Podcasts about Royal Brompton Hospital

Perhaps you couldn't drift off, or maybe you woke in the middle of the night and then couldn't nod off again. In this edition of Inside Health we're talking all about insomnia. It's an issue that may affect many of us at some point in our lives – but for some it goes beyond a short period of not being able to sleep and becomes something more serious. James is joined by a trio of experts ready to answer to them: Dr Allie Hare, president of the British Sleep Society and consultant physician in sleep medicine at the Royal Brompton Hospital, Colin Espie, a professor of sleep medicine at Oxford University and Dr Faith Orchard, a lecturer in psychology at Sussex University. We're going to find out why we get insomnia, when to seek help and how much factors like ageing, menopause, needing the loo or shift work matter. And we'll look at the latest advice and treatments. Can insomnia be fixed?

Tal Golesworthy was born with a genetic condition called Marfan syndrome which affects the body's connective tissue and can lead to cardiovascular, skeletal and visual problems. For Tal, an engineer by trade, the condition took a particular toll on his heart, weakening the walls of the aorta and causing them to expand. Surgical intervention would involve total root replacement of the aorta, including the valve, and re-implanting the coronary arteries. The idea of major surgery, and the ensuing lifelong dependency on anticoagulant medicine to prevent blood clots, was enough for Tal to explore an alternative route. With the help of Professor John Pepper, consultant cardiac surgeon at Royal Brompton Hospital, Tal drew on his expertise as an engineer to develop a prototype of a device – called a Personalised External Aortic Root Support (PEARS), pictured above – that could be placed around the ascending aorta and prevent aortic root expansion. Four years on since conceiving the idea, in 2004 Tal became the first patient to undergo this surgical procedure, which was performed by Professor John Pepper himself. In this episode of More than a Hospital, Tal and Professor Pepper recall the journey that led to that moment, and how they forged an unexpected partnership to help not only Tal, but the hundreds of lives that the revolutionary procedure would go on to benefit. Hosted on Acast. See acast.com/privacy for more information.

Join me for the first episode of a 6-part series on becoming a consultant pharmacist in the UK, featuring Sukeshi Makhecha, a consultant pharmacist with 25 years of experience in paediatric respiratory care and asthma. Sukeshi shares her inspiring journey, highlighting her passion for paediatrics and her dedication to enhancing asthma care for children through education and research. This episode delves into the essential clinical skills, competencies, and specialist knowledge required for this role, as well as the importance of maintaining a work-life balance to prevent burnout. We explore the evolving role of consultant pharmacists and the competencies required by the Royal Pharmaceutical Society (RPS). Sukeshi discusses the milestones necessary to master respiratory and paediatric care, illustrated through a compelling case study on addressing environmental concerns related to metered dose inhalers. The episode also offers strategies for continuous learning, including the benefits of professional networks and conferences. Sukeshi works at the Royal Brompton Hospital as a lead paediatric pharmacist and a paediatric respiratory specialist pharmacist at the Evelina London Children's Hospital. She is also: credentialed as a consultant pharmacist in pediatric asthma by the Royal Pharmaceutical Society co-chairs the Pharmacy London Asthma Implementation Group (LALIG) chairs the NPPG Respiratory Interest Group (RIG), and serves on the Pharmacists Consortium London North West (PCLNW) steering committee.  Her research interests include adherence in asthma and vaping in children, and she is passionate about raising the profile of pharmacists in pediatric asthma care to improve outcomes for children and young people with asthma. BEHIND THE MIC! Have you been thinking about starting your own podcast? We know that starting a podcast can feel daunting and overwhelming. But guess what? You're not alone.  We are on a mission to create a fantastic community of individuals just like you! Together, we'll break down the entire podcasting process—from ideation to recording, editing, technology, publishing, social media, marketing, branding, sponsorship and more. Sign up to our FREE community called Behind The Mic!  We are excited to engage with you and provide you with the support & guidance you need to get started.  Register here: https://behindthemic.circle.so/  SIGN UP to my NEWSLETTER below so you'll be the first to know when new episodes are being released. You'll also receive regular inspiration, tips, tools, and free content. https://pharmacistdiaries.ck.page/newsletter PARTNERSHIPS: The Naked Pharmacy is offering my podcast listeners a 20% discount on all their products. Use discount code PD20 at checkout to receive the offer. https://www.thenakedpharmacy.com/ CONNECT WITH SUKESHI: LinkedIn: https://www.linkedin.com/in/makhecha-sukeshi-05030048/ X: https://x.com/SukeshiMakhecha Follow me on⁠ My Website⁠,⁠ YouTube⁠,⁠ Instagram⁠,⁠ Facebook⁠,⁠ LinkedIn⁠, and/or⁠ Twitter⁠. Feel free to subscribe to the podcast on your favourite podcast platform so you can be notified when a new episode is released or leave a review on apple podcasts. If you have any suggestions for guests you want me to talk to or if you'd like to come on yourself, please feel free to contact me via social media, or email at info@pharmacistdiaries.com.

Durant cet épisode, Coach Frank discute avec François Simard, MD., de cardiologie sportive, de soccer professionnel, du syndrome de mort subite, et de prévention des problèmes cardiaques chez les athlètes. À propos de François : François Simard a complété son doctorat en médecine et sa résidence en cardiologie de l'adulte à l'Université de Montréal. Son parcours académique l'a mené à s'intéresser à la physiologie de l'exercice et le remodelage cardiaque secondaire à l'exercice physique. Il a donc complété sa formation en échocardiographie cardiaque (Institut de cardiologie de Montréal, Canada) et en résonance magnétique (Royal Brompton Hospital, Londres, Royaume-Uni). Il a finalement réalisé une surspécialisation en cardiologie sportive et réadaptation cardiaque à l'Hospital Clínic de Barcelone, Espagne. Il travaille actuellement comme professeur adjoint de clinique au département de cardiologie non-invasive de l'Institut de Cardiologie de Montréal et en réadaptation cardiovasculaire au centre EPIC. Pour une consultation avec François, nous vous invitons à consulter votre médecin de famille ou un médecin du sport. Pour les professionnel·les de la santé qui désirent rejoindre François pour des demandes professionnelles, prière d'écrire à Coach Frank au frank@coachfrankphd.com NOTES D'ÉMISSION Bienvenue et introduction de François Simard. (1 :23) Qu'est-ce qui peut être négatif du remodelage que notre cœur va subir à l'entraînement? (6:36) Que faut-il prendre en considération lorsque tu travailles avec un athlète qui est susceptible de développer des problèmes cardiaques ? (12:38) Quels sont les symptômes de problèmes cardiaques qui devrait nous mettre la puce à l'oreille ? (18:38) Les distinctions entre l'approche médico-sportif européenne et celle de l'Amérique du Nord. (25:04) Les exigences de la FIFA pour minimiser les risques de morts subites sont-ils justifiés ? (32:12) Le syndrome de la mort subite expliqué. (36:36) Des cas d'actualités de mort subite chez les athlètes professionnelles. (42:14) L'impact des virus respiratoires sur notre santé cardiaque. (47:16) Après combien de temps faut-il se poser des questions au sujet de notre cœur ? (54:40) Si tu pouvais retourner en arrière et donner un conseil à toi-même quand tu avais 22 ans, ce serait quoi ? (57:43) Si tu pouvais mettre une citation sur un jumbotron, dans un aréna ou dans un stade, ce serait laquelle et qu'est-ce que tu aimerais que les gens comprennent ? (58:35) Mot de la fin et comment rejoindre François Simard. (1:00:26) PERSONNES ET ORGANISATIONS MENTIONNÉES Université du Québec en Outaouais UQO | Université du Québec en Outaouais François Simard | François Simard Université de Montréal UdeM | Université de Montréal Institut de Cardiologie de Montréal | Institut de Cardiologie de Montréal Royal Brompton Hospital | Royal Brompton & Harefield hospitals Hospital Clinic Barcelona | Hospital Clinic Barcelona Hopital Montfort Montfort | Hopital Montfort Bronny James Bronny James | Wikipedia FIFA | FIFA Damar Hamlin Damar Hamlin | Wikipedia Christian Eriksen Christian Eriksen | Wikipedia Alphonso Davies Alphonso Davies | Wikipedia Roger Federer Roger Federer | Wikipedia

There are more than 100 Cochrane Reviews relevant to the care of people with cystic fibrosis and an update for the one looking at the effects of nebulisers was published in November 2023. Here's the new lead author, Gemma Stanford, from the Royal Brompton Hospital in London UK to tell us about it.

There are more than 100 Cochrane Reviews relevant to the care of people with cystic fibrosis and an update for the one looking at the effects of nebulisers was published in November 2023. Here's the new lead author, Gemma Stanford, from the Royal Brompton Hospital in London UK to tell us about it.

In this episode of the Heart podcast, Digital Media Editor, Professor James Rudd, is joined by Dr Ali Vazir from The Royal Brompton Hospital in London. They discuss all aspects of sleep-disordered breathing and why it's important to be aware of this condition. If you enjoy the show, please leave us a podcast review at https://itunes.apple.com/gb/podcast/heart-podcast/id445358212?mt=2 or wherever you get your podcasts - it's really helpful. Link to published paper: https://heart.bmj.com/content/109/24/1864.info

Close-up images detailing the Milky May's Horsehead Nebula have been captured by Nasa's James Webb Space Telescope. Royal Brompton Hospital's robotics-assisted trial to treat lung cancer with microwaves. Self-driving truck fleet ‘planned for end of 2024'. Lock up pupils' smartphones all day, teachers urged.Also in this episode:Phoning Earth with 140-million-mile laser zap messagePoison pen...toxic chemicals hiding in Victorian booksUS Air Force $13bn ‘doomsday fleet' to protect POTUSHealthy living ‘could add extra five years to life' Hosted on Acast. See acast.com/privacy for more information.

How did you sleep last night? Perhaps you couldn't drift off, or maybe you woke in the middle of the night and then couldn't nod off again.In this special edition of Inside Health we're talking all about insomnia. It's an issue that may affect many of us at some point in our lives – but for some it goes beyond a short period of not being able to sleep and becomes something more serious.You've been getting in touch with your questions, and James is joined by a trio of experts ready to answer to them: Dr Allie Hare, president of the British Sleep Society and consultant physician in sleep medicine at the Royal Brompton Hospital, Colin Espie, a professor of sleep medicine at Oxford University and Dr Faith Orchard, a lecturer in psychology at Sussex University.We're going to find out why we get insomnia, when to seek help and how much factors like ageing, menopause, needing the loo or shift work matter. And we'll look at the latest advice and treatments. Can insomnia be fixed? You can keep in touch with the team by emailing insidehealth@bbc.co.ukPresenter: James Gallagher Producer: Gerry Holt Researcher: Katie Tomsett Production coordinator: Liz Tuohy Studio managers: Jackie Margerum & Andrew Garratt

This week, James Hull, Consultant Respiratory Physician, Royal Brompton Hospital, London, UK, takes Jonathan on a deep dive into respiratory care, from combatting breathlessness to airway collapse in athletes. The pair also discuss the common misconceptions surrounding asthma diagnosis, recent technological advancements, and the potential challenges behind emerging treatments. Use the following timestamps to navigate the content in this episode: (00:00)-Introduction (2:17)-What got Hull into medicine? (03:34)-Relationship between exercise and breathlessness (06:22)-Anxiety and breathlessness (10:24)-Optimising respiratory health in elite athletes (13:52)-RELACS; managing large airway collapse (16:10)-New methods for diagnosing upper airway problems (20:09)-New developments in treating asthma (23:10)-Challenges in respiratory medicine (25:04)-Respiratory medicine and sports committees (26:38)-Three wishes for the future of healthcare 

Infant Feeding - With Stacey Zimmels Today's Bitesize clip is from episode E.25. As you move through pregnancy and into motherhood one of the main things you may be considering is how to feed your baby. Breast, Bottle, Expressing and Mixed Feeding are amongst some of the many terms and choices we hear of when we start to navigate our choices. From the benefits, equipment to purchase, tounge ties and feeding positions it can feel like a mind field. On this week's episode I am very excited to be joined by the perfect expert to help you navigate these choices and crucially to share some of her expert tips and tricks to a successful feeding journey. Stacey Zimmels is a feeding and swallowing specialist speech therapist (SLT) and International Board Certified Lactation Consultant (IBCLC). Stacey has worked for almost 20 years supporting infants and children with a wide range of feeding and swallowing difficulties. Her breadth of knowledge and experience runs across the spectrum; including but not exclusive to, preterm infants, breast and bottle feeding, weaning difficulties, managing allergies and reflux, swallowing difficulties and fussy eating. Stacey runs a private practice and continues to hold an honorary contract at the Royal Brompton Hospital where she continues to work on clinical research and provides as a locum services. Stacey has published abstracts and articles in her field of interest and has presented at conferences. In addition to her work supporting children and families she is passionate about training others in her field, she provides clinical supervision services for a number of other feeding specialist SLT's within the NHS. She has also consulted on NHS service management and development for feeding and swallowing services. Check out Stacey's Social Media Links below: www.feedeatspeak.co.uk Instagram https://www.instagram.com/feedeatspeak/ On Stacey's Instagram you will find her wonderful video mentioned In our chat. Facebook https://www.facebook.com/feedeatspeak/ Here is the link to the WHO information discussed in our chat too: https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding And some more information on Responsive Feeding: https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/relationship-building-resources/responsive-feeding-infosheet/ If you have found this podcast useful, please don't forget to subscribe and leave a review so it can help reach other expectant parents. Extra Stuff: Follow Midwife Pip on Instagram - https://www.instagram.com/midwife_pip Check out Midwife Pip's website - http://www.midwifepip.com/ Get access to my free courses → https://www.midwifepip.com/free-pregnancy-courses Get in Touch: Instagram: https://www.instagram.com/midwife_pip Facebook: https://www.facebook.com/midwifepip Email: https://www.midwifepip.com/contact-us Enjoy Listening... and don't forget to subscribe!  Midwife Pip x  Learn more about your ad choices. Visit megaphone.fm/adchoices

