interest rates.”In Berkeley Talks episode 219, Messac, now an attending physician at Brigham and Women's Hospital and an instructor in emergency medicine at Harvard Medical School, discusses how the changing role of hospitals, and the passage of Medicare and Medicaid in the 1960s, transformed how medical debts are collected in the U.S.This talk took place on Sept. 17, 2024, and was sponsored by the Berkeley Center for Social Medicine at the Institute for the Study of Societal Issues (ISSI) and cosponsored by Berkeley Public Health. Listen to the episode and read the transcript on UC Berkeley News (news.berkeley.edu/podcasts) or on YouTube @Berkeley News (youtube.com/@BerkeleyNews/podcasts).Music by Blue Dot Sessions.Photo by Ahmed for Unsplash+. Hosted on Acast. See acast.com/privacy for more information.

S5 E4 Understanding Disordered Eating with Dr. Aubrey CarpenterIn this episode, we welcome our friend and colleague, Dr. Aubrey Carpenter, a licensed clinical psychologist who has spent over a decade working as a pediatric psychologist, educator and researcher in Child Mental Health and parenting support. Dr. Carpenter has extensive training and experience from the likes of Boston University, Massachusetts General Hospital, Boston Children's Hospital, Hasbro Children's Hospital and Rhode Island Hospital. In this nuanced discussion, we dive deep into a comprehensive understanding of people's relationship with food, the signs of disordered eating, self- and body-image, treatment for eating disorders, and resources for individuals and families affected by disordered eating. Be curious. Be Open. Be well.The ReidConnect-Ed Podcast is hosted by Alexis Reid and Dr. Gerald Reid, produced by Cyber Sound Studios, and original music is written and recorded by Gerald Reid.*Please note that different practitioners may have different opinions- this is our perspective and is intended to educate you on what may be possible.Follow us on Instagram @ReidConnectEdPodcast and Twitter @ReidConnectEdShow notes & Transcripts: https://reidconnect.com/reid-connect-ed-podcast

Ping! Another episode of Brains On just dropped! And it's all about phones: how they help us, why they're so hard to put down – and how to have a balanced relationship with them.In this episode, Molly and co-host Linden do a deep dive on phone use. They'll chat with an expert about whether screens are bad for us and hear from some teenagers about how they really feel about their phones! Meanwhile, Marc takes his camels Humpty and Dumpty to a phone-free picnic, and Dwayne the Brain demonstrates the powerful connection between phones and dopamine. All that, plus a stumper of a mystery sound!We've been thinking about our phones a lot here at Brains On – so we started this new thing called Analog August, a month-long campaign to unplug our phones and get out in the world. If this episode inspires, we hope you and your family will join in the fun, and do your best to use your phones less! Parents can attend our virtual event about kids and phones on Thursday, August 15th from 12pm PT / 2pm CT / 3pm ET and sign up for our newsletter of ideas for phone-free adventures and tips on finding a healthy screen-life balance. Read more here.Featured experts:Julia Storm is a digital wellness specialist, educator, and advocate. She helps families work through issues around tech.Jacqueline Nesi is an Assistant Professor of Psychiatry and Human Behavior at Brown University and a Clinical Psychologist at Rhode Island Hospital. She specializes in issues affecting kids and teens. Subscribe to Smarty Pass for ad-free feeds, bonus episodes, and ticket discounts!Today's episode is sponsored by:- Indeed.com/brainson - Receive a $75 sponsored job credit with code brainson

Dr Ankur Kalra's guest this week is Dr Saraschandra Vallabhajosyula, Interventional and Critical Care Cardiologist, Assistant Professor of Medicine at the Warren Alpert Medical School of Brown University and the Director of the Cardiac Intensive Care Unit at Rhode Island Hospital, the Miriam Hospital and Lifespan Cardiovascular Institute. In this episode of Parallax, they delve into the latest insights from ACC.24 through the lens of five pivotal late-breaking trials. Dr Vallabhajosyula offers a deep dive into the nuances of each study. Together, Dr Kalra and Dr Vallabhajosyula distil the complexities of these trials into key messages for practice, grounded in their own clinical experiences. In the spotlight are five key trials: 1. DanGer Shock: Microaxial Flow Pump or Standard Care in Infarct-Related Cardiogenic Shock 2. RELIEVE-HF: Safety and effectiveness of the V-Wave® Ventura® Interatrial Shunt for the treatment of heart failure (HF) 3. PREVENT: Preventive PCI or medical therapy alone for vulnerable atherosclerotic coronary plaque 4. REDUCE AMI: Decreased usage of beta-blockers after acute myocardial infarction 5. ORBITA-COSMIC: Coronary sinus reducer for the treatment of refractory angina Dr Kalra and Dr Vallabhajosyula dissect the practical implications of these trials, answering pressing questions and addressing emerging dilemmas. What are the key takeaways from ACC.24? How do these findings shape contemporary clinical practice?

This episode discusses four MMWR reports. First, there was a rapid increase in the number of reported measles cases during the first quarter of 2024. Almost all cases occurred in people who were unvaccinated or with unknown vaccination status. Second, backyard poultry might increase the risk of Salmonella in infants and newborns, even in the absence of direct exposure. Third, new data show COVID-19 vaccines did not cause cardiac death in teens and young adults in Oregon. Finally, a cluster of central nervous infections at the Rhode Island Hospital was associated with a medical device commonly used in neurosurgery.

Rollin Wright, MD, is an Associate Professor of Medicine at Penn State Health – Hershey Medical Center. She holds a medical degree from Albany Medical College and completed her fellowship in Geriatric Medicine at Rhode Island Hospital. In addition to her clinical experience, Dr. Wright has developed curricula in areas such as dementia care, interprofessional education, and post-acute and long-term care. Mentioned in the show: Medicare vs. Medicaid HMO vs. PPO HSA vs. FSA Atul Gawande The Price We Pay by Marty Makary

Dr. Colleen Jackson discusses cognitive testing in a way that makes it easily understandable, alleviating any apprehension associated with the assessment. She starts by distinguishing between neuropsychological testing and cognitive assessments. Colleen shares insights into her approach and describes the valuable information that can be obtained from the testing process. Emphasizing a holistic perspective, she looks at an individual's overall health and well-being when giving her recommendations. Listeners will learn about cognitive assessments and neuropsychological testing to determine whether they might benefit a loved one.   IN THIS EPISODE:   [2:11] Colleen begins by describing the difference between neuropsychological testing and cognitive assessments [4:17] Colleen explains what the tests look like from a client perspective and what is involved [7:36] Colleen talks about how a family member can encourage a loved one to seek a provider and what is learned through the testing [12:06] Colleen discusses older adults, specifically  [16:06] Colleen refers to different treatment protocols based on test results [20:25] Colleen ends by discussing other illnesses that can impact mental health or cognitive impairment   KEY TAKEAWAYS:   [2:01] There is a difference between neuropsychological testing and cognitive assessment [7:27] There are some tips that family members can use to encourage a person to seek a provider [11:44] You can identify different conditions or illnesses through testing.   RESOURCES:   Beyond the Balance Sheet Website Dr. Colleen Jackson - LinkedIn   BIOGRAPHY:  Dr. Colleen Jackson received her doctorate in clinical psychology from the University of Connecticut. She pursued a clinical internship in clinical neuropsychology and dementia clinical research at Rhode Island Hospital through the Warren Alpert Medical School of Brown University, followed by research postdoctoral fellowships in the National Center for PTSD and the Translational Research Center for TBI and Stress Disorders at the VA Boston Healthcare System. After completing postdoctoral training, Colleen assumed a staff neuropsychologist position at the VA Boston Healthcare System, where she was involved in direct clinical care, clinical supervision/mentorship, and research. Colleen served as the Chief of the Neuropsychology Clinic in the Department of Neurology at Boston Medical Center prior to establishing her private practice in 2022. Colleen conducts clinical neuropsychological evaluations with adults presenting with cognitive concerns associated with neurodevelopmental disorders, neurodegenerative conditions, acquired brain injuries, substance use, and psychiatric conditions. Colleen approaches clinical care with a tailored focus on the client's cognitive and psychological needs, individual strengths, and personal values.  

In this best of 2023 episode, I revisit my conversation with Dr. Maslow - easily one of my favorite attendings from Rhode Island Hospital. Listening back, I'm reminded by how smart he is, right from the beginning of the episode. He's inspiring and accomplished in his career. This is a must listen (or relisten if you're a true fan).