Monday at WCLC 2023 features the Presidential Symposium. In this special WCLC 2023 episode of Lung Cancer Considered, hosts Dr. Narjust Florez and Dr. Stephen Liu talk with Dr. Eric Lim about MARS 2: A Multicentre Randomized Trial Comparing (Extended) Pleurectomy Decortication versus No Radical Surgery for Mesothelioma. Dr. Paula Ugalde, discussant for MARS 2, provides her unique overview and perspective on research presented today. The hosts also talk with Dr. P.C. Yang about the new results presented in the TALENT study of lung cancer screening in Taiwan. Patient advocate Emi Bossio adds her unique perspective. Additionally, Dr. Pasi Janne summarizes his presidential abstract: Osimertinib With/Without Platinum-Based Chemotherapy as First-line Treatment in Patients with EGFRm Advanced NSCLC (FLAURA2) and is joined in a discussion with Emi Bossio, a patient with EGFR lung cancer. Professor Eric Lim is a Consultant Thoracic Surgeon at the Royal Brompton Hospital and Professor of Thoracic Surgery at the National Heart and Lung Institute of Imperial College London. Pan-Chyr Yang, MD, PhD--National Taiwan University College of Medicine and National Taiwan University Hospital, Institute of Biomedical Sciences, Genomics Research Center, Academia Sinica, Taiwan. Paula Ugalde – Dr. Paula Ugalde Figueroa, Thoacic Surgeon, Brigham and Women's Hospital Pasi Jänne is the Director of the Lowe Center for Thoracic Oncology at Dana-Farber Cancer Institute and a Professor of Medicine at Harvard Medical School and the David M. Livingston, MD Chair at Dana-Farber Cancer Institute

In CTSNet's flagship podcast, editor in chief Joel Dunning runs through the latest, most popular content on ctsnet.org—the largest online community of CT surgeons and source of CT surgery information—and breaking cardiothoracic surgery news and research from around the world. In this episode, Joel addresses new guidelines for mechanical circulatory support, a five-year follow-up after transcatheter repair of secondary mitral regurgitation, and risk factors in aortic root replacement during frozen elephant trunk procedures. He also talks about two techniques for internal mammary artery harvest, a webinar on advanced aortic root surgery, and recordings from the conference on sublobar resections. After discussing upcoming events in the CT surgery world, Joel closes with a shoutout to Prof. Eric Lim at Royal Brompton Hospital.   JANS Items Mentioned The 2023 International Society for Heart and Lung Transplantation Guidelines for Mechanical Circulatory Support: A 10-Year Update Five-Year Follow-up after Transcatheter Repair of Secondary Mitral Regurgitation Concomitant Aortic Root Replacement During Frozen Elephant Trunk Implantation Does Not Increase Perioperative Risk    CTSNet Content Mentioned Internal Mammary Artery Harvest: Two Techniques with Tips and Tricks Getinge Webinar: Advanced Aortic Root Surgery—A Diversity of Surgical Strategies from Global Experts  Sublobar Resections and Evolving Techniques for Lung Cancer: Session 8, Part 2   Other Items Mentioned CTSNet Events Calendar

Interviewees: Associate Professor Jasper Brugts, Erasmus University Medical Centre of Rotterdam, The Netherlands; Professor John Cleland and Doctor Ross Campbell, University of Glasgow, United Kingdom of Great Britain & Northern Ireland; Doctor Jeroen Dauw AZ Saint-Lucas, Ghent, Belgium and Interviewers: Doctor Antonio Cannata, King's College London, United Kingdom of Great Britain & Northern Ireland; Doctor Jozine Ter Maaten, University Medical Centre Groningen, The Netherlands; Doctor Sotiria Liori, Attikon University Hospital, Athens, Greece; Doctor Francesca Musella, Royal Brompton Hospital, London, United Kingdom of Great Britain & Northern Ireland. This podcast discusses the results of four late breaking clinical trials presented at the Heart Failure congress 2023 in Prague, Czech. First, dr. Brugts shares the results of the MONITOR-HF trial, an open-label, randomized trial showing that haemodynamic monitoring using a cardioMEMS device, significantly improved quality of life and reduced heart failure hospitalizations in patients with moderate-to-severe heart failure. This trial was simultaneously published in the Lancet (Remote haemodynamic monitoring of pulmonary artery pressures in patients with chronic heart failure (MONITOR-HF): a randomised clinical trial - The Lancet). Second, dr. Cleland walks us through a population study from the greater Glasgow area that found that use of loop diuretics in patients without a diagnosis of heart failure was associated with poor outcomes. He consequently discusses possible explanations and clinical consequences. Third, dr. Campbell shares the results of the DAPA-RESIST trial, that found that in patients with diuretic resistance, dapagliflozin was not superior to metolazone at relieving congestion (Dapagliflozin versus metolazone in heart failure resistant to loop diuretics | European Heart Journal | Oxford Academic (oup.com)). Fourth, dr. Dauw discusses the results of the ENACT-HF trial where a strategy of natriuresis guided therapy as recommended by the HF guidelines, in an open label, sequential roll-out (first 10 patients standard of care, followed by 10-30 patients in the natriuresis arm), was shown to improve natriuresis and reduced length of hospital stay. No effect on change in congestion score or in-hospital mortality was observed. The podcast is concluded with a brief discussion of some HFA Young highlights at the congress. 

Radiologists play central roles in the detection of lung cancer, in assessing response to therapy and relapse of disease and increasingly, interventional radiologists are involved with tissue sampling and lung cancer treatment. In this episode of Lung Cancer Considered, host Dr. Stephen Liu interviews two noted radiologists--Dr. Carole Ridge and Dr. Florian Fintelmann. Dr. Ridge is a consultant radiologist at Royal Brompton Hospital and a Senior Clinical Research Fellow at Imperial College London. Her research was awarded the Royal Academy of Medicine in Ireland medal in 2018. Dr. Florian Fintelmann is an Associate Professor at Harvard Medical School and a thoracic radiologist at Massachusetts General Hospital. He also leads the Thoracic Imaging Percutaneous Thermal Ablation program at the MGH.

Topic discuss: “Rental Markets" and "Vaping" Presenter: Sheikh Sharjeel Ahmad Saad Ahmed Rental Markets: With the average rental in London a record £553 with almost 30 participants competing for one property, we look at the reasons why there is a massive property shortage. We will be looking at which areas are the most affected and what can be done to prevent this from happening. Vaping: Vaping is a big issue in schools nowadays, almost as big as cigarettes once were. And it has the potential to become an even bigger problem. It has been reported that secondary school pupils vape between lessons, or are even dealing vapes - despite the fact that it is illegal in the UK to sell vaping products to under-18s. Join us LIVE as we discuss why young people are becoming addicted to vaping, the potential health risks and is it the duty of schools to counteract this? GUESTS: Ruth Jacob (Policy and Parliamentary Affairs Manager for Charity Crisis) Maleeha Tariq (Advisor and Case Worker) Andrew Bush Time: Professor of Paediatrics and Paediatric respirology, Imperial College where he also directs the Imperial Centre for Paediatrics and Child Health, and Consultant Paediatric Chest Physician, Royal Brompton Hospital. Santa Robertson: holds a BA in Education Studies. PRODUCERS: Sabiha Tariq, Rabeeta Khan and Hania Mubarik

This week, please join author Michelle O'Donoghue and Associate Editor Parag Joshi as they discuss the article "Long-Term Evolocumab in Patients With Established Atherosclerotic Cardiovascular Disease." Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. We're your co-hosts, Dr. Carolyn Lam, Associate Editor from the National Heart Center and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, Associate Editor and Director of the Poly Heart Center at VCU Health in Richmond, Virginia. Well, Carolyn, very interesting feature this week. Evolocumab, another application for that in patients with established atherosclerotic cardiovascular disease. But before we get to that feature discussion, how about we grab a cup of coffee and discuss some of the other very interesting articles in this issue? Dr. Carolyn Lam: Oh, I'd love that. And I'd like to go first, because Craig, have you heard of hybrid debranching repair? I know, I know. I had that same look, and can I tell you about it? Because I found it so interesting. Dr. Greg Hundley: Absolutely. Dr. Carolyn Lam: Now, the management of complex aortic aneurysmal disease involving the visceral vessels is challenging due to its very high morbidity and mortality. After four decades of experience in open repair, only a few centers worldwide report laudable results. And numerous factors limit total endovascular repair, including the access to devices, experience in deploying them, and several anatomical restrictions. So, hybrid debranching procedures were introduced for those patients who are unfit for the open or endovascular excluded patients. And while these have been developed, small series have only been done and revealed a wide range of short term results. So, today's paper is very important, and it's from Dr. Oderich from UT Memorial Herman Texas Medical Center and colleagues. It's a large multi-institutional study, which contains the five year outcomes in 200 patients offering greater clarity in the usefulness and limitations of these hybrid debranching repair procedures. What they found was that hybrid aortic debranching had a low early mortality when done in lower risk patients, but mortality remained very elevated in high risk patients. And so, this suggests that deep branching could be a good alternative in patients adequate for traditional open repair, although pulmonary complications are quite common. The bypass grafts to the visceral vessels had very good patency with a five year primary patency of 90%. Permanent spinal cord injury occurred in 6%, suggesting that deep branching in experienced centers may offer outcomes comparable to centers of excellence for open thoracoabdominal aortic aneurysm repair. Dr. Greg Hundley: Wow, Carolyn, very nice and so beautifully explained. Dr. Carolyn Lam: You know what, Greg? I'm on a roll and I'd like to tell you about one more, this time a preclinical study. First, a little bit about the background. You see, transplantation with pleuripotent stem cell derived cardiomyocytes, as we know, represents a very promising therapeutic strategy for cardiac regeneration. We even have first clinical studies in humans, but yet little is known about the mechanism of action underlying graft induced benefits. So in this paper from Dr. Weinberger from University Medical Center Hamburg in Germany and colleagues, they explored whether transplanted cardiomyocytes actually actively contribute to heart function by injecting these cardiomyocytes with an optogenetic off on switch in a Guinea pig cardiac injury model. Dr. Greg Hundley: Wow, Carolyn, this is so interesting. So what did they find? Dr. Carolyn Lam: So, light induced inhibition of endo-grafted cardiomyocyte contractility resulted in a rapid decrease in left ventricular function in about 50% of the animals that was fully reversible with the offset of photo stimulation. So in conclusion, this optogenetic approach demonstrated that transplanted cardiomyocytes can actively participate in heart function, supporting the hypothesis that the delivery of new force generating myocardium can serve as a regenerative therapeutic strategy. Dr. Greg Hundley: Oh wow, Carolyn. That was just fascinating. Such incredible preclinical science in our journal. Well, Carolyn, this next paper comes to us from the world of myocarditis. And Carolyn, it involves a population based cohort of 336 consecutively recruited patients with acute myocarditis enrolled in both London and Maastricht. And the authors, led by Dr. Sanjay Prasad from Royal Brompton Hospital, investigated the frequency and clinical consequences of dilated cardiomyopathy and arrhythmogenic cardiomyopathy genetic variants in this population based cohorts of patients with acute myocarditis. Now, Carolyn, all participants underwent targeted DNA sequencing for well characterized cardiomyopathy associated genes and their comparison to healthy controls, of which they had 1,053 that were sequenced on the same platform. Case ascertainment of their outcomes in England was assessed against their national hospital admission data, and the primary outcome was all cause mortality. Dr. Carolyn Lam: So what did they find, Greg? Dr. Greg Hundley: Right, Carolyn. So these authors identified for dilated cardiomyopathy or arrhythmogenic cardiomyopathy associated genetic variants in 8% of patients with acute myocarditis. This was dominated by the identification of desmoplakin truncating variants in those with normal LVF, and then titin truncating variants in those with a reduced LVF. So Carolyn, importantly, these variants have clinical implications for treatment, risk stratification, and family screening. Genetic counseling and testing would be considered in patients with acute myocarditis to help reassure the majority of individuals that don't have one of these genes, while improving the management of those that do have one of the underlying genetic variants. Very interesting findings from the world of myocarditis. Dr. Carolyn Lam: Great. And a great clinical take home message. Thank you, Greg. Well, this next paper sought to investigate the influence of age on the diagnostic performance of cardiac troponins in patients presenting with suspected myocardial infarction. Dr. Atul Anand from the BHF Center for Cardiovascular Science and University of Edinburgh and colleagues did this by performing a secondary analysis of the high stakes stepped wedge cluster randomized control trial that evaluated the implementation of a high sensitivity cardiac troponin ISA in consecutive patients presenting with suspected acute coronary syndrome. Dr. Greg Hundley: Oh wow. Carolyn. Super interesting, and very applicable clinically. So what did they find here? Dr. Carolyn Lam: In older patients presenting with suspected MI, the majority of cardiac troponin elevations are explained by acute or chronic myocardial injury or type two MI. The specificity and positive predictive value of high sensitivity cardiac troponin to identify myocardial infarction decreases with age and is observed, whether applying sex specific or age adjusted 99th percentile diagnostic thresholds or a rolling threshold for the triage of patients at high probability of myocardial infarction. Serial troponin testing incorporating an absolute change in troponin concentration increased the discrimination for myocardial infarction in older adults. Dr. Greg Hundley: Oh wow, Carolyn. Such clinically applicable findings in this particular study, particularly when managing our aging population. Well, Carolyn, how about we discuss some of the other articles in this issue. And there's a very nice In-depth piece by our own Sami Viskin entitled “Arrhythmogenic Effects of Cardiac Memory.” And then, there's an exchange of letters by Drs. Giannitsis and Mueller regarding the article, “Unexpected Sensitivity Issue of Three High Sensitivity Cardiac Troponin I-Assays in Patients with Severe Cardiac Disease and Chronic Skeletal Muscle Diseases.” Dr. Carolyn Lam: Nice. There's also a Research Letter by Dr. Szendroedi on “Impaired Mitochondrial Respiration in Humans with Prediabetes: A Footprint of Prediabetic Cardiomyopathy.” And there's a CV case series by Dr. Kalra on very high cholesterol mimicking homozygous familial hypercholesterolemia. Interesting case. Well, I suppose that wraps it up. Let's go on to the feature discussion, shall we, Greg? Dr. Greg Hundley: You bet. Evolocumab. Welcome listers to this feature discussion on October 11th, and we're very fortunate today. We have with us Dr. Michelle O'Donoghue from Brigham Women's Hospital and Dr. Parag Joshi from UT Southwestern, the Associate Editor for this paper. Well, Michelle, can you describe for us some of the background information that went into the preparation of your study, and then what was the hypothesis that you wanted to address?   Dr. Michelle O'Donoghue: Sure. Happy to do so, and thank you for having me. So by way of background, the Fourier study, which was previously published in the New England Journal, compared Evolocumab to placebo in 27,000 plus patients with established atherosclerotic cardiovascular disease, and Evolocumab significantly reduced the risk of major adverse cardiovascular events. But, the follow up duration was relatively short. Median follow up was 2.2 years. So this was now an open label extension study to Fourier known as the Fourier OLE study that allowed an additional median follow up time of five years, during which time all patients were now treated with open label Evolocumab. T. He primary hypothesis that we were testing in this extension study was primarily to look at long term safety. We had limited data to really assure us of the safety of PCSK9 inhibitors over the course of several years. And so, safety was the primary hypothesis that we were testing, but also of course of key interest, during the parent Fourier study, we know that the benefit for cardiovascular risk reduction appeared to grow over time. So this was also an opportunity to see that pattern and to see whether or not there was in fact legacy effect for patients who were treated earlier with Evolocumab versus placebo. Dr. Greg Hundley: Very nice, Michelle. And so, sounds like we have a substudy of the Fourier trial. Can you describe for us a little bit more, for this substudy, your study population and your study design? Dr. Michelle O'Donoghue: Sure. So the patients enrolled in the open label extension were a subset of those who participated in the parent study. So as I previously mentioned, more than 27,000 participated in Fourier. It was a global study. For the open label extension, it was more than 6,500 patients who participated, and those were patients who were at sites in Europe and United States. And so, those patients were then followed on average for a meeting of five years. So that means that all together, patients who had been randomized to Evolocumab in the parent study had potentially more than eight years of drug exposure for us to examine safety. Dr. Greg Hundley: Very nice. And so, what did you find? Dr. Michelle O'Donoghue: Well, first, looking at the first hypothesis of safety, we saw no evidence that there was any increased risk of any adverse events of interest when it comes to PCSK9 inhibitors as a drug class, or achieving very low levels of LDL cholesterol. So there was no uptick in terms of neurocognitive events, the risk of diabetes. We do know that there was an increased risk of injection site reactions with the PCSK9 inhibitors, but not one that appeared to persist over time. So first was the safety, but importantly, I think that the more interesting results perhaps were those for MACE, for cardiovascular risk reduction. So we saw, even though all patients were being treated with open label Evolocumab during the extension phase, the benefit that was seen during the parent study persisted. So there was a 15% reduction in the primary outcome, a broad composite of cardiovascular events. There was also a 20% reduction in the triple composite of cardiovascular death, MI, or stroke. And then perhaps of the most interest to your listeners is that there was a 23% reduction in cardiovascular mortality, and that was not something that was seen in the parent study. It really took time for that mortality benefit to emerge. Dr. Greg Hundley: Very nice. Michelle. Just a couple quick clarification points. Did you see these effects in both men and women? And then was there any impact of age on those results? Dr. Michelle O'Donoghue: Great questions. Some of those subgroup analyses are still ongoing, but no, we did not see any evidence of effect modification at first pass. But again, we'll be continuing to dig into all potential subgroups. Dr. Greg Hundley: Very nice. Parag, I know you have many papers come across your desk. What attracted you to this particular manuscript? Dr. Parag Joshi: Yeah, thanks. And congratulations again, Michelle. It's a really phenomenal study, and the findings, as you highlighted, are just really impactful for the field. I think for our journal at circulation, this is a really high impact finding in terms of extending out, giving us a rigorous way to look at long term follow up for people on PCSK9 inhibitors and really reassure that there is safety there. And as you highlighted, a sustained reduction in LDL cholesterol, other compounds in the space, Bococizumab in particular, that there were induced antibodies against the monoclonal antibody, and that sustained response was not there. So I thought that was also really reassuring, that over the course of eight years, we see sustained LDL reduction. And with that, really reaffirming the idea that the longer you can reduce LDL, there's an associated reduction in events. And as you highlighted, the initial Fourier, there was some question about why there wasn't a CV death mortality signal while there was in the Odyssey outcome study and slightly different patient populations of course, but just really needed more time to start to tease that out. So all of this, I think this is the first that we're seeing this kind of long-term data on this impactful class of medications that really made this a fantastic manuscript for us at Circulation. Dr. Greg Hundley: Wow. Boy, Parag, I don't know that you could have stated that any better. So Michelle, looking forward, what is your group thinking? And then maybe just as your comment on the field in general, what do you think is the next study or series of studies that needs to be performed in this sphere of research? Dr. Michelle O'Donoghue: Well, I think he started to touch upon the areas of interest to us, is that I think that there are still many opportunities to answer more questions even within this existing data set. In particular, there was a dedicated neurocognitive substudy that was built into the parent study. And we also have that now through the extension period. So, that was a sort of more rigorous assessment of neurocognitive outcomes. And so, that's another analysis that we're going to be pursuing in the near future and I think is of potential key interest. And then beyond that, I think that the PCSK9 inhibitor class in general is just so interesting. There are additional compounds that are under study, such as small interfering RNA, so different mechanisms of getting to the PCSK9 protein. And I think it'll be reassuring to see whether or not they are consistent results, regardless of how you lower PCSK9, whether it translates into similar types of clinical benefit. So I think it's an exciting field. And then stay tuned. I think there'll be more to come. Dr. Greg Hundley: Parag, do you have anything to add? What do you see really as the next series of studies that might be performed here in this area of research? Dr. Parag Joshi: Yeah, I think Michelle hit the nail on the head that seeing confirmatory evidence here would be great. And then really, what's so exciting about this space is there's so much interest in ways to address this protein, including gene editing, vaccination against it. And now you're getting the necessary evidence that, hey, you can really suppress these levels in patients for years without concerning safety signals, at least from what we've seen so far. So that's more excitement as to long term ways to address cardiovascular risk. Dr. Greg Hundley: Wow. Well, listeners, we've been very fortunate today to have with us Dr. Michelle O'Donaghue from Brigham and Women's Hospital, and Dr. Parag Joshi from UT Southwestern as the Associate Editor of Circulation to really bring us these exciting results, highlighting that long term LDL-C lowering with Evolocumab was associated with persistently low rates of adverse events over eight years that did not exceed those observed in the original placebo arm during the parent Fourier study, and led to further reductions in cardiovascular events compared with delayed treatment initiation. Well, on behalf of Carolyn and myself, we want to wish you a great week and we will catch you next week on the run. Dr. Greg Hundley: This program is copyright of the American Heart Association 2022. The opinions expressed by speakers in this podcast are their own and not necessarily those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

In today's #AskAboutAsthma podcast, Dr Louise Fleming from the Royal Brompton Hospital and Imperial College provides a helpful overview around an anti-inflammatory reliever approach, with practical considerations around Maintenance and Reliever Treatment(MART)to relieve asthma symptoms in children and young people. For more #AskAboutAsthma content, visit: www.healthylondon.org/ask-about-asthma

Development of The Greenest Inhaler podcast was supported and reviewed by Trudell Medical International. This EMJ podcast explores the carbon footprint of different inhaler devices and features the expert insight of guest speakers Omar S. Usmani, Professor of Respiratory Medicine, Imperial College London, UK, and Consultant Physician, Royal Brompton Hospital and St Mary's Hospital, London, UK; and John N. Pritchard, Private Consultant and Member of United Nations (UN) Committee on Propellant Medical Usage.

David Duncker (Host), Hannover Heart Rhythm Center, Hannover - Germany and Katarzyna Malaczynska-Rajpold (Guest), Royal Brompton Hospital, London - United Kingdom - UK. This podcast tackles tips and tricks to complete your EP fellowship

My guest this week is Heather McClelland, a singer, songwriter, musician and music educator based in Sussex UK, and a mum of 1.Heather grew up in a very musical family. Her family were a travelling band with West African and Irish influences and Heather's first gig was the at an Irish Busking Festival at the age of 6. She has been writing songs since the age of 13. In her high school years, Heather sang backing vocals for her mother's performances and was playing in bands.During her university years Heather and her band toured Ireland supporting Mad Dog Mcrea . After finishing school Heather went to Brazil for three years, studying music and performing with some of Brazil's leading musicians. This trip cemented her decision to pursue her music as a full time career.On returning to the UK in her mid-twenties, she continued to perform Brazilian-influenced music (appearing at Festinho, The Royal Festival Hall and Favela Chic) as well as collaborating with other artists including champion beatboxer Bellatrix, Wah Wah 45's Stac, and Ninja Tune's Submotion Orchestra.As a soloist, Heather's debut EP China Mind was released in 2020 just before the pandemic hit. It occupies the space between folk and electronica, singer-songwriter and neo-classical. Her songs are ethereal and haunting, featuring her uniquely pure-toned voice and her evocative harmoniesHeather's vocal group The Sugar Sisters is a 40s inspired trio, specialising in close 3 part harmonies. While busking, the trio were spotted by the producer of Irish radio presenter Sir Terry Wogan and that lead to some amazing opportunities, including performing on BBC Radio 2 and at Royal Albert Hall.Heather has many years experience in music education. She currently works at the Royal Brompton Hospital as lead Artist on the Vocal Beats programme, which she helped to create and develop. The project works with paediatric heart and lung patients from birth to 25 years, offering a diverse range of music, including lullaby singing, beatboxing classes and singing for breathing sessions. Heather also works as a musician in residence at Great Ormond Street Hospital for children.**This episode contains discussion around the loss of a parent and grief.**Heather - Website / youtube / spotify / The Sugar Sisters / VocalBeatsOnlineRead about Royal Brompton Hospital VocalBeats projectVocal Beats Nursery RhymesGeorgia Fields' Find The MotherLodePodcast - websiteHeather's music used throughout with permission.

‘Quality Sleep, Sound Mind, Happy World' is the campaign slogan for this year's World Sleep Day on March 18th 2022. And not without good reason as sleep and mental health are intrinsically linked. Lack of sleep is related to many psychological conditions such as depression, anxiety, ptsd and psychosis. And those suffering with mental health problems are likely to have insomnia, suffer from sleep disturbances, or other sleep disorders. It's a vicious cycle that can be difficult and frustrating to break.  My Possible Self welcomes renowned sleep specialist Dr Allie Hare who breaks down and explains why sleep is so important to us; physically, mentally, and emotionally. Dr Allie, a consultant in sleep and respiratory medicine at the Royal Brompton Hospital in London and Secretary of the British Sleep Society, also shares what happens to our brain when we dream, why naps are best avoided, the daytime habits to avoid sabotaging your sleep and what we can send signals to our body that it's slumber time. 

I speak to Dr Alexander Lyon, consultant cardiologist at the Royal Brompton Hospital about the effects of COVID on the NHS, the effects of long COVID on adults who have suffered with ongoing chest pains and heart palpitations as well as some great tips on how to keep your heart healthy. "I'm a great believer in vaccination. It's one of the great successes of the NHS." Dr Alexander Lyon

Is chest pain a side effect of the vaccine? In this short episode, I discuss post vaccine care with consultant cardiologist Dr Alexander Lyon, Royal Brompton Hospital, as well as the importance of the vaccine and booster. 

We all feel better when we've had a good nights sleep, right? However, many people are finding it harder than ever to sleep, especially due to stress and anxiety which has been heightened due to the pandemic. The number of people suffering from sleep loss due to stress has risen from one in six to one in four, how is this sleep loss impacting physical and mental health?Joining us today to delve into the subject are Alanna Hare, Consultant in Sleep and Ventilation, Royal Brompton Hospitals Trust and Dr Neil Stanley, Director of Sleep Science at Sleepstation.org.uk. They'll explain the role sleep plays in our overall health, the impact of the pandemic and the latest developments in our understanding of how to improve sleep.About our panelAlanna Hare, Consultant in Sleep and Ventilation, Royal Brompton Hospitals TrustDr Alanna Hare is a consultant in sleep and ventilation at Royal Brompton Hospital with responsibility for specialist clinics in sleep disorders and domiciliary ventilationDr Neil Stanley, Director of Sleep Science at Sleepstation.org.ukDr Neil Stanley is Director of Sleep Science at Sleepstation.org.uk. He has been involved in sleep research for 39 years starting his career at the Neurosciences Division of the R.A.F. Institute of Aviation Medicine.In the early 1990s, he moved to the Human Psychopharmacology Research Unit, part of the University of Surrey, where as Director of Sleep Research he created and ran a 24-bed sleep laboratory for clinical trials. He is past Chairman of the British Sleep Society (2000-2004) and a member of the European Sleep Research Society; the American Academy of Sleep.He has published 38 peer-review papers on various aspects of sleep research and psychopharmacology and is widely quoted by the media as a sleep expert.