Bill Bartholomew welcomes Dr. Elizabeth Benz, the head of Samuels Sinclair at Rhode Island Hospital – and Michelle Muscatello, Vice President of Communications and External Affair for Delta Dental to discuss a new oral surgery partnership Delta Dental and the Samuels Sinclair Dental Center at Rhode Island Hospital.Support the show

Rebecca Karb, MD, PhD, Co-Director, Comprehensive Stroke Center, Rhode Island Hospital, Attending Physician, Emergency Medicine, Rhode Island Hospital and House of Hope's Director of Outreach Sara Melucci join the show to discuss Lifespan's Street Outreach Program which seeks to provide direct care to vulnerable Rhode Islanders. Support the show

BUFFALO, NY- September 27, 2023 – A new editorial paper was published in Oncotarget's Volume 14 on September 22, 2023, entitled, “Reassessing the risks and benefits of COVID-19 precautions in 2023.” The COVID-19 pandemic has killed over one million Americans with many dying during the Omicron wave. By now most Americans have either had COVID-19 and/or been vaccinated against it. Despite the availability of updated immunizations, only 16.7% of Americans are now up-to-date on bivalent boosters. In their new editorial, researchers Thomas A. Ollila, Rashida Taher and Prashanth Moku from the Alpert Medical School of Brown University and Rhode Island Hospital discuss the current state of COVID-19 treatment. “At our cancer center, we treat many patients with hematologic malignancies, most of whom are older adults.” Patients with hematologic malignancies, especially lymphoma, are at increased risk of poor response to vaccination and worse outcomes from COVID-19 infection. The researchers state that most of their patients have been abundantly cautious since the onset of the pandemic and some have avoided ever becoming infected. Patients in their clinic frequently inquire about the safety of being outdoors, spending time with their families during large gatherings (Christmas, Thanksgiving, etc.), and methods to prevent the contraction of COVID-19. “Despite these precautions, too many patients reached remission from cancer only to then perish from COVID-19 in the first years of the pandemic.” The concerns behind their questions are very real, but understanding how to best answer them is not always easy and their abundance of caution is not without cost. Grandchildren's birthdays went uncelebrated, weddings were forgone, and memorable moments with loved ones were lost. With both aging and malignancy, an acute awareness of the limited days means that there may not be years ahead to make up for all that was missed. “Although COVID-19 continues to pose a serious threat, medical advancements have now allowed for a more in-depth risk-benefit discussion to weigh the risk of infection versus the challenges of social isolation.” DOI - https://doi.org/10.18632/oncotarget.28468 Correspondence to - Thomas A. Ollila - thomas_ollila@brown.edu Sign up for free Altmetric alerts about this article - https://oncotarget.altmetric.com/details/email_updates?id=10.18632%2Foncotarget.28468 Subscribe for free publication alerts from Oncotarget - https://www.oncotarget.com/subscribe/ Keywords - cancer, COVID, immunosuppression, coronavirus, vaccination, lymphoma About Oncotarget Oncotarget (a primarily oncology-focused, peer-reviewed, open access journal) aims to maximize research impact through insightful peer-review; eliminate borders between specialties by linking different fields of oncology, cancer research and biomedical sciences; and foster application of basic and clinical science. To learn more about Oncotarget, please visit https://www.oncotarget.com and connect with us: SoundCloud - https://soundcloud.com/oncotarget Facebook - https://www.facebook.com/Oncotarget/ X - https://twitter.com/oncotarget Instagram - https://www.instagram.com/oncotargetjrnl/ YouTube - https://www.youtube.com/@OncotargetJournal LinkedIn - https://www.linkedin.com/company/oncotarget Pinterest - https://www.pinterest.com/oncotarget/ Reddit - https://www.reddit.com/user/Oncotarget/ Media Contact MEDIA@IMPACTJOURNALS.COM 18009220957

The Assessment of Implementation of Methods in Sepsis and Respiratory Failure (AIMS) Study seeks to determine the safest and most effective approach to sepsis intervention using the evidence-based Surviving Sepsis Campaign guidelines. Marylin N. Bulloch, PharmD, BCPS, FCCM, was joined by Mitchell M. Levy, MD, MCCM, at the 2023 Critical Care Congress to discuss the goal of the AIMS Study and the elements of both the Hour-1 and 3-Hour bundles. Dr. Levy is chief of the Division of Critical Care, Pulmonary, and Sleep Medicine and professor of medicine at the Warren Alpert Medical School of Brown University. He is also the medical director of the medical ICU at Rhode Island Hospital in Providence, Rhode Island, USA.

In this podcast, Editor-in-Chief Dr Jeanette Hasse interviews Dr Marion Winkler and Dr Kelly Tappenden, authors of the paper, “Epidemiology, survival, costs, and quality of life in adults with short bowel syndrome” published in the June 2023 Nutrition in Clinical Practice Supplement on short bowel syndrome. Dr Winkler is a Professor of Surgery, at the Alpert Medical School of Brown University and a Surgical Nutrition Specialist at Rhode Island Hospital in Providence RI. Dr Tappenden is currently Professor and Head of the Department of Kinesiology and Nutrition at the University of Illinois at Chicago and as of July 1, will be the Dean of the College of Health at the University of Utah. Business Corporate by Alex Menco | alexmenco.net Music promoted by www.free-stock-music.com Creative Commons Attribution 3.0 Unported License creativecommons.org/licenses/by/3.0/deed.en_US June 2023 SUPPLEMENT

Welcome back to Behind the Drapes. In this episode, we talk to Dr. Caramez - one of our recent graduates from Brown Anesthesia Residency who stayed on as staff here at Rhode Island Hospital. Paula is vibrant with energy and her story of how she found a career in Anesthesiology is a unique one! Stay tuned to hear more about her life in Brazil, moving to America, experiencing a second residency, and how she's adopting to her new role as the Anesthesiologist in the OR. Here's what you have to look forward to: 00:09 Introduction 01:40 Medical Career in Brazil 09:10 Coming to the USA 11:30 Path to Citizenship + Residency 18:50 Residency Take Two 26:00 How is life as an attending? 30:30 Becoming a Medical Educator

Key takeaways: The changing role of the Oncologist - Starting as the Sherpa, transitioning to a mentor, and then breaking up! Awareness of barriers the LGBTQ community faces in accessing healthcare The distinction between addressing reproductive health and sexual health in cancer care About Dr. Don Dizon: Don S. Dizon, MD, FACP, FASCO, is an oncologist who specializes in women's cancers. He is the director of women's cancers at Lifespan Cancer Institute and director of medical oncology at Rhode Island Hospital. He is also a professor of medicine at The Warren Alpert Medical School of Brown University. His research interests are in novel treatments of women's cancers and issues related to survivorship, particularly as they relate to sexual health after cancer for both men and women. He is a prolific researcher and writer, and he has authored hundreds of publications, including peer-reviewed articles, books and book chapters. He is an active member of the American Society of Clinical Oncology, SWOG cancer research network, and the National Consortium of Breast Cancers, of which he has served as both vice president and president. Key moments: 12 minutes 27 seconds That person may be more interested in symptom control, in which case they would find more affinity in a metastatic brain tumor group. But they also may want to see people that look like them, that are like them who are going through this experience because of the threats metastatic brain cancer has on people's sexual health. 14 minutes 35 seconds It's what makes cancer care so multifaceted today. There's no one person who can really manage all the aspects of cancer care. By that, I mean whole-person cancer care. It really brings in the importance of having a team approach. 21 minutes 8 seconds There's a relationship between medical oncologists and their patients that is very difficult to walk away from for a lot of people. It almost feels like severing a relationship and it's quite an unsettling thing. Disclaimer: This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this podcast or materials linked from this podcast is at the user's own risk. The content of this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard, or delay in obtaining, medical advice for any medical condition they may have, and should seek the assistance of their health care professionals for any such conditions. --- Support this podcast: https://podcasters.spotify.com/pod/show/manta-cares/support

Season 2 | Episode 43 | October 26, 2022Rheumatologist Matthew Stanishewski, DO, practices with SVMC Rheumatology, part of Southwestern Vermont Medical Center, in Bennington. Stanishewski earned his medical degree from Philadelphia College of Osteopathic Medicine and most recently served as a fellow in Rheumatology at Roger Williams Medical Center, Rhode Island Hospital, and the VA Medical Center in Providence. He is the chair of Internal Medicine at SVMC and the vice president of the medical staff. In addition, he is a fellow of the American College of Rheumatology. Stanishewski will see patients in suite 307 of the Medical Office Building, which is located at 140 Hospital Drive in Bennington.Underwriter: Mack MoldingMedical Matters Weekly features the innovative personalities who drive positive change within health care and related professions. The show addresses all aspects of creating and maintaining a healthy lifestyle for all, including food and nutrition, housing, diversity and inclusion, groundbreaking medical care, exercise, mental health, the environment, research, and government. The show is produced with cooperation from Catamount Access Television (CAT-TV). Viewers can see Medical Matte...