Infant Feeding - With Stacey Zimmels As you move through pregnancy and into motherhood one of the main things you may be considering is how to feed your baby. Breast, Bottle, Expressing and Mixed Feeding are amongst some of the many terms and choices we hear of when we start to navigate our choices. From the benefits, equipment to purchase, tounge ties and feeding positions it can feel like a mind field. On this week's episode I am very excited to be joined by the perfect expert to help you navigate these choices and crucially to share some of her expert tips and tricks to a successful feeding journey. Stacey Zimmels is a feeding and swallowing specialist speech therapist (SLT) and International Board Certified Lactation Consultant (IBCLC).  Stacey has worked for almost 20 years supporting infants and  children with a wide range of feeding and swallowing difficulties. Her breadth of knowledge and experience  runs across the spectrum; including but not exclusive to, preterm infants, breast and bottle feeding,  weaning difficulties, managing allergies and reflux, swallowing difficulties and fussy eating. Stacey runs a private practice and continues to hold an honorary contract at the Royal Brompton Hospital where she continues to work on clinical research and provides as a locum services. Stacey has published abstracts and articles in her field of interest and has presented at conferences. In addition to her work supporting children and families she is passionate about training others in her field, she provides clinical supervision services for a number of other feeding specialist SLT's within the NHS. She has also consulted on NHS service management and development for feeding and swallowing services. Check out Stacey's Social Media Links below: www.feedeatspeak.co.uk Instagram https://www.instagram.com/feedeatspeak/ On Stacey's Instagram you will find her wonderful video mentioned In our chat. Facebook https://www.facebook.com/feedeatspeak/ Here is the link to the WHO information discussed in our chat too: https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding And some more information on Responsive Feeding: https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/relationship-building-resources/responsive-feeding-infosheet/ If you have found this podcast useful, please don't forget to subscribe and leave a review so it can help reach other expectant parents. For more information on the services and courses I offer (Antenatal Education, Your Pregnancy Journey and to get your hands on my free birth plan... Please visit: www.midwifepip.com Or check me out on my social media pages @midwife_pip Enjoy Listening Midwife Pip x

Georgina Godwin interviews Jehangir Appoo, an incredibly accomplished cardiothoracic surgeon. Among his accolades, are two fellowships, the first from the Royal Brompton Hospital, Imperial College, London and the second from the University of Pennsylvania. He has also held the position of Clinical Associate Professor of Cardiac Surgery at the University of Calgary, helping establish an artificial heart programme and performing Alberta's first artificial heart device implant.   Jehangir discusses his fascinating journey, which began as a well-travelled youngster living in at least 7 countries before the age of 18, finally settling in Canada. Medicine was an unusual choice of career for a young man who hated the sight of blood. After a chance encounter with the Dean of his Medical School, near the Taj Mahal, he offered Jehangir some wise words, ‘once you see the light don't turn your back upon it'. As his plane took off to return home, the decision was made that his future lay in cardiac surgery. Sadly, after a long and illustrious career at the frontline of cardiac surgery, issues with Jehangir's neck, forced him to stop operating. He was determined that his new career would need to have an on-going impact in health care and what followed was two completely different worlds colliding, digital technology and medicine. Jehangir heads up a capital fund called AOIT Health. His aim is to be part of the evolution of how AI is used for medical diagnosis using machine learning technologies. Using his experiences at the front line of health care, his aim is to develop machine learning in an environment that can make a significant change; to the way medicine is practiced. Jehangir is also involved in a non-profit organisation called Creative Destruction Lab, a partnership with scientists coming out of Universities, business schools, venture capital and entrepreneurs with the goal of building businesses. The idea being to take a project from the lab and build it into a big business, which is the whole basis of innovation and venture capitalism. Finally, Jehangir addresses the positive impact that the pandemic has brought by integrating digital technology into health care. Virtual care had never been done before but now it has been accepted as a legitimate form of medical care, the whole space has opened up to remote patient monitoring, COVID has brought 2030 a decade early, accelerating digital technology investment in health care and rethinking how healthcare can work in the future.Full transcript available here:  https://aqfd.docsend.com/view/7wfqnk9sauntku4y Contents:About Jehangir Appoo (00:00)Journey to Cardiothoracic Surgery (03:08)Thoughts on Healthcare Around the World (08:32)Professional Accomplishments (10:58)Career Change – Healthcare Meets Technology (13:26)COVID and Digital Technology (20:07)Jeffersonian Meals (24:33)Thoughts on Exciting Developments in Healthcare (28:24)

This episode is all about breathing – something we know is important, but normally don’t think about. Dr James is a Respiratory Physician & lung doctor at the Royal Brompton Hospital in London and also a specialist sports respiratory clinician at the Institute of Sport, Exercise and Health , at University College London. James is a Doctor Doctor! A medical doctor who went back to University for a PhD in vascular aspects of exercise physiology. His main job now is evaluating ‘unexplained’ exertional breathlessness but also trying to work out why athletes get coughs and wheeze during sport. He promotes awareness of a condition called exercise induced laryngeal obstruction (EILO) which is very common (5% of all adolescence / young athletes) and yet completely misdiagnosed as asthma. In elite sport James is a specialist advisor to the English Institute of Sport – working to optimise the respiratory health of Team GB athletes; trying and reduce risk of infections and asthma problems as well as on a panel of experts advising the International Olympic Committee on respiratory health in athletes and COVID.Dr James Hull BSc MBBS PhD FRCP FHEA FACSM Twitter: @Breathe_to_win Web: www.breathetowin.co.uk

@halpernstudio Think Halpern, think Studio 54 megawatt luxury glamour and sublimely crafted fabrics. Empowering joyful garments that celebrate womanhood. Jodie Comer, Amal Clooney, Anya Taylor-Joy have worn his show-stopping creations on set and off. Michael tells us his personal story from growing up in the USA, attending college in NYC before Central St Martins MA programme and the importance of a team as he responds to the children's fashion questions. Michael also gives some caring and frank advice to any child who wants to go forward into fashion. Michael Halpern has also recently won a Community Award at The Fashion Awards 2020, in response to his contribution to the production of PPE for the Royal Brompton Hospital. @thefashionschooluk

You’re breathing, I’m breathing. But neither of us is probably thinking about our breathing right now. Do you ever think about your breathing during your workouts or races? Do you ever wonder if you should be "training" the act of breathing as a skill? Or whether you should do something differently during rest and recovery, or between intervals, or even on long endurance rides?   In some ways, breathing is a much-discussed topic—often, however, that’s in the context of meditation or in the practice of yoga or other such disciplines. Breathing for performance, in the context of training and racing, however, is not something that gets a whole lot of attention. And that’s the focus of today’s episode.  While Trevor was sitting in Toronto and I was in Boulder, we caught up with a leading expert on the science of breathing, Dr. James Hull, who joined us from London.  Dr. Hull ‘s experience is vast and varied, and all of it focuses on breathing. He is a respiratory physician at Royal Brompton Hospital in London and the clinical lead looking at unexplained breathlessness during exertion. He also works at the Institute of Sports, Exercise, and Health at University College London. He also works with elite athletes, both as part of the English Institute of Sport working with British Olympic athletes, and as a contributor to the International Olympic Committee’s respiratory guidance committee.  Dr. Hull takes us through the science of respiration, from the state of the system—is it overbuilt or underbuilt?—to pathological concerns for athletes. Think you have asthma? There’s a good chance that’s a misdiagnosis. Finally, we discuss the things you can do to improve performance through breathing.  Not to be forgotten, also on today’s episode, we talk with several guests about the meditative side of breathing, as well as the practice of breathing. We hear from coach Colby Pearce—catch him on his own podcast, “Cycling in Alignment” if you haven’t already. We catch up with Erica Clevenger, a member of the Tibco-Silcon Valley Bank women’s pro team, and someone who suffers from asthma. And we also hear from two elite coaches: Julie Young and Neal Henderson.  Inhale, exhale. Let's make you fast!  Learn more about your ad choices. Visit megaphone.fm/adchoices

Tertiary referrals and asthma systems: Dr Louise Fleming, honorary consultant in paediatric respiratory medicine at Royal Brompton Hospital. Louise Fleming discusses the work of tertiary centres, including the teams involving in diagnosing and caring for children with difficult to treat asthma, how they fit with local asthma networks and the benefits of these networks, alongside the challenges associated with Covid-19.

Planning & Production Credits: Victoria Twigg (Lead), Sarah Siddiqui & Jane Gardner-Florence The COVID-19 pandemic has seen the NHS embrace the use of tele-medicine as a way to continue to provide high-quality patient care whilst maintaining social distancing. As we enter the recovery phase it is likely to continue to be used as the key modality for conducting outpatient work. In addition to the benefits of infection prevention, telemedicine has a host of other advantages for patients and the health service but does bring challenges to the clinician and, in particular, to supervision and the trainee-trainer relationship. In this Pandemic Podcast, we are in conversation with clinicians and trainers Jo Szram and Indranil Chakravorty discussing the key issues and trainee Vicky Twigg, reflecting on the benefits of telemedicine, how to conduct teleclinics and common pitfalls and best practice in using teleclinics as a training modality. Bios: Oluseyi Adesalu is a differential attainment fellow in the London & KSS Professional Support Unit. Having completed the academic foundation programme, she will be commencing specialty training in clinical radiology in September. Victoria Twigg is a higher surgical trainee in ENT in North London undertaking a fellowship at HEE looking at early-years surgical education across the region. She has an interest in leadership and management across the healthcare sector, with a focus on workforce policy. Jo Szram is a consultant respiratory physician at the Royal Brompton Hospital, a deputy postgraduate dean in London, chair of NACT UK and sits on the Councils of the Royal College of Physicians and the RSM Patient Safety Section Council. Indranil Chakravorty is director of medical education and a consultant acute physician at St George's Hospital in South London. He has run projects in South London on telehealth monitoring of patients with chronic disease. He is an ex-deputy dean for Health Education England and has a passion for technology enhanced learning. Andrew Viggars is an ST4 specialty registrar in clinical oncology working in the Yorkshire and Humber deanery. He has recently taken up post as a clinical leadership fellow in acute oncology. Nadeev Wijesuriya is a cardiology trainee working in the North West London deanery, sub-specialising in electrophysiology and devices. His academic interests are in the interventional treatment of atrial fibrillation.

Planning & Production Credits: Jo Szram (Lead), Sarah Siddiqui, Peter Brennan, Jane Gardner-Florence Human factors understanding focuses on optimising human performance through better understanding the behaviour of individuals, their interactions, with each other and with their environment. In health care, it underpins patient safety, offering an integrated approach to quality improvement and clinical excellence. In this episode, we are in conversation with HEE deputy dean and physician Jo Szram, surgeon Peter Brennan, BA pilot Graham Shaw and Obs & Gynae trainee Ruth-Anna Macqueen to explore what human factors are, their importance in the health care setting and how knowledge of human factors can help both trainees and supervisors. If you would like to give us some feedback our Episode 5 (Part 1) of our Pandemic Podcast you can find a feedback form on our website here. Bios: Jo Szram is a consultant respiratory physician at the Royal Brompton Hospital, a deputy postgraduate dean in London, chair of NACT UK and sits on the Councils of the Royal College of Physicians and the RSM Patient Safety Section Council. Peter Brennan is a consultant oral and maxillofacial surgeon and honorary professor of surgery with a PhD and 70+ publications on human factors and patient safety. Ruth-Anna MacQueen is a Senior Registrar in Obstetrics and Gynaecology, having worked for Healthcare Safety Investigation Branch and is currently undertaking an MSc in Patient Safety and Clinical Human Factors. Graham Shaw is founder and director of Critical Factors and a 777 Captain for British Airways.

In the early stages of the pandemic, the medical workforce across trusts in London underwent many strategic changes, with trainees being deployed to different sites and disciplines causing disruption to normal working patterns and training pathways. In this episode we are in conversation with the Director of Medical Education across different London trusts and the chair-elect of the NACT (National Association of Clinical Tutors) Council to explore the different strategies and approaches used, the role of the medical education departments and the challenges faces by trainees and supervisors and how they were overcome. If you would like to give us some feedback our Episode 2 of our Pandemic Podcast you can find a feedback form on our website. Bios: Dr Jo Szram is a consultant respiratory physician at the Royal Brompton Hospital, chair-elect of the NACT council and a deputy dean in London. Dr Dan Bailey is a consultant in geriatric and general medicine at King's College Hospital, associate director of medical education, champion for Supported Return to Training and training programme director IMT in South West London. Dr Louise Schofield is a consultant in palliative care and director of medical education at Barnet Hospital. Dr Karwai Tsang is the Chief Registrar at Kings College Hospital and ST7 in Acute Medicine.

Hello Sarc Fighters.   In this bonus podcast, we listen to the Sarcoidosis Associated Pulmonary Hypertension (SAPH) Guidelines Roundtable held on Monday, September 30, 2019, alongside the 2019 ERS Congress in Madrid, Spain. Bayer is the original sponsor of the scientific and educational activities held during the event in Madrid. It is presented in conjunction with the Foundation for Sarcoidosis Research and WASOG - the World Association for Sarcoidosis and Other Granulomatous Disorders.Unlike most of the Sarc Fighter podcasts, this one is primarily for physicians. In particular, those working with patients who suffer severe cases of sarcoidosis in the lungs and how to determine if these advanced cases are driven by Sarcoidosis Associated Pulmonary Hypertension.Panel members include:Robert Baughman, Internist at University of Cincinnati with specialties in Pulmonary Diseases, Lung Disease, Interstitial Lung Disease https://www.wasog.org/committee/BaughmanProfessor Athol Wells, Consultant and chest physician based at Royal Brompton Hospital https://www.rbht.nhs.uk/specialists/professor-athol-wellsProfessor Marc Humbert, Head of the Pulmonology and Intensive Respiratory Care Department at University of ParisSteven D. Nathan, Director of the Advanced Lung Disease Program and director of the Lung Transplant Program at Inova Fairfax Hospital https://www.inova.org/doctors/steven-d-nathan-md

Evidence is building about the impact of air pollution on health, but the relationship between the cocktail of chemicals, gases and particles in the air we breathe and the direct effect on an individual's health is a tricky one to prove. Dr Farrah Jarral cycles to Kings College London to hear about a new study by researcher in respiratory toxicology, Dr Ian Mudway, which revealed, to the surprise of Ian and his colleagues, that particles from brake dust had the same damaging impact on our lung immune system as that familiar culprit, diesel exhaust. It's a result that demonstrates that the toxic risk to our health doesn't just come out of the exhaust pipe and suggests the concept of a zero emissions vehicle might need further work. COPD or Chronic Obstructive Pulmonary Disease is an umbrella term for a range of respiratory conditions that used to be known by names like emphysema or chronic bronchitis. COPD flare ups or exacerbations are the second largest cause of emergency hospital admissions in the UK. Dr Jennifer Quint, consultant physician in respiratory medicine at the Royal Brompton Hospital tells Dr Farrah Jarral about a world-first study where the individual air pollution exposure of COPD patients was tracked in real time to find out how toxic air can make their condition worse. What's it like for healthcare professionals working on the front line of infectious disease outbreaks? Dr Michael Kiuber, a consultant in emergency medicine at University Hospital Southampton NHS Foundation Trust, volunteered to treat patients with the deadly infection, Ebola, in Sierra Leone and he describes the challenges to Farrah of caring for very sick adults and children while taking every safety step to avoid contracting the Ebola virus himself. And Inside Health regular contributor, Dr Margaret McCartney outlines the challenges for the NHS in planning how to protect staff as the UK grapples with the global outbreak of Covid-19. There's a growing trade in female cosmetic genital surgery including hymenoplasty, which claims to the restore the hymen to its virginal state. Scores of private clinics in the UK are offering the procedure with advertising claims like "Get your virginity back!" and "Restore your innocence within one hour!". Dr Leila Frodsham, consultant gynaecologist, specialist in psychosexual medicine and spokesperson for the Royal College of Obstetricians and Gynaecologists discusses the ethics of the procedure. Producer: Fiona Hill

in this episode Dr. Paul Wheatley-Price interviews Dr. Eric Lim, Professor of Thoracic Surgery at Royal Brompton Hospital. Visit Dr. Lim's website at: https://www.drericlim.com

In this series, we invite extraordinary people living with a rare condition and industry experts to talk about their experience and hopes for the future. In our second episode of Raremark Voices, we talk with British Lung Foundation Chair in Respiratory Research & NIH Research Clinician Scientist Toby Maher, and patient advocate and founder of the advocacy group PF Warriors, Bill Vick. Our guests: Toby Maher Professor Toby Maher qualified at Southampton Medical School and trained in respiratory medicine at the Royal Brompton Hospital, the Transplant Unit at Harefield Hospital and at St Mary’s Hospital, Paddington. During his training, he gained an MSc in respiratory medicine from Imperial College London. In 2005, Professor Maher was awarded a Wellcome Trust Clinical Research Fellowship, enabling him to study the molecular mechanisms involved in the development of idiopathic pulmonary fibrosis. Professor Maher is a consultant respiratory physician and continues to see patients every week. He is also an honorary senior lecturer at the National Heart and Lung Institute, Imperial College London, and honorary senior research associate at University College London, as well as the British Lung Foundation Chair in Respiratory Research and Professor of Interstitial Lung Disease at Imperial College London. Bill Vick Bill was training for a triathlon at the age of 72 when he was diagnosed with IPF. His doctor told him he had two years to live. Now at the age of 81, Bill has more than beaten the odds and taken on the mission of helping others to do the Bill is the founder of PF Warriors, a volunteer group of pulmonary fibrosis (PF) patients, families and medical professionals helping each other in living with PF. PF Warriors has now grown to be the world's largest community of people dealing with PF. Bill's aim is to first raise awareness in both the medical community and the general population; and secondly, to inspire other patients to live and live a full life with PF.

Today on the podcast I am speaking to Dr Zarrin Shaikh, a Consultant Cardiologist who specialised in Cardiac Imaging, specifically advanced echocardiography and cardiac MRI, following her PhDin Sleep at Imperial College London and the Royal Brompton Hospital.We’ll be talking about her exciting new project called Fresh Heart Project, which stands for food, relaxation, exercise, sleep and happiness and how these lifestyle features can help us overcome blood pressure issues, atherosclerosis and look after our hearts.We’ll be talking about her personal experience of lifestyle medicine, the cardiologists from America who inspired her journey and a particular focus on Atrial fibrillation something that I personally suffered with and why we may be seeing more of it in clinic.Some of the points that we talked about that I think are really important to consider are below - and don't forget to check out the show notes here too for the papers that Dr Zarrin discusses:Looking at the news in the morning and being aware of what impact that has on your stress levelsThe connection between happiness and cardiovascular diseaseI'll link to the studies that Dr Zarrin mentioned in the notes belowThe nutrition principles that Dr Zarrin stands by - whole grains, quality fats, largely whole and lots of plant based foodsHow lifestyle is an adjunct to therapy - something that we use alongside the current tools that we haveYou’ll find the recipe video that I cooked for Dr Zarrin - Pear and Chocolate Overnight Oats with Fresh Berries - on the show on my youtube channel so you can see how delicious and easy it was to make .. even whilst recording a podcast!And you can find all of this information and more at www.thedoctorskitchen.comMy social media links are:Website: www.lifestylecardiology.comTwitter: @freshheartdocInstagram: @freshheartdocLinkedIn: Zarrin Shaikh See acast.com/privacy for privacy and opt-out information.

How can we effectively manage the symptoms of asthma? We speak to Professor Andrew Menzies-Gow, consultant respiratory physician at the Royal Brompton Hospital to find out. We also hear from Dr Alistair Duff, consultant clinical psychologist at Leeds Teaching Hospital NHS Trust, who explains his role in helping patients manage their asthma-related anxiety. For more information check out our guideline: https://www.nice.org.uk/guidance/ng80

Dr Louise Fleming, clinical senior lecturer at Imperial College London and consultant respiratory paediatrician at the Royal Brompton Hospital, discusses the management of asthma in children aged 6-18.

Dr Carolyn Lam:                                Welcome to Circulation on the run, your weekly podcast summary and back stage pass to the journal and its editors, and welcome to a whole new podcast format in 2019. Ha-ha, I bet that surprised you. Well guess what? This new format promises more interaction, more discussion and a whole lot more fun, and that's because to begin with, you don't have to listen to me talk to myself half the time anymore. I'm Dr Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore, and I am simply delighted that Santa gave me a partner on this podcast, and co-hosted with me, and my gift is none other than Dr Greg Hundley, associate editor from the Pauley Heart Center, at Virginia Commonwealth University Health Sciences. Welcome Greg. Dr Gregory Hundley:                       Thank you so much Carolyn. How exciting is it to start this new year with this exciting format, where we'll take several of the key manuscripts from Circulation and discuss them? Picking five each time, and as you've alluded to, we're not going to get rid of that favorite format, where we take a select paper and interview and work with the authors. Dr Carolyn Lam:                                Exactly. In fact, maybe I could liken it to welcoming everyone to join us over a cup of coffee, each week, with the journal in the hand and we're just going to discuss it, and never forgetting that feature paper with the authors, and this week's paper is huge. I love it. We're actually going to be talking about blood pressure control in the barber shop. But before then, here's the articles that we've chosen to discuss. So Greg, you got your coffee ready? Shall we start? Dr Gregory Hundley:                       Absolutely Carolyn, and let's get going first with Gorav Ailwadi, from University of Virginia, his paper evaluating the utility of MitraClips in those with secondary mitral regurgitation. This is really a follow-up from the EVEREST study. It's not a randomized trial, but it's a longitudinal look over time, at 616 patients. Interestingly, those individuals that had class three or four heart failure, that had the MitraClip, the left ventricular volumes got smaller in a year, the hazard ratio for events became less. The magnitude of mitral regurgitation went from 4+ down to 2+. Exciting findings. Dr Carolyn Lam:                                Interesting, but you know Greg, these all sound so positive. Why is it so different in the Mitra FR study?   Dr Gregory Hundley:                       Absolutely Carolyn. So, as you know, Mitra FR, that was a randomized trial. So, this study doesn't compare, the EVEREST study in this issue, doesn't compare with conventional medical therapy, that's number one, and Mitra FR did. Also, the Mitra FR patients were a little bit sicker. The ejection fraction really was 15 to 40 percent, and in the EVEREST study, much higher, average 45 percent. In fact, many had a normal EF. So it really raises a lot of questions as to whether or not this finding will hold up in future randomized trials, which we'll be looking to see the results. Dr Carolyn Lam:                                Indeed, and it was really nicely discussing the accompanying editorial wasn't it, which I really enjoyed. Well, the paper I picked out Greg is from Dr Gatzoulis from The Royal Brompton Hospital, and it's actually the MAESTRO trial. Now, MAESTRO is a randomized control trial of the endothelin receptor antagonist macitentan in patients with Eisenmenger syndrome. Short and long of it, macitentan did not show superiority over placebo on the primary endpoint of change in baseline to week 16 in exercise capacity. And there was also no relevant trends observed for the secondary endpoints.                                                                 However, among the exploratory endpoints, macitentan did reduce Nt-proBNP in the main cohort, and improved pulmonary vascular resistant index, and exercise capacity, in a hemodynamic sub-study. Importantly also, there were no specific safety concerns with macitentan. Dr Gregory Hundley:                       Sounds really interesting, Carolyn. But how did this compare with prior studies that have really focused on endothelin? Dr Carolyn Lam:                                Great question. So, MAESTRO's only the second randomized control trial of an endothelin receptor antagonist in Eisenmenger Syndrome. BREATHE-5 was the first, and this used a different endothelin receptor antagonist that was bosentan, also in Eisenmenger Syndrome, and actually found that bosentan reduced pulmonary vascular resistance as its primary efficacy endpoint, without worsening systemic pulse of symmetry.                                                                 So, very different trials in terms of endpoints, as you can hear, but also importantly, different populations that were enrolled. MAESTRO enrolled a more heterogeneous population with more complex forms of Eisenmenger, including patients with Down syndrome, had a broader WHO functional class inclusion, and allowed the use of pre-existing therapies such as PDE5 inhibitors.   Dr Gregory Hundley:                       That's really spectacular, Carolyn. Very interesting findings for something that these vasoconstrictors, vasodilators, often very harmful. Switching over, I've got sort of another paper that is also working on vasodilation, but comes really from the world of basic science. And it's from Ingrid Fleming from Goethe University in Frankfurt, Germany, examining how does hydrogen sulfide, a common gas that we have in the environment, it smells terrible, we worry about sulfuric acid and acid rain, but how does this promote vasodilation in the system?                                                                 And so, in this basic science study, they unlocked sort of a key that this hydrogen sulfide is produced by cystathionine gamma-lyase, CSE. And why is that important, and what does it do? Well, production of H2S by CSE goes and inhibits human antigen R, or HuR, that regulates cellular proliferation and growth. And so, basically these authors have unlocked a mechanism by which hydrogen sulfide can be protective.                                                                 So, what's interesting Carolyn is that patients can have elevated levels of L-cysteine, increased expression of CSE, so you've got the components and the manufacturer of H2S, but they still have low arterial levels. Dr Carolyn Lam:                                 Hm. So, how can this be addressed then? How can we raise that H2S? Dr Gregory Hundley:                       That's what's so clever that the investigators found out, Carolyn. They found a slow-release oral active drug, a sulfide donor called sodium polysulthionate, H2R, or sulfhydration, and can inhibit atherosclerosis development or progression when these levels are low. Dr Carolyn Lam:                                Indeed. sodium polysulthionate. Awesome, Greg! That is so cool. Honestly I just loved your explanation of that. Okay. Well, I've got another paper to share. And this is from Dr Bress and colleagues from University of Utah School of Medicine. And this one is really interesting because these authors estimated the number of cardiovascular disease events that could be prevented, and the treatment-related serious adverse events that could occur over ten years, if U.S. adults with hypertension were achieving the 2017 ACC/AHA guideline recommended BP goals, compared to their current blood pressure levels, as well as compared to achieving the older 2003 JNC7 goals, or the older 2014 JNC8 goals.                                                                 Now, basically they found that achieving and maintaining the 2017 guideline blood pressure goals over ten years could prevent three million cardiovascular disease events, a greater number of events prevented compared to prior guidelines, but this could also lead to 3.3 million more treatment-related serious adverse events. Dr Gregory Hundley:                       So, Carolyn, hasn't a main concern of this type of work been that these new guidelines over-extend the reach of our treatment? Dr Carolyn Lam:                                That's a real concern that I've also heard. The lower blood pressure thresholds used to define hypertension in the 2017 guidelines could indeed lead to more diagnoses. However, this paper helped because remember that the recommendation for anti-hypertensive drug treatment in patients with the pre-treatment blood pressure of 130-139 systolic, or 80-89 diastolic, was limited to those at high cardiovascular disease risk. So not everyone, but only those at high cardiovascular disease risk.                                                                 And so, treatment under the 2017 guidelines, by these data, would lead to more health gains, while only extending treatment to 5.4% more adults with hypertension compared to JNC7. So, this paper really modeled these things out with important contemporary U.S. adult populations using a national representative, a sample of U.S. adults, and NHANES, as well as REGARDS, and they also used estimates of benefit from the recent large meta-analysis of 42 blood pressure-lowering trials.                                                                 So, important data that I think are going to be reassuring to a lot of people managing these patients. Well Greg, that really brings us to the end of our little chat. Now, let's move to our future discussion, shall we?                                                                 Could cutting blood pressure in a barber shop be the long-term solution to hypertension in African-American men? Well, the future paper of this first issue in 2019 really talks about it. Greg and I are so delighted to have with us the authors of the paper, Dr Ciantel Blyler, and Dr Florian Rader from Cedars-Sinai Medical Center, as well as our associate editor, Dr Wanpen Vongpatanasin.                                                                 So, Ciantel, can you just perhaps start by telling us what you found. Dr Ciantel Blyler:                               So, what we're talking about today are the 12-month results as a follow-up to our 6-month results that we published earlier this year. So, we took 319 African-American men in Los Angeles County, and randomized them to two groups. One group saw a clinical pharmacist who worked with them to reduce their blood pressure, and the other group just worked with their barber to talk about blood pressure, and encourage usual follow-up.                                                                 And, as we saw at the 6-month mark, blood pressure really improved in the group that was able to work with the clinical pharmacist. So, we saw an almost 29 mm Hg drop in the intervention group, as compared to only 7 mm Hg in the control group. Dr Gregory Hundley:                       Ciantel, Florian, that is really exciting results. What is a collaborative practice arrangement, and how did you affect that in Los Angeles? Dr Ciantel Blyler:                               So, collaborative practice is actually widespread in the United States. California is one particular state that is kind of ahead of the curve with respect to collaborative practice between pharmacists and physicians. But what it essentially allows a pharmacist to do is to prescribe, monitor, and adjust medications underneath a physician's supervision. So, a document is drawn up, medications are selected, and an algorithm so to speak is put together so that a pharmacist can treat a patient independently of a physician needing to be there. Dr Greg Hundley:                             Very nice. And did you find in the pharmacist-led group that these patients were taking a different anti-hypertensive regimen, or were they more compliant? What do you think was the reason for the discrepancy in this magnificent blood pressure drop in this group of hypertensive men? Dr Florian Rader:                              So clearly, there were a lot of differences between the two groups. First of all, we had a protocol with our favorite blood pressure medications that we use clinically here in the hypertension center at Cedars-Sinai. Essentially it is long-acting calcium channel blocker, specifically Amlodipine, longer-acting angiotensin receptor blockers, or ACE inhibitors, and a third line, usually a thiazide diuretic, and also a longer-acting one, not the usual Hydrochlorothiazide, but specifically Indapamide that we used for this research study. Dr Greg Hundley:                             And do you think that there was more compliance in this pharmacist-led group? Dr Florian Rader:                              One would expect that. First of all, I think that seeing the clinical pharmacist, more frequently being reminded of taking the medications, having feedback by actually seeing the blood pressure numbers in the barber shop, I think would help. But then, in addition, we choose these medications not only because they affect it, but also because they're easy to take. They're once-a-day medications with very high continuation rates in larger studies, so they're just easier to take than other medications that are oftentimes prescribed. Dr Greg Hundley:                             It sounds like also, there might have been a trust factor. Because you're seeing the same person over and over in a very nice environment. Was that a factor?   Dr Ciantel Blyler:                               Absolutely. I think there's a different level of trust that's established when you meet somebody on their own turf. So I think the fact that we met men in barber shops where they felt comfortable, where many of them had been going to the same barber for over a decade, it made all the difference in terms of establishing a rapport, and gaining their trust with respect to having them take medications. So, I think that was a huge part of why we saw increased adherence, and really sort of a commitment to the program. Dr Greg Hundley:                             And we certainly recognize how harmful hypertension is in individuals of Black race. How does this group in Los Angeles translate to perhaps other Black men in the United States? Particularly, for example, in the South. Dr Ciantel Blyler:                               I think the program could translate really anywhere. I think what makes it so tailored to African-American men is this notion of going into a barber shop, which is a very important place in the Black community. So, again, sort of going back to what I said earlier, most of these men had been seeing the same barber as frequently as almost every two weeks for over a decade. So, it really helps increase the frequency with which we could interact with the men, and it helped with continued follow-up and adherence to the program.                                                                 With respect to the area of the country again, I think it translates. Dr Carolyn Lam:                                I've got a follow-up question to that, if you don't mind. So, I'm here listening all the way from Singapore, and I'm just so impressed, and frankly just enamored by this study. And wondering what is the barber shop to my local Chinese guy? I'm actually wondering if it's the kafei dian and that stands for coffee shop, and I'm also wondering what about the women? Wanpen, do you have any insights that you want to share? Dr Wanpen Vongpatanasin:         I believe that even Dr Victor had thought about the beauty shops, that is a barber shop study in parallel, and this could very well work very well. Who knows, we could be going to massage parlor, anywhere, that when we feel relaxed and be ourselves, we go out our way, out of our regular activity, and it could really be a neat idea. And for a study, I'm not sure I could do something out of the box. I would say it must have been successful as this approach, and partly it could be because of the additional pharmacists engage likely. So, I think this is a perfect combination. Dr Greg Hundley:                             Wanpen, you had mentioned Ron Victor. Maybe Ciantel, Florian, and Wanpen, you used to work with him. What did Ron mean to this study? Ron Victor unfortunately passed away this past Fall. Dr Florian Rader:                              Ron hired me almost seven years ago now straight out of fellowship. He was personally my mentor. He taught me all the tricks when it comes to the work of the management of hypertension, so personally I owe him a lot. Regarding the study, he's been thinking about this for a long time, this approach to hypertension management. He's tried it in Dallas. It worked partially, but not very well because he didn't have a pharmacist, and he didn't have somebody that made it their goal to lower blood pressure no matter what.                                                                 And in this study, we had somebody like that, the clinical pharmacist. So, Ron Victor has thought about this for a long time, has done a lot of analysis of the Dallas hypertension study, and figured out why it didn't work out in Dallas, and really cooked up a recipe for this trial, and the results speak for themselves. Dr Greg Hundley:                             Wanpen, do you have anything to add about Ron? I think he was your mentor as well. Dr Wanpen Vongpatanasin:         Absolutely. I trained with him actually from the internship until fellowship, and I owe my career to him. And actually, I see this idea stemming from the Dallas heart study when he did the survey, and realized that if you just wait for patients to show up in the clinic, that you're not going to get anywhere, because African Americans have higher blood pressure at a younger age, and are more susceptible for target organ damage. And as we all know, by the time many presented with, they already have end-stage kidney disease or cardiovascular disease by the time first presentation. So, to avoid it, we have to go into much earlier, not wait until they come to the healthcare facility, and I'm glad to see that this idea is really becoming widely successful more than anyone can imagine. Dr Carolyn Lam:                                What a beautiful tribute. What a poignant note. Thank you, all of you, for your great input, and for publishing this amazing paper with us at Circulation!                                                                 Thank you, listeners, for joining us today on Circulation on the Run with Greg Huntley and me. Thank you, and don't forget to tune in again next week.                                                                 This program is copyright American Heart Association 2019.  