On Episode 21 of the Stroke Alert Podcast, host Dr. Negar Asdaghi highlights two articles from the October 2022 issue of Stroke: “Oral Contraceptives, Hormone Replacement Therapy, and Stroke Risk” and “Effectiveness and Safety of Antithrombotic Medication in Patients With Atrial Fibrillation and Intracranial Hemorrhage.” She also interviews Dr. Shadi Yaghi about his article “Direct Oral Anticoagulants Versus Vitamin K Antagonists in Cerebral Venous Thrombosis.” Dr. Negar Asdaghi:         Let's start with some questions. 1) Do hormone replacement therapies or oral contraceptives increase the risk of stroke? And if yes, does the age of the individual or the duration of therapy modify this risk? 2) Should survivors of intracranial hemorrhage who have atrial fibrillation be treated with antithrombotic therapies for secondary prevention of stroke? 3) And finally, what is the anticoagulant of choice for treatment of cerebral venous sinus thrombosis? We have the answers and much more in today's podcast as we continue to bring you the latest in cerebrovascular disorders. You're listening to the Stroke Alert Podcast, and this is the best in Stroke. Stay with us. Welcome back to another amazing issue of the Stroke Alert Podcast. My name is Negar Asdaghi. I'm an Associate Professor of Neurology at the University of Miami Miller School of Medicine, and your host for the monthly Stroke Alert Podcast. The October issue of Stroke covers a number of timely topics. As part of our October Literature Synopsis, we have a nice paper by Dr. Farida Sohrabji and colleague, which summarizes three recently published animal studies to evaluate the association between small vessel ischemic injury and either development of Parkinsonism or the future risk of Parkinson's disease. These studies looked at how ischemia, specifically involving the lenticulostriate arteries, can modulate the nigrostriatal dopaminergic pathway and ultimately lead to Parkinsonism. As part of our Original Contributions, we have the results of a small randomized trial out of Korea, which was led by Dr. Yun-Hee Kim from Sungkyunkwan University School of Medicine in Seoul, where we learned that doing 20 sessions of transcranial direct current stimulation for about 30 minutes for each session at home can improve post-stroke cognition. This was found to be specifically effective in patients with post-stroke moderate cognitive decline. Now, transcranial current stimulation can be given using a handheld device at home, and if truly proven safe and efficacious in larger studies, can dramatically change the landscape of stroke recovery in cognitive rehabilitation. I encourage you to review these articles in addition to listening to our podcast today. Later in the podcast, I have the great pleasure of interviewing Dr. Shadi Yaghi from Brown University. Shadi will walk us through a systematic review and meta-analysis of published studies to compare the safety and efficacy of direct oral anticoagulants to that of vitamin K antagonists in patients with cerebral venous sinus thrombosis. Our devoted Stroke Alert Podcast listeners recall that we did cover this topic in our March podcast when we reviewed the results of ACTION-CVT, a multicenter international study that was led by none other than Shadi himself. I'm delighted to have him as a guest on my podcast today to talk more about the seminal study and all things cerebral venous sinus thrombosis. But first, with these two articles. Millions of women worldwide use exogenous hormones, most commonly in the form of oral contraceptives and hormone replacement therapies. Despite the many different formulations of these drugs that are now available on the market, the two therapies are similar in that both combined oral contraceptives and hormone replacement therapies, or HRTs, contain various dosage of estrogen and progestin. Now, the principal difference between them being that the hormone contents of oral contraceptives are at high enough dosage to prevent ovulation, whereas hormone replacement therapies are considered more physiological as their aim is to return post-menopausal hormone levels to what they were before menopause. Well, by now, you must wonder how is any of this even relevant to vascular neurology? Well, the answer lies in the close relationship between hormonal therapies and stroke. But before we get to that, we have to review a few things. First of all, it's long been known that the endogenous estrogen has strong and protective effects on the arteries. It promotes vasodilation and cell survival of the endothelial layer. It increases the endothelial mitochondrial efficiency and stimulates angiogenesis. In other words, endogenous estrogen is good for vascular health. And in fact, that's why we think that premenopausal women, in general, are at a lower risk of stroke as compared to their age and vascular risk factors–matched male counterparts. And to make things even better for estrogen, there's enough evidence to suggest that exogenous estrogen also does all of these good things for the endothelium. So, why are we even talking about an increased risk of stroke associated with use of hormonal therapies? The problem is, we have to remember that exogenous estrogen also does other things. It can increase the blood concentration of procoagulants, which, in turn, can increase the risk of thromboembolism, especially venous thrombosis. But there's still a lot of unknown on this topic. For instance, the majority of the prior research on the topic involves postmenopausal women using hormonal therapies. Some of that research has actually suggested that HRTs may be protective against vascular events, while others showed the opposite. Well, we know that a majority of oral contraceptive users are actually much younger and use these medications premenopausal. So, there seems to be a lot of gaps in our current knowledge on the simple question of whether or not oral contraceptives and hormonal replacement therapies do, in fact, increase the risk of stroke or not. In the current issue of the journal, a group of researchers led by Drs. Therese Johansson, Torgny Karlsson, and Åsa Johansson from the Department of Immunology, Genetics and Pathology at Uppsala University in Sweden set out to fill some of these gaps with their study titled, "Oral Contraceptives, Hormone Replacement Therapy, and Risk of Stroke," as part of a large UK Biobank population-based cohort. Just a bit about the UK Biobank. This was a large population-based cohort from 2006 to 2010 that included over 500,000 residents of the United Kingdom between the ages of 37 and 73. Participants at the time of enrollment would have extensive information collected from them through questionnaires, interviews, health records, physical measures, as well as some imaging and biological samples. Data on each participant was collected from the time of their birth all the way to the day of assessment, which is interesting, because the day of assessment would then count as the end of the follow-up for each participant. Now, for the current study, they included over 250,000 women of White race in whom information required for the study on whether or not they use hormonal therapies, duration of treatment, age at the time of exposure was available. And just a quick comment about their methodology. They analyzed their cohort once for oral contraceptive use and once for HRT use and compared each group to a reference group of either women who never used their set therapy or the number of years they contributed to the study prior to initiating that set treatment. So, for instance, if a person started using oral contraceptives at the age of 21, all of the years that she contributed to the study before that age would count as non-exposed user years and were included in the control cohort. So now, on to their findings. A total of 3007 stroke diagnosis of any type were identified prior to the initial visit to the assessment center, which, as we mentioned, was the end of the follow-up in the study. Of these, 578 were ischemic strokes, 177 intracerebral hemorrhage, and 478 were subarachnoid hemorrhages. But as expected for any large cohort, over half of total strokes were self-reported as stroke of any type and could not be classified into any of the above subtypes. Now, let's look at the effects of oral contraceptives on the outcome of stroke. Overall of the women included in the study, 81% were classified as oral contraceptive users, while 19% reported never having used oral contraceptives at any point during the study. On the association between oral contraceptive use and the risk of stroke, at first glance, things looked OK. The hazard rates of any stroke for any stroke subtypes were not different between women who had used oral contraceptives as compared to those in the reference group. That's great news. But when they looked deeper, they realized that the odds of development of any stroke was actually quite high during the first year after the initiation of oral contraceptives with hazard rate of 2.49 for any stroke, while there was no difference in hazard rates found during the remaining years of use and after discontinuation of oral contraceptive use. So, meaning that there was no lingering effects of oral contraceptives on increased risk of stroke after the first year or after discontinuing the medication. Now, on to HRTs. In total, 37% of women in the study had initiated HRTs at some point during the study, while 63% had never used this therapy. Here's the bad news. Overall, HRTs did increase the risk of stroke. An approximately 20% increase event rate of any stroke was noted among women who had initiated HRTs as compared to those who had not. When analyzing stroke subtypes, the use of HRTs was associated with increased risk of only the subarachnoid hemorrhage subtypes. We don't know why. Diving deeper, in considering timing of HRT initiation, very similar to what was observed for the oral contraceptives, during the first year after starting the HRTs, the treatment group was twice more likely to suffer from any type of stroke, and the hazard rate was also increased for all three stroke subtypes that were available in the study. But, unlike oral contraceptives, the hazard rate of any stroke remains significantly high even after the first year of use, not just for those who continued HRTs, but sadly, even for those who discontinued the therapy. Though the risk remained high, the hazard ratio declined over time as we went further away from the first year when treatment was initiated. So, bottom line, if women had initiated HRTs at some point in their life, the hazard risk of any stroke increased significantly in the first year. That hazard risk did decline over time, but it always remained significantly higher than non–HRT users. Now, what about timing of treatment in relation to the onset of menopause? Is the risk of stroke any different if women start on HRTs prior to or after their menopause? The answer is no. Initiation of HRTs was associated with an increased hazard rate of any stroke if it was started pre- or postmenopausal, but the risks were higher if the treatment was started prior to menopause. So, in summary, this large population-based cohort has truly given us some very important practical findings. We learned that both oral contraceptives and hormone replacement therapies do, in fact, increase the risk of stroke, an effect that was most notable in this study in the first year after initiation of both of these therapies, and in the case of oral contraceptives, was just actually limited to that one year alone. Why does this happen? I guess the easy answer is that these drugs, as we noted earlier, have an immediate prothrombotic effect, which gradually weakens over time. That's one plausible explanation, but for instance, why HRTs increase the risk of subarachnoid hemorrhage is something we can't explain based on the prothrombotic effects of HRTs. So, we have to come back to the vessels, the impact of hormone therapies and estrogen specifically on the blood vessels, on the endothelial cells, the potential increase in blood pressure, especially early on in the course of treatment with these medications. And also, we have to think about the role these drugs may play in increasing inflammatory markers, providing a more suitable milieu for accelerated atherosclerosis, as to why these associations were noted in this study. And it's fair to say that we need more research on this topic in the future. One challenging scenario that we commonly face in our daily practice is deciding whether or not we should resume antithrombotics in patients with atrial fibrillation who have survived an intracranial hemorrhage. The majority of intracranial hemorrhage survivors with atrial fibrillation actually have a very high CHA2DS2-VASc score, which means that they are actually at a very high risk of future ischemic stroke and systemic embolic events unless they're treated with anticoagulants. On the other hand, the risk of spontaneous intracranial bleeding is substantially higher in a person who has previously suffered from one, let alone if we treat them with anticoagulants. And to make matters worse, we have little evidence from the literature to guide us. So, in the current issue of the journal, in the study titled "Effectiveness and Safety of Antithrombotic Medication in Patients With Atrial Fibrillation and Intracranial Hemorrhage," a group of researchers from the UK led by Dr. Deirdre Lane, Professor of Medicine at the University of Liverpool, performed a much needed systematic review and meta-analysis of the available evidence on this subject. I have to say that lately, it seems that we've been covering a few of these reviews in our podcasts, and we are just getting started. In fact, my next paper in today's episode is also a systematic review and meta-analysis. These papers are packed with details, a testament to the work needed to complete them, but I have to say that even summarizing these papers for a podcast has been a bit challenging. So, feel free to put me on pause, go get some coffee, and let's power through this one together. For their methods, they used the usual search engines looking for papers that included adults over the age of 18 with atrial fibrillation who had survived a non-traumatic spontaneous intracranial hemorrhage of any size, any type, and any location, be it lobar, brain stem, deep, cerebellar, subdural, epidural, or subarachnoid hemorrhage. And very importantly, they included even those with evidence of microbleeds on neuroimaging. The intervention of interest was either long-term oral anticoagulation or antiplatelet therapy versus no antithrombotic use for the following three outcomes of interest: number one, recurrent thromboembolic events; number two, recurrent intracranial hemorrhage; and number three, all-cause mortality. Just a quick note that for this analysis, they excluded studies that looked at either short-term anticoagulation or non-oral anticoagulation use for any reason that was given to the patient other than for secondary prevention of stroke. For example, if a patient suffered from a pulmonary embolism and was treated with IV heparin or, for a short period of time after that, with oral anticoagulation, those patients or those studies were excluded from this meta-analysis. So, with this criteria, they pulled over 4,000 citations and abstracts, and finally included 20 papers that were published between 2015 and 2021 for a total of over 50,000 participants for this meta-analysis, very nice sample size. Most of the papers included were observational cohorts, but in addition, we had two small randomized trials, and I want to take a moment and review these trials for our listeners. The first one was a small noninferiority pilot trial out of the UK, the SoSTART trial, that looked at any anticoagulant versus either antiplatelet therapy or no antithrombotics in this population, and the other trial was the Phase 2 trial, the APACHE-AF, that studied apixaban versus no anticoagulation after anticoagulant-associated intracerebral hemorrhage. A reminder that both of these trials were published in Lancet Neurology in 2021. And before we move on to the findings of the meta-analysis, it's worth noting that they had included a mix of patients, some were oral anticoagulant–naive, and some had developed their index intracranial hemorrhage while already on treatment with anticoagulants or antiplatelet therapies. OK, now on to their findings, as mentioned, we're going to review three outcomes of recurrent thromboembolism, recurrent intracranial hemorrhage, and all-cause death for the following three groups: group one, oral anticoagulant therapy versus no therapy; group two, oral anticoagulation therapy versus either antiplatelet treatment or no therapy; group three, comparing new oral anticoagulants versus warfarin. So, for the first outcome of recurrent thromboembolic events in group one, when comparing oral anticoagulant therapy to no therapy, the study showed a significant reduction in thromboembolic events in favor of oral anticoagulation compared to no therapy. That's great news. Next, analysis of the studies that compared oral anticoagulation versus either antiplatelets or no therapy didn't show the same difference in prevention of embolic events in favor of either groups. Actually, no difference was noted between the two groups. Number three, now, in terms of comparing NOACs to warfarin, three studies had the information on this comparison, and they reported a significant reduction in the risk of thromboembolic events with NOAC as compared to warfarin. So, great news for oral anticoagulation overall, and especially for NOACs. Now, on the next outcome. Our second outcome was a recurrent intracranial hemorrhage. Keeping in mind that they included some studies where the outcome was defined as any form of intracranial hemorrhage, meaning they included subdurals, epidurals, etc., and some studies only included the outcome of intracerebral hemorrhage. So, on to the first group, comparing oral anticoagulants to no therapy, the pooled estimate revealed no statistically significant difference between oral anticoagulant–treated patients to those who were not treated with any antithrombotics on the risk of recurrent intracranial hemorrhage. That's great news. Next, on our second group, for the same outcome of recurrent intracranial hemorrhage, comparing oral anticoagulants to either antiplatelet therapy or no treatment, they found that oral anticoagulation was associated with a higher risk of recurrent intracranial hemorrhage as compared to antiplatelets or no therapy. And finally, third group comparing new oral anticoagulants to warfarin for the same outcome, the risk of recurrent intracranial hemorrhage was significantly reduced in patients treated with NOACs as compared to warfarin. And now, we're finally on to our last outcome of the study, which is the outcome of all-cause mortality. So, again back to group one, comparing oral anticoagulants to no therapy, this meta-analysis showed a significant reduction in all-cause mortality rate associated with oral anticoagulation. That's, again, great news. Next group, for the same outcome of mortality, comparing oral anticoagulants to either antiplatelet therapy or no treatment, they found no significant difference in the mortality rates between the two groups. And finally, comparing NOACs to warfarin, the pooled estimate showed that NOACs were associated with a significantly reduced risk of all-cause mortality. Amazing news for NOACs. So, in summary, here's what we learned from this big study. Oral anticoagulation use after intracranial hemorrhage in patients with atrial fibrillation did significantly reduce the risk of thromboembolic events and all-cause mortality without significantly increasing the risk of recurrent intracranial hemorrhage. In general, new oral anticoagulants, or NOACs, are preferred to warfarin as they do prevent embolic events with a lower risk of recurrent intracranial hemorrhage. But, of course, we still have a lot more questions. For instance, would any of the outcomes mentioned above be different in patients with lobar intracerebral hemorrhage, a condition typically associated with amyloid angiopathy, which carries a high risk of development of intracerebral hemorrhage? Also, we have to keep in mind that the majority of the studies included in the meta-analysis were observational. So, there remains an urgent need for a larger randomized trial on this subject, and we have to stay tuned for more research. Cerebral venous sinus thrombosis, or CVST, is an uncommon form of stroke resulting in headaches, seizure, or focal neurological symptoms due to either intracranial hemorrhage or venous ischemic infarcts. The rarity of the disease has made it difficult to study as part of randomized trials, so current treatment guidelines for CVST are consensus-based with much of the recommendations extrapolated from data on treatment of patients with systemic deep vein thrombosis. In general, based on the current evidence, the field agrees that a patient with CVST should be anticoagulated. The decision that is difficult and sometimes inappropriately delayed in the setting of acute hemorrhage in the brain. And not surprisingly, there's significant equipoise around the choice of anticoagulant, duration of therapy, and the role of heroic therapies, especially in the acute setting. Currently, there are a number of ongoing trials to address some of these issues. The direct oral anticoagulants present an attractive alternative to vitamin K antagonists for treatment of patients with CVST. This is partly because of their convenience of use. But how do direct anticoagulants compare in safety and efficacy to the vitamin K antagonists in the setting of CVST is less known. In our March podcast, we reviewed the results of ACTION-CVT, which was a multicenter international study that compared the safety and efficacy profile of the direct oral anticoagulants to that of warfarin in routine practice. The study included over a thousand imaging-confirmed CVST patients from multiple centers in the US, Italy, Switzerland, and New Zealand. And if you missed it, no worries at all. We're here to review some of the results again, as in this issue of the journal, many of the ACTION-CVT investigators, led by Dr. Shadi Yaghi, present the results of a systematic review and meta-analysis comparing the safety and efficacy of DOACs, or direct oral anticoagulants, to that of vitamin K antagonists. I'm joined today by Dr. Yaghi himself to discuss ACTION-CVT and the current meta-analysis. Dr. Yaghi is a Director of Vascular Neurology at Lifespan and Co-Director of Comprehensive Stroke Center and a Director of Research at the Neurovascular Center at Rhode Island Hospital. Good afternoon, Shadi, and welcome to our podcast. Dr. Shadi Yaghi:               Good afternoon, Dr. Asdaghi. Thank you so much for having me. Dr. Negar Asdaghi:         Thank you. And please call me Negar. Congrats on the paper. Before we talk about the meta-analysis, can you please remind us of the results of ACTION-CVT and why the systematic review, in your opinion, was an important next step to that effort? Dr. Shadi Yaghi:               Thank you so much for having me and for bringing up ACTION-CVT. So ACTION-CVT is a real-world multicenter international study that used real-world observational data to compare the safety and efficacy of direct oral anticoagulants to vitamin K antagonists in patients with cerebral venous thrombosis. The reason why we did ACTION-CVT was, as you know, cerebral venous thrombosis is a rare disease, and it's hard to have large studies that would be powered enough to compare the safety and efficacy of direct oral anticoagulants to vitamin K antagonists. So, most of the studies that were done are small, retrospective. There's one randomized controlled trial, but most of them are underpowered to detect the difference between the two groups. So, we decided to do a large-scale international multicenter study using real-world data to compare the safety and efficacy of both. Dr. Negar Asdaghi:         OK, so we're glad you did. Let's start with the methodology of the current meta-analysis. Can you please give us an overview of the inclusion criteria for selection of the papers and the intervention and outcomes that you were interested in? Dr. Shadi Yaghi:               Of course. So, this is a systematic review and meta-analysis that included studies comparing direct oral anticoagulants to vitamin K antagonists in patients with cerebral venous thrombosis. The studies needed to have the two groups included, the direct oral anticoagulants and vitamin K antagonists, and they need to include at least one of the outcomes in our study to compare this outcome between the two groups. In addition, we included articles published in English, and we also included papers that had five patients