Dr Susanna Price trained in both cardiology and intensive care medicine in the UK, and completed a fellowship at the Thorax center with Jos Roelandt. She was awarded a PhD from Imperial College London, and following completion of her training was awarded the two-year BHF Jill Dando GUCH Fellowship in order to train further in critical care and imaging in congenital heart disease. She is a consultant at the Royal Brompton Hospital where she is Clinical Lead for Critical Care, Honorary Senior Lecturer at National Heart & Lung Institute, Imperial College London. Dr Price is President-elect of the European Society of Cardiology (ESC) Acute Cardiovascular Care Association, and sits on numerous committees including the ESC Education Committee, ESC Press & Media Committee, ALS subcommittee of the RCUK and SCCM US guideline committee. She is an Associate Editor of the European Heart Journal of Acute Cardiovascular Care, and an invited reviewer for a number of other journals. She has been a member of a number of Task Forces relating to international guidelines including VA-ECMO, acute cardiovascular care, the management of cardiovascular diseases including valvular disease, endocarditis, non-cardiac surgery, pulmonary hypertension, pericardial disease, cardiovascular disease in pregnancy and grown-up congenital heart disease. Dr Price has authored numerous papers and book chapters on cardiology, echocardiography and intensive care, and lectures regularly globally

CICMxJellybean 6 Recorded at ASM 2018 Hobart The GUCH Jellybean with Intensivist and Cardiologist Susanna Price Dr Susanna Price,Clinical Lead in Critical Care, Royal Brompton Hospital, President Elect of the European Society of Cardiology, published everywhere and part of so many guidelines related to cardiology. Fresh off the flight from London Susanna stepped up and talked sense to the biggest crowd ever to attend a CICM ASM. The cardiology focussed meeting was a bit of a silo smasher. Perhaps no group of patients bridge across the divide between paediatric and adult intensive care more than the “Grown Up Congenital Heart Disease” (GUCH) patient. These are amazing people with amazing medical histories and they are around in greater and greater numbers. They may have started in a hyper-specialised surgical centres but they might end up in any emergency department anywhere. The catch is that these people will not always know all the details of their past interventions. They were, after all, children at the time. Even if you understand what their original pathology was you may not know what type of surgery was done, where, why, when, who and do we still do that? Don’t be afraid, be informed. Susanna Price opens a GUCH treasure chest to show us what is in there. The organisers of the CICM ASM in Hobart worked hard to shine a light on the areas of critical care cardiology that cross the borders between specialities and the borders between paediatric, adolescent and adult intensive care. Dr Price clinical practice crosses borders and she is a Dual Trained UK Cardiologist and Intensivist, which is a rather rare combination in Britain. (It would be good to have a Different Strokes picture but it seems that all available images are under copyright. There are some great Different Gooch clips here though: http://heliotricity.com/diffrentstrokes.html) https://www.dailymotion.com/video/x548zhx Sometimes doing one specialty is not enough. For some it's an intellectual journey, for others it might be a migration. For a few it is a way to make things happen. Important things. Like getting your patient to the cath lab or into theatre. So not satisfied with just being a good intensivist, Susanna Price also became a cardiologist. That helps when you are working at the Royal Brompton Hospital, the largest specialist heart and lung centre in the UK [http://www.rbht.nhs.uk/#]. Add to the mix that Susanna worked with Adult Congenital Heart Disease pioneer, Dr Jane Somerville [YouTube URL - https://youtu.be/QmrUOK2dhO0]. It turns out that adult intensivists still need to know about paediatric congenital heart diseases and their management, because having survived their childhood, with or without surgery, they turn up as adults in any hospital. This matters. It affects assessment, monitoring and therapies. They may not even know they have or “had” a congenital heart disease. But there is help. Susanna and her European Society of Cardiology [https://www.escardio.org/] colleagues have decided that this is so important, they built an educational platform and give access away for free: ESC Grown Up Congenital Heart Disease (GUCH) E-Learning - https://www.escardio.org/Education/E-Learning/Clinical-cases/grown-up-congenital-heart-disease-guch Here is Susanna's talk on ICN; https://intensivecarenetwork.com/guch-a-growing-problem/

In this episode of the Heart podcast, Digital Media Editor Dr. James Rudd is joined by cardiologist and cardiac CT expert Dr. Ed Nicol from The Royal Brompton Hospital, London. They discuss what the updated NICE guidelines for the assessment of stable chest pain mean for the UK imaging community. They also cover the differences between the UK, European and US guidelines and how technological developments in CT might help patients and save money. Please leave us a podcast review at itunes.apple.com/gb/podcast/heart…id445358212?mt=2 Link to published papers and podcasts: Podcasts on the NICE guidelines from authors for, and against, the new approach: https://soundcloud.com/bmjpodcasts/assessing-stable-chest-pain-a-nice-win-for-ct?in=bmjpodcasts/sets/heart-podcast https://soundcloud.com/bmjpodcasts/stable-chest-pain-assessment-revisited-the-case-against-cardiac-ct?in=bmjpodcasts/sets/heart-podcast Assessment of patients with stable chest pain : http://heart.bmj.com/content/early/2017/10/30/heartjnl-2017-311212 Challenges in delivering computed tomography coronary angiography as the first-line test for stable chest pain : http://heart.bmj.com/content/early/2017/11/14/heartjnl-2017-311846