or more in each group. Dr. Negar Asdaghi:         Perfect. So just recap for our listeners, in order to have been included in the meta-analysis, the paper had to have a reasonable number of patients, and you put that reasonable at the number five, and also they had to have at least one of the outcomes of interest reported in their papers. And those outcomes were either recurrent venous thromboembolism or recanalization rates. Right? Dr. Shadi Yaghi:               Correct. Yes. Dr. Negar Asdaghi:         Perfect. So with that, how many papers did you have to go through to come up with the current number of papers included? Dr. Shadi Yaghi:               That's a great question. We had a little over 10,000 papers, and then we went through a screening process. We used this tool that was developed by Brown University. It's called Abstrackr, and what you do is, we did the search and using several databases like PubMed, Cochrane, and then we included all these studies. We uploaded them in Abstrackr, and Abstrackr was utilized to be able to review all these abstracts and select studies that may or will probably qualify and then go through the studies and details that would qualify. So, we had about 10,000 studies with the initial search, and we had two reviewers go through each abstract, and from these 10,665, we excluded 10,411, and that left us with 254 studies. And then we went through these 254 studies in details. And then finally, we had 19 studies included that met our inclusion/exclusion criteria. And these 19 studies included three randomized control trials and 16 observational studies. Dr. Negar Asdaghi:         Incredible effort. So, three randomized trials in this meta-analysis and 16 observational studies. I think we're very ready to hear the primary outcomes. Dr. Shadi Yaghi:               Yeah, so, the primary outcomes were recurrent venous thrombosis, and that included recurrent venous thromboembolism like peripheral DVTs or PEs, for example, and including recurrent cerebral venous thrombosis. And we know that most of the events are recurrent VTEs, not CVTs, like probably about two-thirds to three-quarters were VTEs, and a third to a quarter were CVT. And then the other efficacy outcome is venous recanalization on follow-up imaging. And we found that direct oral anticoagulants and warfarin were not significantly different in the primary efficacy outcomes. Dr. Negar Asdaghi:         Thank you. I just want to repeat this for our listeners. So, you mentioned some important information here. First one was the fact that about three-quarters of recurrent events were actually systemic thromboembolic events rather than cerebral thromboembolism. So, an important outcome to keep in mind for our practicing physicians. And the fact that DOACs did the same as compared to vitamin K antagonist. So, I think you can already guess my next question, and that is, was there any compromise on the safety profile when using DOACs as compared to vitamin K antagonists in this meta-analysis? Dr. Shadi Yaghi:               Thank you. That's a great question. In ACTION-CVT, we found that there was a lower risk of major hemorrhage with direct oral anticoagulants compared to vitamin K antagonists. In this systematic review and meta-analysis, we didn't find a significant difference, but there were fewer events in patients treated with direct oral anticoagulants versus vitamin K antagonists. This did not reach statistical significance, but if you look at the raw data, it's kind of along the same lines as ACTION-CVT, so the risk of major hemorrhage was about 3.5% with warfarin, and that was about 2% with direct oral anticoagulants. Dr. Negar Asdaghi:         So, again, very important finding, and I want to repeat this for our listeners. So, important finding number one was that there was a superiority in favor of DOACs that you found in terms of a reduced risk of intracerebral hemorrhage in ACTION-CVT. You didn't find this superiority in the meta-analysis, but there was sort of a hint to perhaps lower risk of intracerebral hemorrhage in patients that were treated with DOACs. Did I get that right? Dr. Shadi Yaghi:               Yes, that is correct, and in addition, also major hemorrhage in general, and that included also ICH. Dr. Negar Asdaghi:         Oh, OK, so not just intracranial, but systemic hemorrhages as well. All right. Very good. So, I think my next question would be, why do you think that DOACs have a lower chance of causing hemorrhage? Dr. Shadi Yaghi:               Yeah, that's a really good question. This is not unexpected with DOACs as opposed to vitamin K antagonists. We saw these same trends in patients with atrial fibrillation. We saw improved bleeding profiles with direct oral anticoagulants as compared to vitamin K antagonists. And the risks were along the same lines that we found in patients with cerebral venous thrombosis in ACTION-CVT. Also in the VTE trials as well, there was also reduced bleeding complications with direct oral anticoagulants as compared to vitamin K antagonists. So, it was kind of reassuring to see the same results in patients with cerebral venous thrombosis. Dr. Negar Asdaghi:         Perfect, so kind of expected based on what we know from treatment of systemic conditions with DOACs. The next question I have for you is that in routine practice, treatment of cerebral venous sinus thrombosis almost always starts parenterally with either unfractionated heparin or low molecular weight heparin and then we switch to an oral agent. In the observational studies, did you find any differences in terms of timing of this switch or characteristics of the patients in whom vitamin K antagonists were chosen over direct oral anticoagulants? Dr. Shadi Yaghi:               Thank you very much. Most of the studies did not report these details. I think the one study, off the top of my head, that does report the differences in characteristics between the two groups is RESPECT-CVT. That's the randomized controlled trial comparing dabigatran to vitamin K antagonists. In this study, there was a treatment with parenteral anticoagulation for several days, I think seven to 14 days, prior to transitioning to oral anticoagulation. And this is generally my practice. I typically would treat patients with at least seven days or so parenteral anticoagulation, and once they're clinically stable, then I would transition them to oral anticoagulation, either vitamin K antagonists or direct oral anticoagulant. Dr. Negar Asdaghi:         And I think my next question is along the lines of this question as well. We have several direct oral anticoagulants now available on the market. What was the most common DOACs used for treatment of CVST in these studies, and did you note a preference for the use of any particular agent over others? Dr. Shadi Yaghi:               Thank you so much for the question. Anti-Xa inhibitors were much more common than dabigatran, and the anti-Xa inhibitors most commonly used were apixaban and rivaroxaban. It's in line with what we saw in ACTION-CVT as well, although most of the randomized controlled trials or the largest randomized controlled trial, RESPECT-CVT, used dabigatran, but overall people have been using anti-Xa inhibitors, more particularly apixaban, which was also in line with what we saw in ACTION-CVT. Dr. Negar Asdaghi:         But I think it's fair to say that we don't really have data on superiority of one over others. Is that fair? Dr. Shadi Yaghi:               Yes, that is correct. Dr. Negar Asdaghi:         OK, and so now, where are we at in terms of the future of studies on this topic? We have one ongoing randomized trial now? Dr. Shadi Yaghi:               Yes, we have one randomized controlled trial ongoing, and this is the SECRET trial, and it's looking at rivaroxaban versus vitamin K antagonists in patients with cerebral venous thrombosis. There's another study, it's a prospective observational study that's called the DOAC-CVT study. It's an international study also looking at real-world data prospectively to see if there's a difference in outcomes between the two groups. Dr. Negar Asdaghi:         So, we look forward to the results of those studies. Shadi, a follow-up question I have on this topic is, how long should a duration of therapy be in idiopathic cases of cerebral venous sinus thrombosis? Dr. Shadi Yaghi:               Thank you so much for this question. So, it's unknown at this point for how long should we treat. The key things from the treatment are first achieving venous recanalization, and second is preventing another venous thromboembolic event from happening. So, regarding the venous recanalization, studies have shown that there's not a lot of recanalization beyond four months of treatment. So, a lot of the recanalization really happens early, and continuing anticoagulation beyond the six-months interval, for example, in order to achieve further venous recanalization probably has limited utility. And the second important reason why we treat patients with anticoagulation is also to reduce the risk of a recurrent venous thromboembolic event or cerebral venous thrombosis. And for that, if it's a provoked CVT, then I think usually it's three to six months. If it's unprovoked, up to maybe six to 12 months or even longer, depending on the profile. And if there's a persistent provoking factor, such as cancer, antiphospholipid antibody syndrome, then the treatment is lifelong or until this condition subsides. There's a lot of controversy about the duration of treatment. The European guidelines were very helpful in identifying the duration of treatment. Hopefully, also, we have some guidelines or at least a scientific statement by the AHA that also doles details out and provides some guidance to practitioners. Dr. Negar Asdaghi:         Shadi, what should be our top two takeaways from the current meta-analysis and also ACTION-CVT? Dr. Shadi Yaghi:               So, really, the top two from ACTION-CVT and the meta-analysis are, first is direct oral anticoagulants have a comparable efficacy to vitamin K antagonists in terms of recurrent venous thrombosis and achieving venous recanalization on follow-up imaging. And then the second point is direct oral anticoagulants are probably safer than vitamin K antagonists. We have to keep in mind that this data is based mostly on observational studies. And, as we mentioned earlier, we need more randomized controlled trials to support these findings. Dr. Negar Asdaghi:         Dr. Shadi Yaghi, it was a pleasure interviewing you on the podcast. Thank you very much for joining us, and we look forward to having you back on the podcast and reviewing this topic again in the future. Dr. Shadi Yaghi:               Thank you so much. I appreciate you having me. Dr. Negar Asdaghi:         Thank you. And this concludes our podcast for the October 2022 issue of Stroke Please be sure to check out this month's table of contents for the full list of publications, including an important update from the European Stroke Organisation by Prof. Martin Dichgans. I also want to draw your attention to this month's InterSECT paper, which is our International Stroke Early Career and Training section, to discuss the key topic of burnout and mental health amongst physicians, especially amongst neurologists and stroke neurologists. It's alarming to read in this article that neurology is one of the specialties with the highest reported rates of burnout syndrome, and stroke neurologists are at particularly higher risk than other neurological subspecialties. The article tackles some tough subjects, such as the barriers for physicians to seek help and important strategies to mitigate burnout and how to improve mental health in general. I think it's also timely to know that October is the Mental Health Awareness Month, and the theme for October 2022 is "Back to Basics." The basics of recognizing the burden of stress, anxiety, the burden of isolation and depression, not only on those who we take care of, but also on those who give care to us. So, whether you're a stroke physician, a stroke caregiver, or whether you've been touched by this disease in some way or shape, please know that you are part of the stroke community and a part of our Stroke podcast family. Thank you for listening to us, and, as always, stay alert with Stroke Alert. This program is copyright of the American Heart Association, 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, visit AHAjournals.org.  