Dr. Carolyn Lam:               Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the journal and its editors. I'm Dr. Carolyn Lam, associate editor from the National Heart Center, and Duke National University of Singapore. Our featured paper this week confirms the clinical utility of a polygenic risk score of common variants of cardiovascular disease. More soon after this week's summary of articles.                                 The first original article describes distinct cell-specific roles for NADPH oxidase, or Nox2, in blood pressure regulation. This paper from first author, Dr. Sag, corresponding author, Dr. Shah, colleagues from King's College London British Heart Foundation Center of Excellence in the United Kingdom. The authors used novel gene modified mouse models to show that Nox2 in myeloid cells modulates basal blood pressure whereas endothelial cell Nox2 is involved in angiotensin II-dependent hypertension. The finding that Nox2 in different cell types has distinct effects on blood pressure, suggest that different diseases conditions may alter blood pressure through effects on Nox2 in different cell types. For example, it is conceivable that the effects on myeloid cells on basal blood pressure may be enhanced in inflammatory settings, whereas endothelial cell Nox2 activation may be more relevant to renin-angiotensin system-dependent hypertension. The current results are therefore relevant to the design of novel therapeutic approaches for hypertension by targeting NADPH oxidases.                                 The next paper provides a new, more accurate atherosclerotic cardiovascular disease risk prediction tool in familial hypercholesterolemia that may increase the efficiency of care and use of newer lipid lowering therapies. Co-corresponding authors, Dr. Mata and Pérez de Isla, from Hospital Clinicals San Carlos in Madrid, Spain, use data from SAFEHEART, a multicenter, nationwide, long-term prospective cohort study of 2,404 adult patients with molecularly-defined familial hypercholesterolemia and who have followed up for a mean of 5.5 years. They developed a robust risk prediction equation for incident atherosclerotic cardiovascular disease based on the following independent predictors; age, male gender, history of previous atherosclerotic cardiovascular disease, high blood pressure, increased body mass index, active smoking, LDL cholesterol and LPA levels. The new SAFEHEART risk equation performed better with a Harrell C index of 0.81 compared to 0.78 for the modified Framingham's risk equation and 0.8 for the ACC/AHA Pooled Cohort risk Equations. The authors therefore concluded that the risk of incident atherosclerotic cardiovascular disease may be estimated in familiar hypercholesterolemia patients, using simple clinical predictors, and that these findings may improve re-stratification and could be utilized to guide therapy in patients with familiar hypercholesterolemia.                                 The next study tells us that late gadolinium enhancement cardiovascular magnetic residents identifies patients with dilated cardiomyopathy but without severe left ventricular systolic dysfunction, who are still at high risk of sudden cardiac death. In this study, by first author Dr. Halliday, corresponding author Dr. Pennell, from Royal Brompton Hospital in London, United Kingdom, the authors prospectively investigated the association between mid-wall late gadolinium enhancement and the primary composite outcome of sudden cardiac death or aborted sudden cardiac death, among 399 consecutive referrals with dilated cardiomyopathy and a left ventricular ejection fraction above 40% seen at their center between 2000 and 2011. These patients were followed for a median of 4.6 years. 17.8% of patients with late gadolinium enhancement reached the pre-specified end point, compared to only 2.3% without late gadolinium enhancement.                                 Furthermore, following adjustment, late gadolinium enhancement predicted the composite end point, with a hazards ratio of 9.3. Thus, patients with dilated cardiomyopathy and mid-wall late gadolinium enhancement, and mild or moderate reductions of left ventricular ejection fraction should still be recognized as having a high risk of sudden cardiac death. This is important because these patients are not currently offered ICDs for the primary prevention of sudden cardiac death, based on current guidelines. Due to the low competing risk of death from non-sudden causes, it is possible that these patients will benefit from ICD implantation, but randomized trials are now required. These issues are discussed in an accompanying editorial from Dr. Markman of Johns Hopkins University, and Dr. Nazarian, Hospital of University of Pennsylvania.                                 The next study enhances our understanding of the role of immunity in hypertension. Now, the innate antigen-presenting cells and adaptive immune T-cells have long been implicated in the development of hypertension, however, the T-lymphocytes subsets involved in the pathophysiology of hypertension remain unclear. A small subset of innate-like T-cells expressing the gamma-delta T-cell receptor, rather than the more commonly expressed alpha-beta T-cell receptor, could play a role, and these were the focus in today's paper by first author Dr. Caillon, corresponding author Dr. Schiffrin, and colleagues from Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, Canada. In experimental models, the authors showed than angiotensin-2 infusion increased gamma-delta T-cell numbers and activation in the spleen of wall tite mice, as well as in increased the systolic blood pressure, and decreased mesentric artery endothelial function in wild type mice, but not in mice devoid of gamma-delta T-cells, or in mice depleted of gamma-delta T-cells by depleting antibody injections.                                 Furthermore, angiotensin-2 induced T-cell activation in the spleen and peri-vascular adipose tissue was blunted in null mice. In humans, there was an association between systolic blood pressure and gamma-delta T-cells. In summary, this is the first in-vivo demonstration that gamma-delta T-cells, a subpopulation of T-cells, play a fundamental role in the development of hypertension and vascular damage. These results will help design novel treatments to limit the progression of hypertension and vascular damage.                                 The final paper describes a novel multi-modality strategy for cardiovascular risk assessment. Dr. de Lemos and colleagues from UT Southwestern Medical Center in Dallas, Texas, hypothesized that a strategy combining promising biomarkers across multiple different testing modalities would improve global and atherosclerotic cardiovascular disease risk assessments among individuals without known cardiovascular disease. These modalities included: left ventricular hypertrophy by electrocardiogram, coronary artery calcium, N-terminal pro B-type natriuretic peptide, high sensitivity cardiac troponin-T, and high sensitivity C-reactive protein.                                 Using data from 6,621 individuals of the multi-ethnic study of atherosclerosis, or MESA, as well as 2,202 individuals from the Dallas heart study, the authors evaluated the association of test results with the global composite cardiovascular disease outcome, and that would include cardiovascular death, myocardial infarction, stroke, coronary or periphery revascularization, incident heart failure or atrial fibrillation, as well as atherosclerotic cardiovascular disease outcomes, which included fatal or non-fatal myocardial infarction or stroke. Over more than 10 years of follow-up, the authors found that each test result was independently associated with the global composite cardiovascular disease events in MESA. When the 5 tests were added to a base model, the C statistic improved, that was significant integrated discrimination improvement, and net reclassification improvement, and the model was well-calibrated. Using a simple integer score counting the number of abnormal tests, they showed that global cardiovascular disease risk increased with increasing score in a graded fashion. These findings were replicated in the Dallas heart study, and were similar for the atherosclerotic cardiovascular disease outcome.                                 This study therefore supports the potential value of a multi-modality testing strategy in selected individuals, in whom additional risk stratification is desired, beyond measurement of traditional atherosclerosis risk factors. The authors do highlight that additional studies are needed to validate the present findings, determine the optimal approach to implementation, and address direct and indirect cost implications of the additional testing.                                 Well, that wraps it up for your summaries. Now for our feature discussion.                                 Our feature paper today tells us that a polygenic risk score identifies a group of individuals with a higher burden of atherosclerosis, and greater relative benefit from statin therapy in the primary prevention setting. But perhaps even more significant, is that it addresses the fact that even relatively small effect sizes of common snips gathered together in a genetic risk score may have clinical utility in the prediction of cardiovascular disease, and to discuss this I'm so pleased to have the first author, Dr. Pradeep Natarajan from Massachusetts General Hospital, and Dr. Anand Rohatgi, associate editor from UT Southwestern. Welcome, gentlemen. Dr. Pradeep Natarajan:  Thank you very much, Carolyn. Dr. Anand Rohatgi:          Thank you, Carolyn. Dr. Carolyn Lam:               Pradeep, could you start by telling us what you did? This was a tour de force, please. Dr. Pradeep Natarajan:  Yeah, thanks so much for the invitation and the enthusiasm. So, briefly, large-scale, genome-wide association studies have discovered genetic risk variants in the population that individually associate with coronary disease risk. Many others have shown that an aggregate of these genetic risk variants predisposes to an increased risk for coronary disease by about 60%. But we sought to, with this study, understand how primary preventive statins could influence that risk, and whether these insights could be helpful in refining statin eligibility. So, among the individual variants that had been associated with coronary disease, we developed a risk score. This encapsulated 57 individual genetic variants. This risk score is independent of traditional cardiovascular risk factors, and identified individuals with a greater burden of sub-clinical atherosclerosis, defined as coronary artery calcium and carotid plaque, and two observational cohorts in individuals with a greater absolute and relative benefit from statin therapy from a subgroup analysis within the WOSCOPS clinical trial.                                 What we were surprised by is that the conventional wisdom, that all previously described subgroups within statin trials had the same relative benefit, and statins per unit of alveol cholesterol lowering. So, about 20 to 25% lowering of risk per 40mg per deciliter of alveol cholesterol. So we clinically identify individuals who just start out at high absolute risk, assume that the relative benefit will be the same across everyone, and optimize the number needed to treat simply by just finding individuals at high risk. But, here we didn't see the expected 20 to 25% lowering in the high genetic risk group, we saw actually a 44% relative risk reduction for the same lowering of alveol cholesterol. And we have now observed that across three different clinical trials, and these individuals are at high baseline risk, so this translates into an even more optimized number needed to treat, and really the opportunity to identify individuals earlier with an age independent biomarker. Dr. Carolyn Lam:               That's really cool, in fact, the number needed to treat in the high-risk score group was impressively low at 13. Dr. Pradeep Natarajan:  That's correct. Now, overall in the WOSCOPS trial, if you look at all individuals, it's about 38, so it is a high risk primary preventive group of men with, you know, substantial hyperlipidemia, but if you look at at least a relative difference between the two, going from 38 to 13, that's about a three-fold improvement of the number needed to treat. Dr. Carolyn Lam:               You know, what you said about it not correlating with exactly what you expected with the drop in LDL and so on, does that mean that this genetic risk score, that a lot of the snips are probably associated with LDL levels, but that a lot of them may be giving more information beyond LDL? Is that what it means? Dr. Pradeep Natarajan:  Yeah, you know, it's interesting. Most of the genetic variants that are associated with coronary disease actually do not seem to clearly influence traditional cardiovascular risk factors. The latest best estimate of that is about 39% of them associate with traditional cardiovascular risk factors, and then a subset with LDL cholesterol. So the aggregate score actually does not associate with traditional risk factors, and including with LDL cholesterol. Dr. Carolyn Lam:               Wow, and Anand, I'm sure we had so many discussions with the editors about the paper. Could you share some thoughts? Dr. Anand Rohatgi:          Yes, Carolyn. Circulation as a journal represents the best in cardiovascular science, and we're always interested in the highest-level articles related to atherosclerotic cardiovascular disease. So, when we received this manuscript from Pradeep and Sekar's group, really leaders in the field, we were really excited, and as we went through the review process we got even more excited because it, as you said, Carolyn, it really was a tour de force, it was a high-quality article and it combined multiple things, and that's what we're really interested in seeing at Circulation, is combining several aspects, in this case genetics, sub-clinical atherosclerotic imaging, and also treatment effect.                                 And, you know, it's interesting because several recent manuscripts looking at genetic risk scores, they were associated with coronary disease but it wasn't clear that they were improving what we call risk prediction performance indices, at least enough to meet the bar of incorporating them into guideline-type recommendations. So I think the field wasn't sure how to move forwards with this type of information, but now I think this study really demonstrates that this type of risk score, this genetic risk score, really can inform treatment decisions in a big way. And so we were really excited to talk about that and then see it move forward. Dr. Carolyn Lam:               So a question for both of you now. Can these data be extrapolated to other cohorts of patients? I mean, WOSCOPS was predominantly white, and all were males, right? So, Pradeep, would you like to take that first? Dr. Pradeep Natarajan:  That's an excellent observation, and I think ... A clear limitation in the field, but an outstanding question that I think can be addressed going forwards. So, the main challenge is that the epidemiological cohorts that were used for genetic analysis largely have been of European ancestry, and we know that genetic background and a variety of non-genetic factors influence cardiovascular disease risk, so in genetic analysis of European individuals the influencers of coronary disease risk may not influence cardiovascular disease the same in non-European ethnicities. And, you know, we've done some work of this specifically in African-Americans, and there are some differences. You know, African-Americans are largely mixed of both African and European ancestry, some of that seems to also influence how you interpret the cardiovascular genetic risk score.                                 Ideally you would have a risk score that is not influenced by the genetic background, and so the next step going forward are one to look to see how well this risk score predicts in non-European ancestry, because, obviously, not as much statin clinical trial information in non-European cohorts, but I think looking at the treatment effect in non-Europeans will be important. And then, you know, the third step is we and others are participating in several now large ongoing efforts to really define what the genetic influences are in non-European ancestries, and I think that will be a very important next step that's really critical before the clinical implementation. Dr. Carolyn Lam:               Yeah, talking to you from Asia, that's music to my ears, obviously. Anand, did you have any questions for Pradeep or anything else to add about the paper? Dr. Anand Rohatgi:          Yeah, I wanted to add one or two comments. One thing that this study demonstrates is that the genetic risk scores, whether they relate to traditional risk factors or lipids, that doesn't necessarily translate to what it might mean in terms of treatment benefit, and so I think that concept is generalizable and now it needs to be tested in other ethnicities, other types of subgroups, but I think you can disentangle a relationship with risk factors and lipids to its treatment effect and this study really nicely shows that.                                 And I think just to take a step back, we know statins work in intermediate-risk patients, maybe even low-risk patients with the most recent studies, but at a public policy level, and just as a cognition, we really want to narrow the focus, it's something called precision medicine that the American Heart Association is promoting as a concept, and I think that this study really demonstrates that here we have now another tool that can reduce this number needed to treat, make this choice for statins more precise, maximizing the benefits and limiting cost. So, I think that concept is very generalizable, it needs to be tested now in multiple populations, like Pradeep said, and I guess one of the questions I had had for the authors is: how do we incorporate this finding that they saw with sub-clinical atherosclerosis, which we thought was very fascinating among the editors at Circulation, that now they're also linking with sub-clinical atherosclerosis, is that something that the investigators think needs to be pursued further? Would that be something that would be used clinically as well? Dr. Pradeep Natarajan:  I think there are lots of opportunities for this going forward, you know, in prior work we've done the genetic architecture for clinical coronary disease is actually very similar to sub-clinical coronary disease, and there are many influences for sub-clinical coronary disease, and clinical coronary-disease, that are both genetic and environmental, and the aggregate effect from the polygenic risk on sub-clinical atherosclerosis suggests that it's obviously not absolute and there are other factors that influence sub-clinical atherosclerosis. Dr. Carolyn Lam:               Well, listeners, you heard it right here. Thank you for joining us this week, tell all your friends about it, and don't forget to tune in again next week.