In the 100 years since its founding in 1922, the American Society for Clinical Pathology has guided the application and evolution of pathology and laboratory medicine. But how much do you know about the history of ASCP? On this episode of Inside the Lab recorded live at the ASCP Annual Meeting in Chicago, our hosts, Ms. Kelly Swails and Dr. Lotte Mulder, are joined by Team Total Kuality, Dr. Kamran Mirza, MD, PhD, Associate Professor of Pathology at Loyola Medicine, and Dr. Theresa Tellier-Castellone, EdD, MPH, MLS(ASCP)CM, Program Director for the School of Medical Technology at Our Lady of Fatima and Rhode Island Hospital; Team Buffy Coat, Dr. Kim Sanford, MD, MASCP, MT(ASCP), Past President of ASCP, and Dr. Will Finn, MD, MASCP, Medical Director at Warde Medical Lab and Past President of ASCP; and Team Diplococcus, Ms. Christy Nickel, MHA, MLS(ASCP)CM, CPHQ, ASCP CMLA Chair and Director of the Clinical Laboratory at Bryan Health, and Ms. Jeannie Guglielmo, MS, MAT, MLS(ASCP)CM, Chair of the Clinical Laboratory Science Program at Stony Brook University, for an enthusiastic game of ASCP Trivia. Our teams answer questions about the ethical issues that concerned ASCP in its early years and the goals of the organization that have remained consistent since its founding in 1922. They buzz in to share their knowledge of how we made history by electing Dr. Emma Sadler Moss as President in 1955. Listen in as the teams compete for bragging rights (and a glow-in-the-dark Erlenmeyer flask). Topics Covered · Dr. Emma Sadler Moss' roles at Charity Hospital in New Orleans and with ASCP in the 1950s· The ethical issues around the practice of pathology that concerned ASCP in its early years· Other professional organizations founded at ASCP meetings· Why ASCP changed its name to the American Society for Clinical Pathology in 2002· How ASCP's Center for Global Health is responding to disasters and expanding laboratory services all over the world· What goals ASCP established when the organization was founded in 1922 (and how those goals have remained consistent in the years since)· How ASCP made history by electing the first female president of a medical organization in 1955 Connect with ASCPASCPASCP on FacebookASCP on InstagramASCP on Twitter Connect with Team Total KualityDr. Mirza on TwitterDr. Tellier-Castellone on TwitterConnect with Team Buffy CoatDr. Sanford on TwitterDr. Finn on Twitter Connect with Team DiplococcusMs. Nickel on LinkedInMs. Guglielmo on LinkedInConnect with Ms. Swails & Dr. MulderMs. Swails on TwitterDr. Mulder on Twitter Resources ASCP Annual MeetingInside the Lab in the ASCP Store 

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

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

In this episode we talk to Dr Andrew Green, Chief of Shoulder and Elbow Surgery, University Orthopedics, Rhode Island Hospital and Director, the Brown University Shoulder and Elbow Fellowship. Tune in for insights on the biggest advances in shoulder care in the last 30 years, future innovation in shoulder care, and advice for aspiring leaders.

Lifespan Hospital is being overwhelmed with staffing problems as pediatric emergency room visits rise. It's been a persistent issue that is only growing. Dr. Jay Schuur, Chief of the Emergency Department at RI Hospital talks to Gene about what parents should know ahead of a hot and busy weekend.  See omnystudio.com/listener for privacy information.

In this episode we talk to Dr Andrew Green, Chief of Shoulder and Elbow Surgery, University Orthopedics, Rhode Island Hospital and Director, the Brown University Shoulder and Elbow Fellowship. Tune in for insights on the biggest advances in shoulder care in the last 30 years, future innovation in shoulder care, and advice for aspiring leaders.

On this episode, we have returning guest Dr. Abby McElroy who previously was a guest on the Hypermobility Happy Hour discussing EDS in animals. Today, she returns with her principal investigator Dr. Heather Gray-Edwards to discuss the exciting new research they have been working on. Dr. Gray-Edwards is an assistant professor of Radiology at the University of Massachusetts' Chan Medical School and is a member of the Horae Gene Therapy Center. Much of her research has been focused on evaluating therapeutic interventions in testing novel Adeno-associated viral vectors and delivery routes using both biochemical and molecular biology techniques, as well as in vitro evaluation like neurological examinations, MRIs, and electrodiagnostics of GM1 and GM2 gangliosidosis cats. Dr. McElroy is a doctoral student who previously received her Doctor of Veterinary Medicine degree from Tufts University in 2017. She further obtained a master's degree from Michigan State University in 2018 which focused on the characterization of neurological abnormalities in an equine model of Ehlers-Danlos syndrome. From 2018 to 2021, Dr. McElroy was a Postdoctoral Research Associate in the Department of Neurosurgery at Rhode Island Hospital and the Medical School of Brown University where she studied tethered cord syndrome and myodural bridge dysfunction in patients with Ehlers-Danlos Syndrome. In her current position at the Gray-Edwards laboratory at the University of Massachusetts' Chan Medical School focuses on the development of gene therapy for Ehlers-Danlos syndromes and multisystemic smooth muscle dysfunction syndrome (related to the ACTA2 mutation). Abby also has two cats and two dogs and one of her cats has Ehlers-Danlos syndrome and is a bit of a social media star in his own right (his name is Reed and you can follow him at reed_eds)

Welcome back to the Brown survey podcast. Today we are going to kick things off with the important topic of enteral nutrition delivery in the acute care setting. Nutrition delivery can be a challenge at times on surgical services and there are always a lot of questions by clinicians on how to approach enteral delivery with patients, calculating individual caloric goals, route of nutritional delivery, and choosing the correct supplemental formulas. Joining me to discuss this topic is Our local expert on surgical nutrition, Dr. Marion Winkler, PhD, RD, LDN, CNSC. Dr Winkler is a Professor of Surgery at the Alpert School of Medicine here at Brown and a Surgical Nutrition Specialist in the Department of Surgery and Nutritional Support Service at Rhode Island Hospital. Podcast Chapters: (1:46) What are our goals with enteral nutrition delivery? (3:12) When should we consider supplementing enteral nutrition? (6:08) How do we determine caloric goals for patients (9:05) Protein requirements in patients (11:42) Which formula to choose (16:01) Route of administration: gastric vs post pyloric (17:23) Continuous versus Bolus feeding (19:04) Interruptions in feeding/volume based feeding (21:35) Gastric Residuals (24:15) How good are we at delivering nutrition (25:38) When to consider TPN administration ASPEN Guidelines: https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/jpen.2267

This episodes discusses the role of social media in patient care with Dr. Don Dizon. Dr. Dizon is the Director of the Pelvic Malignancies Program at Lifespan Cancer Institute, Head of Community Outreach and Engagement at The Cancer Center at Brown University, and Director of Medical Oncology at Rhode Island Hospital. Living with melanoma is emotionally stressful, no matter which side of the challenge you are on. Melanoma has more than a physical impact when living with the disease. It's also a significant source of emotional distress, anxiety, and depression—both during treatment and after. Our new program, “Beyond the Clinic: Living Well With Melanoma,” will feature topics seldom discussed in the exam room but essential to patients and their families during and beyond treatment. Led by the Director of Cancer Survivorship for Kaiser Permanente San Francisco, Raymond Liu, M.D., Beyond the Clinic: Living Well With Melanoma is a monthly live webinar designed to support patients' and families' emotional needs. --- Support this podcast: https://anchor.fm/aimatmelanoma/support

What is the key to Mark Mandell's success as a trial lawyer?  He questions all assumptions and has spent his entire career in search of answers.  And what he has uncovered along the way is required knowledge for anyone who wants to try cases for a living.  Join  Ben ((Ben Gideon | Gideon Asen LLC) )  and Rahul ((Rahul Ravipudi (psblaw.com) for our probing discussion with Mark as he describes his thoughtful approach to trial work that has led to many successful verdicts and settlement and underpins his two widely acclaimed books on trial practice:  Case Framing and Advanced Case Framing.About Mark MandellMark Mandell graduated from Georgetown University Law Center receiving his J.D. in 1974. When Mark graduated from Georgetown he served as a law clerk for the Honorable U.S. District Judge Edward W. Day in the United States Federal District Court in Providence for a year before entering private practice.Mark is certified for his expertise in civil trials by two national organizations. He is a Board Certified Civil Trial Specialist by the National Board of Legal Specialty Certification. Attorney Mandell is also nationally recognized and Board Certified as an expert in medical negligence litigation by the American Board of Professional Liability Attorneys. Double board certification nationally is rare for trial lawyers. Both certifications require trial experience and passing a national certification examination.Mark is actually Triple Board Certified as he is also board certified in Civil Pretrial Practice by the National Board of Legal Specialty Certification.Mark is a member of the prestigious Inner Circle of Advocates. Membership in the Inner Circle is limited to 100 of the best trial lawyers in the country. The Inner Circle has been described as “an invitation only group of the best plaintiffs lawyers in the United States”.Mark is also a Fellow of the American College of Trial Lawyers. Membership in the College is an honor that is given only after a lengthy and rigorous evaluation.Attorney Mark Mandell is a Fellow of the American Academy of Appellate Lawyers and a member of the American Law Institute. He has also attained bar membership in United States Supreme Court, United States Court of Appeals for the First Circuit, United States District Court for the District of Rhode Island and in the States of Rhode Island and Alabama.Mark Mandell has served as President of the Association of Trial Lawyers of America, the Roscoe Pound Institute of Civil Justice, the Rhode Island Bar Association and the Rhode Island Trial Lawyers Association. He has chaired the Board of Bar Examiners for the United States District Court for the District of Rhode Island and is a Past Chair of the National Center for Victims of Crime. He is also a Past President of the National Crime Victims Bar Association. He not only has served these presidential roles but has served many intermediary positions in these prestigious groups.Attorney Mandell is a current member of the Rhode Island Supreme Court Ethics Advisory Panel and has also served on the Governor's Advisory Commission on Judicial Appointments, the Rhode Island Supreme Court Commission on the Future of Rhode Island Judicial System, the Rhode Island Board of Medical Licensure and Discipline, and the Governor's Council on Mental Health.He is currently a member of the Alabama Bar Association, the American Bar Association, the American Association for Justice, the Rhode Island Association for Justice, and the Rhode Island Bar Association. Mark has written 22 articles in well known journals and has lectured many hundreds of times to Trial Lawyers Associations, state and national, in 45 different states and internationally. Attorney Mandell is currently listed in the publication “The Best Lawyers in America“.Mark Mandell focuses his practice on catastrophic personal injury cases, wrongful death cases, liquor liability cases, and medical negligence cases. He has obtained many million dollar trial verdicts and settlements for his clients. Mark has obtained more verdicts of $1,000,000 and also of $10,000,000 or more than any other lawyer in Rhode Island history. Mark was the Chair of the Plaintiff's Settlement committee in the Station Fire litigation, which resulted in a settlement of more than $176,000,000.Attorney Mandell has also lectured on Medical/Academic topics at well respected establishments such as Brown University Medical School, Harvard Medical School, Women and Infants Hospital in Providence, Rhode Island, The Massachusetts Anesthesia Council on Education/Massachusetts, Society of Anesthesiologists, Rhode Island Hospital, The Miriam Hospital, and State of Rhode Island, Department of Health.In 2018, Mark Mandell was honored as the recipient of the Howard Twiggs Award by the American Association for Justice. The Howard Twiggs Award recognizes an AAJ member of at least 10 years standing whose passion, civility, cordiality, and professionalism reflect the high standards set by Howard Twiggs; and whose courtroom advocacy and distinguished service to AAJ have brought honor to the trial bar and the legal profession. Howard Twiggs was selfless and a tireless worker who always put the welfare of his client and AAJ ahead of any personal glory or satisfaction.Mark Mandell has previously been honored with many other awards as well, including:2021- “Best Lawyers” for 2022 and Sept 20212003- “Harry M. Philo Award” in 2003 from the Association of Trial Lawyers of America1999- “Lawyer of the Year Award” from the Melvin Belli National Society1998- “Citizen of the Year Award” from the Rhode Island Trial Lawyers Association1987- “Rhode Island Jewish Citizen of the Year Award” from the Jewish Community Center of Rhode Island1984- “Merrill L. Hassenfeld Leadership in Community Service Award” from the Jewish Federation of Rhode IslandAttorney Mark Mandell is also an active member of the community as he was formerly on the Board of Directors of The Miriam Hospital, Board of Directors of the Jewish Federation of Rhode Island, Board of Directors of the Urban League of Rhode Island, Chair of the Executive Committee of the Holocaust Memorial Committee of Rhode Island, President of the Jewish Community Center of Rhode Island, member of the Executive-Finance Committee of The Wheeler School, Chair of the Education Committee of The Wheeler School, the Board of Trustees of the Wheeler School, the Board of Roger Williams University, and Chair of the Board of Directors of Roger Williams University School of Law.About the Elawvate PodcastThe Elawvate Podcast – Where Trial Lawyers Learn, Share, and Grow is where the practice of trial law meets personal growth. To succeed as a trial lawyer and build a successful law firm requires practice skills, strategic thinking and some amount of business and entrepreneurial savvy. Elawvate is a place to learn and share skills and strategies for success.But it is also a place to dig deeper and achieve personal growth.Those who succeed as trial lawyers at the highest levels cultivate character, principle, integrity, leadership, courage, compassion and perseverance.  We learn and draw inspiration from those who have achieved this success.For more about Elawvate, visit our website at www.elawvate.fm.  You can also  join our Facebook Group at Elawvate | FacebookFor more information or to contact the hosts, see:(Rahul Ravipudi (psblaw.com) (Ben Gideon | Gideon Asen LLC)  