Dr Carolyn Lam:                Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to The Journal and its editors. I'm Dr. Carolyn Lam, associate editor from the National Heart Center and Duke National University of Singapore.                                                 Today's issue features two exciting papers regarding heart failure in patients with breast cancer. We will be discussing this right after these summaries.                                                 Are we any closer to improving survival in Eisenmenger syndrome? Well, today's first original paper looks at contemporary trends and presents a multivariable mortality risk stratification model based on five simple noninvasive predictors of death in this population. Dr. Kempny and colleagues from Royal Brompton Hospital in London in the United Kingdom preform a large multicenter study in 1098 patients with Eisenmenger syndrome followed up between years 2000 and 2015.                                                 At the end of the study almost two-thirds of patients were on advance therapy for pulmonary arterial hypertension, while only six patients underwent lung or heart and lung transplantation. The study showed that despite advances in management, there was significant mortality amongst contemporary adults with Eisenmenger syndrome and 25.3% of patients died over a median follow up period of 3.1 years. Mortality was higher in older patients, those with a pre-tricuspid shunt, lower oxygen saturation, absence of sinus rhythm, or with a pericardial effusion.                                                 This important study is accompanied by an editorial by Drs. Lange, from Texas Tech University Health Sciences Center El Paso and Dr. Brickner from UT Southwest Medical Center in Dallas, Texas. The editorialists call for a prospective randomized control trials of the effect of current, or future pulmonary vasoactive disease targeting therapies on mortality in Eisenmenger syndrome patients, and say it's time to direct our efforts from improving risk-stratification towards improving survival.                                                 The next study provides experimental evidence of tolerogenic dendritic cell therapy as a novel anti-remodeling therapy in myocardial infarction. Tolerogenic dendritic cells are promising, potent, beneficial regulators of the post-infarct healing process via their control of T-regulatory cells and M1 M2 macrophages. Plus they have the advantage of the ease of administration and feasibility of a heart specific tolero-dendritic cell production.                                                 In the current paper by co-first authors, Drs. Choo and Lee, and co-corresponding authors, Drs. Chang and Lim, from Catholic University Korea and Chai University in Korea, authors generated tolerogenic dendritic cells by treating bone marrow-derived dendritic cells with TNF-alpha and cardiac lysate from mice with myocardial infarction. They then injected myocardial infarction mice twice with tolerogenic dendritic cells within 24 hours and at 7 days after LAD ligation. In treated animals, in vivo cardiac magnetic resonance imaging and ex vivo histology confirm the beneficial effects on post-infarct LV remodeling. Furthermore, subcutaneously administered tolerogenic dendritic cells near the inguinal lymph node migrated to the regional lymph nodes and induced infarct tissue specific T-regulatory T-cell populations in the inguinal and mediastinal lymph nodes, spleen, and infarcted myocardium, all of which elicited an inflammatory to reparative macrophage shift. The altered immune environment in the infarcted heart resulted in better wound remodeling, preserved left ventricular systolic function, and an improved survival following myocardial infarction. Thus, this study shows that tolerogenic dendritic cell therapy in a preclinical model of myocardial infarction may be potentially translatable into an anti-remodeling therapy for ischemic repair.                                                 The final paper reports results of cell therapy on exercise performance and limb perfusion in peripheral artery disease from the PACE trial, which is an NHLBI-sponsored randomized double-blind placebo-controlled phase two clinical trial, designed to assess the safety and efficacy of autologous bone marrow-derived aldehyde dehydrogenase bright cells in peripheral artery disease, and to explore associated claudication physiological mechanisms. In this paper from corresponding author Dr. Moye from UT School of Public Health in Houston, Texas and colleagues of the Cardiovascular Cell Therapy Research Network, a total of 82 patients with claudication and infrainguinal peripheral artery disease were randomized at nine sites to receive alcohol dehydrogenase bright cells or placebo. All patients underwent bone marrow aspiration and isolation of aldehyde dehydrogenase bright cells followed by 10 injections into the thigh and calf of the index leg. Results showed that there were no significant differences in the change over six months between study groups for the co-primary endpoint of peak walking time, collateral count, peak hyperemic popliteal flow, and capillary profusion measured by magnetic resonance imaging.                                                 Additionally, there were no significant differences for the secondary endpoints including quality of life measures. There were no adverse safety outcomes. Interestingly, a post-hoc exploratory analysis suggested that aldehyde dehydrogenase bright cell administration might be associated with an increase in the number of collateral arteries in participants with completely occluded femoral arteries.                                                 In summary, cell therapy did not improve peak walk time or magnetic resonance outcomes, and the changes in peak walk time were not associated with the anatomic or physiologic MRI endpoints. However, future peripheral artery disease cell therapy trial design may be informed by new anatomic and perfusion insights. These and other issues are discussed in an accompanying editorial by Drs. Breton-Romero and Hamburg from Boston University School of Medicine. Well, that wraps it up for our summaries, now for our feature discussion.                                                 We are really in the grove here in Washington, D.C. and I am borrowing the words of my very special, star associate editor, guest, Dr. Gregory Hundley, and he's from Wakefield University School of Medicine. We're discussing two very important papers and they deal with the risk of heart failure following breast cancer. Why they're so important? Well, first of all, it's about time we looked at this problem in detail, and secondly, they actually represent papers in a new section of the journal called "Bridging Disciplines," and in this case cardio-oncology. Very, very important topics.                                                 We're here with the corresponding authors of both papers, Bonnie Ky from University of Pennsylvania School of Medicine and Dr. Margaret Redfield from Mayo Clinic. Dr Gregory Hundley:      Thank you, Carolyn. I really appreciate that wonderful introduction and also the chance to talk with Bonnie about this exciting topic.                                                 So, Bonnie, you've got a paper here, now, where you did a study in patients with breast cancer, and it sounds like you acquired echocardiograms over a period of time. Can you tell us a little bit about that? Dr Bonnie Ky:                     Correct. So this is longitudinal prospective cohort study, it's an NIH-funded R01, whereby we are enrolling patients from the breast cancer clinic who are receiving doxorubicin or trastuzumab or a combination of the two therapies. And we're performing very careful cardiovascular phenotyping, from the time at which they initiate chemotherapy through their chemotherapy and then annually once a year we have them come back, for a total follow up time of 10 years.                                                 We took a subcohort, 277 patients, and from their echocardiograms, we analyze them very carefully for various measures of left ventricular size, function, not only systolic function but also diastolic function. We also looked at measures of contractility such as strain in multiple dimensions, and then also measures of ventricular arterial coupling, as well as arterial loads, so how the ventricle interacts with the arterial system. And what we found was that over a 3.2 period time period, on population average, these modest declines in left ventricular ejection fraction, and even across all three treatment groups, and even at three years there were persistent LVF declines. Dr Gregory Hundley:      So, I understand, Bonnie, that you also collected some information as to whether or not these patients were experiencing symptoms associated with heart failure. How did the imaging markers relate to the symptomatology associated with heart failure? Dr Bonnie Ky:                     What we found was that early changes in arterial stiffness or total arterial load, as well as early changes in EF were associated with worse heart failure symptoms at one year. A lot of our other analysis was focused on defining what echo parameters of remodeling, size, function are driving or associated most strongly with LVF decline, as well as LVF recovery. Dr Gregory Hundley:      And then at two years, what happened? Did the echo parameters, were they still associated with heart failure or was there a little discrepancy there? Dr Bonnie Ky:                     Interestingly, at two years ... no, there was no significant association with changes in arterial load and heart failure symptoms at two years. Dr Gregory Hundley:      So there might be something transient that's occurring that is associated with heart failure early, and then the patients still had heart failure late, so maybe something else is operative. What do you think we need to do next? What's the next step in your research and then other investigators around the world; what do we need to do to design studies to look at these issues further? Dr Bonnie Ky:                     Yeah. What does the field need, the field of cardio-oncology that's really growing and developing at rapid paces. Some of the major findings from the study was that changes in total arterial load were very strongly associated with both LVF decline and LVF recovery. So total arterial load is the measure of blood pressure or total arterial stiffness, it's derived from blood pressure. And to me, that begs the question, or begs the next step is that changes in blood pressure are associated with decline as well as recovery. I think, oh, as cardiologists we've also always recognized the importance of afterload reduction. And to me, this study suggests that we need a study, a randomized clinical trial, looking at blood pressure lowering in this population to help mitigate LVF declines. Dr Carolyn Lam:                I'd actually like to turn it back to you. You are world-renowned for your work in cardio-oncology. Where do you think this fits in, and where do you think we need to address most urgently? Dr Gregory Hundley:      I think where this fits in wonderfully is a lot of individuals around the world are collecting echocardiographic measures, and all different types. And what Bonnie has helped do is clarify what we would expect to see in this particular patient population. How those measures change over time and that feeds into another block of data, when the measurements head south, do we change therapy, do we add protective agents, and things of that nature. So I think Bonnie's work really contributes on that front. What she has also pointed out is that more research needs to be performed, not necessarily because the patients had heart failure symptomatology at two years, but not necessarily associated with the decline in EF; are there other systems in the cardiovascular realm that are being affected? The vascular system- Dr Carolyn Lam:                Yeah. Dr Gregory Hundley:      Skeletal muscle, many other areas. So as cardiologists start to work more with oncologists in this space, and we're all working together to make sure that not only patients survive their cancer, but they have an excellent quality of life, I think we'll see, as we have in other heart failure syndromes, a look toward other aspects of the cardiovascular system, body in general, to reduce the overall morbidity associated with the disease.                                                 I think what we need to recognize as cardiovascular medicine specialists is that now for many forms of cancer, cardiovascular events, and certainly morbidity are becoming the primary issue that folks have to deal with with survivors. It's not necessarily the cancer recurrence, it's not necessarily a new cancer, it's cardiovascular. So we've got to integrate cardiology earlier in working with oncologists to improve overall survival and create an excellent quality of life from our different perspectives. Dr Carolyn Lam:                So, Maggie, let's move on to your paper now. You looked at radiotherapy's effect, whereas Bonnie looked at chemotherapy's effect. Could you tell us what you did and what you found? Dr Margaret Redfield:    The rationale for doing this study was, of course, seeing a lot of patients with HFpEF who had had radiation therapy for breast cancer, and I always just sort of assumed that that was because 12% of women over the age of 40 get breast cancer and 20% of women over the age of 40 get heart failure, but it seemed to be somehow more common than that. The other rationale was that radiation therapy does not actually affect the cardiomyocytes; they are very radiation resistant. And what radiation does is cause microvascular endothelial cells damage and inflammation, and that is felt to be fundamental in the pathophysiology for HFpEF.                                                 So we thought we should look at this. I collaborated with a radiation oncologist and oncologists, and they were interested in looking at this because there's a lot of techniques now to reduce cardiac radiation exposure during radiation therapy, including proton beam therapy, and they're trying to prioritize who they use this new technology on. So what we did was start with a population-based study, all women who lived in Olmsted county who received radiation therapy for breast cancer in the contemporary era, where they're already using these dose reducing techniques. So we wanted to make it relevant to what's going on today. And so we started with a base cohort of all women. We matched patients' cases, it was a case-control study, so we matched cases and controls according to their age at the time of breast cancer, whether they had heart failure risk factors, like hypertension or diabetes, whether they got adjuvant chemotherapy, and tumor size, because we felt it was important that radiation could affect different parts of the heart, depending on whether it was right- or left-sided tumor.                                                 And what we found is that the risk of heart failure increased with the mean cardiac radiation dose. We measured the mean cardiac radiation dose in every case and every control from their CT scans and their radiation plants. And as the radiation dose went up, the risk of heart failure went up, even matching or controlling for chemotherapy, which wasn't used that often in this group, or heart failure risk factors. And the vast majority of these cases were indeed HFpEF.                                                 So we then looked at factors that happened in-between the radiotherapy and the onset of heart failure, making sure that this all wasn't just coronary artery disease, 'cause we know radiation can increase the risk of coronary artery disease. And indeed there were, only in about 18% of cases was there a new episode of coronary disease in the interim between the radiotherapy and the breast cancer. So, basically found that the mean cardiac radiation dose, even in today's era, does increase the risk of heart failure with preserved ejection fractions. Dr Carolyn Lam:                The things that stuck out to me ... it's population based. You did such a comprehensive study to really answer very key questions: dose of radiation, is it really just mediated by age and age-related risk factors, is it just about MI or could it be more microvascular disease? Congratulations, I really appreciated this paper. Some of the take-home messages are directly related to the treatment of breast cancer, isn't it? And about the importance of minimizing radiation dose if possible. I suppose one of the take-homes is, as well, for screening and watching out for heart failure. One thing though: how were these woman diagnosed with HEpEF? I mean, this is always the questions I get. How do you get diagnosed with HEpEF? Dr Margaret Redfield:    Right, well, first we started with looking to see if they had a ICD code for heart failure, and then we looked at each case of heart failure and determined if they either met Framingham criteria at the time of the diagnosis and the majority of them did. If they didn't actually meet the Framingham criteria, we looked to be sure there was a physician diagnosis of heart failure in the record and that they had supportive evidence of heart failure: echocardiographic findings, natriuretic peptide findings, and other clinical characteristics of heart failure.                                                 And importantly, in the large control group from where we, you know, got our controls, people, a very large group of patients who did not get heart failure, we'd use natural language processing to look at all those records to make sure we weren't missing anybody who didn't have an ICD diagnosis or code for heart failure to make sure we weren't missing any cases of heart failure. So, we really tried to use very stringent methods to make sure we had true cases and control groups. Dr Carolyn Lam:                Indeed, and it actually goes back to Bonnie's paper as well, where we have to remind everyone that the diagnosis of HEpEF really starts with the symptomatology of heart failure in particular, that you so rigorously determined. I think just one last thing, Maggie: what do you think this implies now, for HEpEF? What do we do in general so the non-radiation-associated, do we believe more the Walter Paulus-Carsten Tschope hypothesis, and if so, what do we do? Dr Margaret Redfield:    Yes, well I think it really does support that hypothesis. We know that radiation therapy, again, we know what it does to the coronary microvascular endothelial cells and that's been elegantly worked out both in patients and in animal models. I think this really supports the Paulus hypothesis because this microvascular damage was able to produce heart failure, so I think that really supports that hypothesis. And there's been some studies showing decreased coronary flow reserve in HEpEF patients; it's very common. So I think indeed it does support that hypothesis and that the coronary microvasculature is key in the pathophysiology of HEpEF.                                                 However it's a little scary to me because that sort of damage, once it's established, may be very hard to treat. You know, proangiogenic strategies in peripheral vascular disease have not yet yielded the benefits that we hoped for, so I think it's a tough therapeutic challenge that'll be very important to try to address in pre-clinical studies to try and figure out once the microvasculature is so damaged how do we treat that? How do we reverse that process? Dr Carolyn Lam:                Yeah. Words of wisdom. Maggie, thanks so much for inspiring, just all of us in this field. I just had to say that. You know, you are the reason that I am totally in love with HEpEF. (laughter) Dr Margaret Redfield:    (laughter) Dr Carolyn Lam:                So thank you so much for joining me today on the show. In fact, thank you to all my three guests.                                                 You've been listening to Circulation on the Run. You must tell everyone about this episode, it is full of gems.                                                 Thank you, and tune in next week.  

The 2016 edition of TCT Show was opened with one of THE most awe-inspiring stories ever to be told in 3D printing. Alex Berry founder of Sutrue and Mr Richard Trimlett, Adult Cardiac Consultant at the Royal Brompton Hospital took to the Main Stage to discuss the developments of a device that will improve keyhole surgery and the potential of the additive technologies that made it to completely revolutionise healthcare.

TCT Podcast Episode 4 – TCT Podcast is back! The 2016 edition of TCT Show was opened with one of THE most awe-inspiring stories ever to be told in 3D Printing. Alex Berry founder of Sutrue and Mr Richard Trimlett, Adult Cardiac Consultant at the Royal Brompton Hospital took to the Main Stage to discuss the developments of […]

In this podcast Dr James Rudd speaks to Dr Alexander Lyon, consultant cardiologist at the Royal Brompton Hospital, about the effects of cancer treatments on the heart, the problems of an aging population, and the new field of cardio-oncology. Editorial >> http://heart.bmj.com/content/early/2015/09/09/heartjnl-2015-308208.full Full paper >> http://heart.bmj.com/content/early/2015/09/08/heartjnl-2015-307848.full

We are delighted to offer you our first podcast. Harry Baumer, a consultant paediatrician from Plymouth, UK who writes about guidelines for ADC, and Ian Balfour-Lynn, a consultant in paediatric respiratory medicine at the Royal Brompton Hospital in London and an ADC associate editor, discuss the new asthma guidelines from both the British Thoracic Society and the National Institute of Health. In the podcast they discuss: Use of inhaled cortical steroids (ICS) in infants What are the side effects of ICS? Are long-acting beta agonists safe in children? What are the differences between the NIH and BTS recommendation regarding environmental approaches to asthma?We have posted both a short (18 minutes) and long version (28 minutes) of their discussion. Please email us your thoughts about this podcast (howard.bauchner@bmc.org) and suggestions for future ones.Professor Howard BauchnerEditorSee also this related article http://ep.bmj.com/cgi/content/extract/93/2/66

Jennifer Quint (Thorax’s journal club editor) talks to Pallav Shah (a respiratory physician at the Royal Brompton Hospital, UK) about his trial of airway bypass for patients with severe emphysema, recently published in the Lancet.Dr Shah explains the procedure and how effective it was.See also:http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2811%2961050-7/abstract