This week we discuss a short series of wrong-sided brain surgery mishaps at Rhode Island Hospital in 2007. Although wrong-sided operations are quite rare, how did three happen at the same hospital in less than one year? Despite the Universal Protocol created in 2003 to prevent surgical mistakes like these from happening, we learn very quickly that instructions aren't very useful if you don't follow them...For a full list of all episode references and pictures, visit our case files and pictures page! https://www.ethicalsideeffects.com/episode-case-filesEmail: ethicalsideeffectspodcast@gmail.comBuy Merch, Subscribe, & Follow Us!https://linktr.ee/EthicalSideEffects Go to https://partner.canva.com/ESEFFECTS to get started with a one-month free trial of Canva Pro today! Stop scrolling and starting listening now, with Newsly! Use promo code ESEFFECT at newsly.me and receive a 1-month free premium subscriptionSupport the show

Dr. Megan Ranney, an ER physician at Rhode Island Hospital and associate professor at Brown University, is our guest this week on Political Roundtable. Here's a transcript of the conversation, which also includes Ted Nesi from WPRI-TV, Channel 12, and URI emeritus professor of political science Maureen Moakley.. Donnis: Let's start with the issue of […]

Expert trainer and Certified Interpreter Eliana Lobo discusses how to raise the bar for interpretation during the global pandemic. Eliana is a CoreCHI™ Certified Healthcare Interpreter and a Washington state authorized Medical Interpreter. She's also a certified Trainer of Trainers of medical interpreters. Eliana holds two M.A.s from Brown University in Bilingual Education, and Portuguese & Brazilian Studies. She started out as a Spanish/Portuguese medical interpreter at Rhode Island Hospital in 1980.

David Reuben MD is the Director, Multicampus Program in Geriatrics Medicine and Gerontology and Chief, Division of Geriatrics at UCLA. He is the Archstone Foundation Chair and Professor at the David Geffen School of Medicine and Director of the UCLA Alzheimer's and Dementia Care Program. Dr. Reuben completed his medical school at Emory and residency at Rhode Island Hospital. He pursued a fellowship from UCLA. He has served as principal investigator of numerous large studies including the STRIDE study aimed at reducing serious falls related injuries in the elderly. His bibliography includes more than 200 peer reviewed publications in medical journals and over 30 books including the widely distributed Geriatrics at Your Fingertips. Dr. Reuben has received numerous awards including the Henderson Award from the American Geriatrics Society and the 2008 John Eisenberg Patient Safety and Quality Award. He has served in a number of important leadership roles including the Board Chair of the American Board of Internal Medicine, President of the American Geriatrics Society and President of the Association of Directors of Geriatric Academic Programs. What is the hallmark of a great physician? Today, Dr. David Reuben reflects on how we as physicians are very powerful people: people listen to us, return our phone calls. A great physician, according to Dr. Reuben, is one who uses that power to advocate for their patients. Sharing anecdotes from his own life, Dr. Reuben shares how many of our real achievements never make their ways on a CV. Oftentimes, those lie in the small differences we can make for our patients and their families. And that is true success. Pearls of Wisdom: 1. In a patient encounter, building a relationship with a patient should be the first thing on our checklist. 2. The move from a good internist to a great internist is built on advocacy for the patient. Physicians are powerful. Use that power to advocate. 3.  Your mentor and your role model don't have to be the same person. Having multiple people as mentors offers a variety of perspectives. 4. Think about the long-haul. Is what you're worrying about now going to matter in five years?

In this episode, I'm joined by Dr. Barbara Hamilton. Barbara is a mom, writer, and a leader. She's the Chief of Interventional Radiology in Desert Regional Medical Center at Palm Springs, California. I was so delighted to have a fellow physician on this show and being that there are very few women in the field of interventional radiology, Barbara was the perfect guest. We talk about the need for leadership training for women, the false assumption that childbirth and childrearing is a liability, self-development tips for female leaders, and much more.  Barbara created TiredSuperheroine.com, a blog and a network dedicated to giving work and life advice to students, early career doctors, and premeds. She also has a book coming this October entitled Tired Superheroine's Guide to Finding Your Place in Medicine. For more information on her blog and upcoming book, click here. Episode highlights: Her childhood and how it shaped her today Her biggest influences in pursuing interventional radiology The importance of financial empowerment for women Her inspiration for her blog's name  How she balances being both a mother and a physician The value of having female colleagues in the workplace Obstacles she faced throughout her training and career The lack of leadership training for women Advice she would give to someone who wants to enter into her field About the guest: Barbara Hamilton, MD is a mom, content writer, interventional radiologist, and a physician leader. She's the Chair of Interventional Radiology in Desert Regional Medical Center for about four years.  Dr. Hamilton began writing for her blog, tiredsuperheroine, in October 2018. She completed her residency in diagnostic imaging in Rhode Island Hospital in 2013 and acquired her medical degree from Rutgers Robert Wood Johnson Medical School in 2008. Connect with Barbara: Website Tired Superheroine LinkedIn @barbara-hamilton Facebook @Tired-Superheroine Instagram @tiredsuperheroine Twitter @TSuperheroine --- Did you enjoy today's episode? Please click here to leave a review for The 6%, with NancyMD. Be sure to subscribe to your favorite podcast app to get notified when a new episode comes out!  Do you know someone who might enjoy this episode? Share this episode to inspire and empower! Let's get social! Instagram @_nancymd Facebook @nancymdpdx Twitter @_nancymd LinkedIn @nancyyenshipleymd Website www.nancymd.com   Subscribe to The 6%, with NancyMD ++ Apple Podcasts ++ Spotify ++ Google Podcasts

Rabies post exposure prophylaxis, or PEP, consists of a rabies vaccine series and human rabies immune globulin (HRIG). Kedrion Biopharma's human rabies immune globulin, Kedrab, was FDA approved in 2017. And now for the first time, the safety of HRIG (Kedrab) was studied in children. Joining me today to discuss rabies, PEP and the pediatric trial is James Linakis, MD, PhD. Dr. Linakis is Professor of Emergency Medicine and Pediatrics at Brown Medical School and Associate Director of Pediatric Emergency Medicine at Rhode Island Hospital's Hasbro Children's Hospital.

Eleftherios Mylonakis, MD, PhD, FIDSA, is the Charles CJ Carpenter Professor of Infectious Diseases at the Brown University. He is also the Chief of Infectious Diseases at Rhode Island Hospital and the Miriam Hospital and the Director of the COBRE Center for Antimicrobial Resistance and Therapeutic Discovery. He has eight patents, has edited five books, and has published more than four hundred articles in peer reviewed literature. Pearls of Wisdom: Focus on being a good doctor and let the titles follow our work Rather than trying to think about the whole path that lies ahead, focus on the next steps. Because when we shine the torch five feet, the next five feet will be visible Go and be proactive in reaching out to mentors, especially those who are not afraid to be honest with us

This week we join Chris Jehle, a fourth year plastic surgery resident at Rhode Island Hospital, for a conversation about creativity and risk within a "safe" profession, innovation in medicine, trendsetting with plastic surgery, and the silver lining of having lots of problems to solve. Topics include pride in your profession, what plastic surgery really is, issues with the medical insurance industry, and treating your patient like you'd treat your family. Show Notes Trendsetting in plastic surgery Risks within the safety of a standard profession Plastic surgery doesn't have an age, gender of body system Issues with the medical insurance industry Links Follow Chris on his Instagram (https://www.instagram.com/chazjehle/) or learn a little about him on the brown website (https://www.brown.edu/Departments/Plastic_Surgery/chris-jehle%2C-md.html) What is plastic surgery? (https://en.wikipedia.org/wiki/Plastic_surgery) Want to become a plastic surgeon after listening to this episode? Here's an 8-step plan... (https://money.howstuffworks.com/how-to-become-plastic-surgeon.htm) Big thanks to NGHTSWM (https://itunes.apple.com/us/artist/nghtswm/1316607579) for the use of their song, Fiji (https://itunes.apple.com/us/album/fiji-single/1436041716), on this